Rhinoplasty Dissection Manual - part 8 docx

Rib graft is fashioned into a columellar strut secured to the medial crura and a dorsal onlay graft that interdigitates with the columellar strut.. A sutured-in­ place columellar strut f

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Y

AA

Figure 5, continued The severely deviated component (U-W) is removed, along with pos­

terior septum (X) The deviated septum is replaced with straight septal cartilage (Y-Z) har­

vested posteriorly A tip graft also was applied (AA)

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Figure 6 A, B: Severe saddle-nose deformity Rib graft is fashioned into a columellar strut (secured to the medial crura) and a dorsal onlay graft that interdigitates with the columellar strut C-EE: (slides) Preoperative (C-F) pho­

tographs of a patient with a severe saddle-nose deformity

She underwent application of an iliac bone graft to her nasal dorsum in the past Lack of an intact L-strut and in­

adequate middle vault support resulted in descent of the graft, airway obstruction, and referral to our office for re­

construction Base view reveals the bone graft in the left nostril and a widened columellar scar

c D

Figure 6, continued

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Figure 6, continued Graphic operative worksheet (G, H) illustrates the surgical high points Rib graft was

harvested (I, J), and exposure was achieved via the external rhinoplasty approach (K, L) A sutured-in­

place columellar strut fashioned from rib graft was secured between the medial crura (M, N) A dorsal-on­

lay graft was carefully carved (0, P) with a notch, allowing it to interdigitate with the columellar strut

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Figure 6, continued

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Figure 6, continued

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Figure 6, continued The dorsal graft was placed and se­

cured (0-T) Example from another patient illustrating in­ terdigitation of strut and dorsal onlay graft (U) A tip graft was placed and covered with a layer of perichondri um to camouflage and soften the leading edge of the tip graft (V, W)

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Figure 6, c ontinued

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Figure 6, continued Preoperative (X, Z, BB, DO) and postoperative (Y, AA, CC, EE) side-by-side com­

parison

• Deviations of the caudal septum can usually be corrected by crosshatching the car"

tilage and other conservative maneuvers described in the text Many cases can be

septal replacement may be necessary

• When using an integrated columellar strut/dorsal graft, the surgeon must take spe­ cial care to stabilize the columellar strut in the midline to avoid shifting or tilting

of the columella Placement of the dorsal graft into a precise dorsal pocket or su-:

ture fixation of the dorsal graft to the middle nasal vault will miriimize the chance

of the graft shifting to one side

• Symmetric carving of the costal cartilage graft will minimize the chance of the graft warping over time:

REFERENCES

I Tard y M E , B e ker D G, Weinb erger MS Il lusion s in rh inopl a s ty F acial Pla st S urg 1 995 ; 11 : 11 7 -1 38

2 T ard y M E R hinoplasty: the ar t a nd the sc ienc e Ph iladelphi a: WB S aunders , 199 7

3 Tor iurni OM C a ud a l s ep ta l e xtension gr a ft f or c orrec tion o f t he r e tracted co lume lla Ope l' T e ch O tolary ng o l Hea d Neck S rg 1 995 ;6 :3 11-318

4 Bee son WH The n a sal s eptum Ot olaryn gol Cl in No rth A m 1 987;20:74 3 - 767

5 To riurni DM, Ri e s WR Inn o vati ve s ur g i ca l ma nag e me nt of t he c roo k e d n o se F a ial P last S urg C lin N orth

Am 1 993;1 :63-78

6 Met z inger S E , Boyce R G , Ri gb y PL , Jo s eph JJ , An derson JR Ethm oid bo ne s a nd w i c h ra ftin g f or c u da l s ep­

ta l d efect s Ar ch Ot olaryn gol H ead Neck S urg 199 4 ;120 : 1121-11 25

7 T oriurni DM S ubtota l r econ stru ction o th e n a s al s eptu m : a pr eliminary r e port La ryn go s cope 19 94 ; 104 :

9 06-9 13

8 Dan iel RK Rhin opl asty a nd r i b grafts : evo lving a fl ex ible o p erati ve t echni qu e P l ast R ec on s tr Surg 1 992 ;94 :

5 97-6 11

9 Wan g TO Ae s theti c s truct ural n asal au g ment ation O p el' T ech Ot olaryn g ol H ead Nec k Sur g 1 990

Auricular cartilage can be harvested using the anterior or posterior approach (1-6) In

most cases, we prefer the anterior approach because we believe it is less traumatic, and the

incision heals well if vertical mattress closure is used Ifsmaller cartilage grafts are needed,

then we use the posterior approach

With a marking pen, outline an incision that follows the outer edge of the cavum and

cymba concha This incision should be placed along the portion of the concha that is verti­

cally oriented in relation to the lateral aspect of the skull (Fig I) Use a syringe with 1% li­

docaine (Xylocaine) solution with 1:100,000 epinephrine (or for the lab demonstration, wa­

ter) to "hydrodissect" the skin of the concha cavum and cymba from the underlying

cartilage

Make the incision with a no 15 blade, and elevate the skin and perichondrium from the

underlying cartilage Dissection proceeds by using appropriate scissors, and also bluntly

with cotton-tip applicators Care should be taken not to damage the soft auricular cartilage,

which can tear The dissection should stop short of the cartilage of the external auditory

canal The radix helicis should be preserved if preservation of ear position is critical Ifthe

entire conchal bowl in excised, the auricle will usually settle closer to the head

Dissect out the desired piece of cartilage, and leave the underlying muscle behind (peri­

chondrium will remain adherent to the posterior surface of the cartilage), Avoiding deep

dissection into the soft tissue minimizes bleeding

Suture the circumferential incision with a 6-0 nylon running mattress suture Alterna­

tively, the incision may be closed with interrupted vertical mattress sutures Special care

must be taken to avoid overlap of the skin edges Place a bolster dressing of Telfa, dental

roll, or other suitable material into the concha, and suture it into position to decrease the

risk of hematoma No residual deformity of the pinna is expected with this approach

139

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B

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F Figure 1

G

K

H

J

L

Figure 1, continued A-T: Injection hydrodissects the skin of the concha cavum and cymba

from the underlying cartilage (A) The incision follows the outer edge of the cavum and cymba concha and is placed along the portion of the concha that is vertically oriented in re­

lation to the lateral aspect of the skull (B, C) Dissection proceeds by using appropriate scis­

sors, and also bluntly with cotton-tip applicators (D-G) The dissection stops short of the car­

tilage of the external auditory canal Incise the cartilage (H, I) and dissect out the desired

piece of cartilage (J, K) Achieve perfect hemostasis before closure (L) The cartilage should

be handled gently to avoid tearing or damaging the soft auricular cartilage

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Figure 2 Rib cartilage harvest Cartilage is typically harvested from the eighth and ninth ribs A 4 cm to 6 cm incision overlying the eighth rib allows adequate expo­

sure (see also Chapter 11, Fig 6) Dissection proceeds

around the rib is undertaken subperichondrially; the

With the donor rib completely separated from surround­

ing soft tissue, the graft is incised and delivered under di­

beneath the rib as it is incised

material into the concha and suture it into position (0-T) to decrease the risk of hematoma

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plished Skin edge eversion can be accomplished with everting subcutaneous sutures

A chest radiograph is obtained in all patients after rib harvest In the rare instance of a difficulty, the surgeon may wish to consult the appropriate surgical colleague

HARVESTING CALVARIAL BONE

Pari etal bon e may be harvested (Fig 3) through a horizontal incision (typically, 4 em to

6 em) superior to the temporal line Typically the nondominant side is chosen Incision to and through the periosteum, followed by subperiosteal undermining, provides proper ex­ posure A drill is used to outline the proposed graft (typical graft size, 1 em to 1.5 em by 4

em to 4.5 em) A trough is drilled through the outer table to the diploe; this allows the proper angle for application of a chisel or powered oscillating saw to harvest the grafts care­ fully Short controlled taps on a sharp osteotome allow increased precision and help de­ crease the risk of inner-table penetration and dural tear

Patients must be cautioned preoperatively of the risk of possible dural tear and possible brain injury Any dural entry should elicit an immediate neurosurgical consultation

The donor site can be contoured with hydroxyapatite cement or any other biocompatible bone substitute material The incision is typically closed in a multilayer fashion

A

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B

C

Figure 3 Calva rial bone harvest Parietal bone m ay be harvested through a horizontal incision (typi­

cally, 4 cm to 6 cm) superior to the temporal line Typically the nondominant side is chosen (A) A drill i s

used to outline the proposed graft (typical graft size, 1 cm to 1.5 cm by 4 cm to 4 5 cm) A trough is drilled

through the outer table to the diploe (B , 0, E) A chisel or powered oscillating saw may be u sed to har­

v est the grafts carefully (C , F-I) Narrower grafts are safer and eas ier to harvest

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Figure 3, continued Short , controlled taps on a sharp os­ teotome (H) allow increased precision and help decrease the r isk of inner table penetration and dural tear

• When harvesting auricular cartilage, the surgeon can simplify the dissection by performing local anesthetic injections in the subperichondrial plane This will act

to hydrodissect the flap and allow blunt dissection to elevate the flap

• Special care must be taken to evert the skin edges when performing the skin clo­

sure Therewill be a tendencyfor the dissectedflap tooverlap theskin on the side that wa s not dissected Vertical mattress sutures are most effective for aligning the

• If lateral ear position is a concern, the radix helicis can be left'intact to support the

auricle and preserve lateral ear position

• Perichondrium can be dissected off the posterior surface of the cartilage and used

as tissue for camouflage or to cushion a tip graft

• If small cartilage grafts are needed, the posterior approach can be used to harvest

• If the patient has one ear that protrudes more than the other; then the cartilage

should be harvested from that side: If the'patient sleeps on one side 'of the head,

-

Patients should be informed of the temporary excess eversion of the skin edges

Harvesting Ethm oid B one

REFERENCES

I Tard y M E , Denn en y J , Frit sch MH Th e ve rsat ile c artilage a ut ogra f t in r econ s tructi o n of t he no se a nd f ace

Lar yn go s c ope 1 8 5;9 5 : 523- 532

2 Met zinger S E , B oyce R G , Ri gb y PL, Jo se ph JJ , A nde r s on JR Ethm oid b on e san dwi c g raf ting for c aud a l s ep­

t al d efect s Arch Ot ol H e ad N ec k Surg 1 994 ; 1 20 : 11 21-11 25

3 Dani el RK Rhin oplasty and rib gr afts : ev olvin g a fle xible o perative te ch niqu e Plast Re con str S urg 19 92 ;94 :

5 97 6 11

4 Wan g TD Aesth etic st ructur al nas al aug men tat ion O p el' T e ch Ot ol aryn gol H ead N e ck Su rg 199 0

5 Tard y ME Rhin oplast y : th e a rt an d e s cie nc e P h iladelphia : W B S aund er s , 997

6 Chen ey ML, G l icklicb RE The u s e of c alvari al bon e in na s al r e onstruction Arch O tola ryng ol Head Neck

S urg 1 995 ; 1 21 :643 -648

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