Use of Lacrimal Retractor in Rhinoplasty: A Boon for the Solo Rhinoplasty Surgeon

Summary:

Open rhinoplasty is a complex procedure that requires precise exposure of multiple anatomic structures. Anatomic dissection typically proceeds from the tip cephalad to the dorsum. Although newer open rhinoplasty techniques exist, many surgeons still perform a bidirectional cartilage-splitting approach. This approach requires precise exposure of the septum while retracting the lower lateral cartilages at their midline. This retraction facilitates tip and dorsum dissection and allows adequate visualization of the septum for modification. Current lower lateral cartilage retraction techniques require either surgical assistants to hold hooks or clamps, or the solo surgeon to use weighted hooks or clamps that are simply allowed to fall laterally, thus providing exposure. Furthermore, for septal exposure, the surgeon often must use a nasal speculum in 1 hand while attempting to dissect and modify the septum with the other. In this article, the author described the technique of using a spring-loaded lacrimal retractor to facilitate dissection of the nasal tip, as well as to provide exposure for dorsal and caudal septal modification. This technique provides a constant and predictable retracting force to the midline cartilages; is atraumatic; and, most importantly, allows the operating surgeon to use both hands while performing the operation. The technical advantages of using such a device could serve as a boon to both structural and preservation rhinoplasty surgeons.

Takeaways

Question: How does a surgeon obtain maximal exposure during a rhinoplasty operation?

Findings: A spring-loaded lacrimal sac retractor optimizes exposure while also allowing the surgeon to have both hands free to operate.

Meaning: A spring-loaded lacrimal sac retractor optimizes exposure during a rhinoplasty operation.

INTRODUCTION

According to American Society of Plastic Surgeons statistics from 2022, rhinoplasty was the eighth most common cosmetic procedure performed in the United States, with more than 40,000 procedures performed.¹ Furthermore, according to the International Society of Aesthetic Plastic Surgery, it is one of the top 5 procedures performed globally, with more than 1.1 million cases reported.² The origins of modern rhinoplasty, however, are not within the field of plastic surgery. Dr. John Orlando Roe, an otolaryngologist, is credited with performing the first cosmetic closed rhinoplasty in 1887. Two years later, Dr. Jacques Joseph, a German orthopedic surgeon, began developing most of the techniques we use in modern open cosmetic rhinoplasty. Therefore, it is an orthopedic surgeon who is credited with developing most of the modern rhinoplasty techniques we use today. This history illustrates the importance of being open to instruments and techniques from other surgical disciplines as we attempt to advance our discipline.

Modern rhinoplasty surgery can be substratified into 2 types: structural versus preservation, and by surgical approach: open versus closed. To discuss the differences between the 2 types and variations in approaches is beyond the scope of this article. However, these details are worth noting, as the described technique deals primarily with an open structural approach. Although any rhinoplasty procedure involving open tip work or lower lateral cartilage retraction can benefit from this technique, the author almost exclusively performs open structural rhinoplasty, and it is this experience that is described.

The current innovation is a modification of a technique the author learned from Dr. Michael Parker of Akron, Ohio. Dr. Parker uses a small, single-pronged spring retractor to facilitate dissection of the nasal tip. This observation led to the author’s usage of a larger spring-activated 3 × 3 prong Agricola lacrimal sac retractor (Fig. 1) to facilitate dissection of the nasal dorsum, tip, and septum. To our knowledge, the use of a spring retractor in rhinoplasty dissection has not been described in the surgical literature.

Fig. 1.

Agricola lacrimal sac retractor, 1.5-inch (38-mm) length, 32-mm blade spread, 3 × 3 sharp prongs (4 mm deep), spring-loaded with screw lock (Integra Miltex).

The Agricola lacrimal sac retractor is most useful at 3 separate times during the operation:

1. Tip dissection: During initial tip dissection, the retractor is placed between the domes and activated. This maneuver places the intercrural ligament on stretch and pushes the intermediate and medial crura laterally. Efficient and complete dissection of the media crura can then be facilitated (Fig. 2).

2. Dorsal dissection: Lateral retraction of the lower lateral cartilages allows maximum visualization of the nasal dorsum. This not only facilitates dissection of the nasal dorsum but also protects the domal structures from surgical trauma arising from dorsal modification (Fig. 2).

3. Septal dissection: During initial septal dissection at the anterior septal angle, the activated spring retractor can be “joysticked” over the caudal septum. Stretching of the intercrural soft tissues by the retractor facilitates identification of the anterior septal border (Fig. 2). This is particularly useful in cases of a deformed or deviated caudal septum. Once the anterior septal border is identified, the retractor arms continue to provide lateral retraction of the soft tissues, whereas the septum is scored and a mucoperichondrial flap is developed on either side. This self-retraction allows the surgeon to use 1 hand to stabilize the septum, while the other develops a surgical plane with an elevator (Fig. 3). Once mucoperichondrial flaps are raised and the septum is exposed, the retractor can then be repositioned deeper within the operative field. The retractor can be placed caudally in such a way that it retracts both the lower lateral cartilages and bilateral septal mucoperichondrial flaps, yielding access to the entire septum. This again allows the surgeon to use both hands while performing septoplasty or other septal modifications (Fig. 4).

Fig. 2.

The Agricola lacrimal sac retractor retracting the lower lateral cartilages, providing exposure to the dorsum and caudal septum.

Fig. 3.

The Agricola lacrimal sac retractor repositioned deeper and more cephalad to expose the septum. The retractor’s prongs are neither sharp nor forceful enough to tear mucoperichondrium.

Fig. 4.

Oblique view of the Agricola lacrimal sac retractor in position for septal modification. The septum is stabilized with Adson Brown forceps, while the surgeon’s other hand is available for septal modification or tissue harvest. The retractor often obviates the need for a nasal speculum during septal harvest.

The author has spent a great deal of time reading the available literature on rhinoplasty and attending national and international workshops and meetings. In addition, a wealth of surgical video content made available from multiple publishers and organizations has been reviewed. At no point is there a reference to this lacrimal spring retractor technique.

The current method of lower lateral cartilage retraction seems to be by hooks held by assistants or by using clamps to grasp a portion of the cartilages, which are then allowed to fall laterally. Both methods are effective and acceptable. However, there are several disadvantages with these techniques. First, an assistant is not always available to the private plastic surgeon. This obviates the need for many hook retraction techniques. Furthermore, even when an assistant is used, there is variability in the consistency of retraction. The Agricola lacrimal retractor solves these problems in that it can be easily used by the solo surgeon and provides consistent, predictable retraction. Second, hook or clamp retraction, even when used properly, may cause damage to the delicate nasal tissues. Although the Agricola lacrimal retractor can also cause damage, this is less likely, as there is no crushing element, and the amount of retracting force can be controlled by the adjustment screw on the retractor. In the author’s experience, little screw modification is necessary, as the retracting force from the spring is seldom enough to not cause undue trauma. Third, the lacrimal retractor is exceptional at retracting the tissues away from the septum. This allows the surgeon to have both hands available while performing maneuvers on the septum. One hand can provide stabilizing counterforce to the septum, while septal dissection or harvest is performed with the other operating hand.

One may hypothesize, “Why not use other types of small self-retaining retractors?” Specifically, the Agricola lacrimal sac retractor is preferred over other self-retaining retractors due to its spring mechanism. The spring mechanism allows constant tension during dissection without the need for activating a screw or ratchet to adjust tension and retractor arm width. This maintains the retractor in an ideal position and optimizes surgical efficiency throughout the dissection.

The lacrimal sac retractor does have several limitations. First, the device does need to be sharp to function effectively. The prongs will dull over time, resulting in poor tissue purchase and, therefore, poor retraction. Second, one needs to approach very weak nasal cartilage with caution. Although the retractor is suitable for most surgical cases, damage can occur to very weak upper or lower lateral cartilages if the device is used too aggressively. Third, the device does not provide retraction deep within the nose. Using this technique, one can consistently gain exposure only up to the mid-septum. High septal exposure or exposure of the ethmoid will require supplementation with a standard nasal speculum.

In conclusion, the author believes that the use of the Agricola lacrimal sac retractor will find its place in the toolbox of many rhinoplasty surgeons. It provides excellent exposure while freeing the surgeon’s hands to focus on the delicate precision required by a rhinoplasty operation.

DISCLOSURE

The author has no financial interest to declare in relation to the content of this article.