PRESERVATION. A RHINOPLASTY ¢ BARIS CAKIR” YVES SABAN ROLLIN DANIEL \. PETER PALHAZI >Preservation Rhinoplasty Table of Contents ‘What is Preservation Rhinoplasty? Rationale and Overview. Rollin K. Daniel... A. Preservation Rhinoplasty: Basic Steps Photography Standards, Bars Cakir,Aykut zp... Rhinoplasty Anesthesia. Mustafa Ogon, Bary Cala. Local Anesthesia in Closed Preservation Rhinoplasty. Yves Saban The Rhinoplasty Surgical Set. Bans Cala, Salih Emre Uregen Aoalysis and Surgical Planning, Bari Cakir, Yves Saban a : Essential Operative Anatomy for Preservation Rhinoplasty. Petr Palhavi, Rollin Degel Step by Step Preservation Rhinoplasty. Bans Cakir, Eren Tastin Preservation Tip Surgery Nasal Ligaments and Compartments, Yes Saban, Rolin K. Danie, Petr Palhazi, Roberto Polselli, Baris Cakir Tip Projection. Baris Caku, Tayfun Ako... Tip Rotation, Bang Cakar, Salih Emre Oregen Subperichondrial Rhinoplasty. Baris Cakut, Ai Akkus.. ron ‘Treatment Methods for Nostril and Alar Problems. Baris Caku, Mithat Akan Acstetic Tip surgery with Ligament Preservation. Bans aku, Bulent Geng ‘The Leaming Curve of Preservation Rhinoplasty. Valerio Finocchi Dorsal Preservation Preservation Rhinoplasty: Indications, contraindieations. Charles East, Lydia Badia Preservation Septoplasty and Rhinoplasty in Deviated Nose, Yves Saban, 7 ‘Advanced Septal Surgery in Preservation Rhinoplasty: Parisi Jurado, Freie Régo Lime Piezo Asisted Let-Down Rhinoplasty. Abdilkadir Goksel. Refinements in Dorsal Preservation. Milos Kovacevic ae ma Dorsal Preservation by Subvdorstl Septal Stip Resection and Push Let-Down Procedure Yoon Saban Step by Step Closed Rhinoplasty with Dorsum Preservation, Yves Saban My firs 50 Dorsal Preservation Rhinoplasties, Aaron KosinsWhat is Preservation Rhinoplasty Rationale & Overview Rollin K. Daniel ~ Based on my experience with over 6,000 rhinoplastes, Ihave concluded that we surgeons need to fundamentally change how we perform rhinoplasty surgery in order to minimize the need for complex secondary rib reconstructions, The three basic principles are preservation ofthe skin sleeve, dorsum and alar cartilages. The goal isto replace reseetion with preservation, excision with manipulation, and secondary rib reconstruction with minimal revisions. On reflection, this new approach marks a distinet change fom both “resection rhinoplasty” and “structural rhinoplasty,” thus leading to a new terminology—that is, “Preservation Rhinoplasty.” This fundamental advance was summarized in an editorial entitled “The preservation rhinoplasty: The next rhinoplasty revolution’ [Daniel 2018}. Shorty after its publication, Dr. Gakar asked if the next meeting could be entitled Preservation Rhinoplasty. I thought it was a brilliant idea because surgeons should learn new procedures from teachers experienced in this very procedure, In addition, I emphasized that the proceedings of the meeting should be summarized in advance and published as a text book to futher assist surgeons in learning these new techniques. Our collective goal isto shorten the learning curve for other surgeons and to minimize post-operative problems that could lead to revisions. Over the past year, it has become obvious that Preservation Rhinoplasty is not just a series of surgical techniques, but rather a firtdamental approach and philosophy for rhinoplasty operations in their entirety.Preservation Rhinoplasty: Rationale & Overview PRINCIPLES Preservation Rhinoplasty (hereafter PR) is composed of the following three pats: 1) clevating the skin sleeve in a subperichondial-subperiosteal dissection plane, 2) preserving the osseocartilaginous dorsum, and 3) maintaining the atar eartages with minimal excision wile achieving the desired shape using sutures. For decades, surgeons have elevated the skin sleeve in the sub-SMAS plane, which has led to significant poste operative swelling, numbness, prolonged scar remodeling, and long-term thinning of the soft tissue envelope (hereafter STE). In contrast, elevation of the STE in a deeper plane results in minimal sweling remodeling, and avoidance of long-term thinning of the soft tissue envelope. ‘near normal sensation, minimal sear Dorsum {nthe majority of thinoplastes, removing the dorsal hump has been dane by reseeton, which leas to the ereaion ofan “open oo?” which in tum requires midvautreconsrution using either spreader grafts or spreader aps, In contest ‘rst reservation (hereafter DP) maintains the dra strictures while eliminating the dorsal hump using septal resection followed by osteotomies to reduce the height ofthe dorsal line. Essentially, one divides the dual goal of dorsal resection fey uo Fao $ 17 4 Below you can see my photography studio, Ihave been using a 100 mm macro lens and the soft boxes below for ten years now.I era ergata gg gg ge rs arg ggg ga gv gear SE SESEEEE 19 It is important how natural beautiful noses look in your photography studio. I ask my patients’ accompanying family members or friends with beau ful noses for permission to take their photographs. I have a “beautiful nose” folder in my computer. | ook at these photographs every now and then. I would recommend the same to you. Learning the details of proportional noses is | 2 good method to understand natural lights and shadows. Please pay attention to the light from the tip to the nasal ala of the beautiful nose below. The caudal edge of the lateral erus and the facet polygon beneath can be clearly visualized. The parabolic dorsal aesthetic lines stand out in the case below.Please notice the relationship between the lateral supratip breaking point that is the beginning of the right scroll line, the K 4 Both ears should be equally visible in the frontal view, ‘The forchead and chin should be aligned, and the contralateral point and the nasal radix. eyebrow not visible in the lateral view24 Photos when smiling give an idea about muscle activity. The patient can be asked to lift the nasal tip «0 show its softness. ‘Aligning the nasal tip with the cheek contour is an easy way to standardize the oblique view. The nasal tip ean be located at the middle of the lip in the helicopter view.2 Photos when smiling give an idea about muscle activity. The patient can be asked to lift the nasal tip to show its softness ] Aligning the nasal tip with the cheek contour is an easy way to standardize the oblique view. The nasal tip can be located at the middle of the lip in the helicopter view: Si h22 Basal photos can be standardized by aligning the nasal tip with the eyebrows.25 Obtaining @ medium quality SLR camera will be sufficient, The macro lens is more important than the camera. I use a 100 s. T tried the 50 mm portrait lens but did not like it, The 100 mm macro lens shows more details. The photos on the left were taken with a 100 mm macro lens and the ones on the right with a 35-85 mm lens, mm lens as a macro |26 Photography Standards ‘Standard photographs ean NOT be obtained with zoom lenses. It willbe difficult to guess the settings and zoom values of the pre-operative photos when taking one- to two-year post-operative photographs. Try to take photos are using zoom lenses, ith the zoom at 100 if you Have a standard background, Decide well on your colour, as you can not change it afterwards. The best colours are black, rey, blue and deep blue. I chose black, since it looks more artful, but have to admit that blue gives a more scientific impression. Furthermore, blue does not blend into hair color. If you keep distance of 1 m between the patient and the background, no shadows will forn. Black backgrounds have an advantage of preventing shadow formation. If you have @ photography studio with soft boxes, you will achieve very good photographs. ‘Take vertical (portrait) photographs, These are easier to archive and make collages with. If you do not put a certain distance between you and the patient, you cannot take good photographs. If you are using a macro lens, the distance to the patient should be approximately 2 m to get the patient's face in the frame. ‘Another important issue is the patient's position relative to the lights If the patient stands in different locations, the position and density of the light reflections change. Therefore, the locations of the patient and lights shoule be constant. There sould be @ circle fixed on the floor for the patient fo stand on, Such stickers can be obtained from print companies. Intra-operative Photographs: have been taking photographs intta-operatively before and after the surgery. Evaluating post-operative first year results ‘with these photographs speeds up progress. [ use another SLR camera with 100 mm macro lens to take standard photographs intra-operatively. We have taken the intra-operative photographs in this book in manual mo, with flash and in settings ISO 400, F: 10-12. The macro lens shows even the tiny hairs on the nose. It is possible to get images ofthe i flash, Jide of the nose with a ring28 ‘The locations of the lights, patient and photographer should never change. [look at the eyes fst in the photographs shown during meetings, Pre-operative single flash and post-operative 2 soft boxes is a commonly used illusion. Single flash exaggerates the deformity, Both of the below photographs are taken pre-operatively, only 10 seconds between the photographs. The photograph on the left is taken with a single flash and the right with two soft boxes.Below you can see the real pre-operative and post-operative photographs of the patient taken with two soft boxes. a ‘ Ifyou get close to the patient and zoom out with the lens, the photograph becomes a fisheye photograph, The cheeks cover the ears more in fisheye photographs.30 Photography Standards The nasal tip looks more bulbous in fisheye photographs than it normally is, Photographs are not standard if the ears are not equally visible behind the cheeks, Both of the pictures below are pre-operative. The photograph on the left is taken with a 35: 100 mm tens. Pay attention to how the nasal tip looks different in both of the photographs. The ear appears bigger and the nose smaller in the profile fisheye photographs. Normally the heights of the nose and ear are similar. 5 mm lens at 35 mm. The photograph on the right is taken with a ‘You will not face problems associated with the fisheye illusion when you use a 100 mm macro lens. ISO: 180 is light sensitivity. An ISO value of 100 and 200 is appropriate. As the ISO value increases, the color quality of the photographs becomes impaired. Low ISO values require strong lighting. If you have two soft boxes, you can easily get ‘good-quality photographs at an ISO value of 100, Shutter Speed: It shows the length of time a camera shutter is open. If the shutter speed is less than 1/125, shaking starts to become a problem. I usually use a shutter speed of 1/160. When a shutter speed of less than 1/200 is chosen, disharmony between the camera and lights may occur. This leads to semi-dark photographs. Artistic photographs ean be taken with low focal lengths-~ that is f values. What is in front of and behind the focal point become blurred, We need focal depth. Do not decrease the f value below 10. co vie0 10 alot B20 P @ OES © oust =m ral ( 100)Cakir, Ozpiir 31 Focal Points: ‘The focal point can be adjusted as well in manual settings. The focal points can be used so that the nose is always in the same location of the photographs frame. I always choose the nasal tip as the focal point. In this way, tke nose is always in focus and the lights and shadows formed by the nasal cartilages can be illustrated in a constant manner, The central focal point ean be selected for frontal, helicopter and basal views, and the left middle focal point (for @ left-handed surgeen) for lateral and oblique Skin Color: Different skin colors reflect light in different amounts, Ifthe patient’s face is dark in the photograph, decrease the f value. If the patient's face is light in the photograph, increase the f value. I take my photographs with an f value between 10 and 13 Color Settings: ‘The photographs taken in photography studios with soft boxes may be blue, red or green dominant, Fine-tuning may be necessary in the white balance setting. I take my photographs at a slightly blue setting, as I find my photcgraphs to be dominant in red, The aim here is to match real life skin colour with the color in the photographs.32 Photography Standards Soft Box Settings: If'your photographs appear dark or bright at F:10-13, ISO: 100-200 and shutter speed 1/160-200 settings, it may be necessary to adjust the power of the flash, Ask the experts setting up the studio for help. If one of the soft boxes has a brighter light, the dorsal aesthetic lines can be better visualized, but problems will be encountered with right and left photographs. It may be wiser to equalize the flash on the right and left, as photographs with multiple views are used for evaluation. [lengthened the legs of the soft boxes to get more natural light reflections. In this way, the light eomes from above the patient’s head level. Photographs with Mobile Phones: Even the best mobile phone takes fisheye photographs. Patients decide on the shape of their noses with photographs they take with their mobile phones. Many of my patients complain of having a big nose in photographs. You should be aware of the fisheye illusion, and explain this to your patient. The below photographs were taken with an iPhone, the left side with a close ‘photo shoot and the right side with a distant photo shoot and zooming in, Itis clearly visible from the ears thatthe left hand side is fisheye. have a basic understanding of photography. You can take wonderful photographs with a limited number of adjustments. It is disappointing to receive criticism about your photographs’ quality instead of compliments for good surgical results. A medium quality SLR camera is sufficient if you have appropriate lighting instruments. Just as we can understand the lighting system by looking at the eyes, the distance of the photographer to the subject can be predicted by looking at the ears, The ears should be equally visible behind the cheeks. Otherwise itis impossible to evaluate in haw far the surgical technique has corrected bulbosiy ‘This is because the fisheye illusion corrects tip bulbosity better than the surgery itself.33 The front view gives information about the dorsal aesthetic lines. It shows the nostril shapes, Even a retraction of 1-2 mim leads to an operated look. ‘The biggest change after rhinoplasty can be seen in the lateral view.34 Photograph while smiling shows nasal tip dynamics, Dorsal aesthetic lines and the convexity of the lateral crus are best seen in the helicopter view. Deviations in the nasal body I very much prefer the oblique view. The caudal edge of the lateral erus, the facet and lobule polygons are best visualized in this view. Noses with inadequate definition look round, I think this is the view that gives away that a nose has been surgically altered ‘This is the most important angle in movies.35 The oblique view never hides a pinch nose, ‘The basal view is very important in meetings. It never hides mistakes, A nose that is beautiful in other views may look deformed inthis view. The columella may appear abnormally wide in over-grafted noses. My art teacher asked me once why some operated noses became extremely triangular; he said that they do not look normal Hee taught me that the transitions from the ala to the nasal tip should form symmetric paraboles.During rhinoplasty surgery, the goals of anesthesia are to ensure bloodless surgery and patient comfort ‘The patient is seen by the anesthesiologist atleast one day prior to surgery, and the pre-operative tests are performed. The paticat is taken to the pre-op assessment room on the day of surgery and monitored (ECG, Sp02, NIBP), their tympanic. temperature is measured, and the baseline values are recorded. An intravenous line is started, and 250 mi %0.9 isotonic NaC! with 1g Metamizole + 45,5 mg Pheniramine maleate + $0 mg Ranitidine is administered (medication dosages are adapted toa patient of weight 60 kg and height 160 cm).38 Rhinoplasty Anesthesia ee I-°# ft =a ove ‘Ari ope aa Pseudoephedrine nasal spray is used for septal mucosal vasoconstriction. The spray is given to the patient who is asked to take a deep breath while squirting one spray into each nostril and clean the nose afterwards. In this way the spray acts homogenously on the mucosa. Using the spray 30 minutes prior to surgery ensures a bloodless septoplasty and decreases the systemic absorption of septal injections. It also eliminates the need for intra-operative use of nasal packings with adrenaline. An IV bolus of Img Midazolam + 10 mg Metoclopramide + 40 mg Methylprednisolone is administered as premedication, Dexmedetomidine is administered with an infusion pump at a rate of 40 mcg/h, The patient rests for 15 minutes in the pre-op39 Once the preparations are completed, the patient is taken into the operating room and monitored again. The anesthesia device is placed next to the patient’s head, at 45 degrees on the right side (for a left-handed surgeon) of the patient, Room around the patient’s head is preferable. The surgeon may need to check for symmetry with a cranial view. The patient is positioned on their back, with a pillow under their head, the arms by their side and supported by a silicone cushion placed under the legs so that the heels do not touch the operating table. The arms are secured with a sheet , With the head extended 20-30 degree so that itis parallel to the allows the hip to be in the lowest position and decreases blood pressure in the heac. Keeping the head parallel ‘The patient is positioned in reverse Trendelenburg posit Aloor. This posi to the floor decreases the likelihood of mab ng rotation errors (Weenec Ose Cyert LIKse Ose C1 hive D1 LoKAL40 Rhinoplasty Anesthesia ‘The patient is informed, and anesthesia induction begins. Infusions of Propofol 50 mg/h and remifentanil 250 mog/h are administered. After an infusion of 50mg 2% Lidocaine + 50 meg Fentanyl, $ mg Rocuronium are given for the purpose of priming, and the timer is started, Following 150 mg of Propofol, another 25 mg of Roeuronium is administered. Once the eyelash reflex disappears, the eyes are covered with a line of Viscotears eye eream and taped crosswise with 0,5 cm transparent tape, After three minutes, the patient is endotracheally intubated with a 7.0 spiral tube. The cuff is inflated with a cuff pressure of 25 em H20. The cuff is connected to @ manometer with an extension, and the cuff pressure is continuously ‘monitored ducing the operation and adjusted to be at 25 + Sem H20 pressure. After it is ensured that both lungs are equally aerated, the endotracheal tube is fixed to the lower teeth at approximately 21-23 em with 0 silk suture. In the presence of dental braces, the tube is fixed with 2 em wide Hyperfix tapes at 1 em distance to the right side of the mouth in the shape of omega, taking care not to pull on the upper lip. Tae endotracheal tube is connected to the anesthesia device with a semi-closed circuit via an extension tube, Breathing support is secured with 44 % oxygen + 50% ‘Nitrous Oxide and 6% Desfluran at ET CO2: 30 mmHg (tidal volume &-10mV/kg, f: 10-12/min, rate of fresh gas flow 2 Limin) in the volume control mode. TV infusion of 1g Paracetamol is administered over 30 minutes, ‘The mouth and stomach are checked with a 16 G orange aspirator cannula, Heating systems are stopped, and the patient is handed over (othe surgical team.Local anesthetic solution is prepared with 10 ec Mepivacaine +9 cc 0.9% Nacl + 1 ec 0.25 mg Adrenaline ‘Wait until systolic blood pressure drops below 90 mmHg. Bleeding during surgery is usually encountered if systolic blood pressure goes above 110-120 mmHg when injecting the local anesthetic solution. The half-life of adrenaline is 1-2 minutes. Injection of small doses can prevent the cumulative adverse side effects of adrenaline. Therefore, the injections are administered | slowly and intermittently over 10 minutes. Injecting the nose with 4 ce of 1/80,000 adrenaline and the septum with 1,5 ec of 1/240,000 adrenaline solution is sufficient fora bloodless surgery. The solution is injected to the caudal septum, anterior to the maxillary spine, the medial and lateral erura, the caudal part of tte dome, the dorsum, the starting point of lateral osteotomy and over the upper lateral cartilages.instead of decreasing it. As absorption is high at the septum, pulse rate and blood pressure may increase, Injecting a total of 1-1.5 ce of 1/240,000 adrenaline containing solution to key points in the septum (septal floor, posterior septum and radix mucosa) is sufficient for bloodless septoplasty. We believe that injecting the septum with adrenaline containing local anesthetic solutions increases bleed43 ye") hm rl ‘Avoid injecting in the Kiesselbach area, asthe circulation is extensive there. Two ce aeaineet containing Mepivakain 4 is diluted with 2 cc of isotonic solution for septal injection A slow and intermittent injection will not lead to a significant QT lengthening or atrhthymia in the ECG and increase in ETCO2 will not pass 10%. Increase in ETCO2 or QT lengthening in ECG due to the adrenaline in the local anesthetic solution is accepted to be an early warning sign to pause injecting solution, and the minute volume in the ventilation deviee is increased t0 ‘biain normocapnia, After dissection, washing the surgical ficld with 3% Tranexamic Acid may decrease intrs-operative bleeding and postoperative bruising. (1) ‘Throughout the surgery, balanced salt solutions: Isolyte-S and Lactate Ringer in $% Dextrose are administered intravenously at a rate of 8-10 milkg/hou. Additional intervention is usually not necessary during the surgery. ‘The same constant numeric values of haemodynamic parameters are not applicable to every single patient. Patient-specific regular pulse and blood pressure values that ensure a bloodless surgical field are provided. This protocol usually maintains surgical comfort with litle use of the aspirator and litle swellin 4 244 Rhinoplasty Anesthesia Dexmedetomidine and Propofol infusions are discontinued at the end of the first hour of surgery. Towards the end of the surgery, while the silicone splints are being placed, Nitrous Oxide and Desflurane are tuned off. After a wash-out with 100% oxygen, 44% oxygen and 56% air is administered. Dexamethasone 8mg + Ondansetron 4 mg are administered intravenously. Upon completion of the surgery, the mouth and stomach are aspirated with an 18 G green aspirator eannula before applying the bandages. Infusion of remifentanil is discontinued, and the body heating system is tamed on. Note: Right-o left-sided rotation ofthe head may assist withthe placement ofthe orogasvic eatheter (Ozgbn Maneuver. ‘The patient may sometimes open the eyes upon contact with cold wet gauzes; if the patient can follow verbal directions, he or she can be extubated and given oxygen with a simple mask at 5-6 /min. If the patient has waits until the patient wakes up, which is usually in less than 15-20 minutes. A conscious patient with sufficient spontaneous breathing is kept on the operating table for S more minutes and then transferred to the post-operative Tecovery roomn, not woken up at this stage, the team Summary: Harmony between the anesthesia and surgery teams affects the surgical outcome. Mutimodal analgesia and prophylaxis of nausea and vomiting with combined HI + H2 receptor blockage, nitrous oxide supported desflurane anesthesia and TIVA at ‘minimal doses are applied. Premedication is supported with an alpha 2 agonist. Sufficient analgesia and anesthesia ate provided. Local anesthetic containing adrenaline is administered over more than 10 minutes in controlled doses, The cuff pressure of the intubation tube is monitored continuously with a manometer and kept at a certain level to prevent tracheal mucosal damage. The ‘most important factors for a bloodless surgery are stable blood pressure, pulse and CO2 parameters, The patient rests in the bed in the first post-operative hour. After an hour, the patient stats drinking water. If the patient ‘does not have nausea, the patient starts an oral diet. The patient rests for another hout. Ifthe patient has no complaints, the patient is made to sit and mobilize. Ifthe patient feels comfortable, the IV line is removed. The patient is advised not to take alcohol or drive for 24 hours and taken to the transfer vehicle in a wheelchair LNayak LM, et al. The role of tranexamic acid in plastic surgery: Review and technical corsiderations. Plast Reconstr Surg 2018;142(3):423¢,Local Anesthesia in Closed Preservation Rhinoplasty Yves Saban Local anesthesia is the mandatory compliment to all types of anesthesia in rhinoplasty. Why is local anesthesia an z lengthens the intra-operative time, leads to bad visual control of the surgery important stop? Intra-operative bles increases post-operative swelling and bruising as well as post-operative pain and discomfort. When inadequate, hemostasis stresses both the surgeon and the anesthesiologist. In rhinoplasty, local anesthesia represents the first step when starting the surgical procedue and is usually done before the surgeon scrubs their hands. Once the patient is the operating room, it is recommended to perform the local anesthesia, which requires careful attention to detail46 Local Anesthesia in Closed Preservation Rhinoplasty PRINCIPLES What are the aims of local anesthesia? The three main reasons for performing a well-controlled and complete local anesthesia are as follows: (1) the vasoconstriction reduces intraoperative bleeding, (2) the hydro-dissection facilitates dissection in the surgical planes, (3) the anesthesia reduces general anesthesia medications and the necessity for morphixe mimetics that can lead to nausea or vomiting, and post-operative nasal bleeding, eechymosis and discomfort, ‘Two types of local anesthesia are performed before the closed preservation rhinoplasty: injectable and topical local anesthesia, Injectable local ancsthesia employs long-lasting injectable drugs (ropivacaine, levobusivacaine) which produce an immediate vasoconstriction effect, plus a prolonged action in the post-operative period. We employ a short-acting agent (lidocaine) and « few drops of adrenalin to minimize bleeding, both of which are effective at the very beginning of surgery ‘The mixture consists of 1 vial of Lidocaine with 10 drops of adrenalin (1/100.000) added and then the preparation is diluted in 20 ce saline, if larger volumes are required ©BD Microlance™ 3 306 1" [Zax timm Rex 204000 2022-08 tot] 1710 21 ar parahycronbona Expense a Iustnje de soci, Deu sos Teh Usage local strict, pen47 Topical local anesthesia is used to soak small gauzes (preferably with radiopaque strings) and rolled like cigarette, They are introduced into the nasal fossa using a Politzer forceps, taking care not to injure the mucosa: one is inserted superior, just under the osscocartilaginous (longitudinal), and one along the inferior turbinate (vertical) PS Wi We prefer using two 3-cc syringes with a # 3-gauge needle. A total of Gee is generally sufficient for completing @ perfect local anaesthesia, To achieve the desired effect, the anatomic placement of the local anesthesia must be precise, One should carefully consider cach of the desired individual aspects of the injection: anesthesia, vasoconstriction and hydrodissection, even if these effects work all together. ‘The supratrochlear, inftatrochlear and infraorbital nerve blocks are done separately. The extemal nasal branch of the anterior ethmoidal nerve is blocked as it exits from underneath the nasal bones at the nasal bone-ULC junction. This truncal anesthesia reduces the intraoperative blood flow and will be maintained for approximately 5 hours post-operative. i dofKnowledge of nasal vascularization anatomy is helpful. Let’s keep in mind that nasal arteries are located in the SMAS layer and follow the eat wges borders. Therefore, he pre-operative drawings serve as perfect landmarks for local anesthesia injections: columellar base, alar crease, LLC lower and upper borders.49 ‘The plica nasi/septum junction area and the plica nasi; the marginal LLC border, the inferior turbinate head — External bony pyramid, along the osteotomy lines at the bony contact and pyriform aperture, a ok Percutaneous direct high septum and K-Area infiltrations are specific to the preservation rhinoplasty (PR) procedure. Three shots are given inthe high septum and three inthe K-area, To inject the high septum, press the dorsum in between the fingers and inject perpendicularly, inside the septal cartilage itself through the sott tissues; a special feeling ot mild resistance 1s noticeable duc to -he needle piercing the ‘and push it in the direction of the cartilage. To inject the K-area, insert the needle just under the nasal bones’ caudal lateral K-area under the nasal bones; this is done bilaterally and medially > ro, aOnce completed, wait at least 10 minutes before beginning surgery. Often, this time is spent washing hands and draping for surgery. Don’t forget to ask the scrub nurse to have iced water on the field for cooling the operative field intra- operatively.Saban 51 CONCLUSION How does this method and injection sequence differ from my routine technique, an why is it necessary? Percutaneous direct high septum and K-Area infiltrations are specific to the preservation rhinoplasty (PR) procedure. Three injections are given along the dorsal septum ane three in the K-area. These steps are essential to facilitate the submucosal dissection beneath the dorsum, especially in the keystone arca ~ an area not widely dissected in che average rhinoplasty. One is elevating the mucosa widely in this area to facilitate exposure for the high septal resection. Also, one wants to avoid bleeding from the medial internal nasal branch of the anterior ethmoidal artery REFERENCES ‘Saban Y, Daniel RK, Polselli R, Trapasso M, Palhazi P. Dorsal Preservation: The Push Down ‘Technique Reassessed. ‘Aesthet Surg J. 2018;38:117-131The Rhinoplasty Surgical Set Baris Cakir Salih Emre Uregen Preparing my rhinoplasty instrument set was a difficult task. T hardly used 30 of the 100 instruments I bought, and I lost time and money. That is why we have decided to include this chapter. Obtain the correct instruments from the beginning, Practical habits are also important, Therefore, you should have your own instrument set ‘Any kind of nasal surgery can be performed with approximately 25 instruments. Some instruments are especially necessary for closed surgery, If your instruments are not suitable for closed surgery, you may need to turn to open surgery in a case where you started as a closed procedure, Magnetic surgical instrument pads act like a second surgical nurse. When the most frequently used instruments are placed in a specific order om this pad, no time is lost to instrument handing,54 ‘The Rhinoplasty Surgical Set ‘Speculum: You cannot visualize the field in closed surgery if the speculum's blades are not thin enough. Some speculums totally obliterate the nostrils. A medium-size speculum is resourceful, I bought speculums of various sizes but I only use the medium-size, Nasal Retractor: ‘The body of the nasal retractor should be thin. I have come across sharp-edged retractors. Check the edges with your fingers, as they need to be blunt. Sharp-edged retractors may lead to cuts on the nasal alar skin.Cakir, Uregen 55 Elevators: Traditional elevators are not suitable for subperichondrial dissection; therefore, I changed their shape with a metal bur Also I prepared such elevators for many of my colleagues. Finc-tipped elevators ensure an easier dissection, Dr Daniel asked me during a surgery where I bought these elevators. I told him I made them. The process that started with presenting him with one of those elevators ended up with serial production by the company Medicon, . Small Cottle Elevator: Used for septal dissection, b, Daniel Perichondrium Elevator: Used for the dissection of the crural perichondrium. 1 perichondrium of the upper lateral cartilage and medial «. Cakar Periosteum Elevator: Used for periosteal dissection. 4. Calar Perichondrium Elevator: Used for dissection of the nasal dorsum, upper lateral certilages and tateral crural perichondrium,56 The Rhinoplasty Surgical Set ‘Small Retractor (Krill): ‘The retractor should be thin and the tip concave, Closed-approach surgery is very d:fficult without this retractor. The dissection, and especially the subperichondrial dissection, stars with minute pockets. The rettactor should be fi into these pockets and provide a working area. enough to fit im er a ' ; i | } yCakir, Uregen 57 Tissue forceps: 4. Forceps without Teeth: Used to place grafts into pockets and to hold cartilages when suturing them, ’b, Adson Brown Forceps: Used to stabilize grafts when shaping them, «. Forceps with extra fine single tooth: Used to hold the perichondrium. 4d Forceps with fine single tooth: Used to hold the mucosa. Scissors: 1. Long Curved Sharp Scissors: Used to enter the perichondrial plane. ». Short Sharp Scissors: Used to open pockets for grafts ¢, Long Curved Serrated Scissors: Used to cut cartilage and mucosal excess. 4, Septum Scissors: Used for nasal dorsal cartilage resection. Scissors with angled handles are useful for dorsal cartilage resection in closed surgery. Prefer sc'ssors with serrated cutting, blades.58 A fine needle holder capable of holding a 6/0 suture is sufficient. It is possible to suture mucosal lacerations with a long, needle holder, [remove the bony hump with bone seissors which is possible in a very controlled manner.Cakar, Uregen 59 Osteotomes: Osteotomes 2 and 5 mm should be present. If the cutting edge of the osteotome is fine, it can cat bone without bursting i Lateral osteotomes with a cutting tip of 3 mm rarely cause mucosal injury. The stee!"s hardness is important for cutting bone. A 1 :mm osteotome ean perform external osteotomy from a pinprick. AT The surgical nurse usually uses the hammer, Prefer flat surface and steel hammers. Lead hammers become deformed easily, Hammer: and the metal falls off60 ‘The instruments below are indispensable fo evert the nasal alae and catch the lateral crural mucosa, | designed this instrument at a dentist colleague's office. We bought bone from the butcher and worked on it with an aimmotor, piezo and rasp. We saw that the sharp rasp performed a very fine rasping when rubbec perpendicular (90 degrees) ‘against the bone. It is very useful for rasping bone surface asymmetries. It thins the bone, producing a very fine powder, and docs not Iead to serration on the bone. This instruments is useful for radix reduction without causing glaballar swelling, We also use it in the dorsal preservation technique to mobilize the bony dorsum, by inserting it into the eut of the racix saw and rotating itCalur, Uregen 61 Rongeur: Rongeur is indispensable for let-down. It has to have a very fine and long tip. This instrument needs to be used like a nail clipper. It works quite effectively when 1 mm pieces of bone are cut off, Breaking off bone by grabbing and twirling is not safe. I ‘am satisfied with both of the single-joint Storz and Aesculap brand rongeurs pictured below. Grindstone: ‘Blunted instruments can be maintained with Arkansas and degussit stones.‘The Rhinoplasty Surgical Set Sutures: ‘The four types of sutures shown below are sufficient for performing closed rhinoplasty. Headlight: A light-weight headlight is essential for closed rhinoplasty. The axis of the eyes should be on the same level as the axis of the headlight in order to visualize the deepest part of deep dissection pockets. It is difficult to see the inside of pits with the headlight atthe level of the forchead.Cakir, Oregen 63 ‘Tastan-Cakir Micro Hand Saws: ‘The idea to use hand saws belongs to Dr Eren Tastan. The steel and sawteeth have been extensively studied, A convex hand saw is used to perform transverse osteotomy, a concave hand saw to cut the radix. These hand saws make cuts as clean as piezo-electric or micromotor instruments but faster. They do not produce heat and are cheap,[classify skin as thin, medium thickness and thick. It is essential to explain to the patient that skin type directly affects tip definition. If the skin is very sebaceous, a dermatologist may be asked for help. ‘The patient below used oral Vitamin A before her surgery. When the sebaceous glands of the skin smaller, redrape is easier.66 and Surgical Planning ition and projection. We prese-ve the Pitanguy ligament in Preserving the Pitanguy ligament prevents loss of tip defi 80.90% of the patients. It is necessary to cut the Pitanguy ligament in patients with high definition and projection. It is easy to estimate this pre-operatively. In patients with thick skin, Pitanguy's ligament is dissected to a lessor extent, resulting in greater supratip skin control Dorsum: ‘The results of dorsal preservation technique are different from the results of conventional hump rasping techniques. Even ed to straight and sof dorsal lines obtained with though I like parabolic dorsal aesthetic lines, the patients are habitua conventional techniques. In my first six months of performing the let-down procedure, pati hump following surgery. They would say that they did not want any hump, but would like their dorsum to be straight. However, now see I have patients telling me they want a natural dorsum with a small hump. Patients learn; they choose and then request specific characteristics. In other words, it needs to be discussed with the patient what dorsal preservation technique is. Yves Saban asks his patients to self-examine their nasal hump during the medical exam. Moreover, he asks the patient to touch the nasal dorsum before looking at the mittor after the surgery. I can frankly say that I have many patients who prefer to keep their hump anatomy. I definitely prefer to perform a let-down in a patient with a nose that looks good in the front view. I deliberately tell the Patient that there may be a slight residual hump after the surgery. Dorsal straightening may not be sufficient in patients with excessively convex humps and in the elderly. This subject will be studied in depth. ts complained of a persistent smallGalar, Saban 67 Polygon Analysis: We took pictures of people with beautiful noses between 2008 and 2012. We worked with sculptors and painters to analyze beautiful noses. We examined the contour lines, light reflections and shadows of these noses. We prepared nasal models with 3D Max. We analyzed organic models with cubic forms. determining their forms by taking the underlying anatomy into consideration. We could obtain the most natural-looking nasal model by using the polygon mesh tool. Therefore, we defined the sections formed by cartilages over skin with polygons and named them accordingly. Not only the mass, but also the spaces between them should be observed for aestheties. ‘We are trying to simulate the model explained in detail with the help of polygons in tip surgery. Below, each polygon is referred to by the number on the drawing, 1, Domal trigons: Trigons formed by the points Ti, Ts and Rm. Two in number. The domal trigons should be facing forward. 2. Interdomal polygon: The trigon between the points Ts, Ti and Ti’. ‘This polygon faces forward, like the interdomal and domal polygons. The apical angle of the interdomal trigon is 80 in men and 100 in women, Never obliterate the interdomal polygon, particularly with sutures68 Analysis and Surgical Planning 3 Infalobular polygon: The tetragon between the points Ti and C. Dr Rollin Dane! has given this polygon its name, ‘The inflobulr polygon faces downward at an angle of 4S degres. It isa spc polygon. The superficial layer of SMAS fills this space and tums i toa section, Stat gas are also placed in this polygon. thes grafts placed close to the caudal edge ofthe medal cru, the infalobular polygon becomes round. The infilcbular polygon is fomed by the weakest pat ofthe Tower lateral carilages - that isthe middle crm, After dissection this area weakens, and contour gas may be necessary | suengen it 4,Columellar polygon: ‘The space tetragon between the C points and footplates. The columellar tetragon faces downward. The space between the caudal edges of the medial erura should be preserved. A common mistake is over-grafting this area or excessive approximation of the caudal edges. Over-grafling widens the columellar fetragon, Saturing the caudal edge narrows the columellar polygon. However, the columellar polygon is clearly distinguished in a natural and beautiful nose. A slight groove is not bothersome but natural. ‘5, Facet polygon: The tetragon between the points Ti, Rm, RI and C. It faces downward and laterally at 45 degrees. One of my ‘main objections is in this area. This polygon is not a triangle. There is an edge of 2-3 mm between the points Ti and Rm. The facet polygon is not a space to be filled, It is clearly distinguishable in a beautiful nose, A thin-skinned nose without a facet polygon is an explicitly surgical nose. It has a “tent-like” anatomy. It ies between the middle and lateral erura, 6. Lateral crural polygon: It is a mass polygon and formed by the body of the lateral crus. The caudal edge of the lateral crus is anterior to its cephalic edge. This position forms an obvious section polygon and “scroll” line en the skin. Lateral crural resting angle is the angle between the surface of the lateral crus and upper lateral cartilage. This angle should be around 100 degrees. Surgical techniques damaging the nasal tip also distort the lateral crural resting angle. The angle between the lateral crus and "upper lateral cartilages start to exceed 100 degrees. The resting angle is a subject on which I will put particular emphasis. If this angle is proper, the need for rim grafts decreases dramatically. As the resting angle widens, the nose becomes a pinch nose. If the resting angle is 100 degrees, the facet polygon forms pleasantly. We will discuss how the resting angle can be corrected with ‘ cephalic dome suture in the Techniques chapter. 7.Dorsal cartilage polygon: The area from the tip to the keystone area. It is a clearly anteriorly facing section in thin-skinned Patients. There is 2 groove that gets deeper towards the keystone in the middle of the cartilage rbof. This groove is 1-2 mm deep and filled by the dorsal perichondrium. The thickness of the Pitanguy ligament that lies over the dorsal cartilage increases as it gets closer to the tip. The dorsal cartilage ends up forming the septal angle after it enters between the lateral crura, Study the ‘case below where the dorsum is preserved with the let-down technique. 8. Upper lateral cartilage polygons: The area formed by the upper lateral cartilage. It faces lateelly, anteriorly and inferiory. As the upper lateral cartilages are very thin, they rarely present topographic problems. If the do-sal cartilage polygon is shaped properly, this polygon will not cause any headaches. When the height of the upper lateral cartilage polygon is excessive, resection fom the upper lateral cartilages is also performed as the hump is resected, Another problem that we emphasize «enough isthe long upper lateral cartilage. The nasal tip rotation in droopy noses is usually achieved with septal candal resection and lateral crural cephalic resection. (However, cephalic resection should be made to an extent so as to allow lateral crural cxpkals dome suture. This is usualy1-4 ram) If this is not sufficient for rotation, caudal section from the wpper Iateral cartilages should be performed. In this way, the upper lateral cartilage polygon can be shortened, and a higher seroll line an be formed. 9. Dorsal bone polygon: The area between the keystone and nasal radix. The dorsal bone polygon has more rounded contours Compared to the dorsal cartilage polygon. It does not reveal lights as sharp as the dorsal eart age polygon. It is wider in the keystone area and narrow atthe nasal radix, Its shorter in men and longer in women, That is, tae keystone area is located moreNeen 69 superiorly in men when compared to Women, If the root is completely closed with osteotomy, the dorsal bone polygon becomes. too narrow, When spreader grafts or flaps are used for dorsal lights, a controlled open roof is obtained. If the bone is wide and the shape of the cartilage is good, the cartilage can be pushed down and the bony roof opened. I learned this technique from Dr. Hiseyin Guner and Dr. Mehmet Bayramicli. The dorsal cartilage is seperated from the upper latezl cartilages, then a cartilage strip is removed and pushed down. The bony hump is opened with bone seissors and the roof closed with osteotomies. As the mucosa is left attached to the dorsal cartilage flap, there is no need for suturing, 10.Lateral bone polygons: Formed by bones. They face laterally, superiorly and anteriorly. Asyrmetries of bones are very frequent. Wide dissection allows rasping bony convexities. The frequently encountered axis deviations ean be corrected with an agymmetric let-down. A dorsal preservation example is shown below: We must develop a concept of dorsal aesthetic lines that conforms to the underlying anatomy. Incorrect concepts lead to usage of surgical techniques in incorrect doses. We must better understand the dorsal anatomy and use more anatomical techniques. In summary, dorsal aesthetic lines are as follows: 1. Dorsal aesthetic lines are not straight. 2. Dorsal aesthetic lines are narrow at the supratip area, wide at the keystone and narrow again at the radix.70 Analysis and Surgical Planning 3. ifferences between men and women are the width and location of the keystone area, 4. The keystone is narrow and located at the middle ofthe nasal dorsum in women. 5. The keystone is wider and closer to the radix in men, Its 3-4 mm more superiorly located when compared to women. 6. While the nasal radix in men is at the level ofthe supratarsal fold, itis atthe level of the eyelashes or pupil in women. ‘The upper row inthe drawing below shows the conventional dorsal aesthetic lines, wile the lower row shows my | description. The left column shows dorsal aesthetic lines of men, and the right one of women, TY tl So fat, I achieved the most natural nasal dorsum with the dorsal preservation techniques. For a detailed reading, see the following paper: Cakir B, Dogan T, Oreroglu AR, and Daniel RK, Rhinoplasty: Surface aesthetics and surgical techniques. ASS 2013;33:363-75.Cakir, Saban n Lateral Crural ith: Lateral crural width is an important subject. A wide lateral crus is usually treated with cephalic resection only. However, resections of more than 4 mm may result in alar retraction, We use the rim flap technique in patients with caudal lateral erural excess, Please pay attention 0 the relationship between the lateral crus and the nostril in the case below. The shadow facet between the nostril, dome and lateral crus is the facet polygon. The facet shadow is not large enough when the lateral crus is closer than normal to the nostr!. Such patients are said to have lateral erural caudal excess. In the drawing below, both cephalic and caudal excess can be seen. Narrowing the lateral crus with cephalic resection causes serious side effects. Caudal excess is teated with the autorinn flap. With this technique, a resection of more than an is ‘not necessary even in the most bulbous noses,72 ——73 Here I will illustrate my planning procedure by performing surface aesthetic analysis on a patient, I have chosen a thin-skinned patient, since the cartilages are more visible. The dorsal nasal width is very good. I have performed these drawings with photoshop and a wacom tablet. Drawing the cartilages on the pictures can be a useful exercise. Lobular projection is insufficient, The facet polygon is too small| 74 When the patient smiles, the nasal tip moves too much. The body of the depressor muscle is visible. Even deprojection only decreases depressor activity. In my opinion, muscle resection or incision is rarely necessary. Itis obvious that the patient has isolated lateral crural caudal excess in the oblique view. The lateral supratip breaking point shows the seroll line. The scroll line is very close to the nasal tip. This is how we understand that lateral crural Gephalic excess is very limited, The lateral crural caudal edge is very close to the nostril edge. Therefore, the facet shadow is small.rc ‘The lateral crural widih of this patient should be treated caudally. We have planned a 2 mm autorim flap and 1-2 mm lateral crural Tip projection decreases by 2 mm. Nostril apex projection decreases by 4 mm. Lobule projectien increases. The changes in projection can be seen in the superimposed pictures Closed approach under general anesthesia was preferred. The caudal septum was exposed with a low septal incision. Caudal 1 mm of the septum was left attached! to the Pitanguy ligament. The dorsum was dissected on the subperichondrial and subperiosteal plane. The domes were delivered with an infracartilaginous incision leaving the caudal 2 mm of the lateral crura on the skin, Caudal 2 mm of the lateral erus was trimmed. Subperichondrial dissection of the septum was cartied out, and the excess in the septal floor was excised. A resection of 4 mm was made from the caudal septum. A lateral crural cephalic trim of 3 mm was76 ‘made, Lateral erural steal of 3 mm was performed bilaterally. The lateral erural resting angle was corrected with a cephalic dome suture, A strut graft was placed. A resection of 2 mm was made from the caudal upper lateral cartilages for rotation. A strip of 3 ‘mm eartilage and bone was resected from under the dorsum. Transverse and radix osteotomies were performed with a hand saw: A bony wedge of 3-4 mm was excised from the apertura. The nasal body was mobilized with lateral osteotomies. The 1 mm wide cartilage attached to the Pitanguy ligament was sutured to the septum. The seroll ligaments were sutured to the caudal part of the upper lateral cartilages. Camouflage grafts were placed over the radix osteotomy. The low-septal and rim incisions were repaired. ‘Thermal dorsal splints and internal nasal splints were applied. Surgical plan in the cephalic view 43 Days Post-Op. The facet polygons have enlarged, No droopiness when smiling. — weEssential Operative Anatomy for Preservation Rhinoplasty Peter Palhazi & Rollin K Daniel ‘AS with all surgery, Preservation Rhinoplasty (PR) requires an in-depth knowledge of anatomy in order to crucial for PR for two understand and perform the essential operative steps. A detailed knowledge of surgical anatomy reasons. Fist, there has been a dramatic expansion in our understanding of nasal anatomy over the past decade (Daniel, Pathazi, 2018). Second, surgical techniques have evolved based on this new anatomical knowledge. For example, the current techniques for Dorsal Preservation are based on the concept of the osseocartilaginous junction being semi-flexible chondro- ‘osseous joint which can be changed from convex to straight while retaining a natural dorsum, Another example is the elevation of an intact soft tissue envelope in a continuous subperichondtial- e the skin envelope ibperiosteal plane. To dev without damaging it requires advanced technical skills as well as a sophisticated understanding of the nasal anatomy, especially tissue planes and nasal ligaments. The present chapter will discuss and illustrate both the essential anatomy and surgical techniques required for Preservation Rhinoplasty ina step-by-step fashion,80 Essential Operative Anatomy of Preservation Rhinoplasty ANATOMICAL CONCEPTS OF THE SOFT TISSUE ENVELOPE FOR PR: ‘The majority of shinoplasty surgeons have familiarity with nasal anatomy and a relrively routine surgical technique for most noses. However, the transition to Preservation Rhinoplasty requires a greater in-depth knowledge of nasal anatomy and new surgical approaches based on that anatomy. In this seetion, we will emphasize the anatomy ofthe nasal ligaments ‘and their importance in the surgical techniques for elevating an intact soft tissue envelope. Interdomal Ligament: ‘The interdomal ligament connects the two middle crura at the cephalic junction of the infralobular segment. ‘Technically, the ligament does not run between the domes, but rather between the middle crura in a more posterior and cephalic location. It is easily found in all noses and is often quite rigid, Although many surgeons eut the interdomal ligament during insertion of @ columella strut, the interiomal ligament ccan easily be preserved due to its cephalic position away from the caudal border of the middle crura, Obviously, this preservation is not possible if a tip split procedure is performed. Many surgeons routinely insert an interdomal suture 10 narrow the interdomal distance, which in reality merely represents reestablishment of the previously cut interdomal ligament. Imererural Ligament: ‘The intercrural ligament connects the cephalic border of the entire alar cartilages, including the lateral, middle, and ‘medial crura, It passes just above the mucosa and holds the alar cartilages together.Palhazi, Daniel 81 In its cephalic portion along the lateral crus, it acts as the suspensory ligament of converse passing just above the anterior septal angle, In its mid-portion, it is posterior to both the interdomal ligament and the dezp portion of Pitanguy's ‘midline ligament. Its caudal component effectively restrains the medial crus and footplate, pulling them towards the caudal septum. The intercrural ligament unifies the two alar cartilages and acts as a suspensory sling over the anterior septum, During rhinoplasty surgery, this ligament can either be preserved or disrupted. In an open approach, a “tip split” procedure will divide the ligament and require the surgeon to restore support, usually with a columellar strut. However, downward traction on the alar eartlage followed by a “dorsal spit” allows one to maintain the intererural ligament. A bilateral transfixion incision through the membranous septum will disrupt the intererural ligament support between the footplates. Altematively, one can perform a low septal transfixion incision. Essentially. one makes the transfixion incision through the ‘caudal septum approximately 2-3 mm back from the caudal border, thereby ensuring total preservation of the intererural ligament. Vertical Pyriform Attachments: ‘Saban noted distinct superior and inferior lateral nasa ligaments along the pyriform aperture, which he designated ligamentum laterale superius and inferius nasi. We have found these ligaments to be inconsistent as distinct entities, but have detected a consistent vertical attachment between the entire pyriform aperture and the overlying so tissue envelope, which wwe have designated asthe Vertical Pyrform Attachments (VPA). Its pari larly dense at the keystone area and on occasion along the lateral border. Release of this VPA becomes important in the total dorsal exposure associated with complete lateral ‘osteotomies done with a piezo-electric saw,82 Essential Operative Anatomy of Preservation Rhinoplasty |) Pitanguy’s Midiine Ligament: Pitanguy described a ligament originating on the undersurface of the dermis and runring tangentially down to and in between the ala catilages. He reported a connection between this ligament andthe depressor sept nasi (DSN), which was later confirmed by de Souza Pinto. Recently, Saban has demonstrated that the medial SMAS at the level of the internal nasal valve divides into a superficial and a deep layer. The superficial medial layer runs caudally below the interdomal fat pad, but above the interdomal ligament into the columella, The deep medial layer ofthe SMAS runs beneath the interdomal ligament, but above the anterior septal angle into the membranous septum and then davnward toward tke anterior nasal spine, Saban concluded thatthe deep medial SMAS could correspond to Pitanguy’s ligament, Based on the accepted five-layer laminate concept of the nasal sof tissue envelope, Pitanguy’s ligament cannot be a true dermocartilagincus ligament, as it would have vo nun tangentially from the dermis across and through the SMAS to reach the cartilaginous structures in the tip. We have modified the original terminology and advocate the use ofthe term “Pitanguy's midline ligament,” which reflects its origin ‘as part of the midline SMAS layer. Our dissections confirm prior observation (Daniel, Palhazi, 2016). aeep Ne ome Piianzwy \ I" We emphasize that Pitanguy’s midline ligament divides into superficial portion which passes above the interdomal ligament and becomes continuous with the superficial orbiculars oris muscle (SOON) and a deep portion which passes below the interdomal ligament and becomes continuous with the depressor superficial nasalis musele (DSN),Palhazi, Daniel 83 Surgically, division and repair of Pitanguy’s midline ligament has become an important method of supporting the nasal tip. Utilizing a closed approach, Calar identifies the ligament and preserves in approximately 90% of cases. Surgeons using an open approach often mark, divide, and then repair Pitanguy’s midline ligament at the en¢ of the case, Seroll Ligament Complex (SLO): Al jinal fibrous attachment has long been recognized in the seroll area between che cephalic border of the ower lateral cartilages (LLC) and the caudal border of the upper lateral cartilages (ULC), Recently, Saban has identified a distinct fibrous attachment from the undersurface of the transversalis muscles to the seroll junction. Thhus, a ngitudinal (SL) and a Vertical Scroll Ligament (VSL) can be collectively referred to as the Scroll Liganent Complex (see figure below. perichondriur _Petichont ‘The longitudinal scroll ligament occurs atthe junction between the LLC and ULC. Itis basically a perichondrium- derived fibrous tissue in the scroll area that contains multiple interspersed sesamoid cartilages. On the mucosal surface, it is the internal valve area, Tt acts like a swinging door. This ligament is strong connection between th catilages, whose lateral counterpatt is the pyriform ligament (Rohrich etal. 2006).Saban introduced the concept of a vertical seroll ligament (VSL) that emerges from the undersurface of the deep 'SMAS layer and inserts into the intemal nasal valve area. These vertically oriented ligaments cre always problematic to understand, because they are not as distinct as the longitudinal ones between the cartilages. The VSL is actually a line of adherence along the scroll area, between the overlyi f Buta oft tissue envelope (SMAS) and the underlying LSL as seen below. (One can clearly see in the following figure the SMAS and serol! area connections, The VSL appears from the caudal edge of the perimysium of the transversalis muscle, thus transmitting the muscle contraction onto the seroll area and finally ‘onto the internal valve. However, the transversalis muscle is a paradoxical muscle, During inspiration, it contracts to narrow the airway, exaguerates the internal valve, and hence redirects the airflow towards the upper meatuses85 The seroll ligament complex (SLC) has become extremely important in PR and demonstrates the linkage between surface aestheties-anatomy-surgical technique. New analysis and terminology of this area are now required. As seen in the photograph below, itis important that the surface aesthetics ofthis area be carefully analyzed pre-o>cratively.86 The clasic term “alar grove” often denoted a C-shape line which arises in the alarereas, runs vertically through the “alar dimple” before turning toward the alar rim along the caudal border of the lateral crus, and ending at the tuming point (TP). However, we now conceptualize the alar groove as spliting atthe A-l/latral erus junction point into a sroll line and a lobular line. The line slong the cephalic border of the lateral crus is called the serol in. Iti significant as itis both the cephalic border of the lateral crus polygon and the location ofthe esting angle, both important aesthetic considerations. ‘Te lobular line overlies the caudal border of the lateral crus and terminates atthe turning point, thereby separating the tip lobule from the alar base. These concepts have a dramatic impact on surpcal technique as demonszated in the patient below, treated by Dr. Cala. As seen in the pre-operative photo on the lef, the alar groove is very pronounced, andthe serol! ine is angulated upward and far from the im, Surgically, one can elevate the scroll ligament complex intact and then reattach it closer to the alar rim, thereby ercating a more aesthetic tip, as seen post-operatively. Sy, orm, {In conclusion, this photograph shows the relationship of all of the important ligaments in the lower third. 7 ro 5 erPalhazi, Daniel 87 SOFT TISSUE ELEVATION OVER THE OSSEOCARTILAGINOUS VAULT: Elevation of the entire soft tissue envelope (STE) in a continuous subperichondrial -subperiosteal plane (SSP) is a ‘critical frst step in performing a PR. As discussed in the other chapter (Valerio), we shall illstate the C3 approach for exposure of the osseocartilaginous vault, Step #1 A Low Septal Transfixion Incision: ‘The frst incision is a low septal transfixion incision. Most surgeons are familiar with the ransmucosal transfixion incision with its half and full-length extent, plus unilateral orbilateral configurations. Essentially, the columellaris separated from the caudal septum via an incision through the membranous septum. ‘The disndvantage ofthese incisions is thatthe cut many ofthe nasal igaments including the deep layer of the Pitanguy ligament, and it disrupts many of the attachments ofthe elarcatages, including the intererual ligaments n const, the low unilateral septal transfnion incision placed 2 mm cephalic to the caudal border ofthe septum preserves ll these ligaments while providing acess to the sepium. The eartage retuned in the clumelar complex is called the posterior strut by Car, in contrast the columella struts lized orp shaping. Step #2 Intereartilaginous In: The intercartilaginous incision is placed atthe junction between the upper (ULC) and lower lateral (LLC) cartilages. After infiltration with local anesthesia, 2 10-15 mm long incision is made, just penetrating the mucosa. The incision passes from lateral to medial where it joins with the septal transfixion incision bilaterally. ‘Step #3 Subperichondrial dissection over the Cartilaginous Vault: ‘Sharp pointed scissors are then used to expose the upper lateral cartilages along their caucal border. Technical is important to enter the subperichondrial plane and see clean white cartilage. Pitanguy’s Ligament is not preserved in this, dissection so as to demonstrate clearly the dissection planes. ‘The perichondrium is easily swept off the dorsal aspect of the cartilaginous vault ina lateral to medial direction and then progressing upward tothe bony cartilaginous junetion. The Daniel-Cakir elevators particularly useful for this maneuver. Resisiance will be encountered as one approaches the catilaginous-bony junction,In the photos below, one can see the central and lateral subperichondrial dissection over the cartilaginous vault. r 4 ft Significant resistance is encountered as one passes from the cartilage vault to the bony vault, due fo the vertical pytiform attachments (VPA) which are vertical attachments between the pyriform aperture and the overlying soft tissue envelope, These may provide significant resistance and require sharp dissection to enter the subperiosteal plane. ‘Sut Tasus Envelope NB89 Frequently, it may be necessary to use a #15 blade to seratch along the caudal border ofthe nasal bone in order to enter the subperiosteal plane. It is often best to find the plane laterally over the nasal bones and then connect medially over the dorsurn, However, once this plane is entered, the dissection is easily done with an elevator. The extext of the subperiosteal dissection cephalically and laterally will depend upon the surgeon’s preferred method of osteotomies. For conventional osteotomes of hand saws, the dissection cephalically will extend to the radix area and laterally midway down the lateral bony ‘all, For those surgeons using power or piezo-electric instruments, a total degloving of the bony vaul: is preferred. [As the lateral dissection continues eephalically in a subperiosteal plane, one tends to encoanter several bleeding points at consistent locations. One group of perforating vessels are usually slightly caudal to the sel fon, in the radix area ‘The bleeding is due to severing the small communicating vessels. These vessels are small (< 0.5 rrm) branches fiom the anterior ethmoidal vessels below the bone, which pass through holes to reach the angular vessels. Cauterizaton is usually suiicient to achieve hemostasis, but bone wax can be applied in eases of persistent bleeding‘A second group of vessels are found in a more lateral location atthe cephalic end ofthe nasofacial groove (see figure con the lef), There are also bleeding vessels through the mucosal space (see figure on the right). These vessels are usually 0.5-1.0 mm in diameter and consist of communicating vessels between the external and intranasa. vessels. They are usually damaged when a lateral osteotomy is done or an incision made through the mucosa internally. ‘The dissection in the central area to unite the upper subperiosteal pocket with the lower subperichondrial pocket ccan be tedious, difficult, and time-consuming. « ‘The reason for this challenging dissection is based on embryology. During fetal development, the nose is made up ofa cartilaginous capsule which is covered with perichondrium, Then the nasal bones with their periosteum ate laid down ‘on top, which results in an overlapping fusion of perichondrium and periosteum. In some ways, this challenging dissection is similar co dividing the conjoined fibers between the anterior and posterior pockets of the septum. Again, judicious scraping ‘with the #15 blade may be of value.4 Soft tissue elevation over the lobule via a subperichoncrial-subperiosteal plane (SSP) is @ demanding technique that must be mastered. ‘As advocated by Cakir (Cakir etal. 2015), an auto-rim fap is an important method for achieving the desired alar highlight line advocated by Toriumi, as well as for preventing alar rim retraction. In addition, it minimizes the need to add lar rim contour grafts at the end of the case, The figures below showa closed approach. is made 2-3 After careful palpation ofthe eaudal border of the lower lateral cartilage, an intratartilaginous in rim back from the caudal margin, It begins at the lateral genu of the domal notch or 2-3 mm lateral to the dome, and then passes laterally to the turning point (TP) of the lateral crus, where it ends. This long narrow sliver of cartilage is retained within the skin sleeve Itis easiest to begin the disetion laterally using a #15 blade held vertically and then scamping along the cartilage ‘The lateral crus is held under tension with a fine hook, pulling the lateral erus downward while a nerrow ribbon retractor on the skin increases exposure. It cannot be over-emphasized that the lateral crus must be absolutely clean, with no muscle or soft issue fragments 4 S omAs seen in the clinical photographs below, the vast majority of surgeons who think they are ting sulperichondrally are notin the correct plane. If one sees muscles or bleeding points onthe elevated skin, then the dissection is sub-SMAS, no matter how “clean” the cartilage appears, Gaining access to this plane is the most tedious and technically challenging aspect of this operation. On the left side below, one ean see a clean dissection over the cartilage, but it is sub- SMAS as the muscles and bleeding sof tissues are obvious. On the right side, one can see a tru subperichoneal dissection with visible perichondrial fibers on the elevated soft tissue, while the dots indicate the serollligement complex ay (Once the lateral erus has been exposed, the dissection continues over the dome, then down the mille erus and onto ‘the medial crus below the columellar breakpoint. The goal of this dissection is to achieve sufficient mobility of the crus to allow delivery of them into one nostril. It is essential that the alars be sufficiently mobile to be in approximation without tension when delivered through one nostril, thus allowing accurate suturing. In the figures below one can see a closed approach on the le, an open approach on the tight. a ah se ‘AL this point, additional mobilization is achieved by releasing the interdomal ligament. Again, the dissection must be meticulous, and the ligament released from the posterior border of the middle crus. Note that the appositional approximation of the interdomal ligament is restored with sutures, including various “loop sutures” between the interdomal soft tissues and cephalic border of the middle eruraPalhazi, Daniel 93 Step # 6 Cephalic Dissection across the Scroll Junction Pushing up the Sesamoids and the Vertical Seroll Ligam Although conceptually simple, this step is ultimately the joining of two preexisting subpe-ichondrial pockets: one ‘over the lateral crus, and the other over the cartilaginous vaule (see figure below). Connecting the pockets starts atthe dorsum and progresses laterally. ‘The figure below demonstrates the preservation of the Pitanguy’s ligament. Note: The trins:olumellar incision was done to show the deep Pitanguy’s ligamentoe 94 Essential Operative Anatomy of Preservation Rhinoplasty Success is noted by visualization of the white sesamoid cartilages in the overlying soft tissue envelope (see figure below; note: dissection was performed to show the scroll cartilages inthe perichondrium/VSL—tke Pitanguy ligament is not preserved) Doing so, one will hve access tothe dorsum, ifthere isa need for any dorsal modifcation;also,Pitanguy’s ligament will be undsrupted. The obvious question is: “Why bother to preserve the ligament?” The three reasons ae the following: 1) Ieelevates the tip, 2) it compresses the infralobular curve, and 3) it pulls the sof tissue envelope downward, thereby accentuating the supratip break, ‘Cutting Pitanguy’s ligament has three negative consequences: 1) derotation ofthe tip with loss of projection, 2) it lengthens the infralobule and causes it to round out, and 4 3) itereatesa soft tissue poly-beak, Preservation leads to predictability. ‘Why is this step so important? Functionally, it means thatthe scroll ligament complex between the longitudinal and. vertical components is maintained and neither disrupted nor searred, In many ways, it is the equivalent of preserving the j internal valve angle by doing submucosal tunnels. Aesthetically, the suture reattachment of the sesamoid area to the ULC | “will st the aesthetic scroll line on the surface and define the upper border of the lateral erus polyen.Preserving the osseocartilaginous dorsum is a major advance in rhinoplasty surgery. Instead of excising the dorsum, one lowers it by removing a subdorsal septal strip, followed by lateral, transverse, and radix osteotomies. Very few surgeons analyze the nasal hump. Rather, they connect the dots between the rasion (N) and ideal tip projection to set the ideal dorsal line and thereby determine the amount of reduction. In PR, itis imoortant to recognize the three aesthetic points: N, K, R. ‘The clinical nasion (N), as opposed to the anthropometric nasion, is the deepest point in he radix area on profile view, which is usually the deepest point on the nasal bones. The kyphion (K,) is the most promizent point on the nasal dorsum, The rhi jon (R) is most caudal point of the paired nasal bone and marks the midline junction between the bony and cartilaginous vaults. One needs to realize thatthe rhinion denotes the keystone junction (do not confuse K & R). After marking these three points, one can classify dorsal humps into V- and S-shaped, The V-shaped dorsum has a straight line configuration from N to K, with one point of angulation, The S-shaped dorsum has a distinct angulation from N to K and then a plateau from K to R (Lazovie et al, 2015). In PR, the more severe the S-shaped kyphotic dorsum, the more difficult itis to fatten (see chapter by Kovacevic),96 Its important to define the keystone area as that portion of the nose where the bony vault overlaps the cartilaginous, vault both dorsally (dorsal keystone area—DKA) and laterally (lateral keystone area—LKA). perpendicular plate py %0! J97 ‘The nasal bones serve as a “bony cap” whose position is largely deter id by growth of the cartilaginous septum, The nasal bones vary in size and dimension, but form a thin “bony cap" contour overlaying the cartilaginous structures. Thus, ‘the nasal hump is a reflection of the underlying cartilaginous vault with a thin bony cap overlay, rather than a large ‘osscocartilaginous structure comprised of 50% cartilage and 50% bone, ‘One of the most important anatomical findings is the variation between the location of the keystone point (R) and the dorsal junction between the cartilaginous septum and the perpendicular plate of ethmoid. Ir most cases, the dorsal cartilaginous septum will extend 8-10 mm beneath the nasal bones.However, one must be aware that significant anatomical variations exist as to the location of the junction point ‘The ability to know the junction point between the subdorsal cartilaginous septum and the perpendicular plate of ethmoid prior to surgery is yet another indication to do a cone-beam CT-seans prior to rhinoplasty surge-y. The periosteum on the deep surface of the bony cap fuses with the perichondrium on the superficial aspect of the cartilaginous vault. The result is a flexible dorsum which allows the convexity of the dorsum to be eliminated by redueing the underlying cartilaginous septal support. Thus, the vault can be modified from convex to concave without losing its continuity bbone__peisteum, _psfchendium _cartlageAs shown in the sonograms below, provided by Dr. Kasins, a very dlstinet fattening cf the osseocartilaginous junction is observed between pre-op (eft) and one-week post-op (right) following a PR OPERATIVE STEPS OF DORSAL PRESERVATION: Dorsal Preservation (DP) is done using the following three steps: (1) excision of a septal stip, (2) total mobilization of the bony vault with osteotomies, and (3) downward impaction of the osseocartlaginous vault. I is important to realize that the sequence of these steps vary based on the surgeon’s preference. Additionally, surgical preference extends to the ‘method of mobilization (push-down vs let-down), which in tum determines the types of lateral osteotomies, Step #1 Push-Down vs Let-Down: Concepts: ‘The classic Push-Down Operation (PDO) requires @ low-to-low osteotomy followed by piaching ofthe completely mobilized osseocartilaginous vault and impacting it downward into the pyriform aperture. In contrast, the Let-Down Operation (L.DO) involves excision ofa tapered triangle ofthe frontal process of the maxilla, which provides space forthe mobilized vault to be lowered into. Most experienced surgeons develop a distinct preference for one technique or the other (Gakir: LDO; Kosins: PDO), while others have specific indications for each, Saban (Saban et al. 2017) prefers PDO for dorsal lowering less than 4 mm, but LDO for larger lowering in the range of 5-18 mm.Essential Operative Anatomy of Preservation Rhinoplasty Step #2 Anatomy of the Septal Strip Excisio Historically, the septal strip excision has varied extensively as to amount, shape and location (Saban et al. 2017). Currently, the majority of surgeons prefer the following: (1) location (high ~ immediately subdorsal), 2) shape (tapered), and (3) amount (varies with desired reduction), ‘Some experienced surgeons can directly correlate the desired dorsal reduction (for example, 4 mm) with the actual septal strip excision. However, most surgeons should take a more incremental approach to achieve the desired lowering, The excision itsef can be divided into a cartilaginous and a bony component, Step #3 Septal Strip Excision: Cartilaginous Component: ‘The cartilaginous strip excision consists of an incisional curved subdorsal cut first and then a straight excisional cut {hough the septum for removal of the intervening cartilaginous strip. I is important thatthe eartlaginous eut NOT start at the ASA point, but rather at the W-point. The W-point represents the point of separation ofthe ULCs from the septum. From the surgeon's viewpoint looking from caudal to cephalic it resembles the leter W. Anatomically, the W-point will be 4.4 mmm (range: 1-8 mm) (Palhazi et al. 2015) from the ASA. However, we recommend clinically o place the incision at the actual W-point, which should beat leat 6-8 mim cephalic tothe ASA.Palhazi, Daniel 101 ‘The incisional eut then continues subdorsal, keeping intimate contact between the scissor ips and the undersurface of the dorsum. The incision passes cephalically until bone is encountered at the junction of cartilaginous septum and the pespendicular plate of ethmoid (PPE), ‘The excisional cut isa straight cut using straight scissors, and it begins 2-4 mm below the W-point. It then continues until the bony septum is encountered. One should conceive ofthis as an incremental strip excision and nota definitive setting of the profile line, Remove half of what you think you need initially, then add incremental excisions. “4 Step # 4 Septal Strip Excision: Bone (PPE) Compoue Once the inital cartilage strip has been excised, one must obtain mobility atthe bony PPE component ofthe septum and provide space forthe dorsum to descend, As previously stated, pre-operative cone-beam CT scans are extremely helpful in estimating the extent of bone removal that willbe required, as well a the method,102 Saban takes @ progressive approach to mobilizing the bony septum, depending on the amount to be excised: simple fracture, triangular excision, or quadrangular excision. Cakar prefers to use a micro-tip Rongeur (Medicon Instruments). Ibis important to remove the bony PPE with multiple small cus and to avoid any twisting motion, At this point, one can begin the osteotomies to mobilize the entire osseocartlaginous vault. Please note that the above seen cadaver case is only for demonstration purposes. Also, the used Rongeur is usually smaller, There is a wide variation in how and in what sequence surgeons do their osteotomies. They differ in the amount of Xposure (limited vs total), type of instruments (osteotomes, hand saws, piezo-electric instruments), and sequence. Put simply, there is no right or wrong method; do whatever you are most comfortable with. Note the very real difference in osteotomy sequence and instrumentation preferred by Cakir, Saban, and Gaksel By definition, a transverse osteotomy extends from the level ofthe lateral osteotomy across the frontal process of the maxilla and nasal bone into the radix area, terminating atthe ipsilateral dorsal aesthetic Line, Its usually straight line ts location may vary depending on the location of the new nasion (N), which in tum corresponds to the location ofthe radix osteotomy. The transverse and also the lateral osteotomy can affect the medial canthal ligament. This clinieally does not ‘cause tarsal instability, cause itis only its anterior limb, The medial canthal ligament (MCL)bas three limbs, The superior and posterior ones are responsible for stabilization of the tarsus. The anterior fim mainly originates from the orbicularis ‘cull muscle. When one performs a total subperiosteal clevation, then the anterior MCI. can be elevated, and it will reattach, Also, bleeding is minimized because the angular artery and vein are superficial to the MCL, as seen below.103 The transverse eut is made first, as the bones are stable; a clean cut can be made, either with a hand saw or a piezo blade, Altematively, a percutaneous osteotomy can be done with 2 2-3 mm osteotome. The radix osteotomy may be called the nasion, or even the nasofrontal osteotomy. Its purpose is simple: (I) 10 unite the fwo transverse osteotomies, and (2) to fracture downward through the fused nasal bones and then the nasal spine of the frontal bone in order to enter the previously resected area of the bony septum. This osteotomy must be approached carefully ‘yet firmly fo cut through the fused syndesmosis of the nasal bones. When using percutaneous osteotomes, itis important to stand at the head ofthe table and angle the osteowme at a 45-deuree angle dowaward away flu the eibaifuun plate lamina cibeos, Ce perpendicular oN 1 \ ¥ 2104 The location of the radix osteotomy is critical: at the desired nasion point (N) within the radix area, In the majority of patients, there will be no desire to change N, and this site will be selected, It should be noted that the nasion or soft tissue sellion is often 4- mim above the medial canthal ligament, As one moves the site of the radix osteotomy caudally, one tends to create a deepening of the radix and caudal displacement of N, leading to an infantilization of the nose (Kosins) A traditional low-to-low osteotomy is performed beginning at the caudal border of the pyriform aperture, then straight across the ascending process of the maxilla, before terminating at the level of the transverse osteotomy. Once ‘completed bilaterally. the entire osseocartlaginous vault should be mobile105 ‘One can see on the figure below that there are veins just on the top of the periosteum; these can bleed during lateral osteotomy if one is not subperiosteal, These veins also connect to the intemal nasal vessels through the mucosal space. This ‘anastomos usually bleeds when one does the mucosal cut along the pyriform aperture to create the approach for the Lateral osteotomy, NB me Many surgeons are now excising the Webster’s triangle area using a small nose rongeur (the same one used for the resection of PPE). This is done prior to the lateral osteotomy. In many ways, this is simply resectng the same area as one ‘would in a let-down procedure. Also, it prevents any potential medial bony displacement toward the head of the inferior turbinate. Once the bony osteotomies are completed, it is important to check that the bony cuts are all connected to each other ‘and deep enough through the bone to allow complete mobilization. The bony vault can be grasped tetween thumb and index finger, and then totally moved from one side tothe other. Alternatively, a 90-degree chisel can be placed inthe cuts to ensure their adequacy. Most often, there will need to be additional mobility achieved atthe radix cut (often just minor mobility, or fracturing with the 90-degree chisel) and along the lateral osteotomy line, The latter problem has been minimized by resection in the Webster siaugle area, hut this excision may need to be extended eephalically106 Essential Operative Anatomy of Preservation Rhinoplasty Step #9 Adjustments Including the W-ASA Segment: Once the osseocarilaginous pyramid has been lowered to the desired position, then the profile line should be ‘evaluated, both for height and alignment. The W-ASA Segment (the area between the W and ASA points) must be checked, as it was deliberately kept high initially to avoid any potential saddling. Frequently, a straight-line cut from ASA to Wis sufficient, Additional adjustments may include the following: (1) minor septal strips excised, (2) the undersurface of the dorsum released with partial vertical cus, or (3) the dorsum shifted to one side or the other. ‘Step #10 Three-Point Suture Fixation/Stabilization: (Once the surgeon is satisfied with the dorsal profil, then the dorsum is fixed to the underlying structures. Kosins has developed a three-point suture fixation technique which allows for minor adjustments, rgid stabilization, and reduction of post-operative problems Suture #1 is placed atthe original K-point of the hump. Small drill holes are made through the bone on either side (most often these holes are placed atthe start ofthe case). A 4-0 PDS suture is passed through one hole, then aeross the dorsal septum, out the opposite bone hole and then tied in a cerclage fashion. The goal is to keep the dorsum flat and resting against the septum, thereby minimizing the chance of a recurrent hump. Suture #2 is placed atthe W-point with 5-0 PDS. Since the distal cartilage vault is still mobile, certain adjustments ‘ean be made, The steps areas follows: (1) the vault is moved from side to side until the best location is found, (2) the vault is then fixed to the underlying septum with a #25 needle, and (3) the suture is then inserted to stabilize the structures in the correct position. Suture #3 is inserted midway between the other two sutures using a 4-0 PDS suture passed in a cerelage fashion Essentially, one has locked down the dorsum inthe desired postion and fixed it at thre pointsPalhazi, Daniel 107 CONCLUSIONS: ‘Anatomy is at the critical center of the rhinoplasty triad of aesthetics-anatomy-surgical techniques. Anatomy determines the surface aesthetics and isthe structure upon which we operate, Yet, for surgeons wantirg to master Preservation Rhinoplasty (PR), there are the problems of having to learn new techniques based on a new anatomy and also the limited visibility that occurs in most clinical cases. Thus, the surgeon must understand the anatomy and surgical techniques which have been illustrated in this chapter in detail. Elevation of the soft tissue envelope in a complete subperichondrial- subperiosteal plane will minimize post-operative morbidity and the need for revision surgery. Understanding the anatomy of the keystone area enables dorsal reduction with retention of the natural dorsum, without the need for intraoperative mid-vault reconstruction or secondary rib graft procedures. Thus, a new era in Rhinoplasty Surgery isevol ing, based on an appreciation of recent advances in our anatomical knowledge. REFERENCES Gakur B. Aesthetic Septorhinoplasty. Springer, 2016, Cakir B, Oreroglu AR, Dogan T, Akan M. A complete subperichondrial dissection technique for rhinoplasty with ‘management of the nasal ligaments, Aesthet Surg J, 2012;32:564-74. Daniel RK. The preservation rhinoplasty: A new rhinoplasty revolution. Aesth Surg J 2018;38:228-29. Daniel RK, Palhazi P. Rhinoplasty: An anatomical and clinical atlas. Springer, 2018, Daniel RK, Palhazi P. The nasal ligaments and tip in rhinoplasty: An anatomical study. Aesth Surg.J, 2018;38(4):357-68, Gerbault 0, Daniel RK, Kosins AM. The role of piezoelectric instrumentation in rhinoplasty surgery. Aesthet Surg J, 2016;36:21-34. Gerbault O, Daniel RK, Palhazi P, Kosins AM. Reassessing surgical management of the bony vauit in rhinoplasty. Aesthet ‘Surg J, 2018;38:590-602. Lazovie GD, Daniel RK, Janosevie LB, Kosanovic RM, Colie MM, Kosins AM. Rhinoplasty: The nasal bones: Anatomy and analysis, Aesthet Surg J, 2015;35(3):255-63, Palhazi P, Daniel RK, Kosins AM. The osscocartilaginous vault of the nose: Anatomy and surgisal observations. Aesthet Surg J, 2015;35:242-51 Saban Y, Daniel RK, Polselli R, Trapasso M, Palhazi P. Dorsal preservation: The push down technique reassessed. Aesthet Surg J, 2018;38:11731‘The subject of the last panel discussion at the Versailles meeting in 2016 was “What will the future of rhinoplasty be?” Dr, Rollin Daniel talked about the dorsal preservation technique with limited incision, making reference to my own work and Yves Saban. Daniel published @ paper on this subject, entitled “Preservation rhinoplasty: A new rhinoplasty revolution,” in the February 2018 issue of the ASJ. Mixed rhinoplasty, which had been my definition of the technique, was becoming short of defining the surgery. As soon as I read Dr Daniel’s paper, I e-mailed him and asked for permission :o name our rhinoplasty meeting “Preservation Rhinoplasty.” He accepted the suggestion, and fen days later told me to write «2 book entitled “Preservation Rhinoplasty.” Dr. Yves Saban was the one who taught me the "Dorsal Preservation Rhinoplasty" technique (ASI 2018;38:117-31). My own contribution to the technique of dorsal preservation has been the use of a hand sav. It should be noted that I have long advocated the subperichondrial-subperiosteal dissection plane as well as ‘minimal alar resection.Step by Step Preservation Rhinoplasty ‘The main principle of plastic surgery is to respect tissues and anatomy, leading us to continuously change our surgical technique. Inthe following, I enumerate our new surgical techniques: ~ Protect the perichondrium of the nasal tip and dorsum so that the nasal skin does not sh ne, the tissue damage is kept at a ‘minimum, and soft tissue thinning is avoided. “Protect the nasal muscles, as they are important for nasal function. As Dr. Seyhan Cenetoglu says: “Avoid a paralytic Preserve the Pitanguy ligament which keeps the nasal tip sof Preserve the scroll ligament, because the seroll ligament joins the nasal muscles to the internal valve and is very important for breathing and redrape control -Spare the vessels and nerves passing along the columella, keep the nasal tip numbness at @ minimum, and keep the nose from feeling cold. (In cold countries like Russia, the noses of thin skinned people may get a bluish discoloration afler open thinoplasty surgery.) -Keep the nasal dorsal cartilage, Once the roof is opened, it is very difficult to imitate natural anatomy. -Keep the septal cartilage. The septal cartilage is very frequently removed and used as a graft, Graft usage is very limited in preservation rhinoplasty, which is why the septal cartilage is not removed. The septal cartikege remains banked for possible revisions. If too much cartilage is taken from the septum, the nose may deviate in the moming towards the side on which the Patient sleeps.