A Practical Approach to Asian Rhinoplasty: How to Design A Fine Nasal Shape [1st ed. 2020] 978-4-431-56883-4, 978-4-431-56885-8

Table of contents :
Front Matter ....Pages i-xiii
Clinical Anatomy (Yasushi Sugawara)....Pages 1-17
The Presurgical Workflow (Yasushi Sugawara)....Pages 19-46
Basic Surgical Techniques (Yasushi Sugawara)....Pages 47-53
Dorsal Augmentation or Height Reduction (Yasushi Sugawara)....Pages 55-71
Altering the Nasal Tip (Yasushi Sugawara)....Pages 73-117
Alar and Pedestals (Yasushi Sugawara)....Pages 119-136
Cases (Yasushi Sugawara)....Pages 137-203

Citation preview

Yasushi Sugawara

A Practical Approach to Asian Rhinoplasty How to Design A Fine Nasal Shape

123

A Practical Approach to Asian Rhinoplasty

Yasushi Sugawara

A Practical Approach to Asian Rhinoplasty How to Design A Fine Nasal Shape

Yasushi Sugawara Lilla Craniofacial Clinic Ginza, Tokyo, Japan

ISBN 978-4-431-56883-4    ISBN 978-4-431-56885-8 (eBook) https://doi.org/10.1007/978-4-431-56885-8 © Springer Japan KK, part of Springer Nature 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms 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 specific 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, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Japan KK part of Springer Nature. The registered company address is: Shiroyama Trust Tower, 4-3-1 Toranomon, Minato-ku, Tokyo 105-6005, Japan

To my parents, Yukiko and Koichiro, and my wife, Noriko, for their support. Yasushi Sugawara

Preface

Rhinoplasty is like building a home, for two reasons: The first is a way of being. A home is a very personal and comfortable place for its owner. Its style might be individual or conventional, but it must also be a safe, functional space that keeps out the cold and heat, the wind and rain. The nose should achieve a shape each patient personally considers lovely. There is no common shape, each nose is very individual, but healthy functions such as breathing and smelling must be secured. The other reason that rhinoplasty is like building a home is the process. The building process includes: 1. Surveying land 2. Researching the surrounding environment 3. Listening to client wishes 4. Drawing a blueprint 5. Procuring material 6. Building work How about the process of rhinoplasty? 1. Clinical assessment 2. Evaluation of facial balance 3. Listening to patient wishes 4. Creating a simulation 5. Presurgical preparation 6. Surgical work As you can see, the rhinoplasty process is quite similar to that of building a home. From this perspective, this atlas explains the process of rhinoplasty along a clinical workflow, showing how to create a surgical plan by using digital technology, as well as how to fulfill this plan by using surgical guides to meet patient expectations (rhinoplasty patients are very interested in the final outcome in the same way that, when building “home sweet home,” you are interested in the blueprint). I hope that surgeons benefit from this atlas and make their patients happy. Tokyo, Japan

Yasushi Sugawara

vii

Acknowledgment

I thank all my mentors, colleagues, hospital staff, and patients for giving me a chance, as well as sharing their imagination, courage, joy, and happiness with me. Also, I would like to thank the entire staff at Springer, particularly Lee Klein for his patient support.

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Contents

1 Clinical Anatomy�����������������������������������������������������������������������������������������������������������   1 1.1 General Concept���������������������������������������������������������������������������������������������������   1 1.2 Basic Surface Anatomy���������������������������������������������������������������������������������������   1 1.2.1 Points�������������������������������������������������������������������������������������������������������   1 1.2.2 Lines���������������������������������������������������������������������������������������������������������   1 1.2.3 Subunits���������������������������������������������������������������������������������������������������   2 1.2.4 Measurements �����������������������������������������������������������������������������������������   2 1.3 Topological Analysis�������������������������������������������������������������������������������������������   5 1.4 Structural Nasal Anatomy �����������������������������������������������������������������������������������   5 1.4.1 Bony Framework�������������������������������������������������������������������������������������   5 1.4.2 Nasal Septum�������������������������������������������������������������������������������������������   5 1.4.3 The Cartilaginous Framework�����������������������������������������������������������������   5 1.4.4 The Nasal Superficial Musculoaponeurotic System �������������������������������  13 1.4.5 Nasal Movement and Aesthetics �������������������������������������������������������������  13 1.4.6 The Skin and Soft Tissue Envelope (S-STE)�������������������������������������������  13 1.4.7 The Relation Between Nasal Framework and Surface Topology �����������������������������������������������������������������������������  15 1.4.8 Directional Terminology �������������������������������������������������������������������������  17 Suggested Reading�������������������������������������������������������������������������������������������������������  17 2 The Presurgical Workflow�������������������������������������������������������������������������������������������  19 2.1 Interview �������������������������������������������������������������������������������������������������������������  19 2.2 Photographs���������������������������������������������������������������������������������������������������������  19 2.2.1 Lighting���������������������������������������������������������������������������������������������������  20 2.2.2 Camera Setting�����������������������������������������������������������������������������������������  20 2.2.3 Shooting of a Complete Set of Clinical Facial Photographs�������������������  20 2.3 Analysis of the Nose �������������������������������������������������������������������������������������������  23 2.3.1 Nasion (Radix Break Point)���������������������������������������������������������������������  23 2.3.2 Nasal Tip �������������������������������������������������������������������������������������������������  23 2.3.3 Subnasale�������������������������������������������������������������������������������������������������  23 2.3.4 Rhinion�����������������������������������������������������������������������������������������������������  23 2.3.5 Alar, Pedestal�������������������������������������������������������������������������������������������  25 2.3.6 Facial Proportion�������������������������������������������������������������������������������������  25 2.4 Computer Simulation�������������������������������������������������������������������������������������������  30 2.4.1 Basic Technique of Simulation Using Photoshop�����������������������������������  31 2.4.2 Making a Harmonized Nose �������������������������������������������������������������������  40 2.5 Clinical Examination�������������������������������������������������������������������������������������������  45 2.6 Determine the Final Goal�������������������������������������������������������������������������������������  46 3 Basic Surgical Techniques �������������������������������������������������������������������������������������������  47 3.1 Anesthesia �����������������������������������������������������������������������������������������������������������  47 3.2 Harvesting Autogenous Tissue�����������������������������������������������������������������������������  47 3.2.1 Auricular Cartilage����������������������������������������������������������������������������������  47 xi

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Contents

3.2.2 Septal Cartilage���������������������������������������������������������������������������������������  47 3.2.3 Rib Cartilage �������������������������������������������������������������������������������������������  50 3.2.4 Dermal Fat�����������������������������������������������������������������������������������������������  51 3.2.5 Temporal Fascia���������������������������������������������������������������������������������������  52 3.2.6 Perichondrium�����������������������������������������������������������������������������������������  52 3.3 Approaches ���������������������������������������������������������������������������������������������������������  52 3.3.1 Endonasal Approaches�����������������������������������������������������������������������������  52 3.3.2 Open Approaches�������������������������������������������������������������������������������������  53 3.3.3 Vestibular Approaches�����������������������������������������������������������������������������  53 4 Dorsal Augmentation or Height Reduction ���������������������������������������������������������������  55 4.1 Dorsal Augmentation with Alloplastic Materials�������������������������������������������������  55 4.1.1 Silastic Implant ���������������������������������������������������������������������������������������  55 4.1.2 Gore-Tex Implant�������������������������������������������������������������������������������������  56 4.1.3 Complications and Solutions�������������������������������������������������������������������  56 4.2 Dorsal Augmentation with Autologous Graft �����������������������������������������������������  59 4.2.1 Ear Cartilage �������������������������������������������������������������������������������������������  61 4.2.2 Septal Cartilage���������������������������������������������������������������������������������������  61 4.2.3 Costal Cartilage���������������������������������������������������������������������������������������  65 4.2.4 Dermal Fat�����������������������������������������������������������������������������������������������  66 4.2.5 Complications and Solutions�������������������������������������������������������������������  67 4.3 Dorsal Height Reduction (Humpectomy) �����������������������������������������������������������  67 4.3.1 Bony Area �����������������������������������������������������������������������������������������������  67 4.3.2 Cartilaginous Area�����������������������������������������������������������������������������������  67 4.3.3 Open Roof Closure ���������������������������������������������������������������������������������  67 5 Altering the Nasal Tip���������������������������������������������������������������������������������������������������  73 5.1 Anatomical Features of the Asian Nose���������������������������������������������������������������  73 5.1.1 Cartilage���������������������������������������������������������������������������������������������������  73 5.1.2 Soft Tissue Envelope�������������������������������������������������������������������������������  73 5.1.3 Morphological Relation Between Frame and Soft Tissue�����������������������  73 5.2 Structural Tip Management���������������������������������������������������������������������������������  76 5.3 Frame Structuring �����������������������������������������������������������������������������������������������  77 5.3.1 Tripod Leg Controlling ���������������������������������������������������������������������������  77 5.3.2 Cartilage Suturing �����������������������������������������������������������������������������������  77 5.3.3 Cartilage Grafting �����������������������������������������������������������������������������������  81 5.4 Soft-Tissue Management������������������������������������������������������������������������������������� 116 5.5 Balanced Approach ��������������������������������������������������������������������������������������������� 116 6 Alar and Pedestals��������������������������������������������������������������������������������������������������������� 119 6.1 Principles of Alarplasty��������������������������������������������������������������������������������������� 119 6.1.1 Alar Width����������������������������������������������������������������������������������������������� 119 6.1.2 Nostril Shape������������������������������������������������������������������������������������������� 119 6.1.3 Alar Curvature����������������������������������������������������������������������������������������� 119 6.2 Alar Resection����������������������������������������������������������������������������������������������������� 119 6.2.1 Alar Resection, Inner Side����������������������������������������������������������������������� 119 6.2.2 Alar Resection, Outer Side ��������������������������������������������������������������������� 125 6.3 Nostril Base Resection����������������������������������������������������������������������������������������� 129 6.3.1 Procedure������������������������������������������������������������������������������������������������� 129 6.4 Alar Rim Resection��������������������������������������������������������������������������������������������� 131 6.4.1 Procedure������������������������������������������������������������������������������������������������� 131 6.5 Alar Rim Grafting ����������������������������������������������������������������������������������������������� 133 6.5.1 Procedure������������������������������������������������������������������������������������������������� 133

Contents

xiii

7 Cases������������������������������������������������������������������������������������������������������������������������������� 137 7.1 Case 1: Primary Rhinoplasty: Dorsal Augmentation, Tip Plasty, and Alarplasty ����������������������������������������������������������������������������������������������������� 137 7.1.1 Patient Profile (Figs. 7.1, 7.2, 7.3, and 7.4)��������������������������������������������� 137 7.1.2 Clinical Analysis ������������������������������������������������������������������������������������� 137 7.1.3 Topological Analysis (Figs. 7.6, 7.7, 7.8, 7.9, and 7.10)������������������������� 137 7.1.4 Preoperative Simulation (Figs. 7.11, 7.12, 7.13, 7.14, 7.15, 7.16, and 7.17) ������������������������������������������������������������������������������������������������� 138 7.1.5 Surgical Plan ������������������������������������������������������������������������������������������� 138 7.1.6 Procedures����������������������������������������������������������������������������������������������� 138 7.1.7 Result������������������������������������������������������������������������������������������������������� 141 7.2 Case 2: Primary Rhinoplasty: Hump Reduction������������������������������������������������� 154 7.2.1 Patient Profile (Figs. 7.51, 7.52, 7.53, and 7.54)������������������������������������� 154 7.2.2 Clinical Analysis ������������������������������������������������������������������������������������� 154 7.2.3 Topological Analysis (Figs. 7.55, 7.56, and 7.57)����������������������������������� 156 7.2.4 Preoperative Simulation (Figs. 7.58, 7.59, and 7.60)������������������������������� 156 7.2.5 Surgical Plan ������������������������������������������������������������������������������������������� 157 7.2.6 Procedures����������������������������������������������������������������������������������������������� 158 7.2.7 Result������������������������������������������������������������������������������������������������������� 163 7.3 Case 3: Primary Rhinoplasty: Short Nose����������������������������������������������������������� 166 7.3.1 Patient Profile (Figs. 7.86, 7.87, 7.88, and 7.89)������������������������������������� 166 7.3.2 Clinical Analysis ������������������������������������������������������������������������������������� 166 7.3.3 Topological Analysis (Figs. 7.90, 7.91, and 7.92)����������������������������������� 168 7.3.4 Preoperative Simulation (Figs. 7.93, 7.94, and 7.95)������������������������������� 168 7.3.5 Surgical Plan ������������������������������������������������������������������������������������������� 168 7.3.6 Procedures����������������������������������������������������������������������������������������������� 168 7.3.7 Result������������������������������������������������������������������������������������������������������� 175 7.4 Case 4: Secondary Rhinoplasty: Dorsal Deviation and Tip Drooping���������������� 180 7.4.1 Patient Profile (Figs. 7.127, 7.128, 7.129, and 7.130)����������������������������� 180 7.4.2 Clinical Analysis ������������������������������������������������������������������������������������� 180 7.4.3 Topological Analysis (Figs. 7.131, 7.132, and 7.133)����������������������������� 182 7.4.4 Preoperative Simulation (Figs. 7.134, 7.135, and 7.136)������������������������� 183 7.4.5 Surgical Plan ������������������������������������������������������������������������������������������� 184 7.4.6 Procedures����������������������������������������������������������������������������������������������� 184 7.4.7 Result������������������������������������������������������������������������������������������������������� 186 7.5 Case 5: Secondary Rhinoplasty: Dorsal Augmentation, Tip and Alarplasty ����������������������������������������������������������������������������������������������������� 192 7.5.1 Patient Profile (Figs. 7.156, 7.157, 7.158, and 7.159)����������������������������� 192 7.5.2 Clinical Analysis ������������������������������������������������������������������������������������� 192 7.5.3 Topological Analysis (Figs. 7.160, 7.161, and 7.162)����������������������������� 193 7.5.4 Preoperative Simulation (Figs. 7.163, 7.164, and 7.165)������������������������� 193 7.5.5 Surgical Plan ������������������������������������������������������������������������������������������� 194 7.5.6 Procedures����������������������������������������������������������������������������������������������� 194 7.5.7 Result������������������������������������������������������������������������������������������������������� 197

1

Clinical Anatomy

Abstract

1.2

Rhinoplasty surgeons should know not only the anatomy but also the anatomical relationship between the bone or cartilage as the frame and the skin and soft tissue as the envelope. What the surgeon does to correct the nasal shape is mainly done by altering the frame shape. The key to rhinoplasty is in knowing how to change the shape of the envelope by altering the frame.

Nasal shape is quite various and explaining the shape is as difficult as explaining the taste of wine, because the surface has no clear boundary. There are several fairly clear points in the profile view, however, which are the basic surface points of the nose.

Keywords

1.2.1 Points

Surface topography · Nasion · Rhinion · Supratip break point · Tip · Tip-defining point · Infratip · Subnasale · Subalare · Nasal mid line · Nasal line · Nasal base line · Supra-alar groove · Alar cheek junction · Glabella · Radix · Dorsum · Side wall · Tip lobule · Supra-tip lobule · Infra-tip lobule · Columella · Alar lobule · Alar rim · Soft triangle · Nostril sill · Columella base · Footplates of the medial crura

1.1

General Concept

Rhinoplasty surgeons should know not only the anatomy but also the anatomical relationship between the bone or cartilage as the frame and the skin and soft tissue as the envelope. What the surgeon does to correct the nasal shape is mainly done by altering the frame shape. The key to rhinoplasty is in knowing how to change the shape of the envelope by altering the frame. Also very important is the sense of nasal aesthetics, but it is hard to explain aesthetics in general. Aesthetics depends on culture, society, and community, and it is always changing. There is no single gold standard in nasal aesthetics.

Basic Surface Anatomy

• Nasion (radix break point): in profile, the lowest point in the glabella (Figs. 1.1 and 1.2) • Rhinion: caudal point of the nasal bone • Supratip break point: depressed point between the rhinion and the tip, and/or transition point where tip roundness ends and becomes straight (not always present) • Tip: most projecting point in the profile • Tip defining point: One of two paired points most projecting in ¾ view • Infratip break: break point in columella • Subnasale: end point on the columella base • Subalare: most caudal point in the alar crease junction

1.2.2 Lines • Nasal mid line (Fig.  1.3): the center line of the nose (which is not always straight) • Nasal line (nasal unbroken line): the ridge in the oblique view • Nasal base line: border line between nasal pyramid and cheek

© Springer Japan KK, part of Springer Nature 2020 Y. Sugawara, A Practical Approach to Asian Rhinoplasty, https://doi.org/10.1007/978-4-431-56885-8_1

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1  Clinical Anatomy

Fig. 1.1  Representative points of nose

1.2.3 Subunits • • • • • • • • • • • • • •

Glabella (Figs. 1.4 and 1.5) Radix Dorsum Side wall Tip lobule Supra-tip lobule Infra-tip lobule Columella Alar lobule Alar rim Soft triangle Nostril sill Columella base Footplates of the medial crura

Fig. 1.2  Representative points of nose

1.2.4 Measurements

• Supra-alar groove: groove above the alar lobule; border line between the side wall and alar lobule • Alar cheek junction: border line between alar lobule and cheek

1.2.4.1 Frontal View • Radix base width: width at the level of nasal base line in radix (Fig. 1.6) • Radix top width: width at the level of nasal line in radix

1.2 Basic Surface Anatomy

Fig. 1.3  Representative lines of nose

Fig. 1.4  Representative subunits of nose

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1  Clinical Anatomy

• Dorsal base width: width at the level of nasal base line in dorsum • Dorsal top width: width at the level of nasal line in dorsum • Tip width: width of the tip defining points (Fig. 1.7) • Alar width: width between the most distant alar points • Alar crease width: width of the most distant alar cheek junctions (same as alar width if alar lobules are non-flaring) • Alar base width: length of bilateral subalare height

1.2.4.2 Lateral View • Alar lobule height: vertical length in the center of alar lobule • Columellar show length: length of columella show Fig. 1.5  Representative subunits of nose

Fig. 1.6  Measurements of nose

1.4 Structural Nasal Anatomy

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1.4.1 Bony Framework • The bony framework (Fig.  1.12) consists of nasal bone and the frontal process of the maxillary bone. • The bony frame supports the skin and soft tissue envelope (S-STE) very strongly. • The average thickness of nasal bone at the rhinion is 1.5 mm, and 6 mm at the nasion. This tendency is similar on the nasal base line. • This tendency is important for osteotomy or hump reduction. • Nasal mucosa will exist just beneath the bone.

1.4.2 Nasal Septum Fig. 1.7  Measurements of nose

1.3

Topological Analysis

Careful inspection will show light and shadow on the nasal surface. The boundaries of the light and shadow reveal the key structure of the nose. Topological analysis is one of the best ways to grasp the complex nasal shape simply. Nasal shape is represented by points, lines, and facets. Surface topology consists of subunits, the surface made by connecting the points and lines. If you use surface topology, you can see the shape much more easily. Defining the surface topography of the nasal region also helps in the estimation and planning of rhinoplasty (Figs. 1.8, 1.9, and 1.10).

1.4

Structural Nasal Anatomy

• The nose consists of a framework, muscles, mucosa, and skin and soft tissue (Fig. 1.11). • The framework includes bone, septum, and cartilage. • Muscles are very thin, so they do not affect the nasal shape itself, but they do affect the dynamic nasal shape. • The thickness of skin and soft tissue varies for each subunit and for different individuals, ages, and races.

• The nasal septum connects to ethmoidal bone and vomer (Fig. 1.13). • The septum is thin in the upper area and thicker in the lower area, so its connection to the ethmoid is weak, and to the vomer is strong. • The dorsal side of the septum is flat-groove-flat in shape; the upper two thirds is T-shaped, and the lower one third is I-shaped (Fig. 1.14). • Note this when the septum is to be cut off from the upper lateral cartilage (ULC), or for hump resection.

1.4.3 The Cartilaginous Framework 1.4.3.1 Upper Lateral Cartilage (ULC) • The upper margin of the ULC is located beneath the caudal margin of the nasal bone. • The medial side of the ULC is connected to the septal cartilage. • The lateral side is connected to the frontal process of the maxillary bone with fibrous tissues. • The lower margin is connected to the lower lateral cartilage (LLC) with scroll ligament.

6 Fig. 1.8 (a) Original color photos. (b) 256 levels of gray scale images. (c) 16 levels of gray scale image. (d) 7 levels of gray scale image. (e) 5 levels of gray scale image. It is easy to see highlight and shadow. (f) Put points on 7 levels of gray scale image. (g) Put points on 5 levels of gray scale image. (h) Each point relates clearly. (i) Color image makes difficult to see these points. (j) Surface topology by connecting each point. (k) Topological analysis helps the estimation

1  Clinical Anatomy

1.4 Structural Nasal Anatomy Fig. 1.8 (continued)

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8 Fig. 1.8 (continued)

1  Clinical Anatomy

1.4 Structural Nasal Anatomy Fig. 1.9 (a) Original color photos. (b) Points in 5 levels of gray scale image. (c) Surface topology. (d) Narrow dorsum with wide nasal base and small tip area are easily recognized

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10 Fig. 1.10 (a) Original color photos. (b) Points in 5 levels of gray scale image. (c) Surface topology. (d) Narrow dorsal base width, wide alar base width and columella retrusion are obvious

1  Clinical Anatomy

1.4 Structural Nasal Anatomy

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Fig. 1.11  Relationship among the framework, muscles and skin, and soft tissue envelope

Fig. 1.12 (a and b) Features of the bony framework

1.4.3.2 Lower Lateral Cartilage (LLC) • The lateral crus (1) is wide and firm (Fig. 1.15). • The medial crus (3) is narrow and soft; both are connected by the interdomal ligament (2). • Nasal tip shape and position are basically determined by the LLC shape and position. • The lateral crus is firmly fixed to the piriform aperture of the maxilla, but the medial crus is loosely fixed to the caudal end of the septal cartilage. This means that the nasal tip easily rotates up and down. • Stability of nasal tip position depends on two factors: the stiffness of the LLC and the density of its fibrous connection with the septal cartilage. These are important in tip plasty. Fig. 1.13  Nasal septum connection to ethmoidal bone and vomer

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Fig. 1.14  The shape of the septum top

Fig. 1.15  The cartilaginous framework. 1—lateral crus; 2—interdomal ligament; 3—medial crus

1  Clinical Anatomy

1.4 Structural Nasal Anatomy

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Fig. 1.16  The nasal superficial musculoaponeurotic system

1.4.4 T  he Nasal Superficial Musculoaponeurotic System

1.4.6 T  he Skin and Soft Tissue Envelope (S-STE) 1.4.6.1 Radix Area

• This system has little effect on the nasal shape, so it does not require attention when operating, but it does give dynamic change (Fig. 1.16). • Procerus makes transverse wrinkle on the glabella and radix subunits. • Levator labii superior alaeque nasi muscle changes the alar shape, lifting the alar lobule and subalare. • Depressor septi nasi rotates the nasal tip down following columella movement. • Nasalis brings the alar lobule posteriorly, deepening the alar cheek junction.

• Skin and soft tissue are thick, loose, soft, with little movement. • Thus inserted materials are less visible.

1.4.6.2 Dorsum Area • Skin and soft tissue are thin, loose, soft, movable. • Inserted materials or framework tend to be visible.

1.4.6.3 Tip and Alar Lobule Areas

1.4.5 Nasal Movement and Aesthetics The nose moves. Some movement significantly influences nasal aesthetics. The subalare is lifted and shifted laterally by the action of the levator labii superior alaeque nasi muscle, the tip is rotated down and lowered, and the subnasale is pulled back by the depressor septi nasi muscle, such as when smiling or sniffing. This affects alar and nostril width, increases septal size, and changes the tip shape (Figs. 1.17 and 1.18).

• Skin and soft tissue are thick to thin, firm to soft, with dynamic movement. • There are various types; it is sometimes difficult to predict the S-STE condition. • If thick and firm (so-called heavy skin), it is hard to alter the shape. Heavy skin is common in Asians (Fig. 1.19).

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Fig. 1.17 (a–c) Nasal movement and form change

Fig. 1.18 (a–c) Nasal movement and form change, lateral views

1  Clinical Anatomy

1.4 Structural Nasal Anatomy

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Fig. 1.19 (a and b) The skin and soft tissue envelope (cadaver)

1.4.7 T  he Relation Between Nasal Framework and Surface Topology

surface and framework, which can be as easy to understand as simple paper craft (Figs. 1.20, 1.21, 1.22, and 1.23).

Knowing the relation between the nasal framework and surface topology is important, because most of the rhinoplasty procedure is altering the framework. This relation is not simple, especially in a “heavy-skin” patient, because the S-STE has a shape itself, and it is often different from the frame shape. The surgeon should understand the basic relation of

• Nasal bone and ULC are two folded paper. Each connection is nasion, rhinion, supratip break from top. • The LLC is complex. • The lower corner of the intermediate crus falls into TDP (tip defining point). • The center corner of the medial crus falls into the infratip break.

Fig. 1.20 (a and b) The relation between nasal framework and surface topology

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Fig. 1.21  Representative points and nasal framework Fig. 1.22 Simplified framework model

1  Clinical Anatomy

Suggested Reading

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Fig. 1.23  Simplified framework model

Fig. 1.25  Directional terminology describing tip movement

1.4.8 Directional Terminology Figure 1.24 illustrates directional terminology. Tip movement is sometimes described with other terms (Fig. 1.25).

Suggested Reading 1. Agur AMR, Dalley AF.  Grant’s Atlas of anatomy. 12th ed. Philadelphia: Lippincott Williams & Wilkins; 2009. 2. Radlanski RJ, Wesker RH. The face: Pictorial Atlas of clinical anatomy. Hanover Park: Quintessence Publishing; 2012.

Fig. 1.24  Directional terminology

2

The Presurgical Workflow

Abstract

The presurgical workflow in rhinoplasty consists of several steps. This chapter describes how to know what patients want, how to analyze the difference between ideal and actual forms, how to set the goal shape using a computer simulation system, and how to suggest practical surgical options to patients (Fig. 2.1). Keywords

Interview · Simulation · Clinical photograph · Lighting · Analysis

The presurgical workflow in rhinoplasty consists of several steps. This chapter describes how to know what patients want, how to analyze the difference between ideal and actual forms, how to set the goal shape using a computer simulation system, and how to suggest practical surgical options to patients (Fig. 2.1).

2.1

Interview

To succeed in rhinoplasty, the first and most essential step is selection of patients. There are two points to consider: the first is to exclude patients for whom rhinoplasty is inappropriate; the second is to perform surgery only when the desired result can be expected using techniques the surgeon can provide, as discussed later in this chapter. Good candidates for rhinoplasty are those who can express their problems or demands objectively and understand what to expect. This can be checked by detailed questions. The consultation starts with asking what patients want and checking their demand by interviewing. Sitting at a distance of about 1.5 m, concentrate on listening to patients. Seek as much information as possible about their character, behavior, temper, intelligence, level of cul-

ture, occupation, family relationships, lifestyle, and social standing through their conversation, dress, belongings, hairstyle, makeup, and accessories. With patients looking at themselves in a hand mirror, from a distance of about 1 m observe the detail with palpation. Also ask for their assessment of their present shape and their concrete expectations. Noncommittal requirements such as “higher” or “thinner” must be elaborated to provide detailed demands, such as “make this part higher to this level” or “make this part thinner to this level.” Some patients should not be approved for rhinoplasty: those who are not mentally mature for their age or are extremely childish; those who are sticklers for detail; those with unrealistic expectations, such as that a successful rhinoplasty will bring a new life or partner; those who bring photographs or illustrations and insist on the necessity of the surgery; patients who do not stop speaking for more than 20  min; and patients with whom you feel incompatible or uncomfortable (or who are unpleasant or offensive). If the surgeon feels uncomfortable with the patient, it is better not to perform their surgery. Proceed to the next step only if the patient presents none of the problems listed.

2.2

Photographs

Taking appropriate photographs is important to provide a record before and after surgery, and for use in the computer simulation process. Photographs should be precise and reproducible. Digital single-lens reflex cameras are recommended. A full-size CCD camera is not essential. An APS-C camera with CCD or CMOS image sensing system is sufficient. The focal length of the lens should be longer than 50 mm. A macro lens is also convenient for intraoperative photos. Use of a lens less than 50 mm in focal length will result in distortion of the figure (Fig.  2.2). The focal length would become around 75  mm with a APS-C camera; with a full-­ sized camera the focal length of the lens should be more than

© Springer Japan KK, part of Springer Nature 2020 Y. Sugawara, A Practical Approach to Asian Rhinoplasty, https://doi.org/10.1007/978-4-431-56885-8_2

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2.2.1 Lighting Precise lightning and a proper space are essential for a fine photograph. The studio should be larger than 150  cm in width and 250  cm in depth. Ask the patient to sit about 50  cm from the back wall. The photographer should stay back 1.5–2  m from the patient (Fig.  2.3). The patient can hold a reflection board to prevent an unnatural shadow in the nose and submental area. In taking the profile pictures, position the light box so as not to make a shadow behind the patient. Either direct lighting or bounce lighting can be used (Fig.  2.4). For direct lighting, instead of a strobe, use a light box in front of and slightly higher than the patient. For bounce lighting, prepare the strobe to face the ceiling. The wallpaper (except the back wall) should be white. Ask the patient to hold a reflection board. Settle the angle of the strobe to make the lighting bounce behind the patient. If it is difficult to obtain these conditions in shooting, a built-in strobe can be used. In this case, the light from above produces an unpleasant shadow in the profile picture, but is good in the frontal picture To reduce the unpleasant shadow, the camera should be turned 90 degrees so the light shines from the left side to remove the shadow (Fig. 2.5).

2.2.2 Camera Setting The pixel data should be over 8 million to make a print in a A4 size, but 800,000 pixels would be enough to see on the computer monitor or projector equipment. For trimming the nasal area out of the picture, about 4 million pixels would be adequate. The diaphragm should be over 8.0, and the shutter speed should be under 1/60 s.

2.2.3 S  hooting of a Complete Set of Clinical Facial Photographs Fig. 2.1  Diagram of presurgical workflow

80 mm, but then care is needed to avoid shaking, as the lens becomes long and heavy.

The complete set of photograph should be taken in six directions (Fig. 2.6). In the front face, the line crossing both eyes should be horizontal. This horizontal line should be kept in the lateral and oblique views.

2.2 Photographs

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Fig. 2.2  Left, Focal distance 50 mm lens. Right, Focal distance 19 mm lens (wide-angle lens). Both vertical and horizontal facial proportions are distorted, although the facial height is the same

Fig. 2.3 (a) White board reflects light from above to give natural shadow on the face. (b) With white board (left); without white board (right). Note the difference of shadow below the nose

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Fig. 2.4 (a) Direct versus bounce lighting. Bounce lighting reduces shadows and strong highlights on the face, so that the picture looks more natural. (b) For direct lighting, a diffuser (diffuse soft box) should be used

Fig. 2.5  In case of built-in strobe, pay attention to the light direction: left, from top in front; center, from top in lateral; right, from left side in lateral. Note the difference in shadow in the lateral pictures

2.3 Analysis of the Nose

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Fig. 2.6  A complete set of facial photographs

2.3

Analysis of the Nose

First of all, the doctor should explain the present form and features of the nose to the patient. This step is very important before going further. As often as not, patients do not assess their actual nasal appearance precisely; they may just believe “the taller, the better,” for instance, so they should be helped to realize their real nasal form and features.

2.3.1 Nasion (Radix Break Point)

soft tissue envelope, but the most protruded point in lateral view is the tip (Fig. 2.10a) • First check the tip position, anterior or posterior. Note that it is not related to the tip shape. Tip projection often looks insufficient in the case of a round tip and supratip lobule. Make sure how much “tip” is located anteriorly (Fig. 2.10b) • Then check tip width in frontal view. Tip position is the same as in lateral view. In general, the tip-defining point is located laterally and its width is slightly wider than the dorsal top width. Note that the tip-defining point is not sticking out as a pinpoint, even though it is located very near the tip, especially in the case of a round tip (Fig. 2.10c).

• Check the position in lateral view (Fig. 2.7) • First nasion projection (Fig. 2.8) Second vertical position of nasion: • Average position is the height of eyelashes in cephal, center of cornea in caudal (Fig. 2.9a) • This position is shown as the starting point of highlight in the frontal view (Fig. 2.9b)

2.3.2 Nasal Tip • Check the tip and tip-defining point. Sometimes it is difficult to identify these because of thick heavy skin and

2.3.3 Subnasale Check the position of the subnasale, a key position that defines the image of the tip. When the angle between the nasion tip and subnasale is wide, the nose looks short. When it is narrow, the nose looks long.

2.3.4 Rhinion • First check the position of the rhinion in lateral view (Fig.  2.11). This position is related to the tip position. First draw a line connecting the nasion and tip. Then

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Fig. 2.7  Radix break point (nasion, red dot)

Fig. 2.8  First check the horizontal position of the nasion: left, low; center, average; right, high

check the position of the rhinion (Fig.  2.12). This is described as the dorsal line. • Then check in a frontal view. The rhinion itself is mostly not seen in frontal view. Check the nasal line and nasal base line in front (Fig. 2.13). • The relation between nasal line and nasal base line is various (Fig. 2.14)

• Note that a part of the nasal line is widened at the middle for smooth connection to the cheek. In other words, the side wall shape is not a simple flat board (Fig. 2.15). The radix side wall continues to the orbit, with an acute angle that gives a strong shadow. The dorsal side wall continues to the cheek smoothly, so that it is less acute.

2.3 Analysis of the Nose

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Fig. 2.9 (a) Then check the vertical position of nasion (left, low; right, high). (b) The vertical position of the nasion can be checked by the starting point of the nasal dorsum highlight in frontal view (left, low; right, high)

2.3.5 Alar, Pedestal

2.3.6 Facial Proportion

• Next, the skin–soft tissue (S-ST) envelope is checked. • Check alar width, height, shape, and the relation between the columella and alar rim (Fig. 2.16).

• The ratio of the upper part of the face to the lower part (Fig. 2.17) averages 1:1 to 1:0.8. • When the patient does not want to change the total facial height (vertical length) by some other procedure (such as chin prosthesis or orthognathic surgery), the nasal length can influence the ratio (Fig. 2.18).

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Fig. 2.10  Nasal tip and tip-defining point. (a) Some have a clear tip-­ defining point and some do not. (b) Vertical tip position is different from “tip projection.” The tip projection of these three noses is identi-

2  The Presurgical Workflow

cal. (c) Tip, supratip break point, and tip-defining point. Note the relation between the tip and tip-defining point: In the case of the round tip, they are very close

2.3 Analysis of the Nose

Fig. 2.11 Rhinion. Left, concave; Center, straight; Right, convex (hump) Fig. 2.12 Representative concave, straight, and convex dorsal lines

Fig. 2.13  Nasal line, nasal base line, and dorsal line

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Fig. 2.14  Frontal view of nasal line and nasal base line (left narrow parallel, wide concave, narrow concave, twisted)

Fig. 2.15  Dorsal side wall-shape lined by dorsal line and dorsal basal line is not a simple flat wall

2.3 Analysis of the Nose

Fig. 2.16 (a–c) Various nasal alar shapes

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Fig. 2.17  Facial proportion

Fig. 2.18  Comparison of short nose (left, 1:1), average nose (center, 1:0.9); long nose (right, 1:0.8)

2.4

Computer Simulation

Preoperative simulation is important to translate the patient’s demands into realistic pictures. Before beginning the simulation, perform a clinical examination (see below) to avoid unfeasible planning during simulation. There are many types of simulation software. Adobe Photoshop, a widely used image editor, is generally good

enough for simulation. Lateral view simulation is quite good, but the frontal view is less accurate. It is better to do the simulating with your patient. By sharing the procedure, changing the places according to the demands, it is easier for the surgeon and patient to have a common recognition of the goal shape. Make a simulation that matches the patient’s demands, and then ask whether the plan matches what they have imagined.

2.4 Computer Simulation

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Fig. 2.19  Import the photograph of the frontal view

2.4.1 B  asic Technique of Simulation Using Photoshop

Fig. 2.20  Pick up the trimming (“Crop”) tool

1. Import the photograph of the frontal view (Fig. 2.19). 2. Pick up the trimming (“Crop”) tool (Fig. 2.20). If there is any tilt of the patient’s head, use the tool to correct it (Fig. 2.21). 3. Create a new layer (Fig. 2.22). 4. Select “line” tool on left side tool bar (Fig. 2.23). 5. By pressing the Shift key, rule the horizontal and vertical reference lines (Fig. 2.24). 6. Import the photograph of lateral view (Fig. 2.25). 7. Duplicate the layer (Figs. 2.26 and 2.27). 8. Select “Liquify” tool from “Filter” menu (Fig. 2.28). 9. A new window will come up. From the left side tool bar, select “Forward Warp Tool” (Fig. 2.29). 10. If the brush size is big, change the brush size with the sliding bar in the right box (Figs. 2.30, 2.31, and 2.32). 11. Put the cursor where you want to change, and drag the mouse (Fig. 2.33). 12. Warp the shape as you want (Figs. 2.34 and 2.35). 13. To protect an area you will not change, select the “Mask” tool in the left side tool bar (Fig. 2.36). 14. Paint the area to be protected with the mask brush (Fig. 2.37).

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Fig. 2.21  If there is any tilt of the patient’s head, correct it

Fig. 2.22  Create a new layer

2  The Presurgical Workflow

2.4 Computer Simulation Fig. 2.23  Select “Line” tool on left side tool bar

Fig. 2.24  By pressing the Shift key, rule the horizontal and vertical reference lines

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34 Fig. 2.25  Import the photograph of lateral view

Fig. 2.26  Duplicate the layer

2  The Presurgical Workflow

2.4 Computer Simulation Fig. 2.27  New layer is shown in the layer box

Fig. 2.28  Select the “Liquify” tool from the “Filter” menu

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36 Fig. 2.29  A new window comes up. Select “Forward Warp Tool” in the left side tool bar

Fig. 2.30  If the brush is large, change the brush size with the sliding bar in the box on the right

2  The Presurgical Workflow

2.4 Computer Simulation Fig. 2.31  Size 77 is selected

Fig. 2.32  Put cursor where you want to change

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38 Fig. 2.33  Drag the mouse

Fig. 2.34  Warp the shape as you want

2  The Presurgical Workflow

2.4 Computer Simulation Fig. 2.35  Complete the reshaping

Fig. 2.36  To protect an area you will not change, select the “Mask” tool in the left side tool bar

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Fig. 2.37  Paint the protected area with the “Mask” brush

15. The masked area (red) is not affected by the warp brush (Fig. 2.38). 16. Press “OK”; the result is shown in the layered screen (Fig. 2.39). 17. Comparison is easy by superimposing. Control the “opacity” in the layer box (Fig. 2.40). 18. Dorsal highlight can be changed with “Dodge Tool” in the left side tool bar (Figs. 2.41 and 2.42). Control the shadow and brightness in the frontal view simulation.

2.4.2 Making a Harmonized Nose • It is easiest to begin the simulation work (using the Liquify tool) with the lateral reshaping: 1. First, fix the height and projection of the radix (Fig. 2.43a). 2. Second, confirm the projection of the tip-defining point and the direction of the rotation. 3. Then rule the dorsum line crossing the radix and projection. Fix the shape of the supratip break. 4. Determine the shape of the columella, considering the nasolabial angle. 5. Modulate the alar vertical length.

• Then move to the oblique reshaping (Fig.  2.43b), also using the Liquify tool: 1. Fix the radix, tip-defining point, and dorsum line. Note that the dorsal marginal line shown in the oblique view is the “nasal line” not “dorsum line.” 2. Simulate the continuing line from the columella to the nasolabial angle. 3. Simulate the alar height length. 4. If the paranasal area should have more projection, make that simulation also. • Finally, move to the frontal reshaping (Fig. 2.43c), using the Liquify and Dodge tools: 1. Fix the height of the radix by shifting the highlight using the Liquify tool. The projection cannot be described from the frontal view. 2. The tip-defining point can be changed by shifting the highlight toward the rotation. 3. The line from the columella to the nasolabial angle would influence the shadow behind the tip-defining point, so simulate this shadowing if possible. 4. Following the lateral and oblique view, simulate the line from the tip-defining point to the alar. The width of the alar can be simulated only in this view. Reference values or standard values occasionally help to make a good balance of the nasal shape, but mostly you will be disappointed with the results of simulation using those

2.4 Computer Simulation Fig. 2.38  Masked area (red) is not affected by the Warp brush

Fig. 2.39  Press OK; the result is shown in the layered screen

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42 Fig. 2.40  Comparison is easy by superimposing. Control the “opacity” in the layer box

Fig. 2.41  Dorsal highlight can be changed with the “Dodge Tool”

2  The Presurgical Workflow

2.4 Computer Simulation Fig. 2.42  Put cursor where you want to change; brightness is added

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Fig. 2.43 (a) Simulation will start from lateral view. (b) Oblique view will show the nasal line, which is important for dorsal width control. (c) Control the shadow and brightness in the frontal view simulation

2.5 Clinical Examination

data. They might suggest some aesthetic balance, but balance is mostly just the sense. Performing the simulation process with patients helps provide a harmonized nasal shape, which can vary in accord with differences in the patients’ background (culture, status, society). When patients’ demands are vague, such as “I want to make my nose much prettier,” the surgeon can suggest several simulations to find out what fits their desired image. A surgeon who can suggest nice shapes will be trusted as a surgeon with a sense of beauty. The simulation photographs should be saved in the chart.

2.5

Clinical Examination

• Check the condition of the S-ST envelope. • Look closely at the patient’s skin, subcutaneous tissue, and framework (Fig.  2.44). This is important to avoid unfeasible planning during simulation. The basic ­consideration is that the stronger the cartilage and the thinner the skin, the easier it is to manage the nose shape. • The points for close observation differ according to the three types of cases—elongation or augmentation, reduction, and secondary cases. Fig. 2.44  Check the condition of S-ST envelope

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• In cases when you are planning elongation or augmentation: –– Check if the skin and the lining have enough distensibility. –– Check the thickness of the subcutaneous tissue, and consider grafting if needed. –– Check the size and hardness of the lower lateral cartilage (LLC) and the septum cartilage. Consider whether strengthening is needed, and how it can be done. • If reduction is being considered: –– Check the stiffness and thickness of the skin and subcutaneous tissue, and also the oil glands. In cases with oily, thick, and hard skin, the results of surgery are sometimes poor (Fig. 2.45). • In secondary cases: –– Check for scarring from the initial surgery. –– Next, check the thickness, stiffness, and area of the subcutaneous scarring. Do the skin and lining have enough distensibility? –– Check the thickness of the subcutaneous tissue, and consider grafting if needed. –– Examine the size and hardness of the LLC, whether there is a grafted cartilage, the size of the septum cartilage, and whether there is a deficit of the septum. Consider whether strengthening is needed, and how it can be done.

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2  The Presurgical Workflow

Fig. 2.45 (a) Check the S-ST movability by pulling the nasal tip. (b) Check the cartilaginous frame stability by pushing the nasal tip

a

2.6

Determine the Final Goal

Re-establish a shared awareness of the final goal. Assess whether that plan is feasible with the condition found by the physical examination. If it is not feasible, modify the simulation to reach an agreement with the patient’s demands and the surgeon’s ability, or cancel the surgery. By making a precise simulation, the surgeon can manage the planning according to his or her ability. The surgeon

b

should be confident of the ability to perform all planned procedures, considering not only skill but also risk and fee. If some procedures seem too difficult, shift the plan to make it easier, or abandon the plan. Avoid complex procedures for patients with poor skin and those with many previous surgeries. Make sure that the patient is fully aware of the risks, downtime, and cost of the plan. If any of these are not ­acceptable to the patient, the plan should be changed.

3

Basic Surgical Techniques

Abstract

Except for bony and septal work, almost all rhinoplasty can be performed under local anesthesia and/or intravenous sedation. Lidocaine containing 1:100,000 epinephrine is injected around the foramen of the infraorbital nerve and infratrochlear nerve (1 mL each) (Fig. 3.1). The remaining agent is then injected into the dorsum and tip area for both local anesthesia and homeostasis. For anesthesia of the septal cartilage, lidocaine containing 1:100,000 epinephrine is injected into the caudal part of the muco-perichondrium. When you approach bone and septum, general anesthesia with intubation (or laryngeal mask) is recommended.

Keywords

Anesthesia · Auricular cartilage · Septal cartilage · Killian approach · Trans-fixation approach · Costal cartilage · Rib cartilage · Dermal fat

3.1

Anesthesia

Except for bony and septal work, almost all rhinoplasty can be performed under local anesthesia and/or intravenous sedation. Lidocaine containing 1:100,000 epinephrine is injected around the foramen of the infraorbital nerve and infratrochlear nerve (1 mL each) (Fig. 3.1). The remaining agent is then injected into the dorsum and tip area for both local anesthesia and homeostasis. For anesthesia of the septal cartilage, lidocaine containing 1:100,000 epinephrine is injected into the caudal part of the muco-perichondrium.

When you approach bone and septum, general anesthesia with intubation (or laryngeal mask) is recommended.

3.2

Harvesting Autogenous Tissue

3.2.1 Auricular Cartilage There are three parts for cartilage harvesting: samba concha, cavum concha, and tragus (Figs. 3.2 and 3.3). • Select area where to harvest depending on size and volume. • Both samba concha and cavum concha can be harvested, but the crus helix should be preserved to avoid postoperative ear deformity. • Including perichondrium in harvesting makes it easy to trim and morselize the cartilage. • Either a pre-auricular incision or a post-auricular incision can be used for conchal cartilage harvest, with little difference in postoperative morbidity. • Auricular cartilage is soft and plastic, but it is difficult to trim smoothly at the edge.

3.2.2 Septal Cartilage Septal cartilage is better than auricular cartilage as a graft material because it is easy to access during surgery, is thinner and firmer, and can be harvested in a single, flat piece. On the other hand, septum sometimes is insufficient in volume, and harvesting too much will weaken the septum as a part of the structure. The center part of the septum is excised, leaving the remaining L-shaped cartilage intact, with a width of 10–12  mm (Fig.  3.4). Too much resection will cause of

© Springer Japan KK, part of Springer Nature 2020 Y. Sugawara, A Practical Approach to Asian Rhinoplasty, https://doi.org/10.1007/978-4-431-56885-8_3

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3  Basic Surgical Techniques

a Supraorbital n. lateral branch

Medial branch of supraorbital n. External nasal branch

Supratrochlear n.

Infratrochlear n.

Infraorbital n.

Superior labial branches

b

External nasal branch Supraorbital n. lateral branch

Medial branch of supraorbital n. Supratrochlear n.

Infratrochlear n.

Infraorbital n.

Fig. 3.1 (a and b) Directional terminology. (c) Anesthesia injected to the caudal part of the muco-perichondrium

3.2 Harvesting Autogenous Tissue

49

c

Olfactory bulb

Anterior ethmoidal nerve (CN V1)

Sphenoidal sinus

Nasopalatine nerve (CN V2)

Internal nasal branch of infraorbital nerve (CN V1)

Greater Lesser

Palatine nerve (CN V2)

Fig. 3.1  (continued)

weakness of the nasal frame. Take care not to break the keystone area (junction of the perpendicular plate and septal cartilage). Such breakage will easily result in saddle nose deformity. There are two approaches for excising the septal cartilage: Killian and trans-fixation (Fig. 3.4). After the cartilage has been excised, continuous mattress suture should be placed with absorbable stitches. Nasal packing of sponge is

helpful for reducing postoperative hematoma and mucosal swelling. The packing will be removed after 24 h.

3.2.2.1 Killian Approach • The incision on the mucous membrane is made 3–4 mm beyond the caudal margin of the septal cartilage because perichondrium is firmly attached to the cartilage.

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3  Basic Surgical Techniques

• Soft touch on the perichondrium with a sharp knife is the key to fine dissection. • After completing elevation on one side, a half-depth incision into the cartilage is made. • Cut the remaining cartilage with an elevator instead of a knife, and start to elevate the perichondrium on the opposite side.

3.2.2.2 Trans-Fixation Approach • The incision on the mucous membrane is made along the caudal margin of the septal cartilage. Septal cartilage is excised after completing the mucoperiosteal flap elevation. • This approach is useful if a septal extension graft is being performed at the same time.

3.2.3 Rib Cartilage

Fig. 3.2  Three parts for cartilage harvesting: samba concha, cavum concha, and tragus

Fig. 3.3  Harvested concha and tragus cartilage

• Rib cartilage is usually harvested from the 5th, 6th, or 7th rib. If a female patient prefers the scar at the infra-­

3.2 Harvesting Autogenous Tissue

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Fig. 3.4  Killian and trans-fixation approach to septal cartilage

• • •

•

• • • • • • •

mammary fold, the 5th or 6th rib is better. Otherwise, the 6th or 7th rib is better. A whole shape of rib cartilage is not necessary. Several rectangular strips of cartilage are better in use. After the skin incision is made, the external oblique muscle is excised. Perichondrium of the rib cartilage is elevated and removed where the cartilage is harvested. The perichondrium is used as graft material. Several incisions are made parallel to the rib axis in 2–3 mm width. This incision should stop at a depth of one half to two thirds of the rib thickness. Two incisions are made 20–30 mm apart to harvest cartilage in a strip shape. Cut the rest of the cartilage with the D-knife or small sharp elevator. If pleura is injured, it should be repaired; this is rare. The wound is sutured layer by layer. Place a 24-gauge catheter for painkiller injection after the surgery. There are a few procedures to prevent cartilage warping, but nothing guarantees it. Leave the piece of cartilage in saline for 30  min, then check for warping. Two thin pieces sutured in one piece is more stable than one single, thick piece (Fig. 3.5).

3.2.4 Dermal Fat • Dermal fat graft is used to provide extra thickness of skin, or for augmentation material.

Fig. 3.5  A single piece of rib cartilage (top) and two thin pieces sutured in one piece (bottom)

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3  Basic Surgical Techniques

also diminishes by approximately 50% or more after grafting.

3.3

Approaches

There are two main approaches for rhinoplasty: endonasal and open. Both have advantages and disadvantages.

3.3.1 Endonasal Approaches The endonasal approach is much more difficult to perform because of the limited surgical view, especially in patients with heavy, thick skin and small nostrils. The most common endonasal approaches are inframarginal and intercartilaginous incisions.

3.3.1.1 Inframarginal Incision • This incision allows access to the tip and dorsal area. The incision should be made along the caudal margin of the lower lateral crus. • Avoid destroying the soft triangle. The result will be nostril contracture or notching. Fig. 3.6  Harvesting dermal fat

3.3.1.2 Intercartilaginous Incision

• Optimal donor sites include the buttock, thigh, or abdomen (Fig. 3.6). • Because dermal fat tends to contract after harvest, it is better to design the graft slightly larger than the planned size. Dermal fat will reduce in size approximately 30% after grafting, but it is hard to predict the resorption rate precisely, as it depends on the recipient site conditions such as blood flow and tension.

• This incision allows quick access to the upper lateral cartilage. The incision is made between the lateral crus of the

3.2.5 Temporal Fascia Temporal fascia is used to provide extra thickness of skin, or for augmentation material. It is mostly used because of easy harvesting and a less visible postoperative scar. The size diminishes by approximately 50% or more after grafting, and unexpected severe postoperative contracture may occur.

3.2.6 Perichondrium Like temporal fascia, perichondrium is also used to provide extra thickness of skin or augmentation material. The size

Fig. 3.7  The inframargninaris incision and intercartilaginous incision

3.3 Approaches

53

lower lateral cartilage and the upper lateral cartilage (Fig. 3.7). • It can be extended to the caudal border of the septal cartilage for wider surgical access and view.

3.3.2 Open Approaches • The most common open approaches use the inverted V incision (Fig. 3.8), which allows access for rhinoplasty in almost all areas. • Bilateral inframarginal incisions are connected at the center of the columella. • Avoid destroying the soft triangle or the medial crus of the lower lateral cartilage.

Fig. 3.8  The inverted V incision

3.3.3 Vestibular Approaches The vestibular approach is used for access to the frontal process of the maxillary bone. For osteotomy, a tiny stab incision is made on the margin of the pyriform aperture.

4

Dorsal Augmentation or Height Reduction

Abstract

Materials used for dorsal augmentation basically are divided into alloplastic materials and autologous materials. The most common alloplastic materials for dorsal augmentation are silicone (Silastic), and Gore-Tex (Fig. 4.1). Selection of the implant type depends on each doctor’s choice. Table 4.1 lists some advantages and disadvantages of each type.

Keywords

Dorsal augmentation · Silastic implant · Gore-Tex · Capsule contracture · Operated look · Ear cartilage · Septal cartilage · Costal cartilage · Curving · Milling · Dermal fat · Dorsal height reduction · Humpectomy · Surgical ultrasonic bone cutter Fig. 4.1  Silicone and Gore-Tex implants in dorsal augmentation

4.1

 orsal Augmentation with Alloplastic D Materials

Materials used for dorsal augmentation basically are divided into alloplastic materials and autologous materials. The most common alloplastic materials for dorsal augmentation are silicone (Silastic), and Gore-Tex (Fig.  4.1). Selection of the implant type depends on each doctor’s choice. Table 4.1 lists some advantages and disadvantages of each type.

4.1.1 Silastic Implant • Silicone is a safe and stable material for medical use. An inframarginal approach or open approach is used.

Table 4.1  Alloplastic materials for Dorsal augmentation Material Silicone (Silastic)

Gore-Tex

Advantages No change in size (height remains) Easy to remove Easy to sculpt Stable because of tissue growth in the pores Less capsular contracture Less calcification

Disadvantages Capsular contracture Calcification Unstable in position Difficult to sculpt Difficult to remove, because of ingrown tissue

• The subcutaneous pocket should be continued to the subperiosteal pocket on the nasal bone in one layer (Figs. 4.2 and 4.3). • The pocket size should be slightly larger than the implant.

© Springer Japan KK, part of Springer Nature 2020 Y. Sugawara, A Practical Approach to Asian Rhinoplasty, https://doi.org/10.1007/978-4-431-56885-8_4

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4  Dorsal Augmentation or Height Reduction

Fig. 4.2  Fitting of the Silastic implant

• The implant should not extend beyond the supratip break. Its caudal end should be tapered (Fig. 4.4). • The key to success in the use of a silicone implant is to “fit it perfectly.” • It is especially important to fit the back side of the implant to the anatomical dorsal line.

• The shape of the anatomical dorsal line differs from that of the nasal dorsal line. Consider the difference of skin and soft-tissue thickness at radix and rhinion. • For perfect fitting, a lateral x-ray (cephalogram) is useful to know the basement curvature. • The augmentation ratio—the ratio of the S-ST projection to the size of the implant—is almost 1:1.

4.1.2 Gore-Tex Implant • Gore-Tex has been a popular material in the medical field for more than 20 years. • It is much softer than silicone, so it is useful for glabella augmentation combined with dorsal augmentation in patients who want to have balanced augmentation of the glabella and dorsum (Fig. 4.5). • The approach is the same as used for a silicone implant.

4.1.3 Complications and Solutions

Fig. 4.3  Silastic implant (cadaver)

4.1.3.1 Implant Movement Movement is an uncommon complication with the use of a Gore-Tex implant, but it can easily happen with the use of a silicone implant. If the implant does not fit well, it tends to move laterally, cephalad, or caudally (Figs. 4.6 and 4.7).

4.1 Dorsal Augmentation with Alloplastic Materials

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Fig. 4.4 Dorsal augmentation with a Silastic implant

Fig. 4.5 (a) Gore-Tex implant for glabellar augmentation. (b) Combined glabellar and dorsal augmentation

The most common cause of this complication is insertion of an implant that is excessively high or large. An over-size implant will also produce tension in the bed, resulting in resorption of the nasal bone (Figs. 4.8, 4.9, and 4.10).

4.1.3.2 Deviation Deviation occurs when the implant does not fit well or when the implant base (nasal bone, upper lateral cartilage [ULC]) is deviated. If the implant base is deformed, it should be corrected before implant insertion. In the case of nasal deviation

or facial scoliosis, nasal bone osteotomy with septoplasty will be needed.

4.1.3.3 Capsule Contracture Capsule contracture can be recognized by several symptoms (Fig. 4.11): • Short nose: Contracture in the long axis pull the LLC and nasal tip skin upward, resulting in a short-nose look.

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4  Dorsal Augmentation or Height Reduction

Fig. 4.6 (a) Lateral movement of implant. (b) Cephalad movement of implant. (c) Caudal movement of implant

Fig. 4.8  Features of Silastic implant complication—exposure Fig. 4.7  The Silastic implant is shifted to right side

• Lack of radix: The contracture causes the implant to gradually move upward, resulting in shallowing of the radix break. • Warping: If the implant is soft, warping occurs. • Visible implant margin It is not possible to prevent capsule formation around a Silastic implant, but it is possible to reduce it. The most

c­ommon cause of capsule formation is hematoma and infection. Treatment of capsule contracture is difficult. Even if you remove all capsule, it will form again. Several approaches may solve the problem: • • • •

Replacement of the implant with a smaller size Replacement using Gore-Tex or autologous materials Capsulotomy around the implant Capsulectomy and implant replacement

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4.2 Dorsal Augmentation with Autologous Graft

Fig. 4.9  Features of Silastic implant complication—exposure in the nasal cavity

4.1.3.4 Operated Look The implant is artificial material, so it will sometimes produce an unnatural appearance, including high contrast and an artificial nasal shape. These can result from capsule contracture with a Silastic implant, or soft tissue adhesion with the use of Gore-Tex. Skin tension from an over-size implant is also the cause of high contrast. In addition, because implantation always reduces the vascular circulation above the artificial materials, sometimes the area with less circulation appears paler than its surroundings, especially in patients with thin skin (Fig. 4.12). Artificial shapes include a perfectly straight dorsal profile line, a very narrow dorsal top width that extends to the tip, and a very peaked tip without a tip-defining point (Fig. 4.13).

Another example is an unnatural groove beside the nasal line (Fig. 4.14). Several considerations should be kept in mind to avoid the “operated look.” Though patients’ requests are foremost, it may not be wise to make the dorsal line straight all the way to the tip. A supratip break may be helpful for a natural look (Fig. 4.15). Similarly, a natural nasal line is not perfectly parallel from top to bottom. Some are wider or narrower at the rhinion (Fig. 4.16). A natural nasal base line is not always straight, but arched. The wide area smoothly changes to the mid-cheek area (Fig. 4.17). The natural side wall shape is not a flat plane. The radix side wall continues to the orbit; it is acute and gives a strong shadow. The dorsal side wall continues to the cheek smoothly, so it is less acute. The side wall should be flat without any groove (Fig.  4.18). Poor transition of implant edge on the side wall looks unnatural. The implant should smoothly cover the side wall of the nasal bone.

4.2

Dorsal Augmentation with Autologous Graft

Autologous tissue for dorsal augmentation is preferable to alloplastic materials from the aspects of side effects and complications. On the other hand, it has some limitations, such as donor site morbidity, difficulty in sculpting, and unpredictable resorption. Nevertheless, this technique is useful for patients with thin skin or those who are anxious about alloplastic materials or have experienced trouble with those implants. Fig. 4.10 Features of Silastic implant complication—nasal bone absorption

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4  Dorsal Augmentation or Height Reduction

Fig. 4.11  Deformities due to capsule contracture (initial appearance  (L) and appearance after treatment  with costal cartilage graft (R)). (a) Warping and cephalic shift of the implant. (b and c) Short nose deformity is corrected

Fig. 4.12  Reduced vascular circulation producing pale color compared with surrounding skin

4.2 Dorsal Augmentation with Autologous Graft

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Fig. 4.13  Representative lines of the nose

Fig. 4.14  Unnatural groove beside the nasal line

4.2.1 Ear Cartilage

4.2.2 Septal Cartilage

Ear cartilage is a good graft material because it is easy to harvest. Ear cartilage is soft and firm, but it is difficult to taper the edge of the piece (Fig. 4.19a). The edge may break off easily with a morselizing maneuver. Therefore perichondrium should be attached when harvesting, to prevent marginal breakage. The graft is fixed in place with suturing or pull-out technique (Fig. 4.19b). Figures 4.20 and 4.21 show preoperative and postoperative photographs from cases in which ear cartilage was grafted to the radix (Fig.  4.20) or to the radix and dorsum (Fig. 4.21).

The septal cartilage is fairly flat, smooth, and firm. Septal cartilage is thinner than ear cartilage. Therefore it can be used to augment the radix or dorsum by about 1  mm (Fig. 4.22a). It is easier to sculpt the septal cartilage than ear cartilage. All graft margins should be tapered carefully (Fig.  4.22b), because they tend to be visible through thin skin. Morselizing is also recommended. Figure 4.23 shows a case in which septal cartilage was grafted to the radix. Mild hump resection was also performed.

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Fig. 4.15  Variations of the dorsal line—concave, straight, convex

Fig. 4.16  The sharp and parallel nasal line is corrected with lipo injection preop (L) and postop (R)

Fig. 4.17  Natural tranisition of nasal base line to the mid-cheek

4  Dorsal Augmentation or Height Reduction

4.2 Dorsal Augmentation with Autologous Graft

Fig. 4.18  Note sidewall shape. Acute transition change mild postoperatively

Fig. 4.19 (a and b) Ear cartilage for radix augmentation. A temporary suture for fixation

Fig. 4.20  Ear cartilage graft to radix. Mild augmentation is obtained

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4  Dorsal Augmentation or Height Reduction

Fig. 4.21 (a and b) Ear cartilage graft to radix and dorsum. Two-layed ear cartilage is on radix to middle vault

Fig. 4.22 (a and b) Septal cartilage. The amount of augmentation is limited

Fig. 4.23 (a and b) Septal cartilage graft to radix. Mild hump resection was also performed

4.2 Dorsal Augmentation with Autologous Graft

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Fig. 4.24 Lateral cephalogram for fitting of costal cartilage

4.2.3 Costal Cartilage Costal cartilage is very useful autologous tissue for rhinoplasty. An amount sufficient for grafting can be harvested, it is easy to sculpt, and it has a low rate of absorption. Three aspects are key to success: • Precise fitting • Sculpting of a smooth surface • Prevention of warping For precise fitting, a lateral cephalogram or CT image is very useful to know the graft bed curvature (Fig. 4.24). The

Fig. 4.25 (a and b) Featuring plate template of costal cartilage

cephalogram is usually taken at a 1:1.1 ratio, almost a life-­ size picture. There are two ways to prepare costal cartilage, curving and milling.

4.2.3.1 Curved Type A plate template (Fig. 4.25a) is a good tool to trace the graft bed curvature intraoperatively (Fig.  4.25b). After long-axis and short-axis shapes are traced, the graft curvature is checked. Costal cartilage for grafting should be made straight, but also its surface must be as smooth as possible (Fig.  4.26). Irregularity from inadequate sculpting leads to surface irregularity, which is never corrected as surgeons may hope. A

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4  Dorsal Augmentation or Height Reduction

Fig. 4.26  Poor sculpting of costal cartilage result in deviated nose

Fig. 4.27  The bone scraper

bone scraper (Fig. 4.27) is useful tool for smoothing the surface of costal cartilage. There are many ways to prevent warping, such as balanced cross-section, hatching incision, or K-wire insertion, but nothing will completely prevent costal cartilage warping. Shorter pieces have less warping, so my preference is to use pieces no longer than 25 mm. If the graft needs to be 40 mm long, I use two grafts, 25 mm and 15 mm in length (Fig. 4.28). Each piece is fixed with absorbable suture. The risk of surface notching can be avoided by precise sculpting. Fixation is not always necessary. If the graft is unstable, first carve it again to fit, and then put in small pins, 0.7 mm in diameter (Fig. 4.29). These can be removed 1 week later. Figures 4.30 and 4.31 show preoperative and postoperative photographs of cases in which costal cartilage grafts were applied to the radix and dorsum.

4.2.3.2 Milled Type Costal cartilage can be milled by a bone mill. The average size of milled costal cartilage is less than 0.4 mm. This very

small piece of cartilage can be pushed down and fixed in the syringe. Milled costal cartilage is grafted in free fashion or wrapped with a polyglycol acid mesh sheet. An advantage of milled costal cartilage is that it has little chance of warping postoperatively. If revision is needed, several pieces of milled costal cartilage can be removed through a stab incision and molded with an 18-gauge needle.

4.2.4 Dermal Fat Dermal fat grafting is a good option to provide extra skin thickness, especially for the patient who need a replacement of a Silastic implant. A pocket is made subcutaneously (not subperiosteally, because sufficient blood supply to the graft is necessary). A pullout suture is used for insertion of the graft in the correct position (Fig. 4.32). The suture is left for a week. One of the issues of dermal fat grafts is fat resorption after grafting. The resorption rate is considered approximately 20–50%, and fat is sometimes resorbed inconsistently,

4.3 Dorsal Height Reduction (Humpectomy)

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Fig. 4.29  Fixation with small pins (0.7 mm in diameter)

4.3.1 Bony Area

Fig. 4.28  Costal cartilage graft in two pieces, to minimize warping

resulting in surface irregularity. Unpredictability should be avoided in rhinoplasty, so that only “dermis” is better in use.

4.2.5 Complications and Solutions One of the common complications is visible irregularity. All graft materials should be shaped as smooth as possible. The edge of cartilage should be crushed to smooth the edge, as a thick edge is often seen through thin skin. There are two type of crusher, box type and handle type (Fig. 4.33). The handle type is better in controlling the area and quantity. Gentle crush is recommended. If the graft is broken in pieces, it is difficult to fix a smashed piece with suture in place. Revision can be done by curetting through a stab incision using an 18-gauge needle (Fig. 4.34).

4.3

 orsal Height Reduction D (Humpectomy)

Dorsal height reduction is may involve two areas, the bony area and the cartilaginous area.

The bony area can be approached through either an open approach or an endonasal (intercartilaginous) approach. An open approach is recommended for precise hump resection. After subperiosteal dissection, the bony hump is resected with a rasp or surgical ultrasonic bone cutter. When using the rasp, take care not to rasp the cartilage area, because the ULC may become detached from the septal cartilage, causing a saddle nose deformity. A surgical ultrasonic bone cutter can shave only the hard tissue, so there is no risk of soft tissue injury.

4.3.2 Cartilaginous Area The cartilaginous area can be resected with a knife. Complete dissection and release of the ULC and septal cartilage are required to prevent mucosal injury before hump resection. First the septal cartilage is resected, followed by the cephalic part of the ULC.

4.3.3 Open Roof Closure After bony and cartilaginous hump resection, open roof deformity should be corrected. Osteotomy is performed to narrow this open roof with the classic chisel or surgical ultrasonic bone cutter. The surgical ultrasonic bone cutter is

68 Fig. 4.30  Costal cartilage graft (curved type) to radix and dorsum

4  Dorsal Augmentation or Height Reduction

4.3 Dorsal Height Reduction (Humpectomy)

Fig. 4.31  Costal cartilage graft (milled type) to radix and dorsum (a, b), milled costal cartilage is delivered with syringe (c)

Fig. 4.32 (a and b) Augmentation with dermal fat

69

70 Fig. 4.33  Cartilage crushers. The two types are the handle type (top) and the box type (bottom)

4  Dorsal Augmentation or Height Reduction

4.3 Dorsal Height Reduction (Humpectomy)

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Fig. 4.34 (a and b) Revision of irregularity through stab incision with 18G needle

strongly recommended because it is precise, safe, can perform osteotomy with less injury. The osteotomy line depends on each patient’s bony form. If the patient has a wide nasal base, a low-level osteotomy is

better. If patient has a moderate nasal base, a mid-level osteotomy is good.

5

Altering the Nasal Tip

Abstract

Surgeons who alter the Asian nasal tip should be knowledgeable of the anatomical features typical of the Asian nose. Keywords

Tripod · Cephalic rotation · Caudal rotation · Suturing technique · Domal suture · Interdomal suture · Spanning suture · Pinched nose · Polly beak deformity · Cap graft · Shield graft · Medial crural strut graft · Lateral crural strut graft · Septal extension graft · Derotation graft · Rim graft · Rim extension graft

5.1

 natomical Features of the Asian A Nose

Surgeons who alter the Asian nasal tip should be knowledgeable of the anatomical features typical of the Asian nose.

5.1.1 Cartilage Most Asian noses have very small, thin, hypoplastic, and buckled lower lateral cartilage (LLC), as well as small septal cartilage. The consistency (strength) of the cartilage tends to be weak. The medial crus is usually short, weak, and even buckled in most cases, even if the shape of the soft tissue of the columella is straight.

The medial crus is often asymmetric (Figs. 5.1, 5.2, 5.3, and 5.4) and the lateral crus tends to be vertical (Fig. 5.5). This means that the LLC offers little support for nasal tip projection; soft tissue itself provides support of the nasal tip projection.

5.1.2 Soft Tissue Envelope The thickness of the skin varies. Check the skin-soft tissue (S-ST) condition by clinical examination, but be aware that it is sometimes difficult to predict because the firmness is almost the same as that of the LLC. Sebaceous skin tends to have a thick and heavy S-ST condition, which makes it difficult to change its shape. Some patients do have very caucasian-­like structures, such as very firm LLC and thin skin.

5.1.3 M  orphological Relation Between Frame and Soft Tissue Knowing the relation between nasal framework and surface topology is important. Basically, surface aesthetics depends on frame structure, and (as discussed in Chap. 1), most rhinoplasty consists of altering the framework. However, some Asian noses show hardly any relation between the nasal framework and surface topology; the nasal shape is determined by the skin and soft tissue itself. In those cases, it is often difficult to alter the nasal shape.

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Figs. 5.1 and 5.2  Moderate size of medial crus and big lateral crus

Figs. 5.3 and 5.4  Small, buckled medial crus and small, narrow lateral crus. The position is also asymmetric

5  Altering the Nasal Tip

5.1 Anatomical Features of the Asian Nose Fig. 5.5  Lower lateral cartilage (LLC): Differences between the Asian type (orange) and caucasian type (purple). The length and width of the LLC are the most significant points of difference. The border between the medial and lateral crus is unclear in the Asian type

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5.2

5  Altering the Nasal Tip

Structural Tip Management

There are two aspects of tip management: lateral tip positioning and frontal tip reshaping. These two factors should be managed simultaneously, and the surgeon must understand how the factors affect each other. For instance, when the tip is brought forward, it tends to be narrow because of soft-tissue stretching. When the tip is reduced, it tends to be round because of soft-tissue redundancy (Figs. 5.6 and 5.7). Basically, it is easier to manage the lateral positioning first and then perform the frontal reshaping accordingly. The balance of the frame strength and the weight of the soft tissue envelope is the key to stable and long-lasting tip

position. The stronger frame is, the more reliable the tip shape, but a frame that is too strong causes discomfort to the patient. Well-balanced structure is essential. When you estimate the frame strength, the concept of “load sharing and load bearing” is very helpful. Elements of the load include skin contracture, soft tissue weight, and muscle action. Check the skin and soft tissue envelope and its weight. The thicker it is, the heavier it is. A balanced approach is necessary to obtain a natural-­ looking and attractive Asian nose. The final goal should be kept in mind, but sometimes the planned framework cannot be completed because of insufficient graft material, a hypoplastic LLC, or heavy skin tension. The goal for these patients must be changed to achieve a safe and stable outcome.

Figs. 5.6 and 5.7  Tip management consists of frontal reshaping and lateral positioning

5.3  Frame Structuring

5.3

Frame Structuring

There are three approaches to structural tip management: • Tripod leg controlling • Cartilage suturing • Cartilage grafting (onlay, batten, or extension graft) Usually all three approaches are performed in a combined fashion.

5.3.1 Tripod Leg Controlling Surgeons must understand the “tripod concept” for nasal tip structure, which was introduced by Jack Anderson in 1969 and is now widely accepted by many facial plastic surgeons as a reasonable description of nasal tip dynamics. The LLC is compared with a tripod; the medial crus and lateral crura are the three legs (Fig. 5.8). Tip position can be altered by controlling the length of each tripod leg. For instance, the tip is rotated up by lifting the medial crus up, or by shortening both lateral crura. To rotate the tip downward, you should shorten the medial crus or elongate the lateral crura (Fig. 5.9). Note that the tripod concept is not completely applicable to clinical cases because the legs (cartilages) are not rigid,

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straight legs; they are soft and bendable (Fig. 5.10). Also, the footplate of the medial crus is loosely fixed around the base of the columella (Fig. 5.11), so the pivot point is not strictly located at the foot of each tripod leg, but instead at an uncertain point within the leg. For instance, because of leg bending, shortening of the lateral crura often reduces the tip projection as well as rotating it upward (Fig. 5.12).

5.3.1.1 Cephalic Rotation (Up-Rotation) According to the tripod concept, rotation up is managed by shortening the lateral crus leg of the tripod (Fig. 5.13). The cut end is overlapped, and one or two mattress sutures are placed. This action brings the tip not only upward, but also backward, due to the movable pivot point, as described before. To keep the tip projection, cartilage grafting between the medial crura (medial crural strut graft) should be performed. This graft provides a more stable pivot point and reinforces the medial crura (Figs. 5.14, 5.15, and 5.16). Cephalic trim is another classic approach for tip rotation upward. This is not a tripod leg-controlling procedure. Cephalic trim creates the gap between the upper lateral cartilage (ULC) and the LLC. The lack of support at the scroll area effects the tip rotation up. The amount of tip rotation is unpredictable, however, because the mechanism of the rotation is dependent upon the soft-tissue contracture (Fig. 5.17). Also, because the tripod legs themselves are not shortened, the tip needs to be projected as well as rotated up. 5.3.1.2 Caudal Rotation (Down-Rotation) According to the tripod concept, rotation down is managed by shortening the medial crus. This action is very limited, however, and because the base of the medial crus is not fixed but floats around the columella base, this approach is seldom used for the Asian nose. 5.3.1.3 Side Deviation Tip shifting in frontal view is possible by shortening the unilateral lateral crus (Fig. 5.18). This procedure is often used in the case of a twisted nasal tip (Fig. 5.19).

5.3.2 Cartilage Suturing Cartilage suturing is the technique most commonly performed in rhinoplasty. It is so useful that every surgeon should know the three basic actions:

Fig. 5.8  The LLC is compared with a tripod; the medial crus and lateral crura comprise the three legs

• cartilage forming • structural reinforcement • cartilage position change

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5  Altering the Nasal Tip

Fig. 5.9  Tip rotation down can be performed by shortening the medial crus or elongating the lateral crura. Similarly, tip rotation up can be performed by shortening the lateral crura or elongating the medial crus

5.3.2.1 Cartilage Forming: Domal Suture In this technique, suturing is used to bend the LLC.  It is mainly performed to give a sharper form to the tip (Fig. 5.20). This technique is called domal suture (transdomal suture) (Fig. 5.21). This is a good method by which to change the domal shape by placing a horizontal mattress suture. Usually 5-0 PDS is used. Care must be taken not to penetrate the mucosa. If the stitch is exposed in the nasal cavity, it will cause chronic inflammation.

When this suture is used, three features should be noticed: 1. The actual length of the LLC is shortened by bending. Therefore the created tip position tends to shift to posterior and cephalic (Fig.  5.22). This is important if the patient has a short and small LLC. 2. Twisting of the LLC is caused by its shape; it is originally boomerang-shaped, not straight. When it bends, therefore,

5.3  Frame Structuring

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Fig. 5.10  The tripod of the nose does not have rigid, straight legs (a); instead, they are soft and bendable (b)

3. This technique provides not only sharpening but straightening of the lateral crus, but the amount of flattening depends on the stiffness of the LLC. In the case of a very strong or very weak LLC, suturing does not affect the total LLC. Its effect is limited to just the area around the suture (Fig. 5.24). Also, it often occurs that the LLC has a wide, vertical, concave shape (like the Italian pasta “conchiglie”) (Fig. 5.25). In this situation, there are two solutions: a cephalic trim of the LLC, or a lateral crural strut graft. Cephalic trim of the LLC provides a flatter shape to the lateral crus, so it becomes easier to bend by domal suture (Figs. 5.26 and 5.27). A lateral crural strut graft also gives a straighter shape to the lateral crus.

5.3.2.2 Structural Reinforcement Cartilage suturing is also used for structural reinforcement by binding several structures by stitches (Fig. 5.28). Fig. 5.11  Footplate of medial crus is loosely fixed around the base of columella

it acts as though it is twisting (Fig. 5.23). This deformation results in dome flaring, columella narrowing, and so on.

5.3.2.2.1 Interdomal Suture The interdomal suture is also called the dome binding suture (Figs. 5.29 and 5.30). It gives structural reinforcement to the medial crus, so it is often performed in the case of tip onlay graft (cap graft, shield graft) (Fig. 5.31). It may be the same as repair of the interdomal ligament.

80 Fig. 5.12  LLC shortening often reduces tip projection as well as rotating it upward, because of leg bending

Fig. 5.13  Rotation up is managed by shortening the lateral crus leg of the tripod

Fig. 5.14  To keep tip projection, cartilage grafting between the medial crura (medial crural strut graft) should be performed

5  Altering the Nasal Tip

5.3  Frame Structuring

Fig. 5.15  Preoperative lateral view before upward tip rotation

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Fig. 5.17  Cephalic trim is a classic approach for upward tip rotation, but the result is unpredictable

mattress suture, the shape of the lateral crus is changed. A too-strong suture, or usage in a small lateral crus, may cause buckling or flaring (Fig. 5.34).

5.3.2.3 Cartilage Position Change Interdomal suture is used for another purpose: to make the two-part dome position narrower (Figs. 5.35 and 5.36). Attention should be paid not to disturb the natural tip shape. Too much binding creates a “pinched nose,” with an unnaturally extended supra-alar groove, rim notching, and polly beak deformity (Fig. 5.37).

5.3.3 Cartilage Grafting Cartilage grafting is also performed very often, especially in the case of low tip projection. It has three purposes:

Fig. 5.16  Postoperative lateral view of the same patient as in Fig. 5.15. Shortening of the lateral crura was accompanied by medial crural strut grafting to keep the tip projection

5.3.2.2.2 Spanning Suture The spanning suture gives structural reinforcement to the lateral crura (Fig.  5.32). Usually both lateral crura are sutured to the septal cartilage to prevent cephalic rotation of the tip (Fig. 5.33). When it is performed by horizontal

• volume augmentation • structural reinforcement • cartilage or soft-tissue forming

5.3.3.1 Volume Augmentation One function of cartilage grafting is the addition of volume (Fig. 5.38). 5.3.3.1.1 Cap Graft A cap graft is the most common method of giving additional volume and shape to the nasal tip area (Fig. 5.39). To provide

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5  Altering the Nasal Tip

Fig. 5.18  Tip shifting in frontal view is made possible by shortening the unilateral lateral crus

Fig. 5.19 (a) Tip deviation. (b) The upper lateral cartilage (ULC) was corrected by a spreader graft. Note the twisted shield graft. The right side lateral crus is longer than the left side. (c–e) The right side lateral

crus is shortened and sutured. Tip deviation is completely corrected. (f and g) Preoperative frontal and bottom views. (h and I) Postoperative views

additional projection, another small cap graft or a shield graft can be used (Fig. 5.40). Note that adding these grafts changes the proportions of the tip and nostril. Too much onlay graft makes the proportion worse (Fig.  5.41). The graft shape is also important, because it is one of the factors of tip shape (Fig. 5.42).

All cartilage grafts should be fixed with a 5-0 or 6-0 absorbable suture (Fig. 5.43). In the endonasal approach, it can be fixed with stitching through the skin (Fig. 5.44). For patients with thin skin, the side edges of the tip should be trimmed smoothly or crushed as much as possible (Figs. 5.45 and 5.46).

5.3  Frame Structuring

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5.3.3.1.2 Shield Graft If caudal tip rotation is needed, a shield type of graft is better to bring the tip downward. To provide additional rotation down, another small cap graft is placed behind the shield graft (see Fig. 5.40b).

5.3.3.2 Structural Reinforcement When using a cap graft or shield graft, structural stability is the key to success. Excessive grafting decreases effectiveness because the LLC tripod sinks (Fig. 5.47). The augmentation ratio—the ratio of the soft-tissue projection to the grafted cartilage—depends on the LLC stability. If the LLC tripod is stable enough, the ratio is 1:1. If not, the ratio is less than 1:1. If the LLC tripod sinks, structural reinforcement is required. Cartilage graft is used for structural reinforcement (Fig. 5.48). Types include the medial crural strut graft (columella strut graft, power strut graft), lateral crural strut graft, and septal extension graft.

Fig. 5.20  Cartilage bending by suturing Fig. 5.21  Domal suture (transdomal suture) technique

5.3.3.2.1 Medial Crural Strut Graft Augmentation grafting adds extra volume to the frame, so the frame should be strong enough to hold increased soft-­ tissue pressure. If the structure is not good enough to hold the soft-tissue pressure, the tripod structure will be deformed (Fig. 5.49). In those situations, suturing (interdomal suture, spanning suture) should be performed. If more stability is

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5  Altering the Nasal Tip

Fig. 5.22 (a and b) The length of the LLC is shortened by bending

rior nasal spine, but smiling may cause the columella to tilt by the action of the depressor septi nasi muscle. A shield graft can be used for the same purposes as a medial crural strut graft (Fig.  5.54). When using a shield graft, spanning suture is useful to prevent the relapse force of cephalic rotation. 5.3.3.2.2 Lateral Crural Strut Graft The lateral crural strut graft (Fig. 5.55) can also be used to reinforce the LLC tripod, but it is seldom performed for this purpose because in most cases the spanning suture is good enough to hold the soft-tissue pressure. In cases of secondary deformity cases with deviation, however, it is used very often, because a graft is needed to restore the contracted unilateral lateral crus (Fig. 5.56).

Fig. 5.23  The tip position tends to shift to cephalic and posterior. Bending always includes twisting of the lateral crus

needed, a medial crural strut graft should be used (Figs. 5.50, 5.51, and 5.52). It is acceptable if the medial crural strut graft is not long enough to reach to the anterior nasal spine, or an extended type can be used (Fig. 5.53). More stability can be obtained if the medial crural strut graft reaches to the ante-

5.3.3.2.3 Septal Extension Graft The septal extension graft provides the most rigid stability for the tripod (Fig. 5.57a). The concept is that the tripod legs are fixed to the extended septum, which makes it skeletally stable. In this technique, the whole LLC can be moved to the new position and completely fixed to the extended septum. Therefore, the LLC does not move except in a side-to-side direction. There are several types of septal extension graft. A wide-­ board type is recommended because septal cartilage of the wide-board type is stronger than the narrow-board type. Furthermore, the three-point fixation with suture is much more stable than the on-line two-to-three-point fixation (Fig.  5.57b, c). Commonly used styles include an off-set graft or an end-to-end graft. The end-to-end style is better

5.3  Frame Structuring

Fig. 5.24  Bending sometimes occurs just around the sutured area

Fig. 5.25  Italian “conchiglie” pasta

than the off-set style because it has less need for an intact, flat piece of septal cartilage. The septal cartilage is the most preferred graft material, but conchal cartilage (Fig. 5.58) and costal cartilage also can

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be used. Before trimming the cartilage, a trial template should be used, because the harvested cartilage is limited in size, especially in patients with a short nose (Fig.  5.59). Place the cartilage between the medial crura, and temporarily fix with a small needle. An overlap 7  mm wide offers adequate stability. The septal cartilage is fixed in three points with 5-0 PDS. Nonabsorbable suture should NOT be used, as it might cause chronic inflammation of the nasal mucosa. The septal cartilage should be placed as straight as possible along the midline. If the septum is twisted, it must be corrected before fixing the extension graft, because the septum should be the rigid structure that supports all the structures: the extension graft, LLC, cap graft, and soft tissue (Fig. 5.60). Before fixing the LLC, it should be freed from the ULC (Fig. 5.61). The area where the lateral crus is connected to the ULC is called the scroll area or intercartilaginous ligament. Dissection is performed gently so as not to tear the mucosa. The LLC is fixed to the extension graft with adequate tension, using 5-0 PDS (Fig.  5.62). Too much LLC movement will give high counter-force to the structure, which may be a cause of postoperative relapse or twisted deformity. The cephalic margin of the medial crus is usually sutured to the graft first. If the caudal end is sutured, the columella may appear unnaturally narrow. The overlapped area of LLC on the ULC can be stolen for advancement. This is called lateral crural steal (Fig. 5.63). However, a wide lack of continuity of the ULC and LLC will cause postoperative relapse. It should be within 2 mm. The transfixation suture is very important to establish the stability of the graft during the wound healing period, and to avoid hematoma (Fig. 5.64). Too much release and advancement of the lateral crura creates a risk of relapse due to postoperative soft-tissue contracture. To avoid this, medial crural steal (lateralization of the medial crus) is recommended (Fig.  5.65). Intermediate and medial crura are pulled up and gathered for the tip area (Fig. 5.66). Medial crus has less stability than lateral crus. Therefore this approach is more stable and reliable. One problem is lack of support of the soft triangle and rim. This problem is solved by rim graft or rim extension graft, which are discussed below.

86 Fig. 5.26  The lateral crus has two-dimensional curvature, A–B and C–D. The curvature of A–B restricts the bending by suturing. Cephalic trim of the LLC (red dotted line) gives a flatter shape to the lateral crus

Fig. 5.27 (a–c) Before domal suturing. (d–f) After domal suturing

5  Altering the Nasal Tip

5.3  Frame Structuring

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graft (medial crural strut graft) will be needed to reinforce the medial crus. Ear cartilage is the preferred graft material.

5.3.3.3 Cartilage or Soft-Tissue Forming Cartilage graft is used to improve the shape of cartilage or soft tissue (Fig.  5.67). Grafts of this type include the medial crural strut graft, lateral crural strut graft, rim graft, and rim extension graft (also called “batten grafts” in general). Medial crural strut grafts and lateral crural strut grafts are used not only for reinforcement of the tripod legs but also to correct a crooked form. The medial crural strut graft is often used for the correction of a hanging columella (Fig.  5.68) and for increasing columella width (Fig. 5.69). Lateral crural strut graft is used for the correction of a pinched nose (Fig. 5.70). 5.3.3.3.1 Rim Graft The rim margin has no cartilaginous support, so a cartilage graft is sometimes needed to prevent secondary rim deformities after cartilaginous procedures. A rim graft is used to give extra soft-tissue support to the rim contour. A small graft is inserted to a pocket along the rim margin (Fig.  5.71). If a groove is observed on the rim, this simple technique very easily reduces the groove (Fig. 5.72). In the technique of lateral or medial crural steal with septal extension, the newly created alar rim is less supported than before, resulting in a retracted rim or rim notching deformity that may require tip plasty (Fig. 5.73). Fig. 5.28  Structural reinforcement by suturing

5.3.3.2.4 Derotation Graft Derotation graft provides rigid stability for both lateral and intermediate crura. The concept is that the derotation graft provides an extra leg for the tripod (making a quadra-pod). In this technique, the whole LLC can be moved to the new position and fixed with four legs. Therefore, the LLC is more movable than with a septal extension graft. If the medial crus is weak, the tip tends to rotate and move downward Additional

5.3.3.3.2 Rim Extension Graft A rim graft supports only a very limited area of soft tissue. If more extensive support is needed, a rim extension graft is better (Fig. 5.74). Two pieces of septal cartilage are sutured to the caudal margins of the lateral crura. The graft acts as a part of the lateral crus and intermediate crus, supporting the soft triangle and rim (Fig. 5.75). In cases of severe rim retraction, a composite graft to the nasal lining is required in addition to the rim extension graft (Fig. 5.76).

88 Fig. 5.29  Interdomal suture (dome binding suture)

Fig. 5.30  Cephalic point of medial crus is sutured

5  Altering the Nasal Tip

5.3  Frame Structuring Fig. 5.31  This technique is often performed in the case of a tip onlay graft, to make the medial crus more stable

Fig. 5.32  Spanning suture technique

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5  Altering the Nasal Tip

Fig. 5.33 (a and b) This suture adds to the structural reinforcement of the lateral crura. Both lateral crura are sutured to the septal cartilage to prevent cephalic rotation of the tip

5.3  Frame Structuring

Fig. 5.34 (a–f) If the lateral crura are small and short, a spanning suture may cause them to flare

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5  Altering the Nasal Tip

Fig. 5.35  Interdomal suture also can make the two-part dome position narrower

Fig. 5.36  Preoperative (a–c) and postoperative (d–f) views showing the use of interdomal suture and cap graft, performed with an endonasal approach

5.3  Frame Structuring Fig. 5.37  Too much narrowing by interdomal suture creates a “pinched nose” deformity (preoperative and postoperative views)

Fig. 5.38  Cartilage grafting for additional volume (augmentation)

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Fig. 5.39  Cap graft

Fig. 5.40  Shield graft (a) and combination of a shield and cap graft (b)

5  Altering the Nasal Tip

5.3  Frame Structuring Fig. 5.41  Too much onlay graft worsens the proportions of the tip and nostrils

Fig. 5.42 (a and b) Unnatural tip shape. c, Intraoperative view shows that a two-layered “round graft” was placed

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5  Altering the Nasal Tip

Fig. 5.43  Onlay graft should be fixed with direct suture

Fig. 5.44  It can be fixed through the skin in endonasal approach

5.3  Frame Structuring

Fig. 5.45  If the patient has thin skin, the side edges of the tip graft should be trimmed smoothly (a) or crushed (b and c) as much as possible

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Fig. 5.46  Preoperative (a–c) and postoperative (d–f) views. Only cap and shield grafts were performed

5  Altering the Nasal Tip

5.3  Frame Structuring

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Fig. 5.47  Excessive graft decreases the effectiveness, owing to sinking of the LLC tripod

Fig. 5.49  Completely buckled medial crus due to excessive pressure by an onlay graft

Fig. 5.48  Cartilage graft is used for structural reinforcement

Fig. 5.50  Medial crural strut graft

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Fig. 5.51  Medial crural strut graft provides extra reinforcement

Fig. 5.52 (a–c) Septal cartilage is inserted between the medial crus, and sutured

5  Altering the Nasal Tip

5.3  Frame Structuring

Fig. 5.53  Extended type of medial crural strut graft

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5  Altering the Nasal Tip

Fig. 5.54 (a–d) A shield graft also can be used for the same purpose, but it will be slightly weaker than a medial crural strut graft

5.3  Frame Structuring

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Fig. 5.55  Lateral crural strut graft (a) and an extended type of lateral crural strut graft (b, c). These can be used to reinforce the LLC tripod, but a spanning suture usually is strong enough

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Fig. 5.56  A lateral crural strut graft is often used in cases of secondary deformity with deviation. (a and b) The left lateral crus is contracted

5  Altering the Nasal Tip

and shortened; an elongated lateral crural strut graft was fixed to restore the tripod. Shown are preoperative (c, d) and postoperative (e, f) frontal and bottom views

5.3  Frame Structuring

Fig. 5.57 (a) Septal extension graft. (b and c) The wide-board type is stronger than the narrow-board type

Fig. 5.58  Two-layered conchal cartilage for a septal extension graft

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5  Altering the Nasal Tip

Fig. 5.59 (a and b) Before trimming the cartilage, a trial template should be used. (c and d) Graft is trimmed. (e and f) Place the cartilage between medial crura, and temporarily fix with a small needle. A 7-mm width should be overlapped for adequate stability

5.3  Frame Structuring

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Fig. 5.60 (a) If the septum is twisted, it must be corrected before fixing the extension graft. (b) The septum is cut on the caudal end and shifted to the correct position. (c and d) The septal extension graft was placed as straight as possible along the midline Fig. 5.61  The LLC should be freed from the ULC at the scroll area, and moved caudally

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Fig. 5.62 (a–d) LLC is fixed to the extension graft with adequate tension with 5-0 PDS

5  Altering the Nasal Tip

5.3  Frame Structuring

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Fig. 5.63  Tip position (white dot) is pulled by lateral crural steal

Fig. 5.64  Transfixation suture is very important for stability of the graft and avoiding complications

110 Fig. 5.65  Medial crural steal is used to create a new tip, instead of lateral crural steal

Fig. 5.66 (a–c) Buckled intermediate and medial crura are pulled up and gathered for the tip area

5  Altering the Nasal Tip

5.3  Frame Structuring

Fig. 5.67  Cartilage graft for straightening or soft-tissue support

Fig. 5.68  Medial crural strut graft is used for the correction of a hanging columella. Preoperative views (a, b) and postoperative views (c, d)

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Fig. 5.69  Medial crural strut graft is used for the correction of a narrow columella. Preoperative views (a, b) and postoperative views (c, d)

Fig. 5.70  Lateral crural strut graft is used for the correction of a pinched nose. Preoperative views (a, b) and postoperative views (c, d)

5.3  Frame Structuring

Fig. 5.71  Rim graft

Fig. 5.72  A small piece of septal cartilage is inserted in a tight pocket in the rim

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Fig. 5.73  Retracted rim deformity after septal extension graft, requiring tip plasty. Preoperative views (a, b) and postoperative views (c, d)

Fig. 5.74  Rim extension graft

5.3  Frame Structuring

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Fig. 5.75 (a–c) In this patient, the nasal tip was rotated down by a septal extension graft. Note the lack of support around the soft triangle and rim. (d–f) Rim extension graft was performed to provide soft-tissue support

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5  Altering the Nasal Tip

Fig. 5.76  In a case of severe rim retraction, both rim extension grafts and composite grafts to the nasal lining are required. Preoperative views (a–c) and postoperative views (d–f)

5.4

Soft-Tissue Management

Subcutaneous soft tissue generally should be preserved. Disproportionate fat tissue can be excised, but excessive removal should be avoided. Soft-tissue contracture may continue for approximately 2 years after surgery; the final result can be seen after that time (Fig. 5.77). Steroid injection (triamcinolone acetonide) is very effective in patients with heavy skin. It will be injected subcutaneously every 4 weeks, up to three times. Excessive injections will cause irreversible soft tissue atrophy.

5.5

Balanced Approach

A balanced approach is necessary to obtain a natural, good-­ looking Asian nose. There should be a final goal in mind, of course, but sometimes insufficient graft material, hypoplastic LLC, and heavy skin tension prevent completion of the framework. The goal for these patients should be changed to achieve a safe and stable outcome.

5.5  Balanced Approach

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Fig. 5.77 (a and b) Preoperative views. (c) Three months after the tip plasty, the tip shape is worse than before surgery. (d and e) Three years after surgery. Steroid injection was performed three times

6

Alar and Pedestals

Abstract

Alarplasty is a simple procedure that can provide a dramatic improvement. Reduction and resection are the most common procedures, but augmentation and grafting are another option in some cases. Reduction procedures can be performed on the outer side of the alar area, the inner side, the nostril base, and the alar rim. Each leads to a different outcome, and several approaches can be combined. Keywords

Alarplasty · Lobule · Augmentation · Grafting · Curvature · Resection

6.1

Principles of Alarplasty

Alarplasty is a simple procedure that can provide a dramatic improvement. Reduction and resection are the most common procedures, but augmentation and grafting are another option in some cases. Reduction procedures can be performed on the outer side of the alar area, the inner side, the nostril base, and the alar rim. Each leads to a different outcome, and several approaches can be combined. The key points to consider in designing alarplasty are the alar width, the shape of the nostril, the relation of the nostril and alar lobule, and the angle of the columella and alar rim (Figs. 6.1 and 6.2).

seen in the frontal view, the alar width is equal to the alar crease width (Figs. 6.5 and 6.6).

6.1.2 Nostril Shape A vertically long nostril shape from the basal view is generally considered to be very attractive. Its shape is influenced by the tip in the anterior area; in the basal area, the shape is influenced by the alar or columella. Alarplasty thus affects the lateral and basal shape of the nostril (Figs. 6.7 and 6.8). The lateral and basal shape of the nostril is considered to be favorable if one can draw a slow curve from the medial through the lateral prominence, continuing to the lateral alar. A notch during this curve gives an unnatural impression. The nostril shape is also affected by the alar thickness and alar base thickness (Fig. 6.9).

6.1.3 Alar Curvature The alar draws a curve laterally; a flat alar without this curve appears unnatural. At the same time, this curve is more attractive when it is gentle. A flat alar shape or one with a steep curve lacks balance. The relation between the cranial end of the alar groove and the alar base is also important. In general, the alar base does not locate medially from the cranial end of the alar groove (Fig. 6.10).

6.1.1 Alar Width

6.2

Alar Resection

The alar width is determined by the distance between the two alar grooves, or the distance between the two margins of the alar lobules in the frontal view, whichever is greater (Figs. 6.3 and 6.4). If there is no alar flaring and the alar groove can be

6.2.1 Alar Resection, Inner Side As seen in Figs. 6.11, 6.12, and 6.13, resection of the inner side of the alar base has several effects:

© Springer Japan KK, part of Springer Nature 2020 Y. Sugawara, A Practical Approach to Asian Rhinoplasty, https://doi.org/10.1007/978-4-431-56885-8_6

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Figs. 6.1 and 6.2  There are many terms to express alar form. Alar width: the space between the two alar grooves or the space between the edges of the alar lobules, whichever is wider. Alar crease width: the maximum distance between the two alar creases. Alar base width: the

6  Alar and Pedestals

maximum distance between the lateral edges of the alar base. Columella base width: the width of the columella base (determined from the starting point of the curve at which the columella begins). Nostril base length: width of the nostril base

Figs. 6.3 and 6.4  The alar width is the space between the two alar grooves or the space between the two edges of the alar, whichever is wider

6.2 Alar Resection

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Figs. 6.5 and 6.6  During reduction of the alar base, when the distance between the lateral edge of the alar lobules matches the distance between the two alar creases (in other words, when the alar crease width becomes the alar width), that would be the minimum alar width for that patient

Figs. 6.7 and 6.8  The shape of the nostril is influenced in the anterior area by the tip, and in the basal area by the alar or columella. Alarplasty thus affects the lateral and basal shape of the nostril

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Fig. 6.9  Alar thickness: the thickness of the alar lobule. Alar base thickness: the thickness of the alar base. Note the difference of the alar base thickness in this figure

6  Alar and Pedestals

Fig. 6.11  Resection of the inner side of the alar base

• It shortens the inner circumference of the nostril, reducing the alar width. • It flattens the alar curvature. • It thickens the alar base, by the purse-string effect. • It moves the alar rim downward.

6.2.1.1 Procedure

Fig. 6.10  The relation between the cranial end of the alar groove and the alar base is also important. In general, the alar base does not locate medially from the cranial end of the alar groove

• Give a wedge resection to the inner side of the alar base. Simple wedge resection is likely to cause a notch by even a slight contracture of the suture line. A notch during this curve gives an unnatural impression (Figs. 6.14 and 6.15). • To avoid this problem, the incision line should include an angle at the alar base, 90 degrees or sharper, to the alar rim (Figs. 6.16 and 6.17). • Apply dermal sutures and vertical mattress sutures to be sure to evert the skin (Figs. 6.18, 6.19, 6.20, 6.21, 6.22, 6.23, 6.24, and 6.25). • Avoid too much resection, as the less curved and drooping alar area will look unnatural (Figs.  6.26 and 6.27). The balance of alar thickness and nostril size should be considered (Figs. 6.28 and 6.29).

6.2 Alar Resection

Figs. 6.12 and 6.13  In resection of the inner side of the alar base, the two dot-points shown in the preoperative location (left) are approxi-

123

mated by suturing (right). The inner circumference of the nostril becomes shorter, which leads to smaller alar width. The alar base becomes thicker by the purse-string effect

Figs. 6.14 and 6.15  Simple wedge resection is likely to cause a notch by even a slight contracture of the suture line

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6  Alar and Pedestals

Figs. 6.16 and 6.17  To avoid this notch, the incision line should include an angle (90 degrees or sharper) at the alar base, to the alar rim

Figs. 6.18, 6.19, 6.20, and 6.21  Preoperative and postoperative views of wedge resection (inner side). The nostril becomes smaller, the alar base width is shortened, and the alar base is thicker. In the frontal view, the alar rim drops downward by being stretched to the alar base

Figs. 6.22, 6.23, 6.24, and 6.25  Preoperative and postoperative views of wedge resection (inner side). The nostril becomes smaller, creating a good nostril shape in the basal view

6.2 Alar Resection

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Figs. 6.26 and 6.27  A case of secondary alar deformity due to too much resection

6.2.2 Alar Resection, Outer Side Resection of the outer side of the alar base also can have several effects (Figs. 6.30, 6.31, and 6.32): • It is more effective than inner side resection in flattening the alar curve. • It makes the alar width smaller, if it is wider than the alar crease width (alar flaring). • It makes the alar base thickness slightly smaller. • It makes the alar rim turn downward. On the other hand, it has little impact on the inner circumference of the nostril.

6.2.2.1 Procedure • Perform a spindle-shaped wedge resection along the alar groove.

• A resection including the alar groove is likely to result in a visible notch, so leave the angle and make an incision just beside the groove while reducing the outer side of the alar lobule (Figs. 6.33, 6.34, and 6.35). • To avoid making a notch, make a right-angle incision at the lateral edge of the alar base, and then design a wedge to match this incision. • Apply dermal sutures and vertical mattress sutures (Figs. 6.36, 6.37, 6.38, and 6.39). In patients with no alar flaring, whose alar groove is already visible from the frontal view, outer side resection is not recommended because this procedure does not reduce the alar width itself. This procedure is often combined with inner side resection (Fig. 6.40). Basically, the effect is combined with the two procedures, but it is sometimes very difficult to envision the final result precisely. The initial design should therefore consider using a lesser amount of resection (cut-and-try method) (Figs. 6.41, 6.42, 6.43, 6.44, 6.45, 6.46, 6.47, and 6.48).

126 Figs. 6.28 and 6.29  A case of secondary alar deformity in which the extremely small nostril, compared with the alar base thickness, looks unnatural

Fig. 6.30  Resection of the outer side of the alar base makes the alar curve smaller and decreases alar flaring, but does not influence the inner circumference of the nostril

6  Alar and Pedestals

6.2 Alar Resection

Figs. 6.31 and 6.32  In resection of the outer side of the alar base, the two dot-points shown in the preoperative location (left) are approximated by suturing (right). This technique is more effective than inner side resection in flattening the alar curvature. The alar width is reduced

127

in patients with alar flaring, in whom the alar width was wider than the alar crease width. The inner circumference of the nostril is almost unchanged

Figs. 6.33, 6.34, and 6.35  A resection including the alar groove is likely to result in a visible notch, so leave the angle and make an incision just beside the groove while reducing the outer side of the alar lobule

Figs. 6.36, 6.37, 6.38, and 6.39  Preoperative and postoperative views of wedge resection (outer side). The alar curvature becomes flatter, but the nostril size does not change

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Fig. 6.40  The combination of inner and outer resection. The effects of the two procedures are combined

Figs. 6.41, 6.42, 6.43, and 6.44  Preoperative and postoperative views of combined inner and outer alar resection

Figs. 6.45, 6.46, 6.47, and 6.48  Preoperative and postoperative views of combined inner and outer alar resection

6  Alar and Pedestals

6.3 Nostril Base Resection

6.3

Nostril Base Resection

Resection of the nostril base (Fig. 6.49) has several effects: • The inner circumference of the nostril becomes shorter, decreasing the alar width. • The nostril base length becomes shorter. • The alar base becomes thicker, by the purse-string effect. • The alar shape and nostril both become rounder (Figs. 6.50 and 6.51).

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6.3.1 Procedure • Design a triangle-shaped resection of the amount by which you want to narrow the nostril floor (Fig. 6.52). • The back-cut incision is made and the alar base is rotated medially (Fig. 6.53). • Apply dermal sutures and vertical mattress sutures to be sure to evert the skin edge (Figs. 6.54, 6.55, 6.56, 6.57, 6.58, 6.59, 6.60, 6.61, and 6.62).

Fig. 6.49  Resection of the nostril base

Figs. 6.50 and 6.51  In resection of the nostril base, the two dot-points shown in the preoperative location (left) are approximated by suturing

(right). The inner circumference of the nostril becomes shorter, leading to smaller alar width. The alar shape and the nostril become much rounder, and the alar base becomes thicker

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6  Alar and Pedestals

Figs. 6.52, 6.53, and 6.54  Design of nostril base resection. The nostril floor is resected in 3-mm width. The alar base is rotated and sutured

Figs. 6.55, 6.56, 6.57, and 6.58  Preoperative and postoperative views of nostril base resection. Note little change in the lower end of the nostril shape in the basal view

Figs. 6.59, 6.60, 6.61, and 6.62  Preoperative and postoperative views of nostril base resection

6.4 Alar Rim Resection

6.4

Alar Rim Resection

Reduction of the alar rim can decrease its thickness. Drooping nostril rims and hanging rims also can be corrected by resection of the caudal part of the alar rim.

6.4.1 Procedure

131

• Design a spindle resection centered on the previous line (Figs. 6.63, 6.64, 6.65, 6.66, 6.67, 6.68, and 6.69). • Consider the final width of the alar rim, so as not to make it unnatural. • During design, try to make the edge sharp enough to avoid a dog ear deformity. • Beware of the direction of the scalpel so as not to make the skin too thin (Figs. 6.70, 6.71, 6.72, 6.73, 6.74, 6.75, 6.76, and 6.77).

• Mark the caudal edge of the basal alar rim.

Figs. 6.63, 6.64, and 6.65  Reduction of the alar rim can decrease its thickness

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6  Alar and Pedestals

Figs. 6.66, 6.67, 6.68, and 6.69  Drooping nostril rims and hanging rims also can be corrected, as the alar rim can be lifted by spindle resection

6.5 Alar Rim Grafting

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Figs. 6.70, 6.71, 6.72, 6.73, 6.74, 6.75, 6.76, and 6.77  Preoperative and postoperative views of nostril rim resection

6.5

Alar Rim Grafting

The alar rim edge can be made lower by grafting composite tissue to the inner side of the alar rim (Figs. 6.78 and 6.79). Inform the patient preoperatively that the alar rim might increase in thickness, or the graft might be visible from the basal view. Figs. 6.80, 6.81, 6.82, 6.83, 6.84, and 6.85 show preoperative and postoperative views of alar rim grafting.

• • • •

6.5.1 Procedure • Draw a line at the margin of the hairless and hairy skin in the inner side of the alar (Fig. 6.78). • Design the incision line along the line drawn previously, but closer to the rim at both ends of the region that is intended to be elongated (Fig. 6.79). • Make an incision to the subcutaneous layer by placing the scalpel vertical to the skin, then face the scalpel horizon-

•

•

tal to the skin and move it forward caudally toward the alar rim. By traction with a skin hook, make sure that the alar rim can be extended caudally. Beware of the direction of the scalpel so as not to make the skin (especially the inner side) too thin. Cranial to the incision, make a subcutaneous pocket only at both ends of the incision. Harvest a composite graft from the superior concha. Usually, the width of the graft needs to be 1.5 times larger than the length desired to be elongated. Both ends of the graft should be sharp-angled so as not to influence the shape of the alar rim. Place the composite graft into the subcutaneous pocket and suture the skin. The cartilage should be completely covered. Close the recipient site with simple suture or full-­thickness skin graft from the postauricular area (Fig. 6.86).

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6  Alar and Pedestals

Figs. 6.78 and 6.79  Design the incision line in the nostril close to the rim. Design the incision line along the line drawn previously, but closer to the rim at both ends of the region that is intended to be elongated

6.5 Alar Rim Grafting

Figs. 6.80, 6.81, 6.82, 6.83, 6.84, and 6.85  Preoperative and postoperative views of alar rim grafting

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136

Fig. 6.86  The donor site is covered by a full-thickness skin graft harvested from the postauricular area

6  Alar and Pedestals

7

Cases

Abstract

This chapter presents five typical cases with a step-by-­ step approach: clinical analysis, topological analysis, preoperative simulation, surgical plan, procedures, and result. Precise analysis and the selection of adequate procedures are the keys to successful rhinoplasty. Keywords

Topological analysis · Simulation · Dorsal augmentation · Spreader graft · Septal extension graft · Rim graft · Interdomal suture · Domal suture · Rim extension graft · Costal cartilage graft · Columella strut graft · Osteotomy

This chapter presents five typical cases with a step-by-step approach: clinical analysis, topological analysis, preoperative simulation, surgical plan, procedures, and result. Precise analysis and the selection of adequate procedures are the keys to successful rhinoplasty.

7.1

 ase 1: Primary Rhinoplasty: Dorsal C Augmentation, Tip Plasty, and Alarplasty

7.1.1 P  atient Profile (Figs. 7.1, 7.2, 7.3, and 7.4) The patient is a 25-year-old woman who has had no previous rhinoplasty. The main concerns are low dorsal height and bulbous tip.

Fig. 7.1  Case 1 patient, a 25-year-old woman, primary case; frontal view

• Septal cartilage: caudal end, retruded; thickness, thin • Lower lateral cartilage: thin, weak • CT analysis (optional): very thick soft tissue (Fig. 7.5)

7.1.2 Clinical Analysis

7.1.3 T  opological Analysis (Figs. 7.6, 7.7, 7.8, 7.9, and 7.10)

• Skin thickness: moderate • Soft tissue thickness: dorsum moderate, tip thick

• Nasion: low/caudal • Tip: under projection/upward rotation

© Springer Japan KK, part of Springer Nature 2020 Y. Sugawara, A Practical Approach to Asian Rhinoplasty, https://doi.org/10.1007/978-4-431-56885-8_7

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Fig. 7.4  Case 1 patient, view from below Fig. 7.2  Case 1 patient, three-quarter view. The main concerns are low dorsal height and bulbous tip

7.1.4 P  reoperative Simulation (Figs. 7.11, 7.12, 7.13, 7.14, 7.15, 7.16, and 7.17) Changes in simulation pictures: • • • • •

Nasion: 2 mm anterior, 3 mm superior Dorsal line: straight Tip: 3 mm anterior, 4 mm inferior Rim extension: 1 mm Alar width reduction: 2 mm each

7.1.5 Surgical Plan • Costal cartilage graft (milled and wrapped) for dorsal augmentation • Septal extension graft (septal cartilage) for tip positioning • Suturing and onlay graft for tip contouring • Alarplasty: nasal base incision

Fig. 7.3  Case 1 patient, profile view. Note round tip shape and low radix break point

• Tip defining points: upward/wide • Short dorsum length and wide nasal base line

7.1.6 Procedures • Check present nasion and tip position. Then set the pointers to planned nasion and tip positions (Fig. 7.18).

7.1 Case 1: Primary Rhinoplasty: Dorsal Augmentation, Tip Plasty, and Alarplasty

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Fig. 7.5  CT analysis showing very thick soft tissue. Note the differences of soft tissue thickness at the levels of the radix, rhinion, and tip Fig. 7.6  Case 1, Gray scale analysis. A symmetrical nose in frontal view

• Open approach (Fig. 7.19). Check the size and firmness of the medial and lateral crura (Fig. 7.20). • Very narrow intermediate crus and wide soft triangle (Fig. 7.21). • Measure the distance between the lower lateral crus (LLC) and tip pointer (goal of tip) (Fig. 7.22). • Scroll ligament was released to help the lateral crural movement (Fig. 7.23).

• Septal cartilage was harvested, leaving 9  mm-width L-strut (Fig. 7.24). • A paper template was placed (Fig. 7.25). • Septal extension graft and two spreader grafts are prepared (Fig. 7.26). • Septal extension graft was performed in end-to-end fashion (Fig. 7.27).

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Fig. 7.7  Case 1, Gray scale analysis. Graded gray shadow shows the nasal shape clearly

Fig. 7.8  Case 1, topological analysis. Tip-defining points locate upward in lateral, and separately in front

• Check the position of septal extension graft using tip pointer (Fig. 7.28). • Interdomal suture was performed. No domal suture was done because of very weak and narrow intermediate lateral crus (Fig. 7.29). • LLC is fixed to septal extension graft (SEG) with interdomal and spanning suture (Fig. 7.30). • Supra tip soft tissue was resected slightly (Fig. 7.31).

• Short shield graft was placed to straighten the medial crus (Fig. 7.32). • Check the soft triangle firmness (Fig. 7.33). • A rim extension graft was placed for reinforcement of soft triangle (Fig. 7.34). • Check the tip point again (Fig. 7.35). • Costal cartilage was harvested and milled. Fill the syringe with the harvested cartilage and wrap it with a polyglycolic acid sheet (0.15 mm thickness) (Fig. 7.36).

7.1 Case 1: Primary Rhinoplasty: Dorsal Augmentation, Tip Plasty, and Alarplasty

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Fig. 7.9  Case 1, topological analysis

Fig. 7.10  Case 1, topological analysis. Wide nasal base, narrow nasal width, wide and bulbous tip, wide and large lower part of nose (dark part), short columella

• Place the milled costal cartilage wrapped with sheet on the dorsum. Free graft on the glabella (Fig. 7.37). • Final check of the nasion and tip position (Fig. 7.38). • Alar reduction was done and fixed temporarily with absorbable suture (Fig. 7.39). • Suture the wound (Fig. 7.40). • Operation record (Fig. 7.41).

7.1.7 Result The result achieved was almost the same as the simulation (Figs. 7.42, 7.43, and 7.44). Topologically, the dorsal highlight was elongated and narrower. The tip area was smaller. The balance of highlight and shadow became better. The dorsal line was slightly shifted to the right side (Figs. 7.45, 7.46, 7.47, and 7.48).

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Fig. 7.11  Simulation, preoperative front view

Fig. 7.12  Simulation, postoperative front view. Nasion moves upward. Alar width narrows

Topography shows that the total form was stretched vertically. The nasion was moved upward and the tip was moved

7 Cases

Fig. 7.13  Simulation, preoperative three-quarter view

Fig. 7.14  Simulation, postoperative three-quarter view. Dorsal line straightens. Rim shifts downward a bit

forward. Tip-defining points were moved downward and inward. The tip area also became narrower (Figs. 7.49 and 7.50).

7.1 Case 1: Primary Rhinoplasty: Dorsal Augmentation, Tip Plasty, and Alarplasty

Fig. 7.15  Simulation, preoperative profile view

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Fig. 7.17  Preoperative simulation shows the surgical plan: Nasion movement: 2 mm anterior, 3 mm superior. Tip movement: 3 mm anterior, 4 mm inferior. Dorsal line: straight

Fig. 7.18  Intraoperative estimation. Set the pointers to planned nasion and tip positions

Fig. 7.16  Simulation, postoperative profile view. Radix and tip project and rim shifts downward

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Fig. 7.19  Open approach

Fig. 7.21  Very narrow intermediate crus and wide soft triangle

Fig. 7.20  Checking the size and firmness of the medial and lateral crura. Note the lack of cartilaginous support in the soft triangle area

Fig. 7.22  Measuring the distance between the lower lateral crus (LLC) and tip pointer

7.1 Case 1: Primary Rhinoplasty: Dorsal Augmentation, Tip Plasty, and Alarplasty

Fig. 7.23 Scroll ligament is released to help the lateral crural movement

Fig. 7.24  Harvested septal cartilage

145

Fig. 7.25  Paper template is placed to check the size

Fig. 7.26  Preparation of septal extension graft and two spreader grafts

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7 Cases

Fig. 7.27  Septal extension graft is performed in end-to-end fashion

Fig. 7.29  Domal suture is performed

Fig. 7.28  Checking the position of septal extension graft using tip pointer

Fig. 7.30  LLC is fixed to septal extension graft with interdomal and spanning suture

7.1 Case 1: Primary Rhinoplasty: Dorsal Augmentation, Tip Plasty, and Alarplasty

Fig. 7.31  Supra tip soft tissue is resected slightly

Fig. 7.32  Shield graft is placed to straighten the medial crus

Fig. 7.33  Checking the support of the soft triangle

Fig. 7.34  Rim extension graft is placed to prevent rim notching

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Fig. 7.35  Checking the tip point again. It looks fine; move to dorsal augmentation

Fig. 7.37  Milled costal cartilage is wrapped with a polyglycolic acid sheet (0.15 mm thickness), and placed on the dorsum

Fig. 7.36  Syringe is filled with the milled costal cartilage harvested from the sixth rib

Fig. 7.38  Final check of the nasion and tip position. Planned position is almost obtained

7.1 Case 1: Primary Rhinoplasty: Dorsal Augmentation, Tip Plasty, and Alarplasty

Fig. 7.39  Alar reduction is done and fixed temporarily with absorbable suture. The combined approach used internal and nasal base resection

Fig. 7.40  Suturing the wound

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Fig. 7.41  Operation record Fig. 7.42  Case 1, 1-year-­ postoperative result. Preoperative (left) and postoperative (right) front view

7 Cases

7.1 Case 1: Primary Rhinoplasty: Dorsal Augmentation, Tip Plasty, and Alarplasty Fig. 7.43  Case 1, 1-year-­ postoperative result. Preoperative (left) and postoperative (right) three-quarter view

Fig. 7.44  Case 1, 1-year-­ postoperative result. Preoperative (left) and postoperative (right) profile view

151

152 Fig. 7.45  Gray scale analysis in front view (left, preoperative; right, postoperative). See the change of nasal width, nasal base width, tip width. Midline is almost at the center of nose, but the nasal width line is shifted slightly to the right

Fig. 7.46  Gray scale analysis in profile view (left, preoperative; right, postoperative)

7 Cases

7.1 Case 1: Primary Rhinoplasty: Dorsal Augmentation, Tip Plasty, and Alarplasty Fig. 7.47 Topological analysis in front view (left, preoperative; right, postoperative)

Fig. 7.48 Topological analysis in front view (left, preoperative; right, postoperative)

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Fig. 7.49 Topological analysis in frontal and lateral view

Fig. 7.50 Topological analysis. Preoperative topology (red lines) and postoperative topology (white lines) are superimposed. The total form was stretched vertically. The nasion was moved upward and the tip was moved forward. Tip-defining points were moved downward and inward. The tip area also became narrower

7.2

 ase 2: Primary Rhinoplasty: Hump C Reduction

7.2.1 P  atient Profile (Figs. 7.51, 7.52, 7.53, and 7.54) The patient is a 31-year-old woman who has had no previous rhinoplasty. The main concerns are dorsal hump, wide dorsum, and over-rotated tip.

7.2.2 Clinical Analysis • Skin thickness: thin • Soft tissue thickness: dorsum, thin; tip, thin • Septal cartilage: caudal end, average; thickness, moderate; deviated • Lower lateral cartilage (LLC): moderate

7.2 Case 2: Primary Rhinoplasty: Hump Reduction

155

Fig. 7.51  Case 2 patient, a 31-year-old woman who has had no previous rhinoplasty, front view

Fig. 7.53  Case 2 patient, profile view. The main concerns are dorsal hump, wide dorsum, and over-rotated tip

Fig. 7.52  Case 2 patient, three-quarter view

Fig. 7.54  Case 2 patient, view from below. Note nostril difference. Right side is slightly wider

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7.2.3 T  opological Analysis (Figs. 7.55, 7.56, and 7.57)

7 Cases

7.2.4 P  reoperative Simulation (Figs. 7.58, 7.59, and 7.60) Changes in simulation pictures:

• • • • •

Nasion: high/cephalic Tip: adequate projection/downward rotation Tip-defining points: downward Long dorsum length and hump Hanging columella

Fig. 7.55  Case 2, Gray scale analysis. Nasal width is almost parallel, but nasal base is wide in the middle

Fig. 7.56  Case 2, Topological analysis. Nasion locates high and cephalic. Adequate tip width and projection. Long dorsal length and hump

• Nasion: 1 mm posterior, 3 mm inferior • Dorsal line: slightly concave (reduce height 5  mm maximum) • Nasal base line: narrowing • Tip: 2 mm posterior, 3 mm superior

7.2 Case 2: Primary Rhinoplasty: Hump Reduction

157

Fig. 7.57  Case 2, Topological analysis. Wide nasal base compared with narrow nasal width, adequate tip width, narrow and small lower part of nose (dark part)

Fig. 7.58  Case 2 simulation, front view. Nasion moves caudally. Narrowing nasal base width

7.2.5 Surgical Plan • Hump and radix reduction with shaving (ultrasonic device) for dorsal contouring.

• Osteotomy (ultrasonic device) for nasal base line narrowing. • Spreader graft for open roof reconstruction. • Septal caudal end resection for columella lifting. • Columella strut graft and suturing for tip positioning. • Suturing and onlay graft for tip contouring.

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Fig. 7.59  Case 2 simulation, profile view. Nasion moves posteriorly a bit. Tip projection is same, but rotate up. Hump is removed and dorsum is straightened

7.2.6 Procedures

Fig. 7.60  Case 2 comparison of pre-operation and simulation (dotted line): dorsal hump resection, tip rotation, infratip and columella lifting. Humpectomy may include a part of lower lateral crus (LLC)

• LLC is moderately firm and adequate for suturing technique. Intermediate/medial crus is also of moderate size but buckled and deviated (Figs.  7.61, 7.62, 7.63, and 7.64). • Septal cartilage was twisted in an “S” shape (Fig. 7.65). • Septal cartilage was harvested, leaving a 10-mm width L-strut (Fig. 7.66). • Hump reduction, nasal osteotomy, and spreader grafts were performed (Fig. 7.67). • Domal and interdomal sutures were done for tip contouring. Note the position of stitches. Sutures should be placed cephalically to prevent narrowing of the dome. Medial crus was still buckled (Figs. 7.68, 7.69, and 7.70). • The caudal end of the septum was resected (Fig. 7.71). • The cephalic margin of LLC was resected for better lateral crus contouring (Fig.  7.72). LLC was fixed with spanning suture. • Columella strut was grafted to straighten and strengthen the medial crus (Fig. 7.73). • Final shape of LLC (Figs. 7.74, 7.75, and 7.76). • Operation record (Fig. 7.77).

7.2 Case 2: Primary Rhinoplasty: Hump Reduction

Fig. 7.61  LLC is moderately firm and adequate for suturing technique. Note asymmetry of LLC

Fig. 7.62  Lateral crus is convex both axially and transversally

159

Fig. 7.63  Vertically located LLC

Fig. 7.64  Intermediate and medial crus are moderate in size but buckled

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Fig. 7.65  After separating septal cartilage from upper lateral cartilage, septal deviation is clearly observed. Septum is twisted in an “S” shape

Fig. 7.67  After hump resection and osteotomy, spreader grafts are placed

Fig. 7.66  Harvested septal cartilage

Fig. 7.68  Domal and interdomal sutures were done for tip contouring. Note the position of stitches. Sutures should be placed cephalically to prevent dome narrowing

7.2 Case 2: Primary Rhinoplasty: Hump Reduction

Fig. 7.69  Tip-defining points are created. (Compare Fig. 7.61)

Fig. 7.70  Normal dome shape is preserved. The medial crus is still buckled

161

Fig. 7.71  The caudal end of the septum is resected to lift columella and infratip

Fig. 7.72  Cephalic margin of LLC is resected for more lateral crus flattening

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Fig. 7.73  Medial crus strut graft (columella strut) is sutured with medial crus

Fig. 7.75  Final shape of LLC

Fig. 7.74  Final shape of LLC. Note flat lateral crus

Fig. 7.76  Final shape of LLC.  Tip width is almost same as original one. Buckled medial crus is straightened

7.2 Case 2: Primary Rhinoplasty: Hump Reduction

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Fig. 7.77  Case 2, operation record

7.2.7 Result A smooth dorsal line and adequate tip projection were created. The nasal base line became narrower. The tip is slightly deviated to the right side (Figs. 7.78, 7.79, 7.80, and 7.81).

Topography shows that the total form is stretched vertically. The nasion is in almost the same position. The dorsum line became straight, and the tip rotated upward. Also, the nasal base line became narrower (Figs. 7.82, 7.83, 7.84, and 7.85).

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Fig. 7.78  Case 2 6-month-postoperative result, front view

Fig. 7.80  Case 2 6-month-postoperative result, profile view

Fig. 7.79  Case 2 6-month-postoperative result, three-quarter view. A smooth dorsal line and adequate tip projection were created

Fig. 7.81  Case 2 6-month-postoperative result, view from below. Nostril asymmetry remains

7.2 Case 2: Primary Rhinoplasty: Hump Reduction Fig. 7.82  Gray scale analysis in front view (left, preoperative; right, postoperative). Note that the homogeneous side wall shadow continues from top to bottom. The nasal base width become narrower, but the nasal width is almost the same

Fig. 7.83  Gray scale analysis in profile view (left, preoperative; right, postoperative). Tip is rotated up, and infratip and columella are also lifted. Smooth, straight dorsal line

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Fig. 7.84 Postoperative topological analysis in frontal and lateral view

Fig. 7.85 Topological analysis. Preoperative topology (red lines) and postoperative topology (white lines) are superimposed. The radix has not changed. Nasal base width is narrower; nasal width is the same. Dorsal hump is reduced. Tip, infratip, and columella are lifted

7.3

 ase 3: Primary Rhinoplasty: Short C Nose

7.3.1 P  atient Profile (Figs. 7.86, 7.87, 7.88, and 7.89) The patient is a 31-year-old woman who has had no previous rhinoplasty. The patient had bimaxillary osteotomy for cor-

rection of bimaxillary protrusion 2 weeks before rhinoplasty. The main concerns are a bulbous and under-rotated tip.

7.3.2 Clinical Analysis • Skin thickness: thin • Soft tissue thickness: dorsum, moderate; tip, thin

7.3 Case 3: Primary Rhinoplasty: Short Nose

Fig. 7.86  Case 3 patient, a 31-year-old-woman who has had no previous rhinoplasty, front view

167

Fig. 7.88  Case 3 patient, profile view. The main concerns are a bulbous and under-rotated tip

Fig. 7.89  Case 3 patient, view from below Fig. 7.87  Case 3 patient, three-quarter view. The patient had bimaxillary osteotomy for correction of bimaxillary protrusion 2 weeks before rhinoplasty

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• Septal cartilage: caudal end, retruded; thickness, thin • Lower lateral cartilage (LLC): thin, weak

7.3.3 T  opological Analysis (Figs. 7.90, 7.91, and 7.92) • • • •

Nasion: adequate Tip: under projection/upward rotation Tip defining points: upward/wide Short dorsum length

7.3.4 P  reoperative Simulation (Figs. 7.93, 7.94, and 7.95) Changes in simulation pictures: • Nasion: no change • Tip: 2 mm anterior, 3 mm inferior • Rim extension: 3 mm

Fig. 7.90  Case 3, Gray scale analysis. Tip-defining points are located upward and lateral; short dorsum. Almost symmetrical tip-defining points in front, but slightly laterally located on left side

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7.3.5 Surgical Plan • Septal extension graft (septal cartilage) positioning • Suturing and onlay graft for tip contouring • Rim extension graft for rim positioning

for

tip

7.3.6 Procedures • LLC is very short and vertically positioned. Narrow lateral crus, and moderate intermediate/medial crus. No severe asymmetry, but mild in medial crus (Figs.  7.96, 7.97, 7.98, and 7.99). • Septal cartilage was harvested, leaving 10  mm-width L-strut. Mild septal deviation was corrected by wedge resection on the convex side and scoring on the concave side (Fig. 7.100). • Release the scroll ligament to help the lateral crural caudal shift (Fig. 7.101). • Septal extension graft is placed in offset fashion, also acting as a batten graft for the septum (Figs. 7.102 and 7.103).

7.3 Case 3: Primary Rhinoplasty: Short Nose Fig. 7.91  Case 3, topological analysis

Fig. 7.92  Case 3, topological analysis. Moderate nasal base width and nasal width. Up-turned and bulbous nasal tip, large lower part of nose (dark part), retruded subnasale (columella base) in front

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Fig. 7.93  Case 3, simulation, front view. Tip moves downward and becomes narrower. Nostril rim lower

Fig. 7.94  Case 3, simulation, profile view. No change in radix. Tip is projected, with rotation

• LLC was fixed to SEG with interdomal sutures and spanning sutures (Fig. 7.104). • Fixed lateral crus is slightly shifted to the right side (Figs. 7.105, 7.106, and 7.107).

• Rim extension graft was placed for extra caudal shift of the rim and reinforcement of the soft triangle (Figs. 7.108, 7.109, 7.110, and 7.111). No resection of supratip soft tissue. • Operation record (Fig. 7.112).

7.3 Case 3: Primary Rhinoplasty: Short Nose

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Fig. 7.95  Case 3, simulation, nasal tip detail. Tip-defining point moves 2 mm forward and 3 mm downward. Nostril rim shifts downward

Fig. 7.97  Width of medial crus and intermediate crus is adequate. Tip-­ defining points are slightly different (left side is higher)

Fig. 7.96  Lower lateral cartilage (LLC) is vertically positioned

Fig. 7.98  Very wide angulation at intermediate part of LLC

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Fig. 7.99  Length of medial crus is moderate. Angulation is about 90–95 degrees

Fig. 7.101 Release the scroll ligament to help the lateral crus mobility

Fig. 7.100  Caudal end of septal cartilage is curved. This is corrected by wedge resection on the convex side (right side of nostril) and scoring on the concave side (left side of nostril)

Fig. 7.102  Septal extension graft (SEG) is placed in the right side of the septal cartilage (offset fashion). It also acts as a batten graft for the septum

7.3 Case 3: Primary Rhinoplasty: Short Nose

Fig. 7.103 LLC is moved forward and temporarily sutured to SEG. Check the stability of SEG if it can tolerate the relapse force

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Fig. 7.105  LLC is fixed to SEG with interdomal sutures and spanning sutures. Fixed lateral crus is slightly shifted to the right side, and left side lateral crus is lifted up

Fig. 7.104  SEG is trimmed a bit Fig. 7.106  See the difference of angulation at the intermediate part of the LLC, compared with the preoperative angulation

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Fig. 7.107  Angulation is about 80–85 degrees

Fig. 7.108  Rim extension graft with septal cartilage

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Fig. 7.109  Rim extension grafts are sutured

Fig. 7.110  Soft triangle and caudal margin of lateral crus are reinforced with rim extension graft. Note the difference of graft angulation. Left side graft is more vertically placed

7.3 Case 3: Primary Rhinoplasty: Short Nose

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• Left side nostril was contracted 1  month postoperatively (Figs.  7.113, 7.114, and 7.115). The reason for this was that the lateral crus was slightly up-positioned intraoperatively (see Fig. 7.105). • Postoperative 2 months, a composite graft to the left nostril rim was performed (Figs. 7.116, 7.117, and 7.118).

7.3.7 Result Adequate nasal projection and rim contour were obtained. The result achieved was almost the same as the simulation (Figs. 7.119, 7.120, 7.121, and 7.122). Topography shows that the lower third was stretched caudally. The tip and tip-defining points were moved forward and downward. Also, the columella base and the columella break point were moved downward drastically (Figs. 7.123, 7.124, 7.125, and 7.126).

Fig. 7.111  Graft is placed to prevent rim retrusion

Fig. 7.112  Operation record

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Fig. 7.113  One-month postoperative frontal view. Left side nostril is retruded

Fig. 7.115  One-month postoperative three-quarter view. Rim margin is lifted

Fig. 7.114  One-month postoperative three-quarter view

Fig. 7.116  Frontal view 1  week after the secondary operation. Rim retrusion is over-corrected with rim composite graft

7.3 Case 3: Primary Rhinoplasty: Short Nose

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Fig. 7.117  Bottom view 1 week after the secondary operation Fig. 7.119  Case 3 10-month postoperative result, front view. The rim shape is almost symmetrical

Fig. 7.118  Grafted composite tissue from ear concha

Fig. 7.120  Case 3 10-month postoperative result, three-quarter view. Adequate nasal projection and rim contour were obtained

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Fig. 7.121  Case 3 10-month postoperative result, profile view. The result achieved is almost the same as the simulation

Fig. 7.122  Case 3 10-month postoperative result, view from below. Graft is slightly visible

7.3 Case 3: Primary Rhinoplasty: Short Nose Fig. 7.123  Gray scale analysis in front view (left, preoperative; right, postoperative). See the change of nasal width, nasal base width, and tip width

Fig. 7.124  Gray scale analysis in profile view (left, preoperative; right, postoperative)

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Fig. 7.125 Topological analysis in frontal and lateral view

Fig. 7.126 Topological analysis. Preoperative topology (red lines) and postoperative topology (white lines) are superimposed. The radix is not changed (not operated). The total form was stretched vertically in front. Tip-defining points were moved forward and downward. Subnasale shifts caudally and anteriorly. Lower part of nose (dark part) becomes smaller

7.4

 ase 4: Secondary Rhinoplasty: C Dorsal Deviation and Tip Drooping

7.4.1 P  atient Profile (Figs. 7.127, 7.128, 7.129, and 7.130)

dorsal deviation, too-high radix and dorsum, and bulbous and over-rotated nasal tip.

7.4.2 Clinical Analysis

The patient in this secondary rhinoplasty case is a 30-year-­ old woman with a history of two previous surgeries: open • Skin thickness: thin approach, dorsal implant and tip plasty with septal extension • Soft tissue thickness: moderate in dorsum, thick in tip due graft of two-layered ear cartilage. The main concerns are to scar

7.4 Case 4: Secondary Rhinoplasty: Dorsal Deviation and Tip Drooping

Fig. 7.127  Case 4 patient, a 30-year-old woman with a history of two previous surgeries, front view. The main concerns are dorsal deviation, too-high radix and dorsum, and bulbous and over-rotated nasal tip

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Fig. 7.129  Case 4 patient, profile view

Fig. 7.130  Case 4 patient, view from below. Note nostril difference due to the shift of left side foot plate protrusion Fig. 7.128  Case 4 patient, three-quarter view

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• Septal cartilage: caudal end, unclear; thickness, thin; deviated • Lower lateral cartilage: undetected due to heavy scar formation

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7.4.3 T  opological Analysis (Figs. 7.131, 7.132, and 7.133) • Nasion: high, upward, right-side shift • Tip: adequate, downward rotation • Tip-defining points: adequate, slightly wide

Fig. 7.131  Case 4, Gray scale analysis. Nasal width is almost parallel, but shifted to the right at the radix

Fig. 7.132  Case 4, topological analysis

7.4 Case 4: Secondary Rhinoplasty: Dorsal Deviation and Tip Drooping

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Fig. 7.133  Case 4, topological analysis. Nasion located high and cephalic, and obviously deviated to the right. Long dorsal length with slightly projected supratip. Adequate tip width and projection. Lower part of nose (dark part) is small

Fig. 7.134  Case 4, simulation, before and after front view. Nasion is moved left (to the center) and caudal. Tip is narrower

• Long dorsum length • Wide nasal base line

7.4.4 P  reoperative Simulation (Figs. 7.134, 7.135, and 7.136) Changes in simulation pictures:

• • • •

Nasion: 2 mm posterior, 4 mm inferior Dorsal line: straight (reduce height 2 mm maximum) Nasal base line: narrowing Tip: keep projection, 1–2 mm superior

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Fig. 7.135  Case 4, simulation, before and after profile view. Radix reduced in height. Dorsum becomes lower. Tip is sharper

7.4.5 Surgical Plan • Removal of the mispositioned implant. • Dorsal augmentation with dermal fat graft to add moderate height and soft-tissue thickness (and cartilage graft in case). • Osteotomy for correction of nasal bone deviation and dorsal nasal width narrowing. • Correction of septal deviation. • Septal extension graft (by septal cartilage) for tip positioning. • Suturing and onlay graft for tip contouring.

7.4.6 Procedures

Fig. 7.136  Case 4, simulation, Nasion moves 2  mm posteriorly and 4 mm caudally. Dorsum becomes lower around 2–3 mm. Tip is almost the same position. Infratip and columella are lifted

• Open approach. All grafted ear cartilage was removed. Septal extension graft was performed with two-layered ear cartilage, and that was fixed to nasal septum (Figs. 7.137, 7.138, and 7.139). • The implant was removed. Septal cartilage was harvested, leaving an 8 mm-width L-strut. Dermal fat was harvested from the right-side inguinal area (Fig. 7.140).

7.4 Case 4: Secondary Rhinoplasty: Dorsal Deviation and Tip Drooping

Fig. 7.137  Very heavy scar and tip onlay graft. Implant is already removed

Fig. 7.138  Two-layered ear cartilage is grafted as septal extension graft. Graft is not flat, resulting in right-side shift

Fig. 7.139  Ear cartilage is removed

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Fig. 7.140  The grafted Silastic implant. Septal cartilage and dermal fat were harvested

• Osteotomy was done for correction of nasal bone asymmetry. Spreader grafts were fixed. • Deviated septal caudal end was corrected by swinging-­ door technique (Figs. 7.141 and 7.142). • Septal extension graft was done in offset fashion because of caudal septal deviation (Fig. 7.143). • Radix and dorsum were augmented with morselized ear cartilage graft and dermal fat graft (Fig. 7.144). • Cap graft (crushed ear cartilage) was fixed (Figs.  7.145 and 7.146). • Operation record (Fig. 7.147).

7.4.7 Result

Fig. 7.141  Deviated septal caudal end was corrected by swinging-­ door technique

Deviation was corrected, and dorsal line became more natural. Adequate nasal tip projection and rotation were obtained. Slightly up-rotated tip position was welcomed by the patient (Figs. 7.148, 7.149, 7.150, and 7.151). Topography shows that dorsum and tip height are reduced. Nasal deviation is corrected (Figs.  7.152, 7.153, 7.154, and 7.155).

7.4 Case 4: Secondary Rhinoplasty: Dorsal Deviation and Tip Drooping

Fig. 7.142  Cut ends are overlapped and sutured

Fig. 7.143  Septal extension graft was done in offset fashion because of caudal septal deviation. It acts as a batten graft for reinforcement of the L-strut

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Fig. 7.144  After the osteotomy, radix and dorsum were augmented with morselized ear cartilage graft and dermal fat graft

Fig. 7.145  Cap graft (crushed ear cartilage) was fixed

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Fig. 7.146  Medial crus is fixed to septal extension graft to lift up

Fig. 7.147  Case 4, operation record

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7.4 Case 4: Secondary Rhinoplasty: Dorsal Deviation and Tip Drooping

Fig. 7.148  Case 4 9-month postoperative result, frontal view

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Fig. 7.150  Case 4 9-month postoperative result, profile view

Fig. 7.151  Case 4 9-month postoperative result, view from below. The shift of the left-side footplate remains but is improved Fig. 7.149  Case 4 9-month postoperative result, three-quarter view

190 Fig. 7.152  Case 4 Gray scale analysis in front view (left, preoperative; right, postoperative). Radix is in the center. Nasal width is parallel, then nasal deviation is corrected. Tip became slightly wider and shifted to the right

Fig. 7.153  Case 4 Gray scale analysis in profile view (left, preoperative; right, postoperative)

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7.4 Case 4: Secondary Rhinoplasty: Dorsal Deviation and Tip Drooping Fig. 7.154 Topological analysis in frontal and lateral view. Almost symmetrical form

Fig. 7.155 Topological analysis. Preoperative topology (red lines) and postoperative topology (white lines) are superimposed. Nasion is moved posteriorly and caudally as planned. Dorsum becomes lower. Tip is slightly shifted posteriorly and cephalically. Infratip and columella are lifted

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7.5

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 ase 5: Secondary Rhinoplasty: C Dorsal Augmentation, Tip and Alarplasty

7.5.1 P  atient Profile (Figs. 7.156, 7.157, 7.158, and 7.159) This is a case of secondary rhinoplasty. The patient is a 26-year-old woman. Her history comprises one previous surgery: closed approach, tip plasty with suturing only. The main concerns are low dorsal height, under-rotated and bulbous tip, and retruded columella.

7.5.2 Clinical Analysis • • • •

Skin thickness: thick, sebaceous Soft tissue thickness: dorsum, moderate; tip, thick Septal cartilage: caudal end, retruded; thickness, thin Lower lateral cartilage: unclear due to scar Fig. 7.157  Case 5, three-quarter view

Fig. 7.156  Case 5, patient is a 26-year-old woman with one previous surgery, front view. The main concerns are low dorsal height, under-­ Fig. 7.158  Case 5, profile view. Columella base (subnasale) is not rotated and bulbous tip, and columella retrusion visible

7.5 Case 5: Secondary Rhinoplasty: Dorsal Augmentation, Tip and Alarplasty

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7.5.3 T  opological Analysis (Figs. 7.160, 7.161, and 7.162) • • • •

Nasion: low, downward Tip: under projection, upward rotation Tip-defining points: upward, wide Short dorsum length, retruded columella base, and wide and drooping alar lobules

7.5.4 P  reoperative Simulation (Figs. 7.163, 7.164, and 7.165) Changes in simulation pictures:

Fig. 7.159  Case 5, view from below. Very short columella

Fig. 7.160  Case 5, Gray scale analysis. Dorsal midline is curved slightly to right

• Nasion: 2 mm anterior, 4 mm superior • Dorsal line: slightly concave (increase height by 2  mm maximum) • Tip: 2 mm anterior, 3 mm inferior • Columella caudal shift • Alar rim lift and alar base narrowing

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Fig. 7.161  Case 5, topological analysis. Nasion is low and caudal. Mild dorsal hump

Fig. 7.162  Case 5, topological analysis. Narrow nasal width. Moderate tip projection but up-rotated. Deformed triangular shape of lower part of nose (dark part). retruded subnasale (columella base) with short columella

7.5.5 Surgical Plan

7.5.6 Procedures

• Dorsal augmentation with ear cartilage and dermal fat graft. • Tip and columella positioning with septal extension graft (septal cartilage) and suturing. • Tip contouring with suturing and onlay graft. • Alar resection for lifting and narrowing.

• LLC was completely covered by a very heavy scar (Fig. 7.166). • All scar was resected (Figs. 7.167 and 7.168). The LLC is moderate in size but located vertically. Very narrow intermediate and medial crus.

7.5 Case 5: Secondary Rhinoplasty: Dorsal Augmentation, Tip and Alarplasty

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Fig. 7.163  Case 5 simulation, front view. Nasion is moved cephalically. Columella is shifted caudally. Alar width is narrowed

Fig. 7.164  Case 5 simulation, profile view. Dousum is augmented. Columella is shifted caudally. Alar rim retrusion is corrected

• Septal cartilage was harvested, leaving an 8  mm-width L-strut. Cartilage was fractured (Fig. 7.169). • Septal extension graft (SEG) was performed in end-to-­ end fashion. Note the size of SEG in caudal aspect. It was used for medial crus fixation in tongue-in-groove fashion (Fig. 7.170). • LLC was fixed to SEG with interdomal suture and spanning suture (Fig. 7.171).

• Cap graft was performed for extra augmentation and natural tip shape (Fig. 7.172). • Crushed ear cartilage and dermal fat were grafted for dorsal augmentation (Figs. 7.173 and 7.174). • Rim grafts were placed to correct nostril rim notching. • Operation record (Fig. 7.175).

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Fig. 7.165  Case 5 simulation. Nasion is moved 2 mm anteriorly, 4 mm cephalically. Tip is moved 2 mm forward and 3 mm downward. Dorsum is augmented, and columella is shifted caudally

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Fig. 7.167  All scar was resected

Fig. 7.168  Very small and short medial crus Fig. 7.166  LLC was completely covered by a very heavy scar

7.5 Case 5: Secondary Rhinoplasty: Dorsal Augmentation, Tip and Alarplasty

197

Fig. 7.169  Septal cartilage was harvested. Severely cracked (reasons unknown)

7.5.7 Result Adequate nasal projection and rim contour were obtained. The result achieved was almost the same as anticipated by the simulation. The retruded columella was moved downward and good alar-columella balance was obtained (Figs. 7.176, 7.177, 7.178, and 7.179). Topography shows that the total form stretched vertically. Tip changed very slightly despite SEG and cap graft. Defining points of the tip were moved forward and downward. Also, columella base and columella breakpoint were successfully moved downward (Figs.  7.180, 7.181, 7.182, 7.183, and 7.183).

Fig. 7.170  Septal extension graft (SEG) was performed in end-to-end fashion with spreader graft. Note the size and position of SEG in caudal aspect

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Fig. 7.171  LLC is sutured to SEG

Fig. 7.172  Cap graft was performed for extra augmentation and natural tip shape

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Fig. 7.173  Dermal fat graft for dorsal augmentation

Fig. 7.174  After dermal fat grafting, two-layered crushed ear cartilage is inserted

7.5 Case 5: Secondary Rhinoplasty: Dorsal Augmentation, Tip and Alarplasty

Fig. 7.175  Case 5, operation record

Fig. 7.176  Case 5 1-year postoperative result, front view

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Fig. 7.177  Case 5 1-year postoperative result, three-quarter view

Fig. 7.178  Case 5 1-year postoperative result, profile view

7.5 Case 5: Secondary Rhinoplasty: Dorsal Augmentation, Tip and Alarplasty

Fig. 7.179  Case 5 1-year postoperative result, view from below

Fig. 7.180  Case 5 Gray scale analysis in front view (left, preoperative; right, postoperative). Nasal midline is slightly curved

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202 Fig. 7.181  Case 5 Gray scale analysis in front view (left, preoperative; right, postoperative). Dorsum is augmented but a mild hump remains

Fig. 7.182 Topological analysis in frontal and lateral view

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7.5 Case 5: Secondary Rhinoplasty: Dorsal Augmentation, Tip and Alarplasty Fig. 7.183 Topological analysis. Preoperative topology (red lines) and postoperative topology (white lines) are superimposed. The radix is shifted cephalically and anteriorly as planned. Dorsum is augmented. Tip is not changed, but tip area became narrower. Infratip and columella are well moved downward. Deformed triangular shape of lower part of nose (dark area) became regular triangle shape

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