Ebook Rhinology and skull base surgery: Part 2

(BQ) Part 2 book “Rhinology and skull base surgery” has contents: Cosmetic rhinoplasty, revision rhinoplasty, functional nasal surgery, nasal and paranasal sinus trauma, systemic disease and the nose, endoscopic approach to the sella, nasopharyngeal carcinoma,… and other contents.

Rhinoplasty and Nasal Framework Surgery Section III

23 Assessment of the Rhinoplasty Patient 413

24 Cosmetic Rhinoplasty 436

25 Revision Rhinoplasty 456

26 Functional Nasal Surgery 478

413

Beauty is a form of genius—is higher, indeed, than

genius, as it needs no explanation It is of the great facts

in the world like sunlight, or springtime, or the refl

ec-tion in dark water of that silver shell we call the moon

Oscar Wilde 1

Beauty is a currency system like the gold standard

Like any economy, it is determined by politics, and in

the modern age in the West it is the last, best belief

system that keeps male dominance intact

Naomi Wolf 2

Summary

The preoperative assessment of a rhinoplasty patient

includes several considerations that are unique in this

type of surgery Social and ethical issues must be taken

into account, while during the outpatient consultation the patient’s motivation for surgery, his or her stabil-ity and overall psychological assessment, with a special emphasis on body dysmorphic disorder (BDD) must be assessed BDD is an increasingly recognized disorder of self- perception associated with signifi cant psychiatric comorbidity, high rates of suicide and self-harm, and following cosmetic surgery, high rates of dissatisfaction, occasionally manifesting as aggressiveness Assessment

of the defect (both objectively and subjectively) should be complemented with a clear and honest discussion of the patient’s wishes and the surgeon’s capabilities The use of imaging and image-manipulating software can enhance communication as well as provide useful medicolegal documentation and facilitate audit and self-improve-ment Several software programs, including shareware and widely available photo-editing software, can be used for this purpose

Summary 413

Rhinoplasty: Social and Ethical Issues 414

Value and Meaning of Beauty 414

Meaning and Range of the Principle of Autonomy 414

Proper Goals of Medicine 414

Issue of Publicly Funded Health Care 414

Patient Selection and the Rhinoplasty Consultation 414

Patient’s Motivation for Surgery, Stability, and Overall Psychological Profi le 415

Body Dysmorphic Disorder 415

The Defect 417

Patient’s Wishes and the Surgeon’s Capabilities 417

Written Material/Web Site Referral/ Second Consultation 417

Surgical Anatomy of the External Nose 417

Anatomy of the Bony Pyramid 417

Anatomy of the Cartilaginous Pyramid 418

Blood Supply to the Nose 420

Innervation of the Nose 421

Skin/Subcutaneous Tissue/SMAS Layer 421

Muscles of the Nose: Dynamic Anatomy 422

Nasal Aesthetics and Assessment 422

Surface Anatomical Landmarks 422

Facial Proportions 422

Frontal View 424

Lateral View 424

Smiling Lateral Views 426

Oblique View 426

Basal View 426

Documentation in Rhinoplasty: Photography and Computer Imaging 427

Image Acquisition 428

Image Storing 429

Image Viewing 429

Image-manipulating Software 429

The Future 431

Key Points 433

Review Questions 433

Christos Georgalas

at play for patients who decide to undergo an aesthetic cedure, including social norms and the dominant ideal of beauty These underline the importance of the promotion

pro-of diverse beauty ideals, by governments and the media Of course, one can argue that it is not external factors per se but the way the individual interacts with them that defi ne whether the patient’s decision is a fully autonomous one Healthy, mature patients possess this autonomy, whereas vulnerable, psychologically unstable patients do not

■ Proper Goals of Medicine

Medicine is supposed to be about treatment and disease, whereas aesthetic surgery is about nondisease and en-hancement However, the drawing of clear lines between medicine and aesthetic surgery has been shown to be philosophically impossible Serious suff ering that de-serves treatment is within the domain of aesthetic sur-gery as much as in traditional medicine

■ Issue of Publicly Funded Health Care

All systems have limitations, and in an era of rationing, what criteria can be used to justify a procedure? Diff erent countries have diff erent guidelines, and there is an urgent need of harmonization of procedures within the European Union (EU) Purely aesthetic surgery is theoretically not covered by the social health care system of any country

in the EU However, there are many exceptions that fer from country to country and that are not always clear

dif-In summary, however, appearance that falls outside some range of what is socially acceptable, that hampers the pos-sibilities to get a job, or that causes dysfunction is covered (United Kingdom, Germany, Belgium, and the Nether-lands) In countries where health insurance is primarily provided by the private sector (e.g., the United States), the issue is less acute, although similar issues exist within the private insurance framework What emerges in this way as one single criterion underlying these exceptions is patient suff ering, often but not exclusively caused by social norms

Patient Selection and the Rhinoplasty Consultation

The wider social and moral context of rhinoplasty raises considerable issues However, for the average rhino-plasty surgeon, these issues are often distilled into a single decision—to operate or not—that he or she has to make in a relatively limited time frame: the rhinoplasty

Rhinoplasty: Social and Ethical Issues

By virtue of being a (primarily) aesthetic rather than

func-tional procedure, rhinoplasty is unique among rhinologic

operations As such, it raises moral, philosophical, and

so-cial issues that no other procedure does There has been an

exponential increase in the number of cosmetic procedures

performed over the last 2 decades (a 162% increase since

1997 in the United States), with over 1.3 million procedures

performed in 2009, 3 and a 300% increase in the United

Kingdom since 2002 with 34,000 aesthetic plastic surgery

procedures performed in 2008, 4 while 17 million cosmetic

procedures were performed worldwide in 2009 5 These

data refl ect the wider availability of surgical interventions

but equally testify to a universal culture increasingly

fo-cused on appearance In modern societies, where mobility

and large networks of short-time acquaintances are the

norm, “fi rst impression” becomes crucial 6 Men as much as

women are realizing the importance of an appealing

exter-nal appearance in social life, work, and persoexter-nal relations,

and are more likely to use cosmetic surgery to achieve it

However, although it would be wrong to dismiss some

well-established universal, “objective” norms of beauty, it

would be equally naive to ignore the context within which

specifi c ideals of beauty are created and circulated, that is,

our mass media culture Within this context, the concept

of patient empowerment becomes controversial As the

European Union Bioethics Commission report established, 7

there are four important elements to be considered: the

value and meaning of beauty, the meaning and range of the

principle of autonomy, the proper goals of medicine, and

the issue of publicly funded health care

Note

Core ethical issues in aesthetic surgery:

1 The value and meaning of beauty

2 The meaning and range of the principle of autonomy

3 The proper goals of medicine

4 The issue of publicly funded health care

!

■ Value and Meaning of Beauty

Although a cross-cultural, universal typology of beauty

un-doubtedly exists, there is equally a broader context within

which this is applied; this includes the character,

perfor-mance, and relational capabilities of the person assessed

■ Meaning and Range of the Principle of

Autonomy

Although most patients with chronic rhinosinusitis (CRS)

will seek medical help, the same is not true of patients with

Patient Selection and the Rhinoplasty Consultation 415

various psychological criteria What is emerging as a major issue in many (if not most) problematic patients is body dysmorphic disorder (BDD), or dysmorphophobia BDD is a relatively common obsessive-compulsive spec-trum disorder defi ned by a constant, impairing preoccu-pation with imagined or slight defects in appearance 12 It

is associated with poor quality of life, high rates of suicide, and, following cosmetic surgery, increased rates of dis-satisfaction, occasionally manifesting as aggressiveness

An algorithm has been suggested by Jakubietz et al for screening plastic surgery candidates for BDD 13 According

to this algorithm, patients are divided into three groups:

1 Those with a correctable deformity and reasonable expectations who can be treated by plastic surgery

2 Those with no deformity and unreasonable behavior who would be inappropriate candidates for surgery and instead should be referred for psychiatric evaluation

3 Those with minimal deformity and inadequate ior who should be considered for referral and resched-uled for a second appointment and reevaluation The diagnosis of BDD is established after psychiatric con-sultation, where a 34-item Body Dysmorphic Disorder Examination may be used For screening purposes, the Body Dysmorphic Diagnosis Questionnaire (BDDQ) can

behav-be used 14 The BDDQ has been shown to have, depending

on the sample, a sensitivity of 100% and specifi city of 89

to 93% 15

Body Dysmporphic Diagnosis Questionnaire

1 Are you very worried about your appearance in any way?

2 Does this concern preoccupy you? That is, do you think about it a lot and wish you could worry about it less? How much time do you spend thinking about it? (More than 1 hour per day is suggestive and more than

3 hours highly specifi c for BDD.)

3 What eff ect has this preoccupation with your ance had on your life? Has it

a Signifi cantly interfered with your social life, work, job, other activities or other aspects of your life?

b Caused you a lot of distress?

c Aff ected your family or friends?

For the busy clinician, the Dysmorphic Concern naire (DCQ), a seven-item screening questionnaire, can be used for the initial assessment of patients DCQ has good psychometric properties, including internal consistency, unidimensional factor structure, and strong correlations with distress and work and social impairment; 16 a cutoff value of 9 has been shown to have excellent discriminative validity, correctly classifying 92% of patients and controls 17

Question-Note

Using the DCQ in the outpatient setting can be an easy and convenient way of screening patients for BDD

!

consultation During this consultation, the surgeon must

make an objective assessment of the real or perceived

de-fect, understand how the patient views it and what he

or she wants to be done about it, decide and explain to

the patient what can be accomplished, and, most

impor-tantly, assess the patient’s motivations, inner stability,

and overall psychological profi le

Tips and Tricks

An initial rhinoplasty consultation should include the following:

• Assessment of the patient’s motivation for surgery,

stability, and overall psychological profi le

• Objective assessment of the real or perceived defect itself

• Discussion of the patient’s wishes and the surgeon’s

capabilities

• Off ering of informative printed material and/or Web site

referral, as well as arrangement for a second consultation

■ Patient’s Motivation for Surgery, Stability,

and Overall Psychological Profi le

(How can I help you? What brought you here today?

How long have you been thinking about surgery?

What caused you to begin thinking about surgery?

Why do you want to do the operation at this particular

time? What is the attitude of your family to your

op-eration? Whose idea was it to have the surgery? How

many previous operations have you had? Were you

happy with the results of the previous operations?

What do you think this operation will do for you? 8 )

The surgeon has the duty to assess the patient’s

motiva-tion for the operamotiva-tion and his or her mental and physical

ability to deal with the stress of surgery and

poten-tial complications, as well the stress of a nonreversible

change in his or her appearance (including that brought

about by a successful result) Only a patient who fully

un-derstands the goals, risks, and limitations of the

opera-tion can provide real informed consent Although several

studies have shown improvement in patients’ quality of

life, as well as improvement on many psychosocial

well-being indicators after rhinoplasty, 9–11 recent large-scale

observational studies have also shown that there is a

higher risk of suicide in patients who undergo cosmetic

surgery and a vastly increased rate of psychiatric

disor-ders 6 Although this is not to say that all cosmetic surgery

patients have psychological problems, it does mean that

a disproportionately larger number of such patients tend

to undergo cosmetic surgery

■ Body Dysmorphic Disorder

Thus, it is vital to screen potential rhinoplasty

candi-dates; indeed, several studies have been performed using

threat-ened by a patient with BDD 24 Although patients with BDD may have trouble ac-cepting it, often choosing instead to self-refer to another surgeon, their management should be psychiatric, not surgical A recent Cochrane review showed that cognitive behavioral treatment and selective serotonin reuptake inhibitors (SSRIs; fl uoxetine/clomipramine) are eff ective and should be the treatment of choice 27

Tips and Tricks

Failing to recognize and operating on patients with BDD can

be a reason for litigation

Interestingly, a recent study 26 showed that psychiatric tients with BDD seeking rhinoplasty are diff erent from “nor-mal” (or mild BDD) rhinoplasty patients in a variety of ways: they are signifi cantly younger, more depressed, more anx-ious, more preoccupied by their nose, and have more com-pulsive behaviors (e.g., mirror checking, feeling their nose with their fi ngers, and even self-mutilation) It also appears that they are signifi cantly handicapped in their occupation, social life, and intimate relationships Patients with BDD are especially more likely to have been discouraged from sur-gery by friends or relatives, more likely to believe that there will be dramatic changes in their life after surgery, and have dissatisfaction with other areas of their body All of these characteristics are not new Before the description of BDD, several surgeons used similar terms to describe bad rhino-

pa-plasty candidates The mnemonic SIMON (single,

imma-ture, male, overexpectant or obsessive, and narcissistic) was coined for the male high-risk patient who was more likely to

be dangerous, whereas SYLVIA (secure, young, listens,

ver-bal, intelligent, and attractive) applied to a good candidate 28 Similarly, Adamson and Chen 29 noted several catego-ries of inappropriate patients for rhinoplasty:

1 Patients having a life crisis

2 Unhappy patients

3 Cross-cultural patients (with family friction)

4 Psychologically estranged patients (those with sive-compulsive and borderline personality disorders)

5 Patients with BDD (dysmorphophobia)

6 Sexually dysfunctional patients

7 Patients with “package of pictures” syndrome alistic expectations)

8 Patients with exceptionalism syndrome (narcissistic personality)

9 Patients with “my theory” syndrome (poor listeners)

10 Patients with Goldilocks syndrome (perfectionists)

11 Patients with “exhausted surgeon” syndrome (patients who go “doctor shopping”)

12 Patients with unfocused personality

A recent systematic review of 37 studies on the social aspects of aesthetic surgery showed that there is

The characteristics of BDD are shown in Table 23.1

Although 80% of plastic surgeons in the United States

report that they would not operate on a patient with

BDD, 84% also state that they had unwillingly operated

on at least one 24 Several studies 22,25 have shown that

up to 66% of patients with BDD undergo cosmetic

inter-ventions, with the most common being rhinoplasty 22

Indeed, in a U.K rhinoplasty practice, the use of a

screen-ing questionnaire for BDD identifi ed a 20.7% prevalence

rate 26 Cosmetic surgery is unlikely to be helpful in such

patients In a study of 26 patients undergoing 46

proce-dures in the United Kingdom, rhinoplasty was

associ-ated with marked dissatisfaction and an increase in the

degree of preoccupation and handicap, with the worst

outcome in those with repeated operations 22 Phillips

et al 23 reported on 58 patients with BDD seeking

cos-metic surgery The large majority (82.6%) reported that

symptoms of BDD were the same or worse after cosmetic

surgery Although 31% of patients with BDD reported an

appearance improvement following the procedure, only

1% reported a decrease in their preoccupation with the

defect What is potentially alarming is that these

pa-tients, who may belong in the delusional spectrum of this

obsessive- compulsive disorder, may become threatening;

Table 23.1 Characteristics of body dysmorphic disorder

Surgical Anatomy of the External Nose 417

■ Patient’s Wishes and the Surgeon’s Capabilities

At this stage, the surgeon must explain to the patient what can and cannot be achieved by surgery on the basis of his or her expertise This can be complemented with computer-imaging analysis and manipulation, as discussed later The goals and limitations of surgery should be made clear Pre- and postoperative photographs of previous patients may

be helpful, although the surgeon must resist the tion of focusing exclusively on “poster patients”; indeed, the cases where he or she achieved a less than ideal result, and even cases of patients who were unsatisfi ed and un-derwent revision surgery, should be shown and discussed The patient should be informed of all the potential com-plications of surgery, including the risk of revision surgery, and the rates quoted should not come from literature re-views but from the surgeon’s own audit

tempta-■ Written Material/Web Site Referral/

Second Consultation

Patients tend to use the Internet to gather information, both before and after their consultation 34 A referral to useful rhinoplasty/facial plastic surgery Web sites, includ-ing the surgeon’s personal Web site and reliable sources

of information (e.g., the European Academy of Facial tic Surgery, www.eafps.org, and the American Academy

Plas-of Facial Plastic and Reconstructive Surgery, www.aafprs.org), can complement the information provided by the surgeon Printed material and handouts with information that the patient can absorb at home are also important Indeed, in a recent study, the quality of printed handouts and the information gathered from the Internet were the factors most strongly correlated with overall patient sat-isfaction with the consent process 35

Surgical Anatomy of the External Nose

The external nose consists of the bony pyramid (the bridge of the nose), complemented by the lateral (upper) and alar (lower) nasal cartilages, supported in the midline

by the nasal septum It is divided into the bony vault, the cartilaginous vault, and the lobule

■ Anatomy of the Bony Pyramid

The bony vault or pyramid is the upper one-third of the nose and is formed by the nasal bones and the ascending (frontonasal) process of the maxilla

a distinction between expectations regarding the self

(e.g., to improve body image) and expectations in terms

of external parameters (e.g., enhancement of one’s social

network, establishing a relationship, or getting a job) 30

Patients with external motivation are less likely to be

sat-isfi ed The same study, after pooling the results from all

as-sessed studies, found that common factors associated with

dissatisfaction and poor psychosocial outcome include

• Young

• Male

• Unrealistic expectations of the procedure

• Previous unsatisfactory cosmetic surgery

The common threads in all of these appear to be diffi culty

to engage meaningfully and lack of mental stability The

bottom line, as expressed succinctly by Goode, 31 could be

distilled as follows: listen to your gut feelings and to your

staff —a patient who appears unsuitable for rhinoplasty

during the fi rst minutes of the consultation most likely is

■ The Defect

(When you look [in] the mirror, what is it that you don’t

like? What view of your nose bothers you the most?

What specifi c feature do you want corrected? If you

can have only one thing changed, what would it be? 8 )

During the initial consultation, there should be enough

time for the patient to describe the defect It is said that

80% of patients require less than 2 minutes to express

their main concern 6 (although this may not be strictly

true for rhinoplasty patients) Open-ended questions are

preferable The use of a mirror and/or photographs is vital

Clear and specifi c complaints are easier to deal with,

espe-cially if they are based on observations shared by the

doc-tor Computer imaging may be useful to screen patients

with unrealistic expectations Patients who are not

satis-fi ed with a reasonable computer-produced manipulated

image are unlikely to be satisfi ed with surgical results 32

There are objective and universal canons of facial

beauty, and we know that what the rhinoplasty patient

perceives as an “ideal” nose does not diff er from what is

perceived as such by the surgeon and the general

pub-lic 33 However, the surgeon should be careful to avoid

suggestive questioning It is counterproductive, and some

patients may be insulted if the discrepancy between

their nose and the ideal nose is analytically described

Although a surgeon must be able to perform an objective

aesthetic facial analysis, this analysis should not always

be shared with the patient

The nasal bones are cephalically attached to the frontal

bone, laterally to the ascending process of the maxilla,

medially to each other, and posteriorly to the septum

Their caudal end overlaps for a few millimeters the upper

lateral cartilage, like a roof tile Caudally and laterally, they

form, together with the ascending process of the maxilla,

the pyriform aperture ( Figs 23.1 , 23.2 , and 23.3 )

■ Anatomy of the Cartilaginous Pyramid

The lower two-thirds of the nose are formed by the

carti-laginous pyramid This is a unifi ed, winged structure that

includes the upper lateral cartilage and the cartilaginous

septum, which articulate with each other in a T- or

Y-shaped confi guration 36

Tips and Tricks

Excision of a cartilaginous hump should include the septum,

as well as the upper lateral cartilage, in a T confi guration

Upper Lateral Cartilages

The articulation of the septum with the upper lateral

carti-lage forms an angle, usually 10 to 15 degrees, that is very

im-portant functionally, as it forms (at their cephalic edge and

Radix Nasal bone Rhinion Upper lateral cartilage Sesamoid cartilages Accessory cartilages

Pronasalae

Middle crus Lower

lateral (alar) cartilage

Lateral crus Medial crus Columella

Supratip breakpoint Supratip lobule

Infratip lobule

Fibroareolar tissue Anterior nasal

spine of maxilla

Fig 23.2 Skeleton of the external nose, lateral view.

1a

1b 1c

2

3

1d

Fig 23.3 External rhinoplasty approach: 1 ⫽ lower lateral

(alar) cartilage consisting of 1a ⫽ lateral crus, 1b ⫽ lobular segment of middle crus, 1c ⫽ domal segment of middle crus, 1d ⫽ medial crus, 2 ⫽ upper lateral cartilage, 3 ⫽ scroll area

Fig 23.1 Skeleton of the external nose Visible are the bony

vault, consisting of the nasal bones and the frontonasal

pro-cess of the maxilla, and the cartilaginous pyramid, consisting

of upper and lower lateral (alar) cartilages

Alar marginTip-defining point

Surgical Anatomy of the External Nose 419

and between them and the upper lateral cartilage there

is an area not supported by cartilage (the weak triangle

of Converse) corresponding to the supratip breakpoint or

depression (see Fig 23.1) Lateral and caudally to the

lat-eral crura, fi broareolar tissue lies between them and the pyriform aperture, while laterally and cephalically, there are a few small accessory cartilages More cephalically (be-tween the nasal bones and the pyriform aperture), there are a few sesamoid cartilages The lateral crus is the wid-est part of the alar cartilage and is tightly adherent to the overlying nostril skin The intermediate crus is divided into

a domal and a lobular segment ( Figs 23.6 and 23.7 )

together with the head of the inferior turbinate) the internal

nasal valve area This is the narrowest part of the upper

air-way, and any degree of narrowing of this angle can lead to

nasal obstruction This area is also signifi cant histologically,

as it constitutes the interface between the (external)

squa-mous epithelium and the (internal) nasal mucosa ( Fig 23.4 )

Tips and Tricks

One of the roles of spreader grafts is the widening of the

angle formed by the articulation of the septum with the

upper lateral cartilage

Caudally, the upper lateral cartilage articulates with the

alar cartilage in the scroll area Usually the cephalic edge

of the alar cartilage overlaps the caudal edge of the upper

lateral cartilage, although several confi gurations have

been described ( Fig 23.5 )

Alar (Lower Lateral) Cartilage

Although in traditional anatomical textbooks the alar

car-tilage was divided in medial and lateral crura, a third part is

increasingly recognized: the middle or intermediate crura

The alar cartilage is thus comprised of the medial,

middle or intermediate, and lateral crura They form two

arches, with the medial crus converging in the midline and

thus forming the columella, and the lateral crus

support-ing the lateral wall of the nasal vestibule The medial crura

converge in the midline (columellar segment of the medial

crura) and diverge more inferiorly, toward the nasal spine

(medial crural footplates) Posterior to their convergence

Fig 23.4 The internal valve as seen endoscopically in a

pa-tient presenting with nasal obstruction: A, head of inferior

turbinate; B, septum; C, upper lateral cartilage; IV, internal

valve The internal valve is created by the convergence of the

septum with the upper lateral cartilage at the level of the

head of the inferior turbinate corresponding to the supratip

breakpoint or depression (see Fig 23.2) Fig 23.5 Articulation of the alar with the upper lateral cartilage (scroll area).

Scroll of cephalicedge of lateral crus

of alar cartilage

Scroll of caudal edge

of upper lateral crus

c

Lateral genuMedial genu

Tip-defining pointMIDDLE OR

INTERMEDIATE CRUS:

Domal segmentLobular segment

MEDIAL CRUS:

Columellar segmentFootplate segmentLATERAL CRUS

Fig 23.6 Anatomy of the alar cartilage: frontal view The

lat-eral and medial crura articulate through the middle crus The middle crus consists of the domal segment, containing the tip-defi ning point, and the lobular segment

Tips and Tricks

Endonasal rhinoplasty may result in loss of tip support by ruption of the scroll area through an intercartilaginous inci-sion, while external rhinoplasty disrupts the attachment of medial crura to the septum, the interdomal ligaments, and the soft tissue envelope

dis-Anatomy of the Septum

The nasal septum consists of a bony part posterosuperiorly (perpendicular plate of the ethmoid bone and vomer) and

a cartilaginous part anteroinferiorly ( quadrilateral lage) The bony septum is attached to the palatine bone by the maxillary crest, while posterosuperiorly, it is attached

carti-to the sphenoid via the rostrum; posteroinferiorly, tween the two choanae lies its free edge Superiorly, it is attached to the cribriform plate Only the cartilaginous part plays a role in the support of the nose It is attached posteriorly to the bony septum and posterosuperiorly to the nasal bones Caudally, it is connected with the me-dial crura of the alar cartilage, lying either between them

be-(tongue in groove) or just cephalically to them ( Fig 23.9 )

■ Blood Supply to the Nose

Blood supply to the nose comes from two main sources: via the external carotid, through the facial artery, that

Tips and Tricks

The domal segment of the intermediate crus of the alar

car-tilage can take various shapes, and its confi guration defi nes

to a large extent the shape of the nasal tip (boxy, bifi d, etc.)

The nasal tip is defi ned as the most prominent part of

the nasal lobule The area cephalic to the tip is called

the supratip area and the area just under it, the infratip

The domal segment of the intermediate crus and the

angle of the medial crura and their approximation of the

domes are all important factors that defi ne the tip shape,

rotation, and projection

Note

There are several major and minor tip support mechanisms:

• Major tip support mechanisms

– Attachment of medial crura to the septum

– Resilience of the alar cartilage

– Attachment of cephalic alar cartilage to caudal upper

lateral cartilage (scroll area)

• Minor tip support mechanisms

– Interdomal ligaments

– Cartilaginous and membranous septum

– Anterior nasal spine

– Skin and soft tissue envelope

– Lateral crural attachment to the pyriform aperture

!

A way to understand the support of the tip and how

dif-ferent techniques can produce diff erent results in terms

of positioning of the tip is the tripod theory, as described

by McCollough and Mangat in 1981 37 and further refi ned

using the cantilever model recently 38 According to this

model, the position of the tip is defi ned by the length and

support provided by the three legs of the tripod formed

by the two lateral crura and the (fused) medial crura in

the midline, as shown in Fig 23.8 Shortening or loss of

support of any of the above can lead to predictable

move-ments of the tip

Fig 23.7 Anatomy of the alar cartilage: anterior view.

Fig 23.8 Tripod theory of tip support The projection and

rotation of the tip are regulated by the relative length of the

medial crura (anterior stand, A) and the two lateral crura ( lateral stands, B).

Surgical Anatomy of the External Nose 421

provides the superior labial artery, the (superior and

inferior) alar arteries, and the angular arteries, and via

the infraorbital artery (branch of the internal

maxil-lary) The internal carotid system also contributes to

external nose blood supply via the ophthalmic artery,

which in turns provides the dorsal nasal anterior

etho-moid branch as well as the external nasal branches of

the internal ethmoid artery (For the blood supply to the

internal nose, see Chapters 1 and 27.) All these arteries

run under the superfi cial musculo- aponeurotic system

(SMAS) layer and can be preserved during rhinoplasty

( Fig 23.10 )

■ Innervation of the Nose

Sensory innervation to the external nose is provided

mainly by the infraorbital (V 2) (external nares) and

infratrochlear nerves (nasion, bony dorsum) (V 1 )

( Fig 23.11 ) The medial part of the tip and dorsum are

supplied by the external nasal branch of the anterior

ethmoid nerve (V 1 —nasociliary branch of the

ophthal-mic branch of the trigeminal nerve) The motor

inner-vation to the muscles of the nose is provided by the

facial nerve

■ Skin/Subcutaneous Tissue/SMAS Layer

Starting from superfi cial to deep, the layers over the

external nose are the skin, the superfi cial areolar layer,

the fi bromuscular layer (SMAS, which at the level of the internal nasal valve is divided into a deep and a superfi cial layer), 39 the deep areolar layer, and the perichondral (periosteal) layer 40

All the major arterial, venous, and lymphatic vessels course either within or above the SMAS of the nose 41 The skin is thicker and more adherent over the naso-frontal angle and over the alar cartilage, thinner and

Ethmoid bone,perpendicular plate

Occipitalbone

Fig 23.9 Bones of the nasal septum (From

Baker E Head and Neck Anatomy for Dental Medicine Stuttgart/New York: Thieme; 2010.)

Fig 23.10 Blood supply of the external nose Note the

multiple anastomoses between the internal maxillary, facial (branches of external carotid), and ophthalmic (branch of the internal carotid) arteries

tragus) and both inferior orbital rims ( Fig 23.14 ).

The important landmarks of the nose include the

fol-lowing (abbreviated designations relate to Fig 23.14 ):

• Nasion: the surface anatomical landmark ing to the bony nasofrontal angle (N)

correspond-• Glabella: the most prominent midline part of the forehead (G)

• Radix: centered at the nasion, defi nes the nasal root and represents where the nose has its origin from the glabella (N)

• Rhinion: the soft tissue correlate of the nous junction of the nasal dorsum (R)

osseocartilagi-• Sellion: midline osseocartilaginous junction of the nasal dorsum (R)

• Pronasale: tip-defi ning point—the most prominent part of the nasal lobule (P)

• Subnasale: junction of the columella and upper lip (S)

• Trichion: anterior hairline in the midline (T)

• Pogonion: most prominent part of the chin (Pog)

• Alar sidewalls

• Supratip (Supra)

■ Facial Proportions

Although the nose is anatomically in the center of the face,

it should not be the center of attention; the focus should always be the eyes Hence, a successful rhinoplasty is one that draws attention away from rather than to the nose The facial analysis should start by assessing the face for any evidence of facial asymmetry (vertical thirds, horizontal fi fths), as well as the quality and thickness of

looser over the dorsum, and thinnest over the nasion (the

junction of bony and cartilaginous septa)

■ Muscles of the Nose: Dynamic Anatomy

The main muscles of the nose are divided according to their

action into four groups: the elevators (procerus and levator

labii superioris alaeque nasi), the depressors (alar nasalis

and depressor septi nasi), the compressors (transverse

na-salis), and the dilators (dilator naris anterior and posterior)

From these muscles, only two are clinically important: the

depressor septi nasi, which can deproject the tip with

ani-mation, and the levator labii alaeque nasi, which assists in

keeping the nasal valve open (its paresis can cause valve

compromise and nasal obstruction) ( Fig 23.12 )

Tips and Tricks

Surgical division of the depressor septa nasi can treat

pa-tients with a descending nasal tip and shortened upper lip

Nasal Aesthetics and Assessment

■ Surface Anatomical Landmarks

As discussed in Chapter 24, a frontal view (with and

with-out the subject smiling), two lateral views (right and left),

two three-quarter views (right and left), one basal view,

and potentially also a cephalic (skyline) half basal ( supratip)

are required (Fig 23.13) Facial aesthetic analysis should

Compressor nariumminor m

Depressor septi m.Alar nasalis m

Orbicularis oris m

Fig 23.12 Musculature of the external nose.

Nasal Aesthetics and Assessment 423

Fig 23.14 Geometric points and lines used in profi le analysis

(From Behrbohm H Ear, Nose, and Throat Diseases 3rd ed

Stuttgart/New York: Thieme; 2009.)

PS

Po

T

R

S SupraN

G Glabella

Table 23.2 Preoperative assessment of the nose

Dorsum • Width (wide/narrow)

• Symmetry (R-L deviation)

• Projection radix/rhinion (hump/saddle)Tip • Projection (over-/underprojected)

• Rotation (over-/underrotated)

• Symmetry (right/left deviation)

• Shape (bulbous/boxy/pinched/bifi d/asymmetric)Columella • Over-/underprojected

• Lobule-to-columella ratio

• AsymmetryNasal base • Wide/narrow

• Asymmetry

• Alar sidewalls

Measurements

• Goode’s ratio: tip projection

• Nasolabial angle: tip rotation/nasal length

• Nasofrontal angle: radix projection/nasal length

• Nasofacial angle: nasal projection

• Horizontal thirds: facial symmetry

• Vertical thirds: facial symmetry

• Basal equilateral triangle: columella/alar/lobule symmetry

Fig 23.13 A complete set of photos for the (pre- or postoperative) assessment of the rhinoplasty patient.

the skin Additionally, the position and shape of the

men-ton should be assessed, as these can infl uence the view

of the nose

The preoperative assessment should include

assess-ment of the dorsum, tip, columella, and nasal base in a

systematic way, as shown in Table 23.2

the eyes, as well as the width of the alar base ( Fig 23.16 )

There should be an unbroken, smooth line from the brows to the tip-defi ning points (brow-tip aesthetic lines)

eye-Specifi c Elements

Dorsum

The dorsum can be assessed at this view for symmetry, deviation, and width This should be further described (upper, middle third, or lower third), taking into account that a saddle deformity may produce the illusion of a wide nose and a hump that of a narrow nose

Tip

Normally, the dorsum ends before the tip in a small pratip depression, more obvious in women The width of the base of the nose should be assessed (ideally, it should

su-be equal to the intercanthal distance) The tip also can

be assessed for symmetry, deviation, and shape

(amor-phous, boxy, pointed, or bulbous) ( Figs 23.17 and 23.18 )

■ Lateral View Dorsum

The dorsum can be assessed for contour, height, length,

and interfacing angles The height (or projection) of the

dorsum is assessed at the nasion (radix projection), ion, and tip 42,43 Radix projection is the distance between

rhin-a verticrhin-al line trhin-angent to the rhin-anterior cornerhin-al plrhin-ane rhin-and the nasion, whereas tip and rhinion projections are the distances between a line tangent to the alar sulcus and the tip or rhinion, respectively

The dorsum can be assessed for underprojection, cluding a saddle deformity, or overprojection, including

Overall Assessment

The surgeon can initially get an overall impression of the

nose and grossly classify the nose into one of the types:

tension, short, saddle nose, hump nose, or deviated nose

( Fig 23.15 ) However, initial impression should always be

followed by more detailed analysis

■ Frontal View

Overall Assessment

At this plane, the face can be assessed for symmetry using the

rule of thirds: horizontal lines passing through the trichion,

Fig 23.16 Lines dividing the face into vertical thirds (a)

and horizontal fi fths (b) (From Behrbohm H Ear, Nose, and

Throat Diseases 3rd ed Stuttgart/New York: Thieme; 2009.)

Fig 23.15a–f Diff erent nasal types

(From Behrbohm H Ear, Nose, and Throat Diseases 3rd ed Stuttgart/New York: Thieme; 2009.)

Nasal Aesthetics and Assessment 425

tip-defi ning point and another drawn from the nasion to the pogonion Ideally, the angle formed by these two lines should be 36 degrees 44

The nasofrontal angle is the angle defi ned by the

nasion–glabella and nasion–tip and is normally between

115 and 130 degrees ( Figs 23.19 and 23.20)

a hump The precise size and location of these should be

noted It should be taken into account that dorsal height

diff ers between diff erent ethnic groups, being lower

in blacks Another important angle to calculate nasal

projection is the nasofacial angle This is defi ned by

the intersection of a line drawn from the nasion to the

Fig 23.17 A patient with a boxy tip saddle nose resulting

from almost complete loss of the septal cartilage following a

septal hematoma and a (consequent) wide dorsum

Fig 23.18 Postoperative results after lateral and median

os-teotomies, reconstruction of the septum using auricular tilage on PDS foil, transdomal and interdomal sutures, and a columellar strut graft (external approach)

car-Fig 23.19 Nasofacial angle (N) is normally ⬃36 degrees The

nasal length (A) is normally 45 to 49 mm The tip projection

is calculated by Goode’s ratio (B/A) and should be between

0.55 and 0.60

Fig 23.20 Nasolabial angle (NLA) is normally 105 to 120

de-grees in women and 90 to 105 dede-grees in men The tal angle (NFA) is normally 115 to 130 degrees A, dorsum projection; B, tip projection

■ Smiling Lateral Views

These are important to assess tip retraction associated with an overactive depressor septi nasi

■ Oblique View

The oblique view provides fewer objective data However,

it is important as it brings into view elements from both frontal and lateral views; it is vital in the assessment of the brow-tip line and the overall tip and dorsal shape and their interplay

■ Basal View

The base of the nose ideally should have the shape of an

equilateral triangle Divided in thirds, the nostrils should

take about two-thirds of the total height (ratio of mella to lobule 2:1) In this view, columella width and de-viation can be better appreciated, as well as tip and caudal septum asymmetry and deviation The width and inser-tion of the alar base also can be assessed, as well as the

Tip

Tip rotation is primarily assessed by the nasolabial

angle The nasolabial angle is an angle formed by the

col-umella and the plane of the upper lip, with its point at the

subnasale, and is normally between 105 and 120 degrees

in women and 90 and 105 degrees in men

The projection of the tip can be assessed using

from the nasal tip perpendicular to a line from the

gla-bella to the menton to the nasal length is calculated: a

ratio higher or lower than 0.55 to 0.60 suggests

over-projection or underover-projection accordingly (ratio B:C ⫽

0.55–0.60)

The so-called columellar double break marks the

junction of the medial and intermediate crura

Nasal length (the distance between the nasion and

the tip-defi ning point) is ideally between 45 and 49 mm

and is aff ected by both tip rotation (nasolabial angle) and

nasofrontal angle A more obtuse nasolabial angle

(over-rotated tip) gives the impression of a shorter nose, as does

a more acute nasofrontal angle/deeper radix

The lateral view is also important to assess

⬍ 2 mm from the nares) The columella and/or ala may be

normal, retracted, or hanging, resulting in nine possible

combinations that defi ne how much columella is visible 45

( Figs 23.21 and 23.22 )

Fig 23.22 The same patient after removal of the hump and

(mildly) increased tip rotation through an external rhinoplasty approach

Fig 23.21 Dorsal (mixed bony-cartilaginous hump) with

mild tip underrotation

Documentation in Rhinoplasty: Photography and Computer Imaging 427

The use of digital imaging and morphing software can

do the following

1 Improve Doctor–Patient Communication

Several studies have shown that the use of computer image manipulation may lead to improved patient satisfaction 32,47,48 Patients can communicate their wishes

in a concrete, clear way, while the surgeon can plan and demonstrate the results of surgery Patients who are un-able to clearly formulate their wishes and are not satisfi ed with realistic image manipulations can be identifi ed early and discouraged from surgery 32 As long as the surgeon maintains a conservative outlook, avoids promises that

he or she cannot fulfi ll, and remains within the limits

of his or her surgical capabilities (ideally using the ware to demonstrate the possibility of a less than ideal

soft-alar sidewalls, for symmetry and for concavity/ convexity

( Figs 23.23 , 23.24 , and 23.25 )

Documentation in Rhinoplasty:

Photography and Computer Imaging

Arguably, digital imaging and manipulation have come of

age From the time of drawing on prints with markers and

rulers to the fi rst (programmed) computer analysis

sys-tems in the early 1980s, 46 the development of aff ordable

high- resolution digital cameras coupled with easy-to-use

computer programs has brought this technology to the

mainstream

Fig 23.23 Amorphous, wide tip with decreased projection

and relative widening of the alar base (patient from Fig 23.17).

Fig 23.24 The same patient after septal reconstruction,

col-umellar strut graft, and interdomal and transdomal suturing

DomeLateral crus of the lower

lateral cartilageMedial crus

Septum

ABW

Fig 23.25 Basal view The alar base

width (ABW) must be equal to the length

of the alar sidewalls

image capturing and manipulation is reviewed here

■ Image Acquisition Camera

A single lens refl ex (SLR) camera, set on a tripod, with either normal/telephoto lens or (preferably) a fi xed lens (85-mm focal distance), is typically used The use

of the same focal length (as well as the same exposure and lighting) is important if comparisons and measure-ments are to be made SLR cameras are defi ned by a moving mirror system that allows the photographer

to see exactly what will be captured They are guished from compact cameras by their larger size but also by interchangeable and generally much better quality lenses, more accurate exposure systems, better quality sensors, and compressing algorithms resulting

distin-in overall signifi cantly better image quality They use two types of recording sensors: a smaller Advanced Photo System (APS) sensor ⬍25.1 ⫻ 16.7 mm in size and a larger (full-format) sensor that is 36 ⫻ 24 mm in size and corresponds to the “classic” fi lm format The larger size of the sensor produces a larger negative, which means, for a given number of pixels, larger pix-els and better quality images Typical examples of full-format semiprofessional SLRs include the Nikon D7800, Canon EOS5D Mark 3, and Sony A900 Examples of APS SLRs in the same category include the Nikon D90 and D300s, Canon EOS50, and Pentax K-x

Resolution

The camera resolution describes the number of pixels corded by the sensor and in most current SLR cameras ranges from 10 to 24 megabytes (MB) A higher number

re-of pixels means that a larger print can be made, but this does not necessarily mean better picture quality Other factors potentially more important are the exposure and the amount of noise during the conversion process Some of the best current computer displays may have a resolution of up to 1920 ⫻ 1200 (HD 1080) (2 MB), which means that for images to be displayed on a monitor, any resolution ⬎ 2 MB is more than adequate; any resolutions

⬎ 10 MB should be able to produce a professional-quality print up to A3 size at 300 ppi (pixels per inch) Another important factor is the way the image is captured Raw format refers to the original image fi le, as captured by the sensor, something very similar to the negative in analog cameras Like old fi lm negatives, it is useless as it is, as

it needs special software to be displayed; however, like

fi lm negatives, it can be easily stored and manipulated

to produce or print the images needed, while retaining

result), it is unlikely that patients will develop unrealistic

expectations

2 Provide Useful Medicolegal Documentation

Many surgeons were concerned that the use of morphing

software may be misconstrued as an implicit “guarantee,”

and as such, increase patient dissatisfaction after the

sur-gery and potentially expose the surgeon to legal liability

for breach of contract 49 However, initial fears that image

manipulation may lead to infl ation of patient

expecta-tions and even create legal liability have been shown to

be largely unfounded 50 On the contrary, it can been

ar-gued that computer imaging when used appropriately

improves the consent process by enhancing patient

edu-cation and actually protects the surgeon from subsequent

litigation 50 Whether printed manipulated images should

be handed to the patient is still a matter of disagreement

Although most patients, retrospectively, think that the

ac-tual result is very close to the original imaging, 51,52 should

hard copies be handed over to the patient, a limited

liabil-ity notice should be clearly printed on the photos

3 Facilitate Audit and Self-improvement

Using image-manipulating software, the surgeon can

mentally plan the procedure corresponding the planned

manipulations with specifi c techniques There is a very

good correlation (better on the lateral than the frontal

views, 51 better on the nasolabial and nasofrontal angle

and tip projection than on the columella tip angle 52 )

between the actual result and the preoperatively

manip-ulated images Indeed, it has been shown that surgeons

are more strict than patients and tend to overestimate

the diff erences, whereas patients tend to ignore minor

diff erences 51,53 In this way, a surgeon can look back and

assess the results in light of his or her initial planning and

expectations, as well as create a personal database useful

for patient education

4 Enhance Presentation and Teaching

It is obvious that the wealth of images that can be

ef-fortlessly and inexpensively stored and shared can help

in the education of trainees and colleagues Digital

im-ages can be easily incorporated in PowerPoint or Keynote

presentations, as well as printed in handouts, used for

books and chapters, or shared online Obviously, patient

consent for the specifi c use must always be obtained A

surgeon with a signifi cant facial plastic practice can build

an extensive personal photographic library, which can be

used both to consolidate his or her practice and to attract

new referrals

Surgeons who work in academic or large hospital

settings normally can use the services of the in-house

audiovisual department However, for surgeons working

in smaller hospitals or in private practice, an investment in

appropriate equipment is more than worthwhile and will

Documentation in Rhinoplasty: Photography and Computer Imaging 429

Adobe Bridge, and Aperture for Mac All of them use destructive editing,” meaning that any changes on the image are not applied to the original raw digital negative fi le, which means that the original quality is not reduced; furthermore the digital negatives are maintained, which may be impor-tant for medicolegal issues The advantage of the Aperture and Iphoto is their close integration with other Apple pro-grams, making it easier to include photos in videos, presen-tations, or emails Lightroom, Aperture, and Bridge support the use of keywords, including hierarchical trees, which can

“non-be useful for archiving large sets of photographs

■ Image-manipulating Software

Image manipulation includes both the use of software for preoperative assessments and measurements and the production of “virtual” rhinoplasty results

A short list of such commercially available specialty software includes

• Face Sculptor by Canfi eld Mirror Imaging (Fairfi eld, New Jersey)

• Alterimage 3.3 (includes warp, stretch, and smooth tool) by Seattle Software Design (Seattle, Washington)

• My Morphing by United Imaging Inc (Winston- Salem, North Carolina) (also by the same company: My Archiving and MarketWise)

• Plastic Designer by Nautilus Software (St Petersburg, Russia)

An alternative is Adobe Photoshop, a program that many surgeons already have in their computer 54 Using the liq-uefy fi lter, one can essentially rotate, expand, or reduce any part of the nose Any abnormalities produced can be smoothened with the use of the healing brush tool The process should not take more than a few minutes The basic steps for using Photoshop in this way are summa-rized as follows:

1 Open image using Photoshop

2 Copy image in separate layer (Ctrl/Command C and Ctrl/Command V)

3 Select from the liquefy fi lter and adjust brush size

4 Drag, rotate, and pull using the brush

5 Use clone stamp (right menu) to correct any malities

6 Choose text edit to print disclaimer

7 Flatten image

An example of a manipulated image is presented in

Figs 23.26 , 23.27 , and 23.28 , and the actual tive result in Fig 23.29

An excellent online tutorial for the use of Photoshop for rhinoplasty imaging manipulation can be found at www.granthamilton.com/uifps/morph.html 55

maximum quality In contrast, many cameras produce

a compressed, or “edited,” form of negative (usually in

JPEG [Joint Photographic Experts Group] form), which,

although it may retain the quality of the original when

printing, cannot be enhanced or manipulated without

loss of quality For professional imaging work, it is worth

working with raw fi les, although they may be signifi

-cantly larger (e.g., a raw fi le of a 12-MB camera will be

exactly that, 12 MB, whereas a JPEG version, depending

on the camera and compressing software, will be ⬍3 MB)

The larger size of the negative, however, requires more

storage space and more processing power

A zoom or fi xed focus portrait lens is preferable (80–

90 mm), ideally set on a tripod and a light blue artifi cial

background, using an on-camera fl ash with diff user (or

bounced off the ceiling)

Views

The views to be taken should include

• A frontal view (with and without the subject smiling)

• Two lateral views (right and left)

• Two three-quarter views (right and left)

• One basal view

• Potentially also a cephalic (skyline) half basal (supratip)

All of these should be captured with the head of the

sub-ject arranged so that the Frankfurt plane is horizontal

(see Fig 23.14 )

Most new SLRs have live view, which means that you

see the image as it is being captured Cameras that

sup-port live view also supsup-port tethered shooting, in other

words capturing photos with the camera connected to

the computer, so you can see the image directly on the

computer screen during capture

■ Image Storing

For saving the images, a large hard disk is necessary, and,

importantly, a second hard drive to serve as backup

Rely-ing on rememberRely-ing to back up is not always effi cient;

given the price of a 1.5-terrabyte hard drive, it makes

sense to have a second hard drive permanently connected

making backups in the background (e.g., Time Machine in

Mac or Backup Center in Windows 7)

■ Image Viewing

The major generic image-editing and -viewing software

cur-rently are (shareware) Picassa and GIMP, as well as Adobe

Lightroom (currently in version 4), Adobe Photoshop CS5,

Fig 23.27 Adjusting the

size of the brush and then dragging to achieve the de-sired eff ect

Fig 23.26 Using the liquify

fi lter from the Filter tab

Documentation in Rhinoplasty: Photography and Computer Imaging 431

Fig 23.29 Postoperative result.

Another high-quality software that belongs to the

GNU shareware family is GIMP (www.gimp.org) The

same process can be performed through GIMP using

the iwarp tool from the filters → distort → iwarp

option

For image archiving and preoperative facial analysis,

an interesting program is Rhinobase, 56 which is free to

download at www.rhinobase.net ( Fig 23.30 )

Fig 23.28a, b Original (a) and manipulated (b) preop-

mo-we know them Mobile phones and tablet computers not only are proving capable of doing most computer tasks, but they are also increasing data storage and programs that are run via the Internet This has clear advantages in terms of sharing data and working in diff erent locations; however, it creates new challenges in ensuring data pri-vacy and confi dentiality Although there are already some online rhinoplasty morphing sites, one can easily imagine a future where image acquisition, morphing, and planning will be done without the need for con-nections, cables, hard drives, and so on, with the whole system operating online Similarly, imaging until now has been two-dimensional (2D), with surgeons having

to rely on static pictures There are already programs available for free download (www.osirix.com) that can produce three-dimensional (3D) surface rendering from standard Digital Imaging and Communications in Medi-cine (DICOM) computed tomography (CT) scans, and a recent study used 2D scans for patient information and surgical planning, 57 although the extra radiation is a

considerable drawback ( Fig 23.31 ) (see Videos 28 and

29, Three-dimensional Surface Rendering from dard DICOM CT Scans, one for normal viewing, one for 3D viewing with special glasses ) It is expected that

Stan-in the future such systems will play an Stan-increasStan-ing role as 3D technology comes of age

Fig 23.30 Rhinobase is a software package that allows measurements and fi ling of rhinoplasty photos.

References 433

Key Points

• Rhinoplasty is unique among rhinologic operations

because of its cosmetic implication; hence, it raises

unique social and ethical issues

• The assessment of a patient for rhinoplasty should

always include screening for body dysmorphic

disor-der, a relatively common disorder of self-perception

associated with psychiatric comorbidity and high

rates of dissatisfaction with surgery

• Detailed knowledge of functional anatomy, including

the tip support mechanisms, articulation of upper and

lower cartilages, and the location of the SMAS layer, is

of vital importance for the rhinoplasty surgeon

• The rule of thirds and fi fths and the Frankfurt

horizon-tal plane can help the surgeon to assess overall face

symmetry, while objective aesthetic assessment of the

nose should include measurement of the nasofacial,

nasofrontal, and nasolabial angle, as well as Goode’s

ratio, nasal length, and tip and dorsum projection

• Imaging based on at least six views (frontal, laterals,

three-quarters, and basal) should always be

per-formed prior to rhinoplasty, while the use of easily

accessible image-manipulating software can greatly

facilitate surgical planning and doctor–patient

communication

Review Questions

1 Patients with body dysmorphic disorder (BDD)

a Are almost exclusively female

b Very rarely undergo rhinoplasty

c Have increased psychiatric comorbidity and high

rates of suicide

d Can be diagnosed by the ear, nose and throat (ENT)/

plastic surgeon on the basis of the Body

Dysmor-phic Disorder Questionnaire (BDDQ)

e Represent ⬃1 to 2% of total rhinoplasty patients

2 Which of the following statements regarding tip

sup-port mechanisms is/are correct?

a Tip support mechanisms are divided into major,

intermediate, and minor types

b Minor tip support mechanisms include the

attach-ment of medial crura to the septum and the alar

cartilages themselves

c Tip support mechanisms are not damaged during a

standard endonasal rhinoplasty

d Major tip support mechanisms are the attachment

of medial crura to the septum, the strength of the

alar cartilages, and the scroll area

e Tip support mechanisms can be explained via the

monopod theory

3 The blood supply to the external nose

a Consists mostly of terminal branches

b Includes the infraorbital artery, a branch of the

ophthalmic artery

c Runs superfi cial to the superfi cial

musculo-aponeu-rotic system (SMAS) layer

d Includes an anastomosis between the external

carotid and the internal carotid arteries, through the ophthalmic artery, supplying the dorsal nasal branches and the external nasal braches of the internal ethmoid artery

e Is provided via the superior labial artery, a branch

of the internal maxillary artery

4 Which of the following statements regarding the

aesthetic assessment of a rhinoplasty patient is/are correct?

a The nasofrontal angle (normally 160 degrees) is a

good indicator of dorsum projection

b Goode’s ratio is the ratio of the line from the nasal

tip perpendicular to a line from the glabella to the menton to the nasal length

c Goode’s ratio is the ratio of the line from the nasal

tip perpendicular to a line from the glabella to the menton to the length of this (second) line

d For the projection of the tip, useful measurements

include Goode’s ratio, nasolabial angle, and frontal angle

naso-e Nasofacial angles are normally between 45 and

60 degrees

5 Which of the following statements regarding imaging

in rhinoplasty is/are correct?

a At least four views are necessary (frontal, two

late-ral, and basal views)

b Imaging in rhinoplasty is only useful for legal

purposes

c Imaging in rhinoplasty can improve doctor–patient

communication and in this way help avoid litigation

d Image manipulation preoperatively should be

avoided, as it could lead to medicolegal problems

e When comparing the postoperative result with

preoperative manipulated images, patients are stricter than doctors and tend to overestimate small diff erences

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2098–2104

24 Cosmetic Rhinoplasty

Roxana Cobo

Summary

Cosmetic rhinoplasty is still one of the most frequently

performed facial plastic procedures and probably the

most challenging one Reductive techniques have been

replaced by techniques that emphasize remodeling,

re-structuring, and reinforcing existing structures of the

nose with very little resection of tissue Surgeons today

must focus on obtaining noses that are well balanced with

the patient’s face, that fulfi ll the patient’s desires and

ex-pectations, and that retain the patient’s ethnic features

Introduction

Cosmetic rhinoplasty is one of the most challenging

operations a facial plastic surgeon can perform The

sur-gery has evolved over the years, and reductive sursur-gery, in

which a lot of tissue is resected, has been replaced by

pro-cedures that emphasize restructuring and strengthening

the existing anatomical fi ndings A successful rhinoplasty

will depend on whether the surgeon has a clear

under-standing of what the patient’s desires are, has been able

to make a correct anatomical diagnosis, is able to off er the

patient realistic expectations, and has the training and

ex-pertise to be able to make things happen Today surgeons

must focus on long-term results that look balanced and

on noses that are in harmony with the rest of the face

Approach to the Nasal Septum/

Graft Harvesting

Most rhinoplasties will need diff erent amounts of grafting material Cartilage for grafting can be harvested from many places, the most common being the nasal septum and the auricular concha In extreme cases where large amounts

of cartilage will be needed or in the cartilage-depleted tient, cartilage can be harvested from the rib

Septal cartilage is the grafting material that is most commonly used in rhinoplasty It is easy to harvest, has a very low morbidity rate, is easy to carve, and off ers excel-lent long-term results The downside is that quantities are limited, and in revision cases very little is left to harvest Septal cartilage is especially useful for structural grafts like struts, spreader grafts, dorsal augmentation grafts, and septal extension grafts This cartilage is ideal to mor-celize and use to fi ll in depressions or hide irregularities Septoplasty can be performed through several incisions: a hemitransfi xion incision, a Killian incision, or through the same open approach by dividing the medial crura Carti-lage is harvested depending on the patient’s needs, always

Management of the Upper Third of the Nose:

The Bony Nasal Vault 440

Hump Reduction 440

Osteotomies 442

Management of the Middle Third of the Nose:

The Cartilaginous Vault 443

Management of the Lower Third of the Nose:

The Nasal Tip 445Columellar Strut 447Caudal Septal Extension Graft 447Contouring the Nasal Tip 448

Alar Base Reduction 452

Skin–Soft Tissue Envelope 453

Postsurgical Follow-up 454

Conclusion 454

Key Points 454

Review Questions 454

■ Nondelivery Approach

The nondelivery approach is a technique used when very small changes are needed on the nasal tip or when limited dorsal work is going to be performed The

taking care to leave at least 1 to 1.5 cm of cartilage in the

form of an inverted L caudally and dorsally ( Fig 24.1 )

This will prevent collapse of the support structures of the

nose Any septal deviations should be corrected If there is

a need to perform turbinate surgery or functional

endo-scopic surgery of the paranasal sinuses, this is performed

prior to management of the septum Septal mucosa is

su-tured with a continuous 5–0 mattress absorbable suture

If the septum does not have enough cartilage for

grafting, this can be obtained from the auricular concha

Auricular cartilage can be harvested using an anterior or

posterior approach, taking special care not to tear the

car-tilage and performing careful hemostasis of underlying

structures Skin is sutured with 5–0 Prolene, and conchal

packing with gauze impregnated with antibiotic ointment

is secured by a single through-and-through mattress

su-ture to help prevent the formation of hematoma, possible

skin necrosis, or deformity of the ear Auricular cartilage

is especially useful in the nasal tip because of its concave

shape Alar batten grafts, tip grafts, and even dorsal onlay

grafts can be used with good results ( Fig 24.2 ) 1,2

Approaches in Rhinoplasty

Rhinoplasty is not an easy operation, and proof of this is the

variety of approaches that exist to perform this operation

There are three basic surgical approaches that can be used

Fig 24.1a, b

a Diagram showing placement for harvesting cartilage A

strip of cartilage 1 to 1.5 cm long should be left dorsally and

caudally to prevent collapse of the middle and lower third of

the nose Harvesting of the cartilage should be done carefully

to prevent tears in the septal mucosa

b The piece of cartilage should be taken out en bloc The

photo shows a harvested piece of cartilage where the diff ent grafts that are going to be used have been marked

er-1–1.5 cm

1–1.5 cm

and the cephalic margin of the alar cartilages ( Fig 24.3b )

The incision should follow the anterior septal angle, lowing the caudal edge of the nasal septum

fol-Tips and Tricks

Care should be taken to make sure the incision is placed dal to the internal nasal valve to avoid scarring in this area

The marginal incisions can be connected in the midline at the level of the anterior septal angle and the upper por-tion of the caudal edge of the septum to expose the upper two-thirds of the nose

transcartilaginous incision is used basically to resect

the cephalic portion of the lateral crus The caudal and

cephalic margins of the alar cartilage should be clearly

identifi ed An incision is made at least 5 mm cephalic

to the caudal margin of the lateral portion of the alar

cartilage The vestibular skin is dissected cephalically,

and the cephalic portion of the lateral crura of the alar

cartilage is incised and removed after careful dissection

in the subperichondrial plane Ideally, an intact strip of

at least 7 to 8 mm of alar cartilage in its lateral portion

should be left behind The same procedure is performed

on the contralateral side, taking care to leave the same

amount of cartilage on both sides The vestibular skin

incision is closed with 5–0 absorbable suture material

( Fig 24.3a )

Note

Indications for a nondelivery approach: small supratip

full-ness and small cephalic rotation of the nasal tip

!

■ Delivery Approach

The delivery approach is indicated when bigger modifi

ca-tions are going to be performed on the nasal tip

Fig 24.2a–c The site for harvesting auricular concha.

a Photo showing the anterior incision site marked.

b The incision is performed with a no 15 blade, taking care

to incise only skin The fl ap is elevated, and the amount of cartilage to be excised is marked

c Photo showing the harvested conchal cartilage.

a

c

b

Approaches in Rhinoplasty 439

Medially, the dissection is completed after the dome area and the intermediate crus are dissected free of the overlying soft tissue Once the dissection is completed, the alar carti-

lages can be delivered and structures modifi ed ( Fig 24.4 )

Caution

When delivering the nasal tip structures, care must be taken not to dissect the alar cartilages too far laterally or medially

The marginal incision is placed following the caudal

margin of the alar cartilage It is not a rim incision

Tips and Tricks

Two helpful hints can be used to keep the incision in the

proper area: laterally, the caudal margin of the alar cartilage

lies in a non-hair-bearing area, and its edge can be palpated

with the handle of the scalpel Care must be taken not to

damage the dome area The middle fi nger of the

nondomi-nant hand can be used to expose the alar cartilages properly

Fig 24.4a, b

a Marginal incision The incision should

be placed following the caudal gin of the alar cartilages and is ex-tended all the way down to the cau-dal margin of the medial crura

mar-b Bipedicle fl ap Once the two incisions

are completed (marginal and cartilaginous), the cartilage is dis-sected free, and the fl ap is lowered

Fig 24.3a, b

a Transcartilaginous incision The caudal and cephalic margins

of the alar cartilage are identifi ed An incision is placed 4 to

5 mm cephalic to the caudal margin of the lateral portion of

the alar cartilage The mucosa is dissected in a

subperichon-drial plane, and resection is performed in the cephalic portion

of the cartilage, trying to leave at least 8 mm of alar cartilage

b Intercartilaginous incision The incision is placed between

the cephalic margin of the alar cartilage and the caudal gin of the upper lateral cartilage The surgeon must place the incision in front of (caudal to) the internal nasal valve This incision must be extended to the anterior septal angle and should follow the caudal border of the nasal septum

mar-b a

the columellar arteries are seen, they are cut and if essary cauterized Dissection of the fl ap is continued up-ward and laterally using skin hooks and keeping as close

nec-as possible to the cartilage structures of the nnec-asal tip If the proper plane of dissection is achieved, it is a relatively avascular approach, and only a thin perichondrial layer is left covering the cartilage

After the skin muscle fl ap has been elevated off the eral crura, the dissection is shifted to the midline, the an-terior septal angle is identifi ed, and dissection is continued over the cartilaginous nasal vault Once the correct carti-laginous plane has been identifi ed, the areolar tissue found here can easily be dissected in a blunt fashion with a cot-

lat-ton-tip applicator all the way up to the rhinion ( Fig 24.6 )

Management of the Upper Third of the Nose: The Bony Nasal Vault

The bony nasal vault can be accessed through the sal or external approach If accessed endonasally, the two intercartilaginous incisions are connected by a partial or complete transfi xion incision just anterior to the caudal edge of the nasal septum The plane of dissection over the dorsum is done under direct vision using an Aufricht or Converse retractor It should be directly above the peri-chondrium of the upper lateral cartilage in the middle nasal vault and below the periosteum over the bony vault Care must be taken not to dissect too far laterally Incision

endona-of the periosteum should be performed 2 mm above the caudal end of the nasal bones with a no 15 blade, and el-evation is completed with a Joseph dissector, taking care not to undermine too far laterally over the nasal bones The basic surgical techniques performed on the upper third of the nose are hump reduction and osteotomies

■ Hump Reduction

A bony nasal hump can be removed with an osteotome

or a rasp, depending on the preference of the surgeon

■ External Approach

The external rhinoplasty approach provides the surgeon

with the best exposure of the tip, the middle

cartilagi-nous nasal vault, and the bony dorsum (see Video 30, The

Crooked Nose, and Video 31, The Up-rotated Tip, Revision

Surgery ) With this technique, the surgeon is able to

diagnose accurately any presence of deformities or

asym-metries and is also able to perform in a more precise

manner resections and placement of sutures and grafts 5

Note

Indications for an external approach:

• Important asymmetries or deformities of alar or upper

lateral cartilages

• Nasal tips that have poor structural support (poor

projec-tion, poor rotation)

• Deviated nose

• Long overprojected nose

• Presence of congenital or acquired deformities: saddle

nose, septal perforations, cleft lip noses

• Elderly patients

• Revision rhinoplasty

!

Transcolumellar Incision/Elevation of the Flap

The transcolumellar incision is marked as an inverted V at

the level of the midcolumella The lower margin of the

inci-sion is placed above the feet of the medial crura to give

sup-port to the fi nal scar ( Fig 24.5 ) This incision is connected

to bilateral marginal incisions that are placed no more than

2 mm behind the caudal margin of the medial crura and

follow the caudal margin of the entire alar cartilage

later-ally The incision can be performed with a no 15 or a no.11

blade, taking care to keep the blade perpendicular to the

skin, not to bevel skin edges, and keeping the incision

su-perfi cial to avoid damage to the medial crura

Flap elevation is performed with angled Converse

or Walter scissors that are placed below the musculo-

aponeurotic layer of skin that covers the medial crura and

directly above the cartilage Clean cuts are made with the

scissors completing the midcolumellar incision The fl ap is

Fig 24.5a, b

a Diagram showing placement

of inverted V columellar sion It should be placed above the feet of the medial crura in the middle third of the colu-mella

inci-b The columellar incision is connected to bilateral mar-ginal incisions that are placed

2 mm behind the columella and follow the caudal margin

of the alar cartilages

Management of the Upper Third of the Nose: The Bony Nasal Vault 441

Usually osteotomes are used for big humps and rasps for

smaller deformities Generally, the bony part of the hump

is much smaller than the cartilaginous part

The cartilaginous portion is lowered fi rst beginning

at the osseocartilaginous junction and then following

the resection caudally toward the anterior septal angle

The cartilaginous dorsum is incised using a no 15 or

no 11 blade transecting the dorsum evenly on both

sides Ideally, the incised cartilaginous dorsum should

be left attached to the bony dorsum because this will help when the osteotome is placed for hump removal

An adequate hump resection should extend into the nasofrontal angle Several points should be kept in mind:

• The skin is thick over the nasofrontal angle and the pratip region and thin over the rhinion and the domes

su-( Fig 24.7 )

Fig 24.6a–f Photos showing inverted V columellar incision, elevation of the fl ap, and dissection of the middle third of the

nose and bony dorsum

on the preference and expertise of the surgeon 6 Indications for an osteotomy include

• To close an open roof deformity, which is usually the result of a dorsal hump excision

• To correct a crooked nose

• To narrow wide nasal sidewalls

Medial Osteotomies

Indications for a medial osteotomy include

• To mobilize lateral sidewalls

• To correct a crooked nose

• To narrow a wide nose that does not have a hump This type of osteotomy is not performed routinely It is usually done using a 2- to 3-mm osteotome that is placed

at the junction of the septum with the nasal bone The osteotome should be angled laterally away from the mid-line, taking care to avoid entering the thick frontal bone

( Fig 24.9 )

• If the surgeon wants to achieve a straight dorsum, the

highest point should be the osseocartilaginous junction

or rhinion, directing the osteotome toward the

naso-frontal angle ( Fig 24.8 )

• Final dorsal refi nements are made with a rasp It should

be angled away from the midline to avoid avulsion of

the upper lateral cartilage from the undersurface of

the nasal bones Debris is washed away with saline

solution

• Any irregularities on the dorsum can be palpated with

a fi nger moistened in hydrogen peroxide or water and

sliding it carefully down from the radix to the anterior

septal angle

Fig 24.7 Diagram showing skin thickness over the nose It is

thick at the nasofrontal angle and supratip area and thin over

the domes and rhinion

Fig 24.8 To achieve a straight dorsum, the highest point

should be the rhinion, where the skin is slightly thinner

Medialosteotomy

Lateral osteotomy

Fig 24.9 Medial osteotomies are performed with a 3-mm

osteotome that is placed at the junction of the dorsal tum with the nasal bone The osteotome is angled outward

sep-to avoid entering the thick frontal bone

Management of the Middle Third of the Nose: The Cartilaginous Vault 443

path is used The osteotomy starts at a point high at the level of the head of the inferior turbinate, taking care to preserve a small triangle of bone at the piriform aperture This preserves the lateral attachment of the suspensory ligaments, preventing medialization of the inferior tur-binate, which could obstruct the nasal airway The oste-otomy then goes low into the nasofacial groove, curving

fi nally upward into the thin nasal bone at the level of the inner canthus At this point superiorly, the fracture can be completed by turning the osteotome medially, creating a backfracture; by using the fi ngers to creating pressure to fracture the bone inward; or by performing a percutane-ous transverse osteotomy superiorly with a sharp 2-mm osteotome

Lateral osteotomies also can be performed using a perforating transcutaneous or intranasal approach A se-ries of small perforations are placed on the lateral side-wall and completed digitally to control the backfracture properly

Management of the Middle Third of the Nose: The Cartilaginous Vault

Modern rhinoplasty techniques include managing the middle nasal vault and identifying risk factors that can help prevent long-term functional and cosmetic compli-cations and deformities in this area The middle vault is composed of paired upper lateral cartilages that cephali-cally attach to the undersurface of the nasal bones and caudally form a scroll that attaches to the undersurface

of the lower lateral cartilage ( Fig 24.11a ) Cephalically,

the cartilaginous vault has a trapezoidal appearance that changes to an inverted V shape when it reaches the junc-tion with the alar cartilage forming the internal nasal valve The angle that is formed between the septum and the upper lateral cartilage ranges from 10 to 20 degrees and should be respected when performing rhinoplasty procedures 7

When performing a rhinoplasty, maintaining a strong dorsal line is desirable not only for aesthetic but also for functional reasons Hump reduction, overaggressive os-teotomies trying to achieve a narrower nose, or simply failing to detect an overly weak upper lateral cartilage can result in complicated postsurgical deformities These de-formities include dorsal asymmetries, collapse of a lateral nasal cartilaginous sidewall, inverted V deformity, middle vault collapse, and compromise of the internal nasal valve

( Fig 24.11b, c )

Risk factors associated with the middle cartilaginous vault deformities are

• Short nasal bones ( Fig 24.12a )

• Weak upper lateral cartilage ( Fig 24.12b )

Intermediate Osteotomies

Intermediate osteotomies are not performed routinely

and have special indications:

• Extremely wide nasal dorsum that does not have

a hump

• Deviated nose where the height of one lateral sidewall

is much higher than the contralateral side

• Crooked nose with convex bones

An intermediate osteotomy should be performed before a

lateral osteotomy using a sharp 3-mm osteotome The

os-teotomy should be placed somewhere in the midportion

of the lateral nasal wall following a path that runs

par-allel to the path of the lateral osteotomy It is important

not to detach the periosteum or the soft tissue from the

bone, as this will help keep the bone fragments in place

( Fig 24.10 )

Lateral Osteotomies

Lateral osteomies can be performed endonasally using

the linear technique or using a perforating technique

that can be performed endonasally or externally To help

prevent postsurgical swelling and chemosis, usually a

2–3 mm guarded or nonguarded osteotome is used The

periosteum is usually not dissected from the bone Lateral

osteotomies extend from the piriform aperture to a point

at the level of the inner canthus medially A high-low-high

Fig 24.10 Intermediate osteotomies when necessary are

done with a 3-mm osteotome and should be performed

be-fore lateral osteotomies

• Tall, narrow nose with thin skin

• Large osseocartilaginous hump

• Short, fl attened cartilaginous vault with overlying thick

skin

• Previous rhinoplasty procedures

• Nasal trauma ( Fig 24.12c )

These risk factors can be seen frequently in noses where

bony and cartilaginous structures are not strong 8

Problems in the middle third can be corrected with

grafts or sutures Sutures can be used to align cartilaginous

structures that are strong and have not lost their ing support

Spreader grafts are commonly used to strengthen the middle nasal vault in primary and revision rhinoplasty patients These are rectangular pieces of cartilage that measure 2 to 3 mm in thickness, 3 to 5 mm in height, and

15 to 20 mm in length These spreader grafts will help give structural support to the middle third of the nose, main-taining its anatomical trapezoidal contour, and will help prevent the appearance of an inverted V deformity in this

area ( Fig 24.13 ) Spreader grafts can be used to widen an

Nasal bone

Attachment

a

Fig 24.11a–c

a The middle third of the nose is formed by the upper lateral

cartilage and the nasal septum, giving it a trapezoidal

con-fi guration Cephalically, the upper lateral cartilage attaches

to the undersurface of the nasal bones and inferiorly forms

a scroll attaching to the undersurface of the alar cartilage

b Patient showing collapse of the right nasal sidewall.

c Patient showing bilateral collapse of the upper lateral

carti-lage, creating an inverted V deformity

Management of the Lower Third of the Nose: The Nasal Tip 445

overly narrow middle third of the nose, correct any dorsal

septal deviation, or strengthen naturally weak upper

lat-eral cartilage They can be placed on one side or bilatlat-erally,

depending on the defect They can extend from the nasal

bones all the way down to the nasal tip or can be fi xed only

in the middle third of the nose In cases where there is a

persistent depression on one side, bilateral spreader grafts

can be placed, or dorsal onlay grafts of morcelized cartilage

can be used to camoufl age these defects ( Fig 24.14 )

Management of the Lower Third of the Nose: The Nasal Tip

A practical way of planning surgery on the lower nasal third of the nose is by having a clear understanding of the tripod and pedestal concepts The tripod is formed

by the conjoined medial crura and both lateral crura These are fl exible structures that are designed to be

c

Fig 24.12a–c Risk factors that predispose to deformities in the

middle third of the nose

a Short nasal bones.

b Weak, long upper lateral cartilage with narrow middle third of the

nose

c Dorsal septal deviation.

able to bend, move, and slide The tripod sits on a

ped-estal that is basically the caudal septum, which lies on

top of the nasal spine This structure is more rigid and

gives support to the tripod Covering this

tripod–ped-estal skeleton is the skin–soft tissue envelope (S-STE)

The relationship of these three anatomical structures is

what gives shape to the nasal tip 9 (see also Chapter 23,

Fig 23.8 )

The tripod must be analyzed adequately when

per-forming surgery on the nasal tip Things that must

be taken into account are the shape, width, length,

strength, and existing asymmetries on any of the limbs

of the tripod The strength of the pedestal must be

evaluated, as well as its length and its position over

the nasal spine The interrelationship of these two

structures is what will give the shape to the

underly-ing skeleton of the nasal tip The coverunderly-ing, or S-STE,

is something that we as surgeons cannot control and

that should be taken into account when planning tip

surgery

When work is going to be performed on the lower

third of the nose, the nasal base should be stabilized

be-fore any tip work is done A stable pedestal will provide

a solid structure to be able to place grafts in a proper

Fig 24.14 Drawing depicting placement of a dorsal onlay

cartilage graft over upper lateral cartilage

fashion This will allow the surgeon to defi ne the tion and projection of the nasal tip and placement of the nasolabial angle Techniques used frequently are the columellar strut and the caudal septal extension graft 8,10

rota-Fig 24.13a–c Ideally, spreader grafts should be carved from septal cartilage Auricular cartilage can also be used with good results.

a

a Photo showing spreader grafts carved from septal cartilage.

b Grafts are fi xed in place with a needle.

c Photo of bilateral spreader grafts sutured in place with

ab-sorbable 5–0 Vicryl sutures

Management of the Lower Third of the Nose: The Nasal Tip 447

• Corrects buckling or asymmetries that may be found in the medial crura

■ Caudal Septal Extension Graft

The caudal septal extension graft has a special indication

in primary rhinoplasty patients where a columellar strut will not give the necessary support to the pedestal It is indicated in patients with

• Acute nasolabial angles

• Tips with poor projection

• Caudal septa that are weak and short

• Inadequate alar/columellar relationships 11,12

A relatively straight piece of cartilage is needed for this type of graft Ideally, it should be harvested from septal cartilage; when septal cartilage is not available, conchal cartilage can be substituted, taking care to straighten the piece that will be used The graft is placed overlap-ping the caudal edge of the patient’s nasal septum and

is fi xed securely with 3–0 Vicryl sutures superiorly and

■ Columellar Strut

The columellar strut is used in most rhinoplasties to

maintain the existing projection and rotation of the nasal

tip Struts can be carved from cartilage obtained from the

septum, ear, or rib The cartilage should be as straight as

possible; its length and width will depend on the needs

of the patient A pocket should be dissected between the

medial crura and the graft fi xed in place with absorbable

sutures The sutures should not be placed too high up in

the medial crura or near the domes if the natural double

break of the columella is to be preserved Inferiorly, the

strut should be placed a few millimeters above the nasal

spine Care should be taken not to leave the inferior

tion of the strut touching or overlapping the anterior

por-tion of the caudal septum or the nasal spine, because if it is

not fi xed properly, a clicking sensation on the base of the

nose will result The superior portion of the graft should

be cut 1 to 2 mm below the existing domes ( Fig 24.15 )

The strut is designed to

• Give additional support to the tripod and pedestal

• Maintain or increase tip projection and rotation

Fig 24.15a–d Columellar strut.

a Correct placement of the columellar strut The inferior portion

should be placed a few millimeters above the nasal spine

b Ideally, the columellar strut should not go all the way down

to the nasal spine and should not overlap the caudal edge

of the nasal septum

c Strut fi xed in place with a needle.

d Strut sutured in place The suture should not be placed too

high up near the domes to be able to preserve the natural double break of the columella

Fig 24.16a, b Septal extension graft.

a Drawing showing the septal extension graft The graft

should be carved from a relatively straight piece of

car-tilage It overlaps the caudal edge of the nasal septum

and is fixed in place with 4–0 Vicryl sutures

b Photo showing a septal extension graft in place Note how

the nasolabial angle is pulled out The feet of the medial crura are sutured to the caudal edge of the graft, and the height of the nasal tip is set according to the patient’s needs

b

inferiorly at the level of the nasal spine The feet of the

medial crura are then fi xed to the caudal edge of this

graft, and the height of the nasal tip is set depending on

how much tip rotation and projection the patient needs

( Fig 24.16 )

Once the pedestal has been strengthened properly, the

nasal tip lobule can be addressed in a proper fashion, and

tip grafts can be placed knowing that with a stable base,

reliable long-term results can be achieved

■ Contouring the Nasal Tip

Tip-defi ning techniques in rhinoplasty are always a

chal-lenge There are no standard tip procedures, although

most are focused on increasing rotation, projection, and

defi nition of the tip lobule without compromising

sup-port Techniques should be conservative and

predict-able, reserving the more aggressive techniques for more

prominent deformities

Surgical techniques of the nasal tip can be divided into

diff erent categories:

• Suturing techniques

• Techniques in which cartilage is resected

• Techniques in which the alar cartilage is divided

( incomplete strip procedures)

• Techniques using grafts

Suturing Techniques

Sutures are the fi rst step in managing the tip These niques help refi ne, project, and rotate The ones that are used most routinely are the lateral crural steal, dome- defi ning, transdomal suture-narrowing, and double dome These are usually done with 5–0 or 6–0 nonabsorbable suture material

Lateral Crural Steal

The lateral crural steal is probably one of the most ful techniques because it helps increase rotation and projection in otherwise undefi ned bulbous tips 8,10,13,14 Lengthening the medial crura at the expense of the lateral crura will result in an increase in projection and rotation The vestibular skin is dissected at and around the dome area; the new lateral position of the domes is marked, and

use-a nonuse-absorbuse-able 5–0 continuous truse-ansdomuse-al muse-attress ture is placed, fi xing the domes in their new position This technique rotates the tip superiorly, increases projection,

su-and creates a more triangular base ( Fig 24.17 )

Dome-defi ning Sutures

Dome-defi ning sutures are placed on the existing dome area These mattress sutures defi ne the existing domes and narrow the domal angle Special care must be taken

to prevent pinching of the domal area with a resulting convexity of the lateral crus and buckling If this occurs,

Management of the Lower Third of the Nose: The Nasal Tip 449

distance ( Fig 24.19 ) The same recommendations for the

transdomal suture-narrowing technique are applicable 16

Cephalic Resection of Alar Cartilage

In patients in whom alar cartilage is excessively wide, a conservative cephalic resection can be performed How much is left behind is important Nine to 10 mm at the lat-eral crus and 5 to 7 mm at the dome area is standard, taking care to bevel the cut so that no sharp edges can be seen over the skin on the tip area The excision should not extend into the lateral portion of the lateral crus This will prevent su-pra-alar pinching and/or collapse of the lateral nasal wall that with time will tend to worsen Cephalic trim is not per-formed routinely and is usually reserved for those tips that are overly wide or where the alar cartilage is strong

placement of a lateral crural strut graft will help correct

the buckling and pinching of the cartilage

Transdomal Suture-narrowing Technique

The transdomal suture-narrowing technique is used in

broad, boxy tips that have an increased interdomal

dis-tance The suture improves support and enhances tip

projection A 5–0 Prolene suture is passed through the

domes and knotted in the midline This suture changes

the tip shape to a more triangular one and decreases the

interdomal distance ( Fig 24.18 ) Care must be taken not

to tie the suture too tightly or to place the domes too close

together An adequate interdomal distance must be

main-tained to preserve the double light at the dome area 15

Double Dome Unit

The double dome unit combines suturing techniques to

obtain more lobular refi nement A 5–0 mattress

dome-defi ning suture is placed on each existing dome,

creat-ing a more acute interdomal angle A third continuous

mattress suture is passed through these domes,

secur-ing them in the midline and decreassecur-ing the interdomal

b a

Fig 24.18a, b Transdomal suture-narrowing technique.

a In this technique, a nonabsorbable 5–0 mattress suture is

passed through each dome and tied in the midline

b The domes are brought closer together This decreases the

interdomal distan ce and creates a more triangular-shaped

nasal tip Care must be taken not to tie sutures too tightly

Fig 24.19a–d Double dome unit.

a, b In this technique, a suture is used to defi ne each dome.

c, d Additionally, a continuous transdomal suture is used to

decrease the interdomal distance Sutures should not be tied too tightly to avoid pinching of the nasal tip area

Fig 24.17a–c Surgical procedure using lateral crural steal The medial crura are lengthened at the expense of the lateral crura.

a The red area shows the area that is going to be taken from

the lateral crura to lengthen the medial crura

b, c This increases the rotation and projection of the nasal tip

and is performed via a suture that includes the medial and lateral crura

Tip grafts are used to improve defi nition, increase support, and enhance projection Using grafts indiscriminately can create postsurgical problems because any graft used in the nose can shift, reabsorb, or become noticeable over time Because the availability of cartilage grafting material is limited, surgery must be planned carefully, and a judicious decision of where grafting material is going to be used be-comes imperative Grafts should be placed carefully and when possible sutured in place to avoid any postsurgical shifting, which could create an unaesthetic result

Shield Graft

Shield graft is very useful in patients with thick, bous tips that need additional projection and defi nition Grafts should be carved according to the patient’s needs Septal cartilage is the ideal grafting source, followed by rib cartilage, although ear cartilage can also be used with good results All edges of the graft should be beveled so they will not be noticeable over time The graft is fi xed in place to the caudal margins of the medial/intermediate crural strut complex with 6–0 nonabsorbable sutures

bul-No matter how thick the overlying S-STE is, the leading edge of the graft is usually left at the level of the existing domes or only slightly above In cases where the superior leading edge of the shield graft is 2 to 3 mm above the existing domes, a small buttress graft should be placed behind to avoid postsurgical cephalic rotation of the graft The leading edge of the graft is then covered with morcelized cartilage or perichondrium to prevent vis-

ibility in the future ( Fig 24.22 ) Today, despite the fact

that many of our patients have a thick S-STE, shield grafts are reserved for those cases where the other tip- defi ning

Division of Alar Cartilage

Alar cartilage should be divided in those patients with

an overprojecting or overly long nose Techniques used

by the author are the lateral crural and medial crural

overlay These techniques reconstruct the alar cartilage,

creating a new intact strip with increased support at

the lateral or medial crus, where the incision was made

Overprojected noses can have a very long lateral crus,

very long medial crus, or both Once the segments are

reconstructed, the domes should be defi ned and fi xed in

place with any of the diff erent suturing techniques

men-tioned above

Lateral Crural Overlay

Noses that have long plunging tips, acute nasolabial

angles, and very long alar cartilage, with the lateral

crus being much longer than the medial one, will need

correction at the level of the lateral crus The lateral

cru-ral overlay technique is an excellent option to increase

rotation and to shorten an overlong nose without

los-ing support 14 The lateral crus of the alar cartilage is

divided, and the cut segments are superimposed and

fi xed in place with 5–0 nonabsorbable mattress sutures

( Fig 24.20 )

Medial Crural Overlay

The medial crural overlay is used when the medial

crus is longer than the lateral crus It helps

counter-rotate an overly counter-rotated nasal tip The medial crus is

divided, and the cut segments are superimposed and

fi xed in place with 5–0 nonabsorbable mattress sutures

( Fig 24.21 )

d c

Fig 24.20a–f Lateral crural overlay This technique is useful in patients with long, plunging noses with a long lateral crus.

a, b If necessary, a conservative cephalic trim is performed

on the alar cartilage The lateral crus of the alar cartilage is

dissected free from the underlying mucosa

c An incision is performed 10 mm lateral to the dome.

d, e The segments are elevated, and the medial segment is

su-perimposed over the lateral segment 3 to 4 mm, depending

on how much the nose is going to be shortened and rotated

f By suturing one fragment over the other, this strengthens

the lateral crural strip