Textbook of Nasal Tip Rhinoplasty : Open Surgical Techniques

401 Pages·2020·38.571 MB·English

by  Natarajan Balaji

Textbook of Nasal
Tip Rhinoplasty
Open Surgical Techniques
Natarajan Balaji
123
Textbook of Nasal Tip Rhinoplasty
Natarajan Balaji
Textbook of
Nasal Tip
Rhinoplasty
Open Surgical Techniques
Natarajan Balaji
NHS Lanarkshire
University Hospital of Monklands
Airdrie, Lanarkshire, UK
ISBN 978-3-030-48156-8 ISBN 978-3-030-48157-5 (eBook)
https://doi.org/10.1007/978-3-030-48157-5
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V
Foreword
It is a pleasure and honour to introduce this textbook on nasal tip rhi-
noplasty. Surgeons practicing rhinoplasty are acutely aware that whilst
it may seem simple to many, they are far from straightforward. It is dif-
ficult to achieve consistently good results, with both minimal need for
revision and pleasing long-term outcomes which are aesthetically bal-
anced, and blend well with other facial features. The nasal tip is a par-
ticularly volatile area, and absolute mastery is a goal we must always
strive for but may never achieve. However, by understanding the assess-
ment of the tip, surgical principles, application of the correct techniques
and resultant outcomes, surgeons may gain near mastery of this coveted
field.
Any surgeon who intends to become accomplished in rhinoplasty
will experience a significant learning curve, particularly with regards to
the nasal tip. Improved outcomes in nasal tip surgery may be achieved
by harbouring in-depth knowledge. Successful senior surgeons, in my
opinion, have the absolute obligation to impart their knowledge for the
younger generation. This is what exactly Mr. Balaji has done in this
publication.
The book illustrates clear learning objectives, details on aetiology,
pathology and pathogenesis of tip deformities and lays the foundation
for the assessment of the tip during consultation in the clinic. This is
followed by discussion on surgical principles, detailed exploration of
suture techniques, grafting techniques and then non-suture and non-
grafting tip techniques. The nasal septum is discussed in depth, leading
into the control of the dorsum and management of the alar base. Par-
ticular attention is drawn to cleft rhinoplasty, closure of skin flap as well
as management of the nasal valves. I urge the readers to read thoroughly
the discussion on the algorithm for nasal tip management. Case studies
and ethical considerations, which often get less attention, are also well
addressed.
This is a masterpiece, in which a single surgeon has delivered his
knowledge, skill and love for nasal tip surgery with unparalleled insight.
It outlines his thinking and lifetime of surgical experience. I congratu-
late Mr. Balaji for all his work and recommend this book to all surgeons
interested in rhinoplasty surgery, regardless of experience, as it is a valu-
able reference guide, full of practical pointers for developing and
improving rhinoplasty, particularly nasal tip surgery.
Mr. Alwyn R. D’Souza
FRCS(ORL-HNS), FRCS Eng.
Past President: British Society of Facial Plastic Surgery.
President Elect: European academy of facial plastic surgery.
Consultant ENT/Facial Plastic Surgeon,
University Hospital Lewisham, London, UK
Preface
To start with, I am happy to be born in a country where the earliest
nasal reconstructive techniques were performed by the ancient Hindu
sage Sushruta in 800 BC, never forgetting the ancient Egyptian texts
dating back to the Old Kingdom (3000 BC). Equally, I am more than
happy to be living in my adopted Scottish land, which taught me the art
of rhinoplasty. Nasal tip surgery involves lot of “thinking” and “reason-
ing” and “problem-solving” skills. I find no two operations the same,
requiring different skill sets with different expected outcomes, which
make this operation so special. My book is intended to cover the nuances
of open approach nasal tip rhinoplasty. Although there are various
approaches to the nasal tip, “open” or “external” approach gives excel-
lent access. The debate of “closed” versus “open” goes on, but as long as
the outcome is good, the approach does not matter.
In attempting to write on nasal tip rhinoplasty, it is impossible to
cover this complex topic in a comprehensive way and I am in no way
able to cover the entire length and breadth of the topic, but at least able
to cover the nuances of nasal tip surgery based on my personal journey
and experience. To my knowledge there is no textbook available dedi-
cated only to nasal tip surgery in the current literature and I have set out
to fill this void. The techniques mentioned in this book are accepted
techniques in the mainstream literature described by various experts in
the field. Throughout the book, I have mentioned and referenced vari-
ous experts in the field, who have described these techniques as much as
I have. However, this list is not exhaustive and I may have inadvertently
missed some and can only apologise for the oversight. This book repre-
sents my way of approaching the topic, how to arrive at a surgical algo-
rithm in nasal tip deformities and how to execute various techniques in
a “sequence” to achieve meaningful results, based on my personal expe-
rience with over 1700 patients over the years. The majority of the book
(around 80%) involves actual description of each surgical technique
stepwise -of “how I do it” with as many illustrations as possible. The art
of nasal tip surgery is to identify the “Key” factor that will make the
patient happy and be “conservative” in executing the “minimum” neces-
sary intervention to achieve the “maximum” outcome as quickly and
effectively as possible with “minimal” tissue trauma.
I am grateful to Prof. Tardy who allowed me to visit him in Chicago
during the early 1990s, which triggered my interest in rhinoplasty. My
book on tip work will not be complete without mentioning the names of
a few doyens in the field who have pushed boundaries in rhinoplasty and
from whom I have acquired knowledge, in both North America and
Europe, notably Prof. Tardy, Dr. Tebbetts, Dr. Daniel, Dr. Adamson,
Prof. G. J.Nolst Trenité and Dr. Fazil Apayddin. My list is not an
exhaustive one, but again apologies if I have left some key figures. Also,
over the years, I have learnt a lot through lectures, meetings and infor-
mal discussions from my colleagues in the UK, notably Mr. White,
Mr. Sheikh, Mr. Calder, Mr. A.D’Souza and Prof. Woolford. I am
extremely thankful for that knowledge. I would like to thank Mr. Simon
VII
Preface
Ravichandran for his constructive comments on the hierarchy of chap-
ters. I feel nasal tip surgery is about “thought process”, and surgical
skills are only secondary factors in achieving a good outcome. Discus-
sions with teachers, colleagues and even trainees contribute to this
“thought” process.
Finally, most of the financial proceeds and royalties from the sale of
this book will be donated to the Scottish Otolaryngological Society for
the advancement of teaching and training in facial plastic surgery for
overseas fellows in Scotland.
Natarajan Balaji
Airdrie, Lanarkshire, UK
Acknowledgement
The first person I would like to thank is my wife Meena who has been a
constant source of support and encouragement over the last 10 years.
Without her words of motivation, I doubt this project would have been
possible. I am extremely grateful to my two daughters Anita and Priya,
both in the medical field, who have kept me focussed. Also to my late
parents and uncle for their tireless efforts in supporting my endeavour to
become a doctor.
I am extremely thankful to all my patients in both the NHS Lanark-
shire and private sector for allowing me to use their clinical photographs
for publication. I would like to thank Dr. Jane Burns, the Medical Direc-
tor, and Dr. Rory Mackenzie, Chief of Medical Services at the Univer-
sity Hospital of Monklands, NHS Lanarkshire, for their kind permission
in allowing me to use the clinical photographs of NHS Lanarkshire
patients. I would like to thank Eric, John and Christine from the Medi-
cal Illustrations Department at the University Hospital of Monklands,
Scotland, for their excellent help and support in taking high quality pic-
tures. Some of the photographs have already been published by me over
the years in various journals and have been reproduced in this book
with the kind permission of the editors of the respective journals, and I
offer my sincere gratitude to them. The articles have been referenced
accordingly to the best of my knowledge.
I would like to thank Mr. Nicholas Calder, my colleague who has
done a thorough review of the manuscript. I am indebted to the edito-
rial and production staff, particularly Ms. Smitha Diveshan and Ms.
Daniela Heller, at Springer for their professionalism and commitment
towards this publication. Finally, I dedicate this work to my teachers,
notably Mr. A. Baxter, Mr. B. W. Irvine, Mr. B. O. Reilly and Mr.
A. Johnston, for being who I am today.
IX
Contents
1 Introduction to Nasal Tip Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . 1
1 .1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2 Surgical Anatomy of the Nasal Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2 .1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2 .2 Surgical Anatomy of the Nasal Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2 .3 Nasal Tip “Tripod” Concept . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2 .4 Concept of “Big Guy – Small Guy” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2 .5 M-Arch Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2 .6 Skin and Soft Tissue Envelope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2 .7 Aesthetic Sub-units of the Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2 .8 Blood Supply of the Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2 .9 Aesthetic Tip Parameters (Definition, Projection and Rotation) . . . . . . . . 14
2 .9 .1 Projection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2 .9 .2 Rotation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
3 Aetiology, Pathology and Pathogenesis of Nasal
Tip Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3 .1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
3 .2 Types of Tip Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
3 .3 Aetiology of Primary Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
3 .4 Aetiology of Secondary Tip Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3 .5 Pathogenesis of Primary and Secondary Tip Deformities
and Clinical Correlation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3 .6 Clinical Types of Tip Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3 .6 .1 Pathogenesis of a Bulbous Nasal Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
3 .6 .2 Pathogenesis of a Narrow Nasal Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
3 .6 .3 Pathogenesis of an Over Projected Nasal Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
3 .6 .4 Pathogenesis of an Under Projected Nasal Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
3 .6 .5 Pathogenesis of an Under Rotated Droopy Nasal Tip . . . . . . . . . . . . . . . . . . . . . 37
3 .6 .6 Pathogenesis of an Over Rotated Nasal Tip with Short Nose . . . . . . . . . . . . . . 39
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
4 Assessment of the Nasal Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
4 .1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
4 .2 Assessment of the Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
4 .3 Assessment of the Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
4 .3 .1 Is It a Primary or a Secondary Tip Problem or a Combination
of Deformities? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
4 .3 .2 How Can You Say on Inspection a Tip Deformity Is Primary
or Secondary? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
4 .3 .3 Clinical Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
4 .3 .4 Projection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
4 .3 .5 Rotation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
4 .3 .6 Dorsal Aesthetic Lines (D-A-L) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
X Contents
4 .4 Assessment of Skin and Subcutaneous Tissue . . . . . . . . . . . . . . . . . . . . . . . . 61
4 .5 Assessment Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
4 .5 .1 Palpation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
4 .6 Functional Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
4 .7 Pathology Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
4 .7 .1 Septum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
4 .7 .2 Hump . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
4 .7 .3 Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
4 .7 .4 Deviation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
4 .7 .5 Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
4 .7 .6 Palpation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
4 .7 .7 Skin and Subcutaneous Tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
4 .8 Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
5 Nasal Tip Rhinoplasty: Consultation Process . . . . . . . . . . . . . . . . . . 67
5 .1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
5 .2 Following Are the ‘Top” Tips of the Clinical Consultation Process . . . . . . . 68
5 .3 Consultation Scenarios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
5 .3 .1 Scenario 1: The Over Flattering, “Ego” Flaming Talkative Patient . . . . . . . . . . . 71
5 .3 .2 Scenario 2: The Young Patient Who Comes in with a Relative
but Remains Silent During the Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
5 .3 .3 Scenario 3: “Beware of Young Lone Males” with Psycho-social
Issues and on Anti-depressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
5 .3 .4 Scenario 4: Guilt, Low Self-Esteem and Wants to Justify
the Money Spent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
5 .3 .5 Scenario 5: Patients Who Came Alone for the Initial
Consultation but Comes with Three People in the Post-op
Period – Dealing with the Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
5 .3 .6 Scenario 6: Dealing with Expectations of Revision Surgery . . . . . . . . . . . . . . . 72
5 .4 Patient Information Leaflet for Septo-Rhinoplasty . . . . . . . . . . . . . . . . . . . . 72
5 .4 .1 How Is This Operation Performed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
5 .4 .2 What to Expect After the Operation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
5 .4 .3 What Are the Possible Complications? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
5 .5 Informed Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
6 “Surgical Principles” in Nasal Tip Rhinoplasty . . . . . . . . . . . . . . . . . 75
6 .1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
6 .2 The Aims of Nasal Tip Plasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
6 .3 Knowledge and Understanding of the Pathogenesis
of Tip Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
6 .4 Knowledge and Understanding of the Nasal Tip “Tripod” Concept . . . . . 77
6 .5 Knowledge Gained by “Clinical Assessment” . . . . . . . . . . . . . . . . . . . . . . . . . 78
6 .6 Concept of “Big Guy – Small Guy” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
6 .7 Understanding the Importance of Skin and Soft Tissue Envelope . . . . . . 79
6 .8 Selecting the Surgical Approach and Tissue Handling . . . . . . . . . . . . . . . . . 80
6 .9 Selecting the “Right” Tools and Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
6 .10 Selecting the “Right Sequence” to Reconstruct the Nasal Tip . . . . . . . . . . 82
6 .10 .1 Reconstructing the Caudal Septal Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85