CHAPTER 6 Rhinoplasty ‘Angelo Cuzalina Rhinoplasty, the quintessential “nose job,” is considered to be the most complex and challenging cosmetic pract sts in aesthetic surgery today. Nevertheless, itremains an extremely bar surgery for men and women. Its popularity has stexily increase over the years, even f not nearly as rapidly in rate some proce- dures such as lposucton or aes ast surgery. Rhinoplasty surrertly remains in the top fe cosmetic surgical formed far both men and wamen in the United States Surgeons must be corsiderably dedicated to continual learning and improve- ment. This surgery deals micrometers versus inches and invoWes structure thats srategcaly placed in the middle ofthe face, where any mistake can be extremely obvious, To make matters more challenging, there 's unquestionably no single method or technique that can work forall roses, Its essential to have a systematic method for evaluating the nose and planning treatment. A completely dog- matic protocol isimpossible to cause the nose is composed (of a misture of various skin types, cartlagnous shapes, and bony deformities that can challenge the most experienced surgeon, Most gatient secking ehinoplasty are doing it for rationale reason to improve their appearance and selfesteem, However, a diagnostic challenge can occasionally be to identiy seking thinoplasty or revision rhinoplasty that may have body dysmorphic disorder (BDD). Another dagnestic challenge is that many patients seeking chinooksty or revision rhinoplasty may have me degree of body dysmorphic disorder. Surgeons mist deter= mine ifthe patient fals into arnotable category called SIMON: Single Immature Male Obsessive Narcissst. Unfortunately, many nts and other patients with body dysmarphic disorder can appear relatively normal curing the consultation phase. Regar< all efforts s made to discover memral health iss alstc expectations before a surgery is performed. Asingle chapter dedicated to rhinoplasty cannat come close to all diagnoses ar However, this chapter should be a clear and detailed enough overview of rasal anatomy, diagnosis, common techniques, and complication prevention to lace a respectable basic general knowledge of rhinoplasty. Regrettably, expertise in rhinoplasty takes years of continued study, surgical case volume, and review of long-term results, | was told 220 sures p to make thi lsty part of thie re those isolated patients techniques, a story of one ‘who performed well over 10 many he would wish to ¢ moment and onstrates the chal best Italan rhinoplasty surgeons of all ime 100 rhinoplaties and was asked how again. The surgeon paused answered, “Al of them but two," which dem= enge of tis surgery even to experts. Many giants in the field of rhinoplasty, such as Dean Toriumi Gilbert Aizch, Jack Sheen, Jack Gunter, Eugene Tardy, Red Roch, and John Tebbetts, have dedicated their ves to understanding ths exciting procedure and have mule pub that are worth reading for any rhinoplasty surgeon, This chapter seeks fo give a basic understanding of classic rhinoplasty and some advanced reconstructive techniques. An anatomic basis for typical techniques is used in a somewhat step-by-step fashion, Alo, a large segment of this chapter reviews cosmetic rhinoplasty for a teenage or adult cleft p and palate (CLP) patient. Great rhinoplasty surgeons would Ukely agy da Vinci who, 500 years ago, demonstrated how important facal proportion is to beauty. Nowhere i it more important than in the le ofthe face, where the proportion of the nose is absol jel to the s operation. Understanding correct proportion and how to achieve this related to all subunits of the hase and how this relates to the face isan absolute necessity before taking on the nuances and details of rhinoplasty itself (Fig. 6.1), he extraordinary mic of suspended cartlages that make up the lower one-haf to two-thirds ofthe nasal structure is immeasurably key for achieving the desired aesthetic outcome. Nasal cartlages typically make up the majority of manipulation during rhinoplasty Cartilage and/or bony manipulation are generally necessary t© ructure of that is both aes cally pleasing and functional. An a: mprehension of nasal appreciate the minutiae of rhinoplasty for a cations on rhinoplasty with Leonar anatomy s pararnourt Anatomy Nas anatomy aréeten some orns of the teinalogy canbe caving forte nonce ropa surgeon, parody bese eau, and dsb ie 62)Trichion, Glabella ‘Subnasale Menton, Fig. 6.1 Nasal and general faal proportion is ypilly described as seen in this igure. Achieving harmony from cosmene surgery ofes| rears correcting disproportion. The nose takes up the middle rd Sand rigcl fin, and ts strategie locaton mates proper proportion even ‘more eral. eel the alr base i approximately equal the itercanhal ditance, However the nose fe has other important proportions that are ideal such asthe width of te approximately half the wth asthe nasal base p oer Cephali SPN superior orsal Posterior Anterior Basal’ Inferior Fig. 6.2. Directional anatomy difers from standard body terminology and can be confusing italy For instance, the yp erms superior and are replaced by cepholc and cauc, respacively. Ths gram demonstrates common Use ofthis term nology for specie surgial anatomy tat ae Frequently treated, The “cephale” sina ofthe lower lateral url extlage (peer), the “anterior” septal ange (Due), the “caudal septum (ed). and the "dorsal hump {yelow) ae shown, The terms cephalic, dorsal, and coudel to describe positioning during rhinoplasty is more specific because of patent postioning. Surgeons use terms interchangeably, and many other anatomic terms used to describe the nese may difer among surgeons such as the term nasal tip versus nasal ebule, Most would deserbe the nasal tip as the rmost projected point of the nose posto between two domes and between the supratip break and infratip break points. However, confusion arses because of the angulation the nose in relationship to the up-and-down position ofthe head because the terms cephalic, dorsal, and caudal to describe postion- ing during rhinoplasty are more spectc. The tip of the nose probably the most important area because ofits location and alo the finer details that make up its shape (Fig. 6.3). The thdefned nose, which s oer one wth an amorphous to. & Simply one that has los of ts tp-defring pons. This may be caused by ‘genes catlge thats defined, previous sural damage, or tiksin thats riding (amoutaging) the cartilaginous structure (Fe 6.4) Sn thickness isan important pat ofthe nasal anatomy that must be recognized preoperative THpicalh, the thidcess of the skin ders ong the dorsum compared with the rest ofthe nase and ras tip. At the root of the nose or rad the skins relatively thick and some- mobile. The th 1se is classically over the thinion, whichis inthe mid-dorsal region, and itis quite mobile inthis he sein then becomes thick again in the tip region, where itis most adherent and characteristically sebaceous in nature The very sebaceous rasal tip ski scars. For example, an exteral incision for removal of a mole or a laceration injury often incurs a worse scar on the nasal tip compared with areas on the nose that have thn sli, Fortunately the columella has minimal sebaceous glands compared with the «quite cel from an open transcolumellar rhinoplasty incision, what test sk of the oes not heal well rom extemal a tip and heals Nasal Musculature “The anatomic lyer immediately below the thin subcutaneous tissue contains the small but important muscles of the nose. The muscles ofthe nose are commonly thought of as an extension oft ‘cial musculeaponeuratic system (SMAS), which isa flbromuscular bbyer that involves not only the muscles ofthe nose but extend ater- ally into the other facil musculature and is commonly used laterally for faceliting. There is some argument whether or nota true SMAS exits or iftis simply a histologic diagnaxis, but mast surgeons tend to use the term cincally to explain a certain level of cissection The muscles that make up the nose de function in facil expres- sion and even help with the function of breathing and animation during smiling. The muscles can be divided into eevatars, depres- sors, compressors and dlatrs ofthe nose, Typically, the muscles are paired and are extremely thin and much more superficial than the er musdes of the body (Fig. 6.5}. Because agood portion ofthe layer, sungcal cissecion must be raintaned well below the muscular bayer and ermeciately ajacent tothe bory anc catlaginous structures, Staying well below the nasal muscusture helps prevert damage to vessel, nerves, and banphats. aso lis unnecessary bleeding that may lead to excessve ecchymoss, edema, and scaring. Certain muscles do occasionally require surgical treatment. For ce, a depressor sept nasi muscle that is overactive can create 4 significant ptotic-ype displacement of the nasal tip when the patient smiles. Tansection ofthis muscle is easy accomplished and «an dramatically improve this deformity, Simirly, the ditors ofthe ala including the ala and nasals muscles may occasionally be treated if excessive alar smling is noted on high smile, In general, the nasal muscles are avoided particularly to prevent excessive bleeding and abnormal fsross. The ideal plane for nasal dissection is below the muscular postion in mast cases od vessels course into the muscUar ai> 5 s a 5 Zz z z Radix by J j og (Root ofthenose) Si LWY Vy Nasion 2 - Rhinion ‘Supra Alar Crease Supratip Break Tip Glabella «— Alar Facial Junction —_, : Infratip Break Alar Margin or Rim Subnasale Infratip Lobule ‘Classic nasal anatonsc landmark ae shown, Four to-defning ports that ake up a well-defined nose are shown (bottom). These four pois are created bythe supra and infra ip breaks a well ase domes ofthe lower Ieteral cartilages. Sore terms are very i such 35 nason andra bt dle sgrtly (op). Naser correles o the nsotortal suture, whereas rade se pot where the forehead jos the nasal dorsum ‘Three amples of ikceined or amorphous rasaltps ae shown. Al lak to-defving points or ary specic tip defnson. (A) This patent's ose has poor defriton because of rregubr nasal tip cartage as well as thick sn (8) Anther patient has an amorphous nasal ip caused by rhinophyma, an overgrowth of sebaceous subcutaneous tissues olen seconcary to rosacea. (C)A thir patient has such enlarged and buloous bower hteral cartilages tat spec Up deition i obscured anFig. 6.5.The nasal musculature composed of elevators, depressrs, compressors, an datas. The two nasal depressor act to date the nosis and lengtien the nose, The to compressors narrow the nostrils ane rotate the nasal ip caucally The three elevators diate the nostik and rotate the tp cophalaly. Nasal muscles, n general, are inenated by the 2ygomatc branch ofthe fal reve, Perpendcrplteof the mad sere (KE: Ls 3 main sources of blood supply to the septum Fig. 6.6 Blood supply to the ras sepn, 8 demeorstate, robs ard comes om tee major ater sources, Kesebac's ows (oed failed repo) an area wher vee atrial sources converge: one om he branch of thespian fom the rao he _Preropasine tery and anaes fom the arteroe shel aety. Ths sa earn ae for eptass bec othe tha sues a a ey Guta expose the rch vaselr network immediately bow the mucosa, especialy cr the wer Nasal Blood Supply ‘The blood supply to the nase and septum is excremely robust and comes from multiple sources, Tor example, the most common spontaneous “nosebleed” cores fram Kiesselbach's plexus on the septum, which is an area three arterial sources conwerge: one from the branch of the superior labial artery, one from the branch of the sphenopalatine artery, and another from the anterior ethmoidal artery (Fe. 6.6) ‘The rich vascular supply in the nose allows it to heal well with a very low rsk for infection, sir to most other aesthetic surgeries (of the face, Local anesthetic with epinephrine must be injected precisely immediately above the cartlages and bony structures ofthe 2B Rhinoplasty> 5 s a 5 Zz z z ‘ota Ethmoid Acaey (Lateral ternal Nasal Branch) Lateral Nasal ‘Branch of the angular Atery Posto Ethmoisal Actor Latoral orn Nasa ranch) Mole eources of blood supply tothe Lateral Nasal Walle Fig. 6.7 Blood supply tothe lateral internal nasal walls vigorous and helps prevert problems when grating the nose or stretching nasal sues. Mutiple branches arse from both the intemal and extemal carotd arenes for excellent oxygenation to the average non-operated nose. ‘nose to produce significant vasoconstriction of this rich blood suzply during cosmetic enoplisty,Addonal local ijecton of aacent key vascular envance sies to the nasil anatomy (eg, supratrochesy, angular artery, and columelar areas) is ako erica fr a relatively bloodless field dusng tis delcate surgery, which requires precion that would be greatly compromised by an excessively bloody fe. ‘The robust blood supply tothe lea and exteral nose comes from both intemal and external carotd aeries, Alough there are branches ofthe ethmoidel and superior bil artery extending tothe atl tip, the eral rasa artery has an even more hearty blood supply ‘that provides the nasal tip with plenty of profusion to allow transection ofthe cokenela without sgnfae schema atthe nase tp (Fe. 6 7) “The senifcant plexus ofthe vessel arising rom multiple sources has a venous and lymphatic network that largely runs parallel to the arterial supply (Fe. 6.8). Many believe that nasal edema may be decreased with closed rhinoplsy, hough arguments can be mace tht there are ade- quate channels of emphatic and venous drainage during open or closed rhinoplasty. Therefore postoperative edema from rhino- ply may be similar because postoperative drainage should be adequate for ether technique # performed careful, OF course, ‘would be cifcult to argue that avoiding the dasic open vanscoli- ella incision does not lily allow at least a slghtly better to perfusion as well as avoiding 2 small exeral scar Nasal Bone and Cartilage Anatomy “The bony va a he mason rasta sire) ithe thickest ane mot sid parton ofthe rasa rare. his composed ofthe pied asl bores an the oral procs ofthe mail The rool anges an rporan cine remark andi ratory created by the jncon othe vil and nas bones (Pe 6) “The nasal bones exerdvarous ngs caudal to connect with the upper biter carlage and can overan the catlages by several a4 mifmeters, The nasal bones are most acherent tthe rot or base Gf the nose. The bones thin sigcanty as they ecend caudal toward the upper lseralcartliges. The root ofthe nose, where the bone is thicest, sa common area for rsping to lower anasl oral humpin he cephalic porvon. ver ge nasal dorsal hump may require the use of Rubin nstumert or other ostectome 0 reduce the bony dorsum (Fg, 6.10), Icey rasing alone is enough to bwer the bony hump on the srjorty of patients wth average to sal don hur, The area of thecardagnous hump hat can radvertetl not be tested adequately is the aneror septal angle (ASA) area, Inadequate reduction of he ‘AS especaly combined wth overresedion or ck ftp support. can lead to 2 very unaesthetic "polly beak deformity (Fig. 6.1!) The cartlage and bone composing the nas hump are quite varaole in thickness and actual len. Patients wth short nasal bones ray be more at sk for intemal nasal valve colapse e612), ‘Valve issues occur more in thi scenario because the mide nasal vauk formes by long uoper bteralcarages has less bony suppor, thereby rejng on less ri cariige “The nasal bones connect caudll 10 the pated upper lateral cartilages. There isa very frm attachment to the nasl bone and upper literal arlages, particular along the mecil edge acjacent to the septum. The upper lseral cartilages can be found extenc- ing just over Sonm beneath the nasal bones to allow fora frmer attachment. Extreme raping with a coarser aggressive rsp can potently dslodge the voper lateral cartlages from the nasal bone insertion, creating a significant deformity f unrecognized ‘The upper lateral eartages provide the marty of suppor inthe middle thre ofthe nasal pyramid alorg with the anterior border of the nasil septum. The literal crtlages continue along the anterior border ofthe seatum with prichonerium covering both the subericial and deep surface. The portion of upper literalFig. 6.8 Blood ply othe exeral rose comes fom tral and exer! caro arteries, The venous draage paral the areal supply aed rans ote renga pews and ophrahic a fl wes, The rc Dood sup ab or ai fp options for reconarscive ‘inaplasy ardhebs ina reat perks to re nas, even caring pen Panos Fig. 6.9 “Two common nasal-acal angle measurements are the nasofontal and tye nasoibal ales. Achieving angulsions within norms for 3 sven patient wil help achieve an aestwically agreeable nose, Abnormal in angulatons and facal proportions appear much worse Gan minor Szymmetres or shape sregurties, The nasofontal angle ofen slgtly more ootuee than ideals certan female pains, as een inthe Dreoperative photo, Postoperatively she has aster ard more pleasing nose in part as a result of beter angubtions, Her nasororal angle was Improved by removing the hump and deepening the radix area sly cartilages that connect to the nasal septum in the ri-vaul region composes a landmark termed the internal nasal valve (Fig. 6.13. ‘The anatomy of the lowest portion of the upper literal cartilage ‘an be quite variable where the upper lateral cartilages connect to the lower bteral cartlages, Thisareais considered the scroll region, ‘The upper lateral cavtlage and lower lateral cartlage connection has been described by different authors, but one of the most common descrigtions shows the cartlages connect by interlocked shape 52% of the time, overlapping 20% of the time, “end-o- enc” 17% of the time, and opposed 1196 of the time (Fe. 6.14) “The lower lateral carlages form the majority of the nasal tip and compose the majorty of patient complaints with regard to the shape 25 Rhinoplasty> 5 s a 5 Zz z z (0) The cartlagnous portion a rg rasl hump & intially tranectee using 2 saoel A Rubin stectome may be used to remove the erie dora hump one continous piece begining below the upper literal carttges(C) and then fis jst below the nasofontal str Ine (O), a8 shown ona sll model, Photo demonsrates use of scisors rather than a salpel1o reduce the catlagous dorsal hump (B). The anterior septal arg is ‘@poses (F by pushing down on she lower lateral careges (LLC) while the hump is berg reseced above. In (G), ater dorsal harp reducion, a5 “open root defrrty is cormenony seen with exposed sept a separated upper laealcartlages (ULCS) an tera nasal bone edges. ‘of the nose. The nasal bones and upper lateral cartlages create the dassic nasal dorsal hump, whereas the lower lateral cartilages are what create the common complant of a bulbous or boxy nose deformity. The structures of the lower lateral cartlages invoWe @ medial, intermediate, and lateral cus. They not only create the nasal tip appearance but help in function, The thicaness and elasticity of the lower lateral cartlages play a major role in the external nasal vae and the overall tp support, The lower cartilages, particulary the intermedate crus, help make up the come (Fg. 6.15) ‘The angulation of the lower lateral cartlages themsehes can vary wernendoualy from patient to patent. The axis ofthe lateral 26 crus can be very oblque or positioned more medially. In addition to varying positions ofthe axis, the cartilage can actually be concave in shape versus the more common convex shape. Often the lateral crus will ako have a somewhat irregulr distorted appearance simply as a congenital anomaly. The relationship of the caudal edge of the lateral crus acjacent to the anterior septal angle makes up the very important supratio region (Fe. 6.18). “The various morphologies of the medial, intermediate, and lateral crural cartlages can dramatically change the appearance of a nasal tip, which explains why the vast majarty of grafts placed in the nose are used in this regionae : 5 s a 5 Zz z z Fig. 6.14 The serll area is where she cephalic edge ofthe lateral crus othe lower lateral caslages (LLCS) jon the caudal edge of the upper ntl cailages (ULC). The scroll ‘ar take mary shapes a shown by the examnp es ‘demonstrating the four most comrran connection snages. An intercarlaginous inesion drecy cuts trough te scroll to gan ces; fo the Corum fypeally From an endorasl (closed) rinoplasy, Insiors inthis region are commonly used aut may increase the vik for Sear contracture near the internal "asl vale. For ths reason we typi donot rake nebions ifn tis gon duing open or closed tecniqus. “The scroll area provides srifeant support to the nasal year, parser the ti. on Fig. 6.15 The lower hteral curalctages (LO) of the nose are shown from a caudal vewpont. Nasal tip shape anc structural stegriy = mast rotabl flected by these tp cartlages. The caucal septum (not shown) ao has a sgnfcant role in tp support and nasal ta shape. Manipukton of the LCC i one ofthe most commen manewers to ater nasal ip appearance caring rhinoplasty, However overresecion of these typically éeeate cartilages isa potential cause of nasa tp collse, alr retractor, 276 breathg compromise, As shown, the shape of the nasal pyramid variable most socordiry to abnormal shaped lower lateral carilages (Ike ‘those show) 28Supratip Break Tip Lobule Caudal Free edge of Upper Lateral Cartilages Upper Lateral Cartilages Fig. 6.16 Key points of reference and terminology for nasal structures are shown from a lteral view, LLC represents the lowe bteral eartages (lexero! ens ofthe LLC shown oni), which commonly requires manipulation curing tip rhinoplasy. The anterior septal angle (a portion of {quacargularsepal cartilage) i an important larark for ip support and final profle appearance. Fale to lower a projected anterior septal angle Dr lick of Sp projection ca lad to fullness o° a “polly beak” deformty The nasal septum, which connects to all of the previously mentioned structures (nasal bones, upper lateral cartlage, and lower lateral cartilage) provides a very significant amount of suppor. to the nose throughout its entre length and plays a big part in ot only a nasal dorsal hump but also actual tip projection and support though the meclal crural cartilages compose a portion of the columeli, the caudal septum itself is classically 2 sturdier type of, cartlage compared with the medial crural cavilages, and it must bbe addressed for problems such as hanging columella and other types of major tip projection issue. The nasal septum is composed of bone and cartilage, the perpendicular plate of the ethmoid, vormer, and the quacrangular cartilage (Fig. 6.17). Italo has a rich blood supply as previously described and can have various shapes when it connects to the maxilary crest, along with multple deformities and deflection types.An asymmetric nose 's basically possible to treat without addressing the septum, which inevitably plays a major role in a croaked shape or asym- metres. Also, the nasal septurn is one of the best sources for cartilage or bone for grafting the tp or dorsum in reconstructing defects. The classic description of cartilaginous sparing during septal resection recommends leaving a I-cr caudal and dorsal strip to provice adequate cartilage to prevent tip ptosis or a saddle nose deformity. Akhough the I-cm rule is certainly a good basic guide- Iie, multiple other factors ply a role in the amount of septum to leave behind. Thiceness of residual bones and upper and lower cartlages 25 well as addtional grafts al affect the strength of tip projection. The key is to realze that the septum has a major function in aesthetics of thinoplasty, particularly with support of the nose, and itis invaluable for use as 2 source for issue grating. The inferior turbinates are often a source for nasal obstruction in add- tion to septal deviation and must be evaluated before and during rhinoplasty Enlarged infesor turbinates can be treated any number of ways, including partial arterior resection or out-sracturing. Over= resection hasbeen known to create chronic problems such as nasal dryness. Finally the nerve supply to the nose comes from sympathetic sensory divisions of the ophthalmic and maxillary branches ofthe trigeminal nerve (cranial nerve V) (Fig. 6.18). Examination and Consultation ‘As with any general clinical examination, this is the chance to get to know the patient and find out theie chief concerns, As always, the fist question should be what bothers them most of al, that is, their chief complaint. Having the patient lookin a mirror while they are cescrioing their chief complaint can be very helpful Ifthe patient does not mention it specfialy, they must be asked if they have any breathing problems currently orin the pastor ithey have had any history of trauma. Despite the fact thatthe palient may rot mention past surgery on an evaluation form, verbally asking ‘agin if they have had any previous nasal surgeries is extremely important. Also, a history of any seasonal allergies or periocic ‘episodes of nosebleeds is important to note. After recording all of the patient's complints on an approprate film or dagram, the surgeon performs an adkitional examination using a systematic method to assess skin qual, the general shape and support of the nose, and any external or internal nasal deformities or lesions, During the entie consultation, the surgeon must perform an assessment of the patient's mental status to ensure that there isn evidence of possible body dysmorphic disorder or any other ‘worries that may create postoperative problems, The young male thinoplasty patient is often one of the more challenging 429 Rhinoplasty> 5 s a 5 Zz z z 430 Anatomic structures that imate tp the nasal septum are shown along with adacent structures. The two bones pls the quadrangular carlage fooming the nasal septum may all eure treatment during aseptornnoplaty # deviation exits or harvesting of gras indicated. Understancing the anatomy in detals cial or the cosmetic surgeon. Devation of tre caucal septum must be ‘rattod to adequately adres the resubrg ‘ecemal nasal devation Sensory nerve supaly tothe extemal nose aries from the ‘ophthaime anc maxllry branches of rail nerve V. The extra nasal brangh ofthe anterior ethical nerve cut during elevation ofthe nasal stn lap during rinophesty, but patents rarely compbin of numbness Because of 2 substantial collateral nerve supaly. Branches of the supratrochlear and infatrochlear nerves supoly the uoper hal ofthe nose, while the infzorbtal (0) nerve and external rasal branch of interior ethmoidal nerve supply most ofthe lower hal ofthe nose, patients to achieve a result that they will be completely happy with on a long-term bass. Classic signs of potential problems are patients who bring in magazines of movie stars wth a particular shape of nose. Although some may stil be realtic, a more in- cepth evaluation of ths patient must be undertaken. Ideally you hope to only operate on a patient one time because secondary surgeries are always more challenging and dficuk. In additon to the routine workup for medications and history of surgery, itis important to rule out any history of chronic use of nasal spray {., Arn) oF history of cocaine use, especialy if large unex- planed septal perforations are noted on examination. “Taking photos is an important part of recordkeeping that can be invakabl for treatment lanring, is important io take evaky photos using sxstandard views: one frontal (UuHace) vw. two eral views ‘ovo 45-cepree (obique) views, and one base view (Fe, 6.19).lite RY (relaxed ling) EES A TC Six sandard views shown shouldbe taken forall hinoplasty patents before an after surgery An adtionalvew ofthe paint sig a good preie, paricubr the patent has sercant widering ofthe abr base orto ptoss on a hgh sile. Excop forthe base wew, the Fatints Fead shoul alvays have the Franko: honzontal plane paral with the floor, The oblque or 45-degree view shoul show a lest a portion ofthe ‘oppaste cheek in te background, Other potas may cecasonally be necessary, such ab relaxed Fantal a wel as hgh smiag frontal anc tral views to evelate nasal tp dspicemert rom an overacive depressor musck. Standardization of te photos i erieal'orflow-up ad for evaluing your ‘own resuls overtime, Because i may lake & year or more to see the Snal amour of changes that ean ocr after rhinepksty, ahotos are rvakible Initial assessment ofthe skin thickness should be noted through= ‘out the upper and lower nose along with the amount of sebaceous {ype nasal skin. Abo, the elasticity is noted by a simple pinch test and stretching of the skin over the nose along wth palpation, particularly in the nasal tip, to assess the amount of support over ‘the nasal tp itself along wih a good sense of possible ireguarties that cannot be simply vsualzed. Thin-skinned patients have the potential for a very nicely sculpted nose but are also at risk for showing every flaw. On the other hand, patients with bulbous tips but very thick skin may not get the result they hoped for because the thick skin limits the amount of shrinkage that can safely be achieved by standard rhinoplasty. Rhinophyma, which is an over= growth of sebaceous glands secondary to rosacea, can be treated by addressing the outer skin alone (ig. 6.20). Evaluation ofthe proportion of the nose, particulary related to the face, is critical. Classic methods that were developed by Leonardo da Vinci and others are commonly used to gain an appreciation fer proportion of the nose as tt relates to its own subunits and the fae ise. For example, the with of the alar base compared with the intercanthal distance is an easy assessment and ‘ean quickly give one an idea of proportion along with simply measuring the distance and recording the base of the nose, The length of the nose is also assessec from the radix to the nasal tip {and must be based on proportion tothe rest ofthe face. In adcition to the nasallength, the angulation from the lateral view is extremely criteal, particularly in the nasal frontal angle and the nasolabial angle. The ideal nasal rontal angle is between 115 and 130 degrees and is sightly more obtuse in females (see Fig. 6.8). It ean appear very different when a nasal dorsal hump is present and also from 2 significant ammount of bossing in the glabellar and frontal region, fr even a deepened or shallow radix area, The depth ofthe radi can also be assessed by evaluating the distance from the pupil the nasion from the lateral view and should be in the range of 4.9mm on average. Reporting the amount of nasal dorsal hump ‘or possible saddle nose deformity is important along with whether the patient feels as though they have a large hump, a small hump, 431 Rhinoplasty> 5 s a 5 Zz z z Dermabrasion & Rhinophyma, Classic Rhinoplasty tip reduction i eh, faa Laser Resurfacing 'Bulbous from skin issues ‘Skin only freatment,_ Before and 6 months afer drctskn shave (dermasrasion) and ser stn resurfacing to treat rhinophyra (tp). The patent had only ‘ecemal skin sresiment, twas previously beleved that hinaahyma was sticy caused by heavy alcohol aaure, but has been showin to be caused marly from an overgrowth of seoaceous ghrds ebted to rosacea, The bottom four ahotos are a young female before anc ater a chssic rhopasty invoking recuction of enbrge lower lateral crus cartlages. Aican Amercars and certain other ethnctes tend to have thicker nasal kin requirng spec tecnriquest0 give the patent the resus they hope 0 achieve. Limtatons must be discussed, ‘oF none at all, The patient should also be asked whether they prefer a straight nasal dorsum or lke the appearance of a more “scooped look to assess what the patient would ulimately be happy with, Performing computer simulation can be helpful in particule patients who may not have a realstic expectation of what can be performed. Surgeons vary in whether they tke tis idea because the result may not ulirmately end up tke the prediction, IF using computer simulation, ts erital to inform the patient that this a simulation only, the results may vary, and itis simply a tool to help surgical planning and assess i the patient is realistic in what can be achieved, Nasal Tip Clinical Evaluation Evaluation of the nasal tips essential to rhinoplasty. Beyond the skin texture and thickness, the general shape of the nasal tip should be evaluated where itis bulbous, pinched, twisted, asyrmetc, boxy, 432 overprojected, or underprojected. The general defrition related to ‘8p defining should be assessed in whether or not there is a good supratip break, good inratip break, or ifthe nose is amorphous in shape wth limited or no tp-defning points or visible architecture ofthe lower cartilages. After evaluating the general shape, i's vital ‘to document the nasolabial angles, the amount of supratip break, Cor whether there is a “polly beak" deformity (reverse of supratip break) created from prominence of the anterior septal angle “The tip projection and support is assessed based on palpablty and visualzation, Assessment of the nasa tio projection i dficuk because occasionally the amount of projection can appear as ‘hough there is more there than in actuality, such as a case that has a ptotc tip with a nasal dorsal hump. Once the other portions of the nase are addressed, the amount of projection aften changes. The Goode method of assessing projection is one of many in which RT isthe dstance between the radix and the pronasale (Fz. 6.21).Fig. 6.21 (A) Nasal ti project the nasal ip (N-NT), whch snout ily equals 35 based on Ines peraendc the glade to the reson ntersece “The ideal tio projection is 0.55-0.60 of RT. It can ako be mea- sured from the nasion to the nasal tip (0-55-0.60 of N-NT). ‘Another method is Crumley’s method, which is based on measure ment ofa nasl triangle that proportionately equals 34-5 based on Ines perpencicuar and parallel to the Frankforthorizontal (3 APN, 4N line to AP 5 N-NT), In other methods, the amount of nasal projection is generally related to the dorsum or the anterior face, The columella must abo be assessed and practically has 2mm to 4mm of show from a bateral view. Not nly should there be 2mm to 4mm of aar show from a kteral view, but also in relation tothe columell, The ala must be assessed along with the postion of the anterior nasal spine and the amount of skin in the base of the columella that can be visualized directly atthe nasolabial angle ase, A retracted columella can be very unaesthetic but may be caused by inadequate tssue support over the anterior nasal spine for also simply from an enlarged ala that gives the ilusion of 2 retracted columella, The re (Fig, 6.22) can be a mix of situations as well-described by Dr. DM Toriumi and Dr DG Becker in Rhincp (Philadelphia: Lippincott Willams and Wiens; 1999), In assessing the overall projection of the nose and proceeding downward to the anterior nasal sine, it is important to evaluat the face as a whole because problems requiring orthognathic surgery, such as mauilary deficiency along with mandbular prob- les, can indirectly affect the shape and appearance of the nose. ‘A patient witn a nasal dorsal hump along with microgenia creates a situation in which the patient shoulé be informed of the propor- tional discrepancy and what may be creating the unaesthetic sat concerns ther, Often, placement of chin implant fon someone who has microgenia with a nasal dorsal hump will inicaly make the nose more appealing anc even appear smaller because of a more proportionate face overall. Patients requiring ‘on of the columells to the alar rim ty Dissection Man evaluation via Goode's method takes the length from aler point to the nasl tip (AP.NT) divided bythe rasion to 5500.60. Cramly’s method is based on measurement ofa nasal ingle that proport 2nd paralel tothe Fandlort horizontal (3 AP-NT, 4 N Ine to AP § N-NT}, (8) The rasofrontal angle is the N-NT line kis likely more obtuse females versus mals. ely orthognathic surgery who have maxillary hypoplasia along with malar typoplasia may have other problems that contribute to the ci rose; therefore achieving the patient's overall desire may require more than a simple rhinoplasty. Simultaneous gathic surgery and rhinoplasty can be performed (Fg. 6.23), but one must understand that major tip changes may occur when the entire maxilla and ts anterior nasal spine is moves. In addition, the nasal base much be controled with intrzoral lar base cinch sutures because releasing the periosteum atthe pyrform rim allows the nasalbase wieth to widen. Like any aesthetic surgery cof the face, proportion s key in ataining a harmonious and natural appearance, keeping in mind that good function is absolutely «1 cal, Cleft palate patents are similar to orthognathic patents in that they often have major bony defects around their nasal defect that must ako be corrected to fully improve their rhinoplasty results ‘An example of this bone deficiency is the clef patient's atrophic pynifo res major augmentae tion to correct nostril as well as facial asymmetry (Fi, 6.24) Function ofthe nose can be assessed by several methods including simply having the patient cake deep bresths in while holding the nose Other tests in oped applicators placed jus inside the nose or a caudal test witha finger auling on the skin on the outside of the nose to assess internal vale problems. Noting vahe prablems beforehand, both internal and external, can help prevent an unhappy patient postoperatively It is much easier to prevent these problems wth spreader grafis performed during the primary surgery if incicated rather than performing reconstructive surgery on an operated nose that has sgrifcant scar tssue (Case 6.9), Patients who have already undergone previous nasal surgery may have external nasal vake collapse from overresection of the lower letra cartilages, Extervalnasal vale collpse can also be seen in athin or narrow nose, a very aged nese, or even in patients wth 433 ‘on the clef side that okten res on each side,> 5 s a 5 Zz z z Columella and Alar Rim Relationship Normal Ala . Normal coumeta Retracted Columeta Hanging ccolumeta Retraced Ala Hooded Ale a? od do? Fig. 6.22 The rebtionship benween the alr and columelbr shapes ae shown, Alar revacion may be genetic in oign but can abo be secondary to ‘overesecton of lower lateral alae or from previous rmtype intranasal incsions, Normal calumelar sw should be 2mm on average, Excess cobimel show may be secondary to excessive caudal septum, medial crural carage, an enlrged arterior nasal spre, or a combination of these. A retracted columella can be very unattractive ard rust be treated based on te correct Gagioss, The nasolabial angle a very mportane measurement to rate anc is dasicly us over 90 degrees mn men ane 95 to 110 degrees n women, The nasolabial angle can be afeced by not orly tne arvount of 1p rotation ane amount of caudal sepaum, but ako bythe arount of arterr nasal spine projection or even the efecs of the entre max and upper incor teeth, Oversealous crtlage resection can create 2rasal ip tht is 00 short and overated and an NL argle that is too obtuse some facal paralyss. Internal nasal vale collapse that may have bbeen created by scarring from previous rhinoalasty offen requires spreader gras to comect. The Colle test, for diagnos of nasal vahe collapse, is performed by using your finger to pull laterally on the cheek and lateral wall of the nose to open the nasal vahe. CCssically patents breathe much easier when ths tests performed (positive Cottle sign). The Breate-Right ® strips thal are regularly used by athletes have adhesive that alow for the device to act as a temporary spreader graft. The splints open the internal nasal valve from the skin side and do allow at least emporary increase of nasal aiflow whether nasal valve collapse exists or not. Actual inspection inside the nose with a nasal speculum can help identfy any major perforations that could be caused by pathology or even a history of cocaine use. The speculurn examination will abo note any major cons of the septum as well as enlargements or asymmetries ofthe turbinate, The state ofthe nasal mucosa, such as inflammation from allergies, should be noted during an intranasal examination Treatment Planning ‘good treatment plan before rhinoplasty isan absolte necessity Its critical to plan for possible problems requiring addtional pro- cedures such as rat harvesting from behind the ear, rb, hip, oF 434 other location, Preoperative photos (Gee Fig. 6.19) along wth possible radiograhs, such as cephalometric raciographs, may be helpful in deciding on a sequence to the surgery as well as a detailed plan. Many surgeons will ako use waxed paper overlays to mark out exaclly what they are hoping to achiewe, which can be invaluable when beginning one's rhinoplasty surgical career, A logical veatment order should be planned and followed. Most surgeons will develop thelr own comfortable treatment outline and follow the general treatment order each time. External versus Endonasal Technique “The argument for or against open or closed rhinoplasty wil kely exist for at least a few mare decades and be easly argued ether ‘way, Undoustedly, there is no one technique that maintains clear superiority over the other. The advantages of open or external rhinoplasty are obvious in that it has superior visualization an, in ‘mast surgeons’ hands, the ail to place grafts or recuce cartlage can be performed more precisely. The argument for a closed technique involves the possiblity of less disruption of blood supplyee! Rhinoplasty & ‘orthognathic / Jaw surgery Rhinoplasty Simultaneous Rhinoplasty & Orthognathic Surgery GZ Wey> Septal cartilage < harvest from below. manila intraorally 3 ‘An [B.year-old female patents shown before and 5 manths after omhograthc surgery and open septo-rhinoslasty (top). A lage nasal dorsal hump was reduced anc used ‘or an anterior str rat. A st was placed for tip refinement and suppor after resecbon of 2 large amount surounding cartlge to prevent deflection from max ry imation, The anterior nasil spine was reduced as well, Easy acces for septal arthge harvesting sone advantage ofa simulaneous Leror osteotomy and rhinoplasty. A 15-year-old patients shown belore and 5 years afer twonaw ‘orthognathic surgery plus open rrinoplasty (bet). An ar base cinch was placed, whichis very important to prevent widening dung LeFor surgery pli rhinoplasty. The bereft ef correcting the facal third discrepancies 2s well a the nasl a proporiens great improved the patient's ‘overall appearance 435RHINOPLASTY Distorted horizontal nostril on cleft side c oa Deviated Columella opposite cleft Thick Pyfiform rim grafts are artical to make a diference oS —~ Flattened Lower Lateral Cartilage on Anterior Caudal cleft side <4 ZR Deviated catidal septum off the maxillary crest Unilateral Cleft Scar ee graft This itusraton and patient demonstrate nasal aesthetic sues that an occur wih a unilateral cle lp and palate. The pared lower lateral cartilages (blue) have move severe aymmetric changes on the side ofthe de, resting in severe fhitenng of te ab and horizontal wicenng of ‘he ala on the cf side, The covdhion fe worsened by the bony cefieney at the pyrorrs pm on the le sce, Inadequate mprovernent ofa let patent’ rhinoplsy is common if te surgeon addresses only carcige sues and fl to aygrent the pytform ren on the lft sde typically using a barge custor-carved piece of rib carte, as shown and lymphatics, leading to possibly less postoneratve edema, The other obvious advantage isthe fact that no external scar woul be present, so, some fel that t may be faster in their own hands and is ess disruptive to some ofthe attachments that may allow for better support of the nose. Although | personally use both techniques, depending on the particular sivation, the external open chinoplst is certainly an easier approach in my hands and allows or teaching purposes. The main benefit for ope" rhinoplasty isthe abllty se everything witrout dstorton for more precision placing tisue gratts and for tisue resection, Fortunately, the externaltearscolumelbr sear; placed welland meticulously closed, is rarely ever an aesthetic complant, andi is nearly insible ater prolonged healing inthe vast majority of cases (Fe. 6.25). 436 ‘The argument and debate over closed versus open rhino- plasty will go on possibly indefinitely. As with any surgical pro- cedure in which multiple techniques exist, the best technique is actually the one that works best for you. The typical patient wil simply be happy if their surgery goes smoothly and the results are all that they had hoped to achieve regardless of the incision ‘ype chosen, General Anesthesia versus Intravenous Sedation ‘Another debate with regard to rhinoplasty is the type of sedation fof anesthetic used during surgery. Local anesthesia, without aAlar Base Fig. 6.25 The view from the nasl base above demonstrates ideal proportions and a general pyramidal shape that i desired. From below the tip lobule should be approxenatelyonezhal the with ofthe rasal base ané one-th the ‘tal projeion heh. The placement of a ranscolumelar Alar Facial Junction Incision scar from open rhinoplasty 'W’ shaped trans columellar incision Nw gl Medial Crural ‘ootpads or incon for an exernaopen rhinoplasty race just tthe top of the medal focipads. The Ight reflection scen inthe postoperative photo demonstrates whst we term the CK poi (which ithe ideal infaip break location) thats the ntersecton ofthe nos ae ane ideally one the distance of te tp ule. One can see thal open rhnoplisty scar can heal exremely wel Is crieal to understand nasal base proportions and where to idealy place te exteral incon just above the medial footpads to alow for te best healing. doubt, is required for vasoconsviction, but the type of sedation varies among providers. In my own practice, all of our rhinopkasty surgeries are performed under general anesthesia for complete control of the airway. Rhinoplasty is a technique that may easly lead to significant blood in the nasopharynx and oropharynx. Major problems with airway management are increased wih sedation techniques in which the away is not protected. Also, simple problems such as coughing or mavement during surgery can cre- ate a nuisance during poorly controlled intravenous sedation. Many surgeons today stll perform the procedure under intravenous sedation, which can work very well but must be carefully managed 10 avoid aieway compromise Incision Options Mutiple incsion options exist for various rhinoplasty techniques; however, the extemal chinophsty has the most andar incision vwhich inves 2 tanscolumelar incision that fs blended into a mar- gral incsion. The marginal incon is one that can be used for an ‘open or closed technique. A marginal incision isan intranasal incision that essentially hugs the caudal margin of the kower lateral cartilages, ‘while the caudal margin ofthe leleral crural cartilage typically fellows just along the entre extent of the lower lteral crus (Fg. 6.26) For the transcolumellar portion of the external rhinoplasty, the incision should be made wth a No. I blade scalpel to create precise edges and disnet corners in which reapproximation can be made easly and predictably, The incsion shoulé preferably be placed in a location that would be at least visible postoperatively, typically approximately one-third ofthe dstance from the alr base ‘extending up toward the nasal tp. This abo typically corresponds with the top of the nasal footpads of the mecial crural cartilages. ‘The actual shape of the incision is variable, A straightne incision should be avoided because this would leave the most notable scar and possibly some notching lateral. Various shapes and techniques have been used to perform this transcolumellar incision, with the most common being either a stai-step technique versus 2 W or inverted V type of incision (Fg. 6.27). 437 Rhinoplasty> & s a 3 Zz zr z ats Photos demonstrating a chssic method for exoosing (keletoniation) of the teal crural catiges (LCC) via a marginal incon thats usec for ene! Causal edge ofthe LLC versus 2 rim incon, which mast of opposng retraction hes isolate the lateral us proaches the fet or internal crs, ofen ca be enace | sor placement of stn ndieted Iya the marginal edge, Ihesions for closed shinophsty can be more varied depending ‘on what must be accomplished as well as surgeon preference, The marginal inci closed shinoplasty and typically stops at n is sil the most basic incision for an internal ot base of the medial an having an extension across the Mootpac rather olumell ‘The medial extent of the marginal incision can alo extend inferiorly if adetional access is required for septoplasty or for cartilage har vesting. Anether optional incision for an endonasal approach isthe transcartlaginaus incision, which is performed approximately inthe midporton of the hteral crus or lower lateral cartilages and can ako be extended medially and inferiorly for septopsty as required, The advantage of a transcartlaginaus incsion is limited dissection to remove a cephalic stip as well as avoidance of the scroll arez between the upper lateral cartlages that may prevent problems with regard to support, Through one transcatlaginous (intracari- laginous) incision, the surgeon can thin the nose by removing 438 sal anc open rnopkaty, (A+B) The location to idarsfy and make the marginal inckion mmeciately ajacent tothe ‘mari’ ofthe avoided Because of ts increased tsk for rim dstortion or abr re ction, (C) The vse ess0rs As the ately ontop ofthe LLC usin crim more cephae than the actual margin of the carsge to neb orevent bon. Aso, the marginal incon along the medial crus can be made further cephacally than the actual arg f signa treatment of hs allows for more exposure ofthe medial curl cartilages than would be attained # te meson cephale cartage ¢ dorsum for dorsal reduction, The transcartlaginaus (intracartlagi- ‘hows) incision, endorsed by some, is somewhat more challenging for the novice surgeon and daes have limitations on the amount cof work that can be performed through it, particularly complex grating (Fe. 6.28). ‘Another incision fo laginous incsion, which is performed as descnbed between the upper lateral and lower lateral cartilages (Fig. 6.29). (Other techniques may involve incsions next to the inferior alar rin for resection of widened alar rims and narrowing of the alar base. An alar base resection, known as a Weir type resection, involves a portion of the nasal sill and occasionally extends to the alarfacal groove (Fig, 6.30). “The Killan incision can also be used for isolated septoplasies or more abbreviated surgeties for access to the septum. Ako, lateral crus and also gain access to the an endonasal rhinoplasty isthe intercart-Marginal Incision “Ths view from the nasal base demorstrtes various design options for transcolumelarinckons, Placement of the external rinophsty trenscolumelar incon connects to the medal portion of inienasal marginal nesions just asove the medal footpacs. Gently manipulating the tisue and ing up the edges perfectly curing closure erica fora well-idden sca. The «ey %0 having 29 nesion that looks nearly invisible Dosioneratvely meticulous sural technigue in which sues are nat crushed or comprarssed by inappropriate reaction, The sue inthe columella aea can be very thi, and rough manpaultion of ths can create poor heaing. Care must be taken in elevating ths fap to prevent crusting the fisue or put excessve stretch wit retractor. Fra, dosure ofthe colunelbr incon must ako be meticulous usng intersted "sutures in & precise Senin to ukimately acheve & very wellhdden scar curing oven rhinoplasy complete transfxion, partial transxion, or heritransfxion incisions are classic incisions through the membranous portion of the nasal septum (Fig. 6.31), Local Anesthesia ‘The local anesthesia component for rhinoplsty, whether open or dosed, is etal for a near bloodless fel and precse techncue. Its needed for postoperative pain control and vasoconstriction. ‘The local anesthesia used must be placed in the proper tissue planes just over the nasal bones and cartges rather than in the subcutaneous tssues or muscular tissue around the nose. On average, I2ce of 2% Iéocaine with :100000 epinephrine is adequate to inject an average nose, An additonal S=I0cc may be requires on large noses or on noses in which a significant amount Cf septal work or turbinate work ray algo be required Before injecting local aneshesa, the nasal hairs are teenmed and avery small amount of 0.05% axymetazolne-soaked cottonaids or pledgets are placed justinside the nose along lhe septum and inferior riddle turbinates as wellas the superior nasal vauk (Fe, 6.32). ‘The use of these topical agents causes a significant increase in vasoconstriction and opens the nasal cavity for better visualiza- tion, particularly when working on the nasal septum or turbinates, They are not absolutely required when performing isolated rhi= noplasty, where litle i any work would be needed an the septum ‘or turbinates. Local anesthesia, if properly placed, will usually suffice, ‘A separate set of instruments for placing and removing nasal packs soaked with topical anesthetics should be availble curing the injection phase before a fullsterle prep and drape. Perform- ing intranasal injection with the use of a good light and nasal speculum allows for precise placement of local anesthesia intra rasaly, After applying topical udicousy, local anesthesiais injected first along the points of major nerve and vessel entry into the nose, both inside and out (see Fg. 6.32). Ibis also injected along the plane just above the upper and lower lateral cartilages as well ‘as nasal bones. Local anesthetic is ako placed along the planned incision line followed by injection along the perichondrium of the septum ifsepral work or harvesting of grafts i incicated. Additional 439 Rhinoplasty> 5 s a 5 Zz z z Marginal Incision Intercartilaginous Transcartilaginous Incision Incision Rim Incision Rim Incision (not preferred) Fig. 6.28 These photos demonsirate a clasic method for exoosing the bteral curl extages (LCS). The rim incision immediately inside the nasal rim should be avoided Because i inreases the chance of ar retraction. The invacardbginous incsoa (aso known 3s tne varscariogina.s incon) splits the lateral crus of the LLCs and i somewhat more tedicaly challenging, The ntercarlagnous incision is made between the LLC fra upper lateral cares throug the sera repon, and some use this or access tothe hump dunrg closed rhnoplesy. The margral inesion = classically usee during open rhinophsty and ean be used asthe solitary ncsion euring closed rhinophsty, injection can be used along with anterior nasal spine as well as the nasal base ifalar base reduction is planned. By injecting before ‘the final stenle prep and drape, addtional time is allowed for adequate vasoconstriction to occur before an incsion is made. Ideally, ISminutes should pass after local anesthesia before making the inital incision, Closed Rhinoplasty The term closed rhinoplosty or endenasalrhineplsty means that there are no external incisons on the nose. Obviously, patients would prefer to not havea sar onthe nose when having aesthetic nasal surgery, even though the classic transcolumella rhinoplasty is rarely objectionable, Other advantages of closed rinoplasty include less swelling resubing from a decrease in lymphatic 440 ‘obstruction as wall as decreased loss of support from attachments that would have otherwise been severed with an open technique. ‘There is no consensus among surgeons that these two additional benefits are actualy of any significance or, infect, truly beneficial in ‘most situations. However, the external scar 6 avoided and, for some patients, may be a deciding factor in whether or not they have the procedure. ‘There are many options with regard to the closed technique in rhinoplasty. The simplest technique invoes a marginal incision ‘only to gain access to the upper portion of the upper and lower laceral cartilages as wellas the rasal bones. Through dissection and elevation of tissues and proper retraction, cephalic strips can be taken to narrow the nose along with nasal dorsal reduction and lateral osteotomies all througn this single marginal incision on each sideDuring closed rhinoplasty, an intercarthginous incon can be used in addon to a marginal incon for acess to the dorsum and to help “deWver’ the lower kteral eartliges (LLCs) for exposure and manpuation, The incson ets through the scroll where the LLC ard upper Isteral eartages (ULC) ae jined. Aanormal searing ere could potentally ceare beating compromise ftom internal vae collapse inthis 3a (8) The lateral crus ofthe LLC is delvered through a marginal ncsion ony without disupson ofthe seroll area. (B) An intercartginous incon was adced through the scroll ares. More inisons were mace fo delwer tre cartilage ‘or sight beter exposure ofthe LC. This nesion cuts through the serall area, which may cause future problems wth support but allows sy access to the nasal dorsum, When combined with the ‘marginal incision dusng an exdonasal ranoplasty, the entre LLC structure can be evertes ane "delvered’ by exterorzng the LLCs use, ssors Exterior the etlage improves visualzation ‘or more complex maneuvers Such a8 car ge grating, (Other options include complete transfxion and partaltransixion of incisions, which can de-project the nose as well as gain access to the nasal septum, as previously discussed, Transixion incisions can be used when one would like to de-project the nose subllety bout nat make major adjustments in the tp cartilages themselves. ‘Additional intranasal incisions for closed rhinoplasty include an intracartlaginous incision performed on each side, The intracart- baginous incsion is made just inside the nostril and approximately in the middle of the lateral crural cartilages. The incision can be made completely through the cartlge to narrow the tip slightly and cause rotation of the nose. Additonal, the cephalc portion ofthis cartilage can be removed to further narrow the nose, Finally, the nasal dorsum can aso be accessed through the intracartlaginous approach, The intracartlaginous approach is somewhat more technique-sersitve and has limitations on how much can be performed related to a tp-plasty without adding an addtional ‘marginal incision. ‘An intercartlaginaus incision can ako be used for closed rhino- plasty. Ts incision, as implied, s placed between the upper lateral cartilages and cephalic edge of the lower crural cartiages. The incision allows easy access to the nasal dorsum, By combining an intracartlaginous incision along with a marginal incsion, a bipedile flap is created that can be rotated causing what is considered ‘delivery’ of lower teal cartilages to easly and precisely remove ‘excessive cephalc portions ofthe lower lateral cartlges along the lateral crural border (see Fig. 6.29). 441 Rhinoplasty> 5 s a 5 Zz z z I iar vase resections Weir" resection for base narrowing Deep suture past alar resection ‘Wedge type skin excision ‘Alar base resections are used to narrow an alr base and nostril se, Care must be taken to avoid asymmetry, dehiscence, and constricion. Ths techn que i lien overusec wien a large strut woul 2e adequate to narrow the base, However sore patents require even acdtional rarrowng such as during onhograthc surgery. The bare retesion sulure shown in the bottom two photos is only used in extreme cases. Certain ethnics often have larger ala that extend laterally beyond the medial canal tangent Ine and require base resection i the patient desres correction. Most minor nostnl nsroming requres only local sn excsion and routine dosure. This is often required for many cleft pate patents to improve symmetry addtion to narowing te nasal base, ‘A Kilian incision is cornmonly used when one would tke to perform an isolated septoplasty from an intranasal approach, par= ticularly when a rhinoplasty is nat going to be performed simultane- ‘aus The incision is made on either side of the septum approximately Smm posterior to the caudal edge of the septum an to gain access. When performing closed rhinoplasty, the nasal septum can be approached through either the intercartlaginous incision as it extends dawn anto the septum or even a marginal incision or intacartieginous incision that can all be extended onto the septum to alow for septal access and harvesting of grafts asPartial Transfixion Incision above medial footpads attachments I (7 & complete transfixion incision severs Fig. 6.31 A complete or partaltransfxion incision extends through the membranous septum, but the complete incision extends through the media footpad connections to te caudal carcbginous septum to de-project the rose, The Kian incon Nypealy used for sobted septoplasty fccess,A paral fansisionineison through the membranous septum can be used for acces to the earlagrous septum win more hmtec ‘ruption to tp support, The ower complete tansxion incon can signfcatly weaken tp suppor and desproject the nose f cess. A hemirarsfsion incon s perferried on one se ofthe membranous septum to gan access to ths porton ofthe nose. Partial or complete trarsixion ncsions can drop the tip somewt or more senifcart, depending on how far the cuts made through the membranous sept, which resides between the caudal septum and medal ural cartlages. needed. A rim incsion has been cssically described and, as the fame implies, curs just to the inside edge of the ale rim, Access can be obtained to all the cartilages and dorsum from ths incision; however, because of its proximity to the rim, significant alarretrac- tion can occur with this incision, which, in most cases, should be avoided. A marginal incsion is typically 2 mare prudent approach and gains the same access as the rim incision but with less risk for abr retracton (see Fe. 6.28) Through any of these incisions, access can be gained with an ‘steatame to the pyriform rim to perform the lateral or medial osteotomy, However, an additional small incsion just over the pyiform rim inside the nase can also be added for improved positioning of the osteotome as needed. Finally, incisions made in the inferior turbinate are accasionally recuired ‘or reduction of ‘enlarged turbinates during the rhinoplasty. Small punctures are made at any point inside the nose to add addtional grafts, such as small plumping grafts over the anterior nasal spine for a retracted ‘columella, Incisions ust insce the ala rim atthe base can aso be performed to reduce 2 wide ale base, but they ako are visualzed ‘externally and are no longer considered an endonasal incision, Sequencing in Closed Rhinoplasty Sequencing for closed rhinoplasty as with open rhinoplsty ‘depends on what the surgeon hopes to achieve as well as surgeon 443 Rhinoplasty> & s a 3 Zz zr z Glabella + & ‘Supratrochlear Vessels = a injoson area ous of ths Nd have ng, Dases shoul be k x pulmonary ecerma secondar 1 topical alpha agorss, most ikely secancary nak for . agonists that are often usec ust, inde the nose include 4% Cocane of 0.125 upto 18% Preryephrinepreference. Many sequences have been described, and each has Its pros and cons, The sequence that follows is for convenience, and the rationale is described, This sequence assumes that all aspects of the nose may require treatment, Obviously, if only a tip-plasty is required, then many steps can be skipped before this portion of the procedure. A typical sequence for closed rhnopkasty is as folows: |. Bilateral marginal incisions (marginal incisions are typically ‘workhorse incisions that are used on most every rhinoplasty and could be converted to an open rhinoplasty if problems ‘occur during the closed technique) 2. Skeletonization and exposure of the nasal bones and cartilages 3. Dosa reduction (this is my preference before tip-pasty because performing ths after delicate tip work may cause disruption of fine sutures and grafts commonly used in the tip) 4. Septoplasty (the extension of the marginal incision fused only, ora Killan incision, or intercarilaginous incsion; performed at this point because f grafts are needed, they are commanly used during the tip-plasty to be performed next) 5. Tip work a. Lateral cephalic strip excision (removal of excess cartge sans adsitional grating materal and is ideally performec before more delcate tp work or suturing) b. Placement of columellar struts along with tip suturing and tip grats 6. Lateral osteotomies (micropuncture technique is performed near the end of the procedure because earlier perfarmance before tip work could potentially produce unnecessary bleeding that would make delcate tip wark more challenging) 7. Alar base modification indicated (this is performed last simply because 2 better idea of proportion can be gained after tip work, osteotomies, and after closure of the tendonasal incsions; closing the alar base incisions before closure of other endonasal incisions will Ikely cause tearing at the alar base requiring re-suturing) 8. Taping and splinting Note: Some surgeors choose to perform tp surgery last (after performing an osteotomy) to prevent the precise and detailed sutures and grafs from becoming displaced later Open Rhinoplasty Open rhinoplasty (external rhinoplasty) is performed to gen beter accesso the nasal skeleton and cartilaginous tsves. As the name implies, an extemal incsion is made, which istypeally tanscolu- mela, in one of several diferent fashions (ee ig. 6.27). A stait= step, V, oF Waype incsion is commonly used to break up the indion and achieve a much better aesthetic outcome than 2 straghtline incon, which shouls be avoided. The incision should bbe made just tthe curvature ofthe medal rural oot pads to hide the incon when the patient is looking straight ahead, incisions apove or below this level are more conspicuous and can have unwanted notehing. Meticulous closure of this incision and proper placement typically produces an excernal incision that is rarely visible or objectionable to the patient The number-one beneft for open rhinoplasty is complete visualization of the cartlages and bony structures that require modfication, This allows much easier graft placement and a better appreciation of what may be required, Also, revision rhi- oplasty cases often require open rhinoplasty to see what has been previously performed and because of the severe scarring that can occur on the nose that has been operated on mutiple times, For teaching purposes, the open rhinoplasty helps clearly demonstrate whien technique is being performed and precsely where grafts are being placed, The challenging nose or over- shortened nose can often be managed much easier with an open approach, One must remember that by detaching all of the tissues and elevating the columellar skin itself, care must be taken riot to damage the skin as it is being retracted, The columellar skin and adjacent vestibular skin is often extremely thi, thus rough handling of tissue must be avoided, For external rhinoplasty, just as in closed rhinoplasty, the sequence is by surgeon preference but must follow atleast a few ‘uidelines. Depencing on what is required for treatment, a comman sequence for external chinopkasty is as follows: 1. Bilateral marginal incisions and transcolumellar incisions 2. Skeletonization and exposure of the nasal bones and cartilages (elevation of the columellar Map can be performed before or just ater exoosure of the lower kteral cartlages| through the marginal incisions) 3. Dorsal reduction (this is my preference before tip-plasty because performing ths after delicate tip work may cause disruption of fine sutures and grafts commonly used in the tip) 4. Septoplasty (the transdomal approach has excellent access ands a deinite advantage of the open approach for harvesting septal cartilage or performing a cifcult septoplasty: itis performed at this point because if gras are needed, they are commonly used on the tipepasly to be performed next) 5. Tio work a. Lateral cephale strip excision (removal of excess cartilage gains additonal grafting material and is ideally performed before more delicate tip work or suturing) b. Tip suturng and placement of columella struts and other tip grafts, such as shield or Baten grafts 6, Lateral osteotomies (micropuncture technique is performed near the end of the procedure because earlier performance before tip work could potentially procuce unnecessary bleeding that would make delicate tip work more challenging) 7. Alar base modification if incicated (hiss performed bt, simply because a better idea of proportion can be gained ater ip work and osteotories and ater closure of the tendonasal incisions; closing the alar base incisions before. dosure of other endonasal incisions will ikely cause tearing at the alar base, requiring resuturing) 8, Taping and splinting 445. Rhinoplasty