Mastering Rhinoplasty: A Comprehensive Atlas of Surgical Techniques with Integrated Video Clips

455 Pages·2010·31.299 MB·English

by  Rollin K. Daniel (auth.)

Mastering Rhinoplasty: A Comprehensive Atlas of Surgical Techniques with Integrated Video Clips
Rollin K. Daniel
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Rollin K. Daniel
Mastering Rhinoplasty
A Comprehensive Atlas
of Surgical Techniques
with Integrated Video Clips
2nd Edition
With 259 Color Figures in 1408 Parts
and 146 Integrated Intraoperative DVD Clips
Jaye Schlesinger, Medical Illustrator
Chuck Cox, Videographer
123
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Rollin K. Daniel, MD
1441 Avocado Ave., Suite 308
Newport Beach, CA 92660, USA
[email protected]
and
Clinical Professor of Surgery
Department of Plastic Surgery
University of California, Irvine
Irvine, CA, USA
Medical Illustrator:
Jaye Schlesinger, MFA
School of Art and Design
University of Michigan
906 Miner St.
Ann Arbor, MI 48103, USA
[email protected]
Videographer:
Chuck Cox, WBV
SD Biomedical Communications
4127 Pallon Court
San Diego, CA, USA
chuckcoxepacbell.net
ISBN 978-3-642-01401-7 eISBN 978-3-642-01402-4
DOI 10.1007 / 978-3-642-01402-4
Springer Heidelberg Dordrecht London New York
Library of Congress Control Number: 2009931340
 2004, 2010 Springer-Verlag Berlin Heidelberg
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Dedication
To Beatrix Tirkanits, MD, FRCS (C)
Diplomat, American Board of Plastic Surgery
Both personal and professional partner whose sacrifi ce
and support made this book possible.
To Andrew Nicholas Daniel, PhD
Son, scholar and fellow adventurer.
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Contents
1
Simplifying Rhinoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2
A Basic Rhinoplasty Operation ............................................ 13
3
Radix and Dorsum ...................................................... 67
4
Tip Techniques ......................................................... 101
5
Nasal Base ............................................................. 155
6
Functional Factors ...................................................... 183
7
Grafts ................................................................. 225
8
Primary Rhinoplasty: Decision Making ................................... 269
9
Advanced Primary Rhinoplasty .......................................... 307
10
Secondary Rhinoplasty: Surgical Techniques .............................. 349
11
Secondary Rhinoplasty: Decision Making ................................. 379
12
Aesthetic Reconstructive Rhinoplasty ..................................... 407
Subject Index ................................................................ 441
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Table of DVD Clips
1 Rhinoplasty Simplified 2.16 Tip Position Suture DVD 1
2.16 d–f Tip Refinement Graft (TRG)
None
2.17 a, b Nostril Sill Excision
2.17 c, d Alar Wedge Excision
2.17 e, f Combined Sill & Wedge
2 Basic Rhinoplasty Operation
Excision
2.1 a Analysis 2.18 Cast & Post-Op Photos
2.1 b OperativePlanning
2.2 Anesthesia
2.3 a–d Open Approach 3 Radix and Dorsum
2.3 e, f Dissection: Columellar to Tip
3.6 Analysis
2.3 g, h Dissection: Bidirectional
3.7 Fascia (F) Graft
2.4 a, b Septal Exposure: Transfixion
3.8 (DC + F) Graft
2.4 c, d Septal Exposure: Tip Split
3.13 Bony Vault Reduction
2.4 e Extramucosal Tunnels
3.14 Split Cartilage Reduction
2.5 a–c Tip Analysis
3.15 a, b Osteotomies: Low to High
2.5 d–f Symmetrical Rim Strips
3.15 c, d Osteotomies: Low to Low
2.6 Bony Hump Reduction
3.15 j–l Spreader Grafts
2.7 a–f Cartilage Hump Reduction
3.19 Fascia (F) Graft to Dorsum
2.8 a–d Caudal Septal Resection
3.20 (DC − F) Graft
2.9 a–c Caudal Septal Relocation
3.22 Decision Making
2.10 Septal Harvest
2.11 a, b Osteotomies: Low to High
2.11 c, d Osteotomies: Low to Low
2.12 Spreader Grafts 4 Tip Techniques
2.13 Columellar Strut & Suture 4.1 Tip: Operative Planning
2.14 Domal Creation Suture 4.5 Tip: Anatomy & Aesthetics
2.15 Interdomal Suture 4.8 Tip: Analysis
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x TableofDvDClips
4.9 Open Approach 5.6 e, f Combined Sill & Wedge
4.10 Exposure: Columellar to Tip Excision
4.11 Exposure: Bidirectional 5.7 Excision: Caudal Septum & ANS
Table 4.2 Open Tip Suture 5.11 Composite Grafts
Technique – Step by Step 5.20 Nostril Splints
4.12 a, b Symmetrical Rim Strips
4.14 Columellar Strut & Suture
4.16 a, b Domal Creation Suture
6 Functional Factors
4.19 a, b Interdomal Suture
4.21 Domal Equalization Suture 6.1 a, b Septal & Valvular
4.23 a, b Lateral Crural Mattress Suture Obstruction
4.25 a, b Tip Position Suture 6.1 e, f Total Septal Deviation
4.27 Tip Refinement Graft (TRG) 6.2 Nasal Obstruction in a Cosmetic
4.29 Alar Rim Graft, Alar Structure Case
Graft 6.3 a, b Septal Exposure: Transfixion
4.31 a, b Open Structure Tip Graft (OST) Approach
4.31 c, d OST: Columellar Strut & Suture 6.3 c, d Septal Exposure: Dorsal/Tip
4.31 e, f OST: Domal Suture Split
4.32 a, b OST: Dome Excision & Tip Graft 6.3 e, f Septal Exposure: Dorsal
4.32 c OST: Integrated Tip Graft Split
4.32 d OST: Projected Tip Graft 6.3 g, h Septal Exposure: Tip Flip
4.39 OST: Operation with 4 year 6.4 a, b Septal Exposure
Result 6.4 c, d Septal Resection
6.6 d Caudal Septal Relocation
5 Nasal Base 6.9 Total Septoplasty
6.10 Nostril Valve
5.4 Analysis
6.11 Vestibular Valve
5.5 Base Analysis
6.12 Internal Valve
5.6 a, b Nostril Sill Excision
5.6 c, d Alar Wedge Excision 6.22 Repair of Mucosal Tear
DVD 2 7 Grafts 7.16 Structured Tip Graft: Integrated
7.17 Structured & Cap Tip Graft:
7.3 Spetal Harvest
Projected
7.4 a Spetal Harvest: BiDirectional
7.18 Spreader Grafts
Approach
7.19 a–c Radix Graft: Fascia
7.5 b–e Conchal Cartilage Harvest
7.19 d–f Combined Radix & Dorsal Graft:
7.6 Composite Ear Graft: Harvest
Fascia
7.8 a Fascia Harvest: Approach
7.19 g–i Radix or Dorsal Graft: DC + F
7.8 b–d Fascia Harvest: Endoscopic View
7.20 Dorsal Graft: Osseocartilaginous
7.9 a, b Fascia: Radix Graft
Rib
7.9 c, d Fascia: Combined Radix–Dorsal
7.21 Dorsal Graft: Double Layer
Graft
Fascia
7.11 a, b Costal Rib: Supraperichondrial
7.22 a DC − F: Overview
Harvest
7.22 b DC − F: Dicing Cartilage
7.11 c, d Costal Rib: Subperichondrial
7.22 c DC − F: Fascia Sleeve
Harvest
7.22 d DC − F: Filling Sleeve
7.12 Inframammary Rib: Full
7.22 e DC − F: Graft Insertion
Thickness Resection
7.25 Alar Rim Grafts (ARG)
7.13 Oseeocartilaginous Rib Harvest
7.26 Alar Rim Structure Grafts (ARS)
7.14 b Columellar Strut: Shaping & 7.27 Lateral Crural Strut Graft (LCSG)
Insertion 7.28 Lateral Crural Strut Graft
7.14 c Extended Columellar Strut (LCSG) with Alar Transposition
7.14 d Septo Columellar Strut 7.30 e Dermis Graft: Harvest
7.15 Tip Refinement Grafts (TRG) 7.30 f Dermis Graft: Insertion
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TableofDvDClips xi
8 Primary Rhinoplasty: Decision 11 Secondary Rhinoplasty:
Making Decision Making
8.17 b Lateral Crural Strut Graft (LCSG) 11.2 Fascia Blanket
8.17 c Lateral Crural Strut Graft 11.11 Case Study: Complex Secondary
(LCSG) with Alar Transposition Rhinoplasty
9 Advanced Primary Rhinopasty
12 Aesthetic Reconstructive
None
Rhinoplasty
10 Secondary Rhinoplasty: Surgical 12.1 b Foundation Layer
12.1 c Spreader Graft
Techniques
12.1 d Dicing Cartilage
10.4 Analysis 12.1 e, f Fixation of Septal Strut
10.5 Skin Defatting to ANS
10.6 Fascia Blanket 12.1 i, j Fixation of Septal Strut &
10.7 Secondary Septum Spreader Graft
10.8 b Structured Tip Graft 12.1 k, l Insertion of Columellar Strut &
10.9 Dorsum/Spreader Grafts Tip Graft
10.10 a Caudal Septal Replacement 12.1 m, n Dorsal Graft: DC − F
10.11 b Micro Osteotomies 12.7 Dorsal Graft:
10.11 e–h Spreader Grafts Osseocartilaginous
10.13 a–c Fascia Coverage 12.8 Nostril Support: Major Rim
10.13 d, f Add-on TRG Grafts Grafts
10.13 g–i Structured Tip Graft (OST) 12.10 Dermis Graft: Insertion
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2 Chapter 1   Simplifying Rhinoplasty 
A Foundation What would constitute the “P.E.R.F.E.C.T.” rhinoplasty operation? I think the following
Rhinoplasty attributes are important and perhaps acronymic.
Operation
Progressive. The surgeon should be able to use the operative technique for increasingly dif-
ficult cases by adding to the foundation operation (Fig. 1.1). Rather than learning an entirely
new procedure, one merely adds additional steps as more demanding cases are encountered.
For example, once the surgeon learns to master open tip suture techniques, then additional
tip definition can be achieved with add-on Tip Refinement Grafts (TRG) of excised cartilage.
Expandable. Although one may begin with a certain patient population, it is inevitable that
one will begin to see different types of patients who require modification of the basic tech-
nique. In Southern California, I saw a large number of Hispanic and Asian patients whose
thicker skin and under-projecting tips forced me to expand my surgical repertoire. Rather
than being a new operation, additions and modifications represent an expansion of the
foundation operation.
Reproducible. Every surgeon wants to achieve reproducible results. The critical first step is
to master a procedure in-depth and learn its surgical cause and effect. Many of the steps in
this operation are consistently reproducible including radix grafts, tip sutures, and spreader
grafts. The number of surprises and revisions can be quite low.
Functional. Form without function is not acceptable. I am convinced that 35% of patients
requesting a cosmetic rhinoplasty have a significant preexisting anatomical nasal obstruc-
tion, which if not corrected will lead to postoperative nasal obstruction. Therefore, a clear
understanding of septal, valvular, and turbinate function, as well as their surgical correction
must be a critical component of a rhinoplasty operation.
Esthetic. The reality is that virtually all female patients want a more attractive nose, but one
that looks natural. The younger the patient the greater the desire for a smaller cuter nose –
nine times out of ten, they inherited their father’s nasal features . In addition to being smaller,
they often want a slightly curved bridge, a slightly rotated columellar, and a well-defined tip.
This operation enables the surgeon to achieve these goals consistently.
Comfort Zone. Each surgeon has his/her own “rhinoplasty comfort zone.” Following comple-
tion of their residency or fellowship, most surgeons have experience with one operative
sequence. Initially, the surgeon should select those patients for whom they are confident
that they can achieve a good result. The advantage of this operation is that the surgeon can
progress to levels of greater difficulty from a solid foundation.
Tip Intentsive. One of the realities of cosmetic rhinoplasty surgery is that patients are con-
vinced that “as the tip goes so goes the result.” If the tip is not attractive, the patient will not be
happy. Thus, tip surgery is emphasized heavily in this operation and through out the text.
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