Plastic Surgery. Volume 2 Aesthetic. Part 2

550 Pages·2016·132.73 MB·English

by  Neligan P.

422 SECTION I •19• Closed technique rhinoplasty
Changes in the nasal skeleton are not independent, however, the patient’s family will not accept an initial interview
but rather have global effects outside their areas. Resection of with the patient alone (which occasionally happens), their
the nasal bridge affects nasal width and length, apparent nasal response is a significant sign that should not be overlooked.
base size, middle vault support, alar rim contour, and colu- When the patient has had prior surgery, it is important to
mellar position. Similarly, alar cartilage reduction can affect obtain a careful chronology and, if possible, photographs that
tip support and projection, nasal length, alar rim contour, and reflect the preoperative appearance. Such pictures provide
external valvular support. These structural interdependencies information about the prior surgeon’s goal and how the
are not just regional. Recognizing them is necessary to pre- current deformities may have occurred and place the patient’s
operative planning, interpretation of intraoperative nasal original objectives in current perspective. For the younger
appearance, postoperative success, and the correction of sec- surgeon, a comparison of preoperative photographs to out-
ondary deformities. comes is invaluable and teaches an enormous amount about
the consistencies and variabilities of nasal skeletal and soft
tissue responses to surgery.
The interview Inquire about the airway first to avoid becoming distracted
by the patient’s aesthetic considerations, which always seem
Although rhinoplasty presents unique difficulties for the more pressing. Ask about periodic or cyclic airway obstruc-
surgeon, it is difficult for the patients as well. Those surgeons tion; which airway is worse; any history of nasal trauma;
who have seen secondary rhinoplasty candidates devastated seasonal allergies that obstruct the airway; clear rhinitis; epi-
by the results of one or more prior operations should sodes of suppurative sinusitis requiring antibiotics; snoring,
immediately recognize the importance of a safe and biologi- epistaxis, and sinus headache; and what nonsurgical remedies
cally sound surgical plan and of an accurate understanding the patient has previously tried, successfully or unsuccess-
between patient and surgeon of the aesthetic goals and the fully. Not infrequently, secondary rhinoplasty patients with
realities of the surgical problem – that is, what is possible and poor airways chronically self-medicate with steroid or vaso-
what is not. constrictive sprays that must be eliminated before surgery.
Making the interview more difficult is the prevalent mis- Also important are the patient’s work environment and a
conception that many patients hold about their nasal deformi- history of tobacco or alcohol consumption (either of which
ties and therefore about the corrective plan. Many patients do may cause nasal congestion) and, more important now than
not recognize that a simple nasal reduction may not achieve in previous years, cocaine use. Finally, inquire about any nasal
their goals. Patients without airway obstruction do not appre- areas that the patient does not wish altered and, if appropri-
ciate the importance of maintaining nasal function, and most ate, whether a change in ethnic appearance is desired.
do not realize that an improperly performed rhinoplasty can
jeopardize the airway. Differences in primary and
The patient must therefore be guided to understand that
secondary candidates
every rhinoplasty is a compromise between the patient’s pre-
ferred aesthetic goals and the limitations that a predetermined
Primary and secondary rhinoplasty patients differ in three
preoperative skeletal and soft tissue configuration imposes.
characteristic ways. First, the secondary patient’s scarred,
Donor materials vary in quantity, character, and composition,
determining their usefulness.66 Finally, many preoperative contracted soft tissues will not tolerate aggressive dissection,
multiple incisions, or tight dressings. Second, graft donor sites
noses already have some desirable features; patient and
may have already been harvested, necessitating the use of
surgeon should be careful not to destroy them.
more difficult (distorted septum or concha), painful (costal),
It is important to elicit the patient’s goals in the greatest
or frightening (calvarial) donor sources. Third, the secondary
possible detail and to prioritize them. Is the major issue bridge
rhinoplasty patient’s morale is often more fragile. Having
height, tip projection, nasal length, asymmetry, or airway?
already invested money, time, discomfort, and emotion in one
How long has the sense of deformity existed? This latter ques-
or more unsuccessful procedures, what secondary rhinoplasty
tion is more critical in older than in younger patients: the
patients fear most and need least are additional disappoint-
60-year-old patient who has disliked her nasal shape for 40
ments. The surgeon should be careful to construct a plan that
years may tolerate a larger change than will one who has been
is based on a clear understanding of what is possible and
troubled for only 5 years and who may be noticing only signs
founded on sound surgical and biologic principles that maxi-
of recent aging.
mize the airway and respect the patient’s aesthetic goals.67
For any patient older than 14 years, the author prefers to
interview and examine the patient alone (in minors after
parental permission), before involving the family, spouse, or The preoperative examination
others of significance in the discussion. Although some pro-
tective family members or spouses initially object to this It is wise to make a habit of examining the internal nose first,
policy, it is important to establish an individual relationship so that this most critical functional area is not forgotten in the
with the patient and to hear his or her concerns and com- discussion of aesthetics. Patients are always grateful to breathe
plaints free of outside influences. Not surprisingly, it is usually well, even when an inadequate airway is not a prominent
the family members who object most strongly who should preoperative complaint; patients who breathe poorly may
most be excluded from the initial consultation, when their be unaware of their obstructions. The surgeon must avoid
presence invariably distracts the patient, and questions to the unintentionally decreasing postoperative nasal function; this
patient (like some odd ventriloquist act) elicit responses from occurs more often than is often recognized and poor airways
the family member instead. If, after an adequate explanation, frequently dominate the complaints of secondary rhinoplasty
Basic nasal aesthetics 423
patients. The internal nose should be examined without considered, as is the balance between nasal base size and
manipulating the airway by asking the patient to breathe bridge height (see below). The patient is asked to discuss each
deeply and observing areas of collapse or asymmetry in the nasal area, whether or not it has been mentioned previously:
nasal sidewalls, high septal deviations, distortion of the colu- width, length, bridge contour, tip shape, nostril size, columel-
mella, protrusion of the caudal septum, or alar rim collapse. lar and upper lip position, and any asymmetries.
Valves
Basic nasal aesthetics
Sidewall collapse with inspiration at one or both of the nasal
valves is surprisingly common. It is important to determine
why valvular incompetence exists (e.g., prior surgery, intrin- On frontal view, the upper nose should be narrower than the
sic weakness, or alar cartilage malposition). If sidewall col- lower nose; symmetric, confluent, divergent lines should
lapse occurs, occlude one nostril and ask the patient to connect the two. On oblique view, there should be no regional
compare flow through the unobstructed airway with and discontinuities, the supratip should be flat, and tip lobular
without supporting the collapsing area with a cotton-tipped mass should fall below the levels of the peaks of the alar car-
applicator soaked in 1% Pontocaine hydrochloride for the tilage domes. On lateral and oblique views, nasal length and
patient’s comfort. Patients with valvular incompetence will base size should balance each other. Ideal parameters have
notice an obvious and gratifying increase in airway size. The been suggested.71–75 The practical difficulty in employing
surgeon may observe valvular collapse and substantial airway many of these guidelines lies largely in the facts that skin
obstruction, even in the patient with a straight, unoperated sleeve volume and distribution have already been predeter-
septum and without turbinate hypertrophy. Here, septoplasty mined and that skin contractility is limited, not infinite.
may be indicated to harvest grafts but by itself will not open Furthermore, ideal aesthetics do not apply to most patients,
the airway; the surgeon must also place appropriate valvular even most Caucasians.75 If the surgeon had the latitude of
grafts. Reconstruction of the internal and external valves can reducing skin volume, the size of the postoperative nose
triple or quadruple airflow in most rhinoplasty patients, even could be altered more radically to a patient’s facial measure-
when septoplasty is not simultaneously performed.8 ments, body habitus, or other parameters. In practice, however,
the surgeon works within narrower limits. The airway should
Septum be patent and stable on forced inspiration. Beyond these
basics, the details depend on the patient’s skeletal framework
The septum should be palpated for substance, contour, and and soft tissue cover and his or her aesthetic goals. Rhinoplasty
mucosal cover (indicating the sequelae of allergy, injury, per- offers, as much as or more than any other aesthetic procedure,
foration, or chronic cocaine use). It is also important to assess the possibility of individualizing an aesthetic goal.
whether a “high” (i.e., toward the anterior edge) septal devia-
tion exists; because hump removal can unmask a high septal Preoperative photographs
curvature, the surgeon should be prepared to camouflage or
correct the septal deflection with unilateral or asymmetrically
For consultation, formulation of an operative plan, and intra-
thick spreader grafts.14,68
operative guidance, good photographs are imperative. The
patient’s photographs should be available before the immedi-
Turbinates ate preoperative visit so that the operative plan on which
surgeon and patient have already agreed may be reviewed or
Although the turbinates are time-honored causes of airway
modified. Photographs should include full head and close-up
obstruction and affect the airways of atopic patients or patients
frontal views, both oblique views (which often differ, particu-
with chronic, severe septal deflection (in which the turbinate
larly in patients with nasal asymmetry), both lateral views,
contralateral to the septal deviation hypertrophies), clinical
and an inferior view. Photographs are best taken with a por-
and rhinomanometric data indicate that obstructing tur-
trait focal length lens (90–105 mm) against a medium–dark
binates are relatively low in the hierarchy of common airway
background, lit so that symmetries and contours will be
obstruction causes in primary and secondary patients. Because
depicted accurately. Camera-mounted flash units are inferior
turbinates warm and humidify inspired air, the surgeon
to studio systems with umbrella lights or wall-mounted
should plan conservative resections even in atopic patients.
strobes to provide backlighting and to illuminate the face
Furthermore, histologic studies have shown that turbinate
and hair.
hypertrophy secondary to septal deviation is characterized by
bony, not mucosal overgrowth.69 Therefore, most patients who
Setting goals with the patient
have had good septal and valvular reconstruction can be
adequately treated by only turbinate crushing and outfracture
(or no treatment at all).70 Because practical rhinoplasty strategies may differ from what
patients imagine, the patient must understand the logic of the
External nose surgeon’s plan and prefer it to other reasonable alternatives.
Unless the surgeon plans only to reduce the nose, he or she
Palpation of the external nose provides important information must help the patient understand the benefits of equilibrium
about cartilaginous size and substance, bony vault length, or conservative reduction; to this end, words like “balance”
nasal sidewall stiffness (another assessment of valvular and “proportion” often serve better than terms that signify
support), and soft tissue thickness. Tip lobular contour is only size. It is best to be specific about the plan down to the
424 SECTION I •19• Closed technique rhinoplasty
last graft and choice of donor sites; this candor places patient sleeve and the limitations that they impose. Three soft tissue
and surgeon on the same side of the problem and also ensures parameters can be used to form any rhinoplasty plan,76,77 and
that minor postoperative imperfections are more likely to be they will therefore apply to both primary and secondary
tolerated by the patient, who understood the necessity of each patients.
surgical maneuver beforehand. Recognizing the rationale for
grafting is more difficult for primary than for secondary Skin thickness and distribution
patients; the latter, who have already seen the effects of reduc-
tion and disequilibrium on their nasal configurations and
It may be intuitively obvious that skin thickness affects
airways, are often easier to convince.
any rhinoplasty plan, but so also does skin distribution. The
preoperative large nasal base does not contract into a small
Discussion of potential complications nasal base; rather, it contracts to a distorted large nasal base.
and revisions Skin quality therefore affects both reduction and augmenta-
tion. Thicker skin requires more skeletal support and con-
tracts less well; the surgeon must thus be conservative in
Patient and surgeon alike must remember that revisions
reduction and will need more substantial grafts to produce a
may be necessary, almost predictable, in some difficult con-
given result (Fig. 19.10A,B). Thinner skin allows greater
figurations if the best possible result is desired. Revisions are
reduction but requires softer grafts to avoid surface distor-
frequently minor, but all patients should understand preop-
tions (Fig. 19.10C,D).
eratively what cannot be predicted and therefore not mistake
the uncontrollable for the uncontrolled. The patient must
know preoperatively that no revision should be undertaken Tip lobular contour
until the end of the first postoperative year. Resolution of
swelling and stabilization of the final appearance take at least
Because the nasal base (the lower nasal third) has a more
that long in the primary nose and often longer in patients
complex topography than the simpler pyramidal bony and
undergoing secondary rhinoplasty; during that time, irregu-
upper cartilaginous vaults, and because the soft tissues are
larities, asymmetries, or poor contours that initially appear to
always thicker in the caudal than in the cephalic nose, it
require revision may improve sufficiently without surgery.
follows that the surgeon should select first those maneuvers
Nothing should be done until healing is complete. The surgeon
that provide the best nasal base contours. Ideal tip aesthetics
should control every possible variable.
(Fig. 19.11A) require a defined point of greatest projection,
Who should perform the revision? To some degree, the answer
a flat supratip, and a tip lobular mass that falls below the
depends on the same factors involved in the prior rhinoplasty.
point of greatest projection. The poorly shaped tip lobule
The surgeon’s model and proposed solution should be clear,
has the opposite characteristics: a poorly defined, low point
and the patient’s goals reasonable; patient and surgeon must
of greatest tip projection, a convex supratip, and a tip lobular
understand each other explicitly. Each operation is geometri-
mass that lies cephalad to the point of greatest projection
cally more difficult than the last.
(Fig. 19.11B).
Tip lobular contour is important for two reasons. Simple
alar cartilage reduction cannot raise the level of the alar dome
Parameters of rhinoplasty planning
peaks or redistribute tip lobular mass but instead only pro-
duces a smaller replica of the same preoperative tip. To create
What limits the applicability of most proposed aesthetic an aesthetic lobule from a poorly shaped configuration, the
ideals is the character, volume, and distribution of the skin surgeon must raise the level of greatest projection and increase
A B C D
Fig. 19.10 (A,B) Patients with thick nasal skin; skeletal reduction must be more conservative and augmentations more substantial to provide a given result. (C,D) Patients
with thin nasal skin. Although more soft tissue contraction can be expected, skeletal irregularities and graft visibility are more likely, and techniques must be altered
accordingly.
Parameters of rhinoplasty planning 425
A B C D
Fig. 19.11 Poorly shaped (A,B) tip lobules and well shaped tip lobules (C,D). The poorly shaped tip lobule requires not only a volume change but a configurational
change. (B from Constantian MB. Experience with a three-point method for planning rhinoplasty. Ann Plast Surg. 1993; 30:1. D from Constantian MB. Four common
anatomic variants that predispose to unfavorable rhinoplasty results: a study based on 150 consecutive secondary rhinoplasties. Plast Reconstr Surg. 2000; 105:316.)
lobular mass caudal to this point, effectively lengthening the advocates of open rhinoplasty properly note that binocular
middle crural alar cartilage segment. The tip change is one of vision is possible, that anatomic points obscured by the
contour, not only of volume. skin sleeve can be uncovered, that certain techniques can be
performed more easily, and that the scar itself is ordinarily
imperceptible.
The balance between nasal base size and
All of these arguments are valid. Open rhinoplasty
bridge height does, however, impose its own constraints on surgeon
and patient. The dissection is slower, and postoperative
Dorsal reduction or augmentation profoundly affects the morbidity may be higher. Poor scars occasionally do occur.
apparent size of the preoperative nasal base.77 The higher Unfortunately, although designed to do so, the open approach
the dorsum, the smaller the nasal base appears (Fig. 19.12). has not diminished the incidence or severity of secondary
The reverse is also true: dorsal reduction increases apparent deformities.
nasal base size. This powerful illusion has its most important These are the common objections, but not necessarily the
practical application in: (1) patients who believe that preop- most important ones. First, by separating columellar skin
erative nasal base size is excessive, in whom the aesthetic goal from the medial crura, the surgeon loses an important com-
may best be reached by a change in balance instead of only ponent of tip stability and projection, which therefore requires
size (Fig. 19.13A,B); and (2) patients whose soft tissues are some method (suture fixation or columellar strut) to support
thick, and who therefore may be more successfully treated the medial crura so that a new nasal tip can be made. The strut
by the combination of reduction and augmentation (Fig. can impart rigidity to the columella and increases graft
19.13C,D), a paradoxical principle that most patients and requirements. In primary patients, this consideration may be
many surgeons have to see to believe. unimportant, but in secondary patients, whose donor sites are
already depleted, every bit of graft material counts. Though
incisions are limited, endonasal rhinoplasty is not a blind
Why this author still prefers endonasal
operation. Most procedures are performed under direct vision
rhinoplasty with greater access than endoscopic surgery permits. The
operative strategy, making skeletal changes through limited
Endonasal rhinoplasty is an operation designed around incisions and judging progress by feeling the surface, is pre-
changes in the skin surface. The skeleton is only a means to cisely the same discipline required by suction-assisted lipec-
that end. Critical indicators such as skin sleeve movement, tomy. Limited pocket dissection minimizes the need for graft
balance changes, and the effects of reduction and augmenta- fixation and simplifies some procedures. Solid or crushed
tion all depend on an ability to see the undisturbed nasal grafts can be used in ways that would be tedious or impos-
surface accurately. This is the anatomy that the patient sees sible by the open approach,78 although some solutions have
and that determines the success of the surgical result; this is been described.79
the right-brain part of the operation. Rhinoplasty is made easier not necessarily by a larger inci-
Although not a new operation, open rhinoplasty has sion but rather by an accurate analysis of the surgical problem
enjoyed its resurgence in the past two decades because of and adherence to a strategy that reflects the real biologic pro-
the frustration that many surgeons experience in performing cesses at work. Almost all secondary deformities result from 
the newer rhinoplasty techniques through the endonasal inaccurate recognition of anatomic variants, tissue characteristics, 
approach. Reinforcing this stimulus is the traditional respect or functional/structural interrelationships and almost none occur 
that all surgeons have for anatomy and exposure. The because the surgeon could not see well.
426 SECTION I •19• Closed technique rhinoplasty
A B
C D E F
Fig. 19.12 (A,B) The effect of bridge height on apparent nasal base size. Although both nasal bases (lower nasal thirds) are the same size, the nasal base on the right
appears larger because the dorsum and nasal root are lower. This illusion provides an important diagnostic and therapeutic tool. (C–F) Low radix, in each case, corrected by
augmentation. Notice the apparent difference in nasal base size and balance, caused by the alteration in dorsal configuration.
A B C D
Fig. 19.13 (A,B) Patients who believe that preoperative nasal base size is excessive, in whom the aesthetic goal may best be reached by a change in balance instead of
only size, and (C,D) patients whose soft tissues are thick, and who therefore may be more successfully treated by the combination of reduction and augmentation, a
paradoxical principle that most patients and many surgeons have to see to believe.
Surgical technique 427
The decision to operate needs to develop their own judgment; sequential photographs 
are the key.
Before agreeing to operate on a patient, the surgeon must be
able to answer each of the following questions affirmatively:
1. Can I see the deformity? This question eliminates Surgical technique
delusional patients or those with minimal defects
that may not e surgically correctable.
Rhinoplasty differs from operations that may be more easily
2. Can I personally fix it? This criterion will vary portrayed step-by-step in atlases. Intraoperative feedback
from surgeon to surgeon and must be based on is both difficult and unconventional: perspective is limited;
operative experience and ease in correcting specific skin volume and texture, skeletal structure, and graft material
problems. produce constant variations among patients; strategies
3. Can I manage the patient? A patient who is unacceptably required for similar deformities differ according to the ana-
nervous, impossible to examine, or unwilling to comply tomic details or the patient’s desire; and the final postopera-
with preoperative and postoperative instructions is a tive contour depends on soft tissue and skeletal changes and
poor candidate, even if all other conditions are met. therefore, does not appear immediately. Surgical success will
be higher if the surgeon remembers the equilibrium model
4. If there is a complication, will the patient remain controlled 
and therefore interprets the intraoperative nasal appearance
and cooperate with treatment? No patient enjoys a
as the product of reduction, disequilibrium, augmentation,
complication, but there are those who, although
and skin sleeve movement. This section describes each opera-
disappointed, quietly understand and will await the
tive step in the order in which the author ordinarily performs
proper time for revision. There are others who become
it; depending on the specifics of nasal configuration and surgi-
hysterical, angry, disruptive, or accusatory and want an
cal plan, some steps may be omitted.
immediate correction. From the author’s experience, the
personal stress of operating on the latter group and
anticipating the outcome if something goes wrong is Routine order of surgical steps
agonizing. More than that, patients whose emotions are
so poorly controlled are in no position to withstand the The operation is routinely performed under general anesthe-
additional trauma of surgery. sia. The patient is placed supine with the arms and legs
5. Does the patient accept the margin of error inherent in  padded and the knees slightly flexed; the operating table is in
surgery? This is the most important criterion. Some 10–15° reverse Trendelenburg position to minimize bleeding.
patients (and even some surgeons) have unrealistically After induction of general anesthesia, the nose is blocked
optimistic opinions about the degree to which any with a freshly prepared solution of 1% lidocaine with epine-
surgeon can control wound healing; the quality and phrine 1 : 100 000 (20 mL of 1% lidocaine plus 0.2 mL of epine-
availability of building materials, the patient’s immune phrine 1 : 1000). Infiltration begins at the nasal root, along each
competence, and the myriad other factors, currently lateral nasal wall, into the columella, across the maxillary
known and unknown, that influence surgical outcomes. arch, and into the alar lobules to vasoconstrict the branches
The patient’s willingness to accept the imperfection that of the primary supplying vessels (angular, anterior ethmoidal,
is inherent in surgery is a willingness to accept the superior labial) and the relevant nerves (anterior ethmoidal,
imperfection that is inherent in being human. infraorbital, infratrochlear). This infiltration usually consumes
about 7 mL of the anesthetic solution, the rest of which is
saved for the septal surgery. Nasal vibrissae are shaved with
How to teach yourself rhinoplasty
a No. 15 blade, and the nose is thoroughly cleansed internally
with a povidone–iodine solution. Internal preparation of the
The following paragraph is from the experience of the author, nose should be even more fastidious than skin preparation,
in the early years of his career. not the reverse, remembering that the nasal lining is the
I recognized early in my career that the rhinoplasty steps real operative surface. For hemostasis and anesthesia of the
that were so neatly drawn in atlases, simply did not apply in nasopalatine nerve, the internal nasal and posterior nasal
the operating room. I soon decided that there had to be a branches of the anterior ethmoidal nerve, the internal nasal
pattern to what I was seeing, but I had no idea what it was or branch of the nasociliary nerve, and the nasal branch of the
how to recognize it; I needed time to think. I began taking anterior superior alveolar nerve, two cotton packs soaked in
sequential, intraoperative photographs after each critical 4% cocaine solution and squeezed dry with sterile gauze are
step, and lateral views at the beginning and end of each of placed in each airway. Only 4 mL of 4% tinted cocaine solu-
the operations, and silhouettes. Although I no longer take tion is made available for each patient (160 mg), safely below
so many intraoperative photographs, at the very least I still the maximum allowable dosage (200 mg). The patient’s face
photograph the nasal appearance at the beginning and end is prepared and draped.
of every operation, and then at every postoperative visit.
Now, after 32 years of practice, these sequences have become Skeletonization
the foundation of my rhinoplasty understanding. After
surgery, there is ample time to examine each image and Skeletonization controls access to the underlying structures
decode the feedback that the nose supplies. Each surgeon and also influences skin sleeve movement; by limiting skele-
needs to learn how different augmentations and reductions tonization, the surgeon can use the undissected soft tissues to
behave in different noses, and in his/her own hands. Surgeon immobilize any cartilage grafts. Skeletonize widely over the
428 SECTION I •19• Closed technique rhinoplasty
upper cartilaginous vault to shorten the nose; otherwise limit width, middle vault position, apparent columellar position,
skeletonization only to those areas that will be changed. and nostril contour. If the radix will be elevated, less dorsal
resection is required (Fig. 19.16). Because resection of the bony
Technical details
and cartilaginous vaults alters their dynamic anterior projec-
The author ordinarily skeletonizes the nose through unilateral tion, reduced support to the upper nasal skin allows the alar
or bilateral intracartilaginous incisions (Fig. 19.14), depending cartilages to rotate cephalad or caudad, depending on the
on whether alar cartilage modification will be necessary. The preoperative nasal configuration. Most noses shorten after
incision runs from the lateral end of the caudal reflection dorsal resection, but long noses, especially those in which a
of the upper lateral cartilage around the septal angle. With dorsal convexity has occupied the caudal half, can lengthen
Joseph scissors (Fig. 19.15) and then a broad Cottle periosteal after dorsal resection. The surgeon should watch for these
elevator, the soft tissues are elevated over the bony and upper intraoperative changes and adjust subsequent steps accord-
cartilaginous vaults only as necessary for access. It is impor- ingly. The surgeon must also observe the effect of dorsal resec-
tant for the surgeon to obtain smooth elevation of all soft tion on middle vault support. If the cartilaginous roof is
tissues to ensure good cover and avoid dermal injury. If resected, the middle vault eventually collapses. The surgeon
no transfixing incision is necessary, the intercartilaginous must observe the contour of the middle third to determine
incision stops at the junction of the anterior and middle thirds the presence of a high septal deviation that may have been
of the membranous septum; if the caudal septum requires masked by a symmetric dorsum or that may have been wors-
shortening, the incision can be carried toward the anterior ened by dorsal resection. These observations will guide the
nasal spine. use of spreader grafts and how they can be used to produce
a symmetric result.
Dorsal resection
Technical details
Producing a straight dorsum from a convex one is not a simple The author performs the dorsal resection under direct vision
matter. The surgical plan must consider: (1) radix position; (2) using a sharp Fomon rasp. Resection of the dorsal border of
dorsal height; and (3) the adequacy of tip support. Dorsal the septum is accomplished with a No. 11 blade from which
resection can affect nasal length, apparent nasal base size and the tip has been broken to avoid lacerating the contralateral
dorsal skin. Despite the fact that the rasp and blade permit
more conservative resections than saws or osteotomes, the
surgeon can still over-resect. The dorsum should feel and
appear perfectly smooth through the skin surface after dorsal
resection.
Fig. 19.14 The intercartilaginous incision, which can be lengthened into a Fig. 19.15 The intercartilaginous skeletonizing incision begins at the apex and
transfixing incision if necessary, gives access to the dorsum, upper and lower proceeds laterally only as far as necessary. Dorsal access and visualization are
lateral cartilages, and the septal angle. Dorsal modification; upper and lower lateral easiest for a right-handed surgeon through a left-sided incision, and vice versa.
cartilage resection; spreader, radix, dorsal, and lateral wall grafts can all be If the surgeon does not need to shorten the upper or lower lateral cartilages, only
performed through this excellent access point under direct vision. a single intercartilaginous incision is needed.
Fig. 19.16 (1) Primary rhinoplasty patient with low radix, narrow middle vault, and inadequate tip projection in which radix, spreader, and tip grafts are planned.
Preoperative appearance before the incision. (2) Nose after skeletonization. Note the difference in columellar position, nasal tip rotation, and apparent flattening of the dorsal
hump, all artifacts of skeletonization. (3) By elevating the radix skin with a fingertip, the surgeon can estimate the amount of dorsal reduction that is actually necessary,
assuming that radix augmentation will be performed. (4) Intercartilaginous incision; a similar incision is made on the patient’s left side. Both give access to the dorsum, the
septal angle, and the alar cartilage lateral crura. (5) Transfixing incision for access to the caudal septum. (6) Rasp used for roughening the nasal root so that radix grafts will
adhere. (7) Fomon rasp for lowering the bony vault. (8) The bony vault is reduced by careful use of this down-cutting rasp. (9) After reduction of the bony vault, the
cartilaginous dorsum seems even higher, further demonstrating the importance of the low root on the apparent height of the nasal bridge.
Surgical technique 429
1 2 3
4 5
6 7
8 9
430 SECTION I •19• Closed technique rhinoplasty
10 11
12 13
14 15
16 17
Fig. 19.16, cont’d—For Legend see p. 428
Surgical technique 431
18 19
20 21
22 23
24 25
Fig. 19.16, cont’d—For Legend see p. 428