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Rhinoplasty Blog

28/Apr/2017

Cosmetic Surgery had its beginnings at the end of the nineteenth century. At first, the morality of people willing to undergo such surgery was questioned, but with time, the procedure gradually became more acceptable.

There were many factors affecting the growth of cosmetic surgery. The development of general anaesthesia was a key issue since, until the 1920’s, dripping Ether onto a rag covering the patients face was the most one could expect. The discovery of the first antibiotic and Sulfanamide, in the 1930’s was also a major factor, as the risk of infection in such operations was high. Antibiotics became more widely used after World War II. Most importantly perhaps, surgeons merely lacked knowledge or the appropriate techniques needed to perform effective cosmetic surgery. With the development of general anaesthesia, antibiotics and new techniques, reliable operations and instruments could then be designed to accomplish cosmetic changes and reduce the risks involved.

Throughout its history, cosmetic surgery has always attracted opportunists; surgeons seeking a quick and easy profit. At first, people were keen to believe in the promise of youthful looks and were prepared to pay handsomely for it. In the early days, patients seeking cosmetic surgery had merely wanted scars concealing, but by the 1950’s women were demanding their noses to be reshaped, purely to be in keeping with fashion and the popular image of beauty.

Reputable cosmetic surgeons are firstly general surgeons, plastic surgeons or otolaryngologists familiar with the body in general. They are therefore able to manage any surgical complaints which might arise. Traditionally, the best surgeons have actually been trained as reconstructive surgeons, helping patients to look normal.


RHINOPLASTY

One’s nose draws the observer’s eye because of its prominent position in the middle of the face. Surgeons have realized the anguish an obtrusive nose can cause to its owner and have developed ways to solve it.

Surgeons at first had to experiment in altering the shape of the nose. They trimmed nostrils that were too wide, elevated drooping tips and flattened humps of bone and cartilage to smooth humped noses. The real challenge was not the operation itself but leaving no obvious scars afterwards.

 

Johann Friedrich Dieffenbach (1794-1847), a Prussian surgeon,made the first recorded attempt to reshape a nose. He removed a wedge of flesh in order to raise a drooping tip and generally reduce the size of the nose. To slim the thick skin of a man’s nostrils, Dieffenbach removed wads of skin using a punch, an instrument similar to the tool used by a leather or metal worker.

John Orlando Roe (1848-1915), an ear, nose and throat surgeon from Rochester, New York, first addressed the problem of the elimination of all visible scarring. He recognized the importance of making the nose blend with the rest of the face and he proposedoperating on the nose through incisions hidden within the nostrils. Using this approach, he showed how he could reshape a pug nose, a deformity of the nasal tip resembling a dog’s stubby snout. Roe reduced an entire nose by removing excess bone and cartilage through an unobtrusive internal incision. The anaesthetic Roe used was cocaine. He applied it to the interior of the nose and injected it under the skin. Roe was unaware of the dangers of cocaine and was using it for his patient’s comfort. He appreciated the psychological benefits of cosmetic surgery. A well performed operation could relieve a patient’s embarrassment by eliminating a disfiguring feature.

Karl Koller (1857-1944), had introduced the use of cocaine in eye surgery while an intern at Vienna’s General Hospital. The world famous ENT Clinic in Vienna, Allgemeines Krankenhaus, was founded in 1884 by a surgeon unable to gain entry into general hospital. Robert Barany who received a Nobel Prize and George Von Bekesy practised at this clinic.

Robert Fulton Weir (1838-1927) of New York, introduced the subtle technique of reducing and refining a large, distorted nose. Weir operated through incisions hidden within the nostrils. To reduce the width, Weir chiselled the bones loose, moved them inward, and secured them by piercing them with a needle that was prevented from slipping by a metal shot

placed at either end. He also reported on how he narrowed the flaring nostrils of the wide, flat nose of an adult patient whose deformity typically accompanies a cleft lip. It is now routine to use Weir’s procedure of removing a wedge from the base of each nostril, then rolling the nostril inwards.

In Weir’s paper `On Restoring Sunken Noses` he identified the patient who is never satisfied with results and demands operation after operation, searching for perfection.

Jacques Joseph (1865-1934) Berlin, performed his first nose operation in 1896. Joseph tackled the problems of reducing a large nose while leaving as few offending scars as possible. He could shorten the nose, reduce its hump, straighten it and make the nostrils smaller by using incisions in the skin. Joseph performed the surgery through the inside of the nostrils. He had great success and, like his techniques, the saws, chisels and clamps that he devised for surgery are still in use today. Joseph was originally trained in Orthopedics. At that time cosmetic surgery was considered unimportant and unethical at Joseph’s University. He was temporarily suspended from his academic post for his unorthodox activities. He was not discouraged by this and continued to develop operations to correct abnormal features. In the year 1898, Joseph presented his procedures to the Medical Society of Berlin, where many local and American doctors were attending. He used intranasal incisions, removed nasal humps, performed lateral osteotomies and employed ivory for augmentation. (Joseph used to obtain ivory from a nearby piano factory). Joseph’s outstanding work enabled him to develop a worldwide reputation and people came from far and wide to have their rhinoplasty performed by him. Even more importantly, surgeons travelled great distances too in order to learn from him. Joseph, who was referred to as `Joseph Noseph`, specialized in rhinoplasty but also performed facelifts, otoplasty and general plastic surgery. In January 1934, Joseph performed his last rhinoplasty on the 16-year-old daughter of a Munich restaurateur. When Hitler rose to power, Joseph fled from Berlin to Prague. After his death, Joseph’s students brought his work to the attention of English-speaking surgeons. Among Joseph’s students were Gustave Aufricht, a Hungarian surgeon and Joseph Safian, both of whom became reputable as facial plastic surgeons in the United States. Safian was a careful and conservative surgeon who concentrated on how to avoid mistakes and how, if they were made, to correct them. Aufricht modified the Weir’s incision, and devised the Aufricht retractor which is still used in every rhinoplasty today.

 

The master rhinoplasty surgeons of the last twenty years (1980-2000) such as Robert Simons, Gaylon McCollough, M.E. Tardy, R.W.H. Kridel, Rollin Daniel, Webster, Dean Toriumi of the United States, and Tony Bull from the United Kingdom and others, have greatly contributed to the advances in our techniques today. The Tony Bull Course, London, has been operating for the last twenty years. The participants are surgeons from all over the world who are wishing to consider a career in rhinoplasty.

EARS
Giovanni Bathista della Porta, a sixteenth-century Neopolitan naturalist and philosopher, described a perfect ear as being neither too long nor too short. Johann Casper Lavater, the eighteenth century Swiss pastor who popularized the belief that external appearance is governed by inner moral qualities, devoted only three pages to ear size and shape and never once mentioned the criteria for judging the beauty of an ear. It is only in recent times that ears have been operated on to improve their aesthetic quality. Before this ears were only reconstructed if they had been partially damaged or completely destroyed.Ears placed closed to the head are recognized as desirable and surgeons have sought ways to make them flat. If one is unfortunate enough to have ears set at a right angle to the skull one is prone to be taunted as stupid or mean.

Edward Talbot Ely (1850-1885), Otolaryngologist at the Manhattan Eye and Ear Hospital pioneered the method for reshaping ears. However, this was not a problem free method since cutting out a strip of cartilage to flatten the ears left them with too sharp a crease. William Henry Luckett (1872-1929), New York, was the first to decide exactly what twist of anatomy made the ear protrude. A normal, visually pleasing ear gently folds back on itself and Luckett speculated that the protruding ear lacked such a fold. He set out to create a fold in the ear and after doing so he secured it with a line of stitches so that the ear was permanently rolled back toward the skull. Luckett took on the problem of setting back protruding ears as just one more in a long series of challenges. He also devised new methods of tying sutures, diagnosing skull fractures and removing diseased gallbladders.

 

 

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28/Apr/2017

People do want to stay `forever young` and from the 1920’s onwards surgeons have worked hard to correct the difficulties of an aging face. Charles Conrad Miller (1880-1950), Chicago, is the man credited with making the first attempt at eliminating signs of facial aging. In 1906, he described removing lax folds of skin from the upper and lower eyelids. At first he cut away only the skin, he didn’t remove the bulging fat from around the eyeball that is standard procedure today. To correct the deep lines along the side of the mouth, Miller tried to burrow under the surface of the skin and cut muscles he believed to be the cause of the trouble. Miller blamed women for the unwanted creases, saying that they used these muscles improperly. He wrote the first book on cosmetic surgery `The Correction of Featural Imperfections`. By today’s standards Millers techniques for smoothing facial wrinkles were unsafe and unsavoury. In the 1920 edition of his book, Miller described some refinements to his facelifting technique. He recommended placing incisions unobtrusively, keeping them within the hairline while snipping and tucking to smooth the forehead. He recommended removing the skin and fat bulge through a long horizontal incision just under the chin for a double chin. Miller also advised surgeons to inform their patients of what to expect and to use fine suture material and fine technique.

Frederich Strange Kolle (1871-1929), suggested a remedy for the problems of loose, wrinkled skin on the upper and lower eyelids. His solution – removing large crescents of the skin from both upper and lower lids _ was fated to cause ectropion, contraction of the skin of the lower lids severe enough to show too much of the whites of the eyes and give the unfortunate patient a permanent, round-eyed stare.

Suzanne Noel (1878-1954), Paris, was the first woman to devote her practice exclusively to aesthetic surgery. In 1926, she published `La Chirurgie Esthetique: Son Role Social`, a book describing her ideas on the psychological impact of cosmetic surgery, as well as offering detailed explanations of her advanced surgical techniques. Noel believed that tugging on the skin alone was insufficient to achieve lasting results; lifting the skin off the underlying structures, then redraping it, provided a better effect.Reputable surgeons described other procedures, such as removing patches of the skin at the hairline and at the fold wherethe ear joins the face to smooth an aging face. Eugene Hollander (1867-1932), claimed he `lifted` the face of a polish aristocrat. Raymond Passot (1886-1933), France, carried out a similar operation. He predicted that cosmetic surgery would be viewed as reconstructive surgery had been in the past and that it would be accepted with enthusiasm by both the public and the medical profession. Albert Bettman (1883-1964), Oregon, U.S.A., presented the first before and after photos in 1919. His incisions in front of and behind the ear were closed with fine silk wire and horse hair and were almost identical to the standard incisions of today. Next Jacques Joseph published a photograph which showed his preoperative and postoperative results on a patient.

In the early days, the public were very gullible and believed in surgery that promised total rejuvenation. Charles-Eduard Brown-Seguard (1819-1894), France, decided that injecting an extract from dog testicles into an aging man could restore feelings and appearance of youth. Serge Voronoff (1866-1951), Russian, living in France, felt that he could achieve better results by transplanting entire testicles into the bodies of aging men. He felt that human organs would be best, but as it was difficult to get donors, young monkeys were used instead. Irradiating ovaries was the process used to attempt rejuvenation in women. The idea of irradiating ovaries and transplanting testicles was discredited but for a while these procedures had kept both public and surgeons hopeful of rejuvenation.


28/Apr/2017

An ENT, head and neck surgeon who is familiar with parotid surgery, should not find a facelift difficult. Also, one who has practised osteoplastic frontal flap operations would find forehead lifting a relatively easy task. Therefore, it is a natural progression for otolaryngologists, once they have mastered rhinoplasty to move on to other parts of the face.

Ira Tresley, MD, President, American Academy of Facial Plastic and Reconstructive Surgery, 1969-1970, one of the best rhinoplastic surgeons. Otolaryngologists met with a lot of opposition as they tried out their new procedures. Many of them had their privileges from the hospital removed and suffered outright ostracism from the medical community. Jack Anderson scheduled his first rhinoplasties as submucous resections because a good friend and famous plastic surgeon called Neil Owens worked at his hospital. He knew that his friendship with Owens would be threatened if he put his procedure down as a rhinoplasty. Once the nature of Anderson’s work was discovered however, Owens never spoke to Anderson again and their friendship was lost.

Trent Smith, had a booming ENT practice before he decided to concentrate on facial plastic surgery. When he began doing facelifts he hired a young general plastic surgeon, who had just finished his residency to help him. Smith also met with a lot of opposition to his work. Morey Parkes was faced with a lot of resistance when he went on to do blepharoplastics and facelifts. He had no one to teach him and blepharoplastics was the hardest area to break into. Parkes commented that the move into facelifts and other cosmetic procedures was very gradual and sporadic. Anderson and Jesse Fuchs were doing it, other surgeons watched and learned from them, but it was a very gradual procedure.

Oscar Becker, Chicago, was a very accomplished plastic surgeon who was willing to allow others to come and watch his operations. One of his students was Sidney Feuerstein who often flew overnight to arrive at Weiss Memorial at six or seven thirty in the morning to watch Becker work and then listen to them discuss the procedure.

John Conley, head and neck cancer surgeon, was one of the first reputable surgeons to perform facelift surgery.

In the early days, surgeons did not have access to the kinds of seminars and courses that are available today. Despite this they were just as diligent in making the time to share their knowledge and hone their techniques.

Beekhuis explained that he had never done a facelift during his residency. To learn about facelifts he read and studied books about the subject, watched other surgeons performing the procedure, spoke to and questioned people about it and saw their results. Beekhuis found that the development of his skills in facelifts was not difficult, as he had already been working in the head and neck region.21

Nowadays, aesthetic facial procedures are practised by many specialists, including otolaryngologist, plastic surgeon, ophthalmologist, dermatologist and maxillo-facial surgeon. It is widely felt that the practice of facial plastic surgery by these varied communities, despite diverse experience and training, have very much attributed to the advances of the surgical techniques and upgraded the expertise and skills in facial plastic surgery.

 

Refrences
History of Facial Plastic Surgery
 

1. Aufricht G: The development of plastic surgery in the United States, Plast Reconstr Surg 1:3, 1942.
2. Weir RF: On restoring sunken noses, NYMJ 56:443, 1892.
3. Roe JO: The correction of angular deformities of the nose by a subcutaneous operation, Med Rec 40:57, 1891.
4. Joseph J: Operative reduction of the size of the nose (translated by G Aufricht). In McDowell F, editor: The source book of plastic surgery, Baltimore, 1977, Williams & Wilkins.
5. Joseph J: Nasal reductions (translated by F McDowell), Deutsch Med Wchnschr 30:1095, 1904. In McDowell F, editor: The source book of plastic surgery, Baltimore, 1977, Williams & Wilkins.
6. Natvig P: Some aspects of the character and personality of Jac`ques Joseph, Plast Reconstr Surg 47:452, 1971.
7. Safian J: Personal recollections of Professor Jacques Joseph, Plast Reconstr Surg 46:175, 1970.
8. Safian J: Failures in rhinoplastic surgery; causes and prevention, Am J Surg 50:274, 1940.
9. Safian J: Deceptive concepts of rhinoplasty, Plast Reconstruct Surg 18:127, 1956.
10. Goldwyn RM: Johann Friedrich Dieffenbach (1798-1847), Plast Reconstr Surg 42:19, 1968.
11. McDowell E: History of rhinoplasty, Aesth Plast Surg 1:321, 1978.
12. Davis JE and Hernandez HA: History of aesthetic surgery of the ear, Aesthetic Plast Surg 2:75, 1978.
13. Lavater JC: Essays on physiognomy (translated by T Holcraft), London, 1789, J Murray.
14. Ely ET: An operation for prominence of the auricles, Arch Otol 10:97, 1881.
15. Rogers BO: A medical “first”: Ely’s operation to correct protruding ears, Aesthetic Plast Surg 11:71, 1987.
16. Rogers BO: Commentary on “A new operation for prominent ears based on the anatomy of the deformity” by WH Luckett, Plast Reconstr Surg 43:83, 1969.
17. Mulliken JB: Biographical sketch of Charles Conrad Miller, “featural surgeon,” Plast Reconstr Surg 59:175, 1977.
18. Robbins HM: First is cosmetic surgery, Am J Cosm Surg 1:47, 1984.
19. Miller CC: Cosmetic surgery: The correction of featural imperfections, Chicago, 1908, Oak.
20. Rogers BO: A brief history of cosmetic surgery, Surg Clin North Am 51:265, 1971.
21. Simon R: Coming of age and thieme, 1989.
22. Romm, Sharon: The changing face of beauty, Mosby, 1992.

28/Apr/2017

An outstanding corrective surgical plan needs to be based on thorough clinical assessment, clear doctor patient communication and frank discussion of the pros and cons of surgery. In addition, a well informed consent, smooth in-patient care and close follow-up are mandatory in order to lessen the patients fear and anxiety, limit complications and cut down the medicolegal cases.

Practical guidelines are presented as follows:

    1. Consultation
      • History
      • Clinical examination
      • Computer imaging
      • Informed consent
      • Photographs
      • Preoperative investigation

 

    1. In-patient management
      • Hospital admission
      • Anaesthesia
      • Immediate postoperative care

 

  1. Instructions and follow-up

Consultation

  1. History
    Ask the patient about:

    1. The main complaint: shape and or function.
    2. What he/she dislikes about his/her nose.
    3. What he/she likes about his/her nose.
    4. Any airways obstruction.
    5. Any previous nasal surgery.
    6. Any medication for nasal obstruction or allergies.
    7. Any other illnesses (diabetes, asthma, heart, hypertension, etc.) and other medications or previous surgeries.


Fig. 2 – 1. The rule of fifths. The width of the base of the nose is approximately equal to the distance between the eyes. This is used as a guide in alar wedge resection

B. Clinical examination

    1. Skin type
      Skin type is evaluated by inspection and palpation. The physician should roll the skin over the bony dorsum and gently pinch the skin between the fingers. The quality of skin is an essential indicator of the surgical outcome and plays a significant role in preoperative planning. Extremely thick skin is the least likely to achieve the desirable refinement and definition. The thick skin may fail to contract favourably on the newly reshaped cartilages and lead to excessive soft tissue scar. Also, very thin skin provides almost no cushion to mask even the minute skeletal irregularities or contour imperfections. The ideal skin type falls somewhere in between these two types. There needs to be enough subcutaneous skin to provide adequate cushioning over the nasal skeleton, but still allow critical definition to the nasal tip.
    2. Dorsum
      Straight _ deviated _ twisted _ depressed _ saddling _ bony collapse _ supratip collapse.
      Hump:
      True or false
      Cartilagenous, bony or both
      Deviation:
      Bony, cartilagenous or both.
      Long or short.
      Any grafts or implants.
    3. Tip
      Wide, bulbous, trapezoid, asymmetry, bifid, drooped, overprojected, underprojected, pointed or deviated, double break, facets.
      Tip recoil:
      Tip recoil is defined as the inherent strength and support of the nasal tip. This can be evaluated by depressing the tip towards the upper lip and watching for the tip’s supportive structure to spring back into position. If the recoil is good, and the tip cartilages resist the deforming influence, then tip surgery can usually be performed without fear of substantial support loss. The size, shape, attitude and resilience of the alar cartilages should be assessed by palpation of the lateral crus between two fingers. Any asymmetry of the alar cartilage should be noted.
    4. Nares:
      Flared, wide floor, asymmetry, scar.
    5. Alae:
      Collapse, dimpling, pinching, notching, alar retraction or wide rim.
    6. Columella:
      Straight, deviated, bifid, short, long hanging, retracted, caudal dislocation, wide thick columella or scar.
    7. Supratip:
      Collapse or pollybeak or supratip break.
    8. Radix:
      Deep or flat.
    9. Nasolabial angle:
      Normal, acute, shallow.
    10. Bony vault:
      Wide, narrow, depressed.
    11. Examination of other facial features:
      Chin, eyelids, eyebrows and facial skin.
    12. Endoscopic nasal examination
      Deviated septum, enlarged turbinates, nasal polyps or chronic sinusitis.
    13. Psychological assessment:
      During the consultation and discussion with patient, the psychological motivation and status will become clear. Patients with high expectations should be well informed about the limitations of surgery. If convinced, they should double sign the consent form. Psychiatric patients or patients on drugs are best avoided as they may be very unhappy in spite of quite satisfactory results

The surgeon should understand the emotional state of his patients. Most patients seeking rhinoplasty are emotionally stable. However, the surgeon should be aware of the three personality types which may present: 1. The hysterical personality shows himself through helplessness and an inability to make his own decisions. 2. The depressed patient blames his nose for his own sadness

and inadequacies. 3. The paranoid personality supposes himself to be the centre of people’s attention because of his abnormal nose. It is essential that the patient is absolutely honest about his motives for rhinoplasty in order to avoid misunderstandings after surgery.

C. Computer Assisted Imaging

In our practice we perform computer imaging as the next step following clinical examination. The patient is asked if he wishes to have this advanced technology and move to the computer imaging room. The procedure is started by our technician and once she finishes I am called for final touch modification. Then the procedure is discussed in detail with the patient.

Advantages:

  1. The patient has the opportunity to visualize the possible surgical modification of the nose.
  2. The patient has the option to accept or reject these modifications prior to surgery.
  3. At the same time the patient has the opportunity to visualize additional facial procedures such as chin implants, blepharoplasty and facelifting.
  4. Implants can be selected, measured and ordered according to the required size.
  5. Teaching and education purposes.
  6. Documentation and medicolegal records.
  7. Marketing advantages:
    Almost all patients nowadays ask about the availability of computer imaging at the time of booking a consultation. The availability of such a facility will definitely encourage patients to come for a consultation.

In our practice we used the following Computer Imaging consent form:

I certify, it has been explained to me that the purpose of the Computer Imaging is to be used as an illustration to show to some extent the changes that might be possible by surgery. I understand that there is no guarantee whatsoever that the result of surgery will be similar to the changes illustrated by Computer Imaging. I certify that the Computer Imaging has no clinical or official legal value.

Patient Name  : ……………………………….

Signature       : ……………………………….

Date             : ……………………………….

 

D. Photography

Preoperative photographs are mandatory. Rhinoplasty or any other plastic procedures should never been performed if preoperative photographs are not available.
Advantages of photographs:
  1. Medicolegal documentation:Many patients may claim that their noses were better before the operation, unless you have the preoperative photographs you can not defend yourself.
  2. Preoperative discussion guide with the patient:
    To show the patient what has been achieved by the procedure.
  3. Self teaching and education:
    A comprehensive view of pre and postoperative photographs will keep the surgeon motivated and looking for improvement of his techniques.

We use:

  1. Lens : Macro 105.
  2. Camera: Nikon F70.
  3. Slide films R-100.
  4. Appropriate Macro flash and lightning.
    Nikon macro speedlight S-B 21.
  5. Green or blue background behind the patient.
    Recently, we started using the new advanced Digital camera, the Nikon 990.

Procedures:

  1. Stand in front of the patient about one metre away. It is desirable to include: the face with the hair and part of the neck in the frame.
  2. Take the following views: – anterior / posterior view – lateral view – oblique view – base view.
  3. Use the best camera and lenses to achieve the best quality slides and photographs.

E. Informed Consent

Once the patient has requested a booking for an operation, more detailed communication and informed consent are mandatory to avoid future misunderstanding, dissatisfaction and medicolegal problems.

The pros and cons and objects of surgery should be fully discussed. The limitation of septorhinoplasty, the factors that affect surgery, listed abnormalities to be corrected and possible postoperative problems should be all made very clear to the patient and should be written in the consent form and signed by the patient.

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28/Apr/2017

The following facts should be made clear prior to surgery:

  1. The aim of the operation is improvement and not perfection. The patient should not have realistic expectations.
  2. There is always the possibility of minor revision procedures two to six months postoperative.
  3. Factors that might affect the outcome and are out of the surgeon`s control:Infection, scarring, keloid, wound contracture, irregularities, the effect of age, diabetes, atherosclerosis and skin elasticity.
  4. The technical skills of the surgeon are limited by:
    1. Nature and thickness of the investing skin.
    2. Strength and contour of the nasal cartilages.
    3. The uncontrollable and unpredictable scar contracture during the healing process.
    4. The autografts availability.
    5. The thickness of fatty tissue and facial asymmetry.
  5. Patient should accept the known risks of surgery such as:
    Infection, bleeding, numbness, swelling, discolouration, keloid and dissatisfaction.
  6. Patient must accept as well the very rare risk of surgery and anaesthesia such as: Blindness, paralysis or even death.
  7. The patient should understand there is no guarantee whatsoever for surgery, because the surgeon has no control over the natural healing process of the body. However, we should emphasize and reassure the patient that we shall all do our best and use the best techniques that are available to achieve (by God`s help) the best possible results.
  8. Patient should be informed about possible airways impairments, and vasomotor rhinitis, which are usually transient but rarely persistent.
  9. Patient should accept using grafts from his ear, ribs, irradiated homografts and the use of necessary implants.

 

Signed informed consent and preoperative photographs are essential documentation that should be in the hands of the surgeons for good defense in medicolegal cases. Inform consent and good quality documented photographs with good doctor/patient relations will convince many unsatisfied patients to be satisfied and reduce medicolegal cases.

In our practice we use the following consent form:

I, the undersigned,_______________________________________________________
visited Dr. Bizrah’s clinic complaining of (all deformities should be listed)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

I authorized Dr. Bizrah to perform the following procedures:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

in relation to my case, these additional information explained clearly
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

I certify that it has been explained to me that the aim of the rhinoplasty operation is to achieve as much improvement as possible and perfection is not guaranteed. It has been explained that secondary procedures may be needed following primary procedures in order to achieve satisfactory results. I certify that it has been explained to me that the power of healing and wound contracture varies from person to person and that infections, fibrosis, scarring, irregularities, notching, pinching, retraction, collapse, deviations and keloids, may all occur due to some problems with wound healing and contracture and has nothing to do with the surgeons skills or surgical techniques. The skin and living tissue are not like wood or marble, so the living tissue may expand and contract and this is beyond the control of the surgeon. I understand that part of this surgery may require external skin incisions that might leave permanent scarring. I allow the surgeon to use cartilage or bony grafts from other areas of my body or from other people or to use medical implants. I understand that airway impairment may occur and might require medical or surgical treatment at a later date although this is rare. I understand and certify that it has been explained to me that the aim of functional nasal surgery is to improve the nasal airways but post nasal phlegm and allergies may persist. Complications of sinus surgery and surrounding structures have been explained clearly to me. Bleeding, septal perforation or adhesion may rarely occur. I allow the surgeon to take photographs and use them for teaching, research and academic purposes. Regarding the computer imaging, I certify that it has been explained to me that the service is only to provide illustrations and what changes might be possible through cosmetic surgery and no guarantees whatsoever are made to the specific outcome. I certify that I understand that complications of surgery and anaesthesia might occur which rarely may be serious. I am convinced that the surgeon and the anaesthetist will do their best and consider the highest possible care and management of my case. Therefore, I read and understand everything written in this consent and I authorize the surgeon and the anaesthetist to perform the required surgery and anaesthesia for my case. I certify that I have been given an informative booklet about my operation and postoperative instructions which I should follow.

________________________            ________________________
Name of patient & signature                            Witness

________________________
Date


28/Apr/2017

Rhinoplastic surgeons have a duty to dispel the horror stories that have become associated with nasal surgery and general anaesthesia. We were urged to apply and develop the technique of local anaesthesia with sedation, in order to reduce the patient’s fear caused by general anaesthesia and to provide a more safe, comfortable and convenient procedure. The application of local anaesthesia with sedation has resulted in shorter hospitalization, shorter total operative time, shorter recovery and quicker turnover of cases, less frequent nausea and vomiting, less operative and intraoperative bleeding and it is more appropriate for patients with asthma, diabetes and hypertension. Local anaesthesia is not recommended for patients under the age of sixteen or the worried and irritable type of patients. The author currently applies local anaesthesia in over 80% of his cases.

Technique of local anaesthesia with sedation:
The local anaesthesia procedure must have been fully explained to the patient at his consultation visit. Patient selection is important, the patient should be cooperative, understanding and willing for local anaesthesia. Many patients, unfortunately, are horrified about anaesthesia. For this reason, the author’s approach to local anaesthesia is based on his own experience and that of others, which is designed to provide a more safe and acceptable procedure. The patient is adequately sedated and has amnesia to much of the operating room experience, but usually is aroused easily by talking to him and alert on returning to the ward. This approach allows early mobilization and the patient is discharged home on the same day. The sedation is administered in a planned and progressive manner, premedication is given on admission one hour before surgery, then in the operating room the intravenous sedation is administered under the supervision of a trained Anaesthesiologist. Once the patient has reached his state of sedation, topical and injectable anaesthetics are delivered to the areas to be operated. (Figs. 3 -1,2,3)

  1. Preoperative medication: one hour before surgery while patient is still in his room.
    – Diazepam 5mg : oral or i.m.
    – Zofran 4mg (Ondansetron) : oral
    – Decadron 8mg (Dexametason) : Intravenous
    – Zinacef 1.5mg (Cefuroxim) : Intravenous
    – Iliadine (Oxymetazoline hydrochloride) nostril : 3 drops each
    – Emla cream (Lidocaine, Prilocaine) : on the nose and vestibular skin


Fig. 3 – 1. Nerve supply to the external nose.

Fig. 3 – 2. Nerve supply of the lateral nasal wall.

 

Fig. 3 – 3. Nerve supply of the nasal septum.

    1. Patient monitoring: In the operating room, an ECG, pulse, respiratory, P0 and PC0 monitoring should be connected to the patient before any intraoperative sedation or local anaesthetic injection.
    2. Intraoperative sedation: Intravenous sedation is given before the use of any sprays, local injections or packs. Sedation: starts with:
        • Dormicum (Midazolam) 2mg/IV
        • Pethidine 30mg/IV
        Xylocaine spray 4% : two puffs in each nostril then wait for three minutes.
    3. Topical anaesthesia: Our aim is to eliminate pain and to achieve vasoconstriction. Xylocaine or Lidocaine 2% with 1:200,000 Epinephrine in 5cc syringe and 27 gauge needle is used. A series of bolus injections and infiltration are administered as follows:
      • The anterior end of the inferior turbinate. (Fig. 3 – 4)
      • Submucously, high under the nasal bones to the region of the anterior ethmoid nerve.
      • Site of the caudal septum and transfixion incision. (Fig. 3 – 5)
      • Site of intercartilagenous incision.
      • Superior septal angle: the needle is passed through in the midline to the rhinion and up to nasion, a bolus is injected along each of these three sites.
      • Site of the marginal incision at the mid lateral crus, then at one cm intervals along the caudal lateral crus.
      • Bolus at mid-columellar between the two medial crus, then a bolus up between the domes and a bolus down at the base of the columella.
      • Infiltrating along the nasofacial junction. The entry site is intranasally at the pyriform aperture, then the needle is pushed to a midpoint between the medial canthus and the nasion, then pulled while infiltrating. Care should be taken not to enter the angular vein.
      • Bolus to the alar base at the nasolabial junction. The needle is pushed down to meet the bone then pulled while infiltrating.
      • Bolus at the frenulum intraorally, behind the upper lip.

 

        One should

never overinfiltrate 

      the nose with local anaesthesia, 5cc is quite enough. Over infiltration causes swelling of tissue, leading to incorrect assessment such as false over projection, false hump, masking of depressions and mild deviations and widening the base of the nose. This will lead to over correction and later complications.
  1. Nasal anaesthetic pack:
    A light nasal pack soaked with Xylocaine gel, Prisoline and 5cc Xylocaine with 1:100,000 Adrenaline. The nasal cavity is packed in a way as to cover the regions of the sphenopalatine ganglion posteriorly, anterior ethmoid nerves under the nasal bones and the pack is made in layers to cover as much of the septum and inferior turbinates. Each pack is sutured to a long silk tie, the tie is fixed with plaster to the cheek. (Fig. 3 – 6)
  2. The procedure starts after fifteen minutes in order to allow time for vasoconstriction and amnesia. Once we start the procedure, the light nasal pack is pushed backward to close the posterior choana to prevent dripping of blood to the throat during surgery. The pack is fixed with a silk tie to the cheek to prevent the pack slipping into the oropharynx. The vestibular hair is trimmed at this stage.
  3. Maintaining the sedation:
    During the procedure, the sedation is maintained by one mg of Dormicum and ten mg of Pethidine every fifteen minutes. To reduce nausea, Zofran 4mg is given on continuous intravenous drip. The average time of our Septorhinoplasty is sixty minutes. Naloxon may be used for overdose.
  4. A trained Anaesthesiologist should be present and should stay at the head of the patient watching the ECG, P0 PC0 vital signs and the airways. Should the patient become agitated or uncooperative during the procedure, the Anaesthesiologist should be quite prepared to administer general anaesthesia. Nasal procedures under local anaesthesia should be carried out in a fully ready and equipped operating room.

 

Refrences
Local Anesthesia
 

1. Anderson, JR. A personal technique of rhinoplasty. Otolaryngol. Clin. North Am. 8:559, 1975.
2. Bachman, W., and Legler, U. Studies on the structure and function of the anterior section of the nose by means of luminal impressions. Acta Otolaryngol. (Stockh) 73: 433, 1972.
3. Batson, O.V. the venous networks of the nasal mucosa. Ann. Otol. Rhinol. Laryngol. 63:571, 1954.
4. Bernstein, L. Submucous operation on the nasal septum. Otolaryngol. Clin. North Am. 6: 549, 1975.
5. Bernstein, L. Surgical anatomy in rhinoplasty. Otolaryngol. Clin. North Am. 8: 549, 1975.
6. Converse, J.M. Corrective rhinoplasty. In I.M. Converse (ed), Reconstructive Plastic Surgery (2nd ed). Philadelphia: Saunders, 1977.
7. Converse, J.M. The cartilaginous structures of the nose. Ann. Otol. Rhinol. Laryngol. 64: 220, 1955.
8. Cottle, J.M., et al. The “maxilla-premaxillary” approach to extensive nasal septum surgery. Arch. Otolaryngol. Head Neck Surg. 68: 301, 1958.
9. Daniel R.K., and Farkas, L.G. Rhinoplasty: Image and reality. Plast. Surg. Clin. 15: 1, 1988.
10. Dion, M.D., Jafek, B.W., and Tobin, C.E. The anatomy of the nose. Arch. Otolaryngol. Head Nech Surg. 104:145, 1978.
11. Farkas, L.G., Kolar, J.C., and Munro, I.R. Geography of the nose: A morphologic study. Aesthetic Plast. Surg. 10:191,1986.
12. Gray, V.D. Physiologic returning of the upper lateral cartilage. Rhinology 8:56, 1970.
13. Hollingshead, W.H. Anatomy for Surgeons: Vol. I. Head and Neck (3rd ed) Philadelphia: Harper & Row, 1982.
14. Lessard, M., and Daniel, R.K. Surgical anatomy of septorhino-plasty. Arch. Otolaryngol. Head Neck Surg. 111:25, 1985.
15. McCollough, E.G. Local anesthesia reactions and treatment. Emerg Med, August, 1974. p.121.
16. McCollough E.G. Effective anesthesia. W.B. Saunders, 1994.
17. Ritter, F.N. Vasculatureof the nose. Ann. Otol. Rhinol. Laryngol. 79: 468, 1970.
18. Robin, J.L. Extramucosal method in rhinoplasty. Aesthetic Plast. Surg. 3:171, 1979.
19. Robison, J.M. Lymphangitis of the retropharyngeal lymphatic system. Arch. Otolaryngol. Head Neck Surg. 105:333, 1944.
20. Rohrich, R.J., and Gunter, J.P. Vascular basis for external approach to rhinoplasty. Surg. Forum 13:240, 1990.
21. Zide, B.M. Nasal anatomy: The muscles and tip sensation. Aesthetic Plast. Surg. 9:193, 1985.

 

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28/Apr/2017

A knowledge of the basic surgical anatomy is needed for the clarification of terminology and for an understanding of the surgical procedures described in subsequent chapters. (Figs. 4 – 1,2,3,4,)

The surgeon should be familiar with the following primary anatomy and basic landmarks:
– Bony vault:             – Paired nasal bones
– Paired frontal process of the maxilla (distal portion)
– Cartilagenous vault: – Paired upper lateral cartilages
– Dorsum septum
– Tip cartilage:          – Paired lower lateral or alar cartilage
– Nasal septum:        – Quadrangular cartilage
– Perpendicular plate of the ethmoid
– Vomer
– Maxillary crest

Key Anatomical Landmarks:

  1. Naison
  2. Rhinion
  3. Supratip
  4. Infratip
  5. Double break
  6. Sheen’s four landmarks on the nasal tip:
    1. The point of tip differentiation (supratip breakpoint)
    2. The right dome
    3. The left dome
    4. The columella-lobular breakpoint
  7. Angle of divergence: which refers to the separation between the two middle crura
  8. Angle of rotation:which is essentially the columella-lobular angle
  9. Columella
  10. Nasolabial angle
  11. Supra-alar
  12. Nares
  13. Alar rim
  14. Alar flare
  15. SIL
  16. Nasofrontal suture
  17. Nasal bone
    1. Bony cartilagenous junction
    2. Upper lateral cartilage
    3. Dorsum septum
    4. Superior septal angle
    5. Dome: cartilage that lies between external and internal soft triangles (Facets)

Lower lateral cartilage

  1. Lateral crus
  2. Medial crus
  3. Intermediate crura
  4. The domal junction: the transition from middle to lateral crus in refined tip
  5. Medial crus footplate
  6. Internal soft triangle
  7. External soft triangle
  8. Pyriform aperture
  9. Interdomal space
  10. Caudal septum
  11. Nasal spine
  12. Nasal vestibule: stratified squamous epithelium
  13. Mucovestibular junction
  14. Nasal septum
  15. Inferior turbinate

 

 

Fig. 4 – 1. Key anatomical landmarks

Fig. 4 – 2. Key anatomical landmarks

Fig. 4 – 3. Nasal landmarks

Fig. 4 – 4. Anatomy of the nasal septum

Refrences
Surgical Anatomy
 

1. Anderson J: A reasoned approach to nasal bone surgery. Arch. Otolaryngol. 110:349, 1984.
2. Anderson J.R. A personal technique of rhinoplasty. Otolaryngol. Clin. North Am. 8:559, 1975.
3. Batson, O.V. The venous networks of the nasal mucosa. Ann. Rhinol. Laryngol. 63:571, 1954.
4. Bernstein, L. Surgical anatomy in rhinoplasty. Otolaryngol. Clin. North Am. 8:549, 1975.
5. Burgett, G., and Menica, F.J. Nasal support and lining: The marriage of beauty and blood supply. Plast. Reconstr. Surg. 84:189, 1989.
6. Byrd, S. aesthetic balance of the nose, lip and chin. Presented at Texas Rhinoplasty Symposium, Dallas, March 1990.
7. Converse, J.M. The cartilaginous structures of the nose. Ann. Otol. Rhinol. Laryngol. 64:220, 1955.
8. Cottle, M.H. Structures and function of the nasal vestibule. Arch. Otolaryngol. Head Neck Surg. 62:173, 1955.
9. Crumley RJ, Lancer M: Quantitative analysis of the nasal tip projection. Laryngoscope 98:202-208, 1988.
10. Daniel RK, Letourmeau A: Nasal anatomy, Ann. Plast. Surg. 205:5-13, 1988.
11. Daniel RK. The nasal tip: Anatomy and aesthetics. Plast. Reconstr. Surg. 89:216, 1992.
12. Daniel, R.K., and Lessard, M.L. Rhinoplasty: A graded aesthetic-anatomical approach. Ann. Plast. Surg. 13:436, 1984.
13. Dingman, R.O., and Natvig, P. Surgical anatomy in aesthetic and corrective rhinoplasty. Plast. Surg. Clin. 4:111, 1977.
14. Dion, M.D., Jafek, B.W., and Tobin, C.E. the anatomy of the nose. Arch. Otolaryngol. Head Neck Surg. 104:145, 1978.
15. Deneke JH, Meyer J: Plastic Surgery on the Head and Neck. New York, Springer-Verlag, 1967.
16. Faigin G: Facial Expression. New York, Watson-Guptill, 1990, pp 24-25.
17. Griesman B: Muscles and cartilages of the nose from the standpoint of a typical rhinoplasty. Arch. Otolaryngol. 39:334, 1944
18. Gilbert, J.G., and Feit, L.J. The nasal aponeurosis and its role in rhinoplasty. Arch. Otolaryngol. Head Nech Surg. 61:433, 1955.
19. Haight JSJ, Cole P: The site and function of the nasal valve. Laryngoscope 93:49, 1983.
20. Hamm J: Drawing the Head and Figure. New York, Putnam Publishing, 1963, p 29.
21. Larrabee WF Jr, Makielski KH: Surgery Anatomy of the Face. New York, Raven Press, 1993, p 154-155.
22. Lessard ML, Daniel RK: Surgical anatomy of the septorhinoplasty. Arch. Otolaryngol. 111-25, 1985.
23. McKinney, P., Johnson, P., and Walloch, J. Anatomy of the nasal hump. Plast. Reconstr. Surg. 77:404, 1986.
24. Mink PJ: Le nez comme voie respiratory. Presse Otolaryngol. (Belg) 418, 1903.
25. Parell, G.J., and Becker, G.D. The “tension nose.” Facial Plast. Surg. 1:81, 1984.
26. Peck, G.C., and Michelson, L.N. Anatomy of aesthetic surgery of the nose. Plast. Surg. Clin. 14:737, 1987.
27. Pitanguy, I. Surgical importance of a dermocartilaginous ligament in bulbous noses. Plast. Reconstr. Surg. 36:247, 1965.
28. Rohrich, R.J., and Gunter, J.P. Vascular basis for external approach to rhinoplasty. Surg. Forum 13:240, 1990.
29. Sheen, J.H., and Sheen, A.P. Aesthetic Rhinoplasty (2nd ed.). St. Louis: Mosby, 1987.
30. Sheen JH: Aesthetic rhinoplasty. St. Louis, CV Mosby, 1978.
31. Sykes JM, Senders CW: Surgery of the cleft lip nasal deformity. Operative Tech Otolaryngol 1:219-224, 1990.
32. Tardy. M.E., and Brown, R.J. Surgical Anatomy of the Nose. New York: Raven, 1990.
33. Zelnik, J., and Gingrass, R.P. Anatomy of the alar cartilage. Plast. Reconstr. Surg. 9:193, 1985.
34. Zide, B.M. Nasal anatomy: The muscles and tip sensation. Aesthetic Plast. Surg. 9:193, 1985.
35. Zmgaro, E.A., and Falees, E. Aesthetic anatomy of the non-caucasian nose. Plast. Surg. Clin. 14:749, 1987.

 

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28/Apr/2017

Incisions are essential in order to approach, reach modify and correct the nasal structure in septorhinoplasty. The septorhinoplasty incisions have a special importance. The intercartilagenous incisions divide the attachment of lateral crus to the upper lateral cartilage and the transfixion incision divides the attachment of the medial crura to the caudal septum. This results in loss of tip support and its unpleasant effects of dropped tip, pollybeak, hanging columella and wider nostrils. Therefore, compensatory means in order to support the tip (new dome creation, or the modified vertical dome division with columellar and tip grafts) are essential manoeuvres following our rhinoplasty incisions.

The choices of incisions varies according to the clinical situation. We currently use the following incisions:

– Intercartilagenous incision – 100%
– Transfixion incision – 95%
– Marginal incision – 90%
– Alar wedge incision – 20%
– Transcolumellar incision – 2%

Types and Indications:

    1. Transfixion incisions:
      1. Modified transfixion incision:
        Carried out around the superior septal angle and extended down one to two cm inferiorly. It is indicated in cases for hump corrections or mild tip bulbousity where there is adequate tip projection and rotation. (Figs. 5 – 1,2,3)

 

      1. Hemitransfixion incision:
        Carried out around the superior septal angle down along caudal septal margin beyond the middle crura-septal attachment. Indicated in cases of hump correction, mild bulbousity and septal deviation where there is adequate tip projection and rotation. (Fig. 17-9)

 

    1. Complete transfixion incision:
      Carried out bilaterally (through and through) around the superior septal angle and down along caudal septal margin beyond the medial crura-septal attachment but stops above the nasal spine. It is indicated in delivery of the alar cartilage, corrections of hump and septal deviation. Compensatory measures (new dome creation, scoring, suture fixation or Bizrah’s modification of vertical dome division with columellar and tip grafts and septocolumellar sutures) should be considered following this type of incision in order to support the tip and achieve adequate tip projection and definition.

 

Fig. 5 – 1. Septorhinoplasty incisions
  1. Intercartilagenous incision: is made at the mucosal-vestibular skin between upper and lower cartilages
    and carried out medially around the superior septal angle to meet the transfixion incision.
  2. Transfixion incision: Carried out around the superior septal angle and extend down along the caudal
    septal margin of two cm.
  3. Marginal incision: it follows intranasally the caudal margin of the lower latreral cartilage from mid-
    columella to mid-alar on the vestibular skin.
  4. Transcolumellar incision: It connects the two marginal incisions at a mid-columellar point in a V or Z design.

 

Fig 5 – 2. Intercartilagenous and transfixion incisions. The intercartilagenous incision is made at the vestibulomucosal junction beween upper and lower latreral cartilages from a lateral point and carried out medially around the superior special angle and down along the caudal septum margin in a hemi or complete transfixion incision.

 

  1. Intercartilagenous incision
    The intercartilagenous incision is made at the mucosal vestibular skin between upper and lower cartilages from the most lateral point and carried out medially around the superior septal angle and down along the caudal septal margin in hemitransfixion incision. (Figs. 5 – 1,2,3)
  2. Marginal incision
    It follows the inferior margin of the lower lateral cartilage from about mid-columella to mid-alar on each side (Figs. 5-1,2,3,). It may as indicated extend from the medial crural foot plate to the pyriform aperture. The skin incision at the columella is made one mm behind the caudal edge at the intermediate and lateral crura to prevent postoperative scarring and alar margin notching and retraction. (Fig. 17-12)
  3. Transcolumellar incision (external incision)
    It connects the two marginal incisions at a mid-columellar point in a V or Z design.
    It may be indicated in:
    Revision rhinoplasty
    Severely crooked noses
    Cleft noses
    Surgeons with outstanding skills rarely need to employ the external incision. It is employed in only 2% of our cases. (Fig 5-1D and Fig. 17-27)
  4. Transcartilagenous incision: Reserved for cases of mild bulbousity with strong alar cartilages and adequate tip projection and rotation. The incision is made horizontally into the vestibular skin and lateral crus, the cephalic portion of the lateral crus is then excised with its connected fibro fatty tissue, but with preservation of vestibular skin. The author does not recommend the use of this blind excision of the cephalic lateral crus and feels that it should be applied only in cases of mild bulbousity with strong cartilages, adequate tip projection and rotation. Even so, in these situations, the author strongly recommends the use of columellar strut through a small mid-columellar incision in order to support the tip, following the division of the soft tissue connection between the lateral crus and upper lateral cartilage. Although this technique is not suitable for use with patients in the Middle East, it remains popular in Northern European countries and Canada. Unfortunately, many surgeons in the Middle East do not differentiate between the characteristics of the tip cartilage and soft tissue between such races. Many of the people from the Middle East have what is called the heavy tip (thick skin, subcutaneous fat and soft cartilage), which is predisposed for postrhinoplasty loss of tip support and its unpleasant effects such as dropped tip, pollybeak and wider nares.
    1. Alar wedge incision:
      Indications and techniques are discussed fully in the chapter on Alar Wedge excision.

Fig. 5 – 3. Inttercartilagenous, transfixion and marginal incisions

 

Hints

  1. Keep the incision sharp and delicate and avoid irregularities and cutting across the edges.
  2. Avoid mucosa and vestibular skin excisions to prevent vestibular stenosis.
  3. Do not extend the intercartilagenous incision too much laterally in order to avoid dividing the attachment in the cartilage to the pyriform aperture which may cause valve collapse and pinching.
  4. Do not extend the transfixion incision too much downwards to the nasal spine to avoid excessive loss of tip support.
  5. Keep your marginal incision close to the caudal margin of the intermediate and lateral crus to avoid notching and scarring of the alar rim.
  6. Close your marginal incision meticulously using 4/0 Dexon. Stitch skin to skin, never cartilage to skin. (Fig. 5-4)
  7. Position your marginal incision sutures obliquely in a way high on the alar rim and low on the lateral crus skin in order to pull up the lateral crus to the alar rim to prevent notching, pinching, retraction and nares asymmetry.
  8. Close your transfixion incision by buried 4/0 Dexon sutures. Trim redundant soft tissue to avoid hanging columella and to avoid later pocket formation and collection of crusts and its unwanted smell. (Fig. 5-4)
  9. Support the buried Dexon suture of the transfixion incision by two septocolumellar sutures to preserve and support the tip projection.
  10. Avoid tight strips around the tip which may push the rim in, predisposing for notching
  11. Always remember that incisions divide the intercartilagenous ligaments and tissue connection, predisposing for the loss of tip support. Therefore, compensatory measures (new dome creation, suture fixation, scoring, columellar strut, tip graft, septocolumellar suture) are mandatory to achieve tip projection, rotation, elevation, definition, refinement and symmetry.

 

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28/Apr/2017

Primary Manoeuvres

– Dorsum undermining.
– Division of upper lateral cartilages from septum.
– Caudal trimming of upper lateral cartilages.
– Conservative trimming of the caudal septum.

  1. Dorsum undermining:
    Following the intercartilagenous incision:

    • Use a sharp scissors to identify the right plane of the caudal upper lateral cartilages.
    • Next, use blunt scissors to proceed with skin elevation. Stay close to the cartilage and then adjacent to the nasal bones up to the glabella. (Fig. 5-5)
    • Now, Aufricht’s retractor is used to visualize the dorsum.
    • Do not undermine too much laterally, elevate only the dorsum in a way that you identify the hump borders, depressions of the deformity to be corrected. Too much lateral dissection may cause bone collapse following lateral or intermediate osteotomy.
    • Avoid injury to the SMAS layer and subcutaneous tissue. So stay close to the cartilage and bone. Injury to the SMAS causes intraoperative bleeding, postoperative oedema, later fibrosis, scarring and possible pollybeak formation.
    • Do not go beyond the glabella as it will lead to postoperative forehead oedema.
  2. Division of the upper lateral cartilages
    • Subperichondrial bilateral tunnels are made at the junction of the septum to the upper lateral cartilages. (Fig. 5-6)
    • A blade No. 11 is pushed through the tunnel and in an upward motion, the septum is divided from the upper lateral cartilage. The Aufricht’s retractor provides exposure and helps to protect the nasal akin.
    • It is of most importance that the upper lateral cartilages are divided as closely as possible to the nasal septum in order to avoid the formation of the T-shaped structure. When the T-shaped structure is wrongly formed, it may later cause pollybeak. But if the T-shaped structure is trimmed to lower the dorsum septum, it may lead to supratip collapse. That is because the medial border of the upper lateral cartilages are involved with the trimmed T-shaped structure and will not adequately overlap the dorsum septum, leading to depression of the supratip region.

 

Fig 5 – 5. Dorsum undermining: Stay close to the cartilage and bone. Do not undermine too much laterally in order to avoid bone collapse following lateral osteotomies and to reduce the postoperative oedma.

Fig 5 – 6. Division of upper lateral cartilages: the upper lateral cartilages are divided as closely as possible to the septum in order to avoid the formation of the T-shaped structure with the later possibility of pollybeak or supratip collapse.

 

Fig 5 – 7. Trimming of the upper lateral cartilages: If the caudal ends are projecting at the end of the procedure, a small triangle of not more than 1.5mm is excised with preservation of mucosa and vestibular skin. Aggressive excision leads to valve collapse.

Fig 5 – 8. Trimming of the caudal septum is considered in order to obtain an aesthetic nasolabial angle of 90o or slightly greater. When rotation is required the outer third is trimmed. In drooped tiip, long nose or caudal dislocation, the outer two thirds or the entire caudal septum is trimmed.

  1. Trimming the upper lateral cartilages
    • This manoeuvre is necessary in a long nose, drooped tip and crooked nose with upper lateral cartilage asymmetry. However, it is not required in all rhinoplasties.
    • At the end of the procedure, if the caudal ends are projecting too far caudally, a small triangle of not more than 1.5mm is excised, with preservation of the mucosa and vestibular skin. (Fig. 5-7)
    • Aggressive excision leads to valve collapse and obstructed breathing due to scarring and pinching in this area. (Fig. 5-9)
    • Fatty fibrous tissue on the upper lateral cartilages may be excised with the small cartilagenous caudal triangle when the central third of the nose is wide in order to enhance the narrowing effects. (Fig. 17-9)
  2. Trimming of the caudal septum
    • Indications:
      • Long nose
      • Drooping tip
      • Caudal dislocation
      • To achieve tip rotation
      • To obtain an aesthetic nasolabial angle of 90 degree or slightly greater.
      • Trimming of the caudal septum is performed following the intercartilagenous and transfixion incisions, skin elevation and division of upper lateral cartilage from the septum. In the author’s experience, that part of the caudal septum which is projecting caudally beyond the caudal margin of the transfixion incision, on the resting position, should be trimmed. (Fig. 5-8, Fig. 9-12 and Fig 17-10)
      • The caudal septum is divided into thirds. If only rotation is required, the outer third is excised. In drooped tip and columellar the outer two thirds are

 


Fig. 5-9. Trimming of the curved end of the upper lateral cartilage. (Fig. 17-9)
 

trimmed. In more advanced cases of long nose, overprojected tip and overdeveloped caudal septum the entire caudal septum is trimmed and may be, as required, the nasal spine is partially reduced. (Fig. 17-19)

 

  • Following trimming of the caudal septum. It is of most importance to consider supportive means to compensate for the loss of the tip support caused by our incision and excisions which divide the natural anatomical ligaments and attachments of the tip to the caudal septum, superior septal angle and upper lateral cartilages. Disregarding these supportive means will end with dropped tip, retracted or hanging columella, pollybeak and wide nares.

Refrences
Septorhinoplasy Incisions
 

1. Anderson JR, Johnson CM, Adamson PA. Open rhinoplasty: as assessment. Otolaryngol. Head Neck Surg. 90:272-274, 1982.
2. Adamson PA. Open rhinoplasty. Otolaryngol. Clin. North Am. 20:837-852, 1987.
3. Broadbent, T.R., and Woolf, R.M. Rhinoplasty. In E.H. Courtiss (ed.), Aesthetic Surgery: Trouble, How to Avoid It and How to Treat It. St. Louis: Mosby, 1978.
4. Daniel, R.K., and Lessard, M.L. Rhinoplasty: A graded aesthetic anatomical approach. Ann. Plast. Surg. 13:436, 1984.
5. Daniel, R.K. Rhinoplasty: The retractable roof. Plast. Reconstr. Surg. 83:976, 1989.
6. Foman, S. Cosmetic Surgery: Principles and Practice, Philadelphia, J.B. Lippincott, 1960.
7. Goodman Ws. External approach to rhinoplasty. Can J Otolaryngol. 2:207-210, 1973.
8. Gunter, J.P. A graphic record of the intraoperative maneuvers in rhinoplasty: The missing link for evaluating rhinoplasty results. Plast. reconstr. Surg 84:204, 1989.
9. Joseph, J. Nasenplastik und sonstige gesichtsplastik nebst einem Anbang ueber Mammaplastik. Leipzig: Kabitsch, 1931.
10. Peck, G.C. Techniques in Aesthetic Thinoplasty (2nd ed.). New York: Thieme-Stratton, 1990.
11. Rees, T.D. Aesthetic Plastic Surgery. Philadelphia: Saunders, 1980
12. Sheen. J.H. aesthetic Rhinoplasty. St. Louis: Mosby, 1974.
13. Sheen. J.H., and Sheen, A.P. Aesthetic Rhinoplasty (2nd ed.). Louis: Mosby, 1987.
14. Wright WK, Kridel RWH. External rhinoplasty: a tool for teaching and for improved results. Laryngoscope. 91:945-951, 1981.

28/Apr/2017

Hints and complications:

  1. Medial osteotomy, if performed aggressively and the medial osteotome is pushed too much towards the root of the nose, may result in:
    • Loss of sense of smell due to fracture of the cribriform plate.
    • Dislocation of the perpendicular plate of the ethmoid causing septal collapse and an intraoperative saddling, which will be followed by additional augmentation procedures.
    • Postoperative frontal oedema and ecchymosis.
  2. Lateral osteotomy
    • Periorbital oedema and ecchymosis.
    • Incomplete mobilization of the lateral wall causes an open roof deformity or the appearance of a crooked nose.
    • Excessive mobilization causes depression on the lateral nasal wall.
  3. To prevent step deformity. Keep lateral osteotomy close to the face.
  4. At the end of the osteotomy procedure and after nasal bone approximation, it is important to check the level of the septum and upper cartilage. The upper lower cartilage and septum may need to be lowered, because of the overlapping following osteotomies.
  5. If the nasal bony dorsum is wide and there is no hump, and even after medial, lateral and intermediate osteotomies are performed, there may still be difficulty in approximating the nasal bones due to thick bone at the dorsum. Therefore, it is important to create a gap at the midline of the bony dorsum by removing some of the dorsum bone by a bone nippler, in order to approximate the nasal bone and obtain a narrower bony dorsum. The gap is closed by the approximated nasal bone borders. (Fig. 7 – 5)
  6. Performing osteotomies needs a lot of concentration and judgement. Assess the situation very carefully, plan the osteotomy lines and decide if there is the need for intermediate or transverse osteotomies. There are no routine or standard rhinoplasty procedures, therefore osteotomies are not routinely indicated in every rhinoplasty we perform.
  7. Cast application: Plaster should be applied like a clip above the lateral osteotomies in order to avoid bone displacement. (Fig. 7 – 6)
Do not penetrate Endostrium
Fig. 7 – 6. The two mm osteotome should not penetrate the endostrium in order to avoid lateral bony wall collapse.
How to apply cast
Fig. 7 – 7. Plaster should be applied like a clip above the lateral osteotomies in order to avoid bone displacement. A large plaster will leave the nasal bones loose with inaccurate positioning.

 


(A)
Fig. 7 – 8. A post traumatic tip. A banana shaped nasal bones. The situation was dealt with medial, lateral and intermediate osteotomies


(B)
Fig. 7 – 9. A patient has spindle shape nasal bones. Medial, lateral and intermediate osteotomies were performed in order to achieve accurate repositioning of the middle nasal bones.

 

Refrences
Bony Wall Mobilization: Osteotomies
 

1. Ford, C.N., Battaglia, D.G., and Gentry, L.R. Reservation of periosteal attachment in lateral osteotomy. Ann. Plast. Surg. 13:107, 1984.
2. Guyuron, B. Precision rhinoplasty. Part II. Prediction. Plast. Reconstr. Surg. 81:500, 1988.
3. Joseph, J. Nasenplastik und sonstige gesichtsplastik nebst einem Anbang ueber Mammaplastik. Leipzig: Kabitsch, 1931.
4. Murakami C., Larrabee W.F. Jr.: Comparison of osteotomy techniques in the treatment of nasal fractures. Facial Plastic Surgery 8:209, 1992.
5. Parkes M.L., Kamer F., Morga W.R., et al: Double lateral osteotomy in rhinoplasty. Arch. Otolaryngol 103:348, 1977
6. Parkes M.L., Kanodiar: Avulsion of the upper lateral cartilage: Etiology, diagnosis, surgical anatomy, and management. Laryngoscope 91:758-764, 1981.
7. Stucker F.J., Smith T.E.: The nasal bony dorsum and cartilaginous vault. Arch. Otolaryngol. 102:695-698, 1976.
8. Wright W.K.: Surgery of the bony and cartilaginous dorsum. Otolaryngol. Clin. North Am. 8:575-598, 1975.

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