Clinical Atlas of Preservation Rhinoplasty: Steps for Surgeons in Training 9783031299766, 9783031299773

Table of contents :
Foreword
Preface
Contents
Editor and Contributors
About the Editor
Contributors
Abbreviations
1: Nasal Biomechanical Anatomy as a Fundamental Basis for Preservation Rhinoplasty
1.1 Background
1.1.1 Biomechanical Anatomy
1.1.2 The Principle of Preservation Rhinoplasty
1.2 Clinical Case
1.3 The Mobility of the Nose
1.4 Biomechanics and Plasticity of Nasal Structures
1.4.1 The Role of SSTE in Nose Biomechanics
1.4.2 The Zones of Junction
1.5 Biomechanics and Surgery
1.5.1 Bony Vault
1.5.2 Upper Lateral Cartilage (Triangular Cartilage) and K Area
1.5.2.1 Weakened ULCs in Open Roof Rhinoplasty
1.5.2.2 Preservation Rhinoplasty and Push-Down Technique
1.5.2.3 Biomechanical Changes in “Let-Down” Preservation Rhinoplasty
1.5.3 The Lower Lateral Cartilage (Alar Cartilage)
1.5.3.1 Cephalic Rotation of the Tip
1.5.3.2 The Cephalic Rotation of the Lobule and the Tip
1.5.3.3 Lateral Deviation
1.5.3.4 Deprojection of the Nasal Tip
1.6 Conclusion
References
2: How Histology Is Pertinent for Surgical Approach
2.1 What Is the Structure of the Nasal Cartilages?
2.2 How to Reach the Subperichondrial Plane in Preservation Rhinoplasty?
2.3 Why Is Septal Subperichondrial Dissection Easier Than the Subperichondrial Dissection of the ULC and LLC?
2.4 Why Dissect the Subperichondrial Plane in the Midline of the Dorsum Rather Than on the Caudal Part of the ULC?
2.5 Can I Perform a Continuous Subperichondrial Dissection from the LLC Up to the Nasal Bones?
2.6 How Does the ULC Connect to the Nasal Bones?
2.7 How Does the LLC Connect to the Pyriform Aperture?
2.8 Case Study
2.9 Conclusions
References
3: Photography Evaluation and Morphing for Preservation Rhinoplasty
3.1 Background Information: Why This Particular Subject Has to Be Particularly Studied?
3.2 Description of the Technique Photos/Videos
3.2.1 Equipment
3.2.1.1 Camera
3.2.1.2 Lens
3.2.1.3 Lighting
3.2.1.4 Background
3.2.1.5 The Lighting Setup
3.2.1.6 Patient Preparation and Positioning
3.2.1.7 Standard Photographic Views
3.2.1.8 Photography Archive
3.2.1.9 Computer Imaging
3.3 Conclusion
References
4: Cone-Beam CT or CT Scan Analysis for Routine Pre-Operative Planning Before Rhinoplasty
4.1 Introduction
4.2 Clinical Case
4.2.1 Pyriform Aperture
4.2.2 Turbinates, and Septum
4.2.3 Nasal Vault, Septum, and Skull Base
4.2.4 Paranasal Sinuses, and Lacrimal Ducts
4.3 Comments
4.3.1 3D Analysis
4.3.1.1 Multiplanar Reformation
4.3.2 3D Layered Volume Rendering
4.4 Conclusion
References
5: Surgical Steps in Dorsal Preservation
5.1 Presurgical Assessment
5.1.1 How to Choose Between TDP and CODP
5.1.2 How to Choose Dissection Plane
5.2 Surgery
5.2.1 Transfixion Incision
5.2.2 Septum Dissection
5.2.3 W Point and Upper Lateral Caudal Dissection
5.2.4 Infracartilagenous Incision, Lower Lateral Cartilage Dissection
5.2.4.1 Subperichondrial Dissection
5.2.4.2 Subareolar Dissection
5.2.5 Opening the Scroll Area to Unite Two Dissection Zones
5.2.6 Dorsum Dissection
5.2.6.1 Limited Dorsal Dissection
5.2.6.2 Wide Dorsal Dissection
5.2.6.3 Taking Out the Low Septal Strip
5.2.7 Vertical Septal Cut
5.2.8 High Septal Strip Cranial to Vertical Cut
5.2.9 Bony Cap Rasp
5.2.10 Lateral Key Stone Area Dissection (Ballerina Maneuver)
5.2.11 TDP or CODP
5.2.12 Bony Work for Letdown
5.2.12.1 Transverse Osteotomies
5.2.12.2 Lateral Ostectomies
5.2.12.3 Radix Ostectomy
5.2.13 Bony Work for CODP
5.2.13.1 Transverse Osteotomy in CODP
5.2.13.2 Medial Oblique Osteotomy and Ostectomy
5.2.13.3 Lateral Osteotomy in CODP
5.2.14 Suturing the Quadrangular Cartilage to Anterior Nasal Spine Periosteum
5.2.15 Fine-Tuning
5.3 Conclusion
References
6: Letdown and Piezo Techniques in Preservation Rhinoplasty
6.1 Background
6.2 Discussion
6.2.1 Patient Selection
6.2.2 Ligamentous Preservation
6.2.3 Group #1
6.2.4 Group #2
6.2.5 Group #3
6.3 Surgical Technique
6.3.1 Skin and Soft Tissue Envelope Elevation
6.4 Management of the Septum
6.4.1 Approaching the Septal Cartilage
6.4.2 Septal Strip Excision
6.5 Management of the Bony Vault
6.5.1 Piezo Osteotomy/Ostectomy
6.5.2 Addressing the Bony Vault
6.6 Adjunctive Measures: To Control the New Shape of the Nasal Dorsum
6.6.1 Ballerina Manoeuvre (Lateral K Stone Dissection)
6.7 Fixing the New Position of the Dorsum
6.8 Conclusion
6.9 Clinical Cases
6.9.1 Case 1
6.9.2 Case 2
6.9.3 Case 3
6.9.4 Case 4
References
7: Combination of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty
7.1 Introduction
7.2 Why Combine Structure and Preservation
7.3 Selection of the Patients for this Technique
7.4 Profile Analysis
7.5 Clinical Cases
7.5.1 Case 1
7.5.2 Case 2
7.5.3 Case 3
7.5.4 Case 4
7.5.5 Case 5
7.6 Conclusion
References
8: Camouflage in Preservation Rhinoplasty
8.1 Background Information
8.2 Solid Grafts
8.3 Free-Diced Cartilage
8.4 Cartilage Paste and Fluid Cartilage
8.5 Diced Cartilage with PRF
8.5.1 DC + PRF Protocol
8.5.2 DC + PRF in Preservation Rhinoplasty
References
9: Functional Considerations for Preservation Rhinoplasty, Nasal Valve, and Clinical Cases
9.1 Background Information
9.2 Anatomical Considerations
9.2.1 The External Nasal Valve
9.2.2 The Internal Nasal Valve
9.3 Rhinoplasty and Nasal Valve Conservation
9.4 Description of the Technique
9.4.1 Modified SAC Flap [7]
9.4.2 Operative Technique (Fig. 9.4 and Video 9.3)
9.5 Conclusion
9.6 Clinical Case
References
10: Dorsal Precision Segmental Preservation and How to Avoid Aesthetic Drawbacks
10.1 Introduction
10.2 Dorsum Conservative Techniques
10.3 The Segmental Preservation Approach
10.4 Surgical Technique: Osteotomies and Pyramid Mobilization
10.5 The Lateral Wall Split Maneuver
10.6 Septal Resection
10.6.1 The Intermediate Split Preservation Rhinoplasty
10.6.2 The Medial Wall Split Maneuver
10.6.3 The Segmental Preservation Rhinoplasty: The Split Tetris Concept
10.6.3.1 Tetris 2.0
10.6.3.2 How to Avoid Aesthetic Drawbacks
Dorsal Segments and Strategies to Avoid Stigma
Profile Drawbacks
Residual Hump or Hump Recurrence
Let-Down Technique
Splitting the Three Walls
Subrhinion Stabilization
Reshaping the Residual Bony Hump
Reshaping the Residual Cartilaginous Hump
Radix Position Control
Periosteum Dissection
Transverse Osteotomies
Septal Wall Work
Supratip Position Control
Pyramid Lateralization
10.6.4 Broad Bony Pyramids and Mid-Third Broadening
10.6.4.1 Cartilaginous Pyramid
Suturing the Middle Third Roof
10.6.4.2 Bony Pyramid
Sculpting the Lateral Wall
Defining Dorsal Aesthetic Lines Osteotomies
10.7 Discussion
10.8 Clinical Cases
10.8.1 Case Study 1
10.8.2 Case Study 2
10.9 Conclusion
References
11: Prevention and Correction of the Most Common Problems in Preservation Rhinoplasty
11.1 Analyzing the Nose
11.2 Visual Planning of the Desired Aesthetic Outcome
11.3 Choosing the Optimal Technique
11.4 STE
11.5 Cartilaginous Vault
11.5.1 High Septal Strip Resection (Fig. 11.3)
11.5.2 Low Septal Strip Resection (Fig. 11.4)
11.6 Bony Pyramid
11.6.1 BP Type 1—Cap Reduction (Fig. 11.5)
11.6.2 BP Type 2—Cap Lowering (Fig. 11.6)
11.6.3 BP Type 3—Bony Pyramid Lowering (Fig. 11.7)
11.7 Tip
11.7.1 Shaping the Dome
11.7.2 Lateral Crus Control
11.7.3 Supporting the Tip
11.8 Solving Common Problems
11.9 Early Postoperative Concerns (3 month)
11.10.1 Osseocartilaginous Vault
11.10.1.1 Dorsal Hump Recurrence (Fig. 11.9)
11.10.1.2 Supratip Saddling (Fig. 11.10)
11.10.1.3 Middle Third Widening (Fig. 11.11)
11.10.1.4 Axis Deviation
11.10.2 Radix Step
11.10.3 Tip
11.10.3.1 Loss of Tip Support
11.10.3.2 Tip Deviations and Asymmetries
11.10.3.3 Scroll-Winding Effect (After Saban)
11.11 Conclusions
11.12 Case 1
11.12.1 Analysis of the Nose
11.12.2 Visual Planning of the Desired Aesthetic Outcome
11.12.3 Surgical Technique Used
11.13 Case 2
11.13.1 Analysis of the Nose
11.13.2 Visual Planning of the Desired Aesthetic Outcome
11.13.3 Surgical Technique Used
11.14 Case 3
11.14.1 Analysis of the Nose
11.14.2 Visual Planning of the Desired Aesthetic Outcome
11.14.3 Surgical Technique Used
11.15 Case 4
11.15.1 Analysis of the Nose
11.15.2 Visual Planning of the Desired Aesthetic Outcome
11.15.3 Surgical Technique Used
References

Citation preview

Sylvie Poignonec Editor

Clinical Atlas of Preservation Rhinoplasty Steps for Surgeons in Training

123

Clinical Atlas of Preservation Rhinoplasty

Sylvie Poignonec Editor

Clinical Atlas of Preservation Rhinoplasty Steps for Surgeons in Training

Editor Sylvie Poignonec Plastic Surgery and Head and Neck Surgery Centre Esthétique Paris - Eiffel Paris, France

This work contains media enhancements, which are displayed with a “play” icon. Material in the print book can be viewed on a mobile device by downloading the Springer Nature “More Media” app available in the major app stores. The media enhancements in the online version of the work can be accessed directly by authorized users. ISBN 978-3-031-29976-6    ISBN 978-3-031-29977-3 (eBook) https://doi.org/10.1007/978-3-031-29977-3 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed 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 Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Foreword

Rhinoplasty Surgery has changed dramatically over the past 5 years. Surgeons no longer look at the patient’s profile hump and think of resection. For experienced surgeons, the first question is: “can I preserve the dorsum anatomically, while eliminating the hump and lowering the profile?” Preservation Rhinoplasty has become the first choice for primary cases, and hybrid techniques have begun to evolve for secondary cases. The speed with which this transformation has occurred is due to two factors: the intrinsic validity that preservation is better than resection/reconstruction, and its adoption by a cohort of rhinoplasty experts who teach at major meetings. The problem for surgeons in training and those just entering practice is that they may not have been exposed to preservation rhinoplasty techniques and only have experience with traditional structural techniques. Yet, what initially looks like a limitation is in reality a critical foundation from which to learn. The first step is to develop confidence with a core rhinoplasty technique based on one’s experience and training. Start with cases that require limited changes compatible with your expertise and compliant patients. If preservation rhinoplasty is new to you, begin to read every article and textbook available, watch videos, and attend meetings. Fortunately, Dr. Sylvie Poignonec has put together a much needed “learner’s guide” to preservation rhinoplasty. She has not only assembled a world-class list of authors, but had them adopt a true step-by-step format, filled with tips and tricks that will make learning the operation much easier. I would suggest that the reader begin their preservation rhinoplasty journey by reading Dr. Poignonec’s chapter first and then the rest of the book in its order. The reason for this recommendation is that the beginner surgeon must see and understand the “forest” before getting lost in the details of the “trees.” Her advice and guidance will help the beginning surgeon to learn and gain confidence in performing rhinoplasty surgery. One of the first challenges in learning preservation rhinoplasty is the necessity to understand nasal anatomy from different perspectives, both biomechanically and histologically. Dr. Saban’s two chapters introduce the concept of biomechanical anatomy and the value of CT scan analysis in preoperative planning. The value of being able to “see” the patient’s anatomy preoperatively and use it for planning their surgery is a recent advance and of particular worth. Dr. Patron summarizes the critical anatomical junctions of the nose in the format of a series of questions and answers which are beautifully illustrated. Opportunely, the reader is able to see the application of this knowledge in his superb case studies. There are three chapters which focus primarily on dorsal preservation. Drs. Cakir and Coksum’s chapter on dorsal preservation is sheer perfection with a profusion of precise illustrations which, coupled with their videos, allows one to learn the details which often separate a great result from a mediocre one. Dr. Goksel describes a progression of techniques applicable to three different groups of patients: it is extremely beneficial for the surgeon who is just beginning and emphasizes the use of piezoelectric instrumentation. The “tetra concept” of Dr. Neves is superbly illustrated and will be welcomed by the experienced surgeon as it offers a more powerful method of correcting hump deformities. Dr. Racy describes functional factors during a rhinoplasty operation and makes a strong case for a modified sliding alar cartilage flap (SAC). This procedure maintains the integrity of the scroll ligament complex while modifying tip shape. The final chapter by Dr. Stubenitsky summarizes the book beautifully and provides great insight into operative ­planning and decision-making, as well as how to progress from easy to difficult in one’s own clinical series. v

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Foreword

Table 1  Level approach to preservation rhinoplasty: building on a foundation operation incorporating new techniques gradually Level Case selection

1 (Beginner) ALARS

2 (Intermediate) Tension nose, males, straight Deviations, humps (1–6 mm)

Approach

Open

Closed or open—Your choice

STE (soft tissue envelope)

SUBSMAS ALARS, SUBPERI OC VAULT

SUBPERI ALARS, SUBPERI OC VAULT

DORSUM

SABAN LONGITUDINAL STRIP EXCISION ROUTINE OSTEOTOMIES & SEPTUM

SABAN LONGITUDINAL STRIP EXCISION COMPLETE OSTEOTOMIES (RADIX, TRANSVERSE, LATERAL), BONY VAULT DISARTICULATION PUSH DOWN OR LET DOWN

ALARS

NO EXCISION, INCISE & SLIDE STRUT & TIP SUTURES

NO EXCISION, INCISE & SLIDE STRUT & TIP SUTURES

3 (Advanced) Asymmetric and deviations Humps (kyphotic and >6 mm) Closed or open—Your choice COMPLETE SUBPERICHONDRIUM SUBPERIOSTEUM COTTLE INFERIOR STRIP EXCISION COMPLETE OSTEOTOMIES (RADIX, TRANSVERSE, LATERAL), BONY VAULT DISARTICULATION PUSH DOWN OR LET DOWN NO EXCISION, INCISE & SLIDE STRUT & TIP SUTURES

What is the best strategy for the reader to implement the surgical techniques presented in this text? Every surgeon has a rhinoplasty operation that they have learned during their residency and then utilized as they begin their practice. If there are no preservation components, one should keep the foundation operation and incorporate new techniques gradually. As seen in the table below, it is my recommendation that surgeons should tackle this challenge with a level approach—Level 1 (beginner), Level 2 (intermediate), and Level 3 (advanced) (Table 1). In the first year, concentrate on lowering the dorsum using a combination of a longitudinal septal strip excision and surface techniques. Preserve the lateral crus using an incise and slide technique, provide tip support with some type of strut, and shape the tip with sutures. For most surgeons, the open approach will facilitate learning and with experience one can employ the closed approach. It should be noted that the open approach was preferred initially by Cakir, Finnochi, and Kosins during their own learning period as beginners, to gain experience before reverting to the closed approach. As one gains familiarity and becomes comfortable with eliminating small humps, one can then progress to more challenging cases. The major challenge will be the incorporation of complete osteotomies (transverse, radix, and lateral) with bony vault disarticulation followed by lowering the nasal vault using either a Push Down (osteotomy) or a Let Down (ostectomy) technique. Also, one can begin doing a subperichondrial dissection over the alars in patients with moderate to thick cartilages. There will be challenges as one learns how to deal with “blocking points,” hump recurrences, and complex tip deformities. It is only with experience that surgeons gain confidence and can progress to more difficult cases. Level 3 cases often require managing severe septal deviations and osseocartilaginous vault asymmetries. Total release of the septum is frequently required, and an inferior septal strip is the optimal solution. Although conceptually simple and easily drawn, its inherent intraoperative instability can be terrifying for the unwary. An asymmetric approach to the bony vault is often necessary with a Push Down on one side and a Let Down on the other. A true preservation approach to the soft tissue envelope and its nasal ligaments is achieved by a complete in-continuity subperichondrial-subperiosteal dissection from the alar rim to the radix area. Throughout this progression, the surgeon should continue to learn as much as possible from attending meetings and the internet. However, be skeptical of immediate postings of early results and non-peer-reviewed publications, as many are more directed to marketing rather than scientific accuracy.

Foreword

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In conclusion, every surgical revolution disrupts the status quo, and leads ultimately to major advances which benefit our patients. The preservation rhinoplasty revolution is no exception, and it has created opportunities for a new generation of surgeons to advance our knowledge of the most challenging of all Plastic Surgery operations. Hoag Memorial Hospital Presbyterian Newport Beach, CA, USA

Rollin K. Daniel

Preface

Il n’y a rien de plus puissant qu’une idée quand l’heure est venue.—(Victor Hugo)

Why another book about rhinoplasty? As a plastic surgeon I am well aware that rhinoplasty is the most challenging facial plastic surgical procedure. From the statistical point of view, rhinoplasty procedures are constantly growing (+3.7% in 2020, International Society of Aesthetic Plastic Surgery ISAPS data), and they represent now 67.9% of the surgical aesthetic procedures in young patients between 19 and 34 years old; an impressive 852,554 interventions were carried out in 2020 (ISAPS data). Therefore, the plastic surgeon and the maxillofacial surgeon have more and more patients to take care of. Throughout one’s career, the rhinoplasty surgeon strives to achieve: –– a safe, reproducible procedure to gain both excellent aesthetic and functional results, –– a result both visible on the table and durable throughout the patient’s life, –– a final nose that does not look over-manipulated or “surgerized”. From its inception, rhinoplasty centered around reducing the nose by removing cartilage, bone, and underlying structural tissue to obtain thinner, smaller, more refined noses (Jacques Joseph’s technique of hump reduction in 1899). In the long run, after years of following patients who underwent significant structural reductions, rhinoplasty surgeons have begun to see the downsides of the technique. Patients frequently developed alar rim weaknesses, retractions or collapses, as well as nasal asymmetry, inverted-v deformities, open-roof deformities, and associated functional problems. Among thin-skinned patients, significant contractures were commonly observed, a condition worsened by greater underlying reductions. From these compelling reasons, structural rhinoplasty came to light, developed by Dr. Dean Toriumi, and granting successful results by very complex and extensive surgical interventions. As light was shed on these significant issues with reduction-only rhinoplasty, two alternative techniques were developed: –– Structural rhinoplasty, which reconstructs what was deficient or surgically removed with the aid of cartilage grafts; –– Preservation rhinoplasty, which aims to conserve the structure including bone, cartilage, and ligamentous support, to preserve the original anatomy as much as possible. Preservation rhinoplasty was thus born from the idea of conserving the original anatomy of patients. As the name suggests, preservation rhinoplasty strives to maintain the structure of the nose, by reshaping the existing structure instead of removing it. As such, this technique avoids the need for reconstruction by grafting. Most importantly, preservation rhinoplasty improves nasal stability over time, yielding a long-lasting result. Preservation rhinoplasty is not new; the first push down was described in 1898 by Goodale; then came Cottle’s paper published in 1954, mentioning an S-shaped septal excision with push down and let down techniques. In 2018, Dr. Yves Saban described a modified high strip procedure, and Dr. Rollin Daniel and Dr. ix

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Baris Çakir made the preservation rhinoplasty popular during the 2018 Istanbul meeting. After these milestones, multiples techniques in dorsal preservation emerged: Dr. Ferreira described the spare roof technique in 2018, Dr. Finocchi described the SPQR operation a few years before in 2010, Dr. Luiz Carlos Ishida in 2020 illustrated the intermediate septal strip and classical hump excision, and many more then followed. Respecting the middle nasal vault contour and ligaments at the time of surgery is of great importance in preservation rhinoplasty. This preservation of the underlying nasal anatomy may be partial or total. Complete preservation rhinoplasty, with a single dissection of the STE (soft tissue envelope) as a single sheet of perichondrium and periosteum, without resection and with a complete dorsum preservation, has very specific indications which are not frequently present. Dissection is often limited to prevent a weak, floating nose, to avoid external incisions, and to preserve cartilage obviating the need for grafts. Total preservation rhinoplasty is more of a philosophical concept, but in confronting reality with its large array of cases and anatomical variations, the surgeon must adapt to actual surgical possibilities. Given the large diffusion of social media, and the related inclination of younger patients to self-representation or posting on all sorts of social networks, the preservation of the existing anatomy is the safest way to obtain aesthetically harmonic and long-lasting results. The readers I mainly address here are the surgeons in training. I spent over 20 years in the head and neck surgery department of the Pitie-Salpétrière Hospital, in Paris, France, teaching rhinoplasty to my fellow surgeons. They were highly motivated, reading heaps of publications and many excellent books (to name a few authors Rollins, Toriumi, Çakir) and still were unsure about the choice of the technique to use in the various cases they were facing, or felt somewhat lost in the abundant rhinoplasty related literature. This was especially true in the case of preservation rhinoplasty. Young surgeons in training well understood that a conventional hump reduction with open roof was frequently complicated by middle vault issues and needing complex grafts. A spreader graft to open the valve could be useful, sometimes dorsal irregularities needing to be camouflaged later. When authors began to speak about dorsal preservation maintaining the nasal anatomy, of replacing resection with preservation, and excision with manipulation (as Rollin Daniel put it), we were all very excited, and wanted to move from structural to preservation. The idea had a flavor of magic, and performing the new technique would spare us some of our scarce and precious time. Soon enough, we noticed that in some cases the results were less than perfect and issues still went unsolved: persistent dorsal hump, saddle noses, deviated noses… As rhinoplasty experts, we felt a need to elucidate the different secrets of the technique to have an understandable and full picture of all implications, to be able to communicate them clearly. The contents feature contributions of 15 different experienced surgeons, and some even highly reputed, all adhering to the idea of sharing a significant token of their expertise in these pages, to the benefit of younger fellow surgeons. Dr. Yves Saban, among the founders of preservation rhinoplasty, introduces the work with his vast experience, incorporating both anatomy and clinical cases and pairing with Dr. Alomani in explaining biomechanical anatomy as the fundamental basis of preservation rhinoplasty. The anatomical and histological considerations are illustrated by Dr. Patron, with the help of fine microscope pictures, to facilitate the understanding of the inner workings of the nose. To assist in surgical decision-making, surgeons should not hesitate in requesting imaging such as TDM 3D and computed tomography to support the pre-op decision process, especially in the presence of asymmetric noses and functional problems. While the comprehension of radiological findings will be bolstered by the related part written by Dr. Saban and Dr. Baldini, Dr. Lekakis clearly demonstrates the importance of photography and simulation in preservation rhinoplasty. My invitation to the reader: be artistic, as rhinoplasty is first and foremost an artistic procedure, one has to be self-confident with the possibilities in one’s hand. Experience also benefits from the exposure to beauty in art; noses in painting, but also in sculpture, as with Dr. Çakir’s

Preface

Preface

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polygon concept centered around the idea of creating an anatomy that directly translates to the skin surface without grafts. In their contributions, Dr. Çakir and Dr. Coşkun share the best practices in decision-making, the choice between intervention variations, safety issues in preservation rhinoplasty and clinical cases, while I explain stepwise the combination of structure for the tip and dorsal preservation. Dr. Racy, Dr. Benmoussa, and Dr. Fanous focus their knowledgeable contributions on how to respect the function of the nasal valve in preservation rhinoplasty, whereas Dr. Carles answers the question of whether we need camouflage in preservation rhinoplasty, by integrating technology and new devices. Dr. Stubenitsky masterly closes our common endeavor with a chapter on the highly sensitive point of complications in dorsal preservation. In building the framework of the book, we selected specific clinical cases for each of the chapters, enriching them with photos, drawings, and surgical videos. As it seems fit to offer some advice to young surgeon readers too, I hope they will keep in mind that results that appear very nice on the operating table can progressively change with time. Dean Toriumi conveys this in stating that healing after rhinoplasty could last the patient’s entire life, especially in patients with thinner skin and short nasal bones due to scar contracture. This is a major challenge. How do we deal with such a difficult surgical procedure and its many complications? My advice is to keep learning; learn, learn, and learn all your life: read different publications, watch videos, and travel. If possible, choose to journey around the world, and shadow other surgeons to pick up their technique. I became a rhinoplasty fan by meeting colleagues, participating in courses, speaking at conferences, and organizing webinars. A surgeon might well feel lonely and lost while performing surgery; this feeling is not uncommon, and decreases with time, as one gains in experience: your confidence will grow. One should also endeavor to be modest; follow up with patients every 3 months the first year after surgery and then once per year afterwards, to make one’s own revisions. This is crucial to learn from mistakes, earn and keep the patient’s trust, and avoid bad reviews. This book is the result of a collaboration between more senior surgeons who have served as mentors, and the next generation mentees, who will be the rhinoplasty surgeons of tomorrow. Ingenious, creative, brilliant: heartfelt thanks to all for their participation in this book. A concluding note: we do not want to oppose or to replace structural by preservation; dorsal preservation or partial dorsal preservation is, in our opinion as well, the gold standard for primary Caucasian rhinoplasty in the majority of cases, although not sufficient to obtain a perfect tip projection, tip structure, or septum straightening. It is therefore our belief that both of these techniques should be associated to obtain the best results: adding preservation for the dorsum to structural for the tip could be the best way to improve aesthetic outcomes. Paris, France March 2023

Sylvie Poignonec

Contents

1 Nasal  Biomechanical Anatomy as a Fundamental Basis for Preservation Rhinoplasty�����������������������������������������������������������������������������������������������������������������   1 Yves Saban and Mohammad Alomani 2 How  Histology Is Pertinent for Surgical Approach�������������������������������������������������  15 Vincent Patron 3 Photography  Evaluation and Morphing for Preservation Rhinoplasty�����������������  35 Garyfalia Lekakis 4 Cone-Beam  CT or CT Scan Analysis for Routine Pre-Operative Planning Before Rhinoplasty�������������������������������������������������������������������������������������  43 Nicolas Baldini and Yves Saban 5 Surgical  Steps in Dorsal Preservation�����������������������������������������������������������������������  57 Erhan Coşkun and Barış Çakir 6 Letdown  and Piezo Techniques in Preservation Rhinoplasty���������������������������������  85 Abdulkadir Goksel and Khanh Ngoc Tran 7 Combination  of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty ������������������������������������������������� 105 Sylvie Poignonec 8 Camouflage  in Preservation Rhinoplasty����������������������������������������������������������������� 137 Guillaume Carles 9 Functional  Considerations for Preservation Rhinoplasty, Nasal Valve, and Clinical Cases������������������������������������������������������������������������������������������������������� 145 Emmanuel Racy, Amanda Fanous, Grégoire d’Andrea, and Nadia Benmoussa 10 Dorsal  Precision Segmental Preservation and How to Avoid Aesthetic Drawbacks ������������������������������������������������������������������������������������������������� 155 J. Carlos Neves and Diego Arancibia-Tagle 11 Prevention  and Correction of the Most Common Problems in Preservation Rhinoplasty����������������������������������������������������������������������������������������������������������������� 183 Bart M. Stubenitsky

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Editor and Contributors

About the Editor Sylvie Poignonec  is a French plastic and head and neck surgeon specialized in rhinoplasty, recognized and qualified by the French Order of Medical Doctors and National Health Authority, as well as by the European Plastic Surgery Board EPOBRAS. Active member of the French Society of Reconstructive Plastic Surgery & Aesthetic SOFCPRE and member of the board of SOFCEP executive committee the French society of plastic and cosmetic surgery, Dr. Poignonec has 25 years of experience in plastic, oral, and maxillofacial surgery, especially at Bichat and Pitié Salpêtrière hospitals in Paris, performing over 2000 rhinoplasty interventions both aesthetic and functional. Adding to her experience, her teaching at APHP medical school and at a large number of surgery and aesthetic courses and workshops led her to open her own private clinic, while still working for the APHP National Health Paris Hospitals as consultant. She has authored and coauthored several books on cosmetic surgery and antiaging medicine and been assigned the Best Clinical Case Award in Rhinoplasty at 2015 AMEC congress. Her teaching techniques and didactic concept for surgeons in training include clinical examination, photography, tomodensitometry (TDM) in 3D, computer simulations, and the building of a dedicated checklist that allows a careful patient approach and the best outcomes for the most frequent rhinoplasty cases .

Contributors Mohammad  Alomani, MD Facial Plastic and ENT Surgery, Kuwait Ministry of Health, Kuwait City, Kuwait Diego Arancibia-Tagle, MD, PhD, IBCFPRS  Otorhinolaryngology, Head and Neck Surgery, Hospital Universitari Son Espases, Palma, Spain Private Practice, Mallorca, Spain Nicolas Baldini, MD  University of Bordeaux College of Health Sciences, Bordeaux, France Nadia Benmoussa, MD  Department of Head and Neck Oncology, Gustave Roussy Cancer Institute, Villejuif, France Barış Çakir, MD  Private Practice, Şişli, İstanbul, Turkey Plastic Reconstructive and Aesthetic Surgery, American Hospital, Şişli, Istanbul, Turkey Guillaume  Carles, MD, EPOBRAS Otolaryngology-Head and Neck Surgery, Institut de Chirurgie Esthétique de Montpellier, Montpellier, France Clinique Clémentville, Montpellier, France Erhan Coşkun, MD  Private Practice, Şişli, İstanbul, Turkey

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Plastic Reconstructive and Aesthetic Surgery, Florence Nightingale Gayrettepe Hospital, Beşiktaş, Istanbul, Turkey Grégoire  d’Andrea, MD Department of ENT and Head and Neck Surgery, Institut Universitaire de la Face et du Cou, GCS Nice University Hospital, Antoine Lacassagne Centre, Côte d’Azur University, Nice, France Amanda  Fanous, MD  Division of Facial Plastic Surgery, Department of Otolaryngology-­ Head and Neck Surgery, McGill University, Montreal, QC, Canada Abdulkadir Goksel, MD  RinoIstanbul Facial Plastic Surgery Clinic, Istanbul, Turkey Garyfalia Lekakis, MD, PhD  Department of Otorhinolaryngology Head and Neck Surgery, Hôpitaux Iris Sud, Brussels, Belgium Louise Medical Centre, Brussels, Belgium Department of Otorhinolaryngology Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium J. Carlos Neves, MD, PhD, IBCFPRS, EBCFPRS  Private Practice MyFace Clinic, Lisbon, Portugal Vincent  Patron, MD Department of ENT—Head and Neck Surgery, CHU de CAEN Normandie, Caen, France Normandie Université, UNICAEN, EA7451 BioConnecT—Biology of Connective and Cutaneous Tissues, Caen, France Sylvie  Poignonec, MD, EPOBRAS Plastic Surgery and Head and Neck Surgery, Centre Esthetique Paris – Eiffel, Paris, France Emmanuel Racy, MD  Maxillo Facial Surgeon, Clinique Saint Jean De Dieu, Paris, France Department of Otolaryngology-Head and Neck Surgery, Adolphe-Rotschild Foundation, Paris, France Yves Saban, MD  Private Clinical Practice, Nice, France Bart M. Stubenitsky, MD, PhD  Dr Bart Clinic, Amsterdam, The Netherlands Khanh Ngoc Tran, MBBS  RinoIstanbul Facial Plastic Surgery Clinic, Istanbul, Turkey

Editor and Contributors

Abbreviations

ANS ASA BP BS CDS CS CBCT CTS DAL DC DCF DE DKA DTF K Zone

LCS LDO LKA

Anterior nasal spine Anterior septal angle Bony pyramid Bony septum Cephalic dome suture Cartilaginous septum Cone Beam Computer Tomography Cranial tip suture Dorsal aesthetic lines Diced cartilage Diced cartilage in fascia Dome equalization suture Dorsal keystone area Deep temporal fascia The keystone area: comprises the nasal bone (NB), cartilaginous septum (CS), bony septum (BS), and upper lateral cartilage (ULC). A portion of the nose where the bony vault overlaps the cartilaginous vault both dorsally. Lateral crural steal suture Let down Lateral keystone area

LLC LSL

Lower lateral cartilage Longitudinal scroll ligament: junction between ULC and LLC NB Nasal bone NMSL Naso maxillary suture line ligament PAL Piriform aperture ligament POD Push down PPE Perpendicular plate of ethmoid PRF Plateletrich fibrin PRP Platelet-rich plasma ROE Rhinoplasty outcomes evaluation SEG Septum Extension Graft Sellion Deepest point in the radix area on side view SLC Scroll ligament complex SMASS Muscular aponeurotic subcutaneous system SSTE Superficial soft tissue enveloppe STE Soft tissue envelope ULC Upper lateral cartilage W Point Point of separation of the ULCs from septum: upper cartilage meet the dorsal septum

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Nasal Biomechanical Anatomy as a Fundamental Basis for Preservation Rhinoplasty Yves Saban and Mohammad Alomani

1.1 Background In the history of primary rhinoplasty, three different philosophies are mentioned in the literature. The most common and most frequently practiced until recently is the rhinoplasty described by Joseph [1], which is principally aimed at removing deformities, especially the osteo-cartilaginous hump. Often, this is carried out via an endonasal approach. The second philosophy is the so-called structural rhinoplasty, which became popular in the 1990s after the introduction of the external transcolumellar approach by Toriumi and Kovacevic [2]. The third philosophy, described first by Goodale [3], and diffused widely by Saban and de Salvador [4], consists in preserving the nasal vaults that form the nasal dorsum and improving the nasal function and shape.

tion from a pure anatomical analysis of the patient’s nasal morphology to the desired aesthetic result, following preoperative simulations (Fig. 1.1). How should biomechanical analysis be correctly carried out? Instead of basically removing the hump, the idea is to create a space in which the surgeon will be able to move nasal structures and modify their form.

1.1.1 Biomechanical Anatomy It is certainly important to understand the anatomy of the nose; however, simple anatomy is not enough, as the biomechanical aspects of nasal anatomy are a cornerstone of the comprehension of preservation rhinoplasty. This analysis allows the surgeon to adapt the surgical procedure, ensuring not only the aesthetic results but preserving/correcting the nasal function as well. Biomechanical anatomy is thus to be understood as the method allowing the transla-

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-­3-­031-­29977-­3_1.

Y. Saban (*) Private Clinical Practice, Nice, France M. Alomani Facial Plastic and ENT Surgery, Kuwait Ministry of Health, Kuwait City, Kuwait

Fig. 1.1  Algorithm of the logic behind biomechanical analysis

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Poignonec (ed.), Clinical Atlas of Preservation Rhinoplasty, https://doi.org/10.1007/978-3-031-29977-3_1

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1.1.2 The Principle of Preservation Rhinoplasty The principle of preservation rhinoplasty is to modify the form of the nose by remodeling most of its structures instead of resecting them, especially the osteo-cartilaginous vault, and protecting or, even better, improving nasal functions, namely breathing. Dorsal reduction is performed instead of resection, then the orienting of the cartilaginous vault, by remodeling the junction between the bone and the septotriangular cartilage at the level of the K-area. Preservation rhinoplasty is designed to be a reduction primary rhinoplasty. It is not limited to the nasal dorsum, as the preservation of nasal ligaments and remodeling of alar cartilage via a sub-perichondral approach is also considered in this philosophy (for French readers see also Gola [5, 6]). A clinical case will illustrate the biomechanical anatomy and further explanations are mentioned later in this chapter.

1.2 Clinical Case 1. Analysis: A 23-year-old woman seeking a primary rhinoplasty. No history of functional problem or nasal trauma. No psychological issues. The physical examination focuses on facial harmony, skin quality and thickness, type of nose from a profile view, shape of the nasal tip, dorsal aesthetic lines, after which the endonasal and functional assessment are performed. The results of this physical examination of the patient’s characteristics (Figs.  1.2–1.4) are: harmonious face but asymmetric face, thin skin, tension nose or ‘type II nasal profile’ (according to the Saban classification [4]), no deformities of the tip; however, the tip drops upon smiling. Slight nostril asymmetry due to caudal septal devia-

Figs. 1.2–1.4  Front view showing good DAL, 3/4 view showing a long nose, profile view showing type 2 nose with a dorsal hump: the following structures are marked in order: radix, rhinion, anterior septal

Y. Saban and M. Alomani

tion. Front view: dorsal aesthetic lines (DALs) are good. The anterior septal angle is prominent on the lateral view. ­Deviated septum to the right side, narrow pyriform aperture as can be seen in the radiological assessment, which is best performed by cone beam CT (Figs. 1.5–1.7). 2. Patient’s expectations: a straight nose with a natural appearance is desired. 3. Technical procedure: type II preservation let-down rhinoplasty [4] in which the superficial soft-tissue envelope (SSTE) was elevated and the dorsum was rasped as the first stage, then the dorsum preservation procedure by let-­ down (LDO) was performed (Video 1.1). 4. Interpretation of the biomechanical anatomy: given the preoperative analysis, the surgeon suggests lowering the hump and achieving a straight dorsum, reducing the length of the nose, and performing a cephalic rotation of the tip. (a) Which surgical approach? As the patient presents thin skin with an harmonious tip shape, an endonasal approach is chosen. An external open approach could have been an option in the case of a problematic tip; however, this open approach generally leads to overdone procedures on the tip, which are not required in such a case. (b) Does the septoplasty destabilize the septum support? The septum is slightly deviated yet stable. Thus, no septum resection is necessary. This septal support stability leads to a high septal strip resection procedure. Septoplasty procedures can be classified into quadrangular cartilage preservation (“swinging door” procedure according to Cottle [7]) versus cartilage resection (“L-strut” according to Killian). As far as possible, it is desirable to preserve as much cartilage as possible. The “L-strut” procedure would lead to excessive resection and loss of support; moreover,

angle (ASA), and the tip. The radix and tip are in the correct position. Normal nasolabial angle and globally long nose

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Figs. 1.5–1.7  Cone beam CT scan, coronal and sagittal planes, 3D sagittal plane showing type 2 nose with caudal septal deviation, stenorhinia, and no adjacent pathological conditions. The blue dots represent

(from superior to inferior) the sellion, the rhinion, the anterior septal angle, and the tip

it does not allow a high strip resection during the preservation rhinoplasty procedure. (c) How should the dorsum be dealt with? The patient shows a tension nose with nice DAL. In the preservation philosophy, keeping the K area intact is one of the main concepts. To achieve this goal, • Nice DAL should be kept intact; therefore, a dorsal preservation procedure is favored. Thus, the procedure will lower the dorsum, without chang-

ing the DAL. A space must be created below the bony–cartilaginous vault allowing the drop of the dorsum into this empty space: a strip of high septum must be resected. • The tension nose convexity requires to be flattened. Basically, the bony dorsum is rigid whereas the cartilaginous vault is flexible. To straighten the dorsal K-zone, the attachments of the underlying septum must be released (“coat-hanger effect”).



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Figs. 1.8–1.10  Six months postoperatively frontal, 3/4 and profile views. We can observe the stability of the result during the follow-up; a small residual hump can be noticed at 6 months postoperatively, which does not bother the patient



So, two actions are required: lowering associated with flattening of the dorsum; thus, a type II dorsal preservation rhinoplasty is planned. (d) What about the lateral sidewalls in this dorsum preservation procedure? Two matters are to be considered: first, do we have to disarticulate the lateral K area (LKA)? Second, do we have to remove the Webster triangle? • Lateral sidewalls must be considered, as they may be a source of resistance which does not permit lowering and ‘stretching’ of the nasal pyramid. The more convex is the nose, the more we need to release the LKA to eliminate any resistance leading to residual hump later. • LKA partial disarticulation ballerina maneuver (see Goksel et  al. [8]) and manipulation of the pyriform ligaments are excellent techniques to allow stretching of the nasal dorsum. • How should lateral osteotomies be managed? How do we choose between push-down (PDO) and LDO? The main difference between PDO and LDO is the bony wedge resection of the frontal process of the maxilla. If the dorsum needs a reduction of 5 mm or more, the PDO technique will be limited by the presence of the inferior turbinate, which will block the descent of the bony side wall; therefore, LDO is mandatory. • Moreover, the narrow pyriform aperture, named ‘stenorhinia,’ along with the inferior turbinate, plays an important role in choosing between the PDO and LDO techniques.



(e) As a consequence of the dorsum lowering, the upper lateral cartilage (ULC) pushes against the spring of the internal nasal valve, thus opening the septal–triangular space and resulting in widening of the middle vault as a side effect on the external front view (Fig.  1.8). There was also a spontaneous cephalic rotation of the lateral crura of the lower lateral cartilage (LLC) that followed the reduction movement of the nasal dorsum. Widening of the nostrils and opening of the nasolabial angle can be observed. 5. Biomechanics of residual humps: one can differentiate, according to the post-operative delay, the cause of hump recurrence: (a) Immediate residual hump (even per-operatively) is most probably due to a technical error in one of the surgical steps. It should be corrected intra-operatively. (b) Early postoperative residual hump is mainly a result of the ‘spring effect.’ This is mostly due to the cartilaginous memory or inadequate release of the lateral K area. Simple postoperative edema (as seen in Figs. 1.8– 1.10) must be rolled out by simple physical examination. This sort of hump can resolve spontaneously up to 1 year postoperatively (Figs. 1.11–1.13). (c) Delayed: sub-dorsal fibrocartilaginous formation could result in progressive hump formation. Diluted steroids could be injected locally to resolve such a problem. (d) Late: fibro-osseous callus is responsible for tardive hump recurrence, which needs correction by simple rasping.

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Figs. 1.11–1.13  Twelve months postoperatively frontal, 3/4, and profile views. Notice the spontaneous resolution of the postoperative residual hump that was seen 6 months postoperatively

During the previous clinical case, highlights of the biomechanical aspects were mentioned. Now, further and deeper explanations of the biomechanical anatomy of preservation rhinoplasty will be discussed in detail.

1.3 The Mobility of the Nose The nose is a mobile structure composed of ductile, malleable, and flexible components; this superficial hollow organ is accessible for external manipulation. Perfectly adapted to movements of ventilation that correspond to its function, it can be compared with a directional aerodynamic structure. However, as the nose is solidly implanted on the face, its position cannot be freely changed. The insertions of the nose into the face divide the nose into three zones. The first zone (upper vault) at the root of the nose is bony and completely immobile. The second zone (middle vault) is semi-mobile and corresponds to the cephalic portion of the ULC and the adjacent fibrous triangles. The third zone (lower vault) corresponds to the alae and columella at the base of the nose. This zone is mobile and directional. Two modalities of movement are possible via the effect of: –– Sliding of the SSTE over deep and rigid planes. –– Folding or bending of cartilaginous and cutaneous structures. Movement of the nasal muscles will affect facial expression and breathing function. These muscles act on the alar cartilage, either at the triangular–alar junction, or at the nasal–labial junction. • Respiration and the nose: the dynamics of the nasal muscles permit adaptation of the airflow in the nasal cavities and thus, participate in the perfection of olfaction and ventilation. However, forced inspiration may produce in some anatomical conditions a nasal valve collapse due to the Venturi effect.

1.4 Biomechanics and Plasticity of Nasal Structures This plasticity is a characteristic of cartilaginous structures and overlying covering planes. It allows movements of the nose or the modeling action of surgical procedures. We can distinguish covering tissues and zones of junction.

1.4.1 The Role of SSTE in Nose Biomechanics Skin, subcutaneous tissues, nasal muscles, adjacent fibrous connective tissues and nasal ligaments, the periosteum, and the perichondrium all constitute the envelope of the nose. These covering tissues drape and grab the osseocartilaginous infrastructure. They also contribute to the stability of these underlying structures by acting as a flexible splint, pulling together the infrastructure and suspending it over the empty nasal cavity. Furthermore, the muscles strengthen and add thickness to the covering planes. Finally, these muscles define a deep plane of surgical dissection in contact with bone and cartilage, a truly natural plane of dissection. Thus, the nasal muscles play a fundamental role, both in nasal static in opposition with dynamic. Certain ‘weak structures’ may cause aesthetic problems owing to a specific risk of distortion: –– The facet (converse soft triangle) has two strictly cutaneous surfaces. –– The weak triangle: the definition of the tip or the occurrence of a “polly beak” deformity depends on the filling of the weak triangle, which corresponds to the supratip area. –– The nasal alae, made of only skin and muscles, are the caudal extension of the fibrocartilaginous continuity of the fibrous triangles and participate in facial expression and respiration.

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1.4.2 The Zones of Junction

1.5 Biomechanics and Surgery

Other functional structures are true fastenings incorporating the mobile nose within the face:

Surgeons have few surgical maneuvers on the SSTEcovering planes where the risk of unsightly scarring is too high. Surgical manipulation will essentially involve the deeper osseocartilaginous framework. The success or failure of deep surgical corrections into improved nasal cosmetics constitute the multiple difficulties of rhinoplasty. Therefore, the results of the rhinoplasty will depend as much on the surgeon’s capacity to evaluate and anticipate the biomechanical reactions of tissues as on his capacity for aesthetic abstraction.

–– The membranous septum situated between the caudal edge of the septum and columella, is a link between the mobile nose, which is the columella, and the fixed nose, which is the quadrangular septal cartilage. –– The lateral fibrous triangle (Fig.  1.14) at the level of the pyriform aperture is a zone of junction between the nose and the cheek. This fibrous triangle corresponds to a lateral extension of the ULC toward the pyriform aperture. The lateral extensions of LLC septum extend the lateral crura (cauda) toward the pyriform aperture. These two lateral extensions of the upper and the LLC toward the pyriform aperture are de facto authentic fibrocartilaginous fastenings joining the mobile nose to the fixed structures of the pyriform aperture. They also directly participate in nasal breathing by avoiding collapse of the lateral nasal wall. They are in contact with the transverse nasalis muscle. –– Last, the labial–columella complex, deeply anchored to the anterior nasal spine by the premaxillary ligament, includes the footplates of the medial crura, the superficial orbicularis oris, and the depressor septi nasi muscles. This complex binds the medial support of the nose to the muscles of the mouth.

Fig. 1.14  Anatomical preparation illustrating the lateral fibrous triangle of the nose. Note the caudal extension of the lateral crus of the lower lateral cartilage and its relations with the free edge of the triangular cartilage and the pyriform aperture

1.5.1 Bony Vault Frequently, the nasal bony vault requires a surgical procedure to achieve lowering or reshaping of this upper segment of the nose. The upper nasal vault is built by nasal bones and the frontal process of the maxilla. On the bony sidewalls, the medial canthal ligaments are inserted. The bones are covered by the periosteal membranous envelope, which gives stability. The nasal bones have their own shape, showing great variability according to individual anatomy. A rhinoplasty procedure needs to reshape these bones. This can be accomplished by sculpture and/or osteotomies and/or fractures. On a lateral view Lazovic et  al. [9] has described V-shaped and S-shaped nasal bones that reflect the radix depth and bony dorsum shape. It is important to remember that the shape of the bone is not absolutely representative of the dorsal convexity. One can divide the bony vault into two segments: the radix and the bony cap; the bony cap corresponds to the bony part of the central K area that covers the underlying quadrangular cartilage and the central part of the triangular cartilage (dorsal K area). Medial canthal ligaments can interfere with manipulation of the bony vault, mainly when the radix requires lowering or in a deviated dorsum. Thus, surgical disinsertion might be necessary to free this blocking point; as a reminder, the anterior head of the medial canthal ligament is not involved in eyelid stability, and undermining it is not risky. The periosteum is firmly attached to the bones. It can be preserved, cut, or undermined. The more the periosteum is freed, the more the bones can be mobilized. Conversely, the

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Fig. 1.15 Surgical manipulation of the septum in Cottle’s technique

Fig. 1.16  High septal strip in Saban’s technique, allowing dorsal descent

less we need to move the bones, the less we should undermine the periosteum. For example, in deviated noses, we need to tilt the nose to one side in order to straighten it. On the long sidewall, important periosteal undermining will be done in order to create a space, which the nose will drop into, whereas on the opposite side (the short sidewall), minimum undermining will be performed. Which technique should be used for preservation rhinoplasty? There are two main techniques for accomplishing dorsal reduction: septal disarticulation by Cottle [7] and

high septal strip by Saban and de Salvador [4]. Different technical variations have been described that follow the same general philosophies. The principle of Cottle’s technique is hump reduction via septal disarticulation and rotation (Fig.  1.15), whereas in Saban and de Salvador’s technique, a simple high septal strip is removed underneath the dorsum controlling the dorsal reduction (Fig. 1.16). Of course, whatever the septal maneuvers, complete osteotomies detaching the nasal pyramid are mandatory to achieve the desired results.

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1.5.2 Upper Lateral Cartilage (Triangular Cartilage) and K Area This intermediate cartilage forms a true semi-mobile zone of transition between the fixed root and the directional base of the nose. Because this cartilage forms approximately the caudal half of a nasal hump, it must be dealt with during reduction rhinoplasty. The K area corresponds to the overlap between the ULC, high septum, and nasal bones. Two segments can be considered: the dorsal K area (DKA) and the LKA. The problem with traditional resection rhinoplasty, is that the resected part of the hump corresponds to the DKA, which is the only support of this ULC “semi-mobile flying wing,” which then becomes a “floating wing.” –– Indeed, the triangular cartilage must be considered as a structure that is “suspended” over the nasal cavity like a semi-mobile wing articulating with a midline axis. –– In our opinion, this cartilage may be analyzed in three different parts. Each part will have a precise role to play on an anatomofunctional, as well as a morpho-dynamic or surgical level (Fig. 1.17). –– The midline axis of support at the articulation of the ULC with the septum is the only part of this cartilage with solid support. At this articulation the ULC forms a true vault over the median septal pillar. This function is confirmed by the specific Y-shape of this zone of junction with a superior convexity that mimics the wings of birds in flight. This structure is maintained by both the septal pillar, which determines the height, and the deep solid insertion under the nasal bones at Cottle’s K area, which links the ULC to the nasal bones. –– Laterally, the wing of the ULC is mobile. This mobility is induced by the weakness of the lateral insertion of the

Fig. 1.17  Anatomical detail of the osseocartilaginous framework of the nose. Note the relations of the triangular cartilage with the nasal bones and with the alar cartilage

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ULC under the nasal bones, the paraseptal caudal end, the lateral extension by the fibrous triangle, and the absence of rigid support throughout this area. –– Caudally, the triangular–alar junction helps to form the spring of the nasal valve where the caudal edges of the triangular cartilage articulate below the cephalic portion of the LLC.

1.5.2.1 Weakened ULCs in Open Roof Rhinoplasty During conventional “open roof” rhinoplasty, the ULCs are weakened after the resection of their central support. Indeed, during resection of a hump, removal of the midline support of the ULC is inevitably the origin of the “flying wing” phenomenon and thus collapse of the ULC.  This collapse is often aggravated by a destabilization of the triangular–alar junction during an intercartilaginous approach and/or resection of the cephalic part of the lateral crura (Fig. 1.18). Here, Figs. 1.18–1.20 show a photographic sequence of an anatomical preparation showing triangular collapse after rhinoplasty using a conventional technique. Finally, an authentic “stripping” of the ULC may occur under two circumstances. The inappropriate use of a rasp may pull out the deep attachments of the cartilage under the nasal bones. However, this is a rather rare event. More frequently, during an en bloc hump resection, the DKA is removed, keeping only the LKA intact at the deep surface of the nasal bones. As a consequence, the medial collapse of the ULC will, as a functional consequence, result in the closure of the triangular–septal angle and thus cause the nasal valve to deteriorate. The aesthetic consequence will be uni or bilateral depression in the form of an inverted V deformity that will disrupt the aesthetic lines of the middle third of the nose (Fig. 1.21). However, this collapse of the ULC is limited by the attachments of the superior surface of the cartilage with the superficial soft tissues that partially contribute to the stabilization of the middle third of the nose. During a rhinoplasty requiring a significant reduction of the dorsum that will interrupt midline support, the surgeon will have a choice of several techniques if he wishes to avoid triangular collapse: –– The use of a preservation rhinoplasty technique is highly indicated for nasal humps with short nasal bones. However, this technique is not always possible. –– Triangular collapse may be avoided by protecting the medial (septal) edge of the ULC and reconstructing the triangular–septal vault named spreader flaps. This is best practiced through an external approach with triangular– septal sutures. –– A “spreader graft” may be harvested on the septum.

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Figs. 1.18–1.20  Demonstration of triangular collapse after rhinoplasty using a conventional technique

will push against the spring of the nasal valve opening the valve angle and the lateral extension of the ULC (2) will push against the pyriform aperture flattening the middle third of the nose. In addition, this pressure will induce a cephalic rotation of the lateral crura of the LLC and individualization of the tip of the nose with opening of the nasolabial angle and flattening of the nostrils. However, this dorsal reduction may result in a saddle deformity of the supratip, in particular, when the hump is very convex. This saddle deformity is due to the sinking of the soft triangle as it is pulled down by the sinking W-ASA segment of the cartilaginous septum. This adverse effect must be corrected, either by performing the septal first incision at the level of the W-point in the high strip procedure, or by rotating the septum anteriorly according to Cottle’s technique. Another aesthetic inconvenience, flaring of the nostrils, is related to the opening of the triangular–septal angle and the nasal valve. A reduction of the nostril can be indicated.

Fig. 1.21  Inverted V appearance related to bilateral triangular collapse and open roof

–– Whichever technique is used, it is highly recommended to limit dissection of the covering planes over the ULC to conserve their role as a splint.

1.5.2.2 Preservation Rhinoplasty and Push-Down Technique Conversely, during preservation rhinoplasty and while performing a “push-down” technique [10], (Figs. 1.22 and 1.23) the nasal hump will decrease; the caudal edge of the ULC (1)

1.5.2.3 Biomechanical Changes in “Let-Down” Preservation Rhinoplasty The biomechanical changes in “let-down” preservation rhinoplasty are quite similar to the “push-down” technique. However, several limitations in the biomechanics of the push-down technique might require a let-down instead. This is particularly important in the case of a narrow nasal cavity, in which pushing the nasal bones into the “already” narrow cavity will affect nasal breathing. Moreover, there is a limited distance in which the bony pyramid could be pushed down to the nasal cavity because of the inferior turbinate and probably the middle turbinate. In fact, the attachments of the head of the inferior turbinate and the head of the middle turbinate could block the descent of the nasal bones. Thus, if a reduction of 5  mm or more of the nasal bone is required, ostectomy of a triangular bony wedge is necessary to allow such a large reduction, as shown in Figs. 1.24–1.26.

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Figs. 1.22 and 1.23  Anatomical preparations: Basic steps of the “push-down” maneuver: complete osteotomies and impaction of the nose

Figs. 1.24–1.26  Anatomical dissection showing the let-down technique and removal of a bony wedge, allowing reduction and strecthing of the dorsum

1.5.3 The Lower Lateral Cartilage (Alar Cartilage) Tip surgery is a difficult task. One of the major keys to success is understanding the relationship between the cartilage and skin of the nasal tip. All the surgeon’s flair will be expressed in his ability to model these structures while adapting to the constraints of each individual patient’s anatomy. The alar cartilage is the major component of the nasal tip [11]. Therefore, together with the skin that covers it, it defines the tip shape. The study of the biomechanical anatomy of this LLC imposes an understanding of a vectorial symmetric anatomy consisting of directional forces and aesthetic consequences. Therefore, the biomechanical anatomy of the alar cartilage takes into account a good anatomical knowledge of:

–– The “enantiomorphic” three-dimensional structure of this cartilage, –– Their morphological interrelations and ligaments, –– Their caudal connections with the skin of the nares and cephalic connections with the ULC. The following section covers the various types of biomechanical action as a function of the movements affecting the tip of the nose. The surgical application to operative techniques results directly from the comprehension of these biomechanical parameters. Therefore, according to the direction of movement given, one may distinguish the movements of ascension, cephalic rotation, lateral deviation, and retrusion of the tip.

1.5.3.1 Cephalic Rotation of the Tip As shown in Figs. 1.27 and 1.28, this rotation is made possible (1) by the presence of the membranous septum that, in turn,

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Figs. 1.27 and 1.28  Anatomical specimen. Simulation of the biomechanical effects of a preservation rhinoplasty

permits the retraction or projection of the columella, (2) by bending of the triangular–alar junction that, in turn, permits the retraction or projection of the lobule, and (3) by shifting of the covering planes over the framework (Figs. 1.27 and 1.28) –– This ascension is limited by tightening of the soft-tissue envelope and by the presence of the cartilaginous septum, which blocks the retraction. –– This movement may be simulated by placing the fingers on the skin overlying the nasal bones and pulling up the skin of the dorsum. –– The aesthetic implications of this movement are essentially to shorten the nose and to open the nasolabial angle. –– The surgical implications (Fig.  1.29) correspond to a shortening of the septal obstacle and/or the membranous septum, a release of the dermal–cartilaginous ligaments and a possible reduction of the triangular–alar zone of junction. The tongue-in-groove technique allows the columella to move upward and eases a tip cephalic rotation. The prototype of this movement is represented by “nose lifting” in elderly patients: resection of the covering planes at the nose root is then possible.

1.5.3.2 The Cephalic Rotation of the Lobule and the Tip This cephalic rotation is made possible (Fig.  1.29) by the conjugated action of (1) the shifting or gliding of the medial crura over the nasal spine that, in turn, if too forceful, may pull the superior lip upward, (2) the cephalic retraction of the membranous septum prolonged by the soft triangle, (3) the conjoint bending of the articulation of the triangular and alar cartilage, and (4) the articulation of the caudal extremity with the pyriform aperture.

This rotation movement is limited (1) by the labial–columellar complex, which is put under tension, (2) by the anterior septal angle that blocks the retraction of the medial crura and the membranous septum, (3) by the undertow of the triangular–alar junction, and (4) by the “alar chain”: the sequential transfer of force as the medial crura push down on the intermediate crura, the intermediate crura push down on the lateral crura, and finally the prolongation of the cauda bear upon the pyriform aperture. –– Simulation of this movement is possible by placing a finger on the infra-tip and pushing up to raise the tip of the nose. In addition, at the same time, the domes may be rolled up with two fingers hooking under the infra-lobular region. This will slightly pull in the triangular–alar junctions. –– The aesthetic implications of this cephalic rotation are (1) a slight shortening of the nose, (2) a cephalic shift of the domes that may individualize the tip and make it rounder or more projected, (3) an obvious opening of the nasolabial angle, (4) increased visibility of the nostrils related to a widening of the columellar–alar angle, and (5) increased soft-tissue thickness of the junction. –– The surgical applications correspond to either the execution of a preservation rhinoplasty or during conventional “open roof” rhinoplasty, elimination of obstacles, facilitation of this rotation movement, and the fixation of the result: reduction of the anterior septal angle, reduction of the triangular–alar junction, release of the caudal extension of the alar, release of the premaxillary ligament and, when necessary, of the frenulum of the superior lip, as well as release of the dermal–cartilaginous ligaments. In extreme cases, the interruption of the “alar chain” by a controlled section of the continuity of this cartilage com-

Y. Saban and M. Alomani

12 Fig. 1.29  Tip rotation: reduction of the triangular– alar junction and the caudal edge of the septum

Nasal bone

Scroll area empty space

LL C

ULC

option ‘1’

Closing space

Nasal bone

ULC

Tongue in groove

S. option ‘2’

Cephalic resection of the tip provocates closure of the space left by the resection of the scrolls And protruding of cartilagineous septum into the membranous septum or in the ontermesial space Option 1 resection of caudal border of the septum allows move back of the columella Option 2 : tongue in a groove

pletes the mastering of this surgery. Fixation of the result is obtained by modeling sutures after careful resection of the excess vestibular skin.

1.5.3.3 Lateral Deviation –– This lateral deviation is made possible by (1) bending of the lateral crura of the LLC, (2) bending of the medial crura and thus of the columella with for effect (3) a deformation of the nostrils by passive adaptation. –– This deviation is limited by the presence of the septum and tightening of the skin, which limits shifting. Furthermore, the interdomal ligament binds together the intermediate segments of the alar cartilage permitting unified movement of the tip elements with little shifting of the position between them.

1.5.3.4 Deprojection of the Nasal Tip • This deprojection of the tip is made possible by a lowering of the “tripod” of the alar cartilage: (1) at the level of the medial crura: the membranous septum allows shifting on the caudal edge of the septum; (2) at the level of the lateral crura: the caudal extremity folds over the pyriform aperture; (3) at the level of the triangular–alar junction: lateral cleavage or shifting. • This deprojection is limited by the action of tip support mechanisms (Figs. 1.30 and 1.31): (1) the pressure of the medial crura on the labial–columellar complex; (2) the lateral pressure of the cauda propped against the pyriform aperture and the spring of the lateral crura; (3) the blocking of the soft tissues pushing against the anterior septum; (4) the recoil of the triangular–alar junction (Figs.  1.30 and 1.31).

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Figs. 1.30 and 1.31  Anatomical preparation. Effects of retrusion of the tip of the nose: “the alar chain”, bending of the caudal extension of the lateral crura and of the triangular–alar junction (“scroll-winding effect”)

• This movement may be simulated by placing a finger on the tip of the nose and pressing perpendicularly to the plane of the face until obtaining contact with the nasal septum. • The aesthetic consequences are retrusion of the tip, flaring of the nostrils, and, sometimes, modifications of the nasolabial angle. • The surgical applications correspond critically to the management of “Pinocchio” noses using one of two principal methods: –– Either modifying the feet of the tripod: Correction (by reduction or burying) of the excessive length of the footplates of the medial crura and the caudal extensions of the lateral crura, as well as reduction of the nostrils; Removal of the blockade of the septum and labial– columellar complex; release of the triangular–alar junction; –– Or by reduction of the apex of this tripod: Section and reduction of the intermediate crura of the LLC sometimes associated with the removal of blocking points if a major reduction is necessary.

1.6 Conclusion The knowledge of biomechanical anatomy is particularly important in preservation rhinoplasty and allows the understanding of the surgical procedures that will help the surgeon to adapt his maneuver to the correction desired, by associating the conservation of the function with the correction of the aesthetic appearance. When this adaptation is not possible, then grafts can reasonably be contemplated.

References 1. Joseph J.  Nasenplastik und sonstige Gesichtsplastik, nebst einem Anhang über Mammaplastik und einige weitere Operationen aus dem Gebiete der ausseren Körperplastik. [Nasal plastic surgery and other facial reconstructive procedures, with an appendix on reconstructive breast surgery and some other procedures in the area of external plastic surgery]. Br J Surg. 1931;19(74):341–2. https://doi. org/10.1002/bjs.1800197416. 2. Toriumi DM, Kovacevic M. Dorsal preservation rhinoplasty: measures to prevent suboptimal outcomes. Facial Plast Surg Clin North Am. 2021;29(1):141–53. https://doi.org/10.1016/j.fsc.2020.09.009. 3. Goodale JL. A new method for the operative correction of exaggerated Roman nose. Boston Med Surg J. 1899;140:112. https://doi. org/10.1056/NEJM189902021400503. 4. Saban Y, de Salvador S. Guidelines for dorsum preservation in primary rhinoplasty. Facial Plast Surg. 2021;37(1):53–64. Epub 2021 Feb 25. https://doi.org/10.1055/s-­0041-­1723827. 5. Gola R. Rhinoplastie fonctionnelle et esthétique. Rappel anatomique et technique. In: Chirurgie esthétique et fonctionnelle de la face. Paris: Springer; 2005. https://doi.org/10.1007/2-­287-­26720-­4_14. 6. Gola R, Nerini A, Laurent-Fyon C, Waller PY.  Rhinoplastie conservatrice de l’auvent nasal [conservative rhinoplasty of the nasal canopy]. Ann Chir Plast Esthet. 1989;34(6):465–75. French. 7. Cottle MH.  Nasal roof repair and hump removal. AMA Arch Otolaryngol. 1954;60(4):408–14. https://doi.org/10.1001/archo tol.1954.00720010420002. 8. Goksel A, Saban Y, Tran KN. Biomechanical nasal anatomy applied to open preservation rhinoplasty. Facial Plast Surg. 2021;37(1):12– 21. Epub 2021 Jan 27. https://doi.org/10.1055/s-­0040-­1715622. 9. Lazovic GD, Daniel RK, Janosevic LB, Kosanovic RM, Colic MM, Kosins AM. Rhinoplasty: the nasal bones—anatomy and analysis. Aesthet Surg J. 2015;35(3):255–63. https://doi.org/10.1093/asj/ sju050. 10. Saban Y, Daniel RK, Polselli R, Trapasso M, Palhazi P.  Dorsal preservation: the push down technique reassessed. Aesthet Surg J. 2018;38(2):117–31. https://doi.org/10.1093/asj/sjx180. 11. Erol O, Buyuklu F, Koycu A, Bas C, Erbek SS.  Evaluation of nasal tip support in Septorhinoplasty. Aesthetic Plast Surg. 2019;43(4):1021–7. Epub 2019 Mar 20. https://doi.org/10.1007/ s00266-­019-­01352-­2.

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How Histology Is Pertinent for Surgical Approach Vincent Patron

2.1 What Is the Structure of the Nasal Cartilages? We have to talk a little about the nasal cartilages: They are made of hyalin cartilage, which is similar to costal and tracheal cartilage (Fig. 2.1). Nasal cartilage is made of an extracellular matrix and the chondrocytes that produce it. The matrix is mainly composed of collagen—type II, IX, and XI—which provide stiffness. The cartilage has no innervation and no vascularization in itself, which means that pain and bleeding during surgery are not caused by the cartilage but rather by the dissection of the surrounding tissues. More important to us than the composition of hyalin cartilage is the structure of its perichondrium (Fig.  2.2). The perichondrium is a connective tissue, mainly composed of collagen I. It is innervated and vascularized, and it is responsible for nourishing the cartilage and its healing. It is therefore of paramount importance when performing a subperichondrial dissection. It is composed of two layers: an outer one and an inner one. The outer one is called the “stratum fibrosum.” It is a fibrous, vascularized, and innervated connective layer that nourishes the inner layer called the “stratum cellulare.” This latter layer is of utmost importance, as it is a chondrogenic layer, composed of chondroblasts, and is

Fig. 2.1  Histological section of an alar cartilage with Masson trichrome staining. Note the arrangement parallel to the surface of the chondrocytes close to the surface, while those in the center are more perpendicular. The white arrow indicates the perichondrium

responsible for cartilage growth. Certain authors described a third, intermediate layer composed only of connective tissues [1].

V. Patron (*) Department of ENT—Head and Neck Surgery, CHU de CAEN Normandie, Caen, France Normandie Université, UNICAEN, EA7451 BioConnecT— Biology of Connective and Cutaneous Tissues, Caen, France

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Poignonec (ed.), Clinical Atlas of Preservation Rhinoplasty, https://doi.org/10.1007/978-3-031-29977-3_2

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Fig. 2.2  Perichondrial layers. Histological section of an alar cartilage with Masson trichrome staining and orcein. Orcein (purple) marks the elastin fibers

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Fig. 2.3  Anatomical dissection of lower lateral cartilage (LLC). Black star: “Sub-SMAS” dissection. Notice the feeding vessels above the cartilage. White star: subperichondrial dissection. Notice the whitish flap corresponding to the perichondrial flap between the forceps (white arrow)

2.2 How to Reach the Subperichondrial Plane in Preservation Rhinoplasty? According to the concept of preservation rhinoplasty, dissection is performed in the subperichondrial plane. Figure 2.3 shows a dissection in the subperichondrial plane (white star) and in the classical plane of rhinoplasty (black star). I think you can easily see the difference between the two planes. Figures 2.4 and 2.5 show a magnified view of a subperichondrial dissection under microscopic examination. You can see that the subperichondrial dissection is made right under the perichondrium, as well as that the chondrogenic and the fibrous perichondrium are elevated as a single flap. This dissection separates the chondrogenic perichondrium from the underlying cartilage, which explains the need to scratch the cartilage firmly to find the correct plane. The presence of the chondrogenic perichondrium at the inner part of the flap explains the whitish and bloodless aspect of the flap once elevated during surgery (Fig. 2.6). Sharp instruments are thus absolutely mandatory for entering this plane. You can use various instruments for this purpose like scissors or a scalpel, but always make sure that your instruments are really sharp. Also, you must have the aim to “attack” the cartilage in order to enter the subperichondrial plane. If you do not do so, you will be on top of the perichondrium (Figs. 2.7 and 2.8).

Fig. 2.4  Histological section of a superichondrial dissection with hematoxyline eosine coloration (HES) staining. The flap includes the fibrous and chondrogenic perichondrium (the cartilage and chondrogenic perichondrium is outlined in purple, and the fibrous perichondrium in yellow for better understanding)

Remember that if you do not actively search for the subperichondrial plane, you will have no chance to find it. Remember that if you have doubt about being in the subperichondrial plane, then you are not!

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Fig. 2.5  Histological section of a subperichondrial dissection with HES staining in ×2.5 magnification. The red arrow shows the dissection plane. The difference in size of the chondrocytes/chondroblasts between the cartilage (white star) and the chondrogenic perichondrium (black star) can be seen clearly (the cartilage and chondrogenic perichondrium is outlined in purple, and the fibrous perichondrium in yellow for better understanding)

Fig. 2.8  Subperichondrial dissection of a left LLC: notice the tear of the perichondrium during the elevation (arrow and arrowhead, leading to a true subperichondrial dissection on the left part of the picture (white star) with the classical “whitish aspect” and an immediate supra-­ perichondrial dissection on the right side (asterisk)

2.3 Why Is Septal Subperichondrial Dissection Easier Than the Subperichondrial Dissection of the ULC and LLC? Fig. 2.6  Whitish aspect of the perichondrium during LLC subperichondrial dissection

Fig. 2.7  Sharp instrument used to enter the subperichondrial plane. One must “attack” the cartilage

The septal subperichondrial dissection is the classical plane for surgery. Why is it more difficult to be subperichondrial for the upper lateral cartilage (ULC) and the lower lateral cartilage (LLC) than in the septum? There are three main reasons to explain this statement: 1. The septal perichondrium is thicker. The thickness of the septal perichondrium is 150 to 200 μm, whereas the ULC and LLC perichondria are only 50 μm thick, and thus less resistant [2]. 2. Septal soft tissues are dense, while the soft tissues around the ULC and LLC are loose. Periseptal tissues are mainly composed of connective tissues and glands, whereas the soft tissues around the ULC and LLC are mainly composed of fat and loose connective tissues (Figs. 2.9 and 2.10). 3. Septal cartilage is stiff, whereas the ULC and LLC are not. The primary task of septal cartilage is to provide the nose with stiffness. The only task of the LLC and ULC is

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V. Patron

Fig. 2.9  Histological section of septal cartilage with Masson trichrome staining. The black arrow shows dense soft tissues and the perichondrium around the septal cartilage

Fig. 2.10  Histological section of LLC with HES staining. The arrow shows the perichondrium. Just above it is loose, fatty tissue

to open the internal and external valve. They are thinner and more flexible. Then, when we need to scratch the cartilage to find the subperichondrial plane, it is easier on the septal cartilage because the septum itself is more resistant and less mobile than the ULC and LLC. You can understand this concept by looking at the painting “The Floor Scrapers” by Gustave Caillebotte (Fig. 2.11): it is easier to scrape something hard and resistant than something weak and mobile. When searching for the subperichondrial plane on the LLC or ULC, try to stretch the cartilage and make counter pressure so that it is easier to scratch.

Fig. 2.11  “The Floor Scrapers,”, Gustave Caillebotte (1848–1894), Musée d’Orsay, Paris (Public domain)

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2.4 Why Dissect the Subperichondrial Plane in the Midline of the Dorsum Rather Than on the Caudal Part of the ULC? Once again, this decision is a matter of perichondrial thickness, cartilage stiffness, and mobility. On the dorsum, the septal perichondrium can be very thick, up to 1000 μm as shown in Fig. 2.12. In addition, the septal Y is resistant, and easy to scratch. One particularity of the dorsum is the presence of the transverse muscle just above the perichondrium. It can be very thick and resistant as well, when under tension (Fig. 2.13). The perichondrium of the ULC is thin, and the ULC a weak, mobile cartilage. It is therefore difficult to scratch it, especially the caudal part, which is very mobile. This is why, in order to dissect the ULC in the subperichondrial plane, it is easier to begin from the midline on the septum, then to go laterally to dissect the ULC perichondrium, rather than trying to find the plane from the caudal part of the ULC (Figs. 2.14 and 2.15). Fig. 2.13  Histological section of the septal dorsum with Masson trichrome with orcein staining, showing a large, transverse muscle (TM)

Fig. 2.12  Histological section of the septal Y with Masson trichrome staining. The two-way black arrows show the 1000 μm thickness of the perichondrium Fig. 2.14  Histological section of the septum and right ULC with HES staining. The dotted line shows the path of the dissection

20 Fig. 2.15 Dorsal subperichondrial dissection: the subperichondrial dissection begins in the midline on the dorsum (a), continues laterally over the ULC (b, c). A sweeping movement is made to dissect the caudal part of the ULC (c, d). Do: dorsum. White star: dorsal perichondrium. Arrow: sweeping movement

V. Patron

a

b

c

d

2.5 Can I Perform a Continuous Subperichondrial Dissection from the LLC Up to the Nasal Bones? When performing a subperichondrial dissection from the caudal part of the LLC to the nasal bones, two areas are difficult to dissect: the scroll area and the ULC/bone junction (Fig.  2.16). In both those transition areas, it is difficult to follow the subperichondrial plane. For some authors, the periosteal and perichondrial envelope is continuous [3–5], especially in the UCL/bone junction where Popko et al. describe the blending of the periosteal and perichondrial fibers, referring to it as the periosteal/perichondrial covering. We will see more in detail the UCL/bone junction in the next paragraph. When examining the scroll area specifically, as in Figs.  2.17 and 2.18, it appears that the scroll area is composed of dense, connective tissue rather than a continuous two-layered perichondrium. This connective tissue may cor-

Fig. 2.16  View of the scroll ligament and ULC/bone junction

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Fig. 2.17 Histological section of a right scroll area with Masson trichrome staining. Scroll sesamoid cartilages (Sc) are embedded in a connective structure which correspond to the scroll ligament complex (SLC)

Fig. 2.18  Histological section of a right scroll area with HES staining showing an image of the scroll similar to Fig. 2.17

respond to the so-called scroll ligament complex [6, 7]. The ULC, LLC, and each scroll sesamoid exhibit their own perichondrium. In some cases, the distinction is more difficult, as in Fig. 2.19, where the scroll area shows a dense, collagenous bundle and continuity of the perichondrium into the scroll area as also described by Karapinar et al. [4]. Regardless of the anatomical variations in the scroll area, a dissection should preserve its integrity. To achieve this goal, when you reach the cranial part of the LLC in a subperichondrial manner, the dissection should continue beneath the scroll ligament just above the vestibular mucosa, then reach the caudal part of the ULC (Fig. 2.20a). Opening the perichondrium here is difficult. At this level, the dissection should join the subperichondrial dissection performed from the midline to the caudal part of the ULC (Figs. 2.20b–d and 2.21).

Fig. 2.19  Histological section of a left scroll area with Masson trichrome staining and orcein. The asterisks indicate the collagenous bundles

22 Fig. 2.20  Dissection of a left scroll area. (a) subperichondrial dissection over the LLC. (b) entering the scroll area. (c) reaching ULC. (d) dissection over the ULC under the scroll area. Sc scroll cartilages, black star LLC perichondrium

V. Patron

a

b

c

d

2.6 How Does the ULC Connect to the Nasal Bones?

Fig. 2.21  Histological section of a right scroll area with HES staining. The black dotted lines indicate the dissection planes from below. The green dotted line indicates the subperichondrial dissection plane from above

This question is of paramount importance if you intend to perform any of the partial dorsal preservation techniques such as Ferreira’s spare roof technique, Ishida’s technique, or Jankowski’s disarticulation technique [8–10]. Two main features characterize the keystone area: First, the ULC and septum form a cartilaginous arch under the bony cap, with an overlap of 8 to 9 mm on average [3, 11, 12]. This overlap is more important on the dorsal keystone area (DKA) than on the lateral keystone area (LKA) [12] (Fig. 2.22). At this level, the septo-triangular cartilage has the same Y-shaped beam as more caudally. For Jankowski, this Y is due to the fusion/invagination of the embryological left and right intermaxillary processes on the midline [13]. For Popko et al., the Y-shaped beam has a supportive effect in the architecture (Fig. 2.23) [3]. It thus makes sense to preserve the

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Fig. 2.24  Histological slice of the Y-shaped beam of the septo-­ triangular cartilage in the dorsal keystone area. Mallory staining. Black arrow: artery. White arrow: vein. B: nasal bone. Double black arrow: thick multilayered perichondrium. Double white arrow: loose perichondrium Fig. 2.22  Left ULC/bone junction. Asterisk: ULC extension under nasal bone; black star: bone periost; dashed lines: site of section of the periosteal/perichondrial covering on the distal part of the nasal bones

Fig. 2.23  Y-shaped beam pillar supporting a bridge. (Photo: Michael Sander)

cartilaginous dorsum, not only for esthetic reasons, but also for mechanical reasons. Another role of this Y-shaped beam seems to be vascularization, via large arteries and veins filling the groove between the cartilage and bone (Fig. 2.24). This is another argument for preserving the dorsum, avoiding both damage to those vessels and a bloody operating area during surgery. The second feature of the keystone is a perichondrial/ periosteal cover, joining the ULC and nasal bone: the pi riform aperture ligament (PAL). It is this ligament that is severed during Jankowski’s disarticulation or Goksel’s ballerina maneuver [7, 14]. The ULC is firmly attached to the bone of the pyriform aperture by a merging of the ULC fibrous perichondrium and nasal bone (or frontal process of the maxilla) periosteum, consistent with a real PAL [3, 5, 12, 15, 16] (Fig. 2.25). This ligament can be as thick as 1 mm and has the particularity of attaching directly to the bone at its distal edge, confirming its anchor role (Fig. 2.26). On the remaining borders of the bone and cartilage, the periosteum and perichondrium fibers remain parallel. Vessels can be found within the ligament. On the dorsal keystone area, the ligament is very thick (more than 1  mm) and made of multiple layers of fibrous periosteum and perichondrium oriented in different directions (Fig.  2.24). Small vessels can be found inside it and larger ones in its inferior part, between two layers of perichondrium (as described above). The perichondrium around the vessels and at the bottom of the groove is looser than at the top. The overlap area between the bone and cartilage shows fewer anchoring structures. Only occasionally is it possible to find dense bundles of fibrous connective tissue

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Fig. 2.25  Histological slice of a right lateral keystone area with Masson trichrome staining and orcein showing the dense PAL between the nasal bone (B) and the ULC. The PAL is a mixture of periosteal and perichondrial fibers. Note the loose connective tissue between the overlap of the ULC and the nasal bone (white arrow). TM transversalis muscle

Fig. 2.27  Histological slice of a right lateral keystone area with Mallory staining. The black arrows show the dense bundles of periosteal/perichondrial fibers stretched between the ULC and the bone (B) in the overlap area

Fig. 2.26  Histological slice of a left PAL with Masson trichrome staining and orcein. The black arrows show the orientation of the periosteal and periosteal fibers of the PAL.  Red arrowhead: vessel into the PAL. The white arrow shows the loose connective tissue at the level of the overlap

unifying the bone and cartilage as anchoring ligaments (Figs.  2.27 and 2.28). Most of the time, the overlapping space is filled with very loose connective tissue, vessels, and nerve, surrounded by thin parallel periosteal and perichondrial fibers. The vessels are mostly veins (Fig. 2.29). What to conclude from these observations? The answer is that the PAL has no significant suspensory action. The forces that push the ULC to the nasal bones or frontal process of the maxilla come from the natural strength of the cartilaginous vault. This explains why disarticulation or ballerina maneuvers do not create step/inverted V deformity.

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2.7 How Does the LLC Connect to the Pyriform Aperture? The area between the most lateral part of the LLC and the pyriform aperture is an area where rhinoplasty surgeons rarely extend their dissection. It is thus not very familiar to them. However, it has a functional interest as it relates to the nasal valve area. This area has been called the pyriform ligament by Rohrich et  al. [17, 18]. Macroscopically, it is possible to isolate a fascial network in that location (Fig.  2.30). Histologically, this tissue is composed of very dense connective tissue, c­ onnecting the bone to the adjacent cartilage (accessory cartilages and LLC) (Fig. 2.31). Its particularity

Fig. 2.28  Histological slice of the dorsal keystone area with Mallory staining. The asterisk shows dense bundles of periosteal/perichondrial fibers stretched between the ULC and the bone in the dorsal keystone (B)

Fig. 2.30  Anatomical dissection of the pyriform ligament

Fig. 2.29  Histological slice of a left overlap area with Masson trichrome staining and orcein. The white asterisk shows the loose connective tissue filling the area. Red arrows indicate veins. Po periosteum, Pc perichondrium, B bone, PAL beginning of the pyriform aperture ligament (see Fig. 2.26)

Fig. 2.31  Histological slice of a left pyriform ligament with Masson trichrome staining and orcein (dotted lines) stretched between the bone in the frontal process of the maxilla (B) and the LLC. Note the wave form of the ligament with a purple center of elastin. Gl mucous glands, Ad adipose tissue, TM transversalis muscle

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is the presence of large layers of elastin fibers, producing the wave form of the ligament, as seen on histological slices (Figs.  2.31 and 2.32). When stretched between the bone

V. Patron

and cartilage, elastin fibers are likely to keep the ligament taut against inhalation maneuvers. The ligament can be crossed by vessels, and lies between glandular structures on the mucosal side, and fat and fibers of the transverse muscle on the skin side.

2.8 Case Study

Fig. 2.32  Closer view of a histological slice of the pyriform ligament with Masson trichrome staining and orcein showing the wave form of the ligament with its purple center of elastin. Gl mucous glands, Ad adipose tissue

Fig. 2.33  Case study 1

Case Study 1 (Fig. 2.33) This patient presented with a right homogeneous nasal pyramid and septal deviation plus a dorsal hump and a boxy tip which she wanted to have corrected. A closed septorhinoplasty was performed by bilateral marginal approach. Septoplasty was performed followed by subperichondrial/periosteal dissection. 5 mm steal and 5 mm crural overlap followed by classical Cakir tip plasty with a 2-cm strut graft. Let Down technique was performed with resection of a 4 -mm left nasal bone resection. Low septal strip and fixation of the septum to the nasal spine. Partial section of the Pitanguy ligament. 1 year result.

2  How Histology Is Pertinent for Surgical Approach

Fig. 2.33 (continued)

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Case Study 2 (Fig. 2.34) This patient presented a nasal obstruction and a crocked nose following multiple ancient traumas (Fig. 2.35). Open septorhinoplasty with subperichondrial and subperiosteal dissection was performed. A septoplasty was per-

Fig. 2.34  Case study 2

V. Patron

formed followed by rhinosculpture of the left nasal bone with Piezotome and lateralization of the right nasal bone. Section with Piezotome of the bony dorsum following the fracture lines and proper replacement of the bones preserving the bony dorsal integrity. Tip surgery with Cranial Dome

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Fig. 2.34 (continued)

Closed septorhinoplasty via a bilateral intercartilaginous approach. Subperichondrial and subperiosteal dissection with rasping of the dorsal hump of 3 mm and nasal bones laterally, septoplasty allowing septal relaxation on midline, reduction of 3  mm of the height of the dorsal septum followed by spreader flaps. 3 mm reduction of the caudal septum to correct a slight hanging columella. No tip surgery or dissection. 1 year result. In this patient, a cartilaginous preservation of the dorsum could have been performed instead and would have surely allowed to maintain an ideal dorsal cartilage width and height. Fig. 2.35  Preoperative 3D volume rendering of the case study 2 patient’s CT scan

Sutures and stabilization of the tip with an ANSA banner. 1 year result. Case Study 3 (Fig. 2.36) This patient presented for a left nasal septal obstruction and desired a nasal refinement, she disliked her nasal profile.

Case Study 4 (Fig. 2.37) This patient presented with a left septal deviation, dorsal hump, plunging tip, and hanging columella. A closed septorhinoplasty was performed by bilateral marginal approach. Septoplasty was performed followed by subperichondrial/periosteal dissection. 1  mm alar rim incisions, 4 mm steal, and 2 mm crural overlap followed by classical Cakir tip plasty with a 2.5-cm strut. 3 mm high septal strip with Push Down technique. 1.5 year result.

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Fig. 2.36  Case study 3

V. Patron

2  How Histology Is Pertinent for Surgical Approach

Fig. 2.37  Case study 4

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32

V. Patron

Fig. 2.37 (continued)

2.9 Conclusions

References

Subperichondrial dissection is truly a subperichondrial dissection below the inner chondrogenic layer of the perichondrium. If the perichondrium is respected during dissection, it does not generate fibrosis or devascularization, but instead activates the chondrogenic activity of chondroblasts, resulting in cartilage production. It is therefore of paramount importance to take care of the perichondrium when you dissect. In addition, histology teaches us that to correctly enter the subperichondrial plane requires three things: (1) sharp instruments, (2) keeping the cartilages stretched during the scratching maneuver, and (3) performing appropriate counter pressure if possible. Starting the dissection at the point where the cartilage is its stiffest and least mobile, and where the overlying tissues are the densest, can make the maneuver easier. In the dorsal and lateral keystone, the PAL anchors the bony pyriform aperture to the ULC but does not seem to have supportive effect. This is the role of the Y beam shape of the septo-triangular cartilage to support the middle third. In the lower part of the pyriform aperture, the pyriform ligament spans the space between the pyriform aperture and the LLC and seems to have a functional effect. Both structures have their own role and should be preserved if possible.

1. Bairati A, Comazzi M, Gioria M.  A comparative study of perichondrial tissue in mammalian cartilages. Tissue Cell. 1996;28(4):455–68. 2. Bleys RLAW, Popko M, De Groot J-W, Huizing EH. Histological structure of the nasal cartilages and their perichondrial envelope. II. The perichondrial envelope of the septal and lobular cartilage. Rhinology. 2007;45(2):153–7. 3. Popko M, Verlinde-Schellekens SAMW, Huizing EH, Bleys RLAW.  Functional anatomy of the nasal bones and adjacent structures. Consequences for nasal surgery. Rhinology. 2018;56(1):89–95. 4. Karapinar U, Kilic C, Develi S, Gamsizkan M, Yazar F. The anatomical and histological features of the area between the upper and lower lateral nasal cartilages: a pilot study. J Exp Integr Med. 2013;3(1):57–61. 5. Popko M, Huizing EH, Menger DJ, Verlinde-Schellekens SAMW, Mackaaij S, Bleys RLAW.  New insights into tip supporting structures. Consequences for nasal surgery. Rhinology. 2020;58(5):506–15. 6. Daniel RK, Pálházi P. Rhinoplasty: an anatomical and clinical atlas. Berlin: Springer; 2018. p. 349. 7. Daniel RK, Palhazi P, Saban Y, Çakir B. Preservation rhinoplasty. 3rd ed. Istanbul: Septum; 2021. 8. Gonçalves Ferreira M, Santos M, Rosa F, Sousa CA, Santos J, Dourado N, et  al. Spare roof technique: a new technique for hump removal—the step-by-step guide. Plast Reconstr Surg. 2020;145(2):403–6. 9. Ishida J, Ishida LC, Ishida LH, Vieira JC, Ferreira MC. Treatment of the nasal hump with preservation of the cartilaginous framework. Plast Reconstr Surg. 1999;103(6):1729–33; discussion 1734–5. 10. Jankowski R, Gallet P, Nguyen D-T, Rumeau C. Septorhinoplasty by disarticulation. Eur Ann Otorhinolaryngol Head Neck Dis. 2021;138(3):195–9. 11. Palhazi P, Daniel RK, Kosins AM.  The osseocartilaginous vault of the nose: anatomy and surgical observations. Aesthet Surg J. 2015;35(3):242–51.

Acknowledgments The author would like to thank Dr. Pauline Géraldy, Pr Guénaëlle Levallet, and Maëlle Guyot for their technical help.

2  How Histology Is Pertinent for Surgical Approach 12. Natvig P, Sether LA, Gingrass RP, Gardner WD. Anatomical details of the osseous-cartilaginous framework of the nose. Plast Reconstr Surg. 1971;48(6):528–32. 13. Jankowski R. The evo-devo origin of the nose, anterior skull base and midface. Paris: Springer; 2013. 210 p. 14. Jankowski R. Septoplastie et rhinoplastie par désarticulation: histoire, anatomie, chirurgie et architecture naturelles du nez. Elsevier Masson; 2016. 370 p. 15. Daniel RK, Palhazi P. The nasal ligaments and tip support in rhinoplasty: an anatomical study. Aesthet Surg J. 2018;38(4):357–68.

33 16. Craig JR, Bied A, Landas S, Suryadevara A. Anatomy of the upper lateral cartilage along the lateral pyriform aperture. Plast Reconstr Surg. 2015;135(2):406–11. 17. Rohrich RJ, Hoxworth RE, Thornton JF, Pessa JE.  The pyriform ligament. Plast Reconstr Surg. 2008;121(1):277–81. 18. Saban Y, Andretto Amodeo C, Hammou JC, Polselli R.  An anatomical study of the nasal superficial musculoaponeurotic system: surgical applications in rhinoplasty. Arch Facial Plast Surg. 2008;10(2):109–15.

3

Photography Evaluation and Morphing for Preservation Rhinoplasty Garyfalia Lekakis

The more importance you give to patient photography, the more you will develop your own standards and make your patients feel valued —Baris Çakir

3.1 Background Information: Why This Particular Subject Has to Be Particularly Studied? Many rhinoplasty surgeons have difficulties in recording consistently standardized photographs in an office setting. The ease and widespread use of the smartphones with increased power cameras has demotivated them from developing those essential photographic skills. Still, perusal and scrutiny of patients’ photographs in articles from the medical literature and from presentations in congresses identifies a number of deficiencies present. It is clear that the art and technology of photography can be overwhelming at first for rhinoplasty surgeons. However, understanding basic photography equipment and principles is critical for developing a successful practice. Rhinoplasty remains very much a visual endeavor, and as such visual cues are the best way to communicate with the patients and build up rapport by providing information that may be difficult to accurately convey with words and measurements only. It is for this reason that the communication process demands more time and effort than any other procedure of the head and neck region [1], particularly because rhinoplasty allows very little or no margin for error. The surgeon unwilling or unable to devote sufficient extra time to planning in the interest of an excellent result

G. Lekakis (*) Department of Otorhinolaryngology Head and Neck Surgery, Hôpitaux Iris Sud, Brussels, Belgium Louise Medical Centre, Brussels, Belgium Department of Otorhinolaryngology Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium

usually finds mediocrity a frequent companion [1]. On the contrary with some attention to detail and a small investment in time and money professional quality standardized images can be achieved, and subsequently computer enhanced in order to simulate surgical goals.

3.2 Description of the Technique Photos/ Videos The standard care in rhinoplasty for the last 50  years has been the use of 2D (two-dimensional) photographs. Guidelines for photography standards have been well documented in the literature by different authors [1–6] for decades now. In the United Kingdom, the Institute of Medical Illustrators (IMI) has published National Guidelines as a guide to good practice (Institute of Medical Illustrators National Guidelines) [7]. The essential aspects of preparing the studio and equipment are presented in this section.

3.2.1 Equipment 3.2.1.1 Camera The recommended camera to use is a digital single-lens reflex (DSLR) camera with a CMOS (complementary metal-­ oxide-­semiconductors) sensor and manual controls [7]. This is also known as a “full-frame” 35  mm sensor. However, cameras with sensors smaller than 35  mm, also known as APS-C (advanced photosystem type C) or “crop frame” can also be used, but they capture a narrower field of view than “full-frame” cameras. One of the advantages of using a DSLR camera is the choice of a wide variety of lenses

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Poignonec (ed.), Clinical Atlas of Preservation Rhinoplasty, https://doi.org/10.1007/978-3-031-29977-3_3

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Fig. 3.1  The author’s DSLR camera and macro lens 105 mm

(Fig. 3.1). The sensor is composed of millions of capacitors, each of which accounts for one pixel of the image [8]. Pixel density is related to resolution, a factor in image quality. A resolution of 1.5 megapixels was once considered acceptable for medical photography [4]. At the present time and the speed of improvement in digital technology for photography, new models of DSLR cameras come with 24-megapixel sensors.

3.2.1.2 Lens In photo documentation of the patient undergoing rhinoplasty, it is important to use a lens that produces the least distortion and provides the largest depth of field (DOF) to ensure that the whole face is in focus [6]. Therefore, proper lens selection is crucial in order to enable facial features to appear natural and non-distorted. The key word here is focal length which ideally should be between 90 and 105 mm [2, 4]. The focal length of lens is defined as the distance in millimeters from the optical center of the lens to the focal point located on the image sensor. These lenses are known as “macro” or “portrait” lenses and are produced for near focusing. This very much allows the option of close-up portrait photography while keeping a comfortable camera to patient distance of 2 m. Lenses with shorter focal lengths should be avoided because they have a wider angle of view and produce a central bulging “fish-eye” appearance when used to photograph the face [3, 4]. In fish-­ eyed photos, you can see less of the ears and the nose tip will also look bulbous. The same effect is achieved if you get close to the patient and zoom out with the lens or if you take photos with a smartphone. Patient counseling regarding this effect is essential especially if we consider the popularity of selfies, the ease with which are taken and the distortion of the nose, most notably an increase in nasal dimensions, due to the short distance from the camera [9]. In addition to focal length of the lens, several other factors influence image characteristics. DOF refers to the distance between the nearest and the furthest points in focus. For the

purposes of rhinoplasty, the DOF should include the entire face with the nose at the focal point and with the greatest definition. DOF may be manipulated by altering three factors: focal length of lens, distance between photographer and subject, and aperture size. The lens aperture is made up of an adjustable diaphragm that controls the passage of light through the lens. Aperture size is measured as f-stops and have an inverse relationship to aperture size. Decreasing aperture size will increase the DOF; f-stops values of f10 to 22 will typically ensure that the entire subject will be in focus [2, 4, 10].

3.2.1.3 Lighting Lighting is of immense importance in photography for patients undergoing rhinoplasty. It is critical to extract the fine anatomic details and contours of the nose for our evaluation and facial analysis. Different light arrangements, light sources or positions can influence the final photographic quality. The most inexpensive form of lighting is to use a single-mounted camera flash, but this will produce harsh shadows and uneven lighting [11] (Fig. 3.2a, b). Additionally single flashlight, although simple and economic, it will exacerbate the deformity; and if used preoperatively only, in combination with good lighting conditions postoperatively will result to what is known as “light cheat” where half the surgery is done by light changes alone [10] (Fig. 3.2c, d). It is therefore recommended that all views are taken with two studio grade electronic flash, which provide diffuse indirect light to produce shadowless images and both positioned at 45° to the patient–camera axis, slightly above head level, in order to prevent facial shadows and get natural light reflections. Large diffuse reflectors, soft boxes, and shoot-through umbrellas may also be used to reduce some of the harshness and improve the quality of the photo-documentation (Fig. 3.3). As a high level of detail must be obtained, a maximum DOF is required, therefore the overall light source must be sufficient.

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a

b

Fig. 3.2 (a) The same patient photographed with one single flash producing harsh shadows and two synchronized studio flashes on the frontal view. Both photos are pre-operative. (b) The same patient photographed with one single flash and two synchronized studio flashes on the left profile view. Both photos are pre-operative. (c) The same

patient photographed with one single flash and two synchronized studio flashes on the right oblique view. Both photos are pre-operative. (d) The same patient photographed with one single flash and two synchronized studio flashes on the basal view. Both photos are pre-operative

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G. Lekakis

c

d

Fig. 3.2 (continued)

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Fig. 3.3  Light and soft box used for portrait photography in the clinic

3.2.1.4 Background The studio background should be of a uniform color and neutral in order to place focus on the patient and avoid distractions. It is important to choose well the background, as it is difficult to change this part of your studio in the office easily [10]. The best choices are black and blue. Black is more artistic but when it comes to an individual with darker complexion it blends into the hair color. Blue provides sufficient contrast, it is complimentary to all skin types, and remains pleasant to the eye without overwhelming the subject [4, 5] (Fig. 3.4). 3.2.1.5 The Lighting Setup The author is using a modified version of the quarter light system (two lights for the patient and two backlights for the background) that demands large space. This modification consists of two synchronized studio flashes of equal intensity positioned at 45° from the subject–camera axis with the patient placed 1 meter from the background to minimize shadows and eliminates the need for backlights (Fig.  3.4). The location of the lights and the position of the patient have to be maintained at all times that photography is performed. The angle of light presentation has to be respected because if the angle is increased, the tip-defining points may seem wider, and vice versa [2]. Maintaining the light sources at a fixed angle for all photos over time ensures that changes in the horizontal angle of incidence reflect the result of surgery and not the result of “photographic tip rhinoplasty.”. 3.2.1.6 Patient Preparation and Positioning Patients need to be aware of the purpose of photography as part of the consultation and that all images will be part of

Fig. 3.4  Photographic studio setup in the clinic

their medical record for surgical planning [2]. Informed consent should be taken for photography [7], especially when the surgeon plans to use the images for education, scientific presentations/publications, or marketing. All detailed intents of the photographs should be incorporated in the consent from [2, 12]. Written informed consent is the key to limiting liability and addressing legal issues related to the use of photography in rhinoplasty practices [12]. Both the patient and surgeon/photographer should be positioned correctly, in a standardized manner, to produce consistent photographs. This can be achieved by

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a

G. Lekakis

b

Fig. 3.5 (a) Preoperative photography for a rhinoplasty patient. (b) Preoperative photography for a rhinoplasty patient

• Ensuring the patient has suitable supportive seating that can be adjusted to account for the height of the patient. Markers on the floor may be used to fix the position of the stool and to guide the patient in obtaining repeatable views (Fig. 3.4). • Removing distracting facial jewelry or spectacles and placing the hair back with discreet bands/clips allow a clear facial outline as well as both ears and forehead to be fully visible. • Instructing the patient to sit upright with their head straight and both feet placed firmly on the floor achieves the correct head alignment using the Frankfort horizontal plane (an imaginary line from the infra-orbital rim to the upper margin of the auditory opening) as a reference, which should be parallel to the floor. The camera lens axis should be horizontal and the camera back vertical (portrait photography), positioned at the same height as the nose of the patient (Fig. 3.5a, b).

3.2.1.7 Standard Photographic Views Standardized, recommended views for rhinoplasty are demonstrated in Fig. 3.6. These views include the anteroposterior, right lateral, right oblique, left oblique, left lateral, inferior, basal, and the superior view. Additional views that might be beneficial for surgical planning are the smiling lateral and smiling anteroposterior views as well as some close­up views. The superior view allows an assessment of subtle deviations of the dorsum and the smiling lateral view depicts the dynamic changes of the nasal tip due to tip ptosis or overactive depressor septi muscle. Standard anteroposterior view: both ears should be clearly visible and the forehead should be aligned with the chin. Standard lateral view: the contralateral eyebrow should not be visible.

Standard oblique view: the nasal tip is aligned with the contralateral cheek contour. Standard basal view: the head should be tilted back so that the nasal tip is aligned to the glabella. Standard inferior view: this view requires less elevated position to include more of the nasal bridge by aligning the nasal tip to the medial canthi. Superior view: ask the patient to lower their head forward below the horizontal midplane, so that the entire nasal bridge can be photographed.

3.2.1.8 Photography Archive An important asset of digital photography is the ability to store and organize images, and the photo archive of a rhinoplasty surgeon is considered priceless [10]. Nevertheless, photography and data management of a rhinoplasty practice has undergone a rapid change in complexity over the last 20 years because of an evolution of mechanisms in data portability combined with governmental focus on health information privacy [13]. Photographs taken and archived in rhinoplasty practices are protected health information and must be handled in a way that is compliant with federal laws such as the Health Insurance Portability and Accountability Act (HIPPA) in the USA [2, 12]. Although digital revolution has made technically simple to take clinical photographs, safeguarding information stored on devices and backup storage media is less simple but of upmost importance [14]. Use of passwords and other means of user authentication is an essential practice. 3.2.1.9 Computer Imaging Another important advantage of digital photography is the potential to use computer imaging to facilitate communication with the patient and education of junior surgeons. Computer imaging, also called morphing, allows surgeons

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Fig. 3.6  Standard views for photography of the rhinoplasty patient: anteroposterior, right oblique, right lateral, left oblique, left lateral, inferior, basal/worm’s eye, and superior/bird’s eye view

to manipulate digital photographs of the nose for patients seeking rhinoplasty [15], allowing photographs to serve a predictive than solely documentary role [16]. It is a process that entails a discussion and a preview of the proposed surgical changes that may be difficult to communicate without visual cues. Consequently, patients can understand better the surgical goals, surgeons can appreciate better patients’ expectations, and to a degree use the application for patient selection [17]. It is after all the surgeon’s responsibility to temper the patient’s desires to realistic goals [18]. Adobe photoshop (Adobe Systems Inc.) is a commonly used imaging editing program and a few articles in the literature serve as step-by-­step tutorials demonstrating different Photoshop tools [19, 20]. Over recent years, three-dimensional (3D) photography and imaging are gaining popularity in rhinoplasty and used routinely in academic practices and private clinics, but they have yet to be universally accepted. The limitations of 2D

images to address facial depth and nasal shape drive the technological evolution of 3D surface-imaging systems which offer additional valuable data, such as volumetric analyses and surface topographic distance measurements [21]. Additionally, there are 3D surface-imaging systems, such as the Canfield Vectra (Canfield Scientific Inc., Parsippany, NJ) that have an integrated system for both image simulation and storage. A number of publications in the literature extols the numerous advantages of this technology for surgeons and patients, making it the current state of the art in preoperative counselling and planning during rhinoplasty [22–26].

3.3 Conclusion Understanding the basic photography equipment and principles, lighting, as well as patient preparation and positioning are crucial to producing consistent, high-quality, standard-

42

ized images. It is vital that these standards are maintained as photography in rhinoplasty is the best instrument for facial analysis, patient education, surgical planning, postoperative follow-up, critical evaluation, and self-improvement. With the continued technology innovation, the importance of 3D surface imaging will only be increasing in the future, pushing rhinoplasty surgery, to even a higher surgical standard.

References 1. Tardy ME, Dayan S, Hecht D. Preoperative rhinoplasty: evaluation and analysis. Otolaryngol Clin North Am. 2002;35(1):1–27. v. 2. Kim CH, Most SP.  Photography and photodocumentation for the rhinoplasty patient. Clin Plast Surg. 2022;49(1):13–22. 3. Swamy RS, Sykes JM, Most SP.  Principles of photography in rhinoplasty for the digital photographer. Clin Plast Surg. 2010;37(2):213–21. 4. Galdino GM, DaSilva AD, Gunter JP. Digital photography for rhinoplasty. Plast Reconstr Surg. 2002;109(4):1421–34. 5. Swamy RS, Most SP. Pre- and postoperative portrait photography: standardized photos for various procedures. Facial Plast Surg Clin North Am. 2010;18(2):245–52. Table of Contents. 6. Becker DG, Tardy ME. Standardized photography in facial plastic surgery: pearls and pitfalls. Facial Plast Surg. 1999;15(2):93–9. 7. https://www.imi.org.uk/wp-­content/uploads/2019/03/2019_Mar_ IMINatGuidelines_Rhinoplasty_V2x-­1.pdf 8. Riley RS, Ben-Ezra JM, Massey D, Slyter RL, Romagnoli G. Digital photography: a primer for pathologists. J Clin Lab Anal. 2004;18(2):91–128. 9. Ward B, Ward M, Fried O, Paskhover B. Nasal distortion in short-­ distance photographs: the selfie effect. JAMA Facial Plast Surg. 2018;20(4):333–5. 10. Çakir B.  Aesthetic septorhinoplasty. 2nd ed. Berlin: Springer; 2021, ISBN 978-3-030-81860-9. 11. Schwartz MS, Tardy ME.  Standardized photodocumentation in facial plastic surgery. Facial Plast Surg. 1990;7(1):1–12. 12. Segal J, Sacopulos MJ.  Photography consent and related legal issues. Facial Plast Surg Clin North Am. 2010;18(2):237–44, Table of Contents.

G. Lekakis 13. Harting MT, DeWees JM, Vela KM, Khirallah RT. Medical photography: current technology, evolving issues and legal perspectives. Int J Clin Pract. 2015;69(4):401–9. 14. Citrome L. Medical photography: it has never been so easy and yet so complex. Int J Clin Pract. 2015;69(4):387. 15. Lekakis G, Claes P, Hamilton GS, Hellings PW. Evolution of preoperative rhinoplasty consult by computer imaging. Facial Plast Surg. 2016;32(1):80–7. 16. De Greve G, Malka R, Barnett E, Robotti E, Haug M, Hamilton G, et al. Three-dimensional technology in rhinoplasty. Facial Plast Surg. 2022;38:483. 17. Lekakis G, Sykes J, Hens G, Hellings PW. Morphing as a selection tool in the rhinoplasty consult: a cross-sectional study. Facial Plast Surg. 2020;36(1):112–9. 18. Swamy RS, Most SP.  Preoperative, anesthetic, and postoperative care for rhinoplasty patients. Facial Plast Surg Clin North Am. 2009;17(1):7–13. v 19. Hamilton GS. Morphing images to demonstrate potential surgical outcomes. Facial Plast Surg Clin North Am. 2010;18(2):267–82, Table of Contents. 20. Hamilton GS. Photoshop tips and tricks every facial plastic surgeon should know. Facial Plast Surg Clin North Am. 2010;18(2):283– 328, Table of Contents. 21. Weissler JM, Stern CS, Schreiber JE, Amirlak B, Tepper OM. The evolution of photography and three-dimensional imaging in plastic surgery. Plast Reconstr Surg. 2017;139(3):761–9. 22. Lekakis G, Hens G, Claes P, Hellings PW. Three-dimensional morphing and its added value in the rhinoplasty consult. Plast Reconstr Surg Glob Open. 2019;7(1):e2063. 23. Dixon TK, Caughlin BP, Munaretto N, Toriumi DM.  Three-­ dimensional evaluation of unilateral cleft rhinoplasty results. Facial Plast Surg. 2013;29(2):106–15. 24. Asher SA, Kakodkar AS, Toriumi DM.  Long-term outcomes of subtotal septal reconstruction in rhinoplasty. JAMA Facial Plast Surg. 2018;20(1):50–6. 25. Toriumi DM, Dixon TK. Assessment of rhinoplasty techniques by overlay of before-and-after 3D images. Facial Plast Surg Clin North Am. 2011;19(4):711–23, ix. 26. Moscatiello F, Herrero Jover J, González Ballester MA, Carreño Hernández E, Piombino P, Califano L. Preoperative digital three-­ dimensional planning for rhinoplasty. Aesthetic Plast Surg. 2010;34(2):232–8.

4

Cone-Beam CT or CT Scan Analysis for Routine Pre-Operative Planning Before Rhinoplasty Nicolas Baldini and Yves Saban

Key Points The main CBCT or CT sections for pre-operative planning are: –– The horizontal sections: with the width and the shape of the pyriform aperture. –– The median sagittal section: with the position of the anterior angle of the perpendicular plate of the ethmoid and the location of the frontal sinuses, which sometimes extend into the radix. –– The horizontal and frontal sections: with the septum, and the turbinates. Pre-operative CBCT or CT scan enables any abnormalities involving the turbinates and paranasal sinuses to be detected, and the need for any associated surgical procedure to be planned. 3D reconstructions offer surgeons new applications, enhancing the analysis of nasal bone characteristics or of surface aesthetics.

4.1 Introduction Medical imaging has been considerably improved and currently enables new considerations in the field of facial analysis and surgical planning. CBCT is a medical imaging technique consisting of X-ray computed tomography where the X-rays are divergent. Therefore, the main difference between CT scan and CBCT is the shape of the beams: CT scans use fan-shaped X-ray beams that rotate while the patient advances to capture limited thickness slices, whereas

N. Baldini University of Bordeaux College of Health Sciences, Bordeaux, France Y. Saban (*) Private Clinical Practice, Nice, France

CBCT uses a cone-shaped area detector that does not require patient movement. Thus, it offers a significantly higher resolution for bone structures. On the other hand, because of its lower dosimetry, it produces a low resolution in contrast, and will be ineffective for the evaluation of the density, and thus of the soft tissues. Digital Imaging and Communications in Medicine (DICOM) is the standard for the communication and management of medical imaging information and related data. DICOM is most commonly used for storing and transmitting medical images, enabling the integration of medical imaging devices. Cone beam CT causes the patient no inconvenience and has very few, if any, drawbacks, with these being limited to radiation exposure and limited cost. The radiation exposure from CBCT is up to four times less than that incurred from a conventional CT scan. Nevertheless, depending on the countries, the cost can act as a brake to its routine use for pre-­operative planning before rhinoplasty [1].

4.2 Clinical Case A 29-year-old woman seeking a primary rhinoplasty. No history of nasal trauma. No psychological issues. Functional and aesthetic complaints. The physical examination focuses on facial harmony, skin quality and thickness, dorsal aesthetic lines, nasal base and tip, type of nose from a profile view; then, the endonasal and functional assessment. The results of this physical examination of the patient’s characteristics are: harmonious face but asymmetric face, thin skin. Front view: dorsal aesthetic lines are good. Significant septal deviation to the right-hand side, narrow pyriform aperture, and inferior turbinate hypertrophy. Squared tip with no deformities, wide nostrils (Fig. 4.1). Profile view: tension nose or “type II nasal profile” (according to Saban’s classification) [2] (Fig. 4.2).

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Poignonec (ed.), Clinical Atlas of Preservation Rhinoplasty, https://doi.org/10.1007/978-3-031-29977-3_4

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The patient complains of nasal obstruction; furthermore, she does not like the hump and the wide nostrils. Patient’s expectations: a more feminine look and improved breathing. A straight nose with a natural appearance is desired.

Fig. 4.1  Pre-operative frontal view

N. Baldini and Y. Saban

This physical examination is then completed by the CBCT or CT scan analysis:

4.2.1 Pyriform Aperture On the left, we can see the narrow pyriform aperture reducing the nasal airway (white stars) (Fig. 4.3). On the right, this is the relevant slice for analyzing the pyriform aperture. In the axial plane, we use the slice passing through the inferior turbinates and showing the frontal process of the maxilla. This slice enables us to evaluate the “functional width” (white stars) at the level of the inferior turbinates, which differs from “anthropometric measurements” referring to the largest width of the pyriform aperture (leptorrhine, mesorrhine, platyrrhine) [3]. When the frontal process of the maxilla narrows the pyriform aperture, we may observe that the direction of the ascending process is not parallel to the inferior turbinates but oblique inside the pyriform aperture. Clinical relevance: Narrow pyriform aperture and furthermore any push-down procedure is likely to compromise a little bit more the nasal airflow. Therefore, resection of the lower pyriform aperture (Webster’s triangle), possibly associated with a let-down in the case of a lowering of the dorsum greater than 5–6 mm, would be the preferred technique.

Fig. 4.2  Pre-operative profile view, and overlay of the 3D bony reconstruction of CBCT

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Fig. 4.3  Narrow pyriform aperture (white stars)

Fig. 4.4  Cone beam CT in frontal view with the corresponding segmented structures in 3D images: septum in blue, right inferior turbinate in red, and right middle turbinate in green

4.2.2 Turbinates, and Septum Cone beam CT or CT scan provides improved visualization of septal deviations and turbinate abnormality compared with physical examination alone (Figs. 4.4, 4.5, 4.6, 4.7 and 4.8). This can also be advantageous in revision rhinoplasty, where one cannot be sure how much septal cartilage is left.

Clinical relevance: In the case of a deviated perpendicular plate of the ethmoid (PPE), posterior disarticulation of the septum from the PPE is advised in order to prevent recurrence of a septal deviation [4].

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Fig. 4.5  Cone beam CT in the axial plane: inferior turbinates in red, septal deviation to the right (arrow)

Fig. 4.6  Cone beam CT in the axial and frontal planes: middle turbinates in green, concha bullosa (arrow)

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Fig. 4.7  Cone beam CT in the axial plane: septal deviation to the right (arrow), and segmented septum on a 3D image showing the vomerine spur

Fig. 4.8  Cone beam CT in the frontal and axial planes: deviated perpendicular plate of the ethmoid to the right (arrow), straight anterior nasal spine

4.2.3 Nasal Vault, Septum, and Skull Base The axial and coronal plane views of each slice is inspected to identify the midline using a vertical marker (Fig. 4.9) and to locate the corresponding sagittal slice passing through the midline of the PPE (Fig. 4.10).

The following points are identified [5, 6] (Fig. 4.10): –– Trans-Radix osteotomy point (TROP) line passing through the trans-radix osteotomy point, which is considered the soft-tissue center point of transition from the glabella to the nasal bones.

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Fig. 4.9  Cone beam CT in the axial and frontal planes: multiplanar reformation for locating the relevant slice in the sagittal plane passing through the PPE

Fig. 4.10  Cone beam CT in the sagittal plane passing through the midline of the PPE

–– Thickness of the nasal bone/frontal spine at the radix. –– S-point: the most anterior and caudal point of the frontal sinus. –– O-point: the most anterior part of the cribriform plate. –– E-point: the junction between the bony and cartilaginous septum at its most cranial aspect. In previous studies, it was shown that there is considerable variation in the thickness of bone at the radix osteotomy point (2.59 mm in mean) depending on the length of the spine of

the frontal bone [5]. The nasal bone seems to be thinner and the K area position more cephalic in females [7, 8]. The mean distance from the TROP to the frontal sinus (S-Point) may be 13.58 mm (7.7–21.2), which means that the frontal sinus is on average more than 1 cm posterior to the osteotomy plane. The mean distance from the TROP to the O-point may be 28.67 mm (7.7–21.2) which means that the cribriform plate is on average more than 2 cm posterior to the transverse radix osteotomy plane [5, 7, 8]. The mean distance from the TROP to the E-point is 7.25 mm (−19.2 to +5.22 mm). It means that the subdorsal junction between quadrangular cartilage and PPE (E-point) is often located posterior to the TROP, so the septum is most of the time cartilaginous below where the radix osteotomy is performed [5]. Thereby, the analysis of this slice enables the surgeon to check the relationship between the area of the transverse osteotomy and the surrounding structures such as the frontal sinuses, PPE, and skull base.

4.2.4 Paranasal Sinuses, and Lacrimal Ducts The fourth main interest of the pre-operative CBCT or CT scan may be the exploration of the nasal surroundings such as the paranasal sinuses, and the lacrimal ducts (Figs. 4.11 and 4.12).

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Fig. 4.11  CBCT in the axial plane showing: the maxillary sinuses (blue), lacrimal ducts (yellow), sphenoid sinus (red), ethmoid sinuses (orange)

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Fig. 4.12  Cone beam CT in the frontal plane showing: the maxillary sinuses (blue), ethmoid sinuses (orange), and frontal sinuses (green)

4.3 Comments 4.3.1 3D Analysis The images were exported for analysis using a triplanar DICOM reader software: InVesalius 3.1.1 (Renato Archer Information Technology Center, Brazil). itk-SNAP 3.x (Penn Image Computing and Science Laboratory, University of Pennsylvania and Scientific Computing and Imaging Institute, University of Utah, USA).

4.3.1.1 Multiplanar Reformation Multiplanar reformation or reconstruction (MPR) involves the process of converting data from an imaging modality acquired in a certain plane, usually axial, into another plane. The acquired data, for example, from the axial plane, can then be converted to non-axial planes such as coronal, sagittal, or oblique. It may be interesting to locate a structure in 3D, for instance, the vomerine spur (Fig. 4.13).

4.3.2 3D Layered Volume Rendering 3D rendering uses multiple thin sections of images and reconstructs them into 3D images, which can enhance visualization of structures, shapes, axes. This technology may

also be referred to as 3D reconstruction or 3D reformation (Figs. 4.14 and 4.15). The thickness and shape of nasal bones may differ considerably from one patient to another [9]. CBCT or CT scan with 3D reconstruction may easily elucidate the different kind of nasal bones (Fig.  4.16). This may be of interest to surgeons in order to choose the better option for the dorsum, especially if a bone reshaping with rasps or rhinosculpting with piezo instruments is considered. Furthermore, 3D reconstruction enables the nasal parentheses (i.e., the width of the base of the bony pyramid) to be checked and to confirm if a refinement of this part is needed. Regarding the profile of the nasal dorsum, the nasal bones comprise the radix and the bony dorsum, and are often quite thin but fused on top of the spine of the frontal bone. Underneath these, there is either a cranial extension of the cartilaginous septum or the thin perpendicular plate of the ethmoid. The dorsal septum determines the support of a new dorsum in preservation rhinoplasty. By lowering the septal height, flexion occurs at the central keystone, producing a flatter bridge from a previous convex shape. A CBCT or CT scan can show the thickness and caudal extent of the bony cap and therefore help to determine if the area will flex or if the bony cap should be removed to create a cartilaginous dorsum (type 1 vs. type 2 in Saban’s classification). Furthermore, it is helpful to visualize the profile shape of the nasal bones: V-shaped or S-shaped nasal bone configuration [10, 11]. By understanding the different anatomical configurations of the nasal bones, rhinoplasty surgeons can better plan their operations within the radix and bony dorsum: preservation or not.

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Fig. 4.13  Multiplanar reformation mode: location of the vomerine spur

Fig. 4.14  Pre-operative 3/4 view, 3D volume rendering: surface aesthetics, bones, and soft tissues

One thing may be confusing about the nasion point, which corresponds to the suture between the nasal process of the frontal bone and the nasal bones [12]. The “nasion cutaneous point” actually corresponds to the bony sellion point, which is the deepest bony depression

at the root of the nose [13, 14]. The nasion to the sellion represents the radix whereas the caudal bone, the sellion to the rhinion, represents the bony dorsum. Thus, the profile shape configurations refer only to the bony landmarks (Fig. 4.17).

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Fig. 4.15  Pre-operative frontal view, surface aesthetics, and nasal parentheses (dotted lines)

Fig. 4.16  Nasal bone characteristics

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Fig. 4.17  Nasal dorsum profile landmarks

4.4 Conclusion Pyriform aperture dimensions, nasal sidewall anatomy, dorsal anatomy, and septal anatomy are all readily assessed, as well as any abnormalities involving the turbinates and paranasal sinuses. Thus, CBCT or CT scans may be helpful to the surgeon in planning the most appropriate modification of modern rhinoplasty. The diagnostic value of a CBCT or CT scan cannot be underestimated, and it should reassure the surgeon, particularly with respect to the skull base. The surface images will also strengthen aesthetic analysis. The passage from a two-dimensional analysis to a threedimensional analysis thanks to 3D reconstructions offers to surgeons new applications (Fig. 4.18, 4.19 and 4.20). Fig. 4.18  Frontal section of the nose

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Fig. 4.19  Pre-operative frontal view, and 6 weeks post-operatively (right). The patient was operated on by Dr. Valerio Finocchi, at the Preservation Rhinoplasty Meeting 2022 in Nice, France

Fig. 4.20  Pre-operative profile view, and 6 weeks post-operatively (right). The patient was operated on by Dr. Valerio Finocchi, at the Preservation Rhinoplasty Meeting 2022 in Nice, France

References 1. Durand PD.  Discussion: cone-beam computed tomography: a user-friendly, practical roadmap to the planning and execution of every rhinoplasty—a 5-year review. Plast Reconstr Surg. 2021;147(5):763e–4e. https://doi.org/10.1097/ PRS.0000000000007912. 2. Saban Y, de Salvador S.  Guidelines for dorsum preservation in primary rhinoplasty. Facial Plast Surg. 2021;37(1):53–64. https:// doi.org/10.1055/s-­0041-­1723827. 3. Saban Y, Polselli R. Atlas d’anatomie Chirurgicale de La Face et Du Cou, vol. 1. Acta Medica; 2009. (French, Italian).

4. Jankowski R.  Septoplastie et Rhinoplastie Par Désarticulation. Elsevier Masson; 2016. 5. Sadri A, East C, Badia L, Saban Y. Dorsal preservation rhinoplasty: cone beam computed tomography analysis of the nasal vault, septum, and skull base—its role in surgical planning. Facial Plast Surg. 2020;36(3):329–34. https://doi.org/10.1055/s-­0040-­1712538. 6. Patron V, Hitier M. Chirurgie Endoscopique Endonasale. Elsevier Masson; 2021. 7. Eravci FC, Özer H, Arbağ H, Eryilmaz MA, Aricigil M, Dündar MA.  Computed tomography analysis of nasal anatomy in dorsal preservation rhinoplasty. Aesthet Surg J. 2022;42(3):249–56. https://doi.org/10.1093/asj/sjab326.

4  Cone-Beam CT or CT Scan Analysis for Routine Pre-Operative Planning Before Rhinoplasty 8. Most SP.  Commentary on: computed tomography analysis of nasal anatomy in dorsal preservation rhinoplasty. Aesthet Surg J. 2022;42(3):257–60. https://doi.org/10.1093/asj/sjab346. 9. Daniel RK, Palhazi P. Rhinoplasty: an anatomical and clinical atlas. Berlin: Springer; 2018. 10. Lazovic GD, Daniel RK, Janosevic LB, Kosanovic RM, Colic MM, Kosins AM. Rhinoplasty: the nasal bones - anatomy and analysis. Aesthet Surg J. 2015;35(3):255–63. https://doi.org/10.1093/asj/ sju050. 11. Gruber RP, Gupta D.  Commentary on: rhinoplasty: the nasal bones—anatomy and analysis. Aesthet Surg J. 2015;35(3):264. https://doi.org/10.1093/asj/sju061.

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12. Saban Y, Baldini N, Alomani M, Fonseca E.  Commentary on: Rhinoplasty: the nasal bones—anatomy and analysis. Aesthet Surg J. 2022. 13. Saban Y.  CBCT before rhinoplasty. Presented at Bergamo Open Rhinoplasty Meeting; 2014. 14. Robotti E, Daniel RK, Leone F.  Cone-beam computed tomography: a user-friendly, practical roadmap to the planning and execution of every rhinoplasty—a 5-year review. Plast Reconstr Surg. 2021;147(5):749e–62e. https://doi.org/10.1097/ PRS.0000000000007900.

5

Surgical Steps in Dorsal Preservation Erhan Coşkun and Barış Çakir

Preservation rhinoplasty (PR) has been gaining popularity among rhinoplasty surgeons since Dr. Daniel introduced this term [1]. The technique is evolving and many variations have been proposed. The term total dorsal preservation (TDP) represents changing the nasal dorsal shape by preservation of the nasal bones and upper lateral cartilages together as a unite. Cartilage only dorsal preservation (CODP) on the other hand is preservation of only the dorsal cartilages but manipulating the nasal bones similar to structural rhinoplasty [2]. Both of these techniques can be done by low septal strip, high septal strip, or intermediate septal strip septoplasty techniques [3–5]. Our purpose in writing this chapter is to guide surgeons through the important steps of the most commonly used dorsal preservation (DP) techniques with detailed explanations.

5.1 Presurgical Assessment 5.1.1 How to Choose Between TDP and CODP The indications of DP techniques are well described in several publications yet they may change according to surgeons’ personal experiences. Generally, indications suggest nasal bones to be not too wide, not too thin from the frontal view, from the side view straight or V shaped is preferred instead of S shape, radix position would not be too high or too low. Some surgeons may use tools like rasps,

E. Coşkun (*) Private Practice, Şişli, İstanbul, Turkey Plastic Reconstructive and Aesthetic Surgery, Florence Nightingale Gayrettepe Hospital, Beşiktaş, Istanbul, Turkey B. Çakir Private Practice, Şişli, İstanbul, Turkey Plastic Reconstructive and Aesthetic Surgery, American Hospital, Şişli, Istanbul, Turkey

sharp needlelike osteotomes or electric-powered devices to further shape the bones, also would use more grafts for the supratip or radix area to extend the indications of TDP. We are using special bone rasps to shape the nasal bones to some extent while trying to keep the need of grafting to radix or supratip area as low as possible in TDP. Below you will find pictures of different nasal dorsal aesthetic lines of different patients and we will try to explain why we have chosen that technique for the case. This patient’s dorsal aesthetic lines have good thickness from the frontal and dorsal view, almost straight dorsum from the side view (Figs. 5.1 and 5.2). She had a TDP with low septal strip, closed polygon tipplasty. 20  days after surgery (Figs. 5.1, 5.2, 5.3, and 5.4). This patient on the other hand had a S-shaped dorsum with a convex prominent bony cap and long nasal bones with low radix (Figs. 5.5 and 5.6). She had a CODP with bony cap rasp with low septal strip, closed polygon tipplasty. Her preop and 3  months postop result (Figs.  5.5, 5.6, 5.7, and 5.8). This patient has broad nasal dorsum on the roof also on the base with thick bones from the frontal view (Figs. 5.9 and 5.10). She had CODP without bony cap, closed polygon tipplasty. Nasal bones are rasped. Her before and 9 months results (Figs. 5.9, 5.10, 5.11, and 5.12). Tip: Physical examination and tissue characteristics give us a clue on which DP method to choose, but our final decision is made in the surgery which will be explained with more details below.

5.1.2 How to Choose Dissection Plane When we do physical examination of the nose, we categorize patients according to skin, soft tissue, and cartilage features such as, thin, medium, thick skin, loose connective tissue, firm connective tissue, weak, medium, strong cartilage strength. If a patient has thin skin and good cartilage strength, subperichondiral dissection is preferred [6]. We usually

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Poignonec (ed.), Clinical Atlas of Preservation Rhinoplasty, https://doi.org/10.1007/978-3-031-29977-3_5

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Fig. 5.1  Frontal view before and 20 days after surgery

Fig. 5.2  Dorsal aesthetic lines

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Fig. 5.3  Lateral view

Fig. 5.4  Lateral oblique view

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Fig. 5.5  Frontal view before and 3 months after the surgery

Fig. 5.6  Dorsal aesthetic lines

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Fig. 5.7  Lateral view

Fig. 5.8  Lateral oblique view

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Fig. 5.9  Frontal view before and 9 months after the surgery

Fig. 5.10  Dorsal aesthetic lines

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Fig. 5.11  Lateral view

Fig. 5.12  Lateral oblique view

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Fig. 5.13  Frontal view of susceptible weak tip cartilages

Fig. 5.14  Lateral crura cephalic border is indistinct in the lateral oblique view of the patient

prefer subsmass dissection for tip if a patient has weak tip cartilages [7]. A weak tip cartilage can be suspected with touching the nose and examining with eye. In this case, the cephalic and caudal borders of the lateral crura is imperceptible, middle crura is thin (Figs.  5.13, 5.14, and 5.15). Also, weak tip cartilages can be felt with palpation.

In this case, we preferred subsmass dissection for tip. Leaving the perichondrium on the weak tip cartilage increases the resistance and makes the cartilages more pliable to shaping with sutures. Here is another case, the cephalic and caudal borders of lower lateral cartilage are indistinctive despite being thin skin (Figs. 5.16, 5.17, and 5.18).

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Fig. 5.15  Lateral view of the patient shows mild alar retraction probably due to weak lateral crura cartilages

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Fig. 5.16  Frontal view

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Fig. 5.17  Lateral oblique view of the patient

Fig. 5.18  Lateral view of the patient shows mild alar retraction similar to the previous case

The tip feels floppy when examined with fingers. So we chose a supraperichondrial dissection. The final decision of the tip dissection plane can be given right after the infracartilagenous incision is made. The cartilage thickness and strength may be felt more precisely at this moment.

5.2 Surgery Here the steps in DP will be discussed briefly as in the surgical order. Tricky points and safety issue in these surgical steps will be mentioned as much as possible.

5.2.1 Transfixion Incision Our first incision is transfixion with a small backcut through intracartilagenous incision on both sides. The mucosa incision is kept about 4  mm away from the caudal septal edge to preserve enough blood supply to the mucosa flap between infracartilagenous and transfixion incisions (Fig. 5.19). The backcut is not more than 4–5 mm (Fig. 5.20).

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5.2.2 Septum Dissection Caudal septum is dissected using Daniel-Çakır elevator subperichondrially (Fig. 5.21). After 1 to 2 cm of caudal septum is dissected with sharp tip, blunt-tipped Daniel-Çakır elevator is used for the rest of the septal dissection. In low septal strip wide dissection of septum is necessary. Tip: In low septal strip, quadrangular cartilage and upper lateral cartilages are in continuity with each other. Subperichondrial septal dissection around the upper lateral-­ septum junction area should be done in a limited manner to preserve this junction safely.

5.2.3 W Point and Upper Lateral Caudal Dissection Septal subperichondrial dissection should be completed all the way up the W point. Holding the nostril cephalically with Crile retractor in one hand, sharp-tipped, curved scissors are used to dissect soft tissue and find the subperichondrial plane (Fig. 5.22).

Fig. 5.20  Transfixion incision is continued with a small backcut

Fig. 5.21  Caudal septum is dissected using Daniel-Çakır elevator subperichondrially

Fig. 5.19  The transfixion incision starts about 4 mm posteriorly from the caudal septal edge Fig. 5.22  Finding the subperichondrial plane over the W point

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This maneuver should be done gently otherwise upper laterals can separate from septum. After finding the subperichondrial plane, an elevator is used to dissect 1–2 cm caudal part of the upper lateral cartilages until the scroll area.

5.2.4 Infracartilagenous Incision, Lower Lateral Cartilage Dissection Right after reaching the scroll area, we stop dissection over W point and pick up double hook and start infracartilagenous incisions. First marking is done (Fig. 5.23). Tip: We do not follow the cartilage border after passing the lateral crura turning point. Instead, we continue incision in a straight line about 5 to 7 mm more toward the alar base (Fig. 5.24). We find this incision useful for correcting lateral crura tail problems such as inverted cartilage or cephalic malposition. Also easier to dissect a pouch and suture lateral crura onlay graft to treat nasal valve collapse problem. If the patient has caudal excess, we usually leave auto-rim flap up to utmost 1.5 mm cephalic to the incisions.

Fig. 5.24  Marking for the incision does not follow the cartilage border. It continues in a straight line after passing the turning point

5.2.4.1 Subperichondrial Dissection Fine-tipped double hook is given to the nurse holding the mucosa right under lateral crura turning point. Fifteen1 blades may be used gently to make a fine incision to the perichondrium (Fig. 5.25).

Fig. 5.25  Lateral crura turning point would be the point of entry to the subperichondrial layer

Fig. 5.23  First lower lateral cartilage lateral crura caudal border is marked

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With a fine-tipped instrument or with sharp scissors, subperichondrial plane is reached (Fig. 5.26). Daniel-Çakır sharp-tipped perichondrium elevator is used to dissect lateral crura (Fig. 5.27). Tip: Usually the hardest part of lower lateral subperichondrial dissection is passing from lateral crura to middle crura. If you feel a resistance here with your perichondrium elevator, instead of forcing with the perichondrium elevator to pass the resistance point,

using the scissors is safer not to damage the cartilage or mucosa (Fig. 5.28). At this point, the double-hook position should be changed from turning point mucosa to a closer point to the dissection area (Fig. 5.29). Feeling the cartilage with the tip of the scissors and doing very tiny cuts for 2–3 mm frees the resistance and then it is easier to go on with the dissector all the way down to the footplates (Figs. 5.30, 5.31, and 5.32).

Fig. 5.26  Sharp scissors is used to reach the subperichondrial plane

Fig. 5.28  The resistance can be felt with the perichondrium elevator close to the domes

Fig. 5.27  Sharp-tipped Daniel-Çakır elevator is used to dissect lateral crura

Fig. 5.29  The double hook is changed closer to the dissection and pulled toward the lateral canthus

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Figs. 5.30 and 5.31  Using the tip of sharp scissors to pass the resistance point while turning from lateral crura to medial crura

5.2.5 Opening the Scroll Area to Unite Two Dissection Zones

Fig. 5.32  After passing the resistance point, the elevator may be used to complete the lower lateral crura dissection

5.2.4.2 Subareolar Dissection If subareolar dissection is planed, the dissection is started from the turning point of lateral crura. We use the back of the scalpel to find the cartilage. The perichondrium is kept intact on the cartilages. The sharp Daniel-Çakır perichondrium elevator is used for the dissection. Subareolar dissection is usually faster and easier compared to subperichondrial dissection.

Crile retractor is hold pulling the rim with the aid of finger behind the skin and with the other hand elevator is used to push the cephalic part of the lateral crura downward (Fig.  5.33). A window will open between upper lateral cartilage and lower lateral cartilage dissection zones (Fig. 5.34). Tip: This maneuver works better if upper lateral caudal part and lower lateral dissection planes are both subperichondrial. If lower lateral cartilage dissection is subareolar, instead of forcing to unite the two dissection planes by pushing the lateral crura down, sharp-tipped scissors can be used. Otherwise subareolar plane dissection will extend to the dorsum which will lead unwanted two separate dissection planes such as subperichondrial and subareolar. Instead, using the tip of the scissors faces the caudal edge of the upper lateral cartilage and dissecting gently by pushing the soft tissue will unite lower lateral subareolar and upper lateral subperichondrial dissection planes easier.

5.2.6 Dorsum Dissection 5.2.6.1 Limited Dorsal Dissection The indications would be good radix position, good dorsal aesthetic lines without any need of nasal bone rasping or dorsal reshaping. Otherwise we prefer wide dissection. For Ishida cases we experienced widening of the nasal bones with limited dissection in big dorsal humps probably due to the soft tissue re-draping problems.

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Figs. 5.33 and 5.34  Dissection of the scroll area

Fig. 5.35 The elevator is advanced medially until the pitanguy ligament tension is felt

Fig. 5.36 Use sharp scissors to complete the infracartilagenous incision

5.2.6.2 Wide Dorsal Dissection Dorsal dissection starts with opening the vertical scroll ligament. The elevator is advanced medially until the pitanguy ligament tension is felt (Fig.  5.35). Medial dissection is completed at this point.

Then dissection is carried out all the way to the nasal bone upper lateral cartilage junction cranially. The lateral border of the dissection is completed all the way down to the piriform aperture. Tip: It is important to dissect the lateral crura tail and the dorsal soft tissue lateral to the upper lateral cartilage lateral border especially in big dorsal humps (Fig. 5.36). Otherwise,

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Figs. 5.37 and 5.38  Using the scissor and the dissector to complete lateral dorsal dissection

Figs. 5.39 and 5.40  Bone edge is scratched by bone elevator, and subperiosteal plane is found

the soft tissue redrape would not be sufficient causing dorsal widening. This wide dissection also allows to do the bony work with a superior vision. Figure: Use the tip of the scissor by opening it to dissect the skin and soft tissue envelope over the lateral border of the lateral crura (Fig. 5.37). Complete the lateral dorsal dissection with the elevator (Fig. 5.38). Start the bone dissection either by scratching the bone edge with the bone elevator or by using the scalpel to incise at the nasal bone border (Figs. 5.39 and 5.40). The dissection is completed on both sides laterally until passing the lateral osteotomy lines, cranially to the transverse

osteotomy lines. Thae the two dissection planes are joined by dissection of the bony cap and dorsal nasal bone. Dorsal nasal bone dissection is stopped passing the radix osteotomy line. Tip: If the radix position is in the right place, it is not necessary to extend the dorsal dissection after the bony cap dissection.

5.2.6.3 Taking Out the Low Septal Strip First use a scalpel to start low septal strip and continue with straight lateral osteotome to cut the quadrangular cartilage (Figs. 5.41 and 5.42).

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Figs. 5.41 and 5.42  A scalpel is used to start the low septal strip cut

Figs. 5.43 and 5.44  Straight 3 mm lateral osteotome is used to complete the low septal strip cut

Tip: Care should be taken not to take out too much cartilage at once. The scalpel position may change according to the desired supratip dorsal height. If it is low and needs to be elevated, the scalpel should be placed lower than the septum anterior nasal spine junction. In all cases, carefully take less than planed but also make sure to secure enough

size for a strong columellar strut. You may take more low strip if necessary at the end of the surgery. After the first incision started with the scalpel, the straight lateral osteotome is pushed obliquely cutting the low septal strip until the vomer bone is felt with the tip of the osteotome (Figs. 5.43 and 5.44).

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Fig. 5.45  A sharp elevator is used to separate the low septal strip from the maxillary crest

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Fig. 5.46  Low septal strip is taken out after completing the separation from maxillary crest and vomer bone

Use the sharp edge of Daniel-Çakır elevator to dissect the lower connection of the low strip from the maxillary crest (Fig. 5.45). Dissect the attachment of low septal strip from the vomer bone. Take the low strip out with a forceps (Fig. 5.46).

5.2.7 Vertical Septal Cut The vertical cut is started from the highest point of the dorsal hump and follow a straight line perpendicular to the dorsum. It is important to leave the septum as big as possible. A fine needle can be inserted from the highest point to see the correspondence on the septum or the elevator can be felt with finger palpation from the dorsum to decide where to start the cut (Fig. 5.47). Tip: Do not try to cut the septum at once, instead start with scoring all the way down and continue scoring maneuver until it is actually cut full thickness. It is safer to start the full thickness cut closer to the dorsum and complete the deep part (Figs. 5.48, 5.49, and 5.50). If the full thickness cut is started deeper and the sharp elevator is pushed up to the dorsum to complete the cut, the elevator may shear the septum caudally causing total detachment of the septum from the upper lateral cartilages. Tip: Always check if the cut is completed all the way up (Fig.  5.51). If not, the dorsum might have resistance to go

Fig. 5.47  The elevator can be felt with finger palpation from the dorsum to decide where to start the cut

down to the desired shape due to the intact septal piece. A sharp scissor can also be used facing the tip up. In most of the cases, vertical cut leaves some part of the quadrangular cartilage attached to the perpendicular plate. This

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Figs. 5.48 and 5.49  It is safer to score with a sharp elevator first, all the way down the quadrangular cartilage so the cut can be precise following this scored area

Fig. 5.50  The full thickness cut is completed all the way down starting closer to the dorsum

Fig. 5.51  It is important to check if the vertical cut is completed all the way up

area can be used to take additional cartilage grafts. The vertical cut may be done directly from the quadrangular cartilage perpendicular plate junction to preserve the quadrangular cartilage as big as possible. But in this case if you need extra cartilage graft, it should be taken from the mobile quadrangular cartilage. It is technically more challenging to take a piece from a mobile cartilage.

Tip: There should be a gap in between quadrangular cartilage and remaining septum. If they overlap each other, dorsum may be pushed to one side. In order to prevent this, another cut should be done cephalic to the vertical cut if that part is still cartilage. If this area is cartilage, sharp perichondrium elevator can be used to take a strip as done in vertical cut (Figs. 5.52 and 5.53). This cartilage can be used as additional graft material (Fig. 5.54).

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Figs. 5.52 and 5.53  If the remaining septum behind the vertical cut is cartilage, a sharp elevator can be used to take another strip

is recommended here not to damage the perpendicular plate cranial base junction.

5.2.8 High Septal Strip Cranial to Vertical Cut As shown in Fig. 5.57, a high strip cephalic to the vertical cut should be taken in order to do both TDP or CODP. This area may be composed of the quadrangular cartilage or perpendicular plate of the ethmoid bone. If it is cartilage, sharp curved scissors can be used to make the first cut as close as possible to the dorsal roof (Fig. 5.58). Second cut can be done with a straight scissor as taking out the desired amount of piece (Fig. 5.59). Then a bayonet forceps is used to take out the cartilage piece (Fig. 5.60). Tip: Attention should be paid here not to take a piece which is more than necessary. This part is one of the limiting points protecting against a dorsal collapse either for letdown or cartilage only pushdown. If this area is composed of bone, we prefer to use a small punch to take small bites as desired amount (Fig. 5.61). Fig. 5.54  This cartilage strip can be used as additional graft material

If that part is perpendicular plate bone, we use a special punch that can remove small pieces with each bite without any torsion maneuver (Figs. 5.55 and 5.56). A strong punch

5.2.9 Bony Cap Rasp Both in TDP or CODP, we usually start with bony cap rasp. We use big-teeth steel rasps as shown below (Figs. 5.62 and 5.63).

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Figs. 5.55 and 5.56  Ayhan punch from Medisoft company is used to remove the bony part behind the vertical cut without any torsion maneuver to prevent perpendicular plate break close the cranial base

Fig. 5.57  A high strip cephalic to the vertical cut should be taken in order to do both TDP or CODP

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Fig. 5.58  A sharp, curved scissors can be used to make the first cut as close as possible to the dorsal roof

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Fig. 5.60  A bayonet forceps is used to take out the cartilage piece

Fig. 5.61  A small punch (Medicone company 2.5 mm trucut punch) is used to take small bites as desired amount

Fig. 5.59  Second cut can be done with a straight scissor to take out the desired amount of piece

Tip: Rasping the bony cap before doing CODP enables to have a smooth passage from bony hump resection side to cartilage dorsum and decreases the need to use grafting for camouflage for dorsal irregularities (Fig. 5.64). Tip: The rasping materials can be collected to use as bone dust graft at the fine-tuning step for dorsal irregularities (Fig. 5.65).

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Figs. 5.62 and 5.63  Big-teeth steel rasps (Medisoft company) is used to rasp the bony cap

Fig. 5.64  Rasping the bony cap with big-teeth steel rasp

5.2.10 Lateral Key Stone Area Dissection (Ballerina Maneuver) The upper lateral cartilages and the cartilage dorsum continue and attache inside the bony roof and nasal bones usually 1 to 2 cm (Figs. 5.66 and 5.67). Using a sharp-edged perichondrium elevator, upper lateral cartilages are dissected from nasal bones all the way down to piriform aperture. Tip: Dissection should be done all the way down to piriform aperture. The depth of the dissection may be 2–3 mm deep as shown with red mark (Figs.  5.68 and 5.69). The

Fig. 5.65  Big-teeth steel rasp collects the bone dust which may be used as graft material to camouflage dorsal irregularities

cartilage dorsum will start to mobilize after this dissection. There are strong connections between upper lateral cartilages and nasal bones 1 to 1.5 cm cephalically shown above with blue mark (Fig. 5.67). If more rotation in letdown or more cartilage pushdown needed in CODP, the depth of the dissection is increased cranially. Unnecessary dissection should be avoided especially in CODP to prevent saddling of the cartilage dorsum.

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Figs. 5.66 and 5.67  The yellow line shows the borders of the upper lateral cartilage advancing inside the nasal bones. Blue mark shows the attachments between the nasal bones and cartilage

Figs. 5.68 and 5.69  The depth of the dissection may be 2–3 mm deep as shown with red mark

5.2.11 TDP or CODP The first 11 steps explained in detail above are identical in TDP and CODP.  Now the surgeon should choose the DP technique and proceed according to the choice.

5.2.12 Bony Work for Letdown Ostectomies can be done by various instruments such as Piezo electric instruments, bone rasps, straight lateral osteotomes, rongers, hand saws, and external osteotomes.

5.2.12.1 Transverse Osteotomies We mark the skin first (Fig. 5.70). We use external 1.5 mm osteotome, holding the osteotome with one hand and using the hammer with the other hand (Fig. 5.71). Marking depends on the patient’s needs. It starts from the radix area where the dorsum needed to be narrowed. We intend to create a banana-shaped transverse osteotomy line in order to smooth the transition from the transverse osteotomy line to the lateral ostectomy. Tip: Banana-shaped transverse osteotomy helps to prevent the step deformity on the medial canthal area and ease downward motion of the nasal bones to the desired position.

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Fig. 5.70  Marking the skin for transverse osteotomies

Fig. 5.72  A convex rasp is used to thin the ostectomy sites before taking out the bones

Fig. 5.71  We use external 1.5 mm osteotome, holding the osteotome with one hand and using the hammer with the other hand

Tip: Do not start transverse osteotomies too high cephalically if the cephalic part of the radix is already in desired thickness. Start from where you want to narrow the dorsum.

5.2.12.2 Lateral Ostectomies A convex rasp is used to thin the ostectomy sites before taking out the bones (Fig. 5.72). Then we use a 3-mm straight lateral osteotome to take out bone segments as needed. First do the high osteotomy and then the lower osteotomy uniting the end points at the lowest point of the transverse osteotomy (Fig. 5.73). The ostectomy fragments are removed by bayonet forceps (Fig. 5.74). Tip: Rasping the ostectomy sites thins the bones, so bones can be taken out more precisely without causing unwanted nasal bone fractures.

Fig. 5.73  First do the high osteotomy and then the lower osteotomy uniting the end points at the lowest point of the transverse osteotomy

If the dorsum is tilted to one side, asymmetric ostectomies are done taking out more bone from the opposite site of the deviation.

5.2.12.3 Radix Ostectomy We prefer to use 1.5 mm osteotome to make the radix cut. Transverse osteotome can be inserted through the external transverse osteotomy skin incision to make the bone cut. Inside out radix osteotomy is also used if necessary. The osteotome is inserted through the transfixion incision,

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sites by leaving a 2–3  mm radix bone intact. Also limited dorsal dissection sparing the radix osteotomy site helps to create a smooth hinge movement. Tip: A true radix ostectomy is only done if the radix drop is necessary. Otherwise, a hinge should be created to prevent radix drop. Tip: High septal strip excision is also important for safety if a radix drop is not desired. The correct amount of septum or perpendicular plate left under the radix area after the high strip excision will be supportive to prevent dorsal saddling even the nasal bones mobilized totally.

5.2.13 Bony Work for CODP

Fig. 5.74  The ostectomy fragments are removed by bayonet forceps

After the bony cap rasping and ballerina maneuver, the cartilage dorsum will go down to the desired position. The nasal bones can be lowered with fine bone scissors precisely (Fig.  5.75). Then an osteotome can be used to take bone hump left on the radix area (Figs. 5.76 and 5.77). Tip: A 5-mm medicone osteotome is very useful to lower the radix bone. This osteotome has a concave side (Fig. 5.76). If the concave side is facing up it goes deep in the bone, if it is turned upside down it goes up taking bone pieces as desired amount. A straight bone rasp is used to soften the edges of the nasal bones at the end of the bony work.

5.2.13.1 Transverse Osteotomy in CODP We usually prefer to do external transverse osteotomy with 1.5  mm osteotome. First skin is marked. The planning depends on the patient’s needs. We start from where we want to narrow and go down until the planed lateral osteotomy ending point.

Fig. 5.75  The nasal bones can be lowered with fine bone scissors precisely

carefully aiming the tip of the osteotome to the desired osteotomy point. Tip: A hinge can be created on the radix osteotomy line with the inside out fracture by holding the osteotome in a 45° angle from footplate to forehead direction. Also, a hinge can be created easily with the external transverse osteotome paying attention not to unite the two transverse osteotomy

5.2.13.2 Medial Oblique Osteotomy and Ostectomy We prefer to use 3 mm straight lateral osteotome to do medial oblique osteotomy (Fig. 5.78). Tip: It is important to take a bone piece in some cases to aid open roof closure (Fig. 5.79). Otherwise after the lateral and transverse osteotomies, the nasal bone will in-fracture in the base but will open on the roof area causing rocker deformity. 5.2.13.3 Lateral Osteotomy in CODP A 3-mm straight lateral osteotome is used to do either low to low or high to low. Tip: Rasping with convex bone rasp and thinning maxilla nasal bone junction before lateral osteotomy helps to do precise bone cut. Unlike letdown, we do not dissect internal mucosa before lateral osteotomy. Intact mucosa helps for bone stability.

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Figs. 5.76 and 5.77  Medicone company 5 mm chisel is used to take bone hump left on the radix area. This chisel is concave on one side

Fig. 5.78  3 mm straight lateral osteotome from Medicone company

5.2.14 Suturing the Quadrangular Cartilage to Anterior Nasal Spine Periosteum 4-0 or 5-0 PDS suture is used to fixate the quadrangular cartilage to anterior nasal spine periosteum (Fig. 5.80). 2 or 3 sutures are enough. One suture passing from the quadrangular cartilage should be inferior to the anterior nasal spine and another one should be superior to anterior

Fig. 5.79  A bone fragment from medial oblique osteotomy side is taken to prevent rocker deformity

nasal spine in axial horizon to fix the dorsum in the desired position preventing going down or going up during the healing period. Tip: If suture is passed deep from the quadrangular cartilage, dorsum can be elevated for several millimeters and the caudal septum can be extended caudally. This affect can be used to fill the supratip saddle or to support the retracted footplate.

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5.3 Conclusion DP techniques are becoming more popular in the last several years. The popularity of this techniques may misguide the unexperienced young surgeons to think this is an easy surgery with superior results aesthetically. We believe the most important variable in rhinoplasty to achieve good aesthetic results is the time and attention the surgeon spends before, during, and after this challenging surgical procedure. With correct application of these techniques mentioned in this chapter are promising to correct septal deviations causing functional problems, as well as correcting axial dorsal deviations with minimal dorsal grafting to achieve predictable results in the long term.

References Fig. 5.80  4-0 or 5-0 PDS suture is used to fixate the quadrangular cartilage to anterior nasal spine periosteum

5.2.15 Fine-Tuning After the tip surgery is finished, fine-tuning can be done. DP techniques give the surgeon the ability to control the dorsal height up or down in millimeters to fine-tune the tip and dorsum transition at the end of surgery. Both in letdown and CODP techniques, the quadrangular cartilage is totally mobile, attached to the dorsal structures. The suture from quadrangular cartilage to anterior nasal spine periosteum can be repositioned to a lower or higher point in the quadrangular cartilage, augmenting or saddling the dorsal structures. Tip: We usually put one suture to the quadrangular cartilage to fix the dorsum after the dorsal work is done. Then tip surgery is finished. The advantage of DP over structure ­dorsal surgery is the ability to fine-tune the dorsal height with only one suture removal and resuturing.

1. Daniel RK.  The preservation rhinoplasty: a new rhinoplasty revolution. Aesthet Surg J. 2018;38(2):228–9. 2. Ishida LC. Nasal hump treatment with cartilaginous push-down and preservation of the bony cap. Aesthet Surg J. 2020;40(11):1168–78. 3. Finocchi V, Daniel RK, Palhazi P. Modified SPQR Cottle rhinoplasty. In: Preservation rhinoplasty. 3rd ed; 2020. p. 256–81. 4. Saban Y, Daniel RK, Polselli R, Trapasso M, Palhazi P.  Dorsal preservation: the push down technique reassessed. Aesthet Surg J. 2018;38(2):117–31. 5. Neves JC, Tagle DA, Dewes W, Ferraz M. A segmental approach in dorsal preservation rhinoplasty: the Tetris concept. Facial Plast Surg Clin North Am. 2021;29(1):85–99. 6. Cakir B, OreroğluAR, Doğan T,Akan M. A complete subperichondrial dissection technique for rhinoplasty with management of the nasal ligaments. Aesthet Surg J. 2012;32(5):564–74. 7. Neves JC, Zholtikov V, Cakir B, Coşkun E, Arancibia-Tagle D. Rhinoplasty dissection planes (subcutaneous, sub-SMAS, supra-­ perichondral, and sub-perichondral) and soft tissues management. Facial Plast Surg. 2021;37(1):2–11.

6

Letdown and Piezo Techniques in Preservation Rhinoplasty Abdulkadir Goksel and Khanh Ngoc Tran

6.1 Background Preservation rhinoplasty represents a growing shift in rhinoplasty philosophy toward preserving structurally sound anatomy and reshaping existing nasal structures into aesthetic and functional ideals. In rhinoplasty, the achievement of straight and smooth dorsal aesthetic lines with results that are both predictable and long lasting continues to be a challenge. The commonly used method of dorsal lowering via conventional hump resection using osteotomies and rasping causes nasal keystone area disruption, necessitating middle vault reconstruction or surface camouflage to address any ensuing irregularities. There is a growing recognition amongst surgeons that even in the best of hands, reconstruction cannot bring back the natural anatomy. Therefore, the question arises that if it is possible to achieve satisfactory functional and aesthetic results whilst preserving the natural dorsal anatomy, then why create a defect that would only need to be later repaired? Instead, why not reshape the nose by lowering the dorsal height whilst simultaneously preserving the dorsal line? This is the philosophy behind preservation rhinoplasty. The expression “preservation rhinoplasty” was first coined in a 2018 editorial by Daniel [1] to describe the three pillars of preservation surgery: dorsal, alar cartilage and soft tissue/ligamentous preservation. The most well known and studied amongst these is dorsal preservation, which dates back in the literature as far as 1899, when Goodale [2] first described it in a closed approach for dorsal hump reduction, followed by notable contributions by Lothrop [3] and Cottle Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-­3-­031-­29977-­3_6. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. A. Goksel (*) · K. N. Tran RinoIstanbul Facial Plastic Surgery Clinic, Istanbul, Turkey

[4] in the first half of the twentieth century. The hallmarks of dorsal preservation are (1) correction of the dorsal hump with simultaneous preservation of dorsal nasal architecture, including all or part of the dorsal osseocartilaginous vault, and (2) avoidance of creating an open roof deformity. Despite its century-long history, widespread adoption of dorsal preservation techniques in the past has unfortunately been slow and oftentimes stagnated, particularly with the advent of open structural rhinoplasty. Whilst it is unclear precisely why this occurred, contributing factors may have included a perception that the former technique was more difficult and that the latter was easier to learn and teach, as well as afforded greater visibility and control [5]. Recently, however, there has been a resurgence of interest in preservation techniques, resulting in the development of several new surgical methods and modifications to existing manoeuvres along with landmark publications that served to demystify, clarify and troubleshoot current preservation techniques, making it more accessible and appealing to a wider audience of surgeons [5, 6]. Furthermore, the introduction of innovative powered surgical instruments such as the piezoelectric device poses a welcome addition to the surgeon’s toolbox, particularly for lowering the bony vault in dorsal preservation surgery, especially with regards to dorsal reshaping and precise and accurate osteotomies for “letdown” and “pushdown” procedures [7]. In this chapter, we describe the various preservation rhinoplasty techniques that enable dorsal modification and preservation, via the open approach and with the assistance of piezoelectric instruments (PEIs). We outline the various indications and applications of preservation rhinoplasty surgery, describing the various advantages as well as the potential difficulties that may be encountered. Particular emphasis is given to important technical points and valuable tips to avoid potential complications. We will also be discussing limited soft tissue dissection techniques, with preservation of the ligamentous attachments and the benefits of doing so.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Poignonec (ed.), Clinical Atlas of Preservation Rhinoplasty, https://doi.org/10.1007/978-3-031-29977-3_6

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6.2 Discussion 6.2.1 Patient Selection The main rhinoplasty indication in Caucasian patients, which constitute the majority of our patients, is the nasal dorsal hump. When deciding whether a patient is suitable for dorsal preservation, the key question the surgeon must ask himself or herself is whether they wish to preserve this dorsum? The ideal candidates for dorsal preservation are primary cases where there is a predominantly cartilaginous small dorsal hump with short v-shaped nasal bones, high to normal radix, and straight dorsal aesthetic lines with linear axis deviation [6]. Narrow tension noses are also suited to this technique. Table  6.1 outlines the indications, according to the various septal techniques. In our practice, we consider (relative) contraindications to dorsal preservation to be the following: (1) difficult septoplasties (multiple fractures septum, large septal perforation, high septal or severe deviations), (2) when total or partial nasal septal reconstruction is required, (3) severe S-shaped axis deviations, (4) secondary cases, (5) patients with prior open-roof reduction rhinoplasty, and (6) patients whose angle between the nasal bone and the upper lateral cartilages (ULCs) is less than 150°. Whilst it ultimately depends on the expertise level of the surgeon and their comfort with applying preservation techniques, oftentimes the aforementioned cases may be better managed using classical structure or hybrid techniques. Having established patient suitability, the next step is to evaluate the dorsal convexity, any deviated aspects of the bony and cartilaginous dorsum and the presence of any septal pathology, before deciding upon the following key techniTable 6.1  Preservation rhinoplasty indications according to septal technique High septal strip (HSS) approach • Dorsal hump ≤4 mm • Hump is mostly cartilaginous • High septal deviation • Over-projected radix • Caudal septum is in the midline • Straight noses • V-shaped nasal bones Mid-septal strip/subdorsal flap approach • Same as HSS • Slight crooked nose Low septal strip approach • Same as HSS • If there is pathology along the connection of the ANS and maxillary crest with the septal cartilage • Crooked nose with straight dorsal aesthetic lines Bony dorsal preservation • Same as HSS • Crooked nose with straight dorsal aesthetic lines, where there is no pathology at the septal base

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cal elements: (1) the surgical approach—open versus closed—and whether ligamentous preservation is possible and if so, the extent of dissection (2) management of the septum; (3) management of the dorsum; (4) whether adjunctive procedures are needed to facilitate dorsal lowering, such as dissection of the lateral keystone area (Goksel’s ballerina manoeuvre) to prevent tissue resistance to dorsal descent and hump recurrence and bony cap removal to convert an osseocartilaginous hump into a purely cartilaginous one; (5) points of fixation to secure the mobilized osseocartilaginous vault to the underlying septum.

6.2.2 Ligamentous Preservation In open preservation rhinoplasty, it is possible to keep the ligaments partially or completely intact and where possible in our practice we endeavour to do so. Since the nasal ligaments are the main connection between the skin and the nasal skeleton, by preserving them we can reduce postoperative swelling, enable faster and more effective re­draping of the nasal skin envelope whilst oftentimes also retain the nose’s natural elasticity [8, 9]. This is particularly relevant in cases where the patient has thick skin and it is difficult to reestablish contours. In our experience, in such patients the preservation of ligamentous attachments can help to create better contours in the postoperative period [9]. The decision on whether or not ligamentous preservation is suitable is made during the patient evaluation process when we divide the patients into three groups, according to their soft tissue and dorsal deformity.

6.2.3 Group #1 These patients have good dorsal aesthetics, V-shaped nasal bones and only need reduction of the dorsal profile line. In this group, it is possible for open preservation rhinoplasty to be performed without any dorsal skin elevation, preserving most if not virtually all the nasal ligaments (Fig. 6.1a–c).

6.2.4 Group #2 These patients have good dorsal aesthetic lines yet require modifications due to the height of the bony hump. In this group, it is necessary to elevate the dorsal skin and partially dissect the ligaments Fig. 6.2a–c. We approach the dorsum via tunnels created between the deep pitanguy and vertical scroll ligament (VSL). With this manoeuvre, we can refine dorsal aesthetic lines whilst still preserving the ligaments.

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a

b

Fig. 6.1 (a–c) Group 1 dissection. The red and orange zones represent the areas dissected. The green zone is intact, with no skin elevation. (Video 6.1) A case of open preservation rhinoplasty using the subdorsal flap. We began with the open approach with inverted V-incision. Because of the patient’s beautiful dorsal anatomy, did not need to approach the dorsum and scroll ligaments and pitanguy’s ligaments were kept intact (Group 1 dissection). Supraperichondrial dissection over the lower lateral cartilages, continuing laterally to expose the pyriform aperture. We create the osteotomy tunnel for piezo osteotomy posterior to the NMSL attachment. For approaching the septum we used a hemitransfixion incision and a subdorsal tetris septal flap was utilized. On the septum, an externally inserted fine needle marked the most prominent portion of the hump and the subdorsal tetris flap was created. Posterior to the flap, cartilage was resected using a baby Rongeur immediately under the bony hump and a long piezo insert was used to

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break the relationship between the ethmoid bone and the nasal bone. Transverse osteotomies were performed using the handsaw, followed by low-to-low lateral osteotomies using the long insert and the piezo device. Webster’s triangles were resected bilaterally to prevent overlapping of the bony fragment. The periosteum on the inner surface of the maxillary bone is elevated, followed by the ballerina manoeuvre, disarticulating the lateral keystone connection from the ULCs to facilitate dorsal lowering. Radix osteotomy was performed percutaneously using a 2-mm osteotome in an oblique direction. The subdorsal flap was then secured with suture fixation once the dorsum was lowered to the desired height and quilting sutures were performed to further secure the septum and close dead space to prevent a haematoma. Following tip plasty, plasma-rich fibrin liquid and gel was prepared by harvesting blood, which was then used to stick the diced cartilage together and placed on the supratip area) (▶ https://doi.org/10.1007/000-­9pm)

c

Fig. 6.2 (a–c) Group 2 dissection. The red zone demonstrates the dissected area. The green zone is not dissected and the skin is not elevated

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Fig. 6.3 (a–c) Group 3 dissection. The red zone represents the area of dissection

process of the maxilla, for the cases in Groups #1 and #2. It is an important structure when it comes to osteotomies, notably because if this ligament can be kept intact during the piezo osteotomies, in our experience skin redraping and healing will be faster. Preservation of the NMS ligament can be achieved by creating a tunnel posterior to this ligament for the low-to-low osteotomies.

6.3 Surgical Technique 6.3.1 Skin and Soft Tissue Envelope Elevation

Fig. 6.4  The dotted line shows the NMSL on the suture line between the frontal process of the maxillary bone and the nasal bone. VPL vertical pyriform ligament

6.2.5 Group #3 In these patients, there are significant dorsal deformities; however, despite the presence of dorsal irregularities and asymmetries, the dorsum is still deemed suitable for dorsal preservation. In this group the dorsum is reshaped and preserved through total dissection of the nasal dorsum skin without any ligamentous preservation (Fig.  6.3a–c). The Pitanguy ligament and scroll ligament can be fixed at the end of the procedure. We can also preserve the nasomaxillary suture line ligament (NMSL) [9], delineated in Fig.  6.4, which is located along the suture line between the nasal bones and the frontal

For the open approach, we prefer an inverted-V incision. For dissection of the skin and superficial musculo-aponeurotic system (SMAS), it is essential to clearly establish what is the planned procedure for the nasal dorsum, as this will dictate the extent of soft tissue dissection. Group #1: If there are no intended nasal dorsum changes, we continue with the ligament preservation method without dorsal skin dissection. Group #2: For patients who require reshaping of the nasal dorsum by rasping or camouflage, we elevate the nasal skin supraperichondrially and dissect between the preserved vertical scroll ligament and Pitanguy’s ligaments. Some dorsums have S-shaped nasal bones [10], in which case we dissect the bony dorsum in the subperiosteal plane in anticipation for requisite rasping of the bony cap. It is important to note that for during skin/SMAS dissection for Groups #1 and #2, we create a subperiosteal tunnel for lateral and transverse osteotomies by approaching the

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pyriform aperture via a rim incision just lateral to the VSL and the Pitanguy’s ligament, without nasal skin elevation. The lateral tunnel should be wide enough to allow for the use of piezo instruments under direct visualization. Group #3: If extensive reshaping of both the bony and cartilaginous dorsum is deemed necessary, we cut through the Pitanguy’s ligament and the VSL, dissecting the skin in the supraperichondrial plane over the cartilaginous area and in the subperiosteal plane over the bony area. With a widened skin dissection, the extent of the dissection extends to the radix area and pyriform aperture, including the superficial portion of the medial canthal ligament, enabling sufficient access for the use of piezo instruments.

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pria, in the regions where one intends to insert a suture to later fixate the dorsum. The intact perichondrial attachment to the septum affords additional strength to the septal cartilage and reduces the risk of suture material tearing through the cartilage upon dorsal fixation. For example, with low septal strip techniques, we recommend that at least the most caudal 1 cm of septal cartilage be elevated in the supraperichondrial plane, before switching to the bloodless subperichondrial plane for the remainder of the septal dissection. If the surgeon anticipates that they will likely use an adjacent septal graft (e.g. septal extension graft, bony or cartilaginous graft to splint the caudal septum), we advise that on the side of intended grafting the septum be elevated in a subperichondrial plane, whilst on the non-graft side the perichondrium be kept intact in the regions of intended future suture fixation.

6.4.1 Approaching the Septal Cartilage

6.4.2 Septal Strip Excision

In open preservation rhinoplasty cases where the intention is to preserve all the ligaments, the septal cartilage is reached via a hemitransfixion incision. On the other hand, if the plan is to cut the Pitanguy’s ligament and make modifications on the nasal dorsum, the septum is accessed through the caudal area without an additional incision. With regards to the plane of septal dissection, we recommend adopting the strategy described by Neves [11], which involves dissecting the septal cartilage in the supraperichondrial plane, which Neves refers to as the sub-laminar plane since it lies below the lamina pro-

Prior to mobilizing the osseocartilaginous pyramid, it is necessary to first create space for the dorsal hump to be lowered, by resecting a septal strip. The main determinant of nasal dorsum lowering is not the amount of bone resected but the amount of septal strip removed. There are several established dorsal preservation septal manoeuvres for the surgeon to select from, as illustrated in Fig. 6.5a–g. They can be grouped into the following categories: (1) high septal strip/subdorsal resection (as popularized by Saban [6]), (2) mid-septal strip/ subdorsal flaps of various configurations (as per Most [12],

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Fig. 6.5  Preservation septal manoeuvres. (a) Saban HSS; subdorsal flap variations include (b) most subdorsal flap, (c) Neves tetris flap, (d) Kovacevic Z-flap; low septal techniques include (e) Cottle low septal strip and (f) Finocchi SPQR; (g) Goksel bony dorsal preservation

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Neves [13] and Kovacevic [14]), (3) low septal strip (Cottle [15] or Finocchi’s [16] “SPQR” simplified preservation quick rhinoplasty/modified Cottle) and (4) bony dorsal preservation (Goksel) [17]. Several factors influencing the choice of septal procedure, including (1) the surgeon’s experience and the technique that he/she is best accustomed to; (2) presence of septal deviation, its location and severity; (3) whether the bony pyramid is deviated (crooked nose) and (4) other indications as previously outlined in Table 6.1.

6.5 Management of the Bony Vault 6.5.1 Piezo Osteotomy/Ostectomy Piezoelectrical instruments have a well-established history in maxillofacial surgery and dentistry. It has been shown to be a precise and safe surgical instrument with good applicability also in rhinoplasty [7]. Thanks to the new generation of devices, procedures such as recontouring, rasping and cutting through the bones can be carried out much faster and with greater accuracy. Furthermore, PEI has been shown to preserve the integrity of the surrounding soft tissues and membranes and thus often prevents significant bleeding during the bone-shaping process, therein drastically reducing both postoperative bleeding and oedema [7, 18, 19]. This technique also helps to avoid potential problems associated with osteotomies using osteotomes, such as unwanted fracture lines and irregularities resulting from palpable bony spicules. Additionally, even after the bony vault has been mobilized, it is possible for to sculpt the bone without causing destabilization when using PEI. Gerbault’s publication on piezo surgery is an important resource for this subject [7, 18].

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6.5.2 Addressing the Bony Vault In preservation surgery, the bony vault can be managed in two main ways—the letdown and the pushdown procedure. In both instances, the entire bony vault is mobilized and lowered using lateral, transverse and radix osteotomies. The let­down procedure involves resecting a strip of bone is resected laterally at the facial groove so that the bony pyramid descends to sit on the ascending frontal process of the maxilla. In contrast, in the pushdown procedure, following osteotomies the bony pyramid is impacted down into the pyriform aperture with bony overlap. In our practice, we use PEIs for all our lateral osteotomies; they enable us to create delicate osteotomies at a more precise level and change the direction of the bony cuts from horizontal to sagittal, thus decreasing the bony resistance to posterior displacement during ­push­down. In both letdown and the pushdown cases, we conduct low-to-low lateral osteotomies placed as close as possible to the maxillary bone, right above the nasofacial groove, as we wish to avoid creating a visible or palpable step deformity in our patients. In our experience, straight, and angled long piezo inserts are the easiest, fastest and most precise method to achieve this. We also often prefer to use a hybrid of the pushdown/letdown procedures in our dorsal preservation cases. At the cephalic portion of the bony pyramid we perform an osteotomy (without ostectomy), which is essentially a pushdown type of manoeuvre. At the caudal portion of the nasal bony pyramid at the pyriform aperture (Webster’s triangle) we perform a triangular shaped ostectomy, thus creating a letdown (Fig. 6.6a, b). It is our preference to excise Webster’s triangle so as to prevent any potential blockage that may arise when the bone of the pyriform aperture is pushed down and overlaps with the head of the inferior turbinate attachment, which is located immediately posterior to the Webster’s triangle (Fig.  6.7).

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Fig. 6.6  Webster’s triangle. (a) In relation to lateral osteotomy, (b) following resection and push down

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The bone fragment of the inferior turbinate could potentially block the intended downward movement of the nasal bone, and such an impediment to dorsal lowering could result in an unwanted residual hump. To prevent this from occurring, we recommend that the Webster’s triangle be resected when

Fig. 6.7  Relationship between Webster’s triangle and the adjacent head of the inferior turbinate, which could be a potential blocking point during pushdown unless the Webster’s triangle is resected

Fig. 6.8  Transverse osteotomy using the Tastan-Cakir hand saw

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using the preservation technique. The PEI is an excellent way to accurately perform this specific bony resection. A recent computed tomography study has demonstrated improved patency of the nasal area with resection of this region when compared with the traditional pushdown procedure [20]. We hypothesize that the reason resection of the Webster’s triangle does not lead to internal nasal valve collapse and obstruction is likely owing to the bony support provided by the overlapped bone. In dorsal preservation surgery we typically perform osteotomies and associated manoeuvres, in the following order: 1. Transverse osteotomies: with Group #1 and Group #2 patients, where we preserve the ligaments and do not dissect the nasal dorsum, we use the combination of Tastan-­ Cakir (Microsaw Medisoft Medical) hand saws and a 2-mm external osteotome. With Group #3 patients, we carry out all the osteotomies including the transverse osteotomies with PEI (see Fig. 6.8). In our experience, in order to prevent irregularities to the radix including step deformities, it is critical that the transverse osteotomy is made at the correct level, taking the intercanthal area as a guide. If the transverse osteotomy is carried out from a level lower than the radix, such as from the beginning of the hump, the inferior radix portion might cause a step deformity or a low projected radix. 2. Low-to-low lateral osteotomies: created with the assistance of PEI with long inserts designed by the senior author. In our practice there are two options for the lateral osteotomies, depending on whether or not the bony vault is deviated. If the bony pyramid is straight and simply requires lowering, we perform bilateral osteotomies in the sagittal plane. As the two borders of the cut bones are parallel to the sagittal plane (see Fig. 6.9a, b), it makes it easier to push down the dorsum without resistance and reduces the risk of residual hump recurrence in the late postoperative period. In contrast, in the case of the crooked bony vault, asymmetrical osteotomies are performed (Fig.  6.10a, b). On the short side of the nasal bone, we make a horizontal-oblique osteotomy, to minib

Fig. 6.9 (a) Sagittal lateral osteotomies using PEI and (b) pushdown manoeuvre in the straight bony vault

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Fig. 6.10 (a) Asymmetrical lateral osteotomies using PEI, with (b) pyramid tilting to correct the deviated bony vault

mize posterior displacement. On the longer side, a sagittal osteotomy is used to allow for posterior displacement and pyramid tilting. 3. Webster’s triangle is excised bilaterally, for reasons previously mentioned, in cases where there is no bony vault deviation. However, in crooked nose correction where there is no significant hump reduction needed, Webster triangle excision is asymmetrical. On the longer side of the nasal bone, we excise Webster’s triangle completely whereas on the shorter side of the nasal bone, either a smaller wedge of Webster’s triangle is removed or it is left intact and used as a stabilizing stopper/pivot point when tilting the deviated bony pyramid. 4. The periosteum on the inner surface of the maxillary bone is elevated on both sides for the straight nose and on the longer side for the deviated nose, to create space for bony descent and to prevent tissue resistance to dorsal lowering (Fig. 6.11). We typically begin elevation at the pyriform aperture and continue cephalically. 5. Finally, radix osteotomy to connect both sides of the transverse osteotomies is performed in an oblique direction and percutaneously using a 2-mm osteotome (Fig.  6.12). Subsequently, the whole dorsum becomes mobile. In cases of an over-projected radix, following completing transverse osteotomy and lowering of the dorsum, there may be a step deformity caused by high projection of the frontal process and nasal bones. In such cases, the piezo scraper insert can be very useful for equalizing the bone level. Furthermore, for patients with an over-projected radix, it should be remembered that the sub-SMAS layer in that area might be thicker and there is also the procerus muscle adding bulk to the radix. Therefore, in cases where radix lowering requires the bone to be rasped, it would also be worthwhile to consider excising the procerus muscle, as it would further

Fig. 6.11  Elevation of periosteum along the inner surface of the maxillary bone

Fig. 6.12  Percutaneous radix osteotomy in an oblique direction

help the skin to settle, allowing us to create a more defined nasal starting point.

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6.6 Adjunctive Measures: To Control the New Shape of the Nasal Dorsum

6.6.1 Ballerina Manoeuvre (Lateral K Stone Dissection)

In order to achieve the desired dorsal lowering and prevent dorsal hump recurrence, there are several adjunctive manoeuvres that can be employed, beyond the previously described septal strip excision and bony base lowering. For example, to change the shape of the dorsal keystone area (DKA) with the high septal strip approach, the remnant dorsal cartilaginous septum can be scored to further weaken their connection. Releasing the longitudinal pyriform ligament can further mobilize the keystone area to help achieve a more concave or straighter appearance [21]. Removal of the bony cap and shaving off any prominent ULC shoulders are other additional manoeuvres to help the nasal dorsum obtain its new shape.

Apart from the release at the DKA it may also be necessary to mobilize the lateral keystone area (LKA) by releasing the LKA side wall connections (Fig.  6.13a). The ballerina manoeuvre [22], which involves separating the ULCs from the nasal bone, eliminates a potential blocking point causing resistance to nasal dorsal lowering and therefore prevents hump recurrence. The hump height and the desired shape determine the extent of lateral K stone dissection for each case. In Fig. 6.13b one can see that the blue line marks the hump, which correlates with the end point for the lateral dissection. Dissection of the LKA, the extent of lateral dissection and effective dorsal lowering can be seen in Fig. 6.13a, c, d, respectively.

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Fig. 6.13  Ballerina manoeuvre. (a) Releasing the connection between the ULCs and the nasal bones. (b) Red line represents the lateral keystone area. Blue line indicates the nasal hump and limit of lateral dissection. (c, d) Effective dorsal lowering following lateral keystone area dissection

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6.7 Fixing the New Position of the Dorsum The final step in dorsal preservation rhinoplasty is to fixate the lowered dorsum into the new position to ensure stability. The fixation method depends on the preservation septal technique used. Fixation should always occur without any tension. In mid-septal/subdorsal flap techniques fixation is with septal sutures to suture the mid-septal cartilages either end ­to ­end or overlapping, with additional transmucosal septal mattress sutures to provide further reinforcement. In contrast, in low septal strip techniques, there is a single point of fixation of the freed caudal septum to the anterior nasal spine (ANS). Our preferred method is to create a notch with a #15 blade on the middle portion of the ANS and then carefully drill a hole from one side to the other with the piezo drill insert through the body of the ANS, followed by second and third holes on either side of the notch. As opposed to standard high-speed spinning drills, the PEI drill device works with vibration, so there is no risk of catching the soft tissue. A 4–0 polydiaxonone (PDS) suture can be used to fix the septum to the ANS, passing through the three holes created (Fig. 6.14). In our experience, this method of direct fixation to the ANS bone is the most stable and reliable means of single suture fixation. High septal strip techniques require fixation between the osseocartilaginous dorsum and the underlying septum. The sutures can be placed in many different ways but the key point is that they should not be tied too tightly, in order to avoid creating middle vault distortion. It is our preference to use the criss-cross suture method for fixating the dorsum in open preservation high septal strip cases. This involves drilling a hole on both sides of the nasal bones using the piezo drill insert. The piezo drill insert can be used to perforate the nasal bones, even when they are mobile, without causing destabilization. Starting from one side a 5–0 PDS suture is passed obliquely through the nasal bone and dorsal septal cartilage, exiting at the opposite ULC.  The suture then loops upwards passing through the contralateral nasal bone drill hole, and courses obliquely again through the septum to exits by passing through ULC on the side of the starting point, and is thus secured. In Fig. 6.15a–c, an open roof is created on a cadaver (for illustrative purposes only as normally the dorsum is preserved) in order to demonstrate how the criss-cross suture traverses through the septum and osseocartilaginous vault. At the completion of the criss-cross suture, the nasal dorsum is fixed to the stable septal cartilage underneath. In the bony dorsal preservation technique, the septum is separated from its attachment to the ULCs and at the end of

Fig. 6.14  ANS fixation for low septal strip single-point fixation

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Fig. 6.15 (a–c) Criss-cross suture for HSS, fixation. For illustrative purposes an open roof has been created on this cadaver model, in order to better demonstrate how the criss-cross suture traverses through the septum and osseocartilaginous vault

the procedure delivers between the ULCs when the bony-­ cartilaginous dorsum drops down to its ideal height. After the emerged dorsal septum is trimmed to the level of the descended ULCs, the septum is reconnected to the ULCs using 6.0 PDS, thus fixating the dorsum in the process. The aforementioned techniques are demonstrated in Video 6.1.

6.8 Conclusion Preservation rhinoplasty represents a paradigm shift in rhinoplasty philosophy towards preserving and reshaping existing nasal structures. The concepts are over a century

old but has experienced a recent resurgence of clinical and academic interest, sparking improvements and refinements of existing techniques and the development of new ones. Preservation rhinoplasty is fast becoming a dynamic, complex and ever-evolving field of rhinoplasty surgery. Incorporating the open approach to preservation surgery enables greater visualization of the nasal tip and dorsum and provides greater ease of powered instrument access. Furthermore, the addition of the piezoelectric device with rhinoplasty-specific inserts serves to improve the precision and accuracy of osseocartilaginous management and dorsal fixation, thus reducing the risk of bony irregularities and optimizing the surgical outcome.

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6.9 Clinical Cases 6.9.1 Case 1 29-year-old female who underwent open preservation rhinoplasty with the assistance of the PEI. She underwent Group 2

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dissection with partial ligamentous preservation, and a subdorsal flap septal technique was used. Piezo-assisted lateral osteotomies with the long insert were made in the sagittal plane. Columella strut and suture tip plasty. Preoperative and 2 years postoperative photos.

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6.9.2 Case 2 24-year-old female who underwent open preservation rhinoplasty using the PEI. She underwent Group 2 soft tissue dissection with partial ligamentous preservation and a low

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septal strip technique was used. Columella strut and suture tip plasty. Clinical photographs are preoperative and 1 year postoperative.

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6.9.3 Case 3 28-year-old female who underwent open preservation rhinoplasty using the PEI. She had Group 1 soft tissue dissection with ligamentous preservation and a subdorsal flap septal

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technique was used. Columella strut and suture tip plasty. Clinical photographs are preoperative and 1 year postoperative.

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6.9.4 Case 4 35-year-old female who underwent open preservation rhinoplasty using the PEI. She had Group 2 soft tissue dissection with partial ligamentous preservation and a subdorsal flap

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septal technique was used. Columella strut and suture tip plasty. Clinical photographs are preoperative and 1 year postoperative.

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References 1. Daniel RK. The preservation rhinoplasty: a new rhinoplasty revolution. Aesthet Surg J. 2018;38(2):228–9. 2. Goodale RL. Joseph Lincoln Goodale, MD. 1868-1957. Trans Ann Meet Am Laryngol Assoc. 1958;79:245–6. 3. Lothrop OA. An operation for correcting the aquiline nasal deformity; the use of new instrument; report of a case. Boston Med Surg J. 1914;170(22J):835–7. 4. Cottle MH, Loring RM.  Corrective surgery of the external nasal pyramid and the nasal septum for restoration of normal physiology. Ill Med J. 1946;90:119–35. 5. Arancibia-Tagle D, Neves JC, D’Souza A. History of dorsum conservative techniques in rhinoplasty: the evolution of a revived technique. Facial Plast Surg. 2021;37:86–91. 6. Saban Y, Daniel RK, Polselli R, Trapasso M, Palhazi P.  Dorsal preservation: the push down technique reassessed. Aesthet Surg J. 2018;38:117–31. 7. Gerbault O, Daniel RK, Kosins AM. The role of piezoelectric instrumentation in rhinoplasty surgery. Aesthet Surg J. 2016;36:21–34. 8. Cakir B, Genc B. Aesthetic tip surgery with ligament preservation. In: Daniel R, Palhazi P, Saban Y, Cakir B, editors. Preservation rhinoplasty. 3rd ed. Istanbul: Septum Publishing; 2020. p. 141–66. 9. Goksel A, Saban Y, Tran KN. Biomechanical nasal anatomy applied to open preservation rhinoplasty. Facial Plast Surg. 2021;37:12–21. 10. Lazovic GD, Daniel RK, Janosevic LB, Kosanovic RM, Colic MM, Kosins AM. Rhinoplasty: the nasal bones – anatomy and analysis. Aesthet Surg J. 2015;35(3):255–63. 11. Neves JC.  Dissection planes and ligaments. Preservation Rhinoplasty Meeting. 25 February 2022. Nice, France.

A. Goksel and K. N. Tran 12. Patel PN, Abdelwahab M, Most SP.  Dorsal preservation rhinoplasty: method and outcomes of the modified subdorsal strip method. Facial Plast Surg Clin North Am. 2021;29(1):29–37. 13. Neves JC, Arancibia Tagle D, Dewes W, Ferraz M. The segmental preservation rhinoplasty: the split tetris concept. Facial Plast Surg. 2021;37(1):36–44. 14. Kovacevic M, Johannes AV, Toriumi DM. Subdorsal Z-flap: a modification of the Cottle technique in dorsal preservation rhinoplasty. Curr Opin Otolaryngol Head Neck Surg. 2021;29:244–51. 15. Cottle MH.  Nasal roof repair and hump removal. AMA Arch Otolaryngol. 1954;60(4):408–14. 16. Finnochi V.  SPQR technique: simplified preservation of quick rhinoplasty. Preservation Rhinoplasty Meeting. 2 February 2019, Nice, France. 17. Goksel A.  A new concept: structure + preservation. Intensive course: preservation and structural rhinoplasty. 9 April 2021. St Petersburg, Russia. 18. Gerbault O, Daniel RK, Palhazi P, Kosins AM. Reassessing surgical management of the bony vault in rhinoplasty. Aesthet Surg J. 2018;38:590–602. 19. Goksel A, Patel PN, Most SP. Piezoelectric osteotomies in dorsal preservation rhinoplasty. Fac Plast Surg Clin N Am. 2021;29:77–84. 20. Abdelwahab MA, Neves CA, Patel PN, et al. Impact of dorsal preservation rhinoplasty versus dorsal hump resection on the internal nasal valve: a quantitative radiological study. Aesthet Plast Surg. 2020;44(3):879–87. 21. Palhazi P, Daniel RK, Kosins AM.  The osseocartilaginous vault of the nose: anatomy and surgical observations. Aesthet Surg J. 2015;35:242–51. 22. Goksel A. Piezo assisted let down rhinoplasty. In: Daniel R, Palhazi P, Saban Y, Cakir B, editors. Preservation rhinoplasty. 3rd ed. Istanbul: Septum Publishing; 2020. p. 217–42.

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Combination of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty Sylvie Poignonec

Aim of the Chapter Why combine the techniques of structural and preservation rhinoplasty? What is a French-touch preservation rhinoplasty? How to select patients for this technique. How is French-touch preservation rhinoplasty accomplished? How I do it step by step. Surgical guide with clinical cases is given.

7.1 Introduction Dorsal preservation rhinoplasty is not a new technique; the first operation was done in 1898; Maurice Cottle popularized the “push-down” [1–3]. Yves Jallut [4] related the history of rhinoplasty. Preservation rhinoplasty involves three points: subperichondrial and subperiosteal dissection, cartilage conservation with plicature and suture instead of resection, and osseocartilaginous dorsum preservation, respecting the middle nasal vault contour and ligaments at the time of surgery. In recent years, many great surgeons such as Yves Saban [5, 6] Rolin K. Daniel [7–9], Baris Cakir [10, 11], and others have modified and improved the initial procedure. Preservation of underlying nasal anatomy may be partial or total. Complete preservation rhinoplasty with a single dissection of the soft-tissue envelope (STE) (Fig. 7.1) as a sin-

gle sheet of perichondrium and periosteum without resection and with complete dorsum preservation has very specific indications, which are not often fully realized. Dissection is often limited to prevent a weak, floating nose, to avoid external incisions, and to preserve cartilage, obviating the need for grafts. Total preservation rhinoplasty is a philosophical concept, but patient anatomical variations often require surgeons to adapt to reality. Most people are addicted to social media; we can see in Fig. 7.2 patients taking daily selfies and they are connected through all types of social networks, frequently comparing their nose with that of their peers. In the setting of rhinoplasty, patients show off their surgical results whether happy or dissatisfied. Like patients, many surgeons do the same, publishing their own before and after results through social media. Although this practice may be questionable because of the medical confidentiality or different interpretations made by on-lookers, social media provide both an audience and a marketing platform for surgeons.

Special thanks to Matt Miller, Md University of Kansas School of Medicine Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-­3-­031-­29977-­3_7. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. S. Poignonec (*) Plastic Surgery and Head and Neck Surgery, Centre Esthétique Paris - Eiffel, Paris, France

Fig. 7.1  Soft-tissue envelope, underlying superficial musculoaponeurotic system, anatomical dissection

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Poignonec (ed.), Clinical Atlas of Preservation Rhinoplasty, https://doi.org/10.1007/978-3-031-29977-3_7

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Fig. 7.2  Selfie generation

In my opinion, the closer the surgeon is to their patient’s aesthetic personality, the better they perform. That said, each patient is unique; don’t do the same nose for every patient. Preserving the existing anatomy is the best way to obtain beautiful and long-lasting results for both real and digital life.

7.2 Why Combine Structure and Preservation In specific indications, as we explain in the text below, dorsal preservation protects the natural dorsum, avoids irregularities or open-roof deformities, and cartilage conservation prevents the long-term retraction of the nostrils and the collapsed lateral alar cartilage from pinching… But for the tip, this technique is not always sufficient. We know that anticipating the long-term results, especially regarding the tip, is important. For example, patients who have a hypo-projected tip or thick skin need to have very stable tip support: in Fig.  7.3 this young patient, 8 months after a preservation rhinoplasty, complained about a slight modification of the tip with fullness of the supra-tip and the start of a polly-beak deformity. Thus, in some cases of heavy skin or dropping tip we need to graft the tip to obtain a stable result. That is why we introduced the notion of combined structural and preservation rhinoplasty.

Fig. 7.3  Modification of tip with a polly-beak deformity

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Fig. 7.4  After 20 years. Closed approach rhinoplasty; the hump has been rasped; no graft was used on the nose refinement of the skin

Patients with thin skin can develop irregularity, which appears after many years. Results of rhinoplasty may sometimes seem random, depending on the technique, patient scarring, and skin quality (Fig. 7.4). French-touch nose: in France, most of our patients ask their surgeons to keep a natural-looking nose without any appearance of surgery. This means that the nasolabial angle should be kept at around 100–110° for women, and 90° to 100° for men. Some of our patients, especially men, want to keep a straight dorsum. Nordic and white color skin is most often associated with thin or moderately thick skin; thus, the structured tip refinement and onlay grafts could be visible under the skin for months. Preservation of the STE and the cartilaginous structure is important. Tensioning and reshaping the alar cartilage are better than resecting. Roundness and softness of the tip are often better in the long term than a thin, pointy tip that is palpable under the skin.

7.3 Selection of the Patients for this Technique Dr. Rollin Daniel [7–9] said “selecting good cases will make you a happy surgeon!” Following his advice could help you throughout your surgical career. 1. First impression: Take a complete look at your patient – size, weight, dress, and attitude. Start the moment that they enter your office. Are they introverted, confident, shy, talkative, or mute? The first impression is often the best to help with patient selection. Have confidence in your own feelings. If you are unsure, ask for advice from a psychiatric colleague. At the beginning, don’t accept exceptionally difficult cases. Try to select good cases to build confidence. See patients twice or more before their surgery date. You may have different impressions after getting to know them better. You can also ask your staff nurse

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S. Poignonec Name: Surname: Date: 1)-Since how long have you been thinking about rhinoplasty or nasal surgery? 2)-Do you feel insecure about your physical appearance? Minor insecurity about my nose (slight dorsal hump) Great insecurity about my nose (too large, deviated, bothered daily) Severe insecurity about my entire appearance (I can’t even look in the mirror) 3)-Have you told your family or friends about your plans for rhinoplasty? 4)-Do you want to change your nose because it represents a family legacy (similar nose as a family member you dislike)? 5)-Do you to change because of your ethnicity 6)-Is rhinoplasty the only surgery plastic surgery you are considering? 7)-Is rhinoplasty going to improve your life? 8)-Do you have any known nasal functional disease/obstruction? 9)-Have you had any prior nasal trauma or injury? 10)-Do you have psychological troubles? 11)-have you had prior rhinoplasty?

Fig. 7.5  Rhinoplasty eligibility questionnaire

anesthesiologist about their own feelings concerning the patient. 2. Medical Questionnaire: Fig. 7.5. Completion of a medical questionnaire helps you to select your patient and save time during the consultation. Questionnaires must be filled out by patients after a 2-week minimum contemplation period. Questionnaires include the Rhinoplasty Outcomes Evaluation [10, 12] and the surgeon-specific one, which should be completed either in the waiting room or at home. Typically, questionnaires take half an hour to complete correctly; these can be adapted to your own practice and can even help with future publications.

Facial malar bone asymmetry: right flat face, asymmetrical nostrils, and facial asymmetry are very common because of many factors (facial, skeletal and muscular issues). Helping patients to see their asymmetries can prevent further frustration after the operation is finished (Figs. 7.6 and 7.7).

Severe insecurity about one’s entire appearance, especially in men who have undergone two or more prior rhinoplasties

4. Nasal analysis: first, we must appreciate the quality of the skin. Thick, seborrheic skin needs to be treated before and after surgery (collaboration with dermatology colleagues is helpful) in the case of a thick tip supraperichondrial dissection is advisable to partially de-fat the tip. For patients with thin skin sub-perichondral dissection is preferable. we must take care of post-operative skin scarring; we have to pay attention to the use of tip grafts, which could be visible and must be covered by some camouflage procedures, as described in Chap. 8.

3. Analyze the entire face: facial asymmetry is very common; but most people never notice it before surgery; photography will help you to explain your to patient that rhinoplasty will not correct this asymmetry, as mentioned by Sozen et al. [13].

Mirror (Canfield) [14] helps you to stitch two right sides and two left sides together (Fig. 7.8) Be aware of different patterns of anatomy. Because anatomy is so variable from one patient to another, technical procedures must be adapted. Every case is different. We must account for our patient’s skin quality and capacity to retract/scar on an individual basis. We all develop a baseline surgical technique that we must customize to each patient. Analysis of multiple facial angles is normal in rhinoplasty procedures. The forehead and chin must be examined for proportions. Sometimes additional procedures may help to improve the aesthetic result: chin augmentation, forehead contouring by fat grafting (Figs. 7.9 and 7.10).

7  Combination of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty ASYMETRY PREOP MUST BE DETECTED PRIOR SURGERY

Fig. 7.6  Front view pre-operatively

ASYMETRY PREOP MUST BE DETECTED PRIOR SURGERY

Fig. 7.7  Basal view pre-operatively

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Fig. 7.9  Additional procedures: 2 years post-operatively, fat grafting of the chin (3 cc) and forehead (10 cc)

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PRESERVATION RHINOPLASTY TECHNIQUES SAVE TIME FOR ADDITIONNAL AESTHETIC PROCEDURES

Fig. 7.10  Fat grafting and procedures

Frontal analysis: generally, dorsal lines are not strictly straight but wider in the K area than in the radix area. For complete dorsal preservation, dorsal lines must be regular and soft; if not, hybrid techniques could be used. The keystone region is located higher in men than in women [10, 11] (Figs. 7.11 and 7.12). Nasal bones must be carefully palpated to find out whether they are short or long; short nasal bones are easier for beginning dorsal preservation; some bones could be convex on one side and concave on the other [7–9]; this is an indication for structural rhinoplasty; the K area (see

Fig. 7.11  Dorsal lines

Abbreviations) is one of the most important parts of the nasal anatomical examination. Breathing and other functions could be studied using the Cottle test [3]; nasal valve dysfunction is studied in Chap. 9. The tip must be precisely examined and palpated; the tip’s lateral crural width and facet polygons [10, 11] can be drawn on the patient’s nose to determine the amount of cartilage to be resected. The resting angle is the angle the between upper cartilage and the lower cartilage; tip modeling and sculpture with cartilage preservation without any excisions constitute the best way to maintain function and have a beautiful aesthetic result (Figs. 7.11 and 7.12).

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S. Poignonec IDEAL RESTING ANGLE :100°

Fig. 7.12  Resting angle

7.4 Profile Analysis Facial angle analysis is explained in Fig. 7.13. The forehead and chin should be in the same vertical line; the nasofrontal angle could be deep or full; the nasolabial angle closed or open. The nasal spine must be palpated. The dorsum could be straight or convex: a kyphotic nose has an S shape or a V shape, as described by Daniel and Palhazi [7]; straight nose or V-shaped nose is ideal for preservation. • In basal analysis we look for columellar deviation, hanging columella, retracted columella, nostril asymmetry • Examination when smiling detects tip drooping; examination when opening the mouth looks for good or bad occlusion and dentition • Deep breathing detects nasal valve alar collapse using the Cottle test [11, 15] • Endonasal speculum or fibroscopic examination fully visualizes the septum, which could be straight, slightly deviated, or complexly deviated. To begin with, a straight or slightly deviated septum is easier At the end, we must know if we have a good tip support and a stable septum. If yes, the columellar strut will likely be

Fig. 7.13  Side view

enough to maintain tip projection, but in the case of poor projection or a heavy ptotic tip, a septal extension graft as described by Toriumi [15, 16] and Kosins and Daniel [17] or an ANSA banner [18] or Teostrut by Dogan [19] is advisable. • CT scans (see Chap. 4) are mandatory with significant deviation of the septum, prior nasal trauma, or full nasofrontal angle. • Photos and simulations have been explained in Chap. 3 Then, a decisional tree can be drawn (Fig. 7.14). Steps-by-step surgical approach to a standard dorsal preservation high strip primary rhinoplasty for a white nose using a closed approach (could be opened at the end of the procedure to check the tip). Good indications: • Straight narrow nose, • V-shaped nose (only one curvature), • Straight septum with deviated dorsum or slightly high deviation of the septum, • Normal radix, • Straight over-projected dorsum.

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Fig. 7.14  Decisional tree

First Impression

- Presentation - Appearance - Mental State - Completed questionnaire

Positive

- Precise Examinaon - Photo Simulaon - Radiographs scanner

Good - Total Preservation - Straight Nose - Small Dorsal Hump - High Strip or low strip - Saban(ref 5-6) - Kovacevic(ref 21) - Cottle - Neves (ref 18) Goksel (ref 26)

Intermediate - Partial Preservation - Dorsal Resection Bony cap - Middle Vault Conservation - Ishida (ref 22)

Negative - Psychological Issue - Medical Contraindicaon - Abnormal Request

Poor - Non-Preservation Technique - Overly broad nose - Prior big Trauma - Complex Deviaon - ethnic noses

Ferreira (ref 24) -kosins (17)

Bad indications: • Very deviated septum, • Secondary rhinoplasty, • Very wide dorsum, • Low radix, • Broad saddle noses. Instrumentation (Fig. 7.15): it is advisable to have your own surgical box. Specific tools are necessary: nasal double hook, angled scissors, Daniel Cakir elevator, microsaw, microrasp, cartilage cutting block with grooves, suction ­elevator, rotatable Heyman nasal scissors, Piezotome baby rongeur (Marina Medical). Positioning of the patient (Fig. 7.16) is very important: surgery is performed under general anesthesia, in a supine position with reverse Trendelenburg, eye protection with eye drops, and adhesive tape. General anesthesia is mandatory. Intubation must be positioned in the middle or laterally and the chin must be seen. Throat packing is mandatory. Drawings are made prior to infiltration: cartilage incision, desired position of the tip, and osteotomies. Patient photographs are taped on the wall in front of the surgeon, as well as any computer simulations.

Fig. 7.15 Instrumentation

Infiltration: 10 cc saline solution, 5 cc xylocaine 1%, with 5 cc Naropeine 1/4 mg adrenaline; slow infiltration is advised with frequent blood pressure checks. In the case of tachycardia, stop infiltration for few minutes. We use 5-cc syringes

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Fig. 7.16  Positioning of the patient. (Video 7.1 Installation of the patient) (▶ https://doi.org/10.1007/000-9pq)

with 25- and 30-gauge needles. It is advisable to add epinephrine a few minutes before injection and wait 15–20 min before beginning surgery to optimize hemostasis.

Surgical steps for preservation: 1. Incision 2. Sub-perichondral dissection reaching the two domes with resection of 2 mm of lower cartilage if necessary, to help the tip sculpture (von Gruber points) 3. Pitanguy window 4. Septum works: high strip 5. Osteotomies: radix, transverse, and lateral 6. Impaction 7. Fixation of osseocartilaginous vault to the underlying septum 8. Tip surgery 9. Ligament repair 10. Closures 11. Taping 1. Incision (Fig. 7.17 and Video 7.2) Closed extended marginal approach: a frank incision with a 25 blade is realized, straight intra-cartilaginous, then infra-cartilaginous 3  mm short of the domes leaving 3  mm of the lateral crura as an auto-rim flap. Incision travels low along the crura up to a few millimeters from the base of the columella.

Fig. 7.17  Incision. (Video 7.2 Incision) (▶ https://doi.org/10.1007/000-9pp)

2. Dissection: the tip of the blade will reach the perichondrium over the cartilage, which is white and bright; if the cartilage is very thin and fragile it is better to stay over the perichondrium. The Daniel Cakir elevator (Marina Medical) is useful for this step (Figs.  7.18 and 7.19; Video 7.3). Then, we reach the subperichondral and subperiosteal dissection with the Daniel Cakir elevator, which scratches the perichondrium to reach the alar cartilage (Fig. 7.18). Then, the dissection reaches the domes and lateral part of the lower cartilage. At this time, we can add a minimal resection of 3 mm of the upper part of the lower cartilage to help the rotation of the tip by sutures. 3. Then, we reach the dorsum with the Pitanguy window. 4. The high strip is done (Fig. 7.19)

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Fig. 7.18  Subperichondral dissection

Fig. 7.20  Oblique radix osteotomy. (Video 7.3 Oblique radix osteotomy) (▶ https://doi.org/10.1007/000-­9pn)

Fig. 7.19  Endoscopic view

Septal strip resection high under the dorsum is performed to separate the dorsum from the septum and flatten the dorsum. Next, submucosal septal dissection is performed. With the cartilaginous scissors, we cut 3 mm under the

upper lateral cartilage to 1 cm behind the anterior septal angle, preserving an appropriate L-strut to avoid any saddle-­nose deformity. If necessary, we use the baby-Bayer rongeur to resect a few millimeters of perpendicular plate of ethmoid (PPE). 5. Osteotomies (Fig.  7.20 and Video 7.3) to mobilize the bony pyramid can be preceded by the use of a Tastan saw [20] Transverse percutaneous osteotomies of the radix to separate the bony pyramid from the facial skeleton; we begin by a median radix osteotomy with a 2-mm bone cut osteotome. This is an oblique transverse percutaneous osteotomy to permit the bone to slide instead of dropping

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Fig. 7.22  Push-down. (Video 7.4 Push-down) (▶ https://doi.org/10.1007/000-­9pr) Fig. 7.21  Lateral osteotomies endonasal approach

vertically and avoid a radix step; next, a transverse lateral osteotomy is performed bilaterally. Then, lateral endonasal osteotomies are performed (Fig. 7.21). Carefully, we move the bones laterally before impaction. Then, the push-down is performed, pinching the bony lateral walls and pushing the nose down. 6. Impaction by push-down is done slowly and carefully (Fig. 7.22 and Video 7.4); finger impaction with excessive force may result in extended fracture on the skull base. At this moment, if we cannot push down the entire pyramid, we must perform two additional maneuvers: verification of the resection of the septum and PPE and the ballerina maneuver [25]. If it is not sufficient, we can

either add a septal strip or proceed to vertical striations of the upper septum. 7. Fixations: then we have to fix the osseocartilaginous vault to the underlying septum with resorbable monofilament PDS 4/0 suture. 8. We proceed to the tip work: the Cakir tip [10, 11] with columellar strut in white normally projected nose. In the case of a heavy tip, hypo-projected nose, Latin, or Arabic patient, we instead perform a septum extension graft, ANSA banner [18] (Fig. 7.23), or Teostrut [19]. 9. At the end of the procedure, all the dead spaces must be closed: ligaments, scroll region and Pitanguy must be sutured with Vicryl 5-0 (resorbable Vicryl suture). Doyle splints are sutured to the septum with nonresorbable 3-0 suture to be removed in 8 days A metallic hand-made splint is placed over Steri-Strips (Fig. 7.24 and Video 7.5).

7  Combination of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty

Fig. 7.24  Metallic splint. (Video (▶ https://doi.org/10.1007/000-­9ps)

Fig. 7.23  Tip work: ANSA- banner

Rhinoplasty post-operative guidelines to give to your patient: • You do not have gauze but instead have small tubes inside your nose that allow you to breath • Sleep with two pillows the first night • Use cold compresses or a cold mask to reduce swelling • The first week, avoid bending over such as when lacing shoes • No sports or gym for 1 month • No hammams or saunas for 10 days • No baths • Shower without wetting your face • No blowing your nose during the first week; instead use nasal rinses • Use serum six times per day and apply antibiotic cream at the base of your nose and inside your nostrils using a Q-tip

7.5

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Metallic

splint)

• For the first few days, do not eat hard foods • You may remove your compression stockings after a few days or the day after you start walking regularly • Keep wearing Steri-Strips on your nasal tip during the evening for 1 month • Protect your nose from heavy glasses • Protect your nose from sun for 2 months • Use sunscreen daily • Post-operative visits –– Day 8 –– Day 15 –– 3 months –– 6 months –– 1 year –– 2 years… The post-operative check-up visit must be regular and free of charge; it is important to follow your patients and to learn from your mistakes; it is important to be able to manage your own failures and do your own retouch(es)

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7.5 Clinical Cases 7.5.1 Case 1 Miss F is a 37-year-old architect with traumatic nasal history at 15 years of age She complains of a dorsal hump and left nasal obstruction in supine position only (Fig. 7.25). Front view: shows an asymmetric face (Fig. 7.26) The dorsal lines are broad with irregularities in the K area The tip is bulbous with caudal and cephalic alar cartilage excess The skin is thick; endonasal examination shows a septal deviation Side view: we notice a high and full frontonasal angle with a hypo-projected tip and a drooping tip when the patient smiles; the nasolabial angle is about 95° Basal view: shows a slight columellar deviation following a deviated septum A CT scan is mandatory (Fig. 7.27), in this case because the nasofrontal angle is very high and we need to see the distance from the skull base. Surgery (Fig.  7.28): this patient underwent an open approach with trans-columellar incision, dorsal preservation

Fig. 7.26  Clinical case 1 before surgery

Fig. 7.27  CT scan of clinical case 1

Fig. 7.25  Clinical case 1 before surgery

rhinoplasty with subperichondrial, subperiosteal dissection: the high-strip size was 7 mm long by 4 mm in height. The PPE resection was performed deeply with a rongeur because of the fullness of the radix. A push-down was realized, and

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Fig. 7.29  ANSA banner (surgical photo)

the tip was projected with an ANSA banner graft (Fig. 7.29). Tip refinement was obtained with 6-0 Prolene Gruber sutures [21]. After 1 year from the front view (Figs. 7.30 and 7.31), the patient shows a more refined nose with smooth nasal lines; from the side view, a good projection of the tip and no more hump (Figs. 7.32 and 7.33).

7.5.2 Case 2 Fig. 7.28  Surgical procedure

Miss M is a 19-year-old woman with an Algerian father She complains of a large nose with a dorsal hump, a bul-

120 Fig. 7.30  Result after 1 year: improvement of dorsal lines

Fig. 7.31  Basal view result after 1 year: good projection of the tip

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7  Combination of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty Fig. 7.32 Post-operative result after 1 year from the side view, good projection of the tip

Fig. 7.33 Post-operative result after 1 year

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Fig. 7.34  Pre-operative view

bous tip that droops when smiling, and a left nasal obstruction. Examination from the front view shows regular nasal lines, thick skin, and a bulbous tip. From the side view the nasofrontal angle is deep (Fig.  7.34), there is an S-shaped nasal hump, and a ptotic hypo-projected tip. A CT scan shows a slight septal deviation (Fig. 7.35). Surgery: a partial preservation procedure is performed (Fig. 7.36) via an open approach with a bony cap resection with a bur (Bien-Air); a low septal strip and ANSA banner septal extension graft are performed (Cakir tip). The result after 1 year shows a great improvement of the side view with opened nasolabial angle, with good projection of the tip (Figs. 7.37, 7.38, 7.39, and 7.40). From the front view, a slight widening of the dorsum is observed; improvement occurs after a few months with edema resorption (Fig. 7.37 and 7.39). Fig. 7.35  CT scan

7.5.3 Case 3 Mr D is a 22-year-old man who complains of nasal deviation after a traumatic football accident; facial asymmetry and a bulbous tip; from the front view we see a deviated nasal dorsum and nostril asymmetry (Fig. 7.41).

From a side view, the nasofrontal angle is deep, and an S-shaped hump is visible (Fig. 7.42). Surgery: a closed partial preservation rhinoplasty is performed. Septoplasty is carried out with a low strip 4-mm high-nasal spine fixation of the septum.

7  Combination of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty Fig. 7.36  Surgical procedure

Fig. 7.37  One year post-operatively

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124 Fig. 7.38  One year post-operatively

Fig. 7.39  One year post-operatively

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7  Combination of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty Fig. 7.40  One year post-operatively

Fig. 7.41  Front view

Fig. 7.42  Side view

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Hump is rasped with a tunsten rasp radix and tarnverse osteotomies are performed transcutaneously then endonasal lateral osteotomies are performed (Fig. 7.43). On the tip we create a dome suture [21]. Result after 18 months shows a good symmetry of the dorsum, best definition of the tip, despite his heavy skin (Fig. 7.44). From a columellar view there is good projection of the tip and nostril symmetrization owing to an ANSA banner graft (Fig. 7.45). From the side view, there is no longer a hump and good profile alignment (Fig. 7.46). Fig. 7.43  Surgical procedure

Fig. 7.44  Result 18 months post-operatively

S. Poignonec

7.5.4 Case 4 Miss C is a 31-year-old woman, who complains of a drooping tip when smiling and a small dorsal hump. Examination from a front view shows irregular nasal lines, a square tip, and hanging columella; from a side view a small V-shaped dorsal hump, good projection of the tip, and a prominent chin are seen (Fig. 7.47). Endonasal examination shows a slight septal deviation.

7  Combination of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty

Fig. 7.45  Columellar view: result after 18 months

Fig. 7.46  Side view 18 months post-operatively

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Fig. 7.47  Photo before surgery

Fig. 7.48  Surgical procedure

Surgery: partial preservation rhinoplasty (Fig.  7.48), K area rasping with a Piezotome is performed via an open approach, high strip, let-down, Cakir tip (columellar strut).

Result after 3 years shows regular nasal lines, there is no longer a hanging columella, there is tip refinement, and a dorsum reduction with an open nasolabial angle (Figs. 7.49, 7.50, 7.51, 7.52, and 7.53).

7  Combination of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty Fig. 7.49  Front view result after 3 years

Fig. 7.50  Basal view after 3 years

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130 Fig. 7.51  Side view pre- and post-operatively

Fig. 7.52  Side view

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7  Combination of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty Fig. 7.53  Helicopter view pre- and post-operatively

7.5.5 Case 5 A 31-year-old woman complains about a dorsal hump and over-projected tip; from the front view the dorsum is straight and narrow, but deviated from the helicopter view. From the side view, deep nasofrontal angle, hump-shaped, hyper-projected nose. A push-down preservation rhinoplasty (Fig. 7.54) is performed via an open approach with a high strip, radix osteotomy, and lateral endonasal osteotomies; Cakir tip overlapping 3 mm with the medial crus. The result after 1 year is shown in Figs. 7.55, 7.56, 7.57, 7.58, and 7.59: dorsum is in a symmetric position, the tip projection is decreased, and there is no longer a hump. Failure: could have had a nasofrontal graft to fill the nasofrontal angle.

Fig. 7.54  Surgical procedure

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132 Fig. 7.55  Before and after surgery

Fig. 7.56  Before and after surgery

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7  Combination of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty Fig. 7.57  Before and after surgery

Fig. 7.58  Before and after surgery

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Fig. 7.59  Before and after surgery

7.6 Conclusion Preservation rhinoplasty is a successful technique if the surgeon chooses the right indications that allow the best outcomes: selection of patients is based on the decisional tree. The best indications are a straight or V-shaped dorsum, a normal radix, a cartilaginous hump only, short nasal bones, and a deviated dorsum without complex septal deviation. The technique needs to be performed very precisely, respecting the chronology of the procedure: the rhinoplasty surgeon must be versatile and has to adapt this procedure to his own patients; each patient is a specific case each time. Much like a pilot before landing a plane under variable weather conditions, surgeons must also adapt their technique during the surgery. The rhinoplasty worksheet presented here is very helpful both during surgery and for following your results. This will help you to build a preoperative strategy and understand the concepts of preservation rhinoplasty. I use closed approach, as often as I can in primary cases, but during the surgical procedure I have the option to transition to an open approach if the result is not as perfect as I wish, especially on the tip. In my opinion, the assessment of dorsal reduction is better using a closed approach because the nose remains in anatomical alignment. In the case of a hypo-projected nose or heavy skin, a caudal septal extension graft could be useful, or at least columellar strut, which is often not enough to obtain a long-lasting result on the tip projection.

The combination of dorsal preservation and structural tip rhinoplasty permits surgeons to obtain both a long-lasting and natural French-touch result. Our results are natural because we are very conservative with the cartilage of the tip; we think that preserving the roundness and softness of the tip is the best way to keep the natural light reflection on the nose without looking like any surgery has taken place. Following our own patients is advisable in order to treat our own failures; it helps us to learn more about our personal technique and to keep our patients’ trust and allegiance.

References 1. Cottle MH, Loring RM. Corrective surgery of external nasal pyramid and the nasal septum for restoration of normal physiology. Ill Med J. 1946;90:119–35. 2. Cottle MH.  An introduction to conservative septum-­pyramid surgery. Int Rhinol. 1964;2:11–4. 3. Cottle MH.  Nasal roof repair and hump removal. AMA Arch Otolaryngol. 1954;60:408–14. 4. Jallut Y, Bardot J.  Naissance de la rhinoplastie en occident texte fondateurs et vrais précurseurs. Ann Chir Plast Esthet. 2021;66:107–14. 5. Saban Y, Daniel RK, Polselli R, Trapasso M, Palhazi P.  Dorsal preservation: the Push-down technique reassessed. Aesthet Surg J. 2018;38:117–31. 6. Saban Y, de Salvador S. Guidelines for dorsum preservation in primary rhinoplasty. Facial Plast Surg. 2021;37(1):53–64. https://doi. org/10.1055/s-­0041-­1723827. 7. Daniel RK, Palhazi P. The nasal ligaments and tip in rhinoplasty: an anatomical study. Aesthet Surg J. 2018;38:357–68.

7  Combination of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty 8. Daniel RK. The preservation rhinoplasty: a new rhinoplasty revolution. Aesthet Surg J. 2018;38:228–9. 9. Daniel RK, Palhazi P. Rhinoplasty: an anatomical and clinical atlas. Heidelberg: Springer; 2018. 10. Cakir B. Aesthetic septorhinoplasty. In: Di Rosa L, Cerulli G, De Pasquale A, editors. Rhinoplasty outcomes evaluation (ROE) questionnaire. Heidelberg: Springer; 2016. 11. Cakir B, Kucuker I, Aksakal IA, Sagir HO.  Auto-­ rim technique for lateral crura caudal excess treatment. Aesthet Surg J. 2017;37:24–32. 12. Di Rosa L, Cerulli G, De Pasquale A. Rhinoplasty outcomes evaluation (ROE) questionnaire. Aesthet Plast Surg. 2020;44(1):131–8. https://doi.org/10.1007/s00266-­019-­01538-­8. Epub 2019 Nov 25. PMID: 31768580. 13. Sozen T, et  al. Awareness of facial asymmetry and its impact on postoperative satisfaction of rhinoplasty patient. Aesthetic Plast Surg. 2021. PMID: 32974739. 14. Majawit LP, Wan Hassan WN, Wey MC, Mohd RR. Anthropometric study of three-dimensional facial morphology in Malay adults. PLoS One. 2016;11(10):e0164180. https:// doi.org/10.1371/journal.pone.0164180. eCollection 2016. PMID: 27706220. 15. Toriumi DM. Discussion: septum-based nasal tip plasty: a comparative study between septal extension graft and double-layered conchal cartilage extension graft. Plast Reconstr Surg. 2008;141(1):57–8. https://doi.org/10.1097/PRS.0000000000004125. 16. Toriumi D, Kovasevic M.  Dorsal preservation rhinoplasty: measures to prevent suboptimal outcomes: facial plasty surgery. Dent Clin N Am. 2021;29:141–53. 17. Kosins AM, Daniel RK.  Decision making in preservation rhinoplasty: a 100-case series with one-year follow-up. Aesthet Surg J. 2020;40:34–48.

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18. Neves JC.  Preservation rhinoplasty: an update. Facial Plast Surg. 2021;37(1):1. https://doi.org/10.1055/s-­0041-­1726413. Epub 2021 Apr 12. PMID: 338455495. 19. Dogan T. The Peruvian fisherman’s knot a new simple, and versatile self-locking sliding knot. Ann Plast Surg. 2010;64(1):128. https:// doi.org/10.1097/SAP.0b013e3181a42d65. PMID: 20023462. 20. Tastan E, Sozen T. Oblique split technique in septal reconstruction. Facial Plast Surg. 2013;29(6):487–91. https://doi.org/10.1055/s-­0033-­1360599. Epub 2013 Dec 10. PMID:24327247. 21. Kovacevic M, Buttler E, Haack S, Riedel F, Veit JA. Dorsal preservation septorhinoplasty. HNO. 2021;69(10):817–27. https:// doi.org/10.1007/s00106-­020-­00949-­3. Epub 2022 Sep 29. PMID: 32995897. 22. Ishida LC, Ishida J, Ishida LH, Tartare A, Fernandes RK, Gemperli R. Nasal hump treatment with cartilaginous push-down and preservation of the bony cap. Aesthet Surg J. 2020;40(11):1168–78. 23. Nakamura F, Luitgards BF, Ronche Ferreira JC.  Combining preservation and structured rhinoplasty: septal extension grafts and the interdomal hanger. Plast Reconstr Surg Glob Open. 2021;9(1):e3323. https://doi.org/10.1097/ GOX.0000000000003323. Collection 2021 Jan. 24. Ferreira MG, Monteiro D, Reis C, Almeida e Soussa C.  Spare roof technique: a middle third new technique. Facial Plast Surg. 2016;32:111–6. 25. Goksel A, Patel PN, Sam P.  Most piezoelectric osteotomies in dorsal preservation rhinoplasty. Facial Plast Surg Clin North Am. 2021;29(1):77–84. 26. Lazovic GD, Daniel RK, Janosevic LB, Kosanovic RM, Colic MM, Kosins AM.  Rhinoplasty: the nasal bones-anatomy and analysis. Aesthet Surg J. 2015;35:255–63.

8

Camouflage in Preservation Rhinoplasty Guillaume Carles

8.1 Background Information As all the rhinoplasty techniques, preservation rhinoplasty (PR) can be source of irregularities, pits, bumps, depressions, that must be corrected to avoid suboptimal results with subsequent unhappy patients and revision rhinoplasties. Thus, camouflage techniques should be in the rhinoplasty surgeon toolbox, beginning from the easiest technique as the “free-diced cartilage” technique to a most complex as “diced cartilage + PRF grafts.” Frequent Etiologies of Dorsal Irregularities in Preservation Rhinoplasty

Supratip saddling Middle third: distortion/irregularities of the cartilaginous vault Keystone: stair step between bony and cartilaginous dorsum (cartilage push down) Radix step: stair step in the bone section line

Fig. 8.1  Cephalic trimming. (Video 8.1 Diced cartilage creation) (▶ https://doi.org/10.1007/000-­9px)

8.2 Solid Grafts Solid graft can be used as camouflage material [1, 2]. The material must be very thin, ideally from cephalic alar resection cartilage. If the septum is used, it must be gently crushed with a Brown Adson forceps and his edges smoothed (Figs. 8.1 and 8.2). Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-­3-­031-­29977-­3_8. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. G. Carles (*) Clinique Clémentville, Montpellier, France

Fig. 8.2  Graft from cephalic trimming. (▶ https://doi.org/10.1007/000-­9pv)

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Poignonec (ed.), Clinical Atlas of Preservation Rhinoplasty, https://doi.org/10.1007/978-3-031-29977-3_8

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The drawback of those grafts is a possible postoperative displacement. The author recommends to insert those grafts, if possible, in a small pocket and/or to fix it (PDS 6/0) to avoid its mobilization.

8.3 Free-Diced Cartilage Free-diced cartilage (FDC) is made from residual cartilage, collected at the end of the intervention (Fig. 8.3) [3–5]. The cartilage will be chopped as finely as possible with a dermatome blade (Fig. 8.4, Video 8.1). The best support for dicing is a PTFE plate (example: ref I000013, Landanger, France). Using a metal or glass plate will make thin dicing more difficult. In order to avoid dispersing the material, it should be slightly moistened.

Fig. 8.5  Diced cartilage. (Video 8.5 Diced cartilage + PRF full procedure) (▶ https://doi.org/10.1007/000-­9py)

Fig. 8.3 Residual cartilage. (Video 8.3 Cartilage paste creation) (▶ https://doi.org/10.1007/000-­9pw)

Fig. 8.4  Dermatome blade. (Video 8.4 Diced cartilage + PRF large grafts) (▶ https://doi.org/10.1007/000-­9pt)

The procedure takes between 5 and 10 min, and is performed by the operating assistant while the surgeon does a step that does not require operating assistance (Fig. 8.5). Once chopped like very fine semolina, the cartilage will be passed through a 1-cc syringe via a #4 ear speculum (Fig. 8.6). The syringe should be pierced with a needle at its distal end to remove excess fluid. If the cartilage does not pass through the syringe, it means that it is not finely chopped enough (Figs. 8.7 and 8.8, Video 8.2). The “FDC trocar” device distributed by Medicon® is easy to use and has the advantage of being thinner than the syringe (Fig. 8.9). If the cartilage is chopped for a long time and very finely, it can be injected transcutaneously through an 18-gauge needle (Fig. 8.10). Free-diced cartilage has the advantage of being “quick and easy” to apply, with a volumizing effect that could be compared to an injection of hyaluronic acid and with a low resorption rate. The FDC has to be used priorly on low skin pressure areas: supratip, infralobule, on the side walls (Fig. 8.11). It should be avoided on the keystone because it is frequently visible on the long time unless it is very finely chopped and used in very low volume. The FDC has the disadvantage of being mobile. It should therefore only be used in low volume on the tip.

8  Camouflage in Preservation Rhinoplasty

Fig. 8.6  Transferring the diced cartilage via an ear speculum. (Video 8.6 Diced cartilage + PRF graft insertion) (▶ https://doi.org/10.1007/000-­9pz)

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Fig. 8.9 Medicon® FDC trocar

Fig. 8.7  Puncture of the seringue to purge excessive liquid

Fig. 8.10  Injection of ultrathin diced cartilage via an 18-gauge needle Fig. 8.8  Injection of diced cartilage

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Fig. 8.12  Creating cartilage paste with 15″ blade

Fig. 8.11  Before-after injection of 0.2 cc of diced cartilage in supratip at the end of a preservation rhinoplasty Fig. 8.13  Creating cartilage paste with 15″ blade

8.4 Cartilage Paste and Fluid Cartilage Cartilage paste is made by rasping cartilage with the edge of a 15″ blade [6, 7]. The blade must be new and must be frequently changed (Figs. 8.12 and 8.13, Video 8.3). The paste is very thin and can be injected transcutaneously via an 18-gauge needle trocar if mixed with saline solution (Fig. 8.14). Cartilage paste has the disadvantage of requiring large fragments of cartilage (at least 10 mm). It therefore finds little indication in preservation rhinoplasty.

Fig. 8.14  Transcutaneous injection via an 18-gauge needle trocar

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8.5 Diced Cartilage with PRF Plateletrich fibrin (PRF) was initially developed for use in maxillofacial surgery by Choukroun et  al. This technique creates fibrin membranes after centrifugation of patient’s blood, which can be mixed with a bone substitute, called “sticky bone” [7–10]. Kovacevic proposed to mix PRF with diced cartilage to create soft grafts in rhinoplasty [11]. Those grafts have the benefit to be easy to create without the need for a second operating site, while promoting healing through growth factors (Video 8.4). More recently, Gode demonstrated that benefits of using injectable platelet-rich fibrin (iPRF) are a diminution of postoperative edema and the reduced rate of resorption of the material compared to free diced cartilage [12, 13]. In 2020, the author created a rhinoplasty template to create thin, standardized grafts. This template is a steel plate developed in collaboration with Landanger, France, containing 11 molds allowing for a wide variety of grafts from 1 to 2 mm thickness (Fig. 8.15) [14].

Fig. 8.16  Choukroun’s centrifuge

8.5.1 DC + PRF Protocol After dicing the cartilage, the surgeon will fill the chosen mold. The most frequent molds used by the author are the 9 × 29 × 1 mm for a whole dorsal lining, and a 10 × 15 × 1-mm diamond-shaped shield graft. The blood is collected in dry tubes during the surgical procedure. In our protocol, two kinds of tubes, acquired from PRF-process (PRF-process, Nice, France) are used: plastic tubes (green) and glass tubes (red). Blood samples are taken and all tubes are centrifuged at 1300  rpm for 14  min (Figs. 8.16 and 8.17). The two keys for success are a fast blood sampling (less than 15 s/tube in our protocol) and blood refrigeration. If the sampling is not performed quickly enough, the fibrin will polymerize and the obtained product will not be usable. Both tubes must be stored in a fridge before surgery

Fig. 8.15  Carles rhinoplasty templates (Landanger France)

Fig. 8.17  Blood sampling tubes

and in a refrigerating collector during the sampling (Figs. 8.18 and 8.19). If sampling is not done fast enough, the chance of success is lower and the procedure might have to be repeated. After centrifugation, the plastic tubes (green) will provide a fluid matrix with leukocytes, platelets, and growth factors on the most superficial layer. This fluid is named iPRF. After collection from the tube using a seringue, the iPRF is injected directly on the diced cartilage to create a scaffold (Fig. 8.20). The glass tubes (red) allow a natural coagulation in the tube. This process created a leucocyte- and platelet-rich fibrin clot in the middle of the tube. This clot, called

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Fig. 8.18 Pompack® refrigerating collector (reproduced with permission from [14])

Fig. 8.21  DC + iPRF graft ready (reproduced with permission from [14])

Fig. 8.19  Blood sampling

Fig. 8.22  DC + iPRF shield graft

is crushed between 2 gauzes using a mallet in a way to create a thin and strong membrane that can be used to reinforce the diced cartilage with iPRF graft if added on top of it. After adding the aPRF membrane on top of the graft, it must be left alone for a minimum of 2 min to have the final DC + PRF graft, ready to be manipulated (Figs. 8.21 and 8.22; Video 8.5).

Fig. 8.20  Injection of iPRF on diced cartilage (reproduced with permission from [14])

“advanced PRF” (aPRF), is removed from the tube and separated from the red blood cells using a scissor. The clot

Procedure

1. Chop the cartilage as finely as possible. 2. Optional: place the chopped cartilage in a mold. 3. Prepare 3 red tubes (glass) and one green tube (plastic). The tubes must be refrigerated before the surgery and placed in a refrigerated container throughout the maneuver (Pompack®). 4. Fast blood sampling: under 15 s/tube.

8  Camouflage in Preservation Rhinoplasty

If the blood flow is low, the vein must be changed. The author suggests to start with red tubes. 5. Centrifugation with Choukroun’s protocol: 1300 rpm, 14 min. 6. Green tube: after the assistant has removed the cap from the tube, the operator will aspirate the liquid part of the tube with a needle mounted on a syringe. The liquid “iPRF” will be injected on the diced cartilage. 7. Red tubes: after the assistant has poured the contents of the tube into a cup, the operator will take the membrane, place it on a compress, then crush it with a metal plate. The crushed membrane will be placed on the diced cartilage + iPRF graft. 8. After 2 min, the graft is ready and can be sutured to the recipient site.

143 Disclosure  Dr. Carles has a conflict of interest with Landanger instruments, France.

References

1. Duron JB, Aiach G.  Greffes cartilagineuses en rhinoplastie [Cartilaginous graft in rhinoplasty]. Ann Chir Plast Esthet. 2014;59(6):447–60. https://doi.org/10.1016/j.anplas.2014.07.008. Epub 2014 Sep 8. PMID: 25213491. 2. Sheen JH.  Tip graft: a 20-year retrospective. Plast Reconstr Surg. 1993;91(1):48–63. https://doi.org/10.1097/00006534-­ 199301000-­00007. PMID: 8416539. 3. Dong W, Han R, Fan F. Diced cartilage techniques in rhinoplasty. Aesthetic Plast Surg. 2021. https://doi.org/10.1007/s00266-­021-­ 02628-­2. Epub ahead of print. PMID: 34731262. 4. Tasman AJ. Advances in nasal dorsal augmentation with diced cartilage. Curr Opin Otolaryngol Head Neck Surg. 2013;21(4):365– 71. https://doi.org/10.1097/MOO.0b013e3283627600. PMID: 23842290. 5. Daniel RK, Calvert JW. Diced cartilage grafts in rhinoplasty surgery. Plast Reconstr Surg. 2004;113(7):2156–71. https://doi. org/10.1097/01.prs.0000122544.87086.b9. PMID: 15253210. 6. Manafi A, Hamedi ZS, Manafi A, Rajabiani A, Rajaee AR, Manafi F. Injectable Cartilage Shaving: An Autologous and Long Lasting Filler Material for Correction of Minor Contour Deformities in Rhinoplasty. World J Plast Surg. 2015;4(2):93–100. 7. Choukroun J, Adda F, Schoeffler C, Vervelle A. Une opportunité en paro-implantologie: le PRF. Implantodontie. 2000;42:55–62. 8. Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, Gogly B.  Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part I: technological concepts and evolution. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101(3):37–44. https://doi.org/10.1016/j.tripleo.2005.07.008. 9. Miron RJ, Fujioka-Kobayashi M, Hernandez M, Kandalam U, Zhang Y, Ghanaati S, Choukroun J.  Injectable platelet rich fibrin (i-PRF): opportunities in regenerative dentistry? Clin Oral Investig. 2017;21(8):2619–27. https://doi.org/10.1007/s00784-­017-­2063-­9. Epub 2017 Feb 2. PMID: 28154995. 10. Dohan Ehrenfest DM, Rasmusson L, Albrektsson T. Classification of platelet concentrates: from pure platelet-rich plasma (P-PRP) to leucocyte- and platelet-rich fibrin (L-PRF). Trends Biotechnol. 2009;27(3):158–67. https://doi.org/10.1016/j.tibtech.2008.11.009. Fig. 8.23  DC + PRF dorsal graft in place Epub 2009 Jan 31. PMID: 19187989. 11. Kovacevic M, Riedel F, Wurm J, Bran GM.  Cartilage scales 8.5.2 DC + PRF in Preservation Rhinoplasty embedded in fibrin gel. Facial Plast Surg. 2017;33(2):225–32. https://doi.org/10.1055/s-­0037-­1598184. Epub 2017 Apr 7. PMID: 28388803. The best indications in preservation rhinoplasty are over-­ 12. Gode S, Ozturk A, Kısmalı E, Berber V, Turhal G.  The reduced noses, from a simple supratip saddling to a full doreffect of platelet-rich fibrin on nasal skin thickness in rhisal defect. noplasty. Facial Plast Surg. 2019;35(4):400–3. https://doi. Thereby, DC + PRF grafts can easily fill 1–2 mm defects, org/10.1055/s-­0039-­1693436. 13. Gode S, Ozturk A, Berber V, Kısmalı E. Effect of injectable platelet-­ covering the dorsal aesthetic unit (Fig. 8.23). rich fibrin on diced cartilage’s viability in rhinoplasty. Facial Plast In closed rhinoplasty, the author suggests using a transcuSurg. 2019;35(4):393–6. https://doi.org/10.1055/s-­0039-­1693035. taneous suture at the level of the radix to help positioning 14. Beaudoin PL, Carles G. Template for diced cartilage with Platelet (Video 8.6). Rich Fibrin (PRF) in rhinoplasty: an easy solution for millimetric camouflage of the full dorsal esthetic unit. Facial Plast Surg. https:// DC + PRF grafts can also be stitched to the tip as cap or doi.org/10.1055/a-­2019-­5433.

shield grafts for a mild augmentation or camouflage.

9

Functional Considerations for Preservation Rhinoplasty, Nasal Valve, and Clinical Cases Emmanuel Racy, Amanda Fanous, Grégoire d’Andrea, and Nadia Benmoussa

Key Points 1. Primary reduction rhinoplasty affects both the bony and cartilaginous dorsum as well as the bulbous tip. The nasal passage is narrowed at various points, resulting in an overall decrease in nasal airflow in particular during the inspiratory phase. It is crucial to preserve nasal valves intrinsic stiffness. 2. Anatomical and functional considerations are mandatory for all nose surgeons. 3. The modified SAC flap is a simple technique allowing tip definition while maintaining nasal airway function by preserving the crucial anatomic scroll area.

9.1 Background Information Nasal valve anatomy is particularly complex as it involves bony, cartilaginous, cutaneous, and mucosal structures. Before discussing the anatomy, it is important to understand

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-­3-­031-­29977-­3_9. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App. E. Racy (*) Maxillo Facial Surgeon, Clinique Saint Jean de dieu, Paris, France Department of Otolaryngology-Head and Neck Surgery, Adolphe-­ Rotschild Fondation, Paris, France A. Fanous Division of Facial Plastic Surgery, Department of Otolaryngology-­ Head and Neck Surgery, McGill University, Montreal, QC, Canada G. d’Andrea Department of ENT and Head and Neck Surgery, Institut Universitaire de la Face et du Cou, GCS Nice University Hospital, Antoine Lacassagne Centre, Côte d’Azur University, Nice, France N. Benmoussa Department of Head and Neck Oncology, Gustave Roussy Institut, Villejuif, France

that nasal respiration is a very abstract and subjective concept. It is quite surprising to realize during consultations that some patients with major septal deviation or valve collapse have no functional complaints. How can the absence of symptoms in the presence of such asymmetrical nasal anatomic findings be explained? In the majority of cases, these nasal deformities are congenital and appear during growth from childhood to adulthood. During this growth phase, mechanical receptors will adapt to the differing influx of air and these differences will also manifest themselves as varying sensory nerve conductions. The article by Zhao and Jiang [1] describing 22 patients denying respiratory obstruction symptoms demonstrates to what extent respiratory influx can differ in a subgroup of the population that claims to be breathing normally. Rhinoplasty surgeons are often faced with multiple requests where cosmesis seems to be center stage. However, neglecting the functional component is no longer acceptable in this day and age. Different types of requests exist: 1. Augmentation rhinoplasty: in general, these surgeries do not lead to functional impairment. 2. Post-traumatic rhinoplasty: regardless of the direction of impact, the ensuing bony and cartilaginous disruptions very often lead to functional obstructive impairment. These patients will usually have both functional and esthetic concerns. 3. Revision rhinoplasty: in this case, the patient’s request is either esthetic, functional, or both. It is very important to perform a proper nasal analysis in order to pick up on potential anatomic disruptions that may have occurred during prior surgeries, particularly in relation to the nasal valves. Of course, the surgeon should refrain from accepting the patient’s request to reduce the size of the nose even further, which will likely aggravate any existing respiratory impairments. 4. Revision rhinoplasty for cleft palate patients, in particular patients presenting both a cleft lip and palate. These cases

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Poignonec (ed.), Clinical Atlas of Preservation Rhinoplasty, https://doi.org/10.1007/978-3-031-29977-3_9

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are very complex and require a separate and well-thought-out treatment plan given the important ­ esthetic and functional concerns. 5. Primary reduction rhinoplasty (the essence of this chapter): in this case, the reduction affects both the bony and cartilaginous dorsum as well as the bulbous tip. The nasal passage is narrowed at various points, resulting in an overall decrease in nasal airflow in particular during the inspiratory phase. This narrowing will need to be compensated by other anatomical structures to avoid the apparition of obstructive symptoms (straightening a previously asymptomatic deviated nasal septum, inferior or middle turbinate reduction, etc.). Indeed, according to Bernoulli’s principle, the quality of nasal airflow on inspiration relies on both the available surface area and the resistance of the nasal passages to collapse, in particular the internal and external nasal valves. If you take a soft plastic straw and suck air through it while gradually applying more force, the straw will collapse pretty rapidly. However, if the same is done with a stiffer straw, it will take longer to achieve collapse. The same concept can be applied to the nasal valves. It is crucial to preserve their intrinsic stiffness in order to overcome the intra­ ­ thoracic negative pressure generated by the diaphragm movements and prevent collapse.

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Fig. 9.1  The nasal valves. (Video 9.1 Inspiratory collapse of the left external nasal valve in a patient suffering from a right-sided, deviated nasal septum. The external nasal valve is floppy (congenitally) and the collapse logically occurs on the side presenting a greater inspiratory force) (▶ https://doi.org/10.1007/000-­9q1)

9.2 Anatomical Considerations 9.2.1 The External Nasal Valve There are two types of valves (Fig. 9.1). The external nasal valve is formed by both cutaneous and cartilaginous components. Resistance to inspiratory collapse depends on the skin thickness and elasticity as well as the inferior border of the lower lateral cartilage (LLC). This cartilage provides resistance to collapse in two ways: its intrinsic stiffness and its position. A malposition of the LLC (higher position) will lead to a deficiency of the alar rim and an increased susceptibility to collapse (Video 9.1).

9.2.2 The Internal Nasal Valve The anatomy of the internal nasal valve is more complex and involves various anatomical structures. Firstly, the bony anatomy of the piriform aperture, which is often neglected, must be analyzed with a preoperative computed tomography scan. This is even more important in cases of cleft palate patients since there is almost systematically a narrowing of the piriform aperture on the side of the cleft. In Fig. 9.2, we can clearly see that the bony structure of the piriform aper-

Fig. 9.2  Bony malformations and their impact on the vomer and turbinates. (Video 9.2 Simulation of the resistance of the scroll area against inspiratory movements) (▶ https://doi.org/10.1007/000-­9q0)

9  Functional Considerations for Preservation Rhinoplasty, Nasal Valve, and Clinical Cases

ture poses a problem, exacerbated by the shape of the bony septum (vomer) and the inferior turbinate. The second fundamental structure is cartilaginous in nature and has been through a long history of surgical violation and destruction, due to a general ignorance of its important functional role: the scroll zone. The scroll is the transition zone between the upper lateral cartilage (ULC) and LLC, represented internally by the plica nasi. The arti-

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cle by Popko et al. [2] describes the anatomical continuity between these two structures, creating a resiliency at the level of the plica nasi (Fig. 9.3). We can assimilate the scroll zone to the longitudinal scroll ligament described by Daniel and Palhazi in their book [3]. They also described a vertical scroll ligament that can be preserved although no article in the literature has demonstrated its functional interest.

Fig. 9.3  Anatomical drawing of the continuity between the two cartilaginous structures, which together form a real spring at the level of the plica nasi. (Video 9.3 The modified SAC flap (simulation and surgery)) (▶ https://doi.org/10.1007/000-­9q2)

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Of course, muscular structures (muscle dilators) play an important role as well. Their importance becomes clearly evident in cases of facial nerve paralysis. However, these muscles are usually spared during rhinoplasty (a muscle that has been detached by sub- or supra perichondrial dissection should have no problem regaining full function). However, reduction in the height of the alar cartilages was considered mainstream for a prolonged period of time, at the expense of creating a void at the cephalic portion of the lateral crus and the functional compromise created by disarticulating the scroll. The concept of preserving this zone is the subject of many ongoing research projects, aiming at restoring harmony between reduction rhinoplasty and preservation of nasal inspiratory function. A second important zone is the junction between the septum and ULCs, forming a natural arched vault. A lack of respect for this zone following a classical hump reduction result in an inverted V deformity, created by stenosis of the junction of the septum with the ULCs. This not only significantly impairs nasal function but also poorly affects the cosmesis. Spreader grafts [4] and spreader flaps [5, 6] were invented to counter this collapse of the ULCs following hump reduction. Spreader grafts are mainly used in revision rhinoplasty since they can be harvested from donor sites other than the dorsum (septum, concha, and rib). It should be noted that the preservation techniques (push down and letdown) may not affect this septo-triangular junction zone, but some authors associate these preservation techniques with width reduction by sectioning and suturing the septo-triangular region. Currently, there exist no functional studies of these new techniques in the literature. The nasal resistance during breathing has been simulated and published in a previous article: Video 9.2 [7].

of the LLC and not only at the level of the dome. If the resection only involves the dome and does not reach the scroll area, there is no reason for a functional consequence on the internal valve. In the case of a bulbous tip, where a major reduction is required along the entire length of the lateral crus, there is a risk of destroying the scroll zone and weakening the internal valve. To avoid this, several techniques have been described in the literature. One of the first techniques described in the literature was the turn-in flap which was first described by Tellioglu and Cimen in 2007 [10]. This technique consists in turning the cephalic part of the LLC under the caudal part after having cut the scroll area to free the LLC from the ULC. It allows both reduction of the height and reinforcement of the LLC; however, cutting through the scroll and destroying the continuity between the ULC and the LLC predisposes to inspiratory collapse of the internal valve. The physiological consequences of this technique have unfortunately not been studied. Murakami et  al. also published this technique in 2009 without further physiological studies [11]. Finally, Apaydin in 2012 described this technique without sectioning the scroll which keeps the continuum between the LLC and the ULC [12]. Unfortunately, once more, no objective physiological studies (e.g., PNIF test) or subjective studies (e.g., NOSE score) exist to demonstrate the impact on the internal valve. Another technique used to preserve the internal valve at the scroll zone to reduce a bulbous tip was the sliding alar cartilage (SAC) flap described by Ozmen in 2009 which our team has modified and studied functionally more recently [7, 13].

9.3 Rhinoplasty and Nasal Valve Conservation

9.4 Description of the Technique

It is very surprising to analyze the history of internal valve preservation in primary rhinoplasty: surgeons first performed state-of-the-art reductions (e.g., Goldman Tip) and very aggressive LLC reductions before realizing the damage these techniques entail, to then repair it during a revision rhinoplasty. The first articles in the literature on the subject were not articles on the preservation of the internal valve but on the repair of internal valves destroyed by aggressive surgeries on the LLC and the scroll zone [8, 9]. Note that the scroll zone is not systematically destroyed in all primary reduction rhinoplasty. The scroll zone is only destroyed when the reduction of the LLC height for a ­bulbous tip requires a resection of a high band along the entire length

9.4.1 Modified SAC Flap [7] In 2009, Ozmen et al. first described their “SAC flap” technique, consisting of sliding the upper portion of the alar cartilage under its remaining lower portion, to refine the nasal tip while maintaining the scroll area [13]. Authors use a similar but modified technique, which he has named the modified SAC flap [7]. Although the authors acknowledge that the proper terminology for this flap is the “scroll-preserving alar sliding flap,” the decision was made to refer to the flap as the “SAC flap” in the remainder of this article for simplicity. The spreader flap and the SAC flap do not act at the same level of the internal valve. The spreader flap acts on the septum-­ ULC junction, while the SAC flap preserves the ULC-LLC zone (scroll area). Admittedly, both of these tech-

9  Functional Considerations for Preservation Rhinoplasty, Nasal Valve, and Clinical Cases

niques are involved in preserving and maintaining the integrity of the internal nasal valve. The varying degrees of action of these respective techniques is impossible to know but the authors feel that the scroll area may be the more important of the two techniques, judging from endoscopic viewing of the anatomy and expert opinion. There is a good functional outcome by the unchanged means of the NOSE and PNIF scores between preoperative and postoperative values. The modified SAC flap is a simple technique allowing tip definition while maintaining nasal airway function by preserving the crucial anatomic scroll area. It can be a valuable addition to any facial plastic surgeon’s armamentarium of procedures.

9.4.2 Operative Technique (Fig. 9.4 and Video 9.3) Infiltration using 1% xylocaine with 1:10,000 epinephrine limited to the tip and septum is performed. A standard open rhinoplasty approach is begun but this surgery can also be done by a marginal endonasal approach. A subperichondral

Fig. 9.4  The SAC flap technique: marking of the incisions. The cartilage is then divided in its mid portion. Over 1 cm of alar cartilage is preserved caudally. The excess portion of the old dome is severed. The

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dissection of the LLC is done only if the cartilage is very thick. The Pitanguy ligament is identified and cut, followed by separation of the medial crura. Two forceps are placed to spread apart the medial crura. A subperichondrial septal plane is identified and dissected. Then a structural our preservation middle vault rhinoplasty is done. After the middle vault surgery, the current dome is marked followed by marking of the desired dome location to be achieved by transposition (lateral crural steal). Marking of the ideal dome height (6–8 mm depending on individual patient characteristics) is done and measurements are taken of the amount of lateral crus to be preserved (9–11  mm depending on individual patient characteristics). Subperichondrial infiltration of the deep surface of the lateral crura is performed. The deep surface of the lateral crura is then dissected with fine scissors, with careful attention not to violate the scroll area. Although the scroll area remains untouched, a sufficiently sized pocket needs to be dissected caudally in order to receive the sliding alar cartilage flap. Potz scissors (sharp and angled) or converse scissors are used to section the LLC starting from the dome and heading laterally in order to create the SAC flap. A cranial tip suture according to the Kovacevic technique is then performed in

cephalic portion of the alar cartilage is then slid under its caudal portion. The cartilage is fixed in place by sutures

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order to plicate the domes [14]. A “U”-type 5/0 PDS stitch is then used to approximate the posterior dome. A septal cartilage graft, which is usually harvested from the septum, is inserted in between the medial crura, maintained in place by two transfixing thin needles, and sutured using two or three 5/0 PDS stitches. The SAC flap is adjusted and sutured in place with two “U”-type sutures using 5/0 PDS generally after the cranial tip sutures, depending on the cases. Suturing the SAC flap helps to fix the nasolabial angle. To fix the nasolabial angle, there are different techniques including: 1. The Haubant technique using a 5/0-PDS or polypropylen stitch placed between the columellar strut and the caudal septum. 2. The Tebbetts stitch using a 5/0-PDS or polypropylen between the septum and both part of the paradomal LLC. The Pitanguy ligament is then sutured, occasionally accompanied by skin defatting if needed. The cutaneous incision is closed using simple interrupted 6/0 prolene sutures. Two Teflon sheets are placed on either side of the septum to serve as a bolster. A thermoregulated cast in placed. A variation of this technique was described by Cakir Baris and Genç Bülent in the book Preservation Rhinoplasty third edition [15]. Through an extended marginal approach and strict subperichondral dissection, the vertical scroll ligament is freed

from its deep mucosal aspect to allow access to the cartilaginous and bony dorsum in the preservation technique. The SAC flap is made and then the ligament is sutured in its insertion zone at the end of the procedure. There have been no functional studies of this modified technique.

9.5 Conclusion There are few objective functional studies that have been able to demonstrate preservation of the internal valve function after primary reduction rhinoplasty. It is certain that the systematic physiological study of the respiratory consequences of rhinoplasty will allow better preservation of respiratory function. One of the only bulbous tip reduction techniques that has benefited from a physiological study showing preservation of the internal valve is the SAC flap.

9.6 Clinical Case Case 1 Before (top) and after 1 year (bottom) result using the modified SAC flap technique.

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Case 2 Before (top) and after 1 year (bottom) result using the modified SAC flap technique. Endoscopic view of both nasal valves: they are patent with no collapse during inspiration with this technique.

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Case 3 Before (top) and after 1 year (bottom) result using the modified SAC flap technique.

9  Functional Considerations for Preservation Rhinoplasty, Nasal Valve, and Clinical Cases

Case 4 Before (top) and after 1 year (bottom) result using the modified SAC flap technique. Endoscopic view of the

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right nasal valve: remains patent with no collapse during inspiration with this technique.

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References 1. Zhao K, Jiang J.  What is normal nasal airflow? A computational study of 22 healthy adults. Int Forum Allergy Rhinol. 2014;4(6):435–46. 2. Popko M, Verlinde-Schellekens SA, Huizing EH, Bleys RL. Functional anatomy of the nasal bones and adjacent structures. Consequences for nasal surgery. Rhinology. 2018;56(1):89–95. 3. Daniel RK, Palhazi P. Rhinoplasty: an anatomical and clinical atlas. Berlin: Springer; 2018. 4. Sheen JH. Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg. 1984;73(2):230–9. 5. Gruber RP, Park E, Newman J, Berkowitz L, Oneal R.  The spreader flap in primary rhinoplasty. Plast Reconstr Surg. 2007;119(6):1903–10. 6. Oneal RM, Berkowitz RL. Upper lateral cartilage spreader flaps in rhinoplasty. Aesthet Surg J. 1998;18(5):370–1. 7. Racy E, Fanous A, Pressat-Laffouilhere T, Benmoussa N. The modified sliding alar cartilage flap: a novel way to preserve the internal nasal valve as illustrated by three-dimensional modeling. Plast Reconstr Surg. 2019;144(3):593–9.

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8. Gunter JP, Friedman RM.  Lateral crural strut graft: technique and clinical applications in rhinoplasty. Plast Reconstr Surg. 1997;99(4):943–52; discussion 953–55. 9. Toriumi DM, Josen J, Weinberger M, Tardy ME. Use of alar batten grafts for correction of nasal valve collapse. Arch Otolaryngol Head Neck Surg. 1997;123(8):802–8. 10. Tellioglu AT, Cimen K. Turn-in folding of the cephalic portion of the lateral crus to support the alar rim in rhinoplasty. Aesthet Plast Surg. 2007;31(3):306–10. 11. Murakami CS, Barrera JE, Most SP. Preserving structural integrity of the alar cartilage in aesthetic rhinoplasty using a cephalic turn-in flap. Arch Facial Plast Surg. 2009;11(2):126–8. 12. Apaydin F.  Lateral crural turn-in flap in functional rhinoplasty. Arch Facial Plast Surg. 2012;14(2):93–6. 13. Ozmen S, Eryilmaz T, Sencan A, Cukurluoglu O, Uygur S, Ayhan S, et al. Sliding alar cartilage (SAC) flap: a new technique for nasal tip surgery. Ann Plast Surg. 2009;63(5):480–5. 14. Kovacevic M, Wurm J. Cranial tip suture in nasal tip contouring. Facial Plast Surg. 2014;30(6):681–7. 15. Daniel RK, Palhazi P, Saban Y, Baris C. Preservation rhinoplasty, 3rd ed. Plast Reconstr Surg. 2021;147(5):1256–8.

Dorsal Precision Segmental Preservation and How to Avoid Aesthetic Drawbacks

10

J. Carlos Neves and Diego Arancibia-Tagle

10.1 Introduction

10.2 Dorsum Conservative Techniques

Conservative dorsal rhinoplasty, until recently called the push-down rhinoplasty [1–22], has been written about extensively, and over the last decade, dorsal preservation rhinoplasty (PR) has regained an impressive popularity and has seen considerable advances in just a few years, since many doctors have improved and developed new ideas on the subject [1]. Since the end of the nineteenth century, some works have shown how to reduce a projected dorsum without impairing the surface anatomy of the nasal pyramid. By many, it was seen as an uninteresting and perhaps mistaken concept but by a few it was seen as the logical approach for preserving structures and avoiding massive complications. Recently, as we already said, we have observed the rebirth of dorsal conservative concepts [6]. In some cases, the technique is incorrectly assumed to be new, and in others they are philosophies and details that really represent a step forward to achieving the best results in an accurate and predictable fashion. Like any other surgical technique, dorsal conservative rhinoplasty has its indications and limitations. In this chapter, we focus on our personal strategies to obtain the best result possible and how to avoid some of the drawbacks and stigmata of the dorsal line PR.

Even though the concept of dorsal preservation was already more than one half of a century old, it was Cottle [2, 3] who popularized the “push-down technique” in 1946, combining several steps described by other surgeons. The principle of the technique was to preserve the continuity of the nasal dorsum by impacting the bony and cartilaginous hump around the keystone point. His technique consisted of a basal strip resection of the septal cartilage, one or two paramedian osteotomies, the preservation of the keystone area, and lateral osteotomies allowing him to move the nasal pyramid downward and inward (or outward) into the frontal process of the maxilla (Fig. 10.1, push down). After the pushdown (PDO) technique became popular, there were other surgeons who also described variations of the technique [11]. The “letdown technique” (LDO) was afterward popularized, even though authors like Lothrop in 1914 had already described the resection of a triangular bony wedge of the lateral nasal wall. This considerably facilitates the downward movement of the nasal bones and avoids the narrowing of the nasal cavity (see Fig. 10.1, let down).

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-­3-­031-­ 29977-­3_10. The videos can be accessed individually by clicking the DOI link in the accompanying figure caption or by scanning this link with the SN More Media App.

J. C. Neves (*) Private Practice MyFace Clinic, Lisbon, Portugal e-mail: [email protected] D. Arancibia-Tagle Private Practice, Mallorca, Spain © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Poignonec (ed.), Clinical Atlas of Preservation Rhinoplasty, https://doi.org/10.1007/978-3-031-29977-3_10

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Fig. 10.1  Artist’s sketch of PDO technique and the letdown (LDO) technique. (Courtesy of Fernando Vilhena de Mendonça, 2022, All rights retained) (Video 10.1 Tetris 2.0) (▶ https://doi.org/10.1007/000-­9q3)

10.3 The Segmental Preservation Approach Whenever there are a considerable number of techniques describing how to achieve the same final surgical purpose, it means that the ideal technique has not yet been found. We can also apply this rule to rhinoplasty techniques, and specifically to dorsal preservation concepts. Some disadvantages can be attributed to the PDO technique/LDO technique family.

Bringing the nasal semirigid pyramidal unit down as a whole structure without addressing each segment for refinement can be the main disadvantage. The main disadvantages are a low radix and radix step, residual dorsal hump (being caused by a global hump relapse or by the inability to correct the residual bony hump), ­supratip saddle, wide dorsum, and eventual impairment of the nasal airway. Based on that factor, the pyramid must be addressed by segments and not as a single block.

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Fig. 10.2  The intermediate septal approach. (a) The intermediate split, where a fragment of septum is removed from the caudal border of the septum till the perpendicular plate at the level of the transverse osteot-

The Tetris concept in combination with the LDO technique aims to control each of them, regarding position and shape. The main author has been doing preservation techniques for more than 10 years, with his preference being the intermediate approach. He has developed one modification of the LDO technique with a septal intermediate resection, the split PR (Fig. 10.2a) that showed the real advantage of the intermediate resection in stabilizing the rhinion position by putting a suture from our free anterior dorsal septal cartilaginous flap to the basal posterior stabile septum. In fact, this is a critical stitch for predictably keeping the rhinion in the desired position with great accuracy. The Tetris concept (Fig. 10.2b) is an evolution of the split preservation technique, with some advantages, which include suturing the free anterior septum (the Tetris block) in two vectors, craniocaudal and posteroanterior, conferring more stability to the pyramid in two axes and preserving a natural caudal septal strut, which allows us to control the supratip area and keep the caudal border and its relationship with the anterior nasal spine stable. As a general concept, these two techniques share the most relevant factor, the design of an intermediate fragment of cartilage below the rhinion to be anchored and consequently creating stability to the final dorsal profile. For more details of the surgical technique, we invite you to read the original articles “The Split Preservation Rhinoplasty, The Vitruvian Man Split Maneuver” and “The Segmental Preservation Rhinoplasty, The Split Tetris concept.”

10.4 Surgical Technique: Osteotomies and Pyramid Mobilization The LDO technique is our preference for approaching the lateral nasal wall because it gives us better mobilization of the pyramid and avoids bone impaction into the nasal cavity (Fig. 10.3).

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omy. (b) The segmental Tetris concept, where three segments are created with the key player being the Tetris block. The common gray area in both images is exactly at the same position

Fig. 10.3  The lateral wall. We prefer the L technique. The blue segment represents the bone to be removed. Note that next to the medial canthal tendon, we create some space where both osteotomies meet to facilitate the pushdown maneuver. The amount of bone removed will not influence the final dorsal profile position. The gray shadow represents the dissection area to perform the lateral splits movement

First, a transverse osteotomy is performed using a h­ andsaw or an ultrasonic device under direct vision or alternatively a 2-mm osteotome that can be used percutaneously. The cut is made from the level of the medial canthal ligament up to the level of the lateral dorsum (Fig.  10.4a). We prefer to keep the dorsal portion of the nasal bones untouched so we can do a green type of fracture when connecting this fracture line with the septal wedge resection beneath the nasal bones. The lateral osteotomy is part of the LDO technique. It consists of two osteotomies followed by the removal of the intervening triangular bony wedge from the frontal process of the maxilla (Fig.  10.4b–d). The excision must be done very low laterally, in the nasofacial groove, to avoid any palpable or visible step.

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Fig. 10.4  The LDO technique. Intraoperative pictures. (a) Upper left: a transverse osteotomy was performed with a Tastan-Cakir’s saw, closed approach. (b) Upper right: The anterior osteotomy of the osseous wedge to be resected is being performed with a 3-mm osteotome, closed approach. (c) Lower left: the posterior osteotomy of the osseous

wedge to be resected is being performed with an ultrasonic device, open approach. (d) Lower right: after the bony wedge resection with an osteotome in close approach; note the periosteum and its vessels were preserved

10.5 The Lateral Wall Split Maneuver

Goksel and Saban [20] also described this maneuver as the ballerina maneuver. After the lateral bony wedge is removed, we dissect the inner surface of the lateral in a subperiosteal plane, to protect ULC and soft tissues. The pyriform ligaments are also liberated. This dissection will allow for an anterior and caudal sliding movement of the middle third of the lateral wall (see Figs. 10.3 and 10.5).

To create the flattening of the dorsal profile, the lateral walls must show some plasticity. To achieve that goal, the lateral articulation between the upper lateral cartilage (ULC) and the nasal bones in its posterior cephalic border can be released so that the lateral wall split maneuver movement is facilitated.

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Fig. 10.5  The lateral wall split. Intraoperative pictures. (a) (left) Dissecting the ULC from the nasal bone with a delicate dissector. (b) (right) The triangular space created in between the ULC and the nasal bones after the anterior and caudal sliding movement

10.6 Septal Resection Conceptually, in preservation techniques the septum can be addressed lower in its base, by keeping the attachment with the cartilaginous vault intact and bringing all the structure down as a unit, and it can be addressed higher at the junction with the ULCs, exclusively pushing down the cartilaginous vault. It can also be addressed by splitting the septum in a strategic medial position, bringing the ULCs and the remaining attached septum down. Each one of these approaches has its pros and cons.

10.6.1 The Intermediate Split Preservation Rhinoplasty The intermediate split PR consists of the following essential steps: (1) A tapered intermediate resection (that represents the amount of hump deprojection) begins at the caudal border of the septum and extending to the perpendicular plate of ethmoid, with its highest point in the most prominent aspect of the hump, at the rhinion level. (2) A vertical chondrotomy just toward this prominent point of the hump is performed, at the K point or, most often, caudal to it. (3) A suture is placed for fixation from the free anterior dorsal septal cartilaginous flap to the basal posterior stabile septum (Fig. 10.6).

10.6.2 The Medial Wall Split Maneuver A perpendicular chondrotomy below the most prominent point of the hump is performed to flatten the profile during the push down maneuver. Generally, this point is exclusively

represented by cartilage, 1–3  mm caudally to the rhinion. This vertical section allows us to mobilize these two new septal segments, like the splits maneuver, allowing the surgeon to obtain the desired nasal dorsum esthetic line. We keep a 5- to 8-mm cartilage strip under the ULCs so we can suture it to the stable basal septum. A suture between these two septal pieces is mandatory and is always performed after mobilizing the bony pyramid. The posterior fixation will define the rhinion height and will stop it from popping up and creating a new hump, providing stabilization. This step is the main goal of this intermediate septal approach; that is, to create a stabilization point that guarantees the final position, and without any upward movement in the postoperative period because of relapsing forces, as seen in other approaches. In the last decade, this approach has been our workhorse, and attempts to be accurate with respect to the final position of the dorsum, by precisely stabilizing the point where more tension that leads to relapses is felt. Additional sutures are placed until the caudal septal border, using figure-of-8 stitches, 5–0 PDS. If more stability is needed, a strut side to side with the caudal septum can be used, which is sometimes useful as an extended septal graft.

10.6.3 The Segmental Preservation Rhinoplasty: The Split Tetris Concept The Tetris concept is a modified intermediate septal resection consisting of the following steps (Fig.  10.7). A 5- to 8-mm rectangular piece of septal cartilage will be designed below the cartilaginous hump in between the most prominent point of the hump (at or slightly caudal to the rhinion) and the caudal border of the ULC (the W point). The block is defined by two lines perpendicular and one horizontal to the

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Fig. 10.6  Artist’s sketch of the intermediate septal strip resection plus the perpendicular chondrotomy and the figure-of-8 sutures creating a very firm and stable cartilaginous septum. (Courtesy of Fernando Vilhena de Mendonça, 2022, All rights retained)

Fig. 10.7  The Tetris concept. A 5- to 8-mm height block is designed in between the WASA and the dorsal hump most prominent point (red line); a trapezoid figure is drawn below the block, which represents the amount of the hump to be reduced (gray trapezoid); a triangular figure is drawn below the bone pyramid, from the block till the lateral wall transverse osteotomy level to facilitate the pushdown movement (blue triangle); to avoid overlapping the caudal aspect of the Tetris block with the natural caudal septal strut we trim a triangular portion of the block cartilage (purple triangle); to adjust the new dorsal profile level a trimming of the anterior border of the caudal septal strut must be performed (blue dots)

dorsum (see Figs.  10.5 and 10.8a). We prefer the block (quadrangular or rectangular) figure compared with a triangular shape, for instance. This is because it is designed to achieve a more stable structure, and once we have stabilized a vertical and a horizontal vector, we can avoid tilting of the free pyramid in the coronal and sagittal planes. Two new shapes will be designed: one below the rectangular block and another below the bony hump. The shape below the block must have the height that we intend to decrease the dorsal projection. The shape of the excised area will usually be trapezoidal because the reduction will be bigger under the most projected point of the hump and less in the more caudal region. Below the bony hump, we draw a triangular excision area (triangular wedge) with its vertex at the level of the transverse osteotomies. The marked areas will be excised, which creates the space for the descending dorsum (Fig. 10.8b).

Using a 15 blade, the caudal, posterior, and cephalic borders of the rectangular block are cut. It is essential to free the cartilaginous hump. When pushed down, the block overlaps with the stable septal cartilage and we create a saddle nose below the UCL caudal border. Next, the triangular segment below the bony hump is removed using scissors. The cut always starts at a tangent to the undersurface of the bony vault to avoid an excess resection that can lead to a radix step. We initially remove a small triangular piece, and then perform the pushdown maneuver and analyze how much we have deprojected. If not enough, we go in again and remove another triangular slice until reaching the desired level. In some cases, we only remove cartilage, whereas in other cases we have to remove a small piece of bone, for which scissors are often necessary as well. Rarely, we use a baby rongeur, which we try to avoid, because it can create a bigger space than is needed and the radix step will appear as a consequence (Fig. 10.8c). Now, the hump can be reduced and the cartilage block overlaps the stable basal septal cartilage; and because we have isolated the Tetris block we press it down, and by a rotational movement, posterior and caudal, we can create the side splits effect, thereby eliminating any residual dorsal hump. We are ready to remove the trapezoid slot, and thus create the space for our Tetris block. The rotational movement of the block, downward and caudal, creates an overlap of a small portion of cartilage of its caudal border with the caudal septum strut we have left intact. Thus, we trim the caudal border of the block so that it fits the slot created perfectly (Fig.  10.8d). This movement brings the pieces down into their spaces in a perfect match resembling the Tetris game, so we have called it the Tetris preservation concept. At this point in the operation, the surgeon decides how satisfied they are with the dorsal profile line. Sometimes, if the dorsum is too convex or a more concave shape is desired then a Tetris split is done at this time (as described elsewhere in this article). The first suture of 5–0 PDS is placed between the posterior aspect of the caudal border of the Tetris block to the caudal septal strut, which stretches and helps to flatten the

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Fig. 10.8  The Tetris block designing (fresh specimen). (a) Designing the Tetris block. (b) Designing the space slots. The trapezoid below the Tetris block, that determines the hump reduction, and the triangular below the bony pyramid. (c) The Tetris block and the pyramid are free

and can be repositioned. (d) A triangle to be resected was marked in the caudal border of the Tetris block to avoid overlapping with the natural caudal strut

dorsum. This movement resembles what we performed in the Cottle PDO technique [2, 3], and because of this here we can see a mini-Cottle, using an intermediate approach, with the advantage of preserving the stability of the rest of the septum. After performing this suture, the hump is reduced. Nevertheless, immediately we observe a small relapse of the hump that will slightly increase with time, the so-called spring effect (Fig.  10.9c). This phenomenon is responsible for the residual hump seen in a considerable number of cases, being a major problem of the dorsal preservation techniques. To prevent recurrent humps, we use a rhinion suture. At the level of the rhinion, we suture the cephalic border of the Tetris block to the underlying stable septal cartilage to guar-

antee precision and predictability (Fig.  10.9d). This suture can be performed as a simple interrupted one (Fig. 10.10) or as a figure-of-8 stitch, which is our preference. Additional sutures must be added between the caudal and the posterior borders of the Tetris block to the surrounding stable septal cartilage. To increase stability, we include the contralateral perichondrium and mucosa. With this approach, our incidence of recurrent cartilaginous humps has been negligible. At this point, the dorsum has been brought down to its ideal position, except at the level of the caudal septal strut, which was previously pre-served. In fact, one can often end up with a slight pollybeak appearance. The anterior border of this natural strut must be addressed, and most often it is

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Fig. 10.9  The Tetris concept (fresh specimen). (a) The space slots are prepared to allow the PDO movement. (b) Adjusting the Tetris block, the profile is checked. (c) Two PDS 5–0 sutures have stabilized the caudal border of the block; the stabilization of this border of the block is paramount to avoid pyramid lateralization. Note the spring effect below

the rhinion, a gap is created in the cephalic aspect of the space slot below the rhinion. (d) The 5–0 PDS suture was placed below the rhinion. The stabilization of the dorsum in a predictable final nasal dorsum position is probably the greatest achievement of this technique

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Fig. 10.10  The Tetris block. Intraoperative picture showing the two most important block sutures. Additional sutures will be added to complete stabilization. (Note that the stabilization of the two borders that are perpendicular promotes an affective stability to the pyramid, eventually like no other dorsal preservation technique)

trimmed to achieve the desired dorsal height (Fig. 10.11b). Alternatively, it can be left partially at its maximum height to act like a strut to the tip or to support the stabilization of a septal extension graft (Fig. 10.11d). In deviated noses, one can suture the overlapped cartilages side by side without resecting the trapezoid piece (gray trapezoid in Fig. 10.5). The rectangular block is sutured on the opposite side to the deviation so it can compensate (Figs. 10.11c, d, 10.12, and 10.13). In a nasal dorsal hump, the cartilaginous component tends to be convex. Even after hump reduction, a curved line can persist that creates a small hump in between the rhinion and the supratip region; in some cases, it is essential to flatten this cartilaginous curve. One or two additional vertical cuts are made into the septal block converting it from a single entity into two or three new blocks that will be brought caudally into rotational movement (see Figs.  10.13 and 10.14). The creation of multiple pieces allows the dorsum to flex, which resembles the spreading of fingers. This movement brings the pieces down into their spaces in a perfect match resembling the popular game and

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Fig. 10.11  The caudal septal strut. Intraoperative pictures showing the natural caudal septal strut. (a) The natural caudal septal strut before being addressed. (b) The septal profile after equalization of the caudal septal segment. Note the slight concave curve that the profile shows; it

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avoids the supratip saddling phenomena of some dorsal preservation techniques. (c) The caudal septal strut lateral to the Tetris back in a deviated pyramid. (d) The caudal septal strut supporting a septal extension graft (the anterior nasal septal angle banner)

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10.6.3.2 How to Avoid Aesthetic Drawbacks

Fig. 10.12  The Tetris concept in deviated pyramids. When there is indication to perform the procedure in deviated pyramids there will be no slot creation below the Tetris block (red line) and consequently no trapezoid resection as seen in previous demonstrations; the block will suture to the stable septum in the opposite site of the deviation for compensation. The gray grid represents the septal harvesting leaving a stable L-shaped septum after suturing the Tetris block

Fig. 10.13  The split Tetris concept. Splitting the Tetris block (red lines) allows the cartilaginous segment to flatten or eventually to become concave. The wider the gray triangle the more concave this segment will be

thus the name—the split Tetris PR. The more the block pieces are moved apart, the more concave the profile becomes.

10.6.3.1 Tetris 2.0 We have introduced a variation at the caudal cut of the Tetris flap. Instead of considering the W point (the caudal board of the ULC) as the starting point, we are preserving now below the ULC 3–5 mm of septum (meaning the caudal limit of the flap is 3–5 mm cephalic to ULC caudal border) that works as an additional stability pillar at the supratip area (Video 10.1).

Dorsal Segments and Strategies to Avoid Stigma The split Tetris is an evolution of the intermediate split approach [1], whose fundamental goal is to stabilize and predict the nasal dorsum final position. It was designed to improve nasal pyramid stability, regarding the coronal and sagittal axis, and to treat each segment of the dorsum more independently. At first, this technique may seem demanding, but once it has been learned it is relatively simple to perform. For many years, the preservation techniques have been criticized for their lack of precision and the stigma of the outcome. With the segmental approach we aim to reduce its weaker aspects. Profile Drawbacks Residual Hump or Hump Recurrence

The ideal scenario for a pyramid PDO/LDO maneuver is a high flat tension nose. When we face a convex dorsal profile that needs to be flattened, several considerations need to be taken into account to avoid a residual hump or other stigmata postoperatively. To some extent, the definition of residual hump depends on the eye of the beholder. Sometimes results are shown and described as having no hump where it is possible to see a residual convexity and based on that some surgeons admit to 1 mm lowering Broad midvault Big noses Tension noses

and raises the supratip area thereby creating tip support (Table 11.1).

11.6 Bony Pyramid Wide bony vaults are unsuitable for preservation techniques. While the cartilaginous vault is preserved, the bony pyramid can be treated with rhinosculpture techniques using either rasp, burs, or a piezoelectric device, in combination with classic osteotomies. Previous work by Kosins [4] has shown there to be two types of nasal bony humps: either V- or S-shaped. The V-shaped bones have a straight-line configuration starting at the sellion, through the kyphion, toward the rhinion. S-shaped nasal bones have a triangular configuration with the kyphion as the high point. It is preferable to convert S-shaped humps, as much as possible, into V-shaped humps by rasping or by careful removal of bone at the high point. There are currently three types of BP lowering described. Fig. 11.4  Low septal strip removal

• • • •

to the anterior nasal spine and broadening as one moves posteriorly. A complete vertical septal cut at the bony-cartilaginous junction of the dorsum. If needed, an excision of cartilage or perpendicular plate under the bony cap area. Final resections of quadrangular cartilage after the bony pyramid lowering, to obtain the desired dorsal height. Fixation of the septum to the anterior spine.

In contrast to the high septal strip, a wide septal dissection and a more significant resection of septum are required. The movement of the dorsum in a low strip is rotational, moving down at the midvault and forward and upward more caudally, thereby straightening the septum and dorsum in one of the most efficient ways. The rotational movement prevents potential midvault widening as seen in the high strip

11.6.1 BP Type 1—Cap Reduction (Fig. 11.5) The bone is removed incrementally by rasp or bur, exposing the underlying cartilaginous vault. This can be combined with classic osteotomies. It effectively changes the proportions of the dorsum by increasing the amount of exposed cartilage while removing excess bone. This maneuver helps to decrease the convexity/kyphosis of the nasal profile, to create a more flexible osseocartilaginous joint.

11.6.2 BP Type 2—Cap Lowering (Fig. 11.6) In this technique described by Ishida [5], the bony cap is freed from the rest of the bony vault using an osteotome or saw, but left attached to underlying cartilaginous cap of the upper lateral cartilage (ULC).  Following pushdown of the released cap, the protruding edges of the nasal bones are then rasped down to the desired height and width. If needed, classic osteotomies to narrow the nasal bones can be performed.

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Fig. 11.5  BP type 1

11.6.3 BP Type 3—Bony Pyramid Lowering (Fig. 11.7) In complete bony pyramid lowering by letdown, pushdown [2]—or a hybrid technique (in which only the Webster’s triangle is removed), the bony pyramid is lowered, and the lateral walls are inside the pyriform aperture to a variable degree. It amounts to transverse osteotomies, a radix osteotomy, and low-to-low osteotomies. These can be performed by osteotome, handsaws, or powered microsaws. Once effectuated, there must be separation of the bony pyramid from the skull. This is confirmed by gentle horizon-

Fig. 11.6  BP type 2

tal mobilization of the pyramid from right to left. Then, the pyramid is pinched and pushed down to achieve the desired lowering. The radix osteotomy in BP type 3 can either function as a hinge or as the site of a downward displacement of the nasion area (Table 11.2). Additional dorsal modifications to optimize the shape of the dorsum can be applied. These include bony pyramid remodeling by rasp, ULC shoulder shaves with the scalpel, hidden spreader grafts (below ULCs), and radix or supratip onlay grafts.

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11.7 Tip Preservation rhinoplasty advances tip surgery even further by preserving virtually the entire alar cartilage, which enhances function and reduces potential long-term problems. Preserving the alar cartilages, and in particular the lateral crus, is a relatively recent development. The critical steps are to shape the domal cartilage with sutures, to control the lateral crus with tensioning techniques, and to achieve tip support with the use of a strut.

11.7.1 Shaping the Dome The foundation for aesthetic tip surgery with ligament preservation was introduced by Cakir using the polygon concept [6]. Within this concept, the desired domal shape can be obtained using sutures with or without lateral crural steal. Based on the preference of the surgeon, either a cranial tip suture [7] or a more aggressive cephalic dome suture [8] can be used. Both sutures create domal definition, stiffen and tension the lateral crura, and evert the caudal border of the lateral crura (Fig. 11.8).

11.7.2 Lateral Crus Control

Fig. 11.7  BP type 3 Table 11.2  Relative indications for BP type 1–3 BP type 1 cap reduction Bony pyramid lowering 2 mm Kyphotic hump Broad bony cap (with osteotomies) Narrow bony cap (without osteotomies) Hinge at nasion

BP type 3 pyramid lowering Bony pyramid lowering >2 mm Large nose Moderate hump Deviated bony pyramid Lowering at nasion

An attempt should made to preserve the maximal amount of lateral crural volume, as transection and excision weaken the alar shape and projection, often leading to long-term problems. If lateral crural volume needs adjusting, one can choose a technique that decreases volume while also strengthening or straightening the lateral crus. The sliding alar cartilage flap as described by Ozmen [9] and Racy [10] strengthens the lateral crus by incising the cephalic lateral crus and then sliding the cephalic portion underneath the remaining strip. The turn-in flap as modified by Apaydin [11] strengthens and straightens the lateral crus by performing a 180° plication of the cephalic portion underneath the remaining strip.

11.7.3 Supporting the Tip In all cases, either a columellar strut or septal extension graft is used. Systematic analysis of the nose and visual planning of the desired aesthetic outcome guide the decision.

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New dome

New dome

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Fig. 11.8 (a) Cranial tip suture (by Kovacevich) and (b) cephalic dome suture (by Cakir). Courtesey of A Kosins

Table 11.3  Relative indications for tip support Columellar strut Normal STE Strong cartilage Normal projection

SEG Thick STE Weak cartilage Underprojection

A columellar strut is advised in a tip with a thin to normal skin, adequate strength of the cartilage, and a normal projection. If a columellar strut is chosen, preservation of ligaments is crucial to maintain tip support. A septal extension graft (SEG) is preferred for a thick STE, weak cartilages, and an underprojected tip. Many variations on SEG exist and can be used according to preference (Teostrut, F-Strut, Tacostrut, ANSA banner graft) (Table 11.3).

11.8 Solving Common Problems Despite the best preoperative preparation and planning, problems will occur. It goes without saying that choosing the correct procedure for the individual case is paramount. In order to prevent complications, it is essential to have a clear understanding of when to use PR techniques and when to realize not to use them. Luckily, most problems seen in can be easily prevented and more importantly, easily corrected postoperatively.

11.9 Early Postoperative Concerns (3 month) Osseocartilaginous vault Dorsal hump Supratip saddling Middle third widening Axis deviation Radix step

Tip Loss of tip support Tip deviation and asymmetries Scroll-winding effect

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11.10.1 Osseocartilaginous Vault 11.10.1.1 Dorsal Hump Recurrence (Fig. 11.9) A recurrence of the hump is the most common problem encountered in PR. It is due to either insufficient release of the septal tension at the K area, the LKA and piriform ligaments (spring effect), and/or inadequate fixation (spring effect in high strip or backward rotation in low strip resection). It can also be caused by ULC asymmetry where one paraseptal cleft is higher as compared to the other. In high septal strip resection, rasping of the K area, scoring of subdorsal septum, release of the LKA and piriform ligaments, and fixation of the mobile osseocartilaginous vault dorsum to the septum (Teodor stitch) can prevent a recurrence of the hump. Sometimes, a partial or unilateral release and excision of the ULC from the septum is necessary to equalize the cartilaginous vault. In low septal strip resection, a “swinging-door” septoplasty with total mobilization of the quadrangular cartilage from its bony attachments is of the essence. The subdorsal dissection must release the junction of the quadrangular cartilage with the perpendicular plate of the ethmoid and should be caudally extended to the rhinion. Once there is no tension left, the quadrangular cartilage (QC) flap is securely fixed to the anterior nasal spine (ANS) periosteum in order to prevent relapse. Here too, sometimes a partial or unilateral release and excision of the ULC from the septum is necessary to equalize the cartilaginous vault. a

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Solving the dorsal hump recurrence Rasp K area Release LKA and piriform ligaments (ballerina move) Release tension cartilaginous vault by scoring, releasing, resecting, or slicing the ULC (Teoslice)

11.10.1.2 Supratip Saddling (Fig. 11.10) Supratip saddling can occur in both high- and low septal strip resection. The incremental resection of distal septum is essential. In high septal strip resection, saddling can happen due to over aggressive lowering of WASA segment. In low strip resection, it is seen due to aggressive resection of the septum at the anterior nasal spine. Solving supratip saddling In high septal strip resection—release of the mobile vault and suturing the septal mucosa together in the space between the mobile vault and the septum under the W point to elevate the supratip area In low septal strip resection—release of the QC, osteotomies, additional rotation QC to raise supratip, resecuring in the correct midline position Placement of cartilage graft Filler

11.10.1.3 Middle Third Widening (Fig. 11.11) The widening of the midvault is a problem that can occur in both high- and low septal strip resections, at different locations and due to different mechanisms. In high septal strip

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Fig. 11.9  From left to right. (a) Preoperative sideview, (b) postoperative sideview with residual hump, and (c) postoperative sideview after rasping K area and scoring of cartilage

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Fig. 11.10  From left to right. (a) Preoperative sideview, (b) postoperative sideview with supratip saddling, and (c) postoperative sideview after placement of filler

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Fig. 11.11  From left to right. (a) Preoperative frontal view, (b) postoperative frontal view with midvault widening, and (c) postoperative frontal view after release of LKA and partial division of the ULCs from the septum with resection of the excess ULC

resection, widening seen at the junction between septum and ULC is purely mechanical due to the downward movement of the dorsum. In low septal strip resection, widening of the ULC is seen at the caudal border near the piriform aperture due to the rotational movement of the quadrangular septal cartilage. Solving middle third widening Incomplete incision on one or both sides of the dorsum at the junction of septum and ULC Partial division of the ULCs from the septum, with resection of the excess ULC (if needed) Excision of the caudal and/or basal edge of the ULC Release of LKA and piriform ligaments

11.10.1.4 Axis Deviation Axis deviation is encountered in both high- and low strip septal resection and is mainly due to inadequate fixation of dorsum and septum or residual tension in the cartilaginous vault. In high septal strip resection, the dorsum must be fixed to the septum at the K area (Teodor stitch) and more caudally to prevent lateralization. The latter is done by suturing the septal mucosa together in the space between the mobile vault and the septum under the W point (after Cakir). In low septal strip resection, the septum must be positioned tensionless, without bowing. Thereafter, it must be fixed to the ANS in a secure fashion to prevent dislodgement and deviation of the axis.

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192 Solving axis deviation In high septal strip resection—release of the mobile vault and resecuring in the correct midline position In low septal strip resection—release of the QC, if needed inferior strip resection to alleviate bowing, and resecuring in the correct midline position Camouflage by use of hidden spreadergrafts, minced cartilage grafts, or filler

revision with a SEG support with or without the addition of a projecting tip graft.

11.10.2 Radix Step

11.10.3.2 Tip Deviations and Asymmetries More frequently seen in the closed approach rhinoplasty. Prevention of asymmetries can be obtained by minimal cartilage excision, carefully and equally placed dome markings and sutures, control of ULC/LLC relation, and tip support. If a deviation or asymmetry occurs, the only solution is to redo the whole tip.

In BP type 1, complete removal of the bony cap can occasionally lead to an unwanted depression or irregularity at the nasion, creating the need for camouflage grafts. If seen in DP type 2 and 3, the cause is more likely due to removal of the PPE.  During surgery, be conservative with the amount of bony cap or PPE removed. Best is to perform the removal in small steps, each time checking if the desired result has been accomplished.

11.10.3.3 Scroll-Winding Effect (After Saban) Middle third fullness due to excess of cartilaginous scroll is caused by the overlap of the caudal scroll at the ULC/ LLC junction. It can be prevented or corrected postoperatively by direct resection of the proximal scroll area after lowering of the dorsum. The same effect can be obtained by caudal ULC excision or by a sliding alar cartilage flap.

Solving a radix step Rasping of the step Microfractures with osteotome above the step to fill the gap Placement of cartilage graft Filler

11.10.3 Tip Unfortunately, the tip often is more susceptible to change through scaring in the postoperative period than the dorsum. To minimize change, cartilage resection to be diminished as much as possible. The use of the sliding alar cartilage flap and the turn-in flap are great tools in accomplishing this. Tip support also must be adequate to prevent loss of projection. Therefore, perhaps indications for the use of SEG should be increased. Additionally, the relation between the ULC and LLC has to be evaluated. As a consequence of lowering of the dorsum by high or low strip resection, a conflict can occur at the level of the scroll causing internal nasal valve problems and fullness. Often, resection of ULC, release and reconstruction of scroll are essential is creating a desirable result.

11.10.3.1 Loss of Tip Support Thick skin, weak cartilages, short medial crura, and underprojection of the tip will all predispose to a postoperative tip drop. The only adequate solution to this complication is tip

11.11 Conclusions Preservation rhinoplasty truly has created a paradigm shift in rhinoplasty. In most patients, the STE as well as the nasal ligaments can be preserved. Overall, dorsal preservation is an excellent technique if patients are chosen properly. No dorsum looks as good as a natural dorsum, and long-term issues with the middle vault and keystone area can be avoided. As for the tip, the lateral crura should be preserved and tensioning techniques should be chosen over excision. True mastery comes to those with a clear understanding of which preservation technique to use for which nose, and to realize when not to use PR.

11.12 Case 1 11.12.1 Analysis of the Nose STE: Normal thickness skin Cartilaginous vault: Strong cartilage, high caudal septum Bony pyramid: Normal height of radix, V-shaped bony hump Tip: Strong cartilages Function: No breathing issues

11  Prevention and Correction of the Most Common Problems in Preservation Rhinoplasty

11.12.2 Visual Planning of the Desired Aesthetic Outcome

11.12.3 Surgical Technique Used Low strip septal resection, BP type 3 (bony pyramid lowering), polygon tipplasty (4-mm lateral crural steal, 3-mm medial crural overlay)

193

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11.13 Case 2 11.13.1 Analysis of the Nose

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Bony pyramid: Normal height of radix, S-shaped bony hump Tip: Medium cartilage strength Function: No breathing issues

STE: Normal thickness skin Cartilaginous vault: Strong cartilage, low caudal septum

11.13.2 Visual Planning of the Desired Aesthetic Outcome

11.13.3 Surgical Technique Used Low strip septal resection, BP type 2 (bony cap lowering with osteotomies), polygon tipplasty (2-mm lateral crural

steal, 2-mm medial crural overlay), tip graft (boomerang graft)

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11.14 Case 3 11.14.1 Analysis of the Nose STE: Normal thickness skin Cartilaginous vault: Strong cartilage, low caudal septum Bony pyramid: Normal height of radix, V-shaped short bony hump

Tip: Medium cartilage strength Function: No breathing issues

11.14.2 Visual Planning of the Desired Aesthetic Outcome

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11.14.3 Surgical Technique Used Low strip septal resection, BP type 1 (cap rasping with osteotomies), polygon tipplasty (2-mm lateral crural steal, 2-mm medial crural overlay), minced cartilage on K area

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11.15 Case 4 11.15.1 Analysis of the Nose STE: Thick skin

11.15.2 Visual Planning of the Desired Aesthetic Outcome

11.15.3 Surgical Technique Used High strip septal resection, BP type 1 (cap rasping with osteotomies), polygon tipplasty (2-mm lateral crural steal, 2-mm medial crural overlay)

203

Cartilaginous vault: Weak cartilage, high caudal septum Bony pyramid: Normal height of radix, V-shaped short bony hump Tip: Medium cartilage strength Function: No breathing issues

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References 1. Daniel RK. The preservation rhinoplasty: a new rhinoplasty revolution. Aesthet Surg J. 2018;38(2):228–9. 2. Finocchi V, Daniel RK, Palhazi P. Preservation rhinoplasty, 3rd ed. Plast Reconstr Surg. 2021;147(5):1256–8. 3. Saban Y, Daniel RK, Polselli R, Trapasso M, Palhazi P.  Dorsal preservation: the push down technique reassessed. Aesthet Surg J. 2018;38(2):117–31. 4. Lazovic GD, Daniel RK, Janosevic LB, Kosanovic RM, Colic MM, Kosins AM.  Rhinoplasty: the nasal bones-anatomy and analysis. Aesthet Surg J. 2015;35(3):255–63. 5. Ishida LC. Nasal hump treatment with cartilaginous push-down and preservation of the bony cap. Aesthet Surg J. 2020;40(11):1168–78.

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6. Cakır B, Öreroglu R, Daniel RK.  Surface aesthetics in tip rhinoplasty: a step-by-step guide. Aesthet Surg J. 2014;34(6):941–55. 7. Kovacevich M.  Cranial tip suture in nasal tip contouring. Facial Plast Surg. 2014;30(6):681–7. 8. Cakir B. Aesthetic septorhinoplasty. St Louis: CV Mosby; 2015. 9. Ozmen S, Eryilmaz T, Sencan A, et  al. Sliding alar cartilage (SAC) flap: a new technique for nasal tip surgery. Ann Plast Surg. 2009;63:480–5. 10. Racy E, Fanous A, Pressat-Laffouilhere T, Benmoussa N. The modified sliding alar cartilage flap: a novel way to preserve the internal nasal valve as illustrated by three-dimensional modeling. Plast Reconstr Surg. 2019;144(3):593–9. 11. Apaydin F.  Lateral crural turn-in flap in functional rhinoplasty. Arch Facial Plast Surg. 2012;14:93–6.