Polly Beak Deformity in Rhinoplasty

Polly Beak Deformity in Rhinoplasty

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Polly beak deformity is a complication of rhinoplasty defined by the typical appearance of a dorsal nasal convexity resembling a parrot’s beak. [1, 2, 3] This dosal hump is located in the supratip region of the nose which then “pushes” the tip downward causing under-rotation. It can occur through several mechanisms. If during the intraoperative evaluation of the nose, a surgeon does not recognize the improper tip-supratip relationship that is the hallmark of this deformity, a polly beak occurs. In addition, polly beak deformity may develop because of the inability of a surgeon to precisely predict the ultimate healing of the nose.

See the image below.

In patients, especially those with a thick skin soft tissue envelope, excess scar tissue can form in the supratip. This will produce a similar effect.

Polly beak deformity describes the postoperative deformity associated with fullness in the supratip that leads to a disproportionate relationship between the tip and the supratip. [4]

The incidence of polly beak deformity is not known; however, it is one of the more common complications of rhinoplasty. One study showed that 64% of patients presenting for revision rhinoplasty had a polly beak deformity. A retrospective study of 28 ethnic patients who underwent revision rhinoplasty found that polly beak deformity and persistent bulbous tip were among the most common indications for revision. [5]

Two general categories of a polly beak deformity are described. Each can result as a consequence of 1 or more conditions.

Cartilaginous polly beak

Overresection of the nasal bones

Underresection of the cartilaginous dorsum

Overresection of the lower lateral cartilages (leading to loss in tip support)

Soft-tissue polly beak

Poor redraping of inelastic nasal skin

Excessive skin thickness at the nasal tip after reduction rhinoplasty

Inadequate trimming of the vestibular mucosa after large reductions

Soft tissue (scar) excess in the region of the supratip

During surgery, excess edema often obscures the deformity. After surgery, scar tissue can replace edema of the supratip.

Patients with a polly beak deformity are generally dissatisfied with the birdlike appearance of their nose. Many patients report that their nose was massively swollen after surgery and that they noticed the deformity after the swelling resolved.

In the case of loss of tip support, patients notice that the nose initially looks fine but that it evolves into a deformed profile. A clear understanding of the support mechanisms for the nasal tip, maintaining them, and reconstructing disrupted elements of tip support are paramount to preventing the eventual settling of the tip that occurs when these mechanisms are disturbed.

Most of the healing from a rhinoplasty procedure takes a full year to complete, though the nose continues to change over a lifetime. In general, the outcome should not be critically assessed until a year after surgery. Delaying treatment of a polly beak deformity for a year is prudent; this delay allows the normal healing process to occur. A delay or more than a year may be necessary in patients with thick skin.

Secondary or revision rhinoplasty is indicated in patients who have an obvious deformity that will not heal in a satisfactory manner.

Surgery is indicated in patients who have a soft-tissue polly beak that is unresponsive to steroid injection.

The supratip is defined as an area of thick skin above the nasal tip (see the images below). The cartilaginous dorsal septum composed of quadrangular cartilage supports the supratip.

The nasal tip is composed of lower lateral cartilages. The most anterior point of the nasal tip, eg, the junction of the lateral and intermediate crus, is known as the tip-defining point.

Understanding the normal relationship of the tip and the supratip region is paramount to predict the outcome of rhinoplasty. The nose may be divided into horizontal thirds, with the upper one third composed of bone and the lower two thirds composed of cartilage (see the image below). The thickness of skin varies according to the region of the nose.

In the normal nose, the tip-defining point should be approximately 6-10 mm anterior to the dorsal septum (eg, supratip) to have a supratip break. The skin in the area of the supratip is thick; take this into account when aligning the patient’s profile. In men, a straight-line profile might be preferred. A straight-line profile helps minimize a height discrepancy between the tip and the supratip.

A polly beak deformity appears unnatural and occurs when the supratip region leads the tip. A clear understanding of the nasal-tip support mechanisms is needed to predict the dynamic changes that occur during the rhinoplasty operation. Major and minor tip support mechanisms are listed below.

Major

Size, shape, and resiliency of the lower lateral cartilages

Relationship of the medial crural feet to the cartilaginous septum

Attachment of the caudal margin of the upper lateral cartilages to the cephalad border of the lower lateral cartilages

Minor

Interdomal ligament

Cartilaginous dorsum (septum)

Relationship of the lower lateral crura to the pyriform aperture and the sesamoid cartilages

Maxillary crest (nasal spine)

Membranous septum

Attachment of the alar cartilages to the overlying skin soft tissue envelope

Correction of a polly beak deformity is contraindicated in patients with clinically significant medical problems that may preclude safe surgery or in patients in whom psychological factors make further surgery unwise. Take care when reducing the nasal dorsum in a patient with a septal perforation.

Gubisch W, Eichhorn-Sens J. Overresection of the lower lateral cartilages: a common conceptual mistake with functional and aesthetic consequences. Aesthetic Plast Surg. 2009 Jan. 33(1):6-13. [Medline].

Harsha BC. Complications of rhinoplasty. Oral Maxillofac Surg Clin North Am. 2009 Feb. 21(1):81-9, vi. [Medline].

Christophel JJ, Park SS. Complications in rhinoplasty. Facial Plast Surg Clin North Am. 2009 Feb. 17(1):145-56, vii. [Medline].

Arslan E, Gencel E, Pekedis O. Reverse nasal SMAS-perichondrium flap to avoid supratip deformity in rhinoplasty. Aesthetic Plast Surg. 2012 Apr. 36(2):271-7. [Medline].

Slupchynskyj O, Rahimi M. Revision rhinoplasty in ethnic patients: pollybeak deformity and persistent bulbous tip. Facial Plast Surg. 2014 Aug. 30 (4):477-84. [Medline].

Conrad K, Yoskovitch A. The use of fibrin glue in the correction of pollybeak deformity: a preliminary report. Arch Facial Plast Surg. 2003 Nov-Dec. 5(6):522-7. [Medline].

Foda HM. Rhinoplasty for the multiply revised nose. Am J Otolaryngol. 2005 Jan-Feb. 26(1):28-34. [Medline].

Hanasono MM, Kridel RW, Pastorek NJ, et al. Correction of the soft tissue pollybeak using triamcinolone injection. Arch Facial Plast Surg. 2002 Jan-Mar. 4(1):26-30; discussion 31. [Medline].

Henry Daniel Sandel, IV, MD Medical Director, The Sandel Center for Facial Plastic Surgery; Consulting Physician, Facial Plastic Surgery, Department of Otolaryngology-Head and Neck Surgery, Georgetown University Hospital; Consulting Physician, Department of Facial Plastic Surgery, Anne Arundel Medical Center

Henry Daniel Sandel, IV, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association

Disclosure: Nothing to disclose.

Jennifer P Porter, MD Assistant Professor, Department of Otorhinolaryngology, Division of Communicative Science, Chevy Chase Facial Plastic Surgery

Jennifer P Porter, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, Texas Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David W Stepnick, MD Associate Professor, Departments of Otolaryngology-Head & Neck Surgery and Plastic Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center

David W Stepnick, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, Society of University Otolaryngologists-Head and Neck Surgeons, American College of Surgeons

Disclosure: Nothing to disclose.

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;Preacute Population Health Management;The Physicians Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Rxblockchain;Bridge Health.

Daniel G Becker, MD Assistant Professor, Department of Otorhinolaryngology-Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, University of Pennsylvania School of Medicine

Daniel G Becker, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons

Disclosure: Nothing to disclose.

Polly Beak Deformity in Rhinoplasty

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