Rhinoplasty: Current Concepts, An Issue of Clinics in Plastic Surgery

David Stepnick, Ronald P. Gruber

Description

Rhinoplasty is a commmon procedure that may be performed by a plastic surgeon or an otolaryngologist specializing in facial plastic surgery. This is the first issue of Clinics in Plastic Surgery to bring together authors who are both plastic surgeons and facial plastic surgeons to share their expertise in performing reconstructive and cosmetic rhinoplasty procedures.

Sujets

• Reconstructive
• Medical
• Médecine
• Cosmetic
• Surgery

Informations

• Publié par: Saunders
• Date de parution: 02 avril 2010
• Nombre de lectures: 0
• EAN13: 9781455700578
• Langue: English
• Poids de l'ouvrage: 3 Mo

Extrait

Clinics in Plastic Surgery , Vol. 37, No. 2, April 2010
ISSN: 0094-1298
doi: 10.1016/S0094-1298(10)00006-4

Contributors List
Clinics in Plastic Surgery
Rhinoplasty: Current Concepts
Ronald P. Gruber, MD
3318 Elm Street, Oakland, CA 94609, USA
David Stepnick, MD
Case Western Reserve University, Brainard Medical Bulding, 29001 Cedar Road, Suite 203, Lyndhurst, OH 44124, USA
ISSN  0094-1298
Volume 37 • Number 2 • April 2010

Contents
Cover
Contributors List
Forthcoming Issues
Preface
Nasal and Facial Analysis
Surgical Anatomy of the Nose
Principles of Photography in Rhinoplasty for the Digital Photographer
Diagnosis and Correction of Alar Rim Deformities in Rhinoplasty
Suture Techniques in Rhinoplasty
Alar Base Disharmonies
Alar Cartilage Grafts
Rhinoplasty 5 Pearls: Value of the Endonasal Approach and Vertical Dome Division
Humpectomy and Spreader Flaps
Rhinoplasty: Dorsal Grafts and the Designer Dorsum
Osteotomies
Surgical Treatment of the Crooked Nose
Lengthening the Short Nose
Asian Rhinoplasty
Ethnic Rhinoplasty
Secondary Rhinoplasty and the Use of Autogenous Rib Cartilage Grafts
Secondary Rhinoplasty in Unilateral Cleft Nasal Deformity
Problems in Rhinoplasty
Index
Clinics in Plastic Surgery , Vol. 37, No. 2, April 2010
ISSN: 0094-1298
doi: 10.1016/S0094-1298(10)00008-8

Forthcoming Issues
Clinics in Plastic Surgery , Vol. 37, No. 2, April 2010
ISSN: 0094-1298
doi: 10.1016/j.cps.2009.12.012

Preface

Ronald P. Gruber, MD
3318 Elm Street, Oakland, CA 94609, USA
Divisions of Plastic & Reconstructive Surgery, Stanford University, University of California, San Francisco
E-mail address: [e-mail]
E-mail address: [e-mail]

David Stepnick, MD, FACS ,
Case Western Reserve University, Brainard Medical Building, 29001 Cedar Road, Suite 203, Lyndhurst, OH 44124, USA
E-mail address: [e-mail]
E-mail address: [e-mail]


Ronald P. Gruber, MD Guest Editor

David Stepnick, MD, FACS Guest Editor
For a number of reasons, rhinoplasty is arguably the most intricate and challenging operation in all of aesthetic plastic surgery. Because the nose is a relatively small structure, a millimeter change makes a discernible difference in its aesthetics. It is located in the middle of the face, constantly available for inspection by the patient and others. The magnitude of the effects of the healing process often equals and occasionally exceeds the magnitude of the changes that the surgeon is seeking to make. Indeed, the healing process can completely distort the sculptured result the surgeon has achieved. Furthermore, almost every surgeon knows what an aesthetically pleasing nose looks like when he or she sees it. However, not every surgeon intuitively understands what components of the nose are responsible for the unaesthetic appearance and knows what components should be altered to achieve an aesthetic nose.
This issue of Clinics in Plastic Surgery , therefore, is devoted to providing surgeons with a better appreciation of the solutions to these problems. Some of the very best rhinoplasty surgeons from a plastic surgery or facial plastic surgery background were asked to share their experience on topics with which they have special expertise. As a result, this issue of Clinics is what we believe to be a state-of-the-art compendium of modern rhinoplasty.
The issue begins with a discussion of facial analysis and imaging. The statement that analysis is responsible for 50% of the final result is a cliché for good reason. Not knowing precisely what aspects of the nasal form will benefit from surgical modification is a recipe for a very unsatisfactory result. The use of imaging facilitates that analysis and that point is strongly emphasized here. Anatomy is vital to the decision-making process because the nasal framework is a complicated structure that does not relate directly to its outside appearance. Consequently, it is the focus of discussion as well.
We then provide individual articles that deal with the actual surgical techniques for specific surgical problems. One often-debated topic is the approach for accomplishing the rhinoplasty: endonasal versus external. One article is devoted entirely to one of the most important means of controlling nasal shape: cartilage grafts. A discussion of the various grafts, such as ear, rib, septum, and diced cartilage, is provided. Suture techniques to sculpture the cartilaginous framework are also presented because they are equally important in controlling nasal shape.
Specific parts of the nose demand special variations in the operative procedure. Therefore, an article has been devoted to the dorsum and its augmentation. Yet another has been dedicated to the alar rim and the special challenges it presents. Osteotomies have been a challenge, as evidenced by complaints from too many surgeons about the difficulty of achieving precise control of the nasal bones. Consequently, a section is devoted to this topic. Even a seemingly mundane issue, such as “humpectomy,” has received its own special coverage because it has become apparent in recent years that an aesthetic dorsum with a proper functioning internal valve is just as important to a successful rhinoplasty result as a high quality “tip-plasty.”
As rhinoplasty is the most difficult aesthetic operation, lengthening the short nose is possibly the most difficult aspect of a rhinoplasty. Consequently one article is devoted to techniques for lengthening a nose that is too short. The same may be said for straightening the crooked nose; it has had a notoriously high recurrence over the decades. Consequently, this is the topic of an article. As any surgeon knows, having to reoperate on a patient poses a unique set of problems. The tissues of such a nose are simply not as compliant, and the procedure is prone to even more scar tissue deposition than occurred with the first operation: an article specifically addresses this subject.
Special problems require individual discussion. These challenges include Asian and other ethic noses with their complicated problems related, in part, to thick skin. Patients with cleft lip nasal deformities require even greater care in that anatomical distortions beyond the nose affect the nose itself and need to be addressed. The final article provides an overview of the complications seen following rhinoplasty.
We feel that this issue of the Clinics has covered virtually every aspect of rhinoplasty, so that today’s surgeon will have a completely up-to-date accounting of all the thought processes, caveats, modalities, techniques, and prognostications for providing patients with the best possible outcome.
Clinics in Plastic Surgery , Vol. 37, No. 2, April 2010
ISSN: 0094-1298
doi: 10.1016/j.cps.2009.12.006

Nasal and Facial Analysis

Charles R. Woodard, MD a , Stephen S. Park, MD b , *
a Department of Otolaryngology - Head & Neck Surgery, University of Virginia Health Systems, 1 Hospital Drive, 2nd Floor OMS, Charlottesville, VA 22908, USA
b Division of Facial Plastic & Reconstructive Surgery, Department of Otolaryngology - Head & Neck Surgery, University of Virginia Health Systems, 1 Hospital Drive, 2nd Floor OMS, Room 2747, Charlottesville, VA 22908, USA
* Corresponding author.
E-mail address: [e-mail]

Abstract
Rhinoplasty remains one of the most challenging aesthetic procedures to master. Astute surgeons must consider a continually evolving societal perception of beauty with their own sense of aesthetic proportion when planning surgical intervention. Optimal results are achieved when the outcome is anticipated and satisfying to patient and surgeon. This requires a careful, thoughtful, systematic approach to preoperative analysis. Patients should leave with a clear understanding of the surgeon’s perspective of their nose, aesthetically and anatomically. Understanding the interplay of surface deformities and their underlying anatomic counterpart is critical, involving a systematic analysis to create a surgical plan that avoids landmines leading to a suboptimal result.

Keywords
• Rhinoplasty • Preoperative analysis • Nasal deformity • Aesthetics
Rhinoplasty remains one of the most challenging aesthetic procedures to master. Astute surgeons must consider a continually evolving societal perception of beauty with their own sense of aesthetic proportion when planning surgical intervention. An optimal result is achieved when the outcome is anticipated and satisfying to the patient and surgeon. This requires a careful, thoughtful, systematic approach to preoperative analysis.

History
A focused history and physical examination is required to design a mutually agreeable operative plan. Information regarding past medical history, past surgical history (especially previous nasal surgery), medications (including herbals), allergies, social habits, and a personal or family history of coagulopathy is important. During the preoperative rhinoplasty history, it is essential to determine the patient’s motivation for surgery, expectations, and psychosocial stability.
Patients seeking rhinoplasty are motivated by several different factors. It is the surgeon’s responsibility to decide whether or not the factors have a positive or negative impact on a patient’s decision-making process. Those who desire surgery secondary to external pressures (ie, want to please others, are in a time of crisis, to salvage a relationship) are poor operative candidates. 1 Patients who are self-motivated to change a nasal deformity are more likely to have a satisfactory outcome.
Expectations must be realistic. This involves clear communication between surgeon and patient, often in front of a mirror. Goals between surgeon and patient must be congruent.
Establishing a patient’s baseline psychological status may uncover red flags in surgical inte