Mastering Rhinoplasty (eBook)

Contents 6
Table of DVD Clips 7
Chapter 1 10
Simplifying Rhinoplasty 10
Introduction 10
A Foundation Rhinoplasty Operation 11
A Standard Operative Sequence 12
Level of Difficulty: A Classification 13
Level 1: Form and Function 14
Level 2: Tip Challenges 15
Level 3: Major Changes 16
Teaching Yourself Surgical Cause and Effect 17
Guiding Principles 19
How to UseThis Book 20
Chapter 2 21
A Basic Rhinoplasty Operation 21
Introduction 21
Consultation 22
Operative Planning 24
Operative Sequence 24
Markings 24
Anesthesia 26
Open Approach 28
Septal Exposureand Extramucosal Tunnels 30
Septal Exposure 30
Extramucosal Tunnels 30
Tip Analysis and Symmetrical Rim Strips 32
Dorsal Modification 34
Caudal Septum and Anterior Nasal Spine 36
Septal Harvestand Septoplasty 38
Osteotomies 40
Graft Preparation and Spreader Grafts 42
Tip Surgery 44
Alar Base Modification 50
Closure, Cast, and Post-op Management 52
The Basic Rhinoplasty Operation: A 95% Solution 54
Decision Making Level 1: Planning a Rhinoplasty 56
A Basic RhinoplastyOperation: Operative Sequence 57
What Are the Most Common Variations? 57
Case Study: Aesthetic Septorhinoplasty (Level 1) 60
Decision Making Level 2: The Harder Nose 62
Case Study: ThePlunging Tip (Level 2) 64
Operative Technique Highlights 64
Decision Making Level 3: The Difficult Nose 66
Case Study: The Ball Tip (Level 3) 68
Operative Technique 68
Postoperative Management 70
Ecchymosis and Edema 70
Breathing 71
Initial Appearance 71
Smiling 71
Numbness 71
Complications 72
Incidence 72
Hemorrhage 72
Infection 72
Septal Problems 73
Nasal Obstruction 73
Reading List 74
Chapter 3 75
Radix and Dorsum 75
Overview 76
Level 1 76
Level 2 76
Level 3 76
Anatomy 78
Aesthetics 80
Radix Augmentation 82
Radix Reduction 84
Dorsal Reduction 86
Osteotomies 88
Specialized Osteotomies 90
Spreader Grafts 90
Dorsal Modification 92
DorsalAugmentation 94
Decision Making Level 1 96
decide on the aesthetic indications for spreader grafts and type of osteotomies.Technique 96
Lessons Learned 96
Case Study:Profile Correction 98
Analysis 98
Operative Technique Highlights 98
Decision Making Level 2 100
Case Study:Asymmetric Bony Vault 102
Analysis 102
Operative Technique Highlights 102
Decision Making Level 3 104
Case Study:Radix Reduction 106
Analysis 106
Operative Technique 106
Reading List 108
Chapter 4 109
Tip Techniques 109
Introduction 109
Overview 110
Case Study: Tip Suture 112
Analysis 112
Operative Technique 112
Tip Anatomy 114
Aesthetics: Intrinsic factors 116
Aesthetics: Extrinsic factors 118
Open Approach 120
Open Tip Suture Technique: An Overview 122
Step # 1Symmetrical Rim Strips (Tip Volume Reduction) 124
Purpose 124
Technique 124
Symmetrical Rim Strips 125
Step #2 Columellar Strut and Suture (Tip Projection) 126
Purpose 126
Technique 126
Step #3 Domal Creation Suture (Tip Definition) 128
Purpose 128
Technique 128
Step #4 Interdomal Suture (Tip Width) 130
Purpose 130
Technique 130
Interdomal Suture 131
Step #5 Domal Equalization Suture (Tip Symmetry) 132
Purpose 132
Technique 132
Domal Equalization Suture 133
Step #6 Lateral Crural Mattress Suture (Crural Convexities) 134
Purpose 134
Technique 134
Step #7 Tip Position Suture (Tip Rotationand Projection) 136
Purpose 136
Technique 136
Step #8 Add-on Grafts (Tip Refinement) 138
Purpose 138
Technique 138
Final Photos 138
Add-On Grafts 139
Step #9 Alar Rim Grafts (Nostril RimShape) 140
Purpose 140
Technique 140
ARG and ARS Grafts 141
Open Structure Tip Graft 142
Open Structure Tip Graft 145
Decision Making: Level 1 146
The Problem 146
Technique 146
Lessons Learned 146
Case Study: An Unattractive Tip 148
Analysis 148
Operative Technique 148
Decision Making: Level 2 150
Case Study: Intrinsic Tip Deficiency 152
Analysis 152
Operative Technique 152
Decision Making: Level 3 154
Case Study:Open Structure Tip Graft 156
Analysis 156
Operative Technique 156
Tip Sutures That Do Not Work for Me 158
Case Study: An Over-Sutured Nose 160
Analysis 160
Operative Technique 160
Reading List 162
Chapter 5 163
Nasal Base 163
Introduction 163
Overview 164
Level 1 164
Level 2 164
Level 3 164
Anatomy 166
Aesthetics/Analysis 168
Base Modification 170
Nostril Sill Excision 170
Alar Wedge Excision 170
Combined Sill/Base Excision 170
Columellar Labial Angle 172
Columella 172
Anterior Nasal Spine 172
The Alar Rim-Nostril Columellar Complex 174
Lowering the Alar Rim 174
Changing Nostril Size and Shape 176
Decision Making Level 1 178
Principles 178
Combined Sill/Wedge Excisions 181
Decision Making Level 2 182
Principles 182
Case Study: Base Collapse 184
Analysis 184
Operative Technique 184
Decision Making Level 3 186
Principles 186
Case Study: Alar Retraction 188
Analysis 188
Operative Technique Highlights 188
Reading List 190
Chapter 6 191
Functional Factors 191
Introduction 191
Overview 192
Anatomy 194
Nasal Valves 194
Septal Surgery 196
Septal Body 198
Bony Septum/ Premaxilla: The Inferior Tunnel 200
Caudal Septum 202
Dorsal Septum 204
Total Septoplasty 206
Nostril Valve 208
Vestibular Valve 210
Internal Valve 212
Bony Valve 214
Turbinates 216
Problems 216
Decision Making Level 1 218
Case Study:Septal Deviation 220
Analysis 220
Operative Technique 220
Decision Making Level 2 222
Case Study: Total Septoplasty 224
Analysis 224
Operative Technique 224
Decision Making Level 3 226
Case Study: Septal Support Surgery 228
Analysis 228
Operative Technique 228
Technical Misadventures 230
Reading List 232
Chapter 7 233
Grafts 233
Introduction 233
Allure of Alloplasts 234
Fillers: Fantasticor Fantasy? 235
Overview 236
Why Grafts Are Essentialand Must BeMastered 237
Case Study:Why Do Grafts? 238
Analysis 238
Operative Technique 238
Conchal Harvest 242
Composite Conchal Grafts 244
Fascia Harvest 246
Rib Harvest 248
Columellar Struts 252
Tip Grafts 254
Tip Refinement Grafts (TRG) 254
Spreader Grafts 256
Dorsal Grafts: The Designer Dorsum 260
Diced Cartilage and Fascia (DC+F) 264
Why Diced Cartilage Grafts? 264
Alar Rim Graft and Alar Rim Support Graft 266
Lateral Crural Strut Grafts 268
Composite Conchal Grafts 270
Specialized Grafts 272
Reading List 274
Chapter 8 276
Primary Rhinoplasty: Decision Making 276
Introduction 276
Tip Definition 277
Case Study: Tip Definition 279
Analysis 279
Operative Technique 279
Tip Width 281
Case Study: Wide Tip 283
Analysis 283
Operative Technique 283
The Wide Nose 285
Case Study: Wide Nose/Wide Tip 287
Analysis 287
Operative Technique 287
The Over ProjectingNose 289
Case Study: Overprojecting Tip 291
Analysis 291
Operative Technique 291
Underprojecting Nose 293
Case Study: Under Projecting Tip 295
Analysis 295
Operating Technique 295
Downward Rotating Long Nose 297
Case Study: Downward Rotation 299
Analysis 299
Operative Technique 299
Upward Rotating Short Nose 301
Case Study: Short Upwardly Rotated Nose 303
Analysis and Commentary 303
Operative Technique 303
Broad, Ball, and Bulbous Tips 305
Case Study: Ball Tip 307
Analysis 307
Operative Technique 307
Boxy Tip and Alar Malposition 309
Case Study: Alar Malposition 311
Analysis 311
Operative Techniques 311
Reading List 313
Chapter 9 314
Advanced Primary Rhinoplasty 314
Introduction 314
Asymmetric Nose and Tip 315
Case Study: Asymmetric Deviated Nose 317
Analysis 317
Operative Techniques 317
Posttraumatic Nose 319
Case Study: Posttraumatic Nose 321
Analysis 321
Operative Techniques 321
Dorsal/Base Disproportion 323
Case Study: Dorsal/Base Disproportion 325
Analysis 325
Operative Technique 325
Hispanic Rhinoplasty 327
Case Study: Hispanic Rhinoplasty 329
Analysis 329
Operative Techniques 329
Middle Eastern Rhinoplasty 331
Case Study: Middle Eastern 333
Analysis and Commentary 333
Operative Technique 333
Asian Rhinoplasty 335
Operative Sequence 335
Case Study: Asian Rhinoplasty 339
Analysis 339
Operative Technique 339
Black Rhinoplasty 341
Surgical Technique 341
Black Rhinoplasty (Moderate) 343
Analysis 343
Analysis 344
Revision Rhinoplasty 345
Case Study: Minor Revision 346
Analysis and Commentary 346
Case Study: Major Revision 348
Analysis and Commentary 348
Nasal Fillers: Restalyne (Dr. Val Lambros1) 349
Personal Preference 349
Postinjection Management 350
Fillers for the Nose (Dr. Miles Graivier2) 351
Indications 351
Injection Technique 351
Specific Areas 352
Posttreatment Care and Adverse Effects 353
Patient Satisfaction 353
Fillers: Final Thoughts 354
Reading List 355
Chapter 10 356
Secondary Rhinoplasty: Surgical Techniques 356
Introduction 356
Overview 357
Case Study: Secondary Rhinoplasty 359
Analysis 359
Operative Technique 359
Consultation 361
Operative Planning 364
Photographic Analysis 362
Operative Planning 364
Skin Envelope 365
Open Approach and Septal Exposure 367
Septal Considerations 367
Tip Analysis 369
Dorsal Modification 371
Secondary Septoplasty and Vestibular Valve 373
Osteotomies and Spreader Grafts 375
Tip Surgery 377
Columellar Strut 377
Preparation of the Alar Cartilages 377
Release of Scar Tissue 377
Incisions, Divisions, and Bossa 379
Tip Sutures 379
Tip Sutures Plus Add-On TRG Grafts 379
Lateral Crural Deformities 379
Structured Tip Grafts 379
Total Tip 381
Isolated Tip Graft 381
Total Alar Replacement 381
Bossas and Bumps 381
Nostrils and Alar Base 383
Reading List 385
Chapter 11 386
Secondary Rhinoplasty: Decision Making 386
Introduction 386
Decision Making: Skin Envelope 387
Thick Skin: Secondary 387
Thin Skin: Secondary 387
Case Study: Thick Skin Sleeve 389
Analysis 389
Operative Technique 389
Case Study: Thin Skin 391
Analysis 391
Operative Techniques 391
Decision Making: Dorsal Modification and Osteotomies 393
Case Study: Secondary Dorsal Deviation 395
Analysis 395
Operative Techniques 395
Case Study: Dorsal Augmentation 397
Analysis 397
Operative Techniques 397
Decision Making: Secondary Septum and Valves 399
Case Study: Secondary Septal Surgery 401
Analysis 401
Operative Techniques 401
Decision Making: Secondary Tip Surgery 403
Case Study: Secondary Tip 405
Analysis 405
Operative Technique 405
Case Study: Secondary Rhinoplasty 407
Analysis 407
Operative Technique 407
Decision Making: Base and Nostrils 409
Case Study: Secondary Base and Nostril 411
Analysis 411
Operative Technique 411
Reading List 413
Chapter 12 414
Aesthetic Reconstructive Rhinoplasty 414
Introduction Aesthetic Reconstructive Rhinoplasty 414
Overview 415
Composite Reconstruction 417
Operative Technique: Step by Step 417
Case Study: Composite Reconstruction 421
Analysis 421
Operative Technique: Step By Step 421
Case Study: Over-Resected Nose 423
Analysis 423
Operative Technique 423
Septal Saddle Nose 425
Case Study: Septal Saddle Nose 427
Analysis 427
Operative Technique 427
Cocaine Nose 429
Case Study: Cocaine Nose 431
Analysis 431
Operative Technique 431
Implant Disasters 433
Case Study: Infected Implant 435
Analysis 435
Operative Technique 435
Unilateral Cleft Lip Nose 437
Case Study: Unilateral Cleft Nasal Deformity 439
Analysis 439
Operative Technique 439
Bilateral Cleft Lip Nose 441
Case Study: Bilateral Cleft Nasal Deformity 443
Analysis 443
Operative Technique 443
The Practice of Rhinoplasty: A Summation 445
Reading List 447
Subject Index 448

"8 Primary Rhinoplasty: Decision Making (p. 269-270)

Introduction

At this point in the text, the surgeon should understand and feel comfortable with each step in the basic rhinoplasty operation. The challenge now is how to progress from Level 1 cases to more complicated deformities, which require a broader array of surgical techniques. What is a logical progression? Surprisingly, many Level 2 nasal deformities are simply Level 1 cases, but with one component being markedly more difficult.

For example, many patients with underprojecting tips require a standard approach to the rest of the nose, but sophisticated use of columellar struts and add-on grafts for the tip. Fortunately, the surgeon can progress to Level 2 cases using the basic skills mastered in Level 1 cases. This chapter will emphasize tip surgery because the reality of private practice is that “as the tip goes so goes the rhinoplasty” for both patient and surgeon. In addition, the surgeon will learn how to recognize Level 3 cases. Ultimately, each surgeon will develop their own grading system for Level 1–3 cases, which will facilitate selection of cases and techniques resulting in an expansion of their comfort zone.

Tip definition

Tip Definition is defined with difficulty, but it is essentially the visibility or distinctive set-off of the dome defining point from the rest of the alar cartilage (Fig. 8.1). Its anatomical correlate is more easily specified – the domal junction line between domal segment and lateral crura. A convex domal segment juxtaposed to a concave lateral crura produces the most attractive tip and is the configuration I try to achieve with the domal creation suture.

Decision Making. Tip definition is carefully assessed from all four views and the patient is asked for their opinion. Tip projection and skin thickness are critical correlates. Thick skin precludes subtle corrections, while thin skin makes any abnormality more visible. An example of the latter is the patient with thin skin who does not like a visible bifidity in the infralobule (a problem easily corrected with a concealer graft of excised alar cartilage). In contrast, too little tip definition is a common complaint for most rhinoplasty patients and will be discussed in depth.

Level 1. In minor deficiencies, the tip is “all right,” but lacks the distinctiveness to set it off from the tip lobule on oblique view and the dorsal line on profile view. One can easily correct these deficiencies with a tip suture technique. First, a columellar strut is inserted to insure adequate support. The domal segment is pinched at the domal notch to determine where to place the domal creation suture. These sutures are inserted bilaterally followed by an interdomal suture.

The skin is redraped and a tip position suture is added if necessary. Level 2. When tip suturing is insufficient, then the desired domal definition can be created using add-on grafts (TRG) of excised alar cartilage. This is either shield shaped to fill the infralobule thereby creating a tip line, or domal shaped to set-off the tip from the dorsal line. These infralobular grafts are designed to fit within the sutured alars while rising above the domal notches. The domal graft is made both short (8 mm) and narrow (4 mm), and then sutured to the domes. It can be either a single or double layer. One is accentuating the domal segments above the adjacent lateral crura."