Rhinoplasty in Binder’s Syndrome: Case Series in Nepal
Dr. Nayan Mahato
Asst. Professor, Department of ENT-HNS, Kathmandu Medical College, Kathmandu, Nepal
Maxillofacial dysplasia, also known as Binder’s Syndrome, described by K.H. Binder in 1962.1 Binder’s syndrome includes midfacial hypoplasia with a flat nose, flattened tip and alar wings, half-moon shaped nostrils, short columella, acute nasolabial angle, absent nasofrontal angle, and a concave midfacial profile.1 Holmstrom also described a palpable depression of the anterior nasal floor, concavity of the inferior border of the pyriform apperture centrally, hypoplastic posterior nasal spine, and recession of the anterior nasal spine. The etiology of Binder’s syndrome is not completely known. Holmstrom proposed that there is inhibition of the ossification center. This center normally have forms the lateral and inferior borders of the pyriform aperture during the fifth and sixth gestational week.2
We have treated a series of 4 patients with maxillonasal dysplasia. Physical exam findings include midfacial hypoplasia, flattened nose, short columella with an acute nasolabial angle, and retrusion or absence of the anterior nasal spine. All the patients underwent open rhinoplasty under general anaesthesia. Transcolumellar incision was made and adequate undermining at the lip-columellar junction was performed. The dissection plane was maintained between the dermis and the superficial fascia of the SMAS. The subperiosteal undermining was released laterally to the nasal cheek junction to allow for a good expansion. Medial oblique and lateral osteotomies were done to narrow the bony nasal vault. Septal cartilage graft was harvested leaving behind intact L-strut. Extended septal graft was fixed on the anterior nasal spine using 5-0 PDS suture by making the hole on the anterior nasal spine using 20G needle.
Nasal tip projection was done by suturing both the medial crura on the extended septal graft as in tongue-in-groove technique. Transdomal and interdomal suturing was done using 5-0 PDS suture to make nasal tip triangular in shape. For more projection of nasal tip, septal cartilage was used for shield graft. In two cases, augmentation of the nasal dorsum was achieved by septal cartilage alone. However in two cases, septal cartilage along with conchal cartilage was used for dorsal augmentation. In all the four cases, we found excellent results aesthetically on 6 months of follow-up. Hence, we conclude that septal and conchal cartilage will be sufficient for nasal correction in Binder’s patients. We do not recommend for harvesting chondrocostal cartilage unlike other authors.
Binder’s Syndrome is a challenge for the surgeon as it has got unique characteristics. Several other techniques of columellar lengthening have been applied for treatment of Binder’s patient.3,4,5 Jackson proposed, placing of bone grafts on the nasal dorsum and paranasalis areas while performing V-Y columellar lengthening.6 Tessier proposed that columellar scarring techniques were not necessary in order to achieve adequate columellar lengthening. He stated that composite grafts and flaps in the columellar area should not be used because soft tissue expansion can be achieved alternatively. He also stated that nasal skin has ability to stretch to almost any extent as long as adequate undermining at the lip-columellar junction is performed. Nasal correction in the adults was accomplished by chondrocostal bone grafts to the dorsum. And placement of costal cartilage grafts to the columella, nasal tip, pyriform areas and in front of nasal spine.
- Binder KH: Dysotosis maxillo-nasalis, ein arhinencephaler missbildungskomplex. Dtsch Zahnaerztl Z 17:438, 1962.
- Cronin TD: Lengthening the columella by use of skin from the nasal floor and alae. Plast Reconstr Surg 21:417, 1958.
- Dingman RO, Walter C: Use of composite ear grafts in correction of the short nose. Plast Reconstr Surg 43:117, 1969.
- Hopkins GB: Hypoplasia of the middle third of the face. Br J Plast Surg 16:146, 1963.
- Meyer R, Flemming Y: Die angeborene Flachnase und ihre Korrektur. Z Laryngol Rhinol Otol 48:808, 1969.
- Jackson IT, Moos KF, Sharpe DT: Total surgical management of Binder’s Syndrome. Ann Plast Surg 7:25, 1981.