Sách phẫu thuật thẩm mỹ mũi (Tiếng anh) Aesthetic rhinoplasty

Sách phẫu thuật thẩm mỹ mũi (Tiếng anh) Aesthetic rhinoplasty Sách phẫu thuật thẩm mỹ mũi (Tiếng anh) Aesthetic rhinoplasty Sách phẫu thuật thẩm mỹ mũi (Tiếng anh) Aesthetic rhinoplasty Hướng dẫn chi tiết về phẫu thuật nâng mũi, sửa mũi, cắt gọt cánh mũi, các phâu thuật tái tạo mũi.

Aesthetic

Septorhinoplasty

123

Barış Çakır

Aesthetic Septorhinoplasty

Barı ş Çakır

Aesthetic

Septorhinoplasty

English translation by Ali Rıza Öreroğlu

ISBN 978-3-319-16126-6 ISBN 978-3-319-16127-3 (eBook)

DOI 10.1007/978-3-319-16127-3

Library of Congress Control Number: 2015949109

Springer Cham Heidelberg New York Dordrecht London

© Springer International Publishing Switzerland 2016

This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software,

or by similar or dissimilar methodology now known or hereafter developed

The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made

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Barı ş Çakır

Private Practice Fulya Teras

Istanbul

Turkey

In memory of my dear father Kemal Çakir who passed away in 2012

Dr Baris Çakır has written a worthy successor to Jack Sheen’s monumental

text Aesthetic Rhinoplasty As a resident, I remember reading Sheen’s

text-book and suddenly seeing rhinoplasty in a fundamentally new way Sheen set specifi c aesthetic goals and achieved them with a range of new techniques which he had developed

For the next 30 years, I learned a great deal in the operating room and from lectures by my colleagues However, I had not had that feeling of excitement

of witnessing a new era in rhinoplasty surgery until I attended the Combined Rhinoplasty Meeting of the Turkish and American Rhinoplasty Societies held

in Istanbul in 2011 As usual, I was taking notes and trying to stay awake late

in the afternoon during the 5 min presentations Suddenly, I became aware that something dramatic was happening A speaker was talking about new concepts for tip aesthetics (polygons), bony vault remodeling (bony sculpt-ing), and nostril sill excision When the session was over, I went up to

Dr Çakır and asked him if he would present the talk again for me the next morning He did and I had him repeat it three times I was totally amazed at his concepts, but wondered if he could really do in the operating room what

he was presenting Therefore, I asked him if he could do a case for me The conversation went as follows: “I’d like to see you do a case.” “When?”

“Tomorrow.” “Okay.” The next day, Dr Çakır did a rhinoplasty employing a wide range of techniques which he had developed and achieved a superb result Later that day at lunch, my head was still reeling from trying to under-stand the nasal polygons, his advanced tip suture techniques, and repair of numerous ligaments that I had routinely cut I reasoned that the only way I could understand his concepts was to help Dr Çakır write up his techniques which he had thus far been unable to publish Subsequently, he came to me and said he had more ideas for journal articles I told him that he would always have too many ideas and too little time I advised him to go ahead and write a book as it would clarify his thinking and allow others to build on his concepts Naively, I thought he would be preoccupied for a couple of years Six months later, he sent me the manuscript and 3 months after that the Turkish Edition was published to be followed by the English Edition

In reading Dr Çakır’s masterpiece, I am struck anew by how original and advanced his concepts truly are Something as mundane as nasal photography and analysis suddenly becomes an art form and the use of preoperative

“shadow photographs” a brilliant break through Some of his polygon concepts require multiple readings before one fully understands them For

example, the concept of a “resting angle” between the lower lateral and upper

lateral crura is totally new At fi rst one may think it is of little importance, but

when linked to the long lateral crus and herniation of the lateral crus into the

vestibule its relevance becomes obvious One suddenly has an answer for a

previously inexplicable problem as well as a method of treatment and more

importantly a method of prevention The discussion of multiple tip points and

defi nition of the soft tissue facets as well as their relation to specifi c tip

sutures is crucial information In the surgical technique chapter, the

impor-tance of the continuous subperichondrial-subperiosteal dissection plane

becomes apparent The novice surgeon should remember that many of his

techniques were perfected through the open approach before Dr Çakır

pro-gressed to the closed approach There are certain ideas with which I disagree,

including scoring of the septum, leaving a 2 mm gap between the septal base

and the anterior nasal spine, and resection of the membranous septum I also

recognize that the book may prove daunting to some given the plethora of

new concepts and the quality of the English translation

Yet, this is a book to be savored and read multiple times before returning

to specifi c chapters for greater insight into the challenges of rhinoplasty

sur-gery For the younger surgeon, the book provides in-depth discussion of how

to analyze and photograph the patient while formulating an individualized

patient-specifi c operative plan The linkage of surface aesthetics to nasal

anatomy to surgical techniques is the foundation of this text For the

experi-enced surgeon, the book will be a revelation of how to set and achieve higher

aesthetic standards using the described methods For the master surgeon, Dr

Çakır challenges many of our accepted principles and techniques ranging

from the aesthetic dorsal lines to the need for lateral crural transposition

Every surgeon performing nasal surgery should purchase a copy of Aesthetic

Septorhinoplasty as Dr Çakır’s concepts, principles, and techniques

repre-sent the future of rhinoplasty surgery

Foreword

Who is Barış Çakır?

After graduating from the Electronics Department of the Çukurova Technical High School, I studied at the Faculty of Medicine upon my parent’s wish, and during the fi fth year of my studies I had to undergo rhinoplasty, followed by revision surgery six months later Within my own medical career in plastic surgery, I focused on microsurgery and performed many such operations, but

my strongest interest has been in nose surgery because it requires both cal skill and aesthetic understanding Even for someone like me who has both undergone and then continually performed nose surgery, this specialization continues to present interesting challenges because it is constantly develop-ing Several years of drawing and sculpting courses have contributed to my own professional development, and in my own practice of eight years—ninety percent of which consists of rhinoplasty—I have made changes to almost half of all the techniques I learned in medical school For instance, I began nose remodeling surgery with the open technique, but since 2008 turned to closed technique instead—a rather unusual turn, as most surgeons move in the opposite direction Today, I am performing approximately 200 to

techni-300 closed-technique rhinoplasties per year

In 2012, at the ASAPS Congress, Dr Rollin Daniel encouraged me to write this book in the format of an instruction manual, so as to allow others to benefi t from my experiences with rhinoplasty as well as visual documenta-tion surrounding this type of surgery, since in the framework of this book, I have defi ned proper standards for surgical photography and technical draw-ings It is my hope that readers will fi nd the present work most useful for their own practice

What Kind of Book is this?

This book describes closed rhinoplasty in which open rhinoplasty techniques are used In order to make the information presented here quickly and easily accessible, the writing style has deliberately been kept simple and more emphasis is put on the images, so that the book reads like detailed surgery notes No extensive explanation accompanies the photographs, but text, pho-tographs, and drawings complement each other and the images illustrate the

Preface to the Turkish Edition

preceding text Photographs of those patients who gave permission of use are

in standard format, while the photographs of those who refused permission

were cropped to make their faces unrecognizable Since I wanted to illustrate

the effects of closed rhinoplasty, dissection and ostectomy techniques on

healing rates, I have also included images with early results

Acknowledgments

Special thanks are due to Tayfun Aköz, MD, and Mithat Akan, MD, who

Çakır; Metin Bahçivan for editing the Turkish text; and Nina Ergin for

proof-reading the English translation

Aesthetic Septorhinoplasty: The English Edition

The English edition of this book was planned while the author was still ing the Turkish original text As with the original, the intent was to offer the reader an introduction of aesthetic rhinoplasty similar to an instruction man-ual, with abundant images but much less text My task as translator was to convey the original content of aesthetic concepts and surgical techniques, while at the same time choosing plain language, keeping in mind that the reader may be a junior plastic surgeon who is not a native speaker of English Being familiar with all the concepts and surgical techniques, I attempted to make the instructions understandable, yet simple and practical I hope that I have achieved this goal and that the English edition will serve its purpose

Preface to the English Edition

1 Preoperative 1

1 Patient Photographs 1

1.1 The Photography System 5

1.2 Preoperative Photographs 6

1.3 Light Cheats 6

1.4 Fish-Eye 7

1.5 Shooting with a Smartphone 7

1.6 Camera Settings 7

1.7 Parafl ash Settings 8

1.8 Imaging 10

1.9 Shadowing the Images 12

2 Surgery Notes and Archiving 17

2.1 Photography Archive 18

2.2 Backup 18

3 Skin Care and Rhinoplasty 18

3.1 Oral Vitamin A 18

4 Menstruation 19

5 Forehead Fat Grafting 19

5.1 Technique 20

6 Jaw and Cheek 28

6.1 Importance of the Cheek 32

7 The Rhinoplasty Instrument Set 34

7.1 Dorsum Retractor 34

7.2 Small Retractor 34

7.3 Forceps 35

7.4 Needleholder 35

7.5 Scissors 35

7.6 Bone Scissors 35

7.7 Rasp and Saw 36

7.8 Osteotomes 36

7.9 Elevators 36

7.10 Hook 37

7.11 Osteoectomy Chisels 37

7.12 Lateral Osteotomes 37

7.13 Arkansas Stone 38

7.14 Sutures 38

Contents

2 How to Draw a Nose 39

1 Exercises 39

1.1 Sketch from the Front 40

1.2 Sketch from the Side 42

1.3 Sketch from Above and Below 44

2 Analysis of Patient Photographs 48

3 Nasal Polygons 51

1 Infratip Triangle 53

2 Tip Defi ning Point 53

3 What Is a Facet? 53

4 The Non-Mobile Nose 53

5 The Mobile Tip Area 53

5.1 Mass Polygons 53

5.2 Space Polygons 53

6 Tip Breakpoints 54

7 Dome Triangles 54

8 Interdomal Triangle 58

8.1 Dome Divergence 59

9 Infralobular Polygon 60

10 Columellar Polygon 61

11 Footplate Polygons 62

12 Facet Polygons 63

12.1 Relation of the Facet and Dome Polygons 65

13 Lateral Crus Polygons 65

14 Resting Angle 66

14.1 Vertical Compression Test 67

14.2 Incorrect Resting Angle and its Effect on the Ala 70

14.3 Wide Lateral Crura 71

14.4 Long Lateral Crura 71

14.5 Convex Lateral Crura 78

14.6 Cephalic Malpositioning 78

15 Scroll Facet 80

16 Scroll Line 83

17 Dorsal Cartilage Polygon 83

18 Dorsal Bone Polygon 84

19 Upper Lateral Cartilage Polygons 85

20 Lateral Bone Polygons 86

21 Dorsal Aesthetic Lines 87

21.1 Summary: Dorsal Aesthetic Lines 90

22 Lateral Aesthetic Lines 92

23 The Polygon Model 93

Contents

4 Surgery 95

1 Patient Position and Tracheal Intubation 95

2 Local Anesthesia 97

3 Head Lamp 99

4 Cleaning 99

5 Lighting in the Operating Room 99

6 Drawings 100

7 Basic Surgical Steps 101

8 Concha 101

8.1 Concha SMR 101

9 Nasal Dorsum Surgery 107

9.1 Transfi xion Incision 107

9.2 Intercartilaginous Incision 108

9.3 Entering the Nasal Dorsum from the Septal Angle 108

9.4 Subperichondrial Dissection in the Open Approach 110

9.5 Periosteum Dissection 114

9.6 Why the Subperichondrial Dissection? 122

9.7 Upper Lateral Cartilage Mucosa Dissection 124

9.8 Dorsal Cartilage Resection 126

9.9 Dorsal Bone Resection 128

9.10 Nasal Radix 130

10 Septum 131

10.1 Dissection 131

10.2 Removing the Septum 137

10.3 The “Gummy Smile” 138

10.4 When there is Extreme “Gummy Smile” 138

11 The Footplates 140

11.1 Narrowing of the Footplate Polygon 140

12 Tip Surgery 143

12.1 Incision 144

12.2 Autorim Flap 145

12.3 Lateral Crus Subperichondrial Dissection 162

12.4 Delivering the Domes 168

12.5 Marking and Resections 175

12.6 How Did the Nose Break Down? 177

12.7 Observation and Theory 177

13 Results 185

13.1 Surgery 187

13.2 How to Perform the Footplate Setback 187

13.3 Lateral Crus Steal Procedure 193

13.4 Dome Symmetry Test 195

13.5 Cephalic Dome Suture 196

13.6 Control 1 198

13.7 Control 2 198

Contents

13.8 Medial Crus Overlap 205

13.9 Suturing the Domes 211

13.10 Columellar Strut Graft 213

13.11 Infralobular Caudal Contour Graft 222

13.12 Columellar Polygon Stabilization 229

13.13 Closure of Tip Incisions 231

13.14 Tip Asymmetry 232

13.15 Cephalic Malpositioning 238

13.16 Interdomal Graft 251

14 Nasal Dorsum 252

14.1 Setting the Dorsum Height 252

14.2 Osteotomy 252

14.3 Osteoectomy 254

14.4 Osteoectomy Technique 256

14.5 Bone Dust and Cartilage Paste 276

14.6 Short Nasal Bones 278

14.7 Dorsal Reconstruction in Men 280

14.8 Stabilization of the Nasal Tip 281

14.9 Reconstruction of the Scroll Line 283

15 Internal Splints 288

16 Internal Valve Functions 288

17 Drains 288

18 The Pitanguy Ligament 289

19 The Superfi cial SMAS 290

20 Internal Taping 291

20.1 The New SMAS Anatomy 291

20.2 Importance of the Pitanguy Ligament in the Supratip Region 292

21 Redrape 295

21.1 Dissection Borders 295

21.2 How to Use the Ligaments for Redraping 296

21.3 Why Internal Taping? 296

21.4 Camoufl age 297

22 Additional Grafts 297

22.1 Extra Columellar Strut 297

22.2 Rim Graft 298

23 Nostril Surgery 299

23.1 Problems and Solutions 299

23.2 Thick Alar Base: Simple Elliptic Resection 299

23.3 Big Nostrils: Avulsion Advancement Flap 302

23.4 Big Nostril and Thick Alar Base: Combination of Avulsion Advancement Flap and Elliptic Resection 307

23.5 Hanging Alae: Alar Rim Excision 311

24 Taping 317

25 Postoperative Care 318

Contents

26 How to Correct the Deviated Nose 320

26.1 How Did the Nose Deviate? 320

26.2 Reference Points 321

26.3 Nasal Dorsum Resection 323

26.4 Septoplasty 324

26.5 Tip Surgery 325

27 Cartilage Grafts 334

27.1 Septal Cartilage 334

27.2 Rib Cartilage 335

28 Columellar Show 339

28.1 Hanging Columella 341

29 Prescription 349

5 Patient Analyses 351

1 Case Analysis: A Common Patient 351

2 Case Analysis: Thick Skin 355

3 Case Analysis: Thick and Oily Skin 357

4 Case Analysis: Revision of My Own Case 359

5 Case Analysis: Thick Skin and Large Hump 362

6 Case Analysis: Closed Approach Healing Rate 364

7 Case Analysis: Supratip Healing Period 366

8 Case Analysis: Wide Dorsum, Wide Radix, Bulbous Overprojected Tip 368

8.1 First Surgery 369

8.2 Second-Year Revision 370

9 Case Analysis: Fractured Nose, Operated Twice 372

9.1 Surgery 374

10 Case Analysis: Long Nose 374

11 Case Analysis: Cephalic Malpositioning 376

11.1 Surgery Photos 376

12 Case Analysis: Closed Approach Revision 378

12.1 Operation 380

12.2 Surgery Photographs 380

13 Case Analysis: Overrotated Saddle Nose 381

13.1 First Operation 382

13.2 Second Operation 383

13.3 Surgery 383

14 Case Analysis: Thin Skin 386

15 Case Analysis: Thin Skin, Deviated Nose, Tip Asymmetry 388

16 Case Analysis: Tip Asymmetry 389

17 Case Analysis: Thick Skin, Low Radix and Cephalic Malpositioning 390

17.1 Surgery 391

18 Case Analysis: Saddle Nose, Notched Nostril 391

18.1 Surgery Photographs 393

Contents

19 Case Analysis: Very Short Infralobule,

Very Narrow Facet Polygon 394

19.1 Surgery Photographs 395

19.2 Surgery 395

20 Case Analysis: Saddle Nose, Hanging Nostril 395

21 Patient Example: Bulbous Tip 396

22 Patient Example: Thin Skin, Big Nose 397

23 Patient Example: Thin Skin, Pseudocephalic Malpositioning and Tip Asymmetry 398

24 Case Analysis: Tension Nose 399

24.1 Surgery 400

25 Case Analysis: Thin Skin, Tension Nose 400

26 Case Analysis: Ideal Patient for the Closed Approach 401

26.1 Surgery 402

27 Case Analysis: Learning from a Patient 402

28 Case Analysis: Bulbous Tip 403

29 Case Analysis: Thin Skin, Axis Deviation and Breathing Problems 404

30 Case Analysis: Thick Skin, Bulbous Tip and Deviated Nose 406

31 Case Analysis: Medium-Thick Skin 407

31.1 Surgery 407

31.2 Surgery Photographs 408

32 Case Analysis: Revision for Droopy Tip 411

32.1 Surgery 412

33 What Not to Eat Before Surgery 413

34 After Surgery: A Few Notes 414

Index 415

Contents

© Springer International Publishing Switzerland 2016

B Çakır, Aesthetic Septorhinoplasty,

“beautiful Nose” folder I take photos of people with beautiful noses I ask my patients’ relatives and my friends who have good-looking noses and take their photo I collect the photographs that patients bring to me Sometimes I look at them I suggest that you also do this You can see a female and a male nose that I consider beautiful below You can return to these photos for the aes-thetic details to be explained further

1

1 Preoperative

You should employ a photographic standard The more importance you give to patient photog-raphy, the more you will develop your own stan-dards and make your patient feel valued Do not take photos just before surgery Be done with your photography and design work during patient consultation

1.1 The Photography System

Obtain an intermediate-level SLR camera A proper lens (e.g macro) is more important than the camera itself I use a 100 mm macro lens Standard shots cannot be taken with zoom lenses

If you use a zoom lens, try to take photos ing the zoom to 100 mm You should have a stan-dard background It’s better to select the correct background color in advance, because you can-not change it later The best choices in my opin-ion are black, grey, blue and dark blue Black will appear more artistic, but blue is a better choice for scientifi c purposes

Shadows will not occur if there is at least 1 m distance between the patient and the background

If you have a studio with parafl ash system you should be able to take good photos

Take vertical (portrait) photos Archiving and photo merging will be much easier If you take horizontal (landscape) photos, you will be creat-ing extra work for yourself later on

Remember that, if you do not allow a distance between you and your patient during photograph-ing, you cannot take good photos If you use a macro lens, you should have at least a 2 m dis-tance between you and your patient in order to capture your patient’s face in the correct quadrage Another important issue is the position

of the patient in relation to light sources

1 Patient Photographs

The location and intensity of light refl ections

change as the patient changes positions Because

of that, the location of the lights and patient

posi-tion must remain stable In our photography

stu-dio there is a circle on the ground, guiding the

patient position You can use self-adhesive

foot-prints for this purpose

1.2 Preoperative Photographs

For years I have been taking photos of the

carti-lage structure during the operation, before and

after the surgery Evaluating your fi rst-year

results with preop photographs will accelerate

your development In my practice, I use an SLR

camera with 100 mm macro lens for preoperative

surgical photographs in the operating room as

well

1.3 Light Cheats

The lights, the patient and your position should

never change Sometimes I look at patient eyes

in photographs presented at congresses Using a

single fl ash for the preoperative photo and parafl ashs for the postoperative one is a common cheat A single fl ash exaggerates any deformity Half of the surgery can therefore be done by light changes alone For instance, no surgery is documented in the photographs below Both photos were taken with a 10 s interval The pho-tograph on the left was taken with a single top

fl ash, and the photograph on the right using parafl ashs

The same cheat occurred with these photographs

You can easily determine what kind of lighting

has been used by simply looking at the patient’s

eyes

1.4 Fish-Eye

If you get close to the patient and zoom out with

the lens, the photograph will be fi sh-eyed Photos

which are taken from the front will make the nose

look bigger and the ears smaller Profi le photos

make the ears look bigger and the nose smaller

In the front view, you should look at how much of

the ears you can see behind the cheeks In fi

sh-eyed photos, you can see less of the ears The

nose tip will also look bulbous You can correct

tip bulbosity just by changing the lens If you use

a 100 mm macro lens without any zoom, you will

not experience any problems

The photos below do not document any

sur-gery in between I took the photo on the left by

using a 35–85 lens set to 35’ and the photo on the

right by using a 100 mm lens There is no

differ-ence in lighting either

1.5 Shooting with a Smartphone

You cannot take patient photos with a smartphone Even the best phone on the market takes fi sh-eyed photos People take their own photos with smart-phones and evaluate their noses accordingly Most

of my patients complain that their noses are big in photos You should know what a fi sh-eye problem

is and be able to describe it to your patient

1.6 Camera Settings

I am not a professional photographer, but I have acquired all the knowledge necessary for my pur-poses You can take incredible photographs with a few adjustments It is unfair to receive criticism as

a surgeon because of bad photos instead of a pliment for good surgical results If you are going

com-to use the parafl ash system, an intermediate-level SLR camera will be suffi cient

1 Patient Photographs

1.6.1 Focus Settings

Photographers usually choose the eyes in portrait

photographs for focusing In rhinoplasty

photo-graphs, it is better to choose the nose as the focus

point The focus point can be set to the nose

1.6.2 ISO

This is the camera sensitivity to light 100 and 200

are appropriate As ISO increases, the color

qual-ity of the photos deteriorates Low ISO values

need intense light If you have parafl ashlights, you

can easily take photos with an ISO setting of 100

1.6.3 Shutter Rate

It shows how long the diaphragm stays open If the

shutter rate is longer than 1/125 the photo can be

affected due to shaking I generally use a setting of

1/160 If you choose a shutter rate faster than 1/200

there can be disparity between your camera and the

parafl ashlights This can cause photos to have a dark

half

1.6.4 F

You can take artistic photos with low “f” valued

focus distance The front and back of the focus

point become blurry We need a deep fi eld of

depth A value of 10 and above is adequate

1.6.5 Skin Color

The patient’s skin refl ects light in different amounts

If the patient’s face is dark in photos, then decrease

the “f” value If the patient’s face is bright in

pho-tos, then increase the “f” value I take my all photos

by changing the “f” value between 10 and 13 In

order to take good photos in an “f” value of 11 you

need to adjust the power of the parafl ashlight

1.7 Parafl ash Settings

You can show aesthetic lines better in front view

if one of the parafl ashlights is more intense, but then you will have problems with profi le photos Since we make evaluations based on photos taken from all angles, it makes sense to adjust the parafl ashlight intensity to the same level for all Taking photos in sunlight coming from windows can give better refl ections, but you cannot take the same photo at different times of day Therefore

a parafl ash system is a must

Since the light intensity of new video cameras

is high, it is possible to have great details in the afternoon light from one angle But it is diffi cult

to archive videos and have one standard for all recordings

Here you can see a patient example with dard settings

1 Preoperative

1 Patient Photographs

1.8 Imaging

I am often asked about my photography niques and imaging Therefore I will show step by step how to design the nose in Photoshop

Open the fi le

1 Preoperative

Choose the nose with Rectangular mask

Open the Liquify fi lter

Make a nose that fi ts the face

Practice it a few times and correct it over and over again

Work on tip details

You can use smaller masks for working in detail

Add an “ a” to the fi lename and save You can therefore save fi les with extensions such as aa, aaa, aaaa and compare them easily Example: IMG_5643a, IMG_5643aa When you choose sorting photos in the folder by name, your fi les will be aligned in order

1.9 Shadowing the Images

Determine the work that fi ts the patient’s face When you paste this photograph with 50 % den-sity into the patient’s original photograph, you can determine the differences between the origi-nal nose and the nose you want

You should choose the whole picture at the beginning in order to copy the work you like Macintosh: cmd-A (Windows: CTRL-A): this will select the entire picture

Macintosh: cmd-C (Windows: CTRL-C): this will copy the picture

Go to the history and choose the original picture

With the paste command, the new nose will be

pasted on the older one as a new layer

Macintosh: cmd-V (Windows: CTRL-V)

In the following photograph, two layers are formed

In the upper layer you can see our work The

origi-nal photo cannot be seen as it is underneath When

decreasing the contrast of the upper layer, the

pho-tograph in the lower layer becomes visible

From the layer adjustment menu on the right,

set the opacity of the upper layer to 50 % In this

way you can see the difference between the two

noses

If we save this document as JPG, we can store it easily The fi le that has more than one layer can only be saved as PSD format and opened by the Photoshop program Because of this choose merge down under the layers menu

cmd-E: Pastes all layers

Now the fi le can be saved as JPG, and you can see one layer on the right

Add “ plan“ to the name of the photograph and

save

Example: IMG_5643plan

The shaded picture gives information to the

sur-geon about the rotation and the amount of the

hump to be removed You can use this picture in

order to determine the new tip point We will use

a shaded picture in surgery drawings

1.9.1 The Importance of

Photography and Imaging

Make your design yourself

Do not undertake surgery without design For instance, you can get rid of a humped nose illusion as a result of a low tip

Make changes to forehead, chin and cheek The lowest point of the nose radix should be a little in front of the eyelashes In the profi le view,

if the eyelashes of the other eye are visible, it is more rational to fi ll the nose radix

Note

It is not appropriate to have fi xed rules for aesthetic issues You can choose to create a higher or lower nose ridge, but you should not forget that, when you lower the dorsum, the nasal body becomes indistinct in frontal view Thus, a low nose ridge requires more infracture

Work with Photoshop to determine if either the nose radix is in front or the glabella is towards the back I should admit that I have made some mistakes with this In the profi le view, if you can-not have suffi cient nose radix depth in spite of lowering the base to the level of the eyelash tip, it

is reasonable to fi ll the forehead with fat If you cannot create a certain nose radix depth, the nose can appear as if it starts from the forehead Such

a result tends to make patients unhappy

If your patient does not like your drawing and results, do not operate Your work should meet your patients’ expectations

Here you can see design and patient result

Our perception of beauty develops through the

observation of other people However, we decide

on the tip position and dorsal height during

sur-gery I think that this is cause for serious

confu-sion It takes time for our brain to rotate the

aesthetic perception by 90° For me, it took about

one year In order to accelerate this, rotate the

pic-tures of the noses that you fi nd beautiful by 90°

and look again Your brain can learn the

appear-ance of a beautiful nose in horizontal position

Important

Aesthetic information feedback is very

impor-tant You should avoid anything that may skew

your perception For example, the head of the

patient should be parallel to the ground If you

change the position of patient’s head at a

differ-ent angle in every operation, your chance of

mak-ing a mistake increases

As I am left-handed, I stay on the left of the patient to make my evaluation Therefore, I set up the computer to show the left view of the patient Right-handed surgeons should change position-ing accordingly You can rotate shadowed photo-graphs by 90°

Note

Do not enter the operation room without a

photograph

Do not operate by heart I never operate

with-out my computer Front, lateral views and

shad-owed photos should be open on your computer

The easiest way to put these views in one

pho-tograph is by opening all photos together and

tak-ing a composite photo of these views With

Shift-Command-F4, you can take a photo of what

you want With shift-Command- F3, you can take

a screen-shot I also integrate my patient photos

with this method Save the merged photo into the

patient’s folder Choose all the photos and create

a preview During surgery, when you want to see

other photos of the patient, your assistant can

show you photos via the left and right buttons

Example

Our patient’s photos were merged and a fi nal photo created

In the photo below you can see the lateral view

of the patient before surgery, the computer design and the result after one month The computer design cannot show a perfect result, but starting surgery without a design is similar to building without a ground plan Planning the main steps of your operation with the help of computer design

is rational If necessary, you can make small changes

2 Surgery Notes and Archiving

I prefer to write surgery notes with words that a computer can read It is possible to record sur-gery in drawings But then it will not be possible

to search 1,000 patient fi les via a word search You should be able to access your patient and surgery notes very quickly, even after a year It is

a waste of time to ask for your patient’s fi le from the archive If you do not record what you did in surgery, your development will be slow

In nose surgery certain results appear after about one year Evaluate your fi rst-year results with the help of your surgery notes In this way, you can fi nd your mistakes and correct them eas-ily Your recording program should be simple and easily accessed Do not spend too much on patient archiving programs You can have an archive with your computer’s simplest program without any technical support

I use the address book program in my puter I have a pre-written surgery note I copy and paste this note and then change the surgery note according to my patient’s operation I e-mail

com-it to the hospcom-ital secretary The secretary prints the epicrisis report and gives it to the patient Before my patient is awake, I have already writ-ten the surgery note and emailed it

Another advantage of this system emerges when preparing conference papers For example, you invented a new technique and want to submit

a paper You want to fi nd out on how many and which patients you have used this technique

Example

On how many and which patients did I use the

autorim fl ap technique? I write “autorim fl ap” in

the address book In less than a second I will get

the patient names and see on how many patients I

have used the technique While writing this

sec-tion, I have done a search for this technique and

found out that I have used it on 178 patients

2.1 Photography Archive

I open a folder with the patient’s name during the

patient consultation and save the photos I take in

that folder When my patient comes for a check-up

I enter the patient’s name into the search box and

easily access the folder Do not lose time making

sub-folders, such as primary and secondary I

archive all my patient folders in one folder These

details can be archived by adding a key word to

your surgery note

2.2 Backup

Make backups regularly The photo archive of a plastic surgeon is priceless “Time Machine” is a quick and automated backup application

3 Skin Care and Rhinoplasty

The skin shows everything that we do in nose operations Therefore, we have to help the skin to change shape Blackheads aggravate the skin and makes redraping diffi cult You should have an esthetician who performs skin care without bruis-ing the skin In my offi ce I have an esthetician who performs skin care on the nose skin before and after surgery In the picture below you can see a patient’s photo before the surgery on the left, one month after the operation in the middle, and after skin care on the right There has been an increase in the patient’s oily skin In my opinion,

an increase in the skin’s oil negatively affects the skin

3.1 Oral Vitamin A

With oily skin you can often see infl ammation due to the sebaceous glands In these patients redraping will not be the same as in thin-skinned patients It is advisable to perform surgery on these patients after they have used oral vitamin

A for some time We offered Roaccutane ment before revision to a patient who had sur-gery with open technique in another clinic Below you can see the effects of the treatment

4 Menstruation

Do not operate on your patients during their strual period Bleeding and edema can be more signifi cant during surgery, and your control can decrease After surgery swelling and bruising can occur more often The same problem can be seen

men-in patients who use oral contraceptive drugs

5 Forehead Fat Grafting

In rhinoplasty, important reference points are the cheek, chin and forehead When planning nose aesthetics, these reference points should also be considered Sometimes these reference points should be changed as well A small chin is cor-rected via chin prostheses In addition, the cheek and forehead reference points can be changed If the malar and zigomatic area are not protruding enough, the nose can seem bigger than it is Changing the forehead reference point is not a well-known procedure, but we can change the

fat injection I, however, think that fat grafting using a cannula is safer

Isik S, Sahin I Contour restoration of the head by lipofi lling: our experience Aesthetic Plast Surg 36(4), 2012:761–6

fore-Why is the forehead important in aesthetic nose surgery?

My patients often say: “Please do not make

my nose start from my forehead, I see it where, and it is very obvious.” It is not easy to lower the radix; dissection is diffi cult, bone den-sity is high and adapting skin to this area is not easy An important issue concerns the following: when the height of the nose radix at its lowest point is lowered more than 1.5 cm, the nasal body starts to disappear from the front view Lowering the nose radix more than normal in order to pre-vent the nose starting from the forehead is not correct It is more appropriate to correct the area where the actual problem lies

else-I learned fat injection to the forehead from Oscar Ramirez In Istanbul we performed rhino-plasties together for three days Ramirez performed our fi rst forehead fat injection to our patient

5.1 Technique

Before starting nose surgery we take fat with a

2.1 mm cannula and 10 cc locked injector We make

it homogenous and hold it perpendicular during

nose surgery Thus for three hours the fat is fi ltered

by itself After taping the nose we give the fat

injec-tion to the forehead I use a 1.2 mm blunt cannula

for injection It is possible to fi ll the glabella and

forehead by means of three holes which are opened

from the eyebrow edges and hair line with a blood

needle We inject aqueous fat without centrifuging

it, so that the fat is distributed more homogenously

In the two drawings below only the foreheads

are different The noses are identical with each

other I recommend fat injection for 10–20 % of

my patients

The navel, waist and knee medial are

appro-priate sites for harvesting fat I usually prefer to

take fat from the waist area

21 Patient Example

We made a fat injection into the forehead and

chin of my patient who had rhinoplasty Note the

effect of bringing forward the forehead and chin

on the appearance of the nose In the fi rst two

photos you can see the result of rhinoplasty

sur-gery In the subsequent photos you can see the

fat-injected state of the forehead and chin The

postoperative fi rst-year results of rhinoplasty and

the fi rst-month results of the fat injection can be

seen here

Patient Example

Below you can see the photos of a patient who has had a fat injection into her forehead 13 months before Note the relationship between the patient’s eyebrow tip and radix The transition between forehead and nose was corrected with-out deepening the radix As this patient’s skin is very thin, the supra- tip break point became more obvious than normal A revision is planned Please note the reduced image of the exophalmus