What treatments are effective for stair step deformity after rhinoplasty identified 4 weeks post-procedure?

Treatment of Stair Step Deformity After Rhinoplasty

Percutaneous lateral osteotomy combined with camouflaging techniques using autogenous cartilage grafts is the most effective treatment for stair step deformity identified 4 weeks after rhinoplasty. 1

Understanding Stair Step Deformity

Stair step deformity is an uncommon complication following rhinoplasty that presents as an irregular step-off along the nasal dorsum, typically resulting from:

• Excessive infracturing of nasal bones
• Over-resection of the osseocartilaginous hump
• Improper osteotomy technique during the primary procedure

Treatment Algorithm

1. Percutaneous Lateral Osteotomy

This is the primary surgical approach for correction when identified early (at 4 weeks):

• Performed through small skin punctures rather than endonasal approaches
• Uses the smallest possible osteotomies to achieve desired mobilization
• Follows a specific path starting on the piriform aperture, just above the turbinate attachment
• Slides low over the nasofacial groove to prevent additional step-off deformities
• Ends high on the nasal bone at the level of the medial canthus 1

2. Camouflaging Techniques

When complete correction cannot be achieved through osteotomies alone:

• Autogenous cartilage grafts (typically harvested from the septum) are used to fill depressions
• Thin cartilage wafers can improve and sometimes completely correct asymmetries
• Onlay grafts may extend over the length of the nasal dorsum to hide the crooked appearance 2

3. Spreader-Splay Graft Combination

For more severe cases with associated functional issues:

• Particularly effective when stair step deformity is combined with middle vault problems
• Provides anatomical restoration for both aesthetic improvement and better respiratory function
• May require outfracturing along the old osteotomy site before placement 3

Surgical Approach Considerations

Open vs. Closed Approach

• External (open) approach provides better visualization of the underlying nasal framework
• Allows for more accurate intraoperative anatomic diagnosis
• Facilitates complete correction of the deformity 4
• Consider a low stairstep columellar incision technique for optimal access while preserving tip anatomy 5

Technical Precautions

• Avoid intermediate osteotomies halfway up the nasal bone as they risk visible irregularities
• Preserve periosteal attachments whenever possible to maintain stability
• Be cautious with short nasal bones as they present higher risks for complications 1

Expected Outcomes

Most patients can achieve good aesthetic and functional outcomes with appropriate surgical correction, particularly when the deformity is identified early and addressed with a combination of osteotomy and grafting techniques 3.

Potential Complications

• Visible irregularities where skin covering is thin
• Persistent asymmetry
• Breathing difficulties if the middle vault is compromised
• Need for additional revision procedures

Early intervention at 4 weeks post-rhinoplasty offers the advantage of addressing the deformity before complete healing has occurred, potentially allowing for better correction with less extensive surgery.