Rhinoplasty Dissection Manual (1999)

• Rhinoplasty •

Dissection Manual

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DEAN M. TORIUMI

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DANIEL G. BECKER

~ L1PPINCOTf WILLIAMS & WILKINS

Rhinoplasty Dissection

Manual

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Rhinoplasty

Dissection Manual

Dean M. Toriumi, M.D. Associate Professor

Division of Facial Plastic and Reconstructive Surgery

Departm ent of Otolaryngology-Head and Neck Surgery

University of Illinois at Chicago

Daniel G. Becker, M.D. Assistant Professor

Division of Facial Plastic and Reconstructive Surgery

Departm ent of Otola ryngology-Head and Neck Surgery

University of Pennsylvania

Illustrated by Devin M. Cunning, M.D.

4~ LIpPINCOTT WILLIAMS & WILKINS •

A Wolters Kluwer Company

Philadelphia • Baltim ore • New York • London Bueno s Ai res • Hon g Kon g • Sydney · Toky o

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Acquisitions Editor: Danette Knopp Developmental Editor: Sara Lau ber Production Editor: Patri ck Carr Manufacturing Manag er: Tim Reynolds Cover Designer: Christine Jenn y Compositor: Maryland Co mposi tion Printer: Couri er Westford

© 1999 by LIPPINCOTT WILLIAMS & WILKINS 227 East Wa shington Square Philadelphia, PA 19106-3780 USA LWW.com All rights reserv ed. This book is protec ted by cop yright. No part of this book may be re produced in any form or by any means, includ ing photocopying, or utiliz ed by any information storage and retrieval system without written permission from the cop yright owner, exce pt for brief qu otat ions em bodied in cri tica l article s and reviews . Material s appearin g in this book prepared by individuals as part of their of ficial duties as U.S. go vernment employees are not covered by the above-me ntioned copyright. Illust rations © Dani el G. Becker. Photograph s © Dean M. Toriumi. Printed in the United States of America Library of Congress Cataloging-in-Publication Data

Toriurni, Dean M. Rhinopla sty dissection manu al/Dean M. Toriumi, Danie l G. Bec ker ; illustrated by Devin M . Cu nning. p.

em,

Includes bibliographical references and ind ex.

ISB N 0-7817 -1783-3

I . Rhinoplasty Handbooks, manu als, etc. 2. Nose-Surgery

Handb ooks, manuals, etc. I. Becker, Dani el G. II. Title.

[DNLM: 1. Rhinopla sty-meth ods Handbo oks. WV 39 T683 r 1999] RDII 9 .5.N67T 67 1999 617.5' 230592---dc2 1 DNLMIDLC for Library of Congress 99-260 58 CIP Care has been take n to co nfirm the accuracy of the information pre sented and to descri be generally accepted practi ces. However, the autho rs, ed itors, and publisher are not responsible for errors or omis sions or for any con sequ ences from application of the information in this book and make no warra nty, expresse d or impli ed, with respect to the currency , completenes s, or accura cy of the contents of the pub licati on. Appli cation of this information in a particular situation rem ain s the profe ssion al respon sibility of the practitioner. Th e authors , editors, and publisher have exerted every effort to ensure that drug selectio n and dosage set forth in this text are in accordance with current recommendations and practi ce at the time of publ ication . Howe ver, in view of ongo ing research, change s in govern ment regul ation s, and the con stant flow of inform ation relat ing to dru g therapy and drug reaction s, the reader is urged to chec k the package insert for each drug for any change in indic ation s and dosage and for added warn ings and preca utions. Thi s is particularly importan t when the recomm end ed agent is a new or infrequently employed drug. Some drugs and med ical de vices present ed in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted rese arch settings. It is the resp onsibil ity of the health care provider to asce rtain the FDA status of each dru g or de vice planned for use in their clinic al practic e. 10 9 8 7 6 5 4 3 2

To my ever supportive wife, Colleen, and our two daughters, Hannah and Olivia, and to my parents who gave me encouragement to practice medicine. Dean M. Toriumi, M.D.

With special appreciation and love for my family-my parent s Bill and Merle, and my brothers and sisters-in-law, Richard and Rachel, Paul, Sam, and Jen. Daniel G. Becker, M.D.

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Contents

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

Preface xiii

Acknowledgments xv

Chapter 1:

Anatomy

Chapter 2:

Rhinoplasty Analysis . 9

Landmarks for Analysis . 9

Lab Exercise: Nasal Analysis . 11

Surface Angles, Planes, and Measurements-

Definitions . 12

Rhinoplasty Analysis . 16

Chapter 3:

Injection Infiltrative Anesthesia Technique

. 25

. 25

Chapter 4:

Septoplasty Nasal Dissection: Septoplasty with

Cartilage Harvest

. 31

Incisions and Approaches Transcartilaginous or Cartilage-Splitting

Approach Delivery Approach The External (Open) Rhinoplasty Approach

. 37

. 37

. 40

. 43

Chapter 6:

Removal of Bony-Cartilaginous Hump

. 59

Chapter 7:

Osteotomies Medial Osteotomies

. 67

. 67

Chapter 5:

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Lateral Osteotomies and Infracture Intermediate Osteotomies

Chapter 8:

Spreader Grafts

Chapter 9:

Surgery of the Tip Exercises

Chapter 10: Alar Base Resection

Internal Nostril Floor Reduction Wedge Excision of Nostril Floor and Sill . .. Alar Wedge Excision Sliding Alar Flap

Chapter 11:

Other Maneuvers . . . . . . . . . . . . . . . . . . . . . .. Plumping Grafts Caudal Extension Grafts Deviated Caudal Septum Rib Cartilage Graft Reconstruction of

Saddle Deformity

Chapter 12:

Harvest of Autogenous Tissue Harvesting Conchal Cartilage Harvesting Ethmoid Bone Harvesting Rib Graft Harvesting Calvarial Bone

Chapter 13: Incision Closure, Nasal Splint, Post-Operative Considerations Closure of Midcolumellar Incision Closure of the Marginal, Intercartilaginous,

or Transcartilaginous Incision Placement of Intranasal Packs, Nasal

Splint Postoperative Care Appendix A: Appendix B: Appendix C: Appendix D: Appendix E Appendix F: Appendix G: Appendix H: Appendix I: Appendix J: Appendix K:

Tripod Concept Guide to Nasal Analysis Aesthetic Analysis Surface Angles, Planes, and

Measurement: Definitions Tip Support, Incision, and Approaches Achieving Surgical Goals: Selected Options . . Selected Complications of Rhinoplasty Adjunctive Procedures Cleft Lip Nasal Deformity Photography Setup Indications for External Rhinoplasty

Approach

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Appendix L: Appendix M: Appendix N:

Suggested Surgical Instruments for Rhinoplasty List of Selected Companies with AddresseslPhone Numbers Selected Recommended Literature

. 171 . 172 . 174

Index

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Foreword

Exce llent surgical outcomes in rhinoplasty derive from two interrelated fac tors: (1) a de­ tailed understanding of the multiple nasal anatomic varian ts encountered, and (2) an ac­ qui red knowledge of the ulti mate long-term effects of surgical altera tions of these anatomic components-the evo lution of healing. The first ski ll ca n be learned by detailed observation, enhanced by cadaver dissection; the second skill only by ca reful foll ow-up of ope rated patients over time. The genera l con cepts of nasal anatomy have been fun damentally clear for centuries , but on ly in recent decades have surgeons appreciated the fine ly det ailed nuances of nasal anatomic dynamic s that influence the surgical crea tion of a natural, plea sing rhinopl asty re­ sult, free of surgical stigmata. A det ailed com prehension of nasal anatomy must therefore transcend knowledge of basic anatomic relationships. Th e surgeo n must j udge , by inspec­ tion and pa lpation, the character of the ski n and subcutaneous tiss ues as they vary from nasal region to region , the influences of faci al mimetic musculature, the relative strength and support of the carti laginous and bony framework and substruct ure, and the lim itations imposed by the int err elation ship of all these struc tures upon the ultimat e fav orable result. As important as the eva luation of what can reasonably be accomplished during rhi noplasty is the acqui red kno wledge and ski ll to assess what canno t be acco mplished. This ju dgment is largel y pre dicated on the critical ana lysis of each pat ient's indivi dual anatomy, coupled with techn ical refin ements guided by experie nce, and generally requires years of personal surgic al result evaluation to beco me kee n. In this diss ection manu al, Drs. Becker and Toriumi have created a unique study guide and cadaver dissection manu al ded icated to guiding the learn er in a disciplined manner. They admirably ex tend the tradit ion of the Universi ty of Illinois Departm ent of Oto laryn­ gology's leader ship in teaching anatomy and surgery in rhin oplasty. Cadaver dissec tion cons titutes a privil ege not available to all, and, as such, this precious material must be wise ly and co nserva tive ly approached . Experie nce teaches that a discipl ined, structured ap­ proach to dissecti on of the nose pro duces the best edu cational outcome . An imp ortant fav orable develop ment in cont empo rary rhinoplasty is the appropria te con­ ce rn for conservative and subtle anatomic changes that by definition derives from a prese r­ vativ e attitude toward nasal tissues. Commonly, rath er than excisional sacrifice of large segments of cartilage or bon e, a phil osophy of preservation and restoration oftissues is de­ ve loping that preclud es crea tion of unnecessary tissue voids whic h may heal and scar un­

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predictably. Wise surgeons recognize that even a larger nose, well balanced to the rounding facial features, is always aesthetically preferable to a nose made over-sma radical surgery. Conservation surgery thereby further extends the surgeon's control the final surgical result, as an appropriate equilibrium between the corrected nasal ske and soft tissue covering is more reliably achieved. Con servative sculpture and volum duction of the alar cartilages clearly produce more favorable results, generally avoi major resections and vertical interruprion of the intact residual strip of lateral and m crus. Notching, pinching, alar cephalic retraction, over-rotation, and asymmetries ar almost entirely eliminated in long-term healing when this conservative philosophy is braced . A further striking example of conservatism is the preservation of a strong , high file in many patients, a distinct contrast to the dramatic retrousee pro files create decades past by sacrifice of over-generous segments of nasal bony humps. Finally, thoughtful nasal surgeons, through accurate anatomic diagnosis , discern w portions of the nasal anatomy are pleasing and satisfactory, striving to avoid distur these structures and areas when correcting (or gaining access to) anatomic componen need of correction. This philosophy further extends the surgeon 's favorable control ove timate healing. Thoughtful cadaver dissection provides the learner with visual pathwa gain access to structures to be modified, while preserving normal tissues and relations Important tissue planes, vital in live surgery, can be appreciated best when viewed at le in the dissection laboratory. This well-conceived work, properly employed, contributes substantially to shorte the steep learning curve characteristic of rhinoplasty.

M. Eugene Tardy, Jr., M.D., F.A.C Profes sor of Clinical Otolaryngolo Director, Division of Facial Plastic Reconstructive Surgery University of Illinois Medical Cen Chicago, Illinois Professor of Clinical Otolaryngolo Indiana University School of Medi

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Preface

The successful rhinoplasty surgeo n' s operative plan is based on a clear understanding of the patient's desired changes, a care ful and accurate diag nosis of the patient's anatomy , and a wide armamentarium of surgica l techniques. Prior techniques and the surgeon's personal experiences with the array of surgical techniques are also primary factors in the decision for a particular operative approach. The successful surgeon's applicatio n of surgica l tech­ niques is designed to accom modate differences in anatomy and to account for varia nt anatomy. For example, noses with thin skin and noses with thick skin each present specific problems that must be considered when choosing techniques for altering nasal struc ture. Also, the effec ts of scar contracture vary from patie nt to patient and can significantly affec t the ultimate aesthetic and functional outcome . The rhinoplasty surgeo n must recognize that the healing process may distort the cha nges made at the time of surge ry, however ex pert ly they were accomplished. The surgeon's only recourse is to build a structurally sound nasal architecture that can withstand the force s of scar contracture and provide an acceptable suc­ cess rate. The importance of experience in rhinopl asty cannot be overemphasized. The experi­ enced rhinoplasty surgeon can anticipate the likelihood of a favorable outcome based on his or her experience using certain techniqu es with a specific deformi ty. Selec tion of the proper technique for each circ umsta nce should provide the opportunity for a high success rate. The purpose of this dissec tion manual is to provide practical infor mation about a wide range of surg ical techn iques in rhinoplasty. The dissection ma nual guides the reader through a step-by-step dissection. It focuse s on the execution of basic and advanced rhino­ plasty techniques and seeks to provide practical information that can be readily applied in surgery. The text is intended to be a procedurally oriented dissection manual and is orga­ nized to allow easy reference to a wide array of basic and advanced rhinoplasty techniques. Illustrations and intraoperative photograph s, along with detailed text, guide the reader through the step-by-step dissection. Important techn ical and clinical "pearls" are high­ lighted in each section. A progra mmatic cadaver dissection videotape acco mpanies the text. Before beginning the nasal dissection, review the chapter on nasal anatomy (Chapter 1) and the chapter on pre-operative rhinoplasty analysis (Chapter 2). Chapter 3 outlines local anesthesia injec tion techniqu es; the dissector is instructed to practice the injections prior to commenci ng the programm atic dissection. The dissection manual guides you through the following dissections: septoplasty, trans­ /'

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cart ilag inous or int er-cart ilaginous app roach , de livery approac h and an external rh ino approach. The remainder of the programmatic nasal dissection detai ls a number of plasty techniques and addresses a number of specific rhinoplasty pro blems. The man cuses primarily on the external rhinopl asty approach; how ev er, all approaches are co and ca n be perform ed sequentially, or the dissector may choo se to foc us on a speci proach. Appro priate targeted reference s for further readi ng are also pro vided . We recommend that the diss ector pro ceed with Chapters 1- 6 with the skin-so ft tiss velope intact. For the remai ning chapters, the dissector may wish to split the ski n dow midl ine for better exposur e. In this fashi on, the dissection can be performed withou t sista nt, and (except for a complete septopl asty) without a he ad light. The cadav er laboratory is the plac e to sharpen one ' s sur gical skills. This manual se provide the dissector with the opportunity to obtai n maximum benefit from performin co mp lex opera tion on cadaver specimens. Th e di ssecti on manual was "field tested " Unive rsity of Pen nsylvan ia Rhinoplasty Co urse : Aesthetic & Fu nction al Rh inopl asty ticipants, many of wh om professed relativel y limited rhinoplasty experience, und erto stepwise, programmatic dissection and work ed through the manu al (with the except rib or clav arial bone harvest) in a sin gle five-hour period. Rhinopl asty is an operatio n that requ ires co nstant thou ght , assimilation of inform and reac tion to unexpected fi ndi ngs . W ith this in mind, the authors strongly recomme vo lve me nt in as many advanced teaching encounters as possible. This ma y involve re time ly literature, attending adv anced rh inoplasty courses, observing other experience geo ns, or sharpening one's skills in the cadav er laboratory. We hope that use of th section manual will stim ulate thought and incite both the en thu siasm of the beginner a as experie nced rhinopl asty surgeons seeking to broaden their surg ical armamentariu

Dean M. Toriumi, Daniel G. Becker,

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Acknowledgments

We wish to thank the follow ing frien ds, colleag ues, and me ntors for their encouragement, support, and guidance . Dr. M. Euge ne Tardy, Jr., has been an inspirational men tor and friend , whose advice and enco uragement were instrumental in this project ' s development. Our mentors in Otolary ngology- Head & Neck Surgery and in Facial Plastic & Recon­ structive Surgery are a continuing source of inspiration and guidanc e. Depar tment Chairm en, Ed Appl ebaum at the University of Illinois at Chic ago, and David Kennedy at the Univ ersity of Penn sylvania, deserv e spec ial than ks for supporting and fa­ cilitating this undertaking. Devin M. Cunning deserves much appreci ation. His medical illu strations speak for them­ selves, but do not tell of the countl ess hour s of collaboration, hard work, and multiple re­ visions. Danette Knopp of Lip pincott Williams & Wi lkins provided publishing leadership from the very co nception of the project to its co mpletion. Sara Lauber of Lip pincott Willi ams & Wil kins play ed an instru mental role in guiding the manuscript through its fina l, critical stage . Patrick Carr deserves thanks for his outstandi ng work as Production Editor.

Dean M. Toriumi, M.D. Daniel G. Becker, M.D.

xv

Rhinoplasty Dissection

Manual

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1 Anatomy

Although the anatomy of the nose has been fundamentally understood for many years, only relatively recently has there been an increased understanding of the long-term effects of surgical changes on the function and appearance of the nose. A detailed understanding of nasal anatomy is critical for successful rhinoplasty. This chapter reviews the surface and structural anatomy of the nose, with an emphasis on important surgical anatomy. Accurate assessment ofthe anatomic variations presented by a patient allows the surgeon to develop a rational and realistic surgical plan. Furthermore, recognizing variant or aber­ rant anatomy is critical to preventing functional compromise or untoward aesthetic results. This chapter presents a limited diagrammatic overview of nasal anatomy. More detailed study of nasal and facial anatomy is recommended (1) (Figs. 1-10).

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Figure 1. Surface anatomy of the nose: Frontal view. 1, Glabella ; 2, nasion; 3, tip-defining points; 4, alar-sidewall ; 5, supraalar crease; 6, philtrum .

Figure 2. Surface anatomy of the nose: Base. 1, Infratip ule; 2, columella; 3, alar sidewall; 4, facet or soft-tissue tr gle; 5, nostril sill; 6, columella-labial angle or junction alar-facial groove or junct ion; 8, tip-def ining points .

Figure 3. Surface anatomy of the nose: Lateral. 1, Glabella; 2, nasion, nasofrontal angle ; 3, rhinion (osseocartilaginous junction) ; 4, supratip ; 5, tip-defining points; 6, infratip lobule ; 7, columella; 8, columella-labial angle or junction; 9, alar-facial groove or junction .

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Figure 4. Surface anatomy of the nose: Oblique. 1, Glabella; 2, nasion, nasofrontal angle; 3, rhinion; 4, alar sidewall; 5, alar-facial groove or junction; 6, supratip; 7, tip-defining points; 8, philtrum.

Figure 6. Nasal anatomy : Lateral (rotated slightly obliquely) . 1, Nasal bone; 2, nasion (nasofrontal suture line); 3, inter­ nasal suture line; 4, nasomaxillary suture line; 5, ascending process of maxilla; 6, rhinion (osseocartilaginous junction) ; 7, upper lateral cartilage ; 8, caudal edge of upper lateral carti­ lage; 9, anterior septal angle; 10, lower lateral cartilage , lat­ eral crus; 11, medial crural footplate; 12, intermediate crus; 13, sesamoid cartilage; 14, pyriform aperture.

Figure 5. Nasal anatomy : Oblique. 1, Nasal bone; 2, nasion (nasofrontal suture line); 3, internasal suture line; 4, naso­ maxillary suture line; 5, ascending process of maxilla; 6, rhin­ ion (osseocartilag inous junction); 7, upper lateral cartilage; 8, caudal edge of upper lateral cartilage ; 9, anterior septal an­ gie; 10, lower lateral cartilage , lateral crus; 11, medial crural footplate ; 12, intermediate crus; 13, sesamoid cartilage; 14, pyriform aperture .

Figure 7. Nasal anatomy: Base. 1, Tip-defining point; 2, in­ termediate crus; 3, medial crus; 4, medial crural footplate; 5, caudal septum; 6, lateral crus; 7, naris; 8, nostril floor; 9, nos­ tril sill; 10, alar lobule; 11, alar-facial groove or junction; 12, nasal spine.

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Figure 8. Nasal septum. 1, Quadrangular cartilage; 2, nasal spine ; 3, posterior septal angle; 4, middle septal angle; 5, an­ terior septal angle; 6, vome r; 7, perpendicular plate of eth­ moid bone; 8, maxillary crest , maxillary component; 9, maxil­ lary crest, palatine component.

Figure 9. Nasal musculature. A: Elevator muscles: 1 cerus; 2, levator labii alaequae nasi; 3, anomalous na Depressor muscles : 4, alar nasalis; 5, depressor septi C: Compressor muscles: 6, transverse nasalis; 7, com sor narium minor. D: Minor dilator muscles : 8, dilator nar terior . E: Other: 9, orbicularis oris; 10, corrugator.

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Figure 10. Nasal vasculature. 1, Dorsal nasal artery ; 2, l nasal artery; 3, angular vessels ; 4, columellar artery.

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PEARLS

The nose may be thought of in anatomic thirds . The upper third roughly corre­ sponds to the bony dorsum; the middle third roughly corresponds to the cartilagi­ nous dorsum; and the lower third generally corresponds to the tip. o When describing relationships of one structure to another in the nose, use the well­ . defined anterior/posterior or caudal/cephalic. (Fig. II). . o The nasal bones are usually small; the ascending process of the maxilla provides a significant contribution to the bony anatomy of the nose. o The alar lobule contain s fat and fibrous connective tissue, but it contains no carti­ lage. The lateral crus of the lower lateral cartilage takes on a more cephalic posi­ tion as it extends laterally and is not found in the alar lobule. o The lobule, alar lobule, and the infratip lobule are terms that designate three dis­ tinct anatomic areas of the nose. The lower third of the nose may be referred to as the lobule or tip. The alar lobule is a fibrofatty nasal subunit that is devoid of car- . tilage and compose s a portion of the lateral nasal sidewall . The infratip lobule o

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should comprise one third of the vertical length of the nose on base v columellar/lobule ratio). • The nasal valve area includes the cross-sectional area described by th and is affected by the inferior turbinate; the caudal septum, and the rounding the pyriform aperture. The nasal valve proper is bounded septum, the caudal margin of the upper lateral cartilage, and the floor and is considered to be the location of the least cross-sectional area in lateral osteotomies, care is taken to preserve a small triangle of bone form aperture to prevent medialization of the inferior turbinate, whi , promise the cross-sectional area of the nasal valve area. • Scroll region: The upper lateral cartilages and lower lateral cartilage in three different configurations. Most commonly, the cephalic edge lateral cartilage overlaps the caudal edge of the upper lateral cartilage region. Less commonly, the cephalic edge of the lower lateral cartila caudal edge of the upper lateral .cartilage. Rarely the cephalic edge lateral cartilage is overlapped by the caudal edge of the upper lateral • Internasal suture line: The nasal bones are fused inthe mid\ine at the i ture. When elevating the skin-softtissue envelope, decussating fibers vided (typically with scissors) from their attachment at the midline i ture to achieve the desired exposure. ' • The caudal margin of the nasal septum has a defined posterior septal a dle septal angle, and an anterior septalangle. This anatomy plays a sig in the shape of the nasal tip, including the infratip lobule, double supratip region . The surgeon attempting to create or allow for tip rota servative excision of a superiorly based triangle of caudal septum m of this anatomy, .', ' , • The septum is composed of contributions from a number of anatom (see Fig . 8). • In performing septoplasty, great care must be taken to preserve a gene to maintain support for the lower two thirds of the nose. Generally, mended that at least 15 mm caudally and 15 mm dorsally (after accou removal of dorsal hump) be preserved. • Rhinion versus sellion: The rhinion is the soft-tissue correlate of th , laginous junction of the nasal dorsum. The sellion corresponds to th ' .'' ' . ' laginous junction ~f the nasal dorsum. • Osteotomies should not extend into "the ha~d nasofront~l bone. When , extend too far cephalically into this thick, hard bone, a rocker deform suit. In a rocker deformity, infracture of the bone may displace th cephalic portion laterally. .

• Vascular supply and lymphatics are found superficial to the nasal mus The soft-tissue layers in .the nose are epidermis, dermis,subcutaneou contains blood vessels and lymphatics; and also a (typically) thin l muscle and fascia (musculoaponeurotic) plane, areolar tissue plane, a drium/periosteum. Dissection during rhinoplasty in the proper tissue olar tissue plane (i.e ., submusculoaponeuroticj] preserves nasal blood minimizes postoperative edema. ' . . • The astute surgeon will be able to anticipate 'the contour of the uppe lateral cartilages by studying the surface topography of the nose.

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Figure 11. Nasal relationships.

REFERENCES 1. Tardy ME, Brown R. Surgical anatomy of the nose. New York: Rav en Press, 1990. 2. Toriu mi DM , Mueller RA, Grosch T, Bhattachary ya TK , Larrabee WF . Vascular anatomy of the nose and the external rhinoplasty approach. Arch 0101Head Neck Sur g 1996 ;122:24-34.

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2 Rhinoplasty Analysis

Development of an oper ative plan that will achieve the desired outcome requires an under­ standing of the patient' s wishes and selection of appropriate surgical maneuvers to effect the propo sed changes. Th e surgeon mu st be able to identify anatomic con straints that will limit the ability to change contour (thick skin, weak cartilages, etc.). Experi ence with rhino­ plasty over time has sho wn that detailed anatomic analysis of the nose is an essentia l first step in achieving a successful outc ome. Failure to recognize a particular anatomic point preoperatively will often lead to a less than ideal long-term result. After you have identified the various anatomic landmarks in Chapter 1, undertake a pre­ operative rhinoplasty analysis of your patient (cadaver specimen) . In this programmatic dissection, you will perform a number of incisions, approaches, and surgic al techniques, but it is also important to develop your skills in rhinoplasty analysis. Repe ated practice of rhinoplasty-analysis skills will improve your preoperative diagno stic abilit y. Therefore, in this exercise, determine what the best approach and techniques would be in your specime n. Follow the simplified rhinoplasty-analysis algorithm provided as you examine the face and nose. Also provided is a more detailed description of terms and a more detailed review of rhinoplasty analysis.

LANDMARKS FOR ANALYSIS (FIG. 1) (Appendix C) Points Trichion: Anterior hairline in the midlin e Glabella: Mo st prominent midline point of forehead , well appreciated on lateral view Nasion: Most posterior midline point of forehead, typically corres ponds to nasofrontal su­ ture Rhinion: Soft-tissue correlate of osse ocartilaginous junction of nasal dorsum Sellion: Osseocartilaginous junction of nasal dor sum Supratip: Point cephalic to the tip Tip: Ideally , most anteri orly projected aspect of the nose Subnasale: Junction of columella and upper lip

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Figure 1. Nasal analysis: Landmarks.

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Labrale superius: Border of upper lip Stomion: Central portion of interlabial gap Stomion superius: Lowest point of upper-lip vermilion Stomion inferius: Highest point of lower-lip vermilion Mentolabial sulcu s: Mo st posterior midline point between lower lip and chin Pogonion: Mo st anterior midline soft-tissue point of chin Menton : Most inferior point on chin Cervical point: Point of intersection between line tangent to neck and line tangent to sub­ mental region Gnathion: Point of intersection between line from subnasale to pogonion and line from cer­ vical point to menton

LAB EXERCISE: NASAL ANALYSIS General

Skin quality: Thin, medium, or thick Primary descriptor (i.e., why is the patient here): For example, "big," "twisted," "large hump "

Frontal View

Twisted or straight: Follow brow-tip aesthetic lines Width: Narrow, wide, normal, "wide-narrow-wide" Tip: Deviated, bulbous, asymmetric, amorphous, other

Base View

Triangularity: Good versus trapezoidal Tip: Deviated, wide, bulbous, bifid, asymmetric Base: Wide, narrow , or normal. Inspect for caudal septal deflection Columella: ColumelJarllobule ratio (normal is 2:1 ratio); status of medial crural footplates.

Lateral View

Nasofrontal angle: Shallow or deep Nasal starting point: High or low Dorsum: Straight, concavity, or convexity; bony, bony-cartil aginous , or cartilaginous (i.e., is convexity primarily bony , cartilaginous, or both) Nasal length: Normal, short, long Tip projection: Normal, decreased, or incre ased Alar-columellar relationship: Normal or abnormal Naso-labial angle: Obtuse or acute

Oblique View

Does it add anything, or does it confirm the other views?

Many other points of analysis can be made on each view, but these are some of the vital

points of commentary.

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SURFACE ANGLES, PLANES, AND MEASUREMENTS: DEFINITIONS (FIG (1-5) (Appendix D)

Facial thirds Upper third : Trichion to glabella Middle third: Glabella to subnasale Lower third: Subnasale to menton (Fig. 2A) Horizontal fifths: Five equally divided vertical segments of the face (Fig. 2B) Frankfort plane: Plane defined by a line from the most superior point of auditory cana most inferior point of infraorbital rim (Fig. 2C) Nasofrontal angle : Angle defined by glabella-to-nasion line intersecting with nasion-to line. Normal, 115 to 130 degrees (within this range, more-obtuse angle more favor in female , and more acute angle in male patients ; Fig. 2D) Nasofacial angle : Angle defined by glabella-to-pogonion line inter secting with nasion tip line . Normal, 30 to 40 degrees (Fig. 2E)

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A Figure 2. Surface angles, planes, and measurements. A: Horizontal facial thirds. B: Vertical facial fifths .

c Figure 2, continued. C: Frankfort plane . D: Nasofrontal angle.

E Figure 2, continued. E: Nasofac ial angle . F: Nasomental angle.

G

Figure 2, continued. G: Relationship of lips to subnasale-to-pogonion line. H: Relationship of lips to na somental line.

Figure 2, continued. I: Mentocervical angle. J: Legan's angle of facial convexity.

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K Figure 2, continued. K: Nasolabial angle. L: Nasal projection : method of Goode.

PEARL Normal projection with a "3-4-5" triangle described by Crumley (see later) gives a riasofacial angle of 36 degrees . Nasoment al angle : Angle defined by nasion-to-tip line intersecting with tip-to-p ogonion line. Normal , 120 to 132 degree s (Fig. 2F) Relation ship of lips To nasomentalline: Upper lip, 4 mm behind; lower lip, 2 mm behind line from nasal tip to menton (Fig. 2H) To subnasale-t o-pogonion line: Upper lip, 3.5 mm anterior; lower lip, 2.2 mm anterio r (Fig.2G) Mento cervical angle: Angle defined by glabella-to-pogonion line intersectin g with men­ ton-to-cervical point line (Fig. 21) Legan faci al-con vexity angle: Angle defined by glabella-to -subnasale line intersecting with subnasale-to-pogonion line; normal , 8 to 16 degree (Fig. 21)

PEARL Useful in assessing chin deficiency, candidacy for chin implant, chin advancement, or other chin alteration Nasolabial angle : Angle de fined by columell ar point-to-subn asale line intersecting with subnasale-to-Iabrale superius line; normal , 90 to 120 degre es (within this range, more obtuse angle more favorable in female, and more acute in male patient s; Fig . 2K) Columell ar show: Alar-columellar relationship as noted on profile view; 2 to 4 mm of col­ umell ar show is normal

Nasal projection: Anterior protrusion of nasal tip from face (Fig. 2L) Goode's method : A line is drawn through the alar crease, perpendicular to the F plane. The length of a horizontal line drawn from the nasal tip to the alar l point-to-nasal tip line) divided by the length of the nasion -to-nasal tip line . 0.55 to 0.60 (2,3) Crumley's method: The nose with normal projection forms a 3-4-5 trian gle [ point-to-nasal tip line (3), alar point-to-nasion line (4), nasion-to-nasal tip (4).

Byrd's method: Tip projection is two-thirds (0.67) the planned postoperative ideal) nasal length . Ideal nasal length in this approach is two-thirds (0.67) the cial height (5)

POWELL AND HUMPHRIES "AESTHETIC TRIANGLE" Nasofrontal: 115 to 130 degrees Nasofacial: 30 to 40 degr ees Nasomental: 120 to 132 degrees Mentocervical: 80 to 95 degrees (3)

RHINOPLASTY ANALYSIS

A thorough phy sical examination and accurate preoperative anal ysis are cr achieving the desired long-term postoperative rhinoplasty result. Some degree of organization assi sts in the execution of the physical examination. Visual examinat finger palpation are equally important in the nasal evaluation. Throughout the eva a mental image of the potential outcome and surgical limitations inherent in every ual should be visualized. In effect, the potential rhinoplasty operation is rehearsed the physical examination proceeds (1,6). Study of the stand ard preoperative photographic images for rhinoplasty (fronta lateral, oblique) allows a systematic, detailed anatomic anal ysis that complements th ical examination proce ss. Thi s chapter focuse s on analy sis of the four standard rhin photographic views (frontal, base, lateral , oblique). Emphasis is placed on ana to scriptions of structures and their relationships to other structures. Analysis begins by examining all four view s and making an assessment of the stature of the patient , the facial skin quality , and the symmetry of the face . The prin dividing the face into horizontal thirds and vertical fifths is a useful tool to obtain a sense of any incongruent areas of the face that may playa key role in nasal appeara the outcome of nasal surgery. It is essential that these incongruent areas or asymme recognized and discus sed with the patient. Thickness and quality of the facial skin taneous tissue complex must be determined, as it plays a critical role in dictating t tations of what can and cannot be accompli shed with aesthetic nasal surgery (1,6,7 After completing the general assessment, note and highlight the most striking ch istics of the nose. These are typically the characteristics that bring the patient fo plasty , such as excessive size, deviation , or a dorsal hump. These primary patient c must be recognized, highlighted, and addres sed above all else. As the surgeon reviews each photographic image, the major aesthetic and te points that can be evaluated on a given view are noted first. Subtleties in analysis a addressed. It is important to recognize both the characteristics of greatest concern to tient and the more subtle findings. The patient may not notice these other subtle ab ities if they are left unaddressed by the surgeon. Postoperatively, the scrutinizing may notice and point out these abnormalities. Stepwise, methodical analysis of the and the photographic view s allows the well-trained surgeon to identify significant an and aesthetic point s.

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Frontal View On frontal view, the observant surgeon first notes nasal width, any deviation from the midline , and characteristics of the nasal tip . Nasal width can be assessed in the upper, mid­ dle, and lower third of the nose. It is important to recognize that a saddle deformity of the bony or cartilaginous dorsum will contribute to the appearance of an overwide dorsum on front al view, whereas a hump will give the impression of a narrow dorsum. Simil arly, a low bony dorsum will create an illusion of a relatively wide upper third of the nose and wide in­ tercanthal distance or pseudohypertelorisrn (7). This appearance can be significantly im­ proved by augmenting the nasal dorsum . The width of the nasal base on frontal view should approximate the interc anthal distance. The contour of the curved aesthetic lines that follow the eyebrows, traverse the radix, and continue down along the lateral nasal dorsum to end at the tip-defining points (the brow-tip aesth etic lines) should be followed , and any asymmetries, twists , or dev iation s noted. The se brow-tip aesthetic lines should be smooth, unbroken , gentl y curved, and symmetric (1,6) . The nasal tip should be characterized on frontal view with regard to symmetry and def­ inition. Concavity or other anatomic findings of the alar sidewall are noted. Vertical and horizontal aspects of bulbosity should be recognized when present. Bifidity of the nasal tip may be visible on this view (but is typically best appreciated on base view) . The gentle "gull-in-flight" relationship of the nasal alae to the infratip lobule should be followed , and any asymmetry should be noted. Exaggeration of this curve is suggestive of alar retraction and/or a dependent infratip lobule. If the columella is not visible ("hidden columella") on frontal view, this also may indicate a retracted columella. The vertical position and sym­ metry of the alar insertions should be described on the front al view. Base View On base view, special attention should be given to triangularity, symmetry, columella/lob­ ule ratio, and width and insertion of the alar base. The nasal base should be configured as an isosceles triangle with a gently rounded apex at the nasal tip and subtle flaring of the alar sidewalls (Fig . 3) (4,8,9). Poor triangularity or trapezoidal configuration with broad domal angles may suggest abnormal divergence of the intermediate crura . The presence of asym­ metry of the tip may best be appreciated on this view. Often one can visualize the outline of

Figure 3. Nasal analysis : Base view. Give special attention to triangularity, symmetry , columellar/lobule ratio, and width and insertion of the alar base.

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the lower lateral cartilages beneath the thin skin of the columella and alar rim, metries or buckling can be noted . Overlong or short medial crura may be appar columella and flaring of the medial crural footplates should be noted when p should look into the nasal vestibule to identify possible recurvature of the later the lower lateral cartilage (lateral crura), which on occasion contributes to nasal or correlates with an alar concavity seen on frontal view. This recurvature of the can be accentuated with application of dome-binding sutures (transdomal sutur sulting in nasal airway obstruction. The caudal septum may be seen protruding tril. Asymmetric nostrils or protruding medial crural footplates may be a clue of dal septal deviation or asymmetry . Asymmetric orientation of the nostril api indicative of underlying abnormalities of the domal region of the lower lateral c The width of the alar base should be noted, with normal width generally bei vertical line dropped from the medial canthi. Variations in the appearance of w base view may be due to the variation in horizontal position of the alar insert face or in the flare of the alar sidewalls. The alar sidewalls themselves are ch with regard to thickness and flare. Alar base insertions are described by degree ture , with straight insertions going directly into the face (i.e., no nostril sill) , and recurved alae inserting directly into the columella (4,8,9) . The ratio of the columella to lobule should approximate a 2: 1 ratio, and the b the flare of the medial crural footplates should divide the alar base into halves. T are commonly oriented 30 to 45 degrees toward the midline and are pear-shape gated. The facets or external soft-tissue triangles are attractive when they are w but can detract if they are overly conspicuous (4,8,9).

Lateral View

The lateral view offers important information on tip projection, nasal length, do and alar-columellar relationship. The nasal tip should ideally project strongly from the the face and gracefu supratip dorsum, creating a modest supratip break. An identifiable but not over ated columellar double break typically marks the junction of the medial and in crus . Nasal tip projection is consistently assessed by using the method describe (see Fig. 2) (2,3). If the length of a line drawn from the tip-defining point perpe a tangent to the alar-facial junction is greater than 0.55 to 0.60 of the line draw nasion to tip-defining point, then the nose ma y be overprojected. However, whe tip projection, relationships between the nose and other aesthetic facial features jection, forehead contour, ethnic background, etc.) must be considered. Nasal length is complicated to define. The nasal length is compared with the thirds of the face and the overall stature of the patient to determine whether th appropriate length. However, the factors contributing to the appearance of nasa complex. The nose can be considered to have three lengths, with nasion to tip be trallength , and nasion to alar margin being the lateral lengths. A short or long la may reflect a retracted or hooded ala, respectively, whereas a ShOl1 or long cen may reflect an obtuse or acute nasolabial (columellar-labial) angle, respective more, a deep nasofrontal angle contributes to the illu sion of a short nose, and a sofrontal angle adds apparent length to the nose (10). In Fig . 4A, three diagram except for the nasofrontal angle illustrate the effect of the nasofrontal angle on ance of nasal length. Another three diagrams (Fig. 4B), identical except for the angle, illustrate the effect of the nasolabial angle on the appearance of length. The nature of the columellar-labial confluence and columellar-lobular ang break) also must be assessed. Webbing or tenting of the columellar-labial should be noted. An overly obtuse columellar- labial angle and/or an exaggera break will make the nose appear ShOI1, whereas the converse (acute columella gle and/or absent double break) will add apparent length. A posteriorly inclinin ficiency of the premaxilla may confound accurate measurement of the colum

c

A,B

D,E

Figure 4. A deep nasofrontal angle and/or an obtuse nasolabial angle contributes to the ap­ pearance of a short nose , whereas a shallow nasofrontal angle and/or an acute nasolabial angle adds appa rent length . In the first three line drawings (A) , the nasolabial angle is the same, whereas the nasofrontal angle is altered to illust rate the effect of the nasofrontal an­ gie on the appearance of nasal length. In the next three drawings (B), the nasofrontal angle is con stant , whereas the nasolabial angle var ies.

angle . The relationship of the nose to other facial structu res also will influen ce nasal length ; for exampl e, a flat forehead will give the illusion of increased nasal length (l0). Byrd (5) described a useful method for determining appropriate aesth etic proportions for tip projection, nasal length , and radix projection. "Ideal" nasal length is two third s of the midfacial height and is equ al to chin vertical. Tip projection is ideall y two thirds of this planned or ide al nasal length. Radix projection may be measured from the junction of the nasal bones with the orbit and ideally should be one third of the calculated nasal length.

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Byrd recommended the plane of the cornea surface as a preferred reference po projection ; from this starting point, the radix projects 0.28 times the ideal nas Byrd's report, the radix projected 9 to 14 mrn from the plane of the cornea sur One should be famili ar with the aesthetic angles applied in facial analysis guidelines for standards of facial aesthetics and facial harm ony. Powell and aesthetic triangle (nasofacial, nasofrontal, nasom ental, and mentocervical ang nasolabial angle or conflu ence are a few of the more commonly cited measure Assessment of the dorsal contour should identify any concavity, convexity, o ity. A high dorsum with a slight concavity at the rhinion is generall y conside thetic ideal in the white female nose. A high dorsum that is straight or with a is ideal in a white male nose. Other notable comp onents of the dorsum includ start ing point, which is ideally positioned at the level of the superior palpebral f tip-supratip relationship, as previousl y mentioned. The ala is analyzed in detail on the lateral view. Insertion of the ala on the fac above the columella in the horizontal plane, as described by Crumley (4), is j normal. The contour of the alar rim in profile ideally approximates a "lazy S" should note if this is normal, exaggerated, or straight. The size of the alar lobu ficd as small , normal , or large. The alar-columellar relationship should be p scribed. The range of norm al columellar show is generally considered to be 2 to complexities of the alar- columellar relationship were categorized by Gunter who identified abnormal positioning of the ala and the columella in relationsh drawn through the long axis of the nostril. All patient s have a hangin g, normal , ala and a hangin g, normal , or retracted columella. Thu s nine possible anatom tions make up the alar-eolumellar relati onship (Fig. 5). On lateral view, the long axis ofthe nostril should rise at approx imately 10 to from a plane horizontal to the Frankfurt plane. This is a reliable determinant of operative rotation of the nasal tip (7). Oblique View

Although it offers the least amount of objective data, this is an important aesthe cause the nose is most often seen at oblique angles. Several aspects of nasal conto lighted on this view and should be assessed. The brow-tip aesthetic lines and th facets are especi ally prominent and should be carefull y assessed , as irregularit highlighted on this view. Furthermore, abnormalities of the lateral aspect of the n nasal length , dorsal height, and tip projection also may be highlighted on the ob Overview

There is no "standard" rhinoplasty. Each operation is unique in that it must be the specific anatomic components involved and the desires of the patient. By d consistent, meticulous routine in which the patient' s nose is analyzed with r anatomic comp onents and their complex interrelationships, the surgeon can sel incisions, approaches, and techniques to achieve the desired surgical outcome. ,,-

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PEARLS

• The soft-tissue point correlating to the osse~cartilaginous jtin~tion of t . dorsum is the rhinion , The skin at this location is relatively thin compared thicker skin of the nasion. This is importantto recognize when planning hump reduction. After hump reduction, this area must be very smooth to a ible or palpable irregularities (see Appendix G): . • The nasal starting point typically corresponds to the nasion. In female pa is ideally situated at the same level as the superior palpebral fold. n

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• The nasaltipshouid be the most anteriorly projecting portion oftbe nose. tip should ideally lead the supratip dorsum, creating a modest supratip b • A "pollybeak" is a postoperative situation in which the supratip lead Causes for a pollybeak include underresection of cartilaginous dorsum at rior septal angle, excessive scar tissue formation, and inadequate suppo~t causing postoperative loss oftip projection. . ... . • An identifiable but not overly exaggerated columellar double break usua the junction of the medial and intermediate crus. . • Nasal-tip projection may be consistently assessed by using the method by Goode. If the length of a line drawn from the tip-defining point perpen a tangent to the alar-facial junction is greater than 0.55 to 0.60 of the li from the nasion to tip-defining point , then the nose may appear overproj • Thickness and quality of the facial skin-subcutaneous tissue complex m termined, as it plays a critical role in dictating the limitations of what can not be accomplished with nasal surgery. • Thin skin, strong cartilages, and bifidity: an important anatomic triad. Th must recognize the need to approximate the tip-defining points to impro angularity. The surgeori must recognize the risk of bossa formation if exce eral crura is excised (see Appendix G). . . . • Facial analysis can describe vertical facial thirds: trichion-to-glabella, gl subnasale, and subnasale-to-menton.However.the hairline is variable, an the glabella is not always precisely identifiable. Another method cons lower two thirds of the face from the nasion to the menton. The.nasion-to-s distance is 47% of the total, whereas subnasale to menton is53% (Fig. 6 • The astute surgeon will be able to anticipate the contour of the lower lat lages by studying surface topography of the nasal tip; . • The basal view provides information about the shape of the lower lateral c A trapezoidal nasal base indicates a wide domal angle and indicates the n tip technique that will create a more acute dome angle (dome-binding sut • Cephalic positioning of the lateral crura is indicated by the "parenthesis" d and lack of lateral wall support. • The "narrow nose syndrome" is noted in patients with a projecting nose, s bones, and long upper lateral cartilages. These patients are at high risk for dial collapse of the upper lateral cartilages after dorsal-hump excision . Thes frequently need spreader grafts. The contour of the caudal margin of the m intermediate crura can frequently be assessed by close examination of the n

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ILLUSIONS IN RHINOPLAS.TY . .

.

• · .A dorsal convexity or hump frequently gives the appearance of narrow frontal view . It also provides the illusion of relative decreased projection changing the relationship between the dorsum and tip can improve the ap of projection. .. . • • A low dorsum gives the appeai·ance of increased nasal width due to less ing along the lateral nasal wall. • A saddle deformity of the bony or cartilaginous dorsum will contribute t . pearance of an overwide dorsum on frontal view, whereas a hump will giv pression of a narrow dorsum. Similarly-a low dorsum will create an illu relatively wide upper third of the nose or pseudohypertelorism. This ap can be significantly altered by augmeriting the nasal dorsum . • A deep nasofrontal angle lends the appearance of a short nose, as does nasolabial angle or an accentuated double break. I

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Figure 6. Relationship of the lower two-thirds of the face.

REFERENCES I. Tardy ME. Rh inoplasty: the art and the science. Philad elphia: WB Saund ers, 1997. 2. Tardy ME, Walter MA , Patt BS. The overprojecting nose: anatom ic component analysis and repair. Facial Plast Surg 1993;9:306- 316. 3. Ridley MB. Aestheti c facial proportions. In: Papel ID , Nachl as NE, eds . Facial plastic and recons tru ctive surgery. Philadelphia: Mosby Year Boo k, 1992:99-109. 4. Crumley RL, Lanser M . Quan titative analysis of nasal tip projection. Laryngoscope 1998;98:202-208. 5. Byrd HS, Hobar Pc. Rhinoplasty: a practical guide for surgical planning. Plast Reconstr Surg 1993;91 : 642-656. 6. Tardy ME, Brown R. Surgical ana tomy ofthe nose. New York : Raven Press, 1990. 7. Johnson CM , Toriu rni DM . Open structu re rhinoplasty. Philadelphi a: Sau nders, 1990. 8. Ta rdy ME, Pan BS, Walter MA. Alar reduction and sculpture: anatomic concep ts. Facia l Plast Surg 1993;9 : 295-305. 9. Becker DG, Weinb erger MS, Gree ne BA, Tardy ME. Clinical study of alar anatomy and surgery of the alar base. Arch Otolaryngol Head Neck Sur g 1997 ;123:789- 795. 10. Tardy ME, Becker DG, Weinberger MS. Illusions in rhinoplasty. Facia l Plast Surg 1995; 11:117-138. I I. Gunter JP, Rohrich RJ, Friedman RM. Classification and correction of alar-columellar discrepan cies in rhinoplasty. Plast Recon str Surg 1996 ;97:643- 64 8.

3 Injection

INFILTRATIVE ANESTHESIA TECHNIQUE Proper local anesthesia is critical to allow atraumatic dissection with minimal bleed­ ing and edema. A total volume of less than 3 ml of 1 % lidocaine with 1: 100,000 epinephrine is typically used to attain anesthesia for rhinoplasty alone. When performing septorhinoplasty, as much as 10 ml of local anesthetic may be used. The anesthetic is al­ lowed to take effect for at least 15 minutes to maximize the vasoconstrictive effect of the epinephrine. To become familiar with a method of injection of local anesthetic agent, saline can be in­ jected with a 5-ml syringe and 27 gauge (1.5 ern) needle along the site of injection in your cadaver specimen. Injection varies in some respects, based on the surgical approach se­ lected; for example, the subdermal columellar injection may be omitted in an endonasal ap­ proach. A generalized approach to injection is described below. For a septoplasty, multiple 0.5-ml to 1.0 rnl injections are made in the subperichondrial and subperiosteal plane along the entire area of anticipated dissection . Injections also should be placed along the site of the proposed incision (Killian, hemitransfixion, etc.). Both sides of the septum should be in­ jected if the surgeon plans to elevate mucosa bilaterally. The injection will aid in the dis­ section if placed in the subperichondrial plane . It is helpful to place an injection on the pos­ terosuperior septum bilaterally to minimize bleeding from the sphenopalatine blood vessels. Inject local anesthetic into the subdermal plane in the midline of the columella from tip­ defining points to the nasal spine in preparation for the external approach (Fig. I). This in­ jection is limited to < 0.3 ml to prevent distortion of the columella or nasal base. For either endonasal or external approach, inject < 0.3 ml of local anesthesia into the soft-tissue be­ tween and around the domes of the lower lateral cartilages (Fig. 2). The injection extends up to the region of the anterior septal angle . After completing this injection, gently massage the domal region between the thumb and index finger of both hands to disperse the anes­ thetic throughout the tip region. Place multiple injections of 0.1 ml of local anesthetic along the caudal margin of the lateral and intermediate crura (along the planned marginal inci­ sion; Fig. 3). Overinjection will result in distortion of the nostril rim and soft-tissue trian­ gle. Inject <0.1 ml to raise a small bleb in the vestibular skin along the lateral aspect of the

25

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Figure 1. Inject < 0.3 ml of local anesthetic into the subdermal plane in the midline of the columella from tip-defining points to the nasal spine in preparation for the external approach. This injection of the col­ umella is necessary for the external approach but may not be necessary for most endonasal ap­ proaches.

Figure 2. Inject < 0.3 ml of local anesthetic into the soft tween the dome s of the lower lateral cartilages . Injecti supratip is illustrated here as a percutaneous injection but al performed endonasally .

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Figure 3. Place multiple injections of 0.1 ml of local anesthetic along the caudal margin of the lateral and intermediate crura (along the planned marginal incision).

Figure 4. Inject < 0.3 ml along the planned incision site for the columellar flap of the exter­ nal rhinoplasty approach.

medial crura, at the planned incision site for the columellar flap of the external rhinoplasty approach (Fig. 4). For an intercartilaginous, transcartilaginous, or delivery approach, place similar injec­ tions of 0.1 ml intranasally along the respective incision sites (Fig. 5). After inserting the needle between the upper and lower lateral cartilages (intercartilagi­ nous), inject local anesthetic along the lateral wall of the nose approximately 1 ern off the midline (Fig. 6). The line of injection is along the lateral aspect of the nose and extends from the nasofrontal suture line to the cephalic margin of the lateral crura . Use <0.5 ml for this injection to prevent distortion of the tissues. Perform no injections along the dorsum of the nose to prevent distortion of the soft tissue that may inhibit accurate evaluation of the contour of the dorsum. In preparation for lateral osteotomies, inject on the outside and in­ side of the nasal bones just above the periosteum. After completing these injections , mas­ sage the injection sites to help disperse the local anesthetic and prevent tissue distortion.

PEARLS

• Subperichondrial and subperiosteal injections of local anesthetic will make dis­ section of the septal flap easier by hydrodissecting the flap. This is particularly

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Figure 5. For an intercartilaginous , transcartllaqlnous , or delivery approach , plac tions of 0.1 ml intranasally along the incision site.

PEARLS, continued '

• • •

•

helpful when dissecting over fracture s in the cartilage, bone, or along the maxi crest. Injection of the osteotomy sites s hould be performed on the i nside and outsi the ascending process of the maxilla. . Avoid excessive injection of local anesthetic into the columell a; otherwise th lation between the ala and columella may be altered. In cases in which dorsal hump excision must extend into the region of the sofrontal angle, additional injection s of local ane~thetic can be placed along path of the supratrochlear artery and just medial to the medial canthus . If the surgeon plans to use lateral crural strut.grafts, injection s of local anest can be placed in the vestibular skin on the undersurface of the lateral crura w the vestibular skin will be dissected. '

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Figure 6. A. Injection of local anesthetic along the lateral wall of the nose . B. Injection for lateral osteotomies.

REFERENCES 1. Beeson WH. The nasal septum. Oto laryn gol Clin North Am 1987 ;20:74 3-767. 2. Kasperbauer JL, Facer GW, Kern EB. Reconstruct ive surger y of the nasal septum. In: Papal!D , Nachlas NE, eds. Facial plastic and reconstructive slIrgely. Philadelphia : Mosby Year Book, 1992:337- 343.

4 Septoplasty

NASAL DISSECTION: SEPTOPLASTY WITH CARTILAGE HARVEST Hemitransfixion Incision with Anterior Septal Tunnels 1. Retra ct the colum ella with a small nasal speculum, multi toothed Brown-Adson forceps, large two-pron g hook , or another suitable instrument. Thi s maneuver exposes the cau­ dal margin of the septum ( 1,2). 2. Make a hemitran sfixion incision along the caud al borde r of the cartilag inous septum with a no. 15 blade or no. 15-C blade . In this exercise, a hemitransfixion incision ex­ tendin g from the anteri or septal angle to the posterior septal angle is used to gain access to the caudal septum. A Killian incision can be used if acce ss to the caudal septum is not necessary (Fig . IA ). 3. In rare cases, the nasal spine should be exposed . 4. With a no. 15 blade, small, sharp -pointed scissors, or other suitabl e instrument, incise the perichondrium of the septum adjacent to the caudal septum on one side . 5. Perform a subperichondrial dissection along the lower half of the septum to allow har­ vesting of septal cartilage. Do not extend this diss ection too high, so that later in the dis­ section a precise pock et tunnel can be made to place a spreader graft via an endon asal approach. 6. Repeat maneuv er 5 on the oppo site side of the septum. 7 . If the septum needs any shortening, now may be a good time to perform selective exci­ sion of the caud al aspect of the septum (Fig. IB-D). If rotat ion of the nasal tip is neces­ sary, a superiorly based triangle of caudal septum can be excised (Appendix F). For an obtus e nasolabial angle, the posterior septal angle can be trimmed . For a tension nose deformity (3) or hangin g-columell a deformity, the entire caudal septum may need to be trimmed. Instead of resection, an overly long midlin e caud al septum can be sutured be­ tween the medi al crura to provide support, increa se proje ction, and set tip-rotation and alar-columellar relation.

31

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Figure 1. A: A hemitransfixion incision (short dotted lines) or a Killian incision (longer dotted lines) ma be used to perform septoplasty. B: Conservative excision in an overlong septum of a thin wedge of cau dal septum to decrease columellar show or shorten the nose . C: Excision of a wedge of caudal septu with the base of the excised wedge anterior, for increased rotation. D: Excision of excess ive septum the posterior septal angle to decrease fullness of the nasolabial angle.

Figure 2. A generous L-strut of :2: 15 mm must be preserved to maintain adequate nasal support. If a dorsal-hump excision is planned, this must also be accounted for in preserva­ tion of an adequate L-strut.

Septal Surgery with Harvesting of Cartilage Carry out a routine septoplasty or submucous-resection operation. To harvest septal car­ tilage, disarticulate the cartilaginous septum from its bony attachment (osseocartilaginous junction), leaving an ample attachment superiorly (dorsally) at the "Keystone" area . Incise the cartilage dor sall y and caudally, preserving 2 15 mm anteriorly to support the nasal tip, and being sure that 215 mm will remain dorsaJly afte r hump removal (Fig. 2). Preserve this harvested septal cartilage for use as struts or grafts later on in this exercise. If inadequate septal cartilage is available, plan to harvest auricular cartilage for grafting purposes. Note: We have described septoplasty via a hernitransfixion or a Killian' s incisi on. A vi­ able alternative is to approach the caudal septum dire ctly by performing an extern al rhin o­ plasty approach and separating the medial crura, thereby coming upon the caudal septum (Fig . 3). Septoplasty may then proceed as described earlier. Although this approa ch avoids the need for a septal mucosal incision, it is a more complex approach and carries with it a higher risk of loss of tip support if appropriate supportive maneuvers (e.g., columellar strut , caudal extension graft) are not undertaken. This approach is ideal in patients who have an overly long midline caudal septum (tension nose deformity). In these cases, the medial crura can be dropped back and sutured to the midline caudal septum. Thi s maneuver will allow shortening of the nose, deprojection of the nasal tip, or correction of the hanging col­ umella deformity .

PEARLS • Special care must be taken .to be sure the dissection is in the subperichondrial plane. If there is any blood-tinged tissue over the surface of the cartilage, there . may be a layer of perichondrium left on the cartilage. • To correct spur along the floor, a subperiosteal tunnel can be dissected along the · floor and connected to the dissection above the junction of the septum and maxil­ "lary crest. This method of dissection will minimize the chance of tearing the mu­ cosal flap along the maxillary crest. . ' . . • If-the surgeon plans to apply spreader grafts into precise submucosal tunnels, a bridge ofmucosa should be left on the dorsal septum. This will allow the surgeon • to create tunnels under the junction of the upper lateral cartilages and septum to

· accept the grafts.

• If the surgeon plans to approach the caudal margin of the septurri to correct defor­

a

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E Figure 3. To perform septorhinoplasty, a viable approach to the septum is to perform an external rhino­ plasty approach and separate the medial crura , thereby coming upon the caudal septum , and then pro­ ceeding with elevation of mucoperichondrial and mucoperiosteal flaps in standard fashion. Before dis­ section, local anesthetic should be injected between the medial crura and into the vestibular skin caudal to the caudal septum. While an assistant holds the lower lateral cartilages laterally (A) , the surgeon dis­ sects between the medial crura (B) until the caudal septum is identified (e). Special care must be taken to remain in the proper plane between the crura. The mucoperichondrial flaps are next further developed with an elevator (D). The dorsal septum can be divided from the upper lateral cartilages in an anterior­ to-posterior direction (E) after both mucoperichondrial flaps have been elevated to the junction of the up­ per lateral cartilage and septum (extramucosal dissection). This will allow preservation of continuity of the intranasal mucosa while dividing the upper lateral cartilages from the dorsal septum. Bilateral mu­ coperichondrial flaps are developed for wide access to the septum (F). Appropr iate support ive maneu­ vers (e.g., columellar strut, caudal extension graft) are undertaken because of the risk of loss of tip sup­ port. With an overly long caudal septum, the medial crura can be sutured back on a midline caudal septum to provide support and set tip position.

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PEARLS, continued , mity or to shorten the septum, the septum can be approached through the external . rhinoplasty approach . . After dissecting between the medial crura to approach the septum, the medial can be dropped back ~nd sutured to an overly long midline caudalseptum. This ma­ neuver will create a more rigid nasal tip without normal tip recoil. o If significant bleeding is noted, the surgeon can reinject the mucosal flaps and place neurosurgical pledgers bilaterally to compress the mucosal flaps. 0

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REFERENCES I . Tardy ME. Rhinoplasty: the art and the science. Philadelphia: WB Saund ers, 1997. 2. Beeson WHo The nasal septum, Otolaryn gol Clin North Am 1987;20:743-767. 3. Johnson Clvl Jr, Godin MS. Th e tension nose: open struc ture rhinoplasty approach. Plast Reconstr Surg 1995; 95:43- 5 1.

5 Incisions and Approaches

Incisions are methods of gaining access to the bony and cartilaginous structures of the nose and include transcartilaginous, intercartilaginous, marginal, and transcolumellar incisions. Approaches provide surgical exposure of the nasal structures including the nasal tip and in­ clude cartilage-splitting (transcartilaginous incision), retrograde (intercartilaginous inci­ sion with retrograde dissection), delivery approach (intercartilaginous, marginal incisions), and external (transcolumellar and marginal incisions). Based on an analysi s of the individ­ ual patient's anatomy, appropriate incisions, approaches, and tip-sculpturing techniques are selected (I) (Appendix E). , In this section , a transcartilaginous incision is performed on one side. Then an intercar­ tilaginous and marginal incision is made on the other side to deliver that cartilage. Next, proceed with the external rhinopl asty approach. Following these instructions will allow an experience with several incisions and approaches in a single specimen.

TRANSCARTILAGINOUS INCISION OR CARTILAGE-SPLITTING APPROACH As demonstrated in the accompanying figure s, use a two-prong retractor and the middle finger of the nondominant hand to expose the lower lateral cartilage (LLC). Locate the caudal and cephali c margins of the lateral crura. (The surgeon must identify the cephalically positioned lateral crus when it is present before executing this incision.) Make an incision through vestibular skin only 5 mm to 8 mm cephalic to the caudal mar­ gin of the lateral crus of the LLC incision . Figure I illustrates the site of a transcartilagi­ nous incision and the more ceph alic location of an intercartilaginous incision. With scis­ sors, dissect free the vestibular skin in a cephalic direction to just beyond the cephalic edge of the lateral crus (Fig. 2). Then incise the lateral crural cartilage and free the cephalic por­ tion (to be removed) from its remaining soft-tissue attachments by dissecting superficial to it in the supraperichondrial plane . Use a skin hook to retract the caudal vestibular skin and another skin hook to retract the nostril margin. An assistant may hold the skin hook that re­ tracts the nostril margin, while the surgeon grasps the cartilage to be removed and com­ pletes the excision by dividing any last soft-tissue attachments with scissors (Fig. 3) (1,2).

37

Figure 1. · Retraction with a wide two-prong retractor and the middle finger of the nondomi­ nant hand exposes the transcartilaginous incision site and also the more cephalically lo­ cated intercartilaginous incision site.

Figure 2. In a cartilage-splitting approach, dissect the vestibular skin in a cephalic direction to just beyond the cephalic edge of the lateral crus. Then assess how much lateral crus should be removed, and incise the lateral crural cartilage . Be sure to leave ~ 7 mm to 9 mm of intact strip.

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Figure 3. A: Use a skin hook to re­ tract the caudal vestibular skin and the nostril margin. Free the cephalic portion (to be removed) from its re­ maining soft-tissue attachments by dissecting superficial to it in the supraperichondrial plane. Grasp the cartilage to be removed , and com­ plete the excision by dividing any last soft-tissue attachments with scissors . B: The cartilage incision must come far enough medially to in­ clude the cephalic lateral crus at the dome region , or else supratip full­ ness may persist. However, it is im­ portant not to incise too far infero­ medially, or the cartilage (which is typically narrow at this region) may be excessively weakened or divided. C: A 3D-gauge needle placed percu­ taneously at the dome can help guide the medial aspect of the tran­ scartilaginous incision in selected cases.

DELIVERY APPROACH (PERFORM ON SIDE OPPOSITE CARTILAGE­ SPLITTING APPROACH) Intercartilaginous Incision

By using a two-prong retra ctor , evert the caudal margin of the nostril and , by ap pressure with the middle finger of the nondominant hand, reveal the gap between t dal margin of the upper lateral and the cephalic margin of the lower lateral cartilage a sca lpel, make an intercartilaginous incision in this location (Fig . 4) (1,2).

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Figure 4. A-C: Intercartilaginous incision. D: For an intercartilaginous approach, bilateral intercartilaginous incisions are connected in the midline over the anterior septal angle, and the incision extends anterior to the caudal septum as a high partial-transfixion incision . Ex­ posure of the middle and upper nasal vault proceed as described in the text. E: After com ­ pletion of the intercartilaginous approach, a Converse retractor (or other appropriate retrac­ tor) may be inserted through the incisions, beneath the skin/soft-tissue envelope, to provide exposure of the upper two thirds of the nose.

Marginal Incision By using a two-prong retractor, evert the caudal margin of the nostril in which an inter­ cartilaginous incision was made and, by applying pressure with the middle finger of the nondominant hand, define the caudal margin of the lower lateral cartilage. Pressing cepha­ lad on the nasal dome will cause the caudal margin to appear laterally. Remember that the non-hair-bearing area is a guide to the caudal margin of the lateral crus. Furthermore, pal­ pation of the cartilage edge with the handle of the scalpel can be helpful before cutting. By using the two-prong retractor to obtain proper exposure, make the marginal incision just caudal to the caudal edge of the lower lateral cartilage (Fig. 5). Great care must be taken as the lateral incision nears the midline. Make sure that the incision follows the cartilage edge and does not take a "short-cut" along the alar rim, which can damage the facet area. Great care must be taken not to cut across a narrow dome or intermediate crus (1,2).

Delivery of lower lateral cartilages At this stage, an intercartilaginous incision and marginal incision on one side and a transcartilaginous incision on the other side have been made. Reinsert the two-prong re­ tractor into the nostril with the intercartilaginous and marginal incisions and present the caudal margin of the lower lateral cartilage with the aid of pressure from the third finger of the nondominant hand. Use a slightly curved, fine-pointed dissecting scissors to lift and dissect the soft tissues from the surface of the lower lateral cartilage (Fig. 6). Perform this dissection by inserting scissors into the marginal incision laterally and then separate the perichondrium of the lower lateral from the overlying external skin and soft tissue with a spreading motion. If this is difficult, caudal traction on the vestibular skin underlying the lower lateral cartilage, with a fine two-prong hook, will facilitate this maneuver (Fig. 7) by pulling the lateral crus into the vestibule and thus opening up the potential dissecting plane. Avoid damaging the overlying muscle and nasal vasculature (1,2).

B

A Figure 5. Marginal incision. The nondominant hand is critical to obtain proper exposure.

Figure 6. Dissect the soft tissues from the superficial surface of the lower lateral car

Do not work too far laterally. The latera l one fourth of the lower lateral cartilage s be avo ided by the surgeon in near ly all cases. Place the hook end of a Nievert retracto r through the inter carti laginou s incision and the now-free later al cr us down , like a visor. until it appears outside of the vestibule. be held in this position by the Nievert or by another suitable instrument (Fig . 8). Examine the lower latera l cartil ages for unique anatomic feat ures and asymmetrie

Figure 7. Caudal traction on the vestibular skin underlying the lower lateral cartilage fine two-prong hook pulls the lateral crus into the vestibule and opens the potential di ing plane.

Figure 8. Delivery of lateral crus of lower lateral cartilage.

THE EXTERNAL (OPEN) RHINOPLASTY APPROACH Background The external rhinoplasty approach to the nose provides ma ximal exposure of the lower lateral cartilages, upper lateral cartilages (Ul.Cs) , middl e nasal vault, and bon y nasal vault. These supportive structures can be manipulated in a precise and sym metric fashion . The in­ creased exp osure facilitates accurate suture placement and fixation of cartilage grafts. The external rhinoplasty approach also facilitates diagnostic capability and is a tremendous aid in teaching rhinoplasty (3-10) (Appendix K). The incisions used in this app roach include a transcolumellar incision connected to bi­ lateral marginal incisions. The actu al configuration of the tran scolumellar inci sion is not as critical as the placement of the inci sion . The incision should be made at the level of the mid­ columella where the caudal margins of the medial crura lie close to the skin and can sup­ port the incision to help prevent a depressed scar. An inverted-V incision , or some other broken -line incision, is used to break up the scar and lengthen it to minimize scar contrac­ ture. The surgical dissection must be performed in the proper areolar tissue planes to min­ imize tissue damage and scarring, maintain hemostasis, and maximize redraping of the skin/soft-tissue envelope. Dissection in proper tissue planes will help preserve vascular structures of the flap , ensure flap viability, and minimize bleeding, postoperative edema, and scarring ( I I) .

NASAL DISSECTION: EXTERNAL (OPEN) RHINOPLASTY APPROACH Marking the Transcolumellar Incision Begin the dissection by outlining the transcolumellar incision used in the external rhino­ plasty approach with a marking pen . Mark an inverted-V transcolumellar inci sion at the level of the midcolumella (Fig. 9). The midcolumellar incision should be marked midway between the top of the nostril and the base of the columella, where the caudal margin of the medial crura lie just beneath the skin, to provide support for the incision. The midcolumel­ lar incision will be connected to bilateral marginal inci sion s, which are placed ju st caudal to the caud al margin of the lateral crura (Fig. 10). The marginal incision should not be made along the rim of the nostril (rim inci sion). The marginal incision may be marked with a marking pen as well.

A

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Figure 9. A-C: Inverted-V incision on the midcolum at a level where the margin of the medial crura lies beneath the skin.

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A Figure 10. A, B: Marginal incisions are placed just caudal to the caudal margin of the in­ termediate and lateral crura .

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Midcolumellar Incision By using a no. 11 blade with a "sawing" motion, follow the midcolurnellar markin gs to complete the midcolumellar incision (Fig. 11). Proceed medial to lateral on one side of the columella and then the other. Take special care to keep the blade perpendicular to the skin edges, thereby preventing beveling of the skin edges. (Beveling of the skin edges may lead to a "trapdoor" deformity with eventual unacceptable scar). While incising laterally, be careful to stay superficial to avoid damage to the caudal margin of the medial crura . Use a no. 15 blade to make the columellar exten sion of the marginal incision on both sides of the columella, 1 to 2 mm behind the leading edge of the columell a (Fig. 12). This incision is made along the caudal margin of the medial and intermediate crura. By minimi zing the dis­ section over the medial crus, damage to this cartilage can be avoided.

Figure 11. A-C: Midcolumellar ' incision made by using a no. 11 blade with a sawing motion. Keep the blade perpendicular to the skin edges, and stay superficial to avoid dam­ age to the caudal margin of the medial crura.

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Figure 12. A: Columellar extension of marginal incision. 8-0: Columellar extension of marginal incision in a patient. E, F: Marginal incision.

Beginning laterally, make a light incision throug h vestibu lar skin 1 to 2 mm cauda l to the caudal margin of the late ral crura . Follow the caudal margin of the lateral crura as the inci­ sion is extended medi ally. (The dissector has already mad e the marginal incision on one side; here simpl y make a marginal incision on the other side .)

Define the Columellar Flap By using angled Con verse scissors, or another suitable dissecti ng scisso rs, elevate the thin vestib ular skin of the flap that covers the medial crura. Insert the scissors beneath the col­ umellar extension of the marg inal incision and dissect med ially in the correct plane of dis­ section, below the musculoaponeurotic layer (Fig. 13). The scissors should then pass super­ ficia l to the caudal margin of the ipsilateral and then contralateral medial crus (Fig . 14). Guide the scissors through the oppos ing colume llar extension of the marg inal incision (Fig . 15). During this dissection, take special care to avoid dama ging the flap or the caudal margin of the medial crura . Use the scissors to spread the tissues in the plane of dissection (Fig. 16). If not positioned properly, the dissector may cut through the cauda l margin of the media l crura. To avoid this, the dissector must remain caudal to the medial crura and dissects very carefully.

Flap Elevation Use the Con verse scissors to compl ete the midcolumellar incis ion without beve ling the incisio n or damaging the medial crura (Fig. 17). Take specia l care to avoi d beveling this in­ cisio n. Use a narrow do uble-prong hook to retract the flap. Th e paired columellar arte ries may be see n, and typic ally must be cauterized with bipolar cautery .

Figure 13. To elevate the thin vestibular skin of the flap that covers the medial crura, insert the scissors beneath the columellar extension of the marginal incision and dissect medially in the correct plane of dissection , below the musculoaponeurotic layer. If one meets resis­ tance, they can alternate dissection to the contralateral side of the columell a.

Figure 14. The scissors pass superficial to the caudal margin of the ipsilateral and then contralate ral medial crus.

Figure 15. Guide the scissors through the opposing columellar extension of the marginal incision.

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Figure 16. A, B: Spread the tissues in the plane of dissection.

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Figure 17. A, B: Complete the midcolumellar inci­ sion. Do not bevel the skin edges, or an unaccept­ able scar (due to a trapdoor deformity) may result.

B

Three-Point Countertraction

•

To elev ate the skin/soft-tissue enve lope over the nasal tip, (a) place a wide doubl e-p hook along the margin of the nostril rim caudal to the latera l crus, (b) place a small dou prong hook on the columellar flap , and (c) place a small double-prong hook on the vest lar skin side of the intermediate crus (Fig . 18). Then use Converse scissors to dissec columellar flap fro m the caudal margin of the medial and intermed iate crus, as the c tertraction acts to expose the areolar tissue plane. The scissors are used to expose the da l aspect of the lateral crus as well. Then the dissection advances cephalica lly over the face of the lateral crus . As the dissec tion continues along the surface of the lateral crus, tissue is eleva ted, leaving only perichondrium on the cartilage . As dissection proceeds erally along the lateral crus, cut the vestibular skin along the caudal mar gin of the la crus, thereb y completing the marginal incision. Make sma ll, calibrated cuts under direc sion to avoid inadvertently cuttin g throu gh the lateral crus . Limit dissection of the la crus to the areolar tissue plane deep to the muscle. A cotton-tip applicator can be use comp lete the dissection of the lateral crus once the deep aero lar tissue plane has been i tified. A portio n of the dissection on the opp osite side was performed with the cartilage livery approac h; nevertheless, repeat these maneu vers on the oppos ite side to complet eva tion of the skin/soft-tissue envelope over the nasa l tip. [An altern ative approach to this dissectio n is to begin dissection thro ugh the margina cisio ns (retrograde dissection) (12).] In this approach, identify the proper tissue plane , eleva te the skin/soft-tissue envelope off the lateral crus . Then proceed med ially with s sor dissection toward the do mes and intermedia te crura. This maneuver is performed b era lly to achieve elevation of the skin/soft-tissue enve lope. This retrograde dis section is helpful if the surgeon is hav ing difficulty followi ng the dal margin of the inte rmediate and lateral crus. Th is is not unusual in cases in which t is buckling of the interme diate crus or domes. Retrograde dissection genera lly is not the proac h of choice for seco ndary rhinoplasty, as the lateral crura may have been exci se previously dissecte d.] [Examine the latera l crura on the side of a transcartilaginous incision and cephalic t Eval uate the excisio n of cephalic cartil age. Was it stoppe d too short, leaving cephalic era l crus at the dome region? Did the incision go too far; was the dome inadvertently vided? Was too much cartilage taken? Measure the amo unt of lateral crus remaining; t shou ld be at least 7 mm to 9 mm.]

•

A Figure 18.

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F

G Figure 18. A, B: With three-point countertraction exposing the areolar tissue plane, use Converse scissors to dissect soft tissue from the caudal margin of the intermediate and lat­ eral crus. Dissection of the skin/ soft-tissue envelope proceeds in the deep areolar plane be­ low the muscle, leaving only perichondrium on the cartilage . C: As dissection proceeds lat­ erally , follow the caudal edge of the lateral crus and cut the marginal incision . Make only a very small cut at a time , and take great care to avoid cutting the cartilage . D: As dissection continues laterally, the marg inal incision is extended laterally as described above . E: When dissecting the proper tissue plane , a cotton -tip applicator can be used to sweep soft tissue off of the lateral crus . F: Completed exposure of the left lateral crus via the external ap­ proach . G: Dissection has been completed of both the left and right lateral crus , and atten­ tion will now be directed toward the midlin e.

Midline Dorsal Dissection

Divide fibrou s connections in the midline near the surface of the domes to releas flap and allow dissection cranially (Fig. 19). Do not dissect tissue from betw een the do otherwise a midline band of tissue may be left on the flap. Shift the dissection to the line, where the anterior septal angle is identifi ed with a spreading action of the Con scissors or other suitable dissecting sciss ors. Once the blue hue of the cartilaginous m third of the nose has been identified, create a midlin e tunnel over the cartilaginous m vault. Then use a cotton-t ip applicator to dissect bluntl y the soft-ti ssue envelope cra and laterall y (Fig. 20). Th is maneuver will frequentl y expose sizable blood vessels tha be spared, as they are dissected laterally. Depending on the degree of exposure th needed, some fibrou s connections may need to be cut near their attachment to the laginous nasal vault (Fig. 2 1). Muscle and vessels can be spared by dividing tissues to the surface of the cartil ages.

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Figure 19. A-C: Shift the dissection to the midline, and divide fibrous connections in the midline near the surface of the domes to release the flap and allow dissection cranially. Do not dissect tissue from between the domes ; otherwise, a midline band of tissue will be left on the flap . With a spreading action of the Converse scissors or other suitable dissecting scissors (D, E), identify the blue hue of the cartilaginous middle third of the nose, and cre­ ate a midline tunnel over the cartilaginous middle vault (F).

B

A Figure 20. A: If dissection proceeds in the proper tissue plane, a cotton-tip applicator can assist in the exposure. B: Divide the dec ussat ing fibers (apply bipolar cautery first ) to con­ nect the dissected spaces over the middle vault and lateral crura .

B

A Figure 21. A, B: Exposure of the middle nasal vault.

Exposure of Cartilaginous and Bony Dorsum Exposure ofthe Cartilaginous Vault

The cartil aginou s vault , typically corresponding to the middle third of the nose, c exposed as described earlier. Alternatively, as with a cartilage-splitting, retrograde, livery approach , the skin/soft-tissue envelope can be exposed either by using sharp s dissection or by scissor dissection in the supraperichondrial plane . Use a scalpel (no. 15 blade) or long , slightly cur ved dissecting scissors to elevate th tissues in the midline, working up toward and just beyond the rhinion, inserting and ing, but not cutting, with the blades under the skin . Lay bare the perichondrium of the ULC in the midline but do not extend too far lat at this stage. Take special care not to follow the ULC below the caudal margin of the bones . Such a maneuver may result in disarticulation of the ULCs from the nasal bo

Elevation of Periosteum/Exposure of Bony Vault

Under direct vision by using an Aufricht or Converse retractor, use a Joseph peri elevator or other appropriate instrument to cut through the periosteum 2 mm cephala parallel to the caudal margin of the nasal bones (Fig . 22) . Alternatively, palpate the junction between the nasal bone and ULCs with the Jose evator beneath the skin/soft-tissue envelope by gently allowing the Joseph to "fall" o nasal bone onto the ULCs as it is withdrawn. The Joseph elevator can then be seated above this junction with certainty, and the periosteum incised. Elevate the periosteu the bony nasal vault up to the nasion. Then elevate in the subperiosteal plane over the dorsum toward the midline and laterally (Fig. 23). Execute these maneuvers bilat (Fig. 24) . Do not extensively undermine over the side walls of the bony nasal pyram

.

Figure 22. Subpe riosteal dissection over bony nasal vault up to the nasion .

Figure 23. Cross section at level of nasal bones, illustrating dissection in subperiosteal plane. Lateral and medial motion of the elevator achieves this elevation in the subperiosteal plane.

Figure 24. After bilateral elevation , the midline decussating fibers remain undivided. These generally are severed with scissors .

this stage . Next , sever the midline internasal suture attachments; this can be accomp with sciss ors or sharp elevator. Make sure that the nasal skeleton is completely free the overlying skin. Pass an elevator or similar instrument from side to side over the cartilaginous dorsum . This completes the execution of the external rhinoplasty appr [The dissector now has exposure via the external rhinoplasty approach. When ach exposure via an endonasal approach, the intercartilaginous or transcartilaginous inc are typically connected caudally in the midline and continue over the caudal septu high partial-transfixion incision, as described previou sly (see Fig. 4D and E). Direc alization of the nasal dorsum is thus achieved with the aid of an Aufricht or Conve tractor inserted through the intercartilaginous or transcartilaginous incision. [Note: If the dissector wishes to place spreader graft s via a precise pocket endona proach, it should be undertaken now. The technical steps are described in Chapter 8. after hump removal (Chapter 6) and osteotomies (Chapter 7), the dissector will spreader grafts via the external rhinoplasty approach.

PEARLS

• If the surgeon plans to place a dorsal graft or radix graft, a precise pocket can made over the upper dorsum and/or radix. This will allow the surgeon to place graft into a precise pocket and minimize the chance of graft migration. • If the surgeon plans to place an alar batten graft, the lateral extent of the dissect should be minimized. . • During the extermil rhinoplasty approach, elevation of the skin/soft-tissue en lope from the underlying supportive structures of the nose results in disruption the minor tip-support mechanism provided by the attachment of the skin/softsue envelope to the lower lateral cartilages. To help offset this loss oftip supp a columellar strut cartilage graft can be 'sutured in a pocket between the med crura . Such a strut is used to support the medial crura to preserve tip projection not necessarily to increase tip projection (Appendix F). • The columellar extension of the marginal incision should beplaced only 1 to 2 m behind the face of the columella to minimize dissection of vestibular skin and avoid damage to the caudal margin of the medial crura, • When advancing the converse scissors across the .columella to the oppos med marginal incision, special care should be taken to remain caudal to crura . • Dissect in the tissue plane just above the perichondrium. Avoid violating the m cle layer. . • DUling dissection; follow the caudal margin ofthe lower lateralcartilages. If caudal margin is lost sight of, move laterally to pick up the lateral crus, and diss retrograde to avoid cutting across a buckled intermediate crus or deformed dom • Precise closure of the midcolurnellar incision, with meticulous alignment of skin edges, is critical to prevent an unsightly scar. Principles ofskin-edge evers and tension-free closure will also help prevent a visible scar. Vertical mattre suture closure aids in skin-edge eversion. ' . ' .

the

REFERENCES

1. Tardy ME, Tor iumi OM . Philo sophy and prin ciple s of Rhinopl asty. In : Cumm ing s CW , Fredri ck Harker LA, et aJ. Otolaryngology -head & neck surgery. 2nd ed. SI. Louis : Mosby Year Book, 1993:2 2. Tardy ME. Rhinoplasty : the art and the science. Philad elphi a: WB Saunders, 1997. 3. John son CM Jr , Toriumi OM . Open structure rhinoplasty. Philad elphia: Saunders, J990 . 4. Adams on PA. Open rhinoplasty . In: Papel 10, Nachl as NE, eds. Facial plast ic & reconstruct ive sur Lou is: Mosby Year Book, 1992:295-304. 5. Larrabee WF Jr. Open rhinoplasty and the upper third of the nose. Facial Plast Surg Clin North Am 23- 38.

cial Pla st Surg Clin North Am 1993;1:1- 22. 7. Tori urni OM. Management of the middle nasa l vault. Oper Tech Plast Reconstr Surg 1995;2: I6-30. 8. To riumi OM , Ries WR. Innovative surgical management of the crooked nose . Facial Plast Surg Clin North Am 1993;1:63-78. 9. Toriumi OM , Jo hnson Clvl. Management of the lower third of the nose: ope n structure rhin oplasty technique. In: Pape1 !D, Nachlas NE, eds. Fac ial plastic & reconstructive su rge ry. St. Lou is: Mosby Year Book, 1992: 305- 313. 10. Gunt er JP. The merit s of the open approach in rhinop lasty . Plast Reconstr Surg 1997 ;99:863- 867. 11. Toriumi OM , Mueller RA , Grosch T, Bhattacharyya TK , La rrab ee WF. Vascular anatom y of the nose and the externa l rhinoplasty approach . A rch Otol Head Neck Sur g 1996; 122:24-34. 12. T homa s JR . Externa l rhinop lasty : intact co lume llar appr oach . Laryngo scope J990; 100:206-208.

6 Removal of Bony-Cartilaginous Hump

In this exe rcise, the car tilaginous and bony hum p are removed en bloc. Be conservative! Plan to take a small amount of the hump off at first and thereby avoid incising the mu­ coperichondrium, which provide s important support. Later, after the bony-cartilaginous hump has been removed, be prepared to make multiple fine adj ustments of both the septum and dorsal margins of the upper lateral cartilages. When lowering the dorsal septum, keep in mind the imp ortance of allowing for the thicker skin over the lower one third of the nose. Also, recogniz e that inadequate resection at the supratip may result in a polly-beak defor­ mity. (Appendix G) [Note: The dissector may wish to incise the skin/soft-tissue envelope down the midline either now or subsequent to this chapter. The hump excision may be done first, and then split the skin to exami ne the result and allow easy exposure for subsequent maneuvers. If the dissector intends to augment the dorsum with a cartilage graft, this may be done first, and then split the skin for easy exposure during the remaining dissection. The skin in the midlin e can be sutured back together as desired at any time.] Expose the cartilaginous dorsum with a Conv erse retractor, and use a no. 15 blade to in­ cise lightl y any remaining soft tissue overlying the cartilaginous dorsum. Reflect this tis­ sue laterally on both sides. Next, beginn ing at the osseocartilaginous junction and pro­ ceeding caudally, incise the cartilag inous dorsum at the planned level of initial excision (Figs. 1 and 2). Try to keep this incision eve n on both sides, but remember that there will be additio nal "fine-tuning" modifications after initial hump excision. Unde r dire ct vision, place an osteotome agai nst the bon y hump at the osseocartilaginous junction (Fig. 3). Use the incised but attac hed cartilagino us dorsum to help seat the os­ teotome at this locat ion. With a gentle, controlled two-tap technique, incise the bony hump with the osteotome (Fig. 4). Take care not to overresect the bon y hump , as the osteotome will tend to cut deepe r into the bone . Remove the hump with a hemo stat or similar instru­ ment , and examine its features (1,2). When exec uting hump excision , preserve the underlying nasal mucoperichondrium. The nasal mucoperi chondr ium provides support to the upper lateral cartilages and help s de­ crea se the risk of inferomedi al collapse of the upper lateral cartilages after hump excision (Fig. 5). [Inferomedi al collapse of the upper lateral cart ilages and inadequate infracture of

59

Figure 1. Beginning at the osseocartilaginous junction and proceeding caudally, incise the cartilaginous dorsum at the planned level of initial excision. This amount of excision is larger than normally performed. Most patients would require smaller dorsal hump excisions .

Figure 2. At this stage, the cartilage remains attached osseocart ilaginous junction.

Figure 3. Under direct VISion, insinuate an osteotome against the bony hump at the osseocartilaginous junct ion. Use the incised but attached cartilaginous dorsum to help seat the osteotome at this location.

Figure 4. A,S: With a gentle, controlled, two-tap technique , incise the bony hump w osteotome . Careful examination of the excised hump can help guide additional cali excision of remnant cartilage or bone. Assess whethe r the nasal mucoperichondrium successfully avoided . C,D: Patient underwent dorsal hump excision and application o graft. E.F: Conservative dorsal hump excision leaving high profile.

B

c

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_

D

F

61

Figure 5. Cross-section at the level of the cartilaginous vault (A). The nasal mucoperichon­ drium provides support to the up­ per lateral cartilages and helps decrease the risk of inferomedial collapse of the upper lateral car­ tilages after hump excision (B, e). When the nasal mucoperi­ chondrium is violated, inferome­ dial collapse of the upper lateral cartilages may occur (D, E). A

B

E

the nasal bones can lead to an "inverted V deformity," in which the upper lateral c collapse inferomedially, and the caudal edges of the nasal bones are visible in broa creating an unacceptable appearance.] (3,4 ) (Appendix G) Now make additional fine-tuning modifications to the cartilaginous dorsum as in Examination of the excised hump may guide any additional excision. Trim the (dorsal) margins of the upper lateral cartilages such that they lie on a level with or low that of the trimmed border of the septum. Additional modification of the bony also may be required. An "open roof" may be created by hump removal. The bony margin s should smoothed with a rasp by using few but firm strokes (Fig. 6). Any bony fragments s removed, making sure that all obvious particles are removed from under the s tissue envelope. An alternative to the manual rasp is a powered reciprocating rasp or sheathed bu 7 and 8) (5). These instruments can be used wherever a manual rasp would be used , less soft-tissue trauma. The site to be treated can be directly visualized. The pow struments are especially useful to smooth the bony marg ins of the open roof. They useful to correct isolated bony irregularities that may be encountered, for example ond ary rhinoplasty. It appears that a more reproducible result can be obtained with incidence of visible or palpable bony dorsal irregularities. After rasping or burrin particles should be irrigated from the surgical site .

Figure 6. Smooth the bony margins with a rasp by using few but firm strokes , cutting only on the downstroke.

Figure 7. The powered reciprocating rasp is an alternative to the manual rasp.

Figure 8. The powered sheathed suction bur is an alternative to the manual rasp.

[Note: This is one approach to hump excision. Another approach is described here some cases, the surgeon may wish first to separate the upper lateral cartilages from the d sal septum. This is accomplished in the submucoperichondrial plane and can be readily complished through the hemitransfixion incision or external rhinoplasty approach (Fig. Then rather tban excising the entire cartilaginou s hump , only a strip of dorsal septum is cised. The remainder of the hump excision proceeds as described earlier; tbe upper late cartilages are then shaved down individually so that they are at the same level as the dor septum.] This method is good for excision of large dorsal humps where preservati on of m cosal cont inuity may be otherwi se difficult.

PEARLS

• Two-tap technique: Overzealous force on the osteotome may lead to loss ~f control and undesired under- or overresect ion of the dorsal hump . A controlled exci­ sion of the bony dorsum is best ach i~ved with a careful , repeated 'two-tap tech­ nique designed to advance the osteotome only a short distance at a time. • The surgeon should be sure that theosteotomesare sharp to allow precise bone cuts. . . • .In cases with large dorsal humps, an extramu cosal reduction can be performed by dissecting mucos a off the undersurface of the middle and upper vaults. . . • The beginning surgeon may wish to premark the proposed hump excision on the nasal skin . . • If the surgeon feels uncomfortable using an osteotome for dorsal-hump removal , a sharp rasp will be effective with less risk of overresection. • The perio steum must be cleared f rom the bone prior to rasping to insure effective lowering of the bone. • Most dorsal humps are primar ily cartil aginous. Therefore, the dissector should limit excision ofthe bony vault : .. ' .

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Figure 9. A-E: Division of the upper lateral cartilages from their attachment to the dorsal septum in the submucoperichondrial plane. Great care should be taken to preserve an intact mucoperichondrium.

F

E

G Figure 9, continued. F: Division of the upper lateral cartilage from the attachment to the dor­ sal septum , with dissection of a submucoperichondrial flap, may be accomplished from above , as shown here via the external rhinoplasty approach . G: This dissection begins at the anterior septal angle, and then subperichrondrial dissect ion is performed .Completed di­ vision of upper lateral cartilages from septum.

REFERENCES

I. Tardy ME . Rhinoplasty: the art and the science. Philadel phia : WB Saunders, 1997. 2. Larrabee WF Jr. Open rhinoplasty and the upper third of the nose . Facial Plast Surg Clin North Am 19 23-3 8. 3. Johnson CM Jr, Toriumi DM . Open struc ture rhinoplasty. Philadelphia : WE Sa unders, 1990. 4. Toriurni DM. Man agement of the midd le nasal vault. Oper Tech Plast Reconstr Surg 1995;2:16- 30. 5. Bec ker DG, Toriumi DM . Gross CW , Tard y ME . Powered instrumentation for dorsal nasa l redu ction. F Plast Surg 1997 ;13:291-297 .

7 Osteotomies

MEDIAL OSTEOTOMIES To perform medial osteotomies, insert the osteotome at the jun ction between the nasal bone and sep tum. With the two-tap technique, advance the cutting edge cephalad and fade laterally as the frontal bone is reached (Fig. 1). Control the sharp leading edge of the chisel, as it moves under the skin, with the forefinger of the nondominant hand . Thi s fading me­ dial osteotomy avoids the thick frontal bone. Medial osteotomies are usually not necessary in cases in which large dorsal humps are excised, leaving an open-roof deformity .

LATERAL OSTEOTOMIES AND INFRACTURE [Note : The dissector may wish to mark the site of the propo sed osteot omy on the skin be­ fore proceedin g. Perform the lateral osteotomy on one side, and then reflec t the skin/soft­ tissue envelope laterally to exa mine it. Is it in proper position? Is the periosteum intact, or has it been violated? Is the mucoperio steum intact? After assessing the first lateral osteotomy, the skin of the oppo site side may be reflected before the osteotomy. Th is will allow observation of the osteotom y unde r direct vision.] T he lateral osteotomi es run from the most lateral point of the pyriform aperture to a point medial to the inner ca nthus of the eye, taking a high to low to high path . In practice, this means a starting point 3 mm to 4 mm abo ve the base of the pyriform aperture and adja cent to the head of the inferior turbinate. The high-to-low lateral osteotomy preserves a small triangle of bone at the base of the pyriform aperture (Fig . 2). Use a 2-mm (unguarded ) or 3-mm (guarded or unguarded) curved or flat osteotom e. Use a guarded or unguarded os­ teotome based on preference. Make a small incision near the base of the pyriform apertur e. Althou gh it is not essen­ tial, many surgeons create a short subperiosteal tunnel along the path of the proposed lat­ eral osteotomy . Seat the osteotome on the bone 3 mm to 4 mm above the base of the pyri­ form aperture, and use a gentle two-tap technique to advance the osteotome gradually. Angle the osteotome in a posterior and cephalic direction initially, and then adjust the os­ teotome so that the cutting edge travels toward a point medi al to the inner canthus of the eye. Thi s creates the typical high-to-low-to-high lateral osteotomy . Control the cutting edge by palpation with the thumb or fingers of the nondominant hand as the osteotome travels toward the inner canthus. When the osteotome approaches the level of the inner canthus,

67

Figure 1. Fading medial osteotomies. Place an osteotome flat against the septum with the edge facing laterally . Control the sharp leading edge of the chisel , as it moves under the skin, with the forefinger of the nondominant hand. Avoid the thick frontal bone.

Figure 2. Lateral osteotomies should be started from a 3 mm to 4 mm above the base of the pyriform aperture point adjacent to the inner canthus of the eye. Some plasty surgeons find it helpful to mark the proposed line osteotomy on the skin before executing this maneuver.

rotate the osteotome clockwise on the patient' s right side and counterclockwise on th side. This will normally fracture the nasal bone inward creating a controlled backfrac It may be necessary to complete the fracture with thumb pressure . INTERMEDIATE OSTEOTOMIES

An osteotomy between the medial and lateral osteotomies is occasionally indicated. cific indicat ions include the abnormally contoured nasal bone that is either excessively vex or conc ave. Intermediate osteotomies are most effective for decreasing the curvatu an excessively convex nasal bone. The intermediate osteotomy allows recontouring o nasal bone for correction of the severely deviated bony vault. This osteotomy is perfo before the lateral osteotomy. A 2-mm transcutaneous osteotomy performed midway u nasal bone is typically used to complete the intermediate osteotomy .

PEARLS .

• Medial osteotomies are performed to control the backfracture of the nasal bon after lateral osteotomies. If a large dorsal-hump removal was performed, leavin an open roof, it may not be necessary to perform medial osteotomies. • High-to-low-to-high lateral osteotomies are performed to leave a small triangle bone at the base of the pyriform aperture and. prevent medialization of the inferi turbinate. " • The dorsal nasal septum at the level of the bony vault must be midline to allo symmetric medialization of the nasal bones; If there is difficulty medializing t nasal bones , a blade handle can be used to shift the bony septum to the midlin with the nasal bones : . ' • If greenstick fracture is noted, a transcutaneous 2-mm osteotome can be used complete the backfracture and infracttire the nasal bone, • Greenstick fractures are acceptable in older patients .

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REFERENCES I. Tardy ME. Rhinoplasty: the art and the science. Philadelphia: WB Saunders, 1997. 2. Larrabee WF Jr. Open rhinoplasty and the upper third of the nose. Facial Plast Surg Clin North Am 1993; 1: 23-28. 3. Johnson CM Jr, Toriumi DM. Open structure rhinoplasty. Philadelphia: WB Saunders, 1990. 4. Murakami CS, Larrabee WF. Comparison of osteotomy techniques in the treatment of nasal fractures. Facial Plast Surg 1992;8:209-219.

5. Farrior RT. The osteotomy in rhinoplasty. Laryngoscope 1978;88: 1449. 6. Thomas JR, Griner NR, Remmler DJ. Steps for a safer method of osteotomies in rhinoplasty. Laryngoscope 1987;97:746-747.

8 Spreader Grafts

Spreader grafts may be placed endonasally or via the external rhinoplasty approach. If en­ donasal placement of spreader grafts is done in this dissection, undertake this before hump reduction and osteotomies. Through a small (5-mm) mucosal incision near the anterior septal angle, develop a pre­ cise subperichondrial pocket along the length of the cartilaginous dorsum near the junction of the dorsal septum and upper lateral cartilage (Fig. 1). A Cottle or Freer elevator can be used to elevate the subperichondrial tunnels. Special care must be taken to get into the sub­ perichondrial plane; otherwise, the mucosa may tear. Additionally, avoid pushing the ele­ vator through the septum to the other side. Fashion rectangular spreader grafts that extend from the osseocartilaginous junction to the internal nasal valve where the upper lateral car­ tilage meets the dorsal septum. Appropriate thickness can be determined to achieve the de­ sired functional effect without causing excessive widening, usually I mm to 3 mm in thick­ ness. Experience is required to develop reliable surgical judgment regarding the appropriate width and length of spreader grafts. Insert the grafts into the precise subperi­ chondrial tunnels, taking great care to preserve the mucosa (see Fig. 1). [Note: After placing endonasal spreader grafts, return to Chapter 6 and perform hump excision and then osteotomies. To exam.ine the precise pocket that was made before hump removal, separate the upper lateral cartilage from the septum, as described below and il­ lustrated in Fig. 2.] Division of the upper lateral cartilages from their attachment to the dorsal septum is un­ dertaken in the submucoperichondrial plane (see Fig. 2). This may be done before hump excision, or in cases in which no hump excision is necessary. Alternatively, this maneuver may be undertaken after hump excision. Again, great care should be taken to preserve an intact mucoperichondrium. The accompanying figures (Figs. 2 through 6) illustrate placement of spreader grafts through the external rhinoplasty approach. At this point, the dissector should have under­ taken hump reduction and osteotomies. (If hump removal has not been completed, return to Chapter 6). Spreader grafts are placed into pockets between upper lateral cartilage and dorsal septum (Figs. 3 and 4). A typical graft extends from the osseocartilaginous junction to the anterior septal angle. The spreader grafts are secured with absorbable suture [we rec­ ommend 5-0 polydioxanone suture (PDS), Monacryl, or other similar suture]. The spreader

71

A

C Figure 1. A-D: Placement of spreader grafts via endonasal approach. A: Mucoperichondrial incision down to the cartilage. B: Careful elevation of subperichondrial tunnel. C: Spreader grafts . D: Insertion of spreader grafts .

D

E,F

G Figure 2. Division of the upper lateral cartilages from their attachment to the dorsal septum in the sub­ mucoperichondrial plane. Great care should be taken to preserve an intact mucoperichondrium.

A

B Figure 3. A: Spreader grafts are placed into a pocket between upper lateral cartilage and dorsal septum. A typical graft extends from the osseocartilaginous junct ion to the anterior septal angle . 8, C: A spreader graft has been carved and is positioned between the dorsal septum and upper lateral cartilage.

Figure 4. A-C: Bilateral spreader grafts in submucoperichondrial pocket between upper lateral carti­ lage and septum.

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Figure 5. Spreader grafts may be secured first with ab­ sorbable suture to the septum to stabilize them in position. (We recommend 5-0 PDS, or other similar suture).

Figure 6. Spreader grafts sutured into position. Several hor­

izontal mattress sutures secure the spreader grafts and up­

per lateral cartilages . A needle of adequate size (such as a

PS-2) facilitates engaging all structures (upper lateral carti­

lage-to-spreader graft-to-septum-to-spreader graft-to-upper

lateral cartilage) in a single pass. Note how this suture

passes through the dorsal edge of the upper lateral cartilage.

grafts may be secured first to the septum to stabilize them in position (Fig. 5). Alterna tively (and commo nly), simply engage all structures (upper lateral cartilage-to-spreader graft-to­ septum-to-spreader graft-to-upper lateral cartil age) with a single mattress suture (Fig. 6). An additional horizontal mattr ess suture may be necessary to secure the spreader grafts and upper lateral cartilages in position . A needle of adequ ate size (such as a PS-2) facilit ates en­ gaging all structures in a single pass (Fig. 6). Do not cinch down the mattress sutures too tightly or inferiorly, or else the upper lateral cartila ges may actually be forced mediall y.

SPREADER GRAFTS In the absence of other causes of nasal obstruction , the nasal valve and nasal valve area constitute the flow -limiting seg ment of the nose. Th e nasal valve is bounded by the caudal border of the upper lateral cartilage and the nasal septum, which join at an angle of 9 de­ grees to 15 degree s in the norm al Caucasian nose (Fig. 7). A valve fulfills the definition of a movable structure that regulates the flow of gas or fluid. The nasal valve area includes the cross-sectional area described by the nasal valve and is affected by the in ferior turbinate, the caudal septum, and the tissues surrounding the pyriform aperture (Fig. 7). The nasal valve area is con sidered to be the location of the least cross-s ectional area in the nose and is belie ved to regulate significantly both nasal airflow and resistance and the velocity and shape of the air stream. The nasal valve area is the major flow -resisti ve segment of the nasal airway (I ). An overnarrow nose in the middle third, whether congenital or (more commonly) the consequence of previous surgery or trauma, requires cartilage graft augmentation to im­ prove the airway and restore aesthetic balance. Examinati on may reveal an overnarrow an­

Figure 7. Nasal valve and nasal valve area.

gle at the nasal valve area, medi al coll apse of the valve on even modes t inspi ration, or col lapse of the upper lateral cartilage against the septal wall , effecti vely compromising the air way. Spreader graft s act as spacers between the upper lateral cartila ge and septum, cor recting an overnarrow middl e vault and internal nasal valv e or preventing excessive narrow ing in the high-risk patient (2-10). A submucoperichondrial tunnel on one or both sides of the dorsal aspect of the septum may be prep ared by elev ating the mucoperichondrium bridging the upper lateral cartilages to the septum. Thi s dissection provides a space to be filled by a cartilage graft insinuated into the pocket, lateralizing the upper lateral cartil age(s), improving the airw ay and effec­ tivel y widenin g, when indic ated , the appearance of the middle third of the nose. In our ex­ perience, spreader grafts are mo re effective when the fibrous connections between the dor­ sal septum and upper lateral cartilage are left intact. Applicati on of the spreader grafts creates a cantilever effect and aids in lateralizing the upper lateral cartilage to provide max­ imal airway improvement. Whereas spreader grafts may be comfortably carried out through traditional endonasa techniques (2), in more complex recon structi ons, particularly complicated by multiple ab­ norm alities, an external rhinopl asty approach may facilitate accurate dissection and graf suture fixation (6) . When the T-shaped configuration (horizontal exten sion) of the nasal septum is resected with dorsal-hump remov al, narrowing of the middle nasal vault may be problematic in the high-ri sk patient. Identifying the high -risk patient during initial preoperative analy sis is es­ sential to the prevention of excessi ve narrowing of the middle nasal vault with internal nasal valve collapse. An anatomic variant referred to as the "narrow-nose syndrome" has been described (2,6). Short nasal bones, long weak upper lateral cartilages, thin skin, and a narrow projecting nose pred ispose to middle vault collapse . A large en bloc hump re­ moval should be avoided, as the T-sh aped horizontal support of the nasal septum is elimi­ nated and the intran asal mucosa (which provides support to the upper lateral cartilage) is at risk of injury . Regardles s of the approach to the middle vault, keepin g the intrana sal mu­ cosa intact with execution of profile alignment (dorsal-hump removal) helps maintain im­ portant support of the upper lateral cartilages (see Chapter 6, Fig. 5). This can be achieved by dissectin g submucosal tunnels and freeing the upper lateral cartilages from the septum before cartil aginou s hump remov al. Alternatively, conservative hump excision followed by millimeter-by-mill imeter shaving of the upper later als under direct vision preserve s the in­ tranasal muco sa. Coll apse of the middle nasal vault may highlight the caudal edges of the nasal bones to produce the characteristic "inverted V" deformity (Appendix G) . When the dorsal hump has been taken down and the upper lateral cart ilages appear desta­ bilized , such as in the high-risk patient, suturing the upper lateral cartilages back to the sep­ tum can be helpful to prevent middle nasal vault collapse. Spreader graft s applied between

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pre ser ve an ade quate nasal valve. An external rhinoplasty approach may faci litate accurate graft-suture fixa tion in this setting. These precautionary maneuvers are not necessary in all cases but may prevent problems in the high-risk pati en t (6) . Commo nly performed surg ical maneuvers can result in loss of support to the midd le vault. Cephalic him (volume redu ction) of the lateral crura disrupts the scro ll (rec urvature) and frees the ca uda l margi n of the upper lateral cart ilage . Lateral osteotomies may further medi­ alize the upper lateral cart ilages . T he upper lateral car tilages can fall toward the narrowed dorsal sept al edge, producing narr owin g of the middl e vault and internal valv ular collapse. In the majority of pa tients, the combi nation of these m aneu vers will not result in a pro blem; however, in high-ri sk patients (narrow-nose syndrome), this combination of maneu vers may co ntri bute to excessive narr owin g of the middle vault with internal valve co llapse. W hen spreader grafts are used, appropria te spreader-graft thickn ess will achieve the de­ sired fun ction al effect wi tho ut causi ng overwide ning . Great care sho uld be taken to avoid overwide ning if poss ible. Experi ence is required to deve lop relia ble surg ical judgment re­ garding the appropriate width and length of spreade r grafts. Careful palp ation of both up­ per lateral cartilages can aid in ver ifying symmetry of the middle nasal vaults. Spreader grafts are usually 1 mm to 3 mm in thickness . It is ge nerally better to use thin ­ ner spreader grafts because if the midd le vault is too wide, rev isio n surgery wi ll be nece s­ sary. After spreader grafts are secured in pos ition via the externa l app roach , or if they are placed endo nasa lly after dissection of the soft-tissue enve lope , the middl e-vaul t width can be assessed by inspect ion and palpa tion . T he middle vault sho uld be no wider than the bony vault and nan-ower tha n the nasal tip. If excessive width or asymm etry is noted, the grafts should be rep osition ed or narrowed, O ver time, this area of the nose tend s to nalTOW as edema resolv es and sca r contracture pulls the upper lateral cartilages mediall y. Asy mme try of the middle nasal vau lt may at times be addressed with the placement of a unilateral spreader gra ft, or alterna tive ly, with the placement of sprea der grafts of unequ al thickn ess (Fig . 8) ( 10). In most cases, we prefer to use bilateral spreader grafts to splint de­ viations of the dorsal sep tum and preven t worsening of the dorsal septal devia tion. A variety of other maneuvers are at the surgeon ' s disposal in addressing the middle nasal vault. O nlay cartilage wafer grafts, derived from the sep tu m or ea r, effective ly ef­ fac e and imp rove middle-third depression s, but may be used to improve aes thetics only when airway blockage does not exist as a co nse que nce of midd le-va ult co llapse . Ca reful preop erati ve ana lysis sho uld determine the need for ot her supportive and reco nstruc tive

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Figure 8. Spreader grafts may be applied unilaterally or asymmetrically to camouflage asymmetry of the middle nasal vault.

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Figure 9. Coronal sinus computed tomography scan in a patient with nasal obstructio lustrating obstructing concha bullosa .

maneu vers, such as conchal cartilage grafts to restore support to a colla psed lateral n wall. External valve collapse and the potential need for alar batten grafts also shoul evaluated.

PEARLS

• If there is difficulty in spreader-graft placement by using an external approach check the expo sure. A common mistake is a failure to carry the marginal incision and dissection over the lateral crura laterally enough, limiting exposure. Extend ing this incision and dissection appropriately will improve exposure of the middl nasal vault and greatly facilitate spreader-graft placement. • Double check middle-vault width and symmetry after applying spreader grafts Careful palpation will allow preci se assessment of middle-vault width. • Spreader grafts applied into preci se submucosal tunnels iritroduce bulk under the intact connection between the upper lateral cartilage and dorsal septum. Th spreader graft creates a cantilever effect and effectively .lateralizes the collapsed upper later al cartil age. • When securing spreader graft s via suture fixation, gently stretch the upper latera cartilage toward the anterior septal angle to ensure that they are not buckled. Th suture will place gentle traction on the upper lateral cartilages to prevent buckling After completing suture fixation, inspect the upper lateral cartilages to be sure tha they are not buckled (6) . . . • In considering nasal ob stru ction , co mplete evaluation is critical. Cau ses of nasa obstruction include allergic rhinitis, chronic sinusitis; rhinitis med icamentosa nasal pol yps, deviated septum, internal and external nasal-valve collapse, and oth ers. One commonly overlooked cause of nasal obstruction is a concha bullosa, o aerated middl e turbinate (Fig. 9), which can be most easily recognized on nasal en dos~opy or coronal computed tomography scan. .

a

REFERENCES

I. Tardy ME. Surgical anatomy of the nose. New York: Raven, 1990. 2. Sheen JH. Spreader graft: a method of reconstructing the roof of the midd le nasal vault following rhin op Plast Recon str Surg 1984;73:230-237.

4. Johnson CM, Toriumi DM. Open structure rhin oplasty. Philadelphi a: WB Saunders, 1990. 5. Toriumi DM , Johnson CM . Open structure rhinopla sty: featured techni cal point s and long-term follow-up . Facial Plast Surg Clin North Am 1993 ; I:1-22. 6. Torium i DM . Mana gement of the middle nasal vault in rhinoplasty . Oper Tech Plast Reconst r Sur g 1995 ;2: 16-30. 7. Constantian MB, Clardy RB. The relativ e importanc e of septal and nasal valvular surgery in correcting air­ way obstruction in primary and secondary rhinoplasty. Plast Recon str Su rg 1996;98:38-54. 8. Te ichgrae ber JF, Wainwri ght DJ. The treatm ent of nasal valve obstructi on. Plast Re constr Surg 1994;9 3: 1174-11 84. 9. Aiach G. Atlas de rhinopl astie. Paris: Masson , J 989:74-85. 10. Toriurni DM, Ries WR. Innovativ e surgical managem ent of the croo ked nose. Facial Plast Su rg Clin No rth A/11 1993;1:63-78.

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9 Surgery of the Nasal Tip

EXERCISES (Appendix F) Placement of Columellar Strut The placement of a rectangul ar cartil age strut between the medial crura can improve tip support and augment tip projection. A columellar strut also can be used to correct buckled medi al or intermediate crura or to increase columellar show. The strut may be placed by us­ ing the externa l approac h or into a precise pocket via the endonasal approach.

Placement of Columellar Strut via an External Rhinoplasty Approach The area between the medial crura is dissected to create a pocket to place the strut. The rect­ angular cartilage strut typically measures 8 mm to 12 rnm in length, 3 mm to 4 mm in width, and 1 mm to 2 mm in thickness. Th e strut is most typically fashioned from harvested septal cart ilage, but also, when necessary, from auricul ar cart ilage, and at times from rib cartilage. The strut is positioned so that it sits above (without extending to) the nasal spine (Fig. 1). It is preferable to leave a small soft-tissue pad between the strut and the nasal spine. The strut should not extend above the intermediate crura . It is secured to the medial crura with several absorbable mattress sutures (e.g., 4-0 plain gut, Keith needle) placed through the vestibular skin. Asymme tries of the lower lateral cartilage (LLC) may be improved with placement of the strut (Fig. 2). Asymmetry of the tip may be created if the medial crura are asymmet rically sutured to the strut (Fig. 3), or if an overlong strut extending beyond the nasal spine shifts to the side of the nasal spine, thereby causing a deviated nasal tip (Fig. 3) ( 1,2).

Placem ent of Columellar Strut via an Endonasal Approach A small incision is made throu gh the vestibular skin and ipsilateral medial cr us (Fig. 4). Scissor dissecti on creat es a precise pocket through this small incision (Fig. 5). The col­

81

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Figure 1. Placement of columellar strut. A, B: The strut sits above (without extending to) the nasal spine, and it should not extend above the intermediate crura. C-F: A columellar strut may be placed via the external rhinoplasty approach . With proper exposure achieved (C), dissection of a pocket between the medial crura is undertaken (0) . The carved columellar strut is placed in the pocket, as described ear­ lier (E) and secured with interrupted 4-0 plain gut on a straight septal (Keith) needle (F).

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Figure 2. A-D: Asymmetries of the lower lateral cartilage may be improved with placement of the strut.

A

B

Figure 3. Asymmetry may be created if the medial crura are asymmetrically attached to the strut (A), or if an overlong strut extending beyond the nasal spine "slips" to the side of the nasal spine, thereby causing a deviated nasal tip (8).

Figure 4. Placement of columellar strut via an endonasal ap­

proach. First, an incision is made through the vest ibular skin

and ipsilateral medial crus.

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Figure 5. Scissor dissection creates a precise pocket.

Figure 6. The columellar strut is inserted into the precis pocket.

umellar strut is inserted into the preci se pocket (Fig. 6) and is manipulated into proper po sition (Fig . 7). A 5-0 chromic mattre ss suture can be used to fix the strut between the me dial crura . The incision is closed with a single absorbable suture (3).

Identify the Dome

Identify the dome and approximate the lateral and medial crura at the dome with a pair o multitoothed Brown-Adson forceps. The line of the dom e should be at approximately 3 degrees to the sagittal plane .

Figure 7. Completed placement of columellar strut via an endonasal approach.

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Identify the scroll region, the cephalic border of the LLC (Fig. 8). Excise the cephalic por­ tion of the LLC by making an incision parallel to the caudal margin with the 15 blade and then peeling off the cephalic portion , leaving the vestibular skin behind. The line of inci­ sion parallel s the caudal margin of the LLC. Leave at least 7 mm to 9 mm of intact carti­ lage . This preserves an intact strip of cartilage from the feet of the medial crura to the most lateral part of the lateral crus. This will produce conservative narrowing of the nasal tip.

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c Figure 8. Cephalic resection of lateral crura of lower lateral cartilages.

Now apply domal/transdornal suture s as outlined.

Place Individual Horizontal Mattress Domal Sutures

For domal sutures (Fig . 9), a mattres s suture of 5-0 polydiox anone suture (PDS) or oth appropriate suture is passed through each dome, and the knot of each mattre ss suture is ti between the domes. As the sutures are secured, narrowing of the tip is accomplished. A interdomal suture sets the width between the domes. If stiff nasal-tip cartilages are e countered, the surgeon should use 5-0 clear nylon instead of PDS (4-6).

Place Single Transdomal Suture

Alternatively, a single transdomal suture that traver ses both domes may be placed, in li of two individual domal sutures and an interdomal suture (Fig . 10) (1-3). The caudal pa should be slightly longer than the cephalic pass of the mattress suture . When the mattre suture is placed in this fashion, the caudal edge will tend to lead the cephalic edge as t suture is tightened. This creates a more favorable tip-supratip relation . If the cephalic ed leads the caudal edge of the lateral crus despite proper placement of the domal suture, small cephalic wedge of the cartilage may be excised and the edges sutured, which repos tions the cephalic edge lower in relation to the caudal edge (Fig. 11).

A,B Figure 9. Individual horizontal mattress domal sutures. The caudal pass is slightly longer than the cephalic pass of the mattress suture . As the sutures are secured, narrowing of the tip is accomplished. An interdomal suture is placed between the two domes, securing the interdomal distance.

B

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Figure 10. A, B: A single transdomal suture may be placed in lieu of two individual domal sutures and an interdomal suture. C-J: Patient with trapezoidal tip and broad domal angles. Transdomal suture tech­ niques were used to improve the patient's tip triangularity as seen in preoperative (G, E, G, I) and post­ operative (0, F, H, J) photographs. K-Z: Patient with trapezoidal asymmetric nasal tip. Columellar strut and transdomal suture techniques were useful to improve tip symmetry and triangularity. K, L: Preop­ erative frontal and base view. M, N: Graphic operative worksheet (Gunter diagram) . O-Q: Intraopera­ tive photographs illustrating placement of columellar strut and suture techniques . R-V: Preoperative (R, T, V, X) and postoperative (S, U, W, V) photographs .

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B Figure 11. If the cephalic edge leads the caudal edge of the lateral crus despite proper placement of domal suture , a small cephalic wedge of the cartilage may be excised , and the edges sutured, which repositions the cephalic edge lower in relation to the caudal edge . In this figure, one lower lateral cartilage illustrates the wedge excised, and the other illustrates the edges resutured (A). B: The effect of this maneuver on the relationship between the cephalic and caudal edge is illustrated .

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Figure 12. A, 8 : Lateral crural steal. When the horizontal mattress domal sutures take a larger bite of lateral crus , a portion of the lateral crus is "borrowed" by the medial crus . The "medial crural" 1eg of the tripod is lengthened , whereas the "lateral crural" legs of the tripod are shortened (see Appendices A and F). This results in increased projection and rotation. Tip refinement also is achieved, as with a standard domal suture. C-F: Rotation of this patient's nasal tip was achieved by using the lateral crural steal tech­ nique and by suturing medial crura back on overly-long midline caudal septum .

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Lateral crural steal (Fig. 12) is an effective method for increasing tip projection and rota­ tion (7). When the horizontal mattress domal sutures take a larger bite of lateral cru s, a por­ tion of the lateral crus is shift ed mediall y. Th e " medial crura]" leg of the tripod is length­ ened , where as the "lateral crural" legs of the tripod are shortened (see Appendices A and F); the result is increased proj ection and rotation . Tip refinement also is achiev ed, as with a standard dom al suture.

Further Refinement with Dome Division with Intact Vestibular Skin and Suture Reconstitution We rarely divide the domes, but when this technique is performed, it is usually in the thick­ skinned patient. In most cases, we use some form of dome-binding suture to change tip con­ tour (8). Rem ove the transdomal sutu res to perform this maneu ver. Dividing the dome by verti­ cal incision allows further narrowing of the nasal lobule. Proje ction also can be alte red by removal of a superiorly based triangle of cartilage lateral or medi al to the vertic al incision. By excising a larger amount of car tilage along the cephalic margin of the later al crus, the cephalic dom e can be positioned below the caud al dome (Fig . ]3 ).

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Figure 13. Divide the dome by vertical incision. Reapproximate the divided cartilages with suture (e.g ., 6-0 PDS) to secure the position of the cartilage and reconstitute the intact strip.

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Figure 14. Suture reappro ximation of divid ed lower lateral cartilages is undertaken simple interrupted stitches. Mattress stitches in this situation may result in overn arrowin

Reapproximate the divided cartilages with 6-0 PDS sutu re (Fig. 14). Th e plac emen sutures to reapproximate the div ided ca rtilage s afte r dome division secures the positio the cartilage and contributes to increa sed tip stability. Simple interrupted sutures are ferred to a mattress suture, because a mattr ess suture may exc ess ive ly narrow the tip ( 14). Note : We rarely perform dome di vision because we find less- aggre ssive techniq (dome-binding suture) very effective for mod ifying tip con tour. We try to avoid dome vision in patients with thin skin.

Lateral Crural Overlay

When the patient's anatomy calls for rotation and deproj ection, lateral crural overla one possibl e techn ique (Fig . 15) (7, 9). Th e lateral crura are incised lateral to the dom es. vestibular muco sa is elev ated from the undersurface of the lateral crus , and the medial tion is overlappe d over the later al and sec ured in place with sutures. When undert aking maneuver, great care must be taken to perform it symmetrically.

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J Figure 15. (left and above) A-J: Lateral crural overlay. Great care must be taken to perform this technique symmetrically.

97

Tip Graft

Sutured in place, shield-shaped tip grafts typically are used to increase tip projection and change tip contour (1,2). They also can be used to camouflage tip asymmetries. Tip grafts should be avoided in patients with thin skin. Carve a shield-shaped tip graft from the harvested septal cartilage. The width generally varies from 8 mm to 12 mrn at the leading edge . The length varies from 8 mm to 15 mm and thickness typically varies from I mm to 3 mm (Fig . 16). The graft is thicker at the lead ing edge and thinner at the base. One may consider cutting the graft larger at the leading edge to allow in situ carving once the graft is secured in position. The graft is sutured to the caudal margins of the medial/intermediate crura that have been stabilized by the sutured in-place columellar strut. An excessively thick tip graft will increase fullness in the infratip lobule . Secure the tip graft with 6-0 PDS or Monacryl sutures (Fig. 17). Four to six sutures are usually applied. Place the lower sutures first.

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Figure 17. A: The tip graft is sutured to the caudal margins of the medial/intermediate crura . Four to six 6-0 PDS sutures are typically placed . Place the middle sutures first. B, C: Intraoperative photographs il­ lustrating placement of tip graft.

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Figure 17, continued. D-K: Preoperative (D, F, H, J) and postoperative (E, G, I, K) photographs of a patient who underwent application of a tip graft . The tip graft was used to increase tip projection and pro­ vide a bidomal shape to the nasal tip. Please refer to text for a more detailed discussion of tip grafts.

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When placing a tip graft in a patient whose dome s have been divided (and suture recon­ stituted ), apply the tip graft so that it camoufl ages the caudal aspect of the cut dom es (Fig. 18), decreasing the risk that this point will be palpable or visible after surgery.

Figure 18. If a tip graft is applied in a patient with divided domes, the caudal aspect of the cut domes should be hidden behind the tip graft to decrease the risk of a palpable or visible point after surgery.

Cap or Buttress Graft

Typically, a tip graft should be projected 1 mm to 2 mm above the existing domes. In pa tient s with thick skin and an underpr ojected tip, a longer tip graft can be projected 2 mm t 4 mm above the existing domes. In these and other appropriate cases, a cap or buttress graf placed behind the leadin g edge of the tip graft may be useful to support the graft (particu larly softer, pliable auricul ar cartilage tip graft s) and to prevent excessive cephalic rotation of the graft under the tension of closure of the skin/soft-tissue envelope. Buttre ss grafts ar sutured to the tip graft and both domes by using 6-0 PDS or Monacryl suture (Fig. 19). The buttress grafts should creat e a smooth transition from the edge of the tip graft to the cauda margin of the lateral crura (2).

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Figure 19, continued. E-L: Preoperative (E, G, I, K) and postoperative (F, H, J, L) pho­ tographs of two patients who had tip grafts with cap-graft placement. Cap grafts were placed to support the leading edge of the grafts , prevent cephalic rotation of the graft, and ensure a smooth transition from the edge of the graft to lateral crus.

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Figure 19, continued. M, N: Intraoperative photograph illustrating tip graft with cap graft.

Alar Batten Graft The external nasal valve is composed of the cutaneous and skeletal support of the mobile alar side-wall. Overaggressive resection of the lateral crura during rhinoplasty and the sub­ sequent postop erati ve soft-tissue contraction may lead to internal and/or external nasal valve compromise. Ceph alic positioning of the lateral crura also will leave suboptimal structural support in the mobile alar side-wall (external valve collapse). Alar batten grafts , typically of curved septal or auricul ar cartilage, placed to support the alar rim, can correct internal or external nasal-valve coll apse (Fig. 20) (l0-12). Create a precise pocket for an alar batten graft. The graft is typically placed caudal to the lateral crura at the point of maximal lateral nasal wall collapse. Fashion a graft from har­ vested auricular or septal cartilage, and insert it into the precise pocket. The pocket is sub­ cutaneous and is placed at the point of maximal supr aalar collapse. Auricular cartilage is preferred becau se of the curvature of the cartilage. The convex side of the graft is oriented laterall y to correct the supraalar pinching. If this pock et is too superficial, the graft may be palpable or visible . When placed via an external rhinoplasty approach, secure the graft with a suture applied medially from the graft to adjacent soft tissue or lateral crus.

Figure 20. A: Alar batten graft .

B

Figure 20, continued. B, C: Intraoperative photographs illustrate location of alar batten graft placement, centered around the point of greatest weakness and concavity of the alar sidewall. The alar batten graft in this case has been fashioned with autogenous auricular cartilage.

D Figure 20, continued. D, E: Alar batten grafts may be placed via a precise pocket endonasal rhinoplasty approach .

with cephalic positioning of the lateral crura requiring alar batten grafts. Preoperative photographs (F-I).

F

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Figure 20 , continued. As demon­ strated on base view (J), gentle inspi­ ration results in valve collapse .

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S Figure 20, continued. The rhinoplasty worksheet (K-L) illustrates that this patient underwent septo­ plasty with cartilage harvest. She underwent conservative cephalic resection. She received a columel­ lar strut , plumping grafts , dorsal onlay grafts , spreader grafts , and alar batten grafts. Preoperative (M, 0, Q, S) and postoperative (N, P, R, T) photographs are seen here. Note the improvement in the nasal valve, best seen on base view.

crura. These grafts are shaped like lateral crura and measure approximately 5 mm in ver cal height. Auricular cartilage has the ideal curvature for lateral crural grafts. The grafts a sutured to the vestibular skin and medial or intermediate crura . Care is taken so the caud margins of the grafts are placed symmetrically; otherwise, there may be asymmetry of t alar rims. Grafts that are too large or curved may create a bulbous tip (2) (Fig. 21) .

Figure 21. Intraoperative photograph illustrating lateral cru­ ral grafts and a shield graft. The grafts are sutured to the vestibular skin and medial or intermediate crura.

PEARLS

Complete Strip • Although many surgeons perform cephalic trim of the lateral crura as a routine ma­ neuver during rhinoplasty, some patients have flat or concave lateral crura that do not contribute to tip bulbosity. Many of these patients do not need to undergo ' cephalic trim of the lateral crura. Cephalic trim should be performed when there is fullness (bulbosity) in the supratip or supraalar region due to protrusion ofthe cephalic margin of the lateral crura. : • The surgeon should leave 7 mm to 9 mm of lateral crus. This determination is made on a patient-to-patient basis. The strength of the lateral crura and alar side­ walls should be considered. With strong cartilages, more cartilage can be excised, and with weak cartilages, more cartilage should be preserved. . .. • Complete strip is illustrated here via the external rhinoplasty approach but was il- '. lustrated earlier in this text via the cartilage-splitting approach (Chapter 5, Figs. 1-3). In a cartilage-splitting approach, the attachments of the lateral crura to the skin/soft-tissue envelope are undisturbed, and a complete strip of 6 mm to 8 mm should be preserved. Cephalic resection of lateral crus may also be accomplished ' via the retrograde dissection approach and via the delivery approach; • Minimize lateral resection of the cephalic margin of the lateral crura. Change iri tip contour is primarily effected by niedial excision, and .lateral excision can con­ tribute to valve collapse and supraalar pinching, I' • Thin skin, strong cartilages, and bifidity is a cornmon triad that should be recog­ nized. These patients are at higher risk for bossa formation if excessive cartilage is excised from the cephalic margin of the lateral crura (Appendix G). . .

.PEARLS, continued Transdomal Sutures . • Tran sdomal suture placement can create excessive fullness in the infratip lobule.

The infratip lobule should be assessed after transdomal suture placement. Addi­

tionally , the lateral aspect of the lateral crura may medialize into the airway with

. placement of a transdomal suture. If this occurs, it may be necessary to apply lat- . . eral .crural strut grafts to straighten the lateral crura . On rare occasions, the lateral- ; most aspects of the lateral crura may need to be trimmed. . • .Separate dome binding sutures are better able to correct asymmetric domes . .. Tip Grafts • Before closure, all edges of the tip graft should be rounded off to prevent visibility

ofthe edges of the graft.

• Excessively stiff tip grafts should be crosshatched on the caudal surface to allow

cephalic bending and a good double break.

o Surgeons tend to make shield grafts too narrow. Most grafts should be approxi­

. matelyB mm to 10 mm in width at the leading edge : In male patients, the tip grafts

are generally wider, and typically measure 10 mm to 12 mm in width at the leading edge : · .. • Most cadaver specimens have thin, atrophic skin, so the tip graft will tend to be more

· . noticeable. Indeed, we try to avoid the use of tip grafts in patients with thin skin.

• Tip grafts are ideal for camouflaging subtle tip asymmetries.

Alar Batten Grafts . • Alar batten grafts may be placed via anextemal rhinoplasty approach or into apre­ cise pocket made through an endonasal incision. This graft is nonanatomic and is typically placed caudal to the lateral crura where there is maximal collapse of the lateral nasal wall and supraalar pinching. .• If alar batten grafts are placed too far cephalic, excessive fullness over the middle vault will be noted. • Patients should be told that there will be temporary fullness in the area of the graft.

This fullness will typically decrease over a 2- to 3-month period. .

. o For maximal support, the alar batten graft should extend over.the bone of the pyri­ form aperture. .

REFERENCES 1. Johnson CM, Toriumi DM. Open struc ture rhin opl asty. Philadelphia: WB Saunders, 1990. 2. Toriumi OM , Johnson CM . Open structure rhinoplasty: featured techn ical point s and lon g-term follo w-up . Facial Plast Surg CUll No rth Am 1993; I : 1-22. 3. Tard y ME . Rhin opla sty : the art and the scienc e. Phil adelphia: WB Saunde rs, 1997. 4. Tardy ME , Cheng E. Tran sdomal suture refinement of the nasal tip . Facial Pla st Surg 1987 ;4:317-326. 5. Tardy ME, Patt BS, Walter MA. Transdoma1 suture refinement of the nasal tip: long-term outco mes. Facial Plast Surg 1989;9:275-284. 6. Toriumi OM, Tardy ME. Cartil age suturing techniques for correction of nasal tip deformities. Oper Tech 010­ lary ngol Head Neck Surg 1995;6 :265- 273. 7. Konior RJ, Kridel RWH . Controlled nasal tip positionin g via the open rhinoplasty approach. Facial Plast Surg CUn No rth Am 1993; I:53- 62. 8. Simon s RL. Vertical dome di vision in rhinopl asty. Otolaryngol Clin Nor th Am 1987;20: 785-796. 9. Kridel RWH , Konior RJ. Cont rolled nasal tip rotati on via the lateral crur al overlay technique. Ar ch Otol Head NeckSurg 1991;117:411-415 . 10. Toriumi OM , Josen J, Weinberger MS , Tardy ME . Use of alar batten graft s for correction of nasal valve col­ lapse . Arch Otol Head Ne ck Surg 1997 ;123 :802-808. II . Con stanti an MB . The incompetent external nasal valve : pathoph ysiolo gy and treatment in primary and sec ­ ondary rhinoplasty. Plast Reconstr Su rg 1994 ;93:919-933. 12. Con stanti an MB , Clardy RB . T he relative importance of septal and nasal valvular surg ery in correcting air­ way obstructi on in primary and secondary rhinoplasty . Plast Reconstr Su rg 1996;98:38-54.

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10 Alar Base Resection

Follow the accompanying figures and text to perform alar base resections (1,2). Th e site of incisions and the amount, deg ree, and geometry of alar red uctions depend on a host of anatom ic variations predetermined before and durin g surgery . Alth ough the sur­ geo n's aesthe tic j udgment will ultimately determine the site and degree of resection, a more precise surgical approach may be determined if several anat omic guidelines are asses sed and inte grated . Co nservatism is mand atory to avoid overreductio n and asy mmetry, condi­ tion s that are difficult to correct satisfactorily. As the need for reductio n increases, both the incision and exc ision become more ex ten­ sive. Alar redu ction is a co mprom ise operation, in which gre ater reductions exa ct the penalty of a larger scar. The surgeon must balance this compromi se with experienced aes ­ thetic j udgment and prov en scar-camo uflage techniques. Skin sutures placed acro ss the alar-facial junction often lead to permanent suture marks. Effe ctive camouflage at the alar- facial junction may be facilitated by positioning incisions I mm to 2 mm above the alar- facia l junction. Skin clo sure can be pe rformed with a cyanoa crylate adhes ive (oc tyl-2 -cyanoacrylate, Dermabond ; Ethicon , Somerville, NJ , U.S.A.).

INTERNAL NOSTRIL FLOOR REDUCTION

In patients requiring minimal alar redu ction, ex cision of a wed ge of epithelium and soft tissue from the nostril flo or only (Fig. I) will slightly reduce the alar flare by reducing the dimension of the internal (medial) border. Althou gh the outward curve of the ala is altered, no medial repo sitioning of the alar-facial junction is effected . The scar is effectively hid­ den within the nostril floor if the nostril sill is not violated. At times , the sha pe of the nos­ tril sill will determine whether this approach is appropriate. Subtle, conservative , but ef­ fective improvements are possible with this approach . Th e dimension of the lateral alar border remains unchanged.

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WEDGE EXCISION OF NOSTRIL FLOOR AND SILL

Further reduction of alar flare is accompli shed by carry ing the incision acro ss the sill in the alar- facial jun ction I mm to 2 mm above the alar-facial crease. Reduction of flare well as slight reduction of the alar bulk is effected (Fig. 2).

ALAR WEDGE EXCISION

If the alar development is excessive and bulbous , excision of a wedge of ala at t alar-facial junction 1 mm to 2 mm above the alar-facial crease will reduce the overall bul iness of the alar anatomy (Fig. 3). Som e medi al repo sitioning of the alae may be effecte with this maneuv er. Reduction of the overall length of the alar sidewalls occurs when ge erou s wedges are excised, ideal in the reduction of the alar flare created when correctin the overprojecting tip. SLIDING ALAR FLAP

More substantial alar reduction with medi al repositioning is effected with a generous i cision above the alar- fac ial jun ction with variou s degree s of alar excision (Fig. 4). Redu tion of th e volume, curve, and flare of both the internal and external alar margins will r sult from this procedure, the extent of each dependent on the angulation of the alar incisio A backcut placed 2 mm above the alar-facial j unction allows the alar flap to slide mediall narr owing the alar base signifi cantly.

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Figure 2. Wedge excision of nostril floor and sill conservatively reduces flare as well as al bulk.

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A

Figure 3. Excision of a wedge of ala at the alar-facial junction 1 mm to 2 mm above the alar-facial crease will reduce the overall bulkiness of the alar anatomy. Some medial repo­ sitioning of the alae may be effected with this maneuver.

B

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Figure 4. Sliding alar flap typically incorporates a backcut to allow the alar sidewall to ad­ vance medially.

PEARLS . ' When performing alar base reduction, the surgeon should err onundercorrecting . the deforrnityto prevent resection of excessive tissue. Once too much tissue is ex­ cised, it is very difficult to correct ; be particularly conservative in male patients . • Internal alar base excision can significantly decrease the internal diameter of the nostril and should be performed in a conservative manrier. When performed, usu- . ally <2 mm of tissue is removed. • Ifan incision is made on the lateral surface of the ala, the incision should be made above the alar crease to minimize scarring. A cyanoacrylate adhesive (Der­ maborid; Ethicon, Somerville, NJ, U.S.A.) can be used to close the lateral alar in­ cision. • In the incision, the skin edges can be favorably beveled to maximize skin-edge eversion and avoid a depressed scar. ,

REFERENCES 1. Tard y ME, Patt BS, Walter MA . Alar reducti on and sculpture: anatomic co nce pts. Facial Plast Surg 1993;9: 295-305. 2. Becker DG, Weinberger MS, Greene BA, Tardy ME. Clinical study of alar anatomy and surgery of the alar base. Arch Otolaryngol Head Neck Surg 1997; 123:789-795.

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11 Other Maneuvers

PLUMPING GRAFTS Plumpin g grafts may be used to open up an acute nasolabial angle, improve a retracted columella, and support a deficient nasal base. Dissect a midcolumellar precise pocket to ju st above the nasal spine. Place multiple small pieces of cartilage (I rom to 2 mm), har­ vested from the septum or ear, in the pocket. These grafts will augment the deficient area (Fig. 1) (1,2). Plumping grafts placed below the medial crural footplates will increase sup­ port of the nasal base (Appendix F)

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CAUDAL EXTENSION GRAFTS

Caudal extension grafts have been described for use in correcting a retracted columell overrotated tip, short nose, or to increase tip support and projection (3) (Appendix F). Th graft is sutured to the caud al margin of the nasal septu m and is secured between the medi crura in the midlin e with 5-0 buried polydioxanone suture (PDS ) (Fig. 2). When suturin the caudal extension graft to the caudal septum, the caudal margin of the graft must be the precise midline. Devi ation off the midlin e will result in a deviation of the nasal base tip. It is critical to assess nasal projection, length, tip rotation, and alar/c olumellar relatio when position ing a caud al extens ion graft. Patient s should be told preoperati vely that the nasal tip will be stiffer, with loss of the norm al tip recoil.

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Figure 2. A caudal extension graft may at times be useful to correct retraction of the colum­ ella (A) . In this patient example (preoper ative, B-E; postoperative, F-I) , a caudal extension graft, harvested from the patient's posterior septal cartilage, was used to address the re­ tracted columella .

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Figure 2, continued. This intraoperative sequence illustrates placement of the graft, ex­ tending beyond the caudal septum (J, K). The caudal septum in this patient was deviated towa rd his left, so the graft was placed to take advantage of the slight curvature of the graft to achieve a midline position.

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DEVIATED CAUDAL SEPTUM

A number of maneuvers are at the surgeon ' s dispo sal in the treatment of a caudal devi ation (4,5) . Traditional approaches include scoring the septal cartilage on the co side, thereby relaxing the "spring" of the cartilage. This may be done as a solitary m ver, or in conjunction with a so-called "s winging door maneuver." As illustrated in F a wedge of cartilage excised along the maxillary crest releases the caud al septal a ments and allows the septum to swing to the midline. The midline position may be se with a 4-0 PDS attached to the periosteum adjacent to the oppo site side of the nasal Ethmoid bone splinting grafts or sandwich grafts also may be of benefit in this sit (6). A straight piece of bone is harvested; a large straight Keith needle may be used as icate hand-held drill to make holes in the bone graft. The deviated portion of cartilag septum may be addre ssed by scoring on the concave side, and the bone graft or graft then be used to splint the septum in a straighter orientation. However, use of the eth bone graft in this location thickens the caudal septum and can contribute to nasal ob tion . The ethmoid bone sandwich grafts may be used to address a deviation of the septum, where the additional septal thickness caused by this graft is well tolerated (F In cases of a severely deviated caudal and dorsal septum, the offending portion m exci sed and replaced with a straight piece of cartilage, typically harve sted from the s more posteriorly (Fig. 5) (4). Suture fixation to a stable segment of cartilage attached osseocartilaginous junction and nasal spine will allow recon struction of an intact L-s support the lower third of the nose. The recon structed caudal segments can be suture tween the medial crura to set nasal length, projection , rotation, and the alar/columel lation .

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Figure 3. Deviated caudal septum , "SWinging door" maneuver.

Figure 5. A, B: Septal replacement for severe cases of deviated caudal and dorsal se C-T: In the first case example (preoperative photographs, C-F), a segment of cauda tum is removed (G, H) and replaced with a straight piece of septal cartilage harvested teriorly (I, J) .

Figure 4. A splinting graft of ethmoid bone may help main­ tain the septum in a straighter orientation.

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RIB CARTILAGE GRAFT RECONSTRUCTION OF SADDLE DEFORMITY: INTEGRATED DORSAL GRAFT/COLUMELLAR STRUT

The severe saddle-nose deformity may be treated by using autogenous rib cartilage (8,9 Harvest of rib is . escribed later. The rib graft is carved into a dorsal graft and a columell strut, which are interdigitated to recreate an intact L-strut (Fig. 6). This type of structural r construction is particularly useful when there is complete loss of septal support . If an inta nasal septal L-strut is present, onlay dorsal grafting will be sufficient to correct the deformit Great care must be taken to adhere to the prin ciple of "balanced cross-se ctional carving" minimize the risk of graft warping. Once in position , the domes can be sutured over the gra with a transdomal suture. An external rhinoplasty approach allows expo sure for facile plac ment of these grafts . A tip graft allows improved tip projection and definition.

Figure 6. A, B: Severe saddle-nose deformity. Rib graft is fashioned into a columellar strut (secured to the medial crura) and a dorsal onlay graft that interdigitates with the columellar strut. C-EE: (slides) Preoperative (C-F) pho­ tographs of a patient with a severe saddle-nose deformity. She underwent application of an iliac bone graft to her nasal dorsum in the past. Lack of an intact L-strut and in­ adequate middle vault support resulted in descent of the graft, airway obstruction, and referral to our office for re­ construction . Base view reveals the bone graft in the left nostril and a widened columellar scar.

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PEARLS ·

• When placing plumping grafts, the surgeon should overcorrect because the graf tend to settle over time. Additionally, the pocket can be gently irrigated with a tibiotic solution to minimize the incidence of infection . • When performing a caudal extension graft, the surgeon must take special care set appropriate tip projection, rotation, length, and alar/columellar relation. Add tionally, the caudal margin of the graft must be in the precise midline. • The inferior border of the caudal extension graft should be stabilized on the po terior septal angle, soft tissue, or other supporting tissues to avoid postoperativ counterrotation of the extension graft. . • Deviations of the caudal septum can usually be corrected by crosshatching the ca tilage and other conservative maneuvers described in the text. Many cases can b corrected by accounting for excessive length of the L-strut. Inrare cases, subtot septal replacement may be necessary. • When using an integrated columell ar strut/dorsal graft, the surgeon must take sp cial care to stabilize the columellar strut in the midline to avoid shifting or tiltin of the columella . Placement of the dorsal graft into a precise dorsal pocket or s ture fixation of the dorsal graft to the middle nasal vault will miriimize the chanc of the graft shifting to one side. • Symmetric carving of the costal cartilage graft will minimize the chance of th graft warping over time:

REFERENCES

I . Tardy ME, Becker DG, Weinb erger MS . Il lusions in rh inopl asty. Facial Pla st Surg 1995;11: 117-1 38. 2. T ardy ME. Rhinoplasty: the art and the sc ienc e. Philadelphi a: WB Saunders , 1997. 3. Tor iurni OM. Caudal septal extension graft for correc tion of the retracted co lume lla. Ope l' Tech Otolar Hea d Neck Surg 1995;6:3 11-318. 4. Beeson WH. The nasal septum. Otolaryngol Clin No rth Am 1987;20:743- 767 . 5. To riurni DM, Ries WR. Innovati ve surg ical ma nageme nt of the croo ked nose. Facial Plast S urg Clin Am 1993;1 :63-78. 6. Met zinger SE, Boyce RG, Rigb y PL, Jo seph JJ, Anderson JR . Ethm oid bone sandwich grafting for cauda tal defect s. Arch Otolaryngol Head Neck Surg 1994 ;120 : 1121-11 25. 7 . T oriurni DM . Subtota l reconstru ction of the nasal septu m: a preliminary re port. La ryn goscope 1994 906-9 13. 8. Dan iel RK. Rhin opl asty and rib grafts : evo lving a flex ible operati ve techni qu e. Plast Recon str Surg 199 597-6 11. 9. Wan g TO . Aesthetic struct ural nasal augmentation. Opel' Tech Otolaryngol Head Nec k Surg 1990 .

12 Harvest of Autogenous Tissue HARVESTING CONCHAL CARTILAGE: ANTERIOR APPROACH Auricular cartilage can be harvested using the anterior or posterior approach (1-6). In most cases, we prefer the anterior approach because we believe it is less traumatic, and the incision heals well if vertical mattress closure is used. If smaller cartilage grafts are needed, then we use the posterior approach. With a marking pen, outline an incision that follows the outer edge of the cavum and cymba concha. This incision should be placed along the portion of the concha that is verti­ cally oriented in relation to the lateral aspect of the skull (Fig. I). Use a syringe with 1% li­ docaine (Xylocaine) solution with 1:100,000 epinephrine (or for the lab demonstration, wa­ ter) to "hydrodissect" the skin of the concha cavum and cymba from the underlying cartilage. Make the incision with a no. 15 blade, and elevate the skin and perichondrium from the underlying cartilage. Dissection proceeds by using appropriate scissors, and also bluntly with cotton-tip applicators. Care should be taken not to damage the soft auricular cartilage, which can tear. The dissection should stop short of the cartilage of the external auditory canal. The radix helicis should be preserved if preservation of ear position is critical. If the entire conchal bowl in excised, the auricle will usually settle closer to the head. Dissect out the desired piece of cartilage, and leave the underlying muscle behind (peri­ chondrium will remain adherent to the posterior surface of the cartilage), Avoiding deep dissection into the soft tissue minimizes bleeding. Suture the circumferential incision with a 6-0 nylon running mattress suture. Alterna­ tively, the incision may be closed with interrupted vertical mattress sutures. Special care must be taken to avoid overlap of the skin edges. Place a bolster dressing of Telfa, dental roll, or other suitable material into the concha, and suture it into position to decrease the risk of hematoma. No residual deformity of the pinna is expected with this approach.

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HARVESTING ETHMOID BONE The perpendicular plate of the ethmoid bone and/or the vomer may be used as a splint­ ing graft in the treatment of a deviated cartilaginous septum. Ethmoid bone may be har­ vested via a standard septoplasty approach.

HARVESTING RIB GRAFT Cartilage is typically harve sted (Fig. 2) from the eighth and ninth ribs or the confluence. If additional cartilage is required, the tenth rib also may be harvested. Bone may be har­

vested with the ninth rib if desired .

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B Figure 2. Rib cartilage harvest. Cartilage is typically harvested from the eighth and ninth ribs. A 4 cm to 6 cm incision overlying the eighth rib allows adequate expo­ sure (see also Chapter 11, Fig. 6). Dissection proceeds to and then through the rib perichondrium . Dissection around the rib is undertaken subperichondrially; the pleura is typically closely adherent to the perichondrium . With the donor rib completely separated from surround­ ing soft tissue, the graft is incised and delivered under di­ rect vision. The surgeon may place a malleable retractor beneath the rib as it is incised.

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... Figure 1, continued. Suture of the circumferential incision is shown here with a 6-0 nylon running vertical mattress suture (M-P). Alternatively, one may close the incision with in­ terrupted mattress sutures . Place a bolster dressing of Telfa, dental roll, or other suitable material into the concha and suture it into position (0-T) to decrease the risk of hematoma.

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A 4-cm to 6-cm incision overlying the eighth rib allows adequate exposure. Disse proceeds to and then through the rib perichondrium. The muscle fibers can be separat stead of cut to minimize postoperative pain. Dissection around the rib is undertaken perichondrially; the pleura is typically closely adherent to the perichondrium. Wit graft completely separated from surrounding soft tissue , the graft is incised and deli under direct vision . The surgeon may elect to place a malleable retractor beneath the it is incised. Saline is placed in the surgical site and Valsalva or positive pressure ap to check for a pleural leak . If a pleural tear is identified, a pursestring suture closure dertaken around a red-rubber suction catheter. The surgeon then requests a "Val salva " the anesthesiologist. The red rubber is then removed and the suture tightened. Saline be placed in the wound and another Valsalva undertaken while the surgeon careful spects for air bubbles. A standard, layered soft-ti ssue closure without a drain is ac plished. Skin edge eversion can be accomplished with everting subcutaneous sutures A chest radiograph is obtained in all patients after rib harvest. In the rare instanc difficulty, the surgeon may wish to consult the appropriate surgical colleague.

HARVESTING CALVARIAL BONE

Parietal bone may be harvested (Fig. 3) through a horizontal incision (typically, 4 6 em) superior to the temporal line . Typically the nondominant side is chosen. Incisi and through the perio steum, followed by subperiosteal undermining, provides prope posure. A drill is used to outline the proposed graft (typical graft size, 1 em to 1.5 em em to 4.5 em) . A trough is drilled through the outer table to the diploe; this allow proper angle for application of a chisel or powered oscillating saw to harvest the grafts fully. Short controlled taps on a sharp osteotome allow increased precision and hel crease the risk of inner-table penetration and dural tear. Patients must be cautioned preoperatively of the risk of possible dural tear and pos brain injury. Any dural entry should elicit an immediate neurosurgical con sultation. The donor site can be contoured with hydroxyapatite cement or any other biocomp bone substitute material. The incision is typically closed in a multilayer fashion .

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F Figure 3. Calva rial bone harvest. Parietal bone may be harvested through a horizontal incision (typi­ cally, 4 cm to 6 cm) superior to the temporal line. Typically the nondominant side is chosen (A). A drill is used to outline the proposed graft (typical graft size, 1 cm to 1.5 cm by 4 cm to 4.5 cm) . A trough is drilled through the outer table to the diploe (B , 0, E). A chisel or powered oscillating saw may be used to har­ vest the grafts carefully (C, F-I). Narrower grafts are safer and easier to harvest.

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PEARLS ·

• When harvesting auricular cartilage, the surgeon can simplify the dissection b performing local anesthetic injection s in the subperichondrial plane . This will a to hydrodissect the flap and allow blunt dissection to elevate the flap. • Special care must be taken to evert the skin edges when perform ing the skin cl sure. There will be a tendenc y for the dissected flap to overlap the skin on the sid that wa s not dissected. Vertical mattre ss sutures are most effective for aligning th skin edges. . " . . " " • If lateral ear position is a concern, the radix helicis can be left'intact to support th auricle and preserve lateral ear position. • Perichon drium can be dissected off the posterior surface of the cartilage and use as tissue for camouflage or to cushion a tip graft. • If small cartilage grafts are needed, the posterior approach can be used to harve "" " ear cartilage. . • If the patient has one ear that protrudes more than the other; then the cartilag should be harvested from that side: If the 'patient sleeps on one side 'of the hea . then the cartilage should be removed from the contralateral side. . .

PEARLS, continued . H arvesting Costal Cartila ge • Palpate appropriat e-shaped cartilage, and place the incision over the rib to be har­ . vested. In female patient s, the incision should be placed in the proxim ity of the in­ framammary crease . • Postoperative pain can be minimized by cutting as little muscle as possible when dissecting over the costal cartilage . The muscle fibers can be bluntly dissected to expose the costal cartilage and .then retracted to perform the dissection. • Postoperative pain can be significantly decreased by keeping the inferior ribs intact to support the rib cage . With the inferior ribs intact, the patient will have much less pain on inspiration. •• Dissect perichondrium off cartilage, taking special care to elevate perichondrium off the inferior surface of the costal cartilage. By leaving the perichondrium intact over the pleura, there will be minimal chance of pneumothorax. • The incision should be closed in multiple layers. After closing the muscle, fascia, . and subcutaneous tissues, evert the dermal sutures [4-0 polydioxanone suture (PDS)] to provide prolonged support to the skin edges: The wound will remain everted for several months; however, the scar camouflage will be excellent. Patients should be informed of the temporary excess eversion of the skin edges. • With costal cartilage for grafting, symmetric carving is essential to avoid postop­ erative warping. Harvesting Ethm oid Bone .• AVOId resecting ethmoid bone high near the cribriform plate !o prev ent cere­ brospinal fluid leak. Use atraumati c instruments and techniques when removing the bone. . . • The bone graft can be shaped with a burr.· Harvesting Cal varial Bone . • Examine the curvature of the skull to determine the 1TI0st favorable shape to the .bone to harvest the bone graft. The parietal or occipitalareas are the most common areas where calvarial bone grafts are harves ted. . • Create a bone trough down to the diploic layer to allow a curved osteotome to ele­ vate the external table gently off an intact inner table. Generou s irrigation is nec­ essary to avoid damage to the bone. . . • Narrower I 'ern to 2 ern strips of bone are easier to elevate off the inner table. • The bone defect can be filled witha bone substitute material.

REFERENCES I. Tard y ME, Denn en y J, Frit sch MH . Th e versat ile cartilage autogra ft in recon structi o n of the nose and face . Laryngoscope 1985;95:523- 532. 2. Met zinger SE , Boyce RG, Rigb y PL, Jo seph JJ , Ande rson JR . Ethm oid bone san dwich graf ting for caudal sep­ tal defects. A rch Otol Head Neck Surg 1994 ; 120: 1121-11 25. 3. Dani el RK . Rhin oplasty and rib gr afts: ev olvin g a fle xible o perative tech niqu e . Plast Recon str Surg 1992 ;94: 597--6 11. 4 . Wan g TD . Aesth etic structural nas al aug men tat ion . Opel' Tech Otolaryngol Head Neck Su rg 1990 . 5. Tardy ME. Rhinoplasty: the a rt an d the scie nce. Philadelphia: W B Saund ers, 1997. 6. Chen ey ML, G licklicb RE. The use of calvari al bone in nasal reconstruction . Arch Otola ryng ol Head Neck Surg 1995; 121 :643 -648.

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13 Incision Closure, Nasal Splint, Postoperative Considerations CLOSURE OF THE MIDCOLUMELLAR INCISION

A single, subcutaneous 6-0 polydioxanone suture (PDS) can be positioned in the dermal tissues to enhance skin-edge eversion and take tension off of the closure (Fig. I). This su­ ture should provide skin-edge alignment and slight eversion . Excessive eversion will cre­ ate a deformity that may require many months to resolve. The level of the skin edges must be preci sely aligned with this suture; otherwise, an unsightly scar may result. If there is no tension on the closure, a subcutaneous suture may not be necessary. To close the skin, five 7-0 nylon vertical mattres s sutures are used. The first suture lines up the apex of the inverted V. The next two sutures are angled from medial on the lower flap to lateral on the upper flap to align the closure properly . A 6-0 chromic suture is used to line up the vestibular skin at the corner of the columellar flap. This corner suture is im­ portant because aberrant healing of this corner can result in a visible notch defect.

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CLOSURE OF THE MARGINAL, INTERCARTILAGINOUS, OR TRANSCARTILAGINOUS INCISION

This incision is closed with one or two 5-0 chromi c sutures located laterally that ac advance the lateral crura slightly toward the domes (Fig. 2) This suture advancement w negate the need for an additional suture placed in the region of the domes. All sutures u to close the marginal incision must be examined to make sure there is no distortion of nostril rim or domal region. If the nostril rim is notched, then the suture should be replac taking a smaller bite.

PLACEMENT OF INTRANASAL PACKS, NASAL SPLINT Intranasal Pack

When extensive septoplasty is undertaken, or when partial turbinectomy or turbinopla is performed, the surgeon may wish to place a temporary intranasal pack. The goal is to p vide some compression of the septal flaps and , in the case of turbin ate surgery, to decre the risk of postoperative bleeding. There are a number of commercially available packs. intran asal pack is typically left in place at most overnight and removed the next mornin

External Splint

A great variety of splints are commercially available. In general, after placement of appropriate adhesive, a small rectangular strip of Telfa is placed over the nasal dorsum facilitate removal of the splint in 5 to 7 days. Tape is applied over the dorsum and the na tip. A splint is carefully applied.

POSTOPERATIVE CARE

The sutures should be removed from the columellar inci sion after 5 days. At that poi the incision may be supported with flesh-colored steri-strips for several week s to act as titension taping. Persistent postoperative supratip edema can be treated with subdermal

jections of triamcinolone acetonide (Kenalog; 10 mg/ml , 0.1 ml) injected into the supratip regio n of the nose. The se subdermal injections should not be used in any region othe r than the supratip and should not be used more frequentl y than once every 8 weeks. Superficial injections or excessive use can result in subdermal atrophy.

PEARLS Closure of external rhinoplasty incisions; , • If there is any tension on the closure, a midline 6-.0 PDS suture can be applied to evert the skin edges . Special care must be taken to align the skin edges properly. If the subcutaneous suture is not plac ed properly, the result wili likely be avisible .scar. • The columellar incision is closed with the first 7-0 nylon vertical mattress suture ' : placed in the precise midline. The next two sutures are placed just off midline and ,' , are angled from medial on the lower flap to lateral on the upper flap. This man eu­ ver will minimize the chances of cre ating a notch at the lateral aspect of the col­ umellar flap . • After closing the marginal iricision , the surgeon should check the alar margin to ensure that there is no notching of the margin . Thi s occurs if too much mucosa is taken and acts to deform the alar rim. '" ~ The surgeon Should examine the columellar extension of the columellar incision. In mostcases , no suture IS needed in this regi on becau se the vestibular skin is ad­ equately aligned. In some cases, the vestibular skin is not aligned properly, and a ' 6-0 chromicsuture should be used to align the incision properly. Application of the Cast ' . A strip of Telfa can be applied over the dorsum to allow the cast and tape to bere­ moved without lifting the dorsal skin off the underlying nasal skeleton, with l'e­ suIting edema. , • The nose should be loosely taped to avoid vascular compromise. The tissues will

become edematous, and if taped tootight, the tissues may become compromised,

• An Aquaplast cast can be loosely applied to the nose and left in place for 5 days . At,the time of cast removal, adhe sive remover applied through the holes in thecast will loosen the tape. A blunt instrument can be used to lift the cast and tape care- .' fully off the nose. ' Postop erative Care , " • At the time of cast removal, the tape should be loosened with adhesive remover ' that is applied through the holes in the Aquaplast cast and allowed to work for 5 to 10 minutes. ' , , • Digital exercisescan be used in the patient who has deviated nose. These patients ,can perform digital exercises on the nasal bone s to avoid postoperative shifting of the bony nasal vault. This must be done within 10 days after surgery; otherwise, the bones wiil have started to fixate . ' • Postoperative steroid injections can be'used to correct subtle aSYrrllnetries of the nose . Triamcinolone acetonide (Kenalog; 10 mg/ml ) can be injected into the sub­ dermal region where excessive asymmetric edema is noted. ' ,

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REFERENCES 1. Toriumi OM , Johnson Cvl. Open struc ture rhino plasty featured tech nical points and lon g-term follow-up, Fa­ cial Plast Surg Clin North Am 1993; I :1-22, 2. John son eM Jr, Toriumi OM, Open structure rhinoplasty. Phi ladelph ia: WB Sau nder s, 1990. 3. Tardy ME, Rhinopla sty: the art and the science. Philadelphi a: WB Sa unde rs, 1997 .

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Appendix A: Tripod Concept TRIPOD CONCEPT When considering the effect of surgical techniques on the nose, one may think of the tip as a tripod, with each lateral crus composing one leg of the tripod , and the paired medial crura composing the third leg (l ,2). Shortening the two "lateral crura!" legs will cause the tripod to fall in that direction, thereby "rotating and deprojecting" the tripod . Weakening these two legs (as with cephalic resection) is also said to have the same effect (although less so), as the healing forces applied to these weakened legs of the tripod will cause the tip to rotate and deproject slightly over time . Similarly, a columellar strut will strengthen the "medial crural " leg of the tripod. Use of a columellar strut to correct buckled medial or in­ termediate crur a may increase tip projection and rotation . Even though the tripod concept oversimplifies the dynamics of the nasal tip, it provides those with little experience in rhinoplasty with a method of predicting the effects of specific techniques.

REFERENCES I. Ander son JR. A reasoned approach to nasal base surgery. Ar ch Otolaryngol Head Neck Surg 1984;110:

349-358. 2. McCollou gh EG. Surgery of the nasal tip. Otolaryngol Clin North Am 1987 ;20:769-784.

155

Appendix B Guide to Nasal Analysi NASAL ANALYSIS General

Skin quality: Thin, medium, or thick Primary descript or (i.e., why is the patient here): For example , "big," "twisted," "l hump "

Frontal View Twisted or straight: Follow brow-tip aesthetic lines Width: Narrow, wide, normal , "wide-narrow- wide" Tip: Deviated, bulbous, asymm etric, amorphous, other

Base View

Triangularity: Good versu s trapezoid al Tip : Deviated , wide, bulb ous, bifid , asymmetric Base : Wid e, narrow, or normal. Inspe ct for caudal septal deflecti on Columella : Columellarllobule ratio (normal is 2: 1 ratio ); status of medial crural footpl

Lateral View Nasofrontal angle: Shallow or dee p Nasal starting point: High or low Dorsum: Straight, concavity, or conv exity; bony, bon y-cartilagin ous, or cartilaginous is conv exity prim arily bony, cartilaginous, or both) Nasal length: Norm al, short, long Tip projection: Norm al, decreased , or incre ased Alar-columellar relationship: Normal or abnormal Nasa-labial angle: Obtu se or acute

Oblique View Does it add anything, or doe s it confirm the other views? Many other points of analysis can be made on each view, but these are some of the points of commentary.

Appendix C: Aesthetic Analysis LANDMARKS FOR ANALYSIS: POINTS See figures on page 10. Trichion: Anterior hairline in the midline Glabella: Most prominent midline point of forehead, well appreciated on lateral view Nasion : Most posterior midline point of forehead, typically corresponds to nasofrontal su­ ture Rhinion: Soft-tissue con-elate of osseocartilaginous junction of nasal dorsum Sellion: Osseocartilaginous junction of nasal dorsum Supratip: Point cephalic to the tip Tip: Ideally, most anteriorly projected aspect of the nose Subnasale: Junction of columella and upper lip Labrale superius : Border of upper lip Stomion: Central portion of interiabial gap Stomion superius: Lowest point of upper-lip vermilion Stomion inferiu s: Highest point of lower-lip vermilion Mentolabial sulcus: Most posterior midline point between lower lip and chin Pogonion: Most anterior midline soft-tissue point of chin Menton: Most inferior point on chin Cervical point: Point of intersection between line tangent to neck and line tangent to sub­ mental region Gnathion: Point of intersection between line from subn asale to pogonion and line from cer­ vical point to menton

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Appendix Surface Angles, Plan and Measuremen Definitio

Facial thirds Upper third: Trich ion to glabella Middl e third : Glab ella to subnasale Lower third : Subnasale to menton Horizont al fifth s: Five equally divid ed vertical segments of the face Frankfort plane: Plane define d by a line from the most superior point of auditory most inferior point of infra orbital rim Nasofrontal angle: Angle defin ed by glabella-to-nasion line intersecting with nasio line. Norm al, 115 to 130 degrees (within this range, mo re-obtu se angle more fa in fem ale, and more acute angle in male patients) Nasofacial angle: Angle defin ed by glabella-to-pogonion line intersectin g with na tip line. Normal , 30 to 40 degrees

PEARL .

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Normal proje ction with a "3-4-5" triangle described by Crumley (see be give s a nasofacial angle of 36 degrees. .

Nasomental angle: Angle defined by nasion-t o-tip line inter sectin g with tip-to-p line. Normal , 120 to 132 degrees Relation ship of lips To nasomental line: Upper lip, 4 mm behind; lower lip, 2 mm behind line from n to menton To subnasale-to-pogonion line: Upper lip, 3.5 mm anterior; lower lip, 2.2 mm an Mentocervical angle: Angle defined by glabella-to-pogonion line intersecting wi ton-to-cervical point line Legan facial-con vexity angle : Angle defined by glabella-to-subnasale line inte with subna sale-to-po gonion line ; norm al, 8 to 16 degrees

PEARl;

Useftil in assessing chin deficiency, candidacy for chin implantchin ad~ancem or other chin alterati on

Nasolabi al angle: Angle defin ed by columellar point-to-subn asale line intersecti subnasa le-to-labrale superius line; normal , 90 to 120 degr ees (within this rang obtuse angle more fav orabl e in female , and more acute in male patient s) Columellar show: Alar-columellar relat ionsh ip as noted on profile view; 2 to 4 mm umell ar show is normal

Nasal projection : Anterior protrusion of nasal tip from face Goode' s method: A line drawn through the alar crease, perpendicular to the Frankfurt plane . The length of a horizontal line drawn from the nasal tip to the alar line divided by the length of the nasion-to-nasal tip line. Normal , 0.55 to 0.60 (2,3) Crumley ' s method: The nose with norm al projection forms a 3-4-5 triangle (i.e., alar point-to -nasal tip line (3), alar point-to-n asion line (4), nasion-to-nasal tip line (5) (4). Byrd's method : Tip projection is two-thirds (0.67) the planned postoperative (or the ideal) nasal length . Ideal nasal length in this approach is two-thirds (0.67) the midfacial height

(5) Powell and Humphries "Aesthetic Triangle": Nasofrontal: 115 to 130 degrees Nasofacial: 30 to 40 degree s Nasomental : 120 to 132 degree s Ment ocervic al: 80 to 95 degree s

REFERENCES 1. Tardy ME, Walt er MA, Patt BS. The ove rprojectin g nose: anatomic component analy sis and repair. Facial

Plast Su rg 1993;9:306-3 16. 2. Ridley MB. Aesthetic facial prop ortions. In: Papel ID, Nachlas NE, eds. Facial pla stic and reconstructive surgery. St. Louis : Mosby Year Book, 1992:99-109. 3. Crumley RL, Lanser M. Quantitative analysis of nasal tip projection. Laryngoscope 1998;98:202- 208. 4. Byrd HS, Hobar Pc. Rhin oplasty: a practical guide for surgical planning. Plast Reconstr Surg 1993;91:

642-654.

Appendix E Tip Support, Incision and Approache MAJOR TIP·SUPPORT MECHANISMS

1. Size, shape, and strength of lower lateral carti lages 2. Medial crura l footplate attachment to caudal septum 3. Attachment of caudal border of upper lateral cartilages to cephal ic border of lowe eral cartila ges [Nasal septum also is considered a major support mechan ism of the nose.]

MINOR TIP·SUPPORT MECHANISMS

1. Ligament ous sling spanning the domes of the lower lateral cartilages (i.e., interd ligament) 2. Cartilaginous dorsal septum 3. Sesamoid complex of lower lateral cartilages 4. Attachment of lower lateral cartilages to overlying skin/soft-tissue envelope 5. Nasal spine 6. Membranous septum

INCISIONS: METHODS OF GAINING ACCESS I. Interc artilaginous 2. Transcartilaginous 3. Marginal (NOT to be confu sed with rim incision) 4. Transcolumellar

APPROACHES: PROVIDE SURGICAL EXPOSURE 1. Cartilage-splitt ing 2. Retrograde 3. Delivery: Marginal + intercartilaginous incision 4. External approach: Marginal + transcolumellar incision

SCULPTING TECHNIQUES: SURGICAL MODIFICATIONS I. Complete strip (i.e., cephalic resection) or volume reduction of lateral crur a 2. Incompl ete strip (dom e division) 3. Transdomal/dornal suture s 4. Augmentation graftin g 5. Tip graft 6. Other

REFERENCES

I . Tardy ME. Rhinoplasty: the art and the science . Philadelphia: WB Saund ers, 1997. 2. Tardy ME, Toriumi DM. Philosoph y and princ iples of rhinopla sty. In: C ummings CW , Fredri ckso Harker LA, et al., eds. Otolaryngology: head & neck surge ry. 2nd ed. St . Louis: Mosby Year Book, 278-294 .

Appendix F:

Achieving Surgical Goals:

Selected Options

INCREASE ROTATION Lateral crural steal Transdom al suture that recruit s lateral crura mediall y Base-up resecti on of caudal septum (variable effect) Cephalic resection (variable effect) Lateral crural overlay Columell ar strut (variable effect) Plumpin g grafts (variable effect) Illusions of rotation : increa sed doubl e break, plumping grafts (blunting nasolabi al angle) DECREASE ROT ATION (COUNTERROT ATE) Full transfixion incision Double -layer tip graft Shorten medial crura Caudal extension graft Reconstru ct L-strut, as in rib graft reconstruction (integ rated dorsal graft/columellar strut) of saddle nose INCREASE PROJECTION Lateral crural steal (increas ed projection, increased rotation) Tip graft Plumpin g graft s Premaxillary graft Septocolumellar sutures (buried) Columell ar strut (variable effect) Caudal extension graft DECREASE PROJECTION High parti al, or full transfixi on incision Lateral crural overlay (decreased projecti on, increased rotation) Nasal spine redu ction Vertical dome division with excision of excess medial crura, with suture reattachment INCREASE LENGTH Caudal extension graft Radix graft Double-layer tip graft Reconstru ct L-strut

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See increas e rotation Also, deepen nasofrontal angle Set-back and suture medial crur a to midline caudal septum TIP REFINEMENT Cephalic resection (volume reduction) Dome-binding sutures Vertical dome divis ion, with suture reconstitution Tip graft REFERENCES

1. Tardy ME. Rhinoplasty: the art and the science. Philadelphia: WB Saund ers, 1997 . 2. Johnson CM Jr, Toriumi OM. Open structure rhinoplasty. Philadelph ia: WB Saunders, 1990. 3. Tardy ME, Toriumi OM . Philosoph y and principl es of rhinoplasty. In: Cummin gs CW, Fredric Harker LA, et al., eds. Otolaryngology: head & neck surgery. 2nd ed. St. Louis: Mosby Year Bo 278- 294.

Appendix G: Selected Complications of Rhinoplasty Bossae: A knuckling of lower lateral cart ilage at the nasal tip caused by contractural heal­ ing forces acting on weakened cartilages. Patients with thin skin, strong cartil ages, and nasal-tip bifidity are especially at risk . Exce ssive resection of lateral crus and failure to eliminate excessive interdomal width may play some role in bossae formation . Polly beak: Postoperative fullnes s of the supratip, with an abnormal tip-supratip relation. This has several etiologies: Failure to maintain adequate tip SUpp0l1 (postoperative loss of tip projection), inadequate cartilaginous hump (anterior sept al angle) removal, and/or supratip dead space/scar formation . Treatment depends on anatomic cau se. If the cartilaginous hump was underresected, then resect additional dorsal septum. One also must ensure adequate tip support. Ma­ neuvers such as placement of a columellar strut may be of benefit. If the bony hump was overresected, consider a graft to augment the bony dorsum. If a polly-beak is from ex­ cessive scar formation , consider triamcinolone (Kenalog) injection or skin taping in the early postoperative period, before any consideration of surgical revision. Inverted V deformity: Inadequate support of the upper lateral cartilages after dor sal-hump remov al can lead to inferomedial collapse of the upper lateral cartilages and an "inverted V deformity." In this deformity, the caudal edges of the nasal bones are visible in broad relief. Inadequate infracture of the nasal bones is also a frequent cause. When executing hump excision, it is helpful to preserve the underlying nasal mucoperichondrium (extra­ mucosal dissection), which provides significant supp ort to the upper lateral cartilages and help s decrease the risk of inferomedial collapse of the upper lateral cartilages after hump excision . When undertaking osteotomies after hump excision, appropriate infra c­ ture and narrowing of the bony vault must be achieved . Rocker deformity: If osteotomies are taken too high, into the thick frontal bone , the supe­ rior aspect of the osteotomized nasal bone may project or "rock" laterally when the bone is infractured . This is a "rocker" deformity . A 2-mm osteotome may be used percuta­ neously to create a more appropriate superior fracture line and correct the rocker defor­ mity. Dorsal irregularities: After creation of an "open roof" by hump removal, the bony mar­ gins should be smoothed with a rasp. Any bony fragments should be removed, making sure that all obvious particles are removed from under the skin/soft-tissue envelope. Fail­ ure to remove all fragments may lead to a visible and/or palpable dorsal irregularity. Nasal valve collapse: The surgeon should recognize the existence of the internal and ex­ ternal nasal valve . The internal nasal valve area is bounded by the caudal margin of the upper lateral cartilage, septum, and floor of the nose. The external nasal valve refers to the area delineated by the cutaneous and skeletal support of the mobile alar wall. Exces­ sive narrowness in either of these locations may cause nasal obstruction. Weakness at ei­ ther of these locations may result in collapse with the negative pressure of inspiration, resulting in nasal airway obstruction. Nasal valve collapse is seen most often as a sequela of overresection of lateral crura or middle vault collapse. Overaggressi ve resection of the lateral crura and the sub sequent postoperative soft-tissue contraction frequently leads to nasal valve compromise.

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REFERENCES

J. Simons RL, Gallo JF. Rhinoplasty complications. Facial Plas t Surg cu« Nor th Am 1994;2 :52 1-529 . 2. Kamer FM , Piepe r PG. Revision rhinoplasty. In: Bailey B, ed. Head an d Ne ck Surge ry Oto laryn Philadelphi a: Lippincott, 1998:2663- 2676. 3. Tardy ME, Kron TK, Younger RY, Key M. The cartilaginous pollybeak: etiology, prevention, and tre Facial Pla st Surg 1989;6: 113-1 20. 4. Larrabee WF Jr. Open rhinoplasty and the upper third of the nose. Facial Pla st Surg Clin No rth Am 23-38 . 5. Toriumi DM. Management of the middle nasal vault. Oper Tech Pl ast Reconstr Surg 1995;2: 16-30. 6. Becker DG, Toriumi DM, Gross CW, Tardy ME. Powered instrumen tation for dorsal nasal reduction Plast Surg 1997; 13:291-297.

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Appendix H: Adjunctive Procedures Chin implant (Fig. 1)

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in the patient with an underdeveloped chin, In this illustration , only the chin differs between

these two line draw ings .

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Submental lipectomy (Fig. 2)

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Figure 2. In the selected patient seeking nasal surgery, submental lipectomy is a useful adjunctive procedure to create facial balance .

REFERENCE 1. Tardy ME , Thoma s JR. Facial aesthetic surgery. Philadel phia : Mosby, J995.

Appendix I: Cleft Lip Nasal Deformity UNILATERAL CLEFT (Fig. 3) Nasal tip: Medi al crus of LLC shorter on cleft side Lateral crus of LLC longer on cleft side (total length of cleft and noncleft side LLC are the same) Tip-defining point on cleft side is flat and laterally displa ced Columella: Short on cleft side Columellar base directed to noncleft side (unopposed orb iculari s muscle ) Nostril: Hori zontal orientation on cleft side Alar base: Laterally , inferi orly, and post eriorly displaced on cleft side Nasal floor: Usually absent Septum: Caudal deflection to noncleft side Posterior deflection to cleft side

BILA TERAL CLEFT

Figure 3. Cleft-lip nasal deform ity. Typical anatomic findings characteristic of unilateral cleft-lip nasal deformities.

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Medial cr ura short bilatera lly Latera l crura short bilaterally, caudally displaced Tip-defining points poorly defined and wide ly separated Columella: Short, with a wide base Nostri ls: Horizon tal orientation bilaterally Alar base : Laterally, inferiorly, and posteriorly disp laced bilatera lly Nasa l floor: Usually abse nt bilaterally

REFERENCE

J. Sykes 1M, Senders CW, Wang T D. Cook TA . Use of the open approach for repai r of secondary cle defo rmity . Facial Plast Surg ChI! North Am 1993 ; 1: 111- 126.

Appendix J: Photography Setup (1) (Fig. A-4) Came ra: 35-mm SLR (single light reflex camera) with 105-mm macro lens Lighting: dual elect ronic flash units; overhead kick er light adds a backlighting effect that improves picture quality and sof tens or elim inates background shadows Background: Nassau blue no. 25 Film : Kodak Ekta chrome ASA 100

STANDARD RHINOPLASTY VIEWS 1:7, front al, base, lateral, oblique 1:5 and 1:3, close-up, base view

Background

~ Overhead Kicker Light

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8 Light Source

Light Source Camera Figure 4. Schematic photography setup.

REFERENCE I. Tardy ME . Brown R. Principles ofphotog raphy in f acia l plastic surgery. New Yor k: Th ieme Publishers. 1992.

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Appendix K Indications For Extern Rhinoplasty Approac

(1, Asy mmetric nasal tip Croo ked-nose deformity (lower two thirds of nose) Sadd le-nose deformity Cleft- lip nasal deformity Secondary rhinopla sty requ iring complex structural grafting Septal -perforation repair

REFERENCES I. l oh nson CM 1r, Toriumi DM . Open structure rhinoplasty. Ph iladelphia: WB Saunders. 1990 . 2. T oriumi DM , l ohnson CM . Open struc ture rhi nopla sty: featured technical point s and long-term follow cial Plast Surg Clin North Am 1993; I: 1-22.

Appendix L: Suggested Surgical Instruments for Rhinoplasty 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. I I. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37.

Needle holder Bayonet forceps Mallet Takaha shi forceps Siegel retractor Converse retractor Hemostat (curved) Hemostat (straight) Small nasal speculum Large nasal speculum Small single skin hook Small double skin hook Small double skin hook Medium double skin hook Wide double skin hook Freer/Cottle elevator Joseph elevator Converse scissors Fomon scissors Straight Stevens scissors Curved Stevens scissors Curved Iris scissors Scalpel handle Scalpel handle Brow n-Adson forceps Brown-Adson forceps Bishop-Harmon forceps Bishop-Harmon forceps 2.0-mm unguarded osteotome 3.0-mrn straight unguarded osteotome 3.0-mm straight guarded osteotome 2.5-mm straight guarded osteotome Medical grade sharpening stone Dorsal (Rubin) osteotomes : small, medium, large Rasps with tungsten-carbide inserts: 1/2, 3/4, 5/6 Aiache cartilage crusher No. 10 Frazier tip suction

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Appendix List of Select Companies wi Address/Phone Numbe RHINOPLASTY INSTRUMENT SETS Anthony Products , Inc., Indianapolis, IN 800 428-1610 Ell is Instruments, Inc., Madison, NJ 800 218-9082 Instruments Unlimited, Quakertown, PA 800 818-0094 Inv otec, Jacksonv ille, FL 800 998-8580 Lorenz Sur gical , Jacksonville, FL 800 874-7711 MicroFrance, St. Aub in, Fran ce 800- 874-5797 Smith-Nephew-Richards, Madi son, WI 888 395-8060 Snowden Pencer, Tucker, GA 800 843-8600 Stor z Instrument s, St. Louis, MO 800 325-9500 Xo med Surgical Produ cts, Jacksonville, FL 800 874-5797

ALLOPLASTIC CHIN IMPLANTS Allied Biomedical, Paso Roble s, CA 800 276-1322 Hanson Medi cal, Inc ., Kingston, WA 800771-2215 Invotec , Jacksonville , FL 800 998-8580 Porex Surgical, Inc ., College Park, GA 800521-8145 W. L. Gore & Associ ates, Inc., Flagstaff, AZ 800 528-8763 Xom ed Surgical Products, Jacksonville, FL 800 874-5797

ALLODERM LifeCell Corporation, The Woodlands, TX 800367-5737

DERMABOND (OCTYL-2-CYANOACRYLATE) Ethicon, Somerville, NJ 800 888-9234

RHINOPLASTY POWER INSTRUMENTATION Lin vatecIHall Surgical Products Group, Largo , FL 800 925-4255 United Ame rican Medical, McMinnville, TN 800 521-5002 Xom ed Surgical Products, Jacks onv ille, FL 800 874-5797

NASAL SPLINTS Invotec, Jacksonv ille, FL 800 998-85 80 Shippert Medical Technologies (Denver Splints), Englewood , CO 800 888-8663

Vision Medical (Thermoplast), Peoria, AZ 800 874-5797

Xomed Surgical Products, Jacksonville, FL 800 874-5797

INTRANASAL PACKS

Invotec, Jacksonville, FL 800 998-8580

Xomed Surgical Products, Jacksonville, FL 800 874-5797

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Appendix Selected Recommend Literatu

Adamson PA. Open rhinopla sty. In: Papel lD, Nachlas NE, eds. Facial plastic & reco nstructive sur Louis: Mosby Year Book , 1992:295-304. Anderson JR. A reasoned approach to nasal base surgery. A rch Otolaryn gol Head Neck Su rg 1984; 110:3 Becker DG, Toriumi DM , Gross CW , Tardy ME. Powered instrumentatio n for dorsal nasal reduction . Fac Surg 1997;13:291-297. Becker DG, Weinber ger MS, Greene BA, Tardy ME. Clinical study of alar anatomy and surgery of the a Arc h Otolaryngo l Head Neck Surg 1997;123:789-795. ' Beeson WHoThe nasal septum. Otola ryng ol Clin North Am 1987;20:743-767. Byrd HS, Andochick S, Copit S, Walton KG. Septal ex tension grafts: a method of controlling tip projecti Plast Reconstr Surg J998 ; I00:999-1 0 I O. Byrd HS, Hobar Pc. Rhinoplasty: a practical guide for surgic al planning. Plast Reconstr Surg 1993;9 I:6 d iscussion 655-656. Cheney ML , Glicklich RE. The use of calvarial bone in nasal reconstru ction . Arch Otola ryng ol Head N 1995; 12 1:643-648. Constantian ME. The incomp etent ex ternal nasal valve: patbophysiology and treatment in primary and s rhinoplasty. Plast Rec onstr Surg 1994;9 3:919-93 3. Constantian MB, Clardy RB. The relative importance of septal and nasaJ valvular surgery in corre cting ai struction in primary and secondary rhinoplasty. Plast Recons tr Surg 1996;98:38-54. Crumley RL , Lanser M. Quantitative analysis of nasal tip projection. Laryngoscope 1998;98:202-208. • Daniel RK. Rhinoplasty and rib grafts: e volving a flexible operative tech nique. Plast Reconstr Surg 597-61 I. Farrio r RT. The osteotomy in rhinoplasty. Laryngoscope 1978;88: 1449. Goode RL. Surgery of the incompetent nasal valve. Laryngoscope 1985;95:546-555 . Gunter JP. The merit s of the open approach in rhinoplasty . Plast Reconstr Surg 1997 ;99: 8 63~867 . Gunter JP, Clark CP, Friedm an RM. Internal stabilization of autogenous rib carti lage grafts in rhinoplas rier to cartilage warping. Plast Recons tr Surg 1998; I00: 161-1 69. Gunter JP, Clark CP, Friedm an RM. Internal stabilization of autoge nous rib cartilage grafts in rhinopla s rierto cartilage warping. Plast Reconstr Surg 1997; J00: J6 1-169. Gunter JP, Friedman RM . Lateral crural strut graft: techniqu e and clinical applications in rhinoplasty. P constr Surg 1997;99:943-955. Gun ter JP, Rohrich RJ. Management of the deviated nose : the importance of septal reconstruct ion. Clin P 1988;15:43-55. Gunte r JP, Rohrich RJ. Augmentati on rhinopla sty: dorsal onlay graft ing using shaped autogenous septal c Plast Reconstr Surg 1990;86:39--45. Gunter JP, Roh rich RJ, Friedman RM . Classification and correc tion of alar-co lumellar discrepancies plasty. Plast Reconstr Surg 1996;97:643-648. Johnson CM Jr, Godin MS. The tension nose: open structure rhinoplasty approach. Plast Reconstr Su rg 43- 51. Johnson CM Jr, God in MS. The tension nose [Letter, comment] . Plast Recons tr Surg 1996;97:246. Johnson CM Jr, Tor iumi DM. Open structure rhinop lasty . Phil adelphi a: WB Saunders, 1990. Kamer FM, Pieper PG. Revision rhinoplasty. In: Bailey B, ed. Head and neck surgery otolaryngo logy . P phia: Lippin cott, 1998:2663-2676 . Kasperbauer JL, Facer GW, Kern EB. Reconstructi ve surgery of the nasal septum In: Papal ID, Nachlas Facial plastic and reconst ruct ive surg ery. Philadelphia: Mosb y Year Book , 1992:337-343. Konior RJ, Kridel RWH . Controlled nasal tip position ing via the open rhinoplasty approac h. Facial P Nort h Am 1993;1:53-62. Kridel RWH , Konior RJ. Contro lled nasal tip rota tion via the lateral crural overlay techn ique. A rch O Ne ck Surg /991;117:411--41 5. Larrabee WF Jr, Open rhinopl asty and the upper third of the nose. Facial Plast Surg Clin Nonti Am 1993; Metzin ger SE, Boyce RG, Rigby PL, Joseph Jl , Anderson JR. Ethmoid bone sandwich grafting for caud defects. Arch Otol Head Neck Surg 1994; 120: 1/ 21- 1125. McCollou gh EG. Surgery of the nasal tip. Otolaryng ol Clin North Am 1987;20 :769-784. McCollough EG, Mang at D. System atic approac h to correction of the nasal tip in rhinoplasty. A rch Oto 1981;J07: 12- 16. Murakami CS, Cook TA, Guida RA. Nasal reconstruction with articulated irradiated rib cartilage. A laryn gol Head Neck 511rg 1991;117:327-330. Murak ami CS, Larr abee WF. Comparison of osteot omy techniqu es in the treatme nt of nasal fractures. Fac Surg 1992;8:209-21 9. Rohrich RJ, Hollier LH. Rhin oplasty with advancing age: characteristics and management. Clin Plast Su 23:281-296.

Schwartz MS, Tardy ME. Standardized photodocumentation in facial plastic surgery . Facial Plast Surg 1990;7: 1-1 2. Sheen JH . Spreader gra ft: a method of reconstructing the roof of the middle nasal vault follo wing rhinoplasty. Pl ast Reconstr S urg 19 84 ;7 3:2 30--237 .

Sheen JH. Tip graft: a 20 year retrosp ective. Plast R econ str Surg 1993;91 :48- 63. Simon s RL. Vertical dome division in rhinoplasty. Otolaryngol Clin North Am 1987 ;20 :785-796. Sim ons RL, Gallo JF . Rhinoplasty complications. Facial Pl ast Surg Cl in North Am 1994; 2:521-529. Sykes JM , Senders CW, Wang TD , Cook TA . Use of the ope n approach for repair of secondary cleft lip nasal de­ formity.. Facial Plast S urg Clin North Am 1993;1:111-126. Tard y ME. Rhinopla sty in midlife. Otolaryngol Clin North Am 1980 ;13:289-303. Tardy ME. Ethics and integrity in facial plastic surgery : imperatives for the 21st cen tury, Facial Pla st S urg 1995 ; 11:111-1 15. Tardy ME. Rhinoplasty: th e art and the s cience. Philadelphi a: WB Saunders, 1997. Tard y ME, Becker DG, Weinberger MS. Illusions in rhinoplasty. Facial Plast Surg 1995;11:117-138. Tard y ME, Broadw ay D. Graphic record-keeping in rhino plasty: a valuable self-learning device. Facial Pla st Su rg 1989;6:108-112. Tardy ME, Brown R. Surgical anatomy of the nose. New York: Raven Press, 1990. Tardy ME, Brown R,. Pr inciples of ph otography in fa cial plastic surge/Yo New York: Thieme Publi shers, 1992. Ta rdy ME, Cheng E. Tran sdomal suture refinement of the nasal tip. Facial Plast Surg 1987 ;4:317- 32 6 . Tardy ME, Cheng EY, Jernstrom V. Misadventure s in nasal tip surgery. Otolaryn gol Clin No rth A m 19 87 ;20 : 797-823. Tardy ME, Denneny J, Fritsch MH. The versatile cartilage autograft in reconstruction of the nose and face. Laryn­ goscop e 19 85 ;95 :52 3- 53 2 .

Tardy ME, Genack SH, Murrell GL. Aesthetic correcti on of alar-co lumellar disprop ortion. Facial Pl ast S urg Cl in North Am 1995 ;3:395-406.

Tardy ME, Heinrich JA, Linbeck EO. Refinement of the nasal tip. Facial Plast S urg Clin No rth A m 1994 ;2: 459-476. Tardy ME, Kron TK, Younger RY, Key M. The cartilaginous pollybeak: etiology , prevention, and treatment. Fa ­ cial Plast Surg 1989;6:113-120. Tard y ME, Patt BS, Waller MA. Transdomal suture refinement of the nasal tip: long-term outco mes. Facial Pla st S urg 1989 ;9:27 5-284 .

Tard y ME, Patt BS, Walter MA. Alar reduct ion and sculpture: anatomic concepts. Facial Pla st Su rg 1993 ;9: 295-305. Tardy ME , Schwartz M, Parras G. Saddle nose deformity: autogenous graft repair. Facial Plast S urg 1989;6: 121-134. Tardy ME, Thom as JR. Facial aesthetic su rge ry. Philadelphi a: Mosby, 1995. Tard y ME, Tor iumi DM. Alar retraction: composite graft correction. Facial Pla st Surg 1989;6:101-107 . Tard y ME, Toriumi DM. Philosoph y and princip les of rhinoplas ty. In: Cummings CW, Fredri ckson JM, Harker LA, et al., eds. Otolaryngology-head & neck surgery. 2nd ed. St Louis: Mosby Year Book, 1993:278-294. Tardy ME , Toriumi DM, Walter MA, Patt BS. The difficult nasal tip. In: Gates G., cd. Current therapy in oto ­ laryngol ogy-h ea d & neck s urg ery . 1993:170- 182. Tardy ME, Walter MA, Patt BS. The overprojecting nose: anatomic component anal ysis and repair. Fac ia l Pla st Surg 199 3 ;9:306-316 .

Tebb ett s JB. Shaping and positioning the nasal tip without structural disruption: a new systematic approach. Pla st ReconstrSurg 1994 ;94 :61-77.

Tho mas JR. Steps for a safer method of osteotomies in rhinoplasty . Laryng oscope 19 87 ;97:746-747 . Thomas JR. External rhinoplasty: intact columellar approac h. Laryngoscop e 1990;I 00(2 Pt 1):206-208. Thomas JR , Griner NR, Remml er DJ. Step s for a safer method of osteotomies in rhinopl asty. Laryn goscop e 19 87 ; 97:746-747. Thom as JR, Tardy ME. Uniform photographic documentation in facia l plastic surgery. Otolaryngol Clin North Am 1980;13:367-3 81.

Toriumi DM. Subt otal reconstruct ion of the nasal septum: a prelimin ary report. Lary ngoscope 1994; I04:906-13 . Toriu mi DM. Caudal septal extension graft for correcti on of the retracted columella. Oper Tech Otol aryn gol Head Ne ck Surg 1995 ;6:3 11-3 18.

Toriumi DM. Management of the midd le nasal vault: operative techniques in plastic & recon structive surge ry 1995;2:16-30. Torium i DM. Surgi cal correction of the aging nose. Facial Plast Su rg 1996; 12:205-214. Toriumi DM, John son CM. Open structure rhinoplasty featured tech nical points and long-term follow-up. Facial Plast Su rg Clin No rth Am 1993;1:1-2 2. Toriumi DM, John son CM. Mana gement of the lowe r third of the nose open structure rhinopla sty technique. In: Papel 10, Nachlas NE, eds. Facial p last ic & recon stru ctive surgery. 1992:305-31 3 . Toriumi DM, Josen J, Weinberger MS, Tardy ME. Use of alar batten grafts for correction of nasal valve collapse. Arch Oto l Head Ne ck S urg J997;123:802-808. Toriumi DM. Mueller RA, Grosch T, Bhauacha ryya TK , Larrab ee WF. Vascular anatomy of the nose and the ex­ tern al rhinopla sty approach. Arch Oto l Head Neck Surg 1996 ;122:24-34. Toriu mi DM, Ries WR . Innovative surgical management of the crooked nose. Facial Pla st Surg CUn North Am 1993; I:63- 78 . Torium i DM, Syke s JM , Johnson CM. Open structure rhinoplas ty for managem ent of the non-caucasian nose . Op er Tech Otola ryngol Head Neck Surg 1990;1:225- 233. Toriumi DM, Tardy ME. Cartilage suturing techn iques for correction of nasal tip deformitie s. Op er Tech Oto­ laryngol Head Ne ck Surg 1995 ;6 :26 5-273.

Toriumi DM, Josen J, Weinberger M, Tardy ME. Use of alar batten grafts for correction of nasal valve collapse. Arch Oto l Head N eck Surg 1997;123 :802-808.

Wang TD . Aestheti c structural nasal augme ntation. Op er Tech Otolaryngol Head Neck S urg 1990 .

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Subject Index

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Subject Index

A page number fo llowed by f indicates a figure. A Aesthetic ana lysis, I I, 157

Aes thetic/cosmetic issues

ala r base red uction , 113

clo sure of midco lumellar incision, 149, 150f- 15 1f

Aesthetic triang le, 16, 20

Airway obstruction. See Nasal obstruction

Ala, rhinoplasty ana lysis, 20

Alar base

cleft lip-nasal deform ity

bilateral, 168

unilateral, 167

resect ion, 113-11 5

alar wedge excision, 114, I ISf

internal excis ions, 115

internal nostril floor reduction, 113, 114f

pearls, l iS

sliding alar flap, 114, 115f

wedge excision of nostri l floor and sill, 114, 114f

rhinoplasty ana lysis, 18

Alar batten graft, 105, 106f-I09f

Alar-columella relationship, 20, 2 1f

Alar-fac ial groo ve (junction), 2f, 3f

Alar flare

internal nostril floor reduction, 113, 114f wedge excision of nostril floor and sill, 114, 114f

Alar lobule, 3f, 5, 20

Alar nasalis muscle, 4f

Alar sidewa ll, 2f

Anatomy of nose, 1- 7

musc ulature, 4 f

nasal relationships, S, 7f

nasal valve area , 6

pearls, 5-6

sc roll region, 6

septum, 4 f

soft tissue layer, 6

surface anatomy, 2f-3f

basal view, 2f

frontal view, 2f

lateral view, 2f

oblique view , 3f

surgical anatomy, 3f-5f

basal view, 3f

lateral view, 3f

oblique view, 3f

vasculature, 4f- 5f

Anesthesia, infilt rative injecti on technique , 25-29

co lumella injection, 25, 26f, 28

intercartilaginous, transcartilaginous, or delivery approach , 27, 28f

lateral wall of nose, 27 , 29f

mul tiple injections along marginal inc ision area, 25, 26f

for osteotomy, 27, 28

pearls, 27-28

soft -tissue, domal region, 25, 26 f

Anomalous nasi, 4 f

Anterior septal angle, 3f

Aquaplast cas t, application and removal, 153

Artery(ies), nasal, 4f-5f

Auricular carti lage

alar batten graft, 105

harvesting, 139, 140f-1 42f, 146-147

B Beve ling of skin edges, 45

Bifidity, nasal tip, 17

Bleed ing, septoplasty, 33

Blood vesse ls, 4 f-5 f

Bone infarction, 6

Bo nes, nasa l, 3f, 5

infracture du ring os teotomy, 67-68

medialization, 68

postoperati ve margins, smoo thing with rasps, 62, 63 f

postoperati ve shifting, digital exe rcises for, 153

Bossa for mation, 22, 110, 163

Brow-tip aesthetic lines, 17

Bulbosity, 17

Buttress graft, 102, 102f-105f

Byrd' s method, nasal projection, 16, 19, 159

C Calvarial bone, harvesting, 144, 144f-1 46f, 147

Ca p graft, 102, 102f- I05f

Cartilage

harvesting. See Tissue harvesting

lower lateral (LLC). See Lower lateral cartilage

quadran gular, 4f

179

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. ,:,_.

~-i

Cartilage tcontd.i sesa moid,3 f upper lateral (ULC). See Upper lateral ca rtilage Cartilage-sp litting approac h, 37 , 38f-39f

Ce phalic trim, 77,11 0

Cervi cal point, IOf, I I, 157

Ch in altera tions

augment ation , 165 f

alloplas tic imp lant manufac turers, 172

Legan faci al-co nvexity angle, 15

Cleft lip- nasal deformity, I67f, 167- 168

bilateral , 167f, 168

unilateral, 167, 167f

Col umell a, 2f cleft lip-nasal deform ity

bilateral, 168

unilat era l, 167

hangin g co lumella deformity, septo plasty, 3 1

infilt rati ve an esthetic injec tion techniq ue, 25, 26 f, 28

retr acte d, 17

caudal ex tension grafts, 118, 118f-12lf

plumpi ng graft , 1l7, 117f

rhino p lasty analys is, fron tal view, l7 Co lumella-labial angle (junc tion), 2f Col umell ar artery , 4f Co lumellar flap , 47, 47f-49f elevation of, 47, 49f infiltrat ive anesthetic inject ion tec hniq ue, 27f

Columell ar-labial confluence, 18

Co lumellar -lob u lar angle, 18

Columell ar show

normal value, 15, 20

rhi noplasty analy sis, 15, 158

Columell ar strut ca rtilage graft, 56, 81-84

dorsal on lay graft interdigit ating wit h. See Sadd le nose deformity

placem ent, 81- 84

endonasal approac h, 8 1, 83f-84f

external rhi noplas ty appro ach, 81, 82f

tripod co ncept, 155

Com plic ations, 163

Compressor muscl es, 4 f

Com presso r narium minor , 4 f

Compute d tom ograph y (CT scan), concha bullosa , 78, 78f

Co ncha bullosa, 78 , 78f

Co nchal carti lage . See Auricu lar cartilage

Converse sc isso rs, nasal dissection, 5 J f

Co rru gator muscle , 4f

Cru mley' s me thod, nasa l projecti on , 16, 159

Crus/crura, 3f. See also specific area

Cyanoacrylate ad hesive

man ufactur er, 172

skin closure, 113

D Del ivery approac h, 40-43

deli very of LLC , 41-42, 42f-43f

intercarti lag inous inc ision , 40 , 40f

marginal incisio n, 4 1, 4 lf

Depressor muscles, 4f

Depresso r septi nasi, 4f

Derma bond. See Octyl-2 -cya noa cry late

Digital exercises, postoperat ive , 153

Dil ato r muscle s, 4f

Dilator naris anterio r, 4 f

Dissection

auricular cartilage harv est ing, 139, 140 f-1 41 f

deli very of LLC, 41-42, 42f-43f

external rhinop lasty app roach . See Ex terna l rhinop lasty approac h dissecti on retrograde, 50

rib cartilage harvestin g, 144

septoplas ty, 31 , 32f, 33

Dome

divided, tip graft in, 101, 10If

divis ion. See Na sal tip, surg ery

iden tification , 84

Dorsal nasal artery , 4f Dorsu m of nose cartilagi nous, ex posure and inc isio n for hump rem oval, 59, 60 f co nto ur assessment, anes thetic inj ection and, 27

irre g ularities, pos topera tive, 163

rhi noplasty an alysis, 11,20

Double break , 18-1 9

Dur al tear , parietal bone harvesting, 144

E

Edema, per sistent postoperative sup ratip edema, 152-1 53

Elevator mus cle s, 4f

Endona sal approa ch alar batten graft placement, 106f columellar stru t cartilage gra ft placement, 8 1, 83f- 84f incision closure, 152, 152f nasal dissecti o n, 56

spreader grafts, 7 1, 72f Ethmoid bone harve sting . 143, 147

pe rpendicular pla te, 4f splinting (sand wich) gra fts, 122, 123f

External rhinoplasty approach, 4 3-56

anes thesia inje ction techn ique , 25- 29, 26f-29f

bac kgrou nd, 43

co lumellar strut ca rti lage graft placem ent, 8 1, 82 f

dissecti on , 43

incisions for, 43

indications for , 170

integrated dorsal graf t-co lumellar strut for saddle no se deformity marg inal incision, 43, 44f

colume llar ex tension, 45, 46 f, 56

nasa l dissection , 43-47

defining columell ar flap, 47 , 47f-49f elev atio n of per iosteum and expo sure of bony vault, 54-56, 55 exci sion of ce phalic car tilage, 50

exposu re of cartilag ino us middle nasal vau lt, 54, 54 f flap elevatio n, 47 , 49f incisio n marking, 43, 44 f lateral cru s, 50 , 5 1f m argina l incision , 43 , 44 f, 47

midcol umellar incisio n, 43 , 44 f, 45, 45f midline dorsal dissecti on, 52 , 52f- 53f retrograde dissect ion , 50

three-poi nt counter trac tion, 50, 50f pearl s, 56

septoplasty, 33, 34f spreader graft placeme nt, 7 1, 72f-75f transcolumellar (midcolu mella r) incision, 43 clo sure , 56

marking for, 43, 44f

F Face Frankfort plane, 12, 13f, 158

hori zontal facial thirds, 12, 12f, 158

surface measu rem ent s, 22, 23f Leg an faci al-conv exity angle, 14f, 15

mentocervica l angle, 14f, 15

nasofaci al angle, 12, 13f, 158

nasofrontal angle, 12, 13f, 158

nasolabi al angle, 15, 15f

nasomental angle, l3f, 15, 158

surface angles, plane s, and meas uremen ts, 12· ·16, 158-159

vertical facial fifths, 12, 12f, 158

Facet ,2f

Flap, co lumellar, 47, 47f-49f

Frankfort plane, 12, 13f, 158

G Gla bella, 9, 10f, 157

Gnathion, 10f, 11, 157

Goo de 's method, nasal projec tion, 15f, 16, 18,159

Grafts/grafting

alar batten graft, 105, 106f-l09f

cap or buttress graft, 102, I02f-1 05f

caudal extension grafts, 118, 118f-1 21f, 138

colume llar strut cartilage gra ft, 56

ethmoid bone splinting (sandw ich) grafts, 122, 123f

harvest of autogenous tissue, 139-147

calvarial bone, 144- 146

conchal (auric ular) car tilage, 139-1 42

ethm oid bone, 143

rib graft , 143-144

integrated dorsal graft -columellar strut for saddle nose defo rmity, 130- 137

lateral crural grafts, I 10, II Of

nasal tip, 98- 10 1

onlay cartil age wafer grafts, 77

plumping grafts, 117, 1 l7f, 138

shield-shaped tip graft, 98 ··10I

spreader grafts, 7 1-79

Greenstick frac ture, in osteotomy, 68

zr,

H Hanging columella deformity, se ptoplas ty, 3 1

Hemitransfixion inc ision, septoplasty, 3 1, 32f

"Hidden colu mella, " l7

Hump, 17

Hump excision, 59- 66

excision of bony hump, 59, 6 1f

expo sure and incision of cartilaginous dorsum, 59, 60f

extramucosal reduction, 64

fine-tun ing modifications, 62

in high-risk patient , 76

in "narrow nose sy ndro me," 76

nasofrontal angl e in , anes thesia considerations, 28

"open roof," 62

preop erative and postoperative views, 61f

se paratio n of ULC from dorsal se ptum, 64, 65f

septoplasty and , 33

smoothing bony margin s, 62, 63f, 64f

Hydrodissection, auricul ar cartilage harvesting, 139, 140f

I

Illusions, 22

Incisions, 160

alar base reduction surgery, 113

auricular cartilage harvesting, 139, 140f

closure. See Wound clos ure

external rhinopla sty approach, 43-47

intercartil aginous, 38f, 40, 40f

closure, 152, 152f marg inal, 41 ,4 1f

clos ure, 152, 152f, 153

colum ellar extension, 45 , 46f, 153

external rhinop lasty appro ach, 43 , 44 f midco lumellar

closure, 149, 150f-151f, 153

external rhinoplasty app roach, 43, 44f , 45 , 45f

suture remo val, 152

parietal bone harvesting, 144

rib cartilage harvesting, 144

septoplasty, 31, 32f

transcartila ginous, 37, 38f

closure, 152, 152f

Infratip lobule, 2f, 5

transdornal sutur e placement and, III

Injection . See Anesthesia

Instrumentation

rasps, 62, 63f

suggested surgical instrum ents for rhinopl asty, 171

manufacturers ' address/ phone numbers, 172

Intermediate crus, 3f

anesthetic inject ion, 25, 26 f

Internasal suture line, 3f, 6

Int ranasal pack, 152

manufacturers, 173

"Inve rted V" deformit y, 76, 163

K Kenalog. See Triamcinolone aceto nide Killian incision, septoplasty, 3 1, 32f

L Labrale superiu s, 10f, II, 157

Lateral crus , 3f, 5

anesthetic inj ection, 25, 26f

ce phalic trim , 110

grafts, 110, II Of

lateral crural over lay, 96 , 96f-97f

reduction of volume and rigidity, 85, 85f

transcartila ginous incision, 37

Lateral nasal artery, 4f

Lega n facial-convexity ang le, definition, 14f, 15, 158

Length of nose

central, 18

definiti on, 18

"ideal," 19

illusions, 22

lateral, 18

rhinoplasty analys is, 11, 18-1 9, 19f

surgical goa ls and options for ac hiev ing, 161-1 62

Levator labii alaeq uae nasi, 4f

Lid ocaine , infiltrative ane sthesia techniqu e, 25-29

Li pectomy , submental, 166f

Lips, rhinoplasty analysis , 14f, 15, 158

Literature recommendati ons, 174-175

LLC. See Lower lateral cartilage

Lo bule, 5

Lowe r lateral car tilage, 3f

asy mmetries, columellar strut for, 83f

cephalic resection of lateral crura, 85, 85f

L-strut

integr ated dorsal graft-c olumellar strut , 130-137

in septoplasty , 33, 33f

M Mattress sutur es closure of auricular cartil age harvest site, 139, 142f closure of midcolumell a incision , 149, 150f-15If spreader graft stabilization, 75, 75f Maxilla, ascendng process, 3f

::-.::::c::"" . -'r,-I­

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Maxillary crest, 4f Medial crura l footplate, 3f Medial crus, 3f Mentocervical a ngle definition, 14f, IS , 158

Powe ll-Humphries "aesthetic triangle," 16

Mentol abial sulcus, 10f, II , 157

Menton, 10f, II, 157

Midcolum ellar incisio n. See Incisions

Mucoperichondrium , support function, 59, 62f

Muscles, nasal, 4f

N Naris, 3f

"Narrow nose syndrome," 22

hump removal in, 76

Nasal analysis. See Rhinoplasty analysis

Nasal floor, cleft lip-nasal deformity

bilateral, 168

unilateral, 167

Nasa l obstruction, 18

causes , 78

concha bullosa, 78, 78f

spreader grafts for, 75-78

Nasal septum. See Septum Nasal spine, 3f, 4f Nasal splint external, 152

ap plication and removal, 153

manufacturers, 172-1 73

Nasal starting point , 20

Nasal tip, 9, IOf, 157

acce ntuating cephalic edge leading caudal edge of lateral crus, 86, 93f dome division with intact vestibular skin and suture recons titution, 95f, 95-96, 96f

individual horizontal mattre ss domal suture tech nique, 86, 86f

lateral crural overlay, 96, 96f-97f

lateral crural steal, 94f, 95

single transdo mal suture technique, 86, 89f-93f

tip grafts, 98-10 1

transdomal surgical techniques for, 86-95

trapezoidal asymmetric tip, 89f-93f

trapezoida l tip and broad doma l angles, 87f-89f

anterior protrusion. See Rhinoplasty analysis, nasal projection

asymm etry, 81, 83f

bifidity, 17

cleft lip-nasal deform ity

bilateral, 168

unilatera l, 167

deviated, 8 I , 83f

grafts

alar batten graft, 105, 106 f- 109f, J II

cap or buttress graft, 102, I02f-1 05f

caudal extension grafts, 118, 118f-1 21f

in divided domes, 101, IOIf

lateral crural grafts, 110, I I Of

pearls, II I

shield-shaped tip graft, 98- 101

narrowing, transdomal surgical techniques for, 86

projection, surgical goals and options for achieving, 16 1. See also

specific procedures

rhinoplasty analysis, I I

frontal view , 17

lateral view, 18

rotation

lateral crura l steal, 94f, 95

surgical goa ls and options for achieving, 161. See also speci procedures support co lume llar strut cartilage gra ft. 56, 81- 84

majo r support mechanisms, 160

minor sup port mechanisms, 160

surgery, 81-1 11. See also specific procedu re

accentuate tip, 86-95

alar batten graf t, 105, 106f-I 09f, II I

cap or buttress graft, 102, 102f-J 05f caudal extension grafts, 118, 118f-1 21f columellar strut cartilage graft placement, 81-84

dome division with intact vestibular skin and suture reco nsti 95f, 95-96, 96f dome identi fication, 84

lateral crura l gra fts, 110, 1JOf lateral crural overlay, 96, 96f-97f lateral crural steal, 94 f, 95

pearls, 110-1 11

reduction of crural volume and rigidity , 85, 85f refinement, 162

sculpting techniques , 160

shield-shaped tip graft, 98-10 I placeme nt, 98 , 99f preoperative and postoperative views, 100f-IOlf size of, 98, 98f, I II

tip gra fts, 98- lOI tip-defining points, zr, 3f tripod conce pt, ISS

Nasal valve, 75, 75f

co llapse, 163

ajar batten graft, 105

Nasal valve area, 6, 75, 75f

Nasal vault

bony, postoper ative shifting, 153

middle asymmetry , 77, 77f collapse, 76-77

excessive narrowing , 77

exposure, 54-56

width, assessment, 77

Nasio n, 2f, 3f, 9, 10f, 157

Naso facial angle

definition, 12, 13f, 158

normal values, 12

Powell-Humphries "aes thetic triangle," 16

Nasofrontal angle, 2f

aesthetic ana lysis, II

definition, 12, 13f, 158

in hump excision, anesthesia considerations, 28

length of nose and, J 8, 19f norma l values, ]2 Powell-Hum phries "aesthetic triangle," 16

Nasofrontal bone, osteo tomy, 6

Nasofrontal suture line, 3f

Nasolab ial angle

aesthetic analysis, 11

definition, IS, 15f, 158

length of nose and, 18, 19f normal values, 15

obtuse , septo plasty, 3 1

Nasomaxi llary suture line, 3f

Nasomental angle

definition, 13f, IS, 158

Powe ll-Humphries "aesthetic triangle," 16

Nasomental line, lip relat ionships, 14f, 15, 158

Nostri l(s) cleft lip-na sal defo rmi ty

bilateral, 168

uni lateral , 167

rhinop lasty ana lys is, 18

Nostri l floo r, 3f intern al nostril floor redu ction , 113, 114f wedge exci sion, 114, 114f Nostr il sill, 2f

wedg e excision, 114, 114f

Notch defe ct, 149

o Octyl-z-cyanoac rylate (Derrnabond)

man ufac ture r, 172

skin closure, 113

O nlay cartilage wafe r grafts, 77

Ope rati ve worksheet integrated do rsal graft -colum ellar stru t for saddle nose deformi ty, 132f sec on dary rhinoplasty pa tien t requiri ng alar batten graf ts, I08f trapezo ida l asym metric nasal tip, 90f Orbicularis or is muscle, 4f

Osseo cart ilagino us j unction , 2f, 3f , 6

Osteotomy, 67-69

anestheti c injection , 27, 28

inter mediate, 68

lateral, 67-68, 68f

high-to-lo w, 67, 68f

high-to-low-to-h igh, 67

inf racture of nasal bone, 67-68

med ial, 67, 68f

nasofron tal bo ne, 6

pearls , 68

p Packs/pack ing, intranasal, 152

man ufactu re rs, 173

Pain , postoperative , rib cartilage har vestin g, 147

" Parenthesis" de formity, 22

Pari etal bone, harvesting, 144, 144f- 146f, 147

Pe rich o ndri um , rib cartilag e barves ting, 147

Phi ltrum , 2f

Photograp hy setup, 169f

Pleural leak (tear), rib carti lage harvesti ng, 144

Pl umpi ng grafts, 117 , 117f, 138

Pne umo tho rax , rib carti lage harves ting , 147

Pogon io n, 10 f, II , 157

Po llyb eak defor mi ty, 22 , 59 , 163

Pol ydioxanone suture

inci sion c los ure, 149

sprea der graft fixa tion, 7 1

Postope rative care, 152-1 53

d igital exercises, 153

per sisten t supratip edema, 152-153

suture rem ova l, 152

Po well-Humphries " aesthetic triangle," 16,20

Procerus mus cle , 4f

Pseudohyperteloris m, 17, 22

Pyriform aperture , 3f

in osteotomy, 67

Q Quadran gular cartilage, 4f

R

Radi x projection, 19- 20

Rasps, 62, 63 f

Rhin ion , 2f, 3f, 9, 10f, 157

sellion vs., 6

Rhi noplasty analysis, 9-23

base view , 17f, 17-18

guide line s, II , 156

co lume llar show , IS, 158

facial planes, 12, 12f, 158

horizo ntal facial thirds, 12, 12f, 22, 23f

lower two third s surface measurements, 23f

vertical facial fifth s, 12, 12f

Frank fort plane, 12, 13f, 158

fro ntal view, 17

guidelines, II, 156

general assessment, 16

guidelines, I I, 156

guide to, 11, 156

lab exercise: nasal ana lysis, II

land mar ks, 157

points,9-1 1,I Of

surfac e ang les , plane s, and measur em ents, 12- 16

lateral view , 18- 20, 19f, 2 lf

g uide lines , II , 156

Leg an facia l-conve xit y angle , 14f, IS, 158

length of nose, 18-1 9 , 19 f

lip relatio ns hips , 14f, 15, 158

me ntocerv ica l angle, 14f, IS, 158

nasal proj ection , 15f, 16, 159

asse ssment, 22

Byrd 's meth od, 16, 19, 159

Crumley's method , 16, 159

Goode's method, 15 f, 16, 18, 22,159

normal values, 16

nasofacial angle, 12, 13f, 158

nasofrontal angle

definitions, 12, 13f, 158

guidelines, 11, 156

nasolabial angle

definitions, IS , 15f, 158

g uidelines , 11, 156

naso me nta l angle, de finitions, 13 f, IS, 158

o bliq ue view , 20

gui delin es, I I, 156

pear ls, 20, 22

photograph ic analys is, 16

physica l examination and anatomic analysis, 16-2 1

Powell- Hum phries "aes the tic trian gle," 16

ski n qu alit y, 11, 15 6

surface angles , planes, and measurement s, defini tions, 12- 16, 158- 159

Rib carti lage (gra ft)

harvesti ng, 143f, 143-144 , 147

pos tope rat ive pai n, 147

integrated dorsal graft-colume llar strut for sadd le nose deform ity,

130-1 37

Rocker deform ity, 6, 163

Rotation. See Nasal tip

S

'.,

Saddle nose deformity, 17,22 integrated do rsal gra ft-colu mellar stru t for, 130-137

dorsal onlay graft, 133f

external rh ino plasty approach, 133f

graft placem ent , 134 f

graft shifting, 138

operative wo rkshee t, 132f

pearls, 138

preoperat ive and postoperative view s, 136f- 137f

preoperative view s, 13 lf

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,

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Scars/scarring. See Aesthetic /cosme tic issues anest hetic injec tion, 25 , 26 f Scr oll reg ion, 6, 85 persistent postoperativ e edem a, 152-,153 Sur gical ex posu re, approaches, 160. See also specific approaches Sc ulpting techniques, 160. See also Nasal tip, surgery Su ture lines , 3f Sell ion , 6, 9, 10f, 157 Sutures/suturing Sept al angle(s) , 4f, 6 auricular ca rtilage graft site, 139, l4 2f Septal devi ation buttress grafts, 102, 102f caud al, 18, 122-129

domal suture techn ique s ethmoid bon e splinti ng (sand wich) graft s, 122

individual hor izontal mattress dornal suture techn ique, 86, 86 scoring septal cartilage for, 122

infratip lobul e after tran sdornal suture placeme nt, III "swinging door" maneu ver for, 122, 122f

singl e transd ornal sutur e technique, 86, 89f-93f dorsal, ethmo id bone splinting (sa ndwich) grafts, 122, 123f suture reapprox irnation of LLC after dome di vision, 95f, 95septal repl acem ent , 122, 123f-1 29f

inc ision closure , 149-152

partial, 122, 123f-1 27f

spreade r grafts, 7.1 , 75, 75 f, 78

total, l2 8f-129f

Septoplasty, 6, 31-34 T anes thesia injection techn ique, 25, 27 Tension nose deformity , septoplasty, 31 harvesting of cartil age, 3 1, 33 Ti ssue harve sting

hernitran sfi xion incision with anterio r septal tunnels, 31, 32f, 33 auricular cartilage, 139, 140f-142f

pearJs,33 calvaria l bone, 144, I44f-14 6f, 147

Se ptorhin oplasty, 33, 34f e thmoid bone , 143

Septum , 6 pearls, 146-1 47

anatomy , 4f rib cartilage , 143f, 143-J44

caudal, 3f septal cartilage, 31, 33

cleft lip-n asal deform ity, 167 Tr ansverse nasali s mus cle, 4f deviated . See Septal de viation T riamcin olone aceton ide (Ken alog), for persistent postoper ative s Sesam oid cartilage , 3f edema , 153

Skin T richion , 9, lOf, 157

at rhinion, 20 Tripod co ncept, 155

rhinoplasty ana lysis, 11 lateral crural steal, 94f, 95 thickne ss and quality, 22 Tunn els Skin edges, beveling, 45 septal, 3 1, 33 Skin mark ing subperiosteal, prop osed osteo tomy path , 67 for osteotomy, 67 T wo-tap technique

transcolu mellar (midcolume llar) incis ion, 43, 44f hump exc ision, 59, 6lf

Skull , parietal bone harvestin g, 144, 144f-146f, 147 osteotomy, 67

Slidin g alar flap, 114, j 15f So ft tissue layer, 6 --~ U Spl ints/spl inting JLC. See Uppe r lateral cartilage ex terna l nasal spl int, 152, 153 .Jpper lateral cartilage, 3f manufactur ers, J72- 173 disarticul ation , 54 Sp read er grafts, 7 1- 79 di vision from dorsal septum, sp reade r gra ft p lace me nt, 73f, 74f bilateral,74f / . inferomedial collapse , 59, 62f cli nical indications, 76-78 separ ation from dorsa l septum, 64 , 65f endo nasa l approach, 7 1, 72 f ex terna l rhino plasty approac h, 7 1~, ~::: ,] 2:-:;.5 f_7 ::.:f~_ _ ~ _ V ove rwidening, 77 ' Vascul atur e,4f-5f pearl s, 78 placement ',.• ,

W endon asal approach, 71, 72f, 76 '.,'~

Wedg e resec tion ex pos ure of middl e nasal vault , 78

accentuating nasal tip, cephalic edge leading cauda l edge of late ex ternal rhinoplasty appro ach , 71, 72f- 75f, 76

86,93 f

ration ale, 76

alar, 114, 115f

size, 71

nostr il floor and sill, lJ4, 114f

suture fixation, 78

Wid th of nose

suture fixation (stab ilizatio n), 75, 75 f

illusions , 22

Stornion, 10f, II , 157 rhinoplasty anal ysis, 11, 17

inferiu s, 10f, 11, 157 Wound clos ure superius, 10f, II, 157 auricula r cartilage har vesting, 142f Subnasale, 9, 10f, 157 closure of margin al, interc artila ginous, or transcartil agin ous inc Sub nasale-to-pogonion line , lip relationship s, 14f, 15, 158 152, 152f Suction drill, postoperative smoothing of bony margin s, 62, 64f closure of midc olum ella incisio n, 149 , 150f--15 If Supraalar crease , 2f pearls, 153 rib carti lage harvest ing, 147 Supr atip, 2f, 9, ior, 157

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