Mastering Rhinoplasty : A Comprehensive Atlas of Surgical Techniques with Integrated Video Clips

Chapter 1  Simplifying Rhinoplasty What would constitute the "P.E.R.F.E.C.T." rhinoplasty operation? I think the following attributes are important and perhaps acronymic.Progressive. The surgeon should be able to use the operative technique for increasingly difficult cases by adding to the foundation operation (Fig. .1). Rather than learning an entirely new procedure, one merely adds additional steps as more demanding cases are encountered. For example, once the surgeon learns to master open tip suture techniques, then additional tip definition can be achieved with add-on Tip Refinement Grafts (TRG) of excised cartilage.Expandable. Although one may begin with a certain patient population, it is inevitable that one will begin to see different types of patients who require modification of the basic technique. In Southern California, I saw a large number of Hispanic and Asian patients whose thicker skin and under-projecting tips forced me to expand my surgical repertoire. Rather than being a new operation, additions and modifications represent an expansion of the foundation operation.Reproducible. Every surgeon wants to achieve reproducible results. The critical first step is to master a procedure in-depth and learn its surgical cause and effect. Many of the steps in this operation are consistently reproducible including radix grafts, tip sutures, and spreader grafts. The number of surprises and revisions can be quite low.Functional. Form without function is not acceptable. I am convinced that 35% of patients requesting a cosmetic rhinoplasty have a significant preexisting anatomical nasal obstruction, which if not corrected will lead to postoperative nasal obstruction. Therefore, a clear understanding of septal, valvular, and turbinate function, as well as their surgical correction must be a critical component of a rhinoplasty operation.Esthetic. The reality is that virtually all female patients want a more attractive nose, but one that looks natural. The younger the patient the greater the desire for a smaller cuter nosenine times out of ten, they inherited their father's nasal features . In addition to being smaller, they often want a slightly curved bridge, a slightly rotated columellar, and a well-defined tip. This operation enables the surgeon to achieve these goals consistently.Comfort Zone. Each surgeon has his/her own "rhinoplasty comfort zone." Following completion of their residency or fellowship, most surgeons have experience with one operative sequence. Initially, the surgeon should select those patients for whom they are confident that they can achieve a good result. The advantage of this operation is that the surgeon can progress to levels of greater difficulty from a solid foundation. Tip Intentsive. One of the realities of cosmetic rhinoplasty surgery is that patients are convinced that "as the tip goes so goes the result." If the tip is not attractive, the patient will not be happy. Thus, tip surgery is emphasized heavily in this operation and through out the text. A Foundation Rhinoplasty Operation Chapter 1  Simplifying RhinoplastyOur assessment of how hard a rhinoplasty is involves integration of anatomy, aesthetics, patient's goals, and requisite operative techniques. Although each surgeon will have their own individual classification, I suggest dividing the range of primary rhinoplasties into three "levels of difficulty" based on the requested degree of change, requisite technical expertise, and complexity of the operative plan. I use a simple Levels 1-3 for classifying primary rhinoplasties -Level 1 (minor), Level 2 (moderate), and Level 3 (major).Patient Request. The majority of Level 1 rhinoplasty patients have three basic complaints: the bump on profile, the wide dorsum, and the poorly defined tip. The challenge is to achieve an aesthetic result that the patient desires. The hallmark of a Level 2 case is that the complaints are similar to a Level 1 case, but the presenting deformity and requisite surgical maneuvers are more challenging. A boxy tip requiring alar rim support would be a Level 2 case. In contrast, Level 3 cases are truly "deformities" where the patient suffers from a significant loss of self-esteem. They are seeking to be "normal." Surgical correction requires an aggressive complex approach. Subtleties will not work.Patient Deformity. Perhaps, the best method for assigning the level of difficulty to a specific nose is to use a classic "standard deviation" system based on deviation from normal.The simplest example is modification of the nasal base. Using a simple ruler or caliper, one measures intercanthal width, alar flare, and alar crease width. If the alar flare is within the intercanthal width, then no modification is usually necessary (Level 1). If the alar base is quite wide and exceeds the intercnathal width by 2 mm or more, then a combined nostril sill/alar base excision is necessary (Level 2). When one encounters extreme widths in ethnic noses or markedly retracted alars due to hypoplasia of the alar cartilages, then advanced techniques will be required (Level 3).Surgical Techniques. After developing an individual set of "aesthetic" grading criteria for Level 1-3 cases based on presenting deformity, it can now be expanded by adding required operative techniques. A radix reduction is a magnitude harder than a radix augmentation. Ethnic noses are more challenging than the usual Caucasian nose. As regards the tip, an open structure tip graft signals a harder case than a tip suture. Yet, an open tip graft added to sutured domes is easier than one where the domes are excised to drop projection.Operative Complexity. Each surgical technique included in the operative plan has both its range of results and risks. Therefore, one should keep the operative plan as simple as possible and do maneuvers only when necessary. Level 1 cases may not require grafts, while Level 3 always do. Lateral osteotomies may range from none for the narrow nose to as many as 8 for the wide nose. Thus, operative complexity is both how many maneuvers are required and how complex is the individual step. Level of Difficulty: A Classification Chapter 1  Simplifying Rhinoplasty As one enters practice and begins to learn rhinoplasty surgery in the real world, decisions have to be made and their consequences must be accepted. Hopefully, these principles will guide the younger surgeon through the challenges of learning rhinoplasty surgery.Rhinoplasty is the most difficult of all cosmetic operations for three reasons: (1) nasal anatomy is highly variable, (2) the procedure must correct form and function, and (3) the final result must meet the patient's expectations. Few surgeons do more than 25 rhinoplasties a year. Thus, one must maximize the learning experience of each case by careful documentation of the operative procedure and frequent follow-up visits -only you can teach yourself surgical cause and effect. Form without function is a disaster. Most postoperative nasal obstruction reflects a failure to diagnose and treat a preoperative subclinical condition. One must identify and correct preexisting anatomical deformities of the septum, nasal valves, and turbinates. There is no excuse for not doing a thorough preoperative internal exam and recording a specific operative plan. One must accept in advance that there is no magic operation that guarantees perfect results. Each surgical maneuver within an operation has its learning curve. Within an operative sequence, the individual maneuvers are additive, but their interactions and potential complications are geometric. Keep the operation simple -maximum gain, minimum risk. Expand what you know from your comfort zone. Do not incorporate every new fad. Early in your practice, select nice patients with obvious deformities that you can easily correct using surgical techniques that you know. With experience, begin to add new maneuvers and then take on cases of greater difficulty. Operate within your comfort zone early on. The preoperative course is finite, but the postoperative course is infinite, so pick your patients carefully. Postoperative problems are most often confirmations of intraop suspicions -if the tip did not look exactly right during the case, it rarely gets better later. Do not cut corners or you will go in circles. Once you operate on a patient, it is your result, regardless of how many previous operations were done or how noncompliant the patient. Select your patient's carefully.Once you have a complication or poor result, admit it directly to the patient and discuss how it can be improved. Do not pretend that it is not there or shame the patient into accepting a minimal improvement or make it financially impossible to correct the problem.Treat patients as family -at worst they will be disappointed, but not litigious. Understand your own limitations and progress through Level 1-3 primary cases before embarking on major secondaries. Secondary rhinoplasty is technically more demanding and requires greater surgical expertise that can only be gained through operative experience. In primary cases one often takes away the negatives to reveal the underlying attractive nose while in secondaries the surgeon must be capable of rebuilding a destroyed framework using numerous grafts. Rhinoplasty is the most rewarding of all cosmetic operations, both for the patient and the surgeon. Few operations can make as great a change in a young person's appearance or in their self-confidence. For the surgeon, rhinoplasty is the ultimate in artistic three-dimensional sculpturing. It is truly worth the patient's risk and the surgeon's commitment. Guiding Principles Guiding Principles 11 At this point in the text, the sophisticated reader will realize that this chapter is, in reality, the Preface to this book. It is my contention that very few surgeons ever read the Preface and therefore I have previewed within this chapter what is to come. Although reading this text in sequence is recommended, the reality is that most surgeons focus on that portion, which is most relevant to them at a particular moment. Thus, it is necessary to make each section complete in a stand-alone fashion, which leads to a certain repetition of important points throughout the text. I do think that is important for the reader to integrate the DVD clips into the learning experience. I consider the opportunity to actually be in the operating room and see how the technique are done to be of infinite value. Ideally, one should have their computer available with the appropriate DVD loaded -read the text, look at the drawings or intraop photographs, and then enter the OR to see how it is done in the real world. The overall experience should be as close to a Rhinoplasty Fellowship as possible. On another note, the number of cited references is low because this book was written from notes and diagrams made during and after surgery. Thus, it is one surgeon's approach to rhinoplasty and not an encyclopedic multivolume text on the entire subject. Once the text was completed, I did review the rhinoplasty literature and added a Reading List to each chapter. Certain references will be cited using the following format (Author, date). Once again, I have found that writing a book on rhinoplasty surgery has made me a much better surgeon and I can only hope that the same will be true for the reader. How to Use This Book Fig. 1.5 Codex of case study diagram A Basic Rhinoplasty Operation Why is rhinoplasty so difficult? The answer is the wide variation in the patient's nasal anatomy and aesthetic desires. For the surgeon, the challenge is mastering the endless number of operative techniques available. Thus, the question becomes can one devise a basic rhinoplasty operation? A former resident who was 3 years into private practice made the following request: "Can you give me a basic rhinoplasty operation with which I can get good results and have few revisions?" My answer was quick and blunt -"It is impossible because both the anatomy and the requisite techniques are too varied. " Despite my negativity, the desire to develop a basic rhinoplasty operation has continued to intrigue me. Gradually, the fundamentals of a standard rhinoplasty operation began to crystallize. The following operation is intended for the average well-trained plastic surgeon. It can be expanded to fit a large range of nasal deformities. However, it requires that the surgeon accepts two principles. First, the surgeon must begin by doing only those cases which fit within their surgical comfort zone. Second, the surgeon must implement a progressive approach for learning rhinoplasty surgery. One begins with easier Level 1 cases and then advances to the more challenging Level 2 deformities before ultimately taking on the most difficult Level 3 problems. Distribution wise, perhaps 70% of the primary cases are Level 1, 25% are Level 2, and only 5% are Level 3. A fundamental operation will be presented in a step-by-step fashion in this chapter and its progressive adaptations for the three levels of deformities will be detailed in the rest of the text. It is important to select only those steps that are appropriate for a specific case. Remember the 95% rule -95% of rhinoplasty articles and lectures deal with the most esoteric 5% of noses, yet 95% of surgeons do not want to do the most difficult 5% of noses. This basic rhinoplasty operation is designed to allow the surgeon to do surgery for 95% of primary patients seen by a surgeon in the private practice of aesthetic surgery.Chapter 2  A Basic Rhinoplasty Operation During the initial consultation, I ask myself two critical questions about the patient. First, will a rhinoplasty make a significant improvement in this patient's nose? Second, do I want this person in my practice? If the answer is no to either question then I do not do their surgery. Rhinoplasty is not a frivolous operation; the procedure must be considered carefully by both the patient and the surgeon. The patient's goals should be to get a realistic assessment of the surgical risk to reward ratio and evaluate whether they feel comfortable with you being their surgeon. Unfortunately, surgeons too often concentrate on the technical challenge and the economic benefit of doing every nose, yet the risks of selecting the wrong patient is very real for the surgeon ranging from frustration to misery to physical abuse.Nasal Deformity. In primary cases, patients are usually very accurate in defining what is wrong with their nose, but often very nonspecific about what they want. The easiest patients are those requesting elimination of obvious deformities (bump on profile, round tip), while the most difficult are those who are unable to say exactly what they desire or those who demand a specific "look." Essentially, one must get patients to commit to what they want. For this reason, I have the patient tell me what three things should be improved in the order of importance. Next, I examine the nose in detail and make my list of what must be done to make the nose attractive and to achieve balance with the face. Perhaps 90% of all the primary consultations have a correctable nasal deformity on evaluation. The other 10% are attractive females with minimal deformities, males seeking "model" refinements, and patients wanting a "major change" when only a limited improvement is realistic.Patient Factors. It is important to assess the patient's motivation. Open-ended questions should be asked as they will often reveal the patient's motivation. "What do you not like about your nose?" "Why do you want surgery at this time?" "What effect will a rhinoplasty have on your life?" It is extremely important to "hear" what the patient is saying psychologically rather than merely listening to the words. Which patients do I reject for primary rhinoplasty? These would include the overly narcissistic male, the perfectionistic female who will never be satisfied, and the unhappy patient who thinks that the operation will change his or her life. Once you choose to operate, you must provide the care and concern that the patient requires, not the amount that is reasonable. I have learned the hard way that "the pre-op course is finite, but the post-op course is infinite."Analysis. Given the choice, would most surgeons rather be a master technician with golden hands or a strategic tactician with a critical aesthetic eye? In rhinoplasty as in chess, it is the thought process before the manipulation of the pieces that is critical. If one fails to recognize that the radix is low, then the dorsum will be lowered excessively resulting in a nose job appearance. In contrast, the simple addition of a fascia graft to the radix allows a more limited dorsal reduction producing a more natural, elegant, unoperated look. The difference is not surgical skill, but rather the design of the operative plan based on preoperative analysis.Prior to my evaluation, I hand the patient a mirror and ask them to show me what bothers them the most, preferably in the order of importance. I write these down on the operative planning sheet and they become the cornerstone of the operative plan assuming they are correctable. After a thorough internal and external exam, I do a top-down region exam. Consultation Consultation 15 Radix and Dorsum. The radix is analyzed on lateral view for both the radix area (from glabella to lateral canthus level) and nasion (the deepest point in the nasofrontal angle). The critical decision is whether the radix needs to be maintained, augmented, or reduced. Fortunately, no modification is necessary in most cases (82%). Next, the dorsum is evaluated for height and width, while the bony base is assessed for width. The key determinant of dorsal height is the nasofascial angle, which is measured from nasion to tip. The desired profile line is slightly curved for females, straight for males. On anterior view, the width of the parallel "dorsal lines" is roughly the same as the philtral columns or tip-defining points, 6-8 mm for females, 8-10 mm for males. The maximum base bony width of the nose is marked as the "X-point" and should be less than the eyes' intercanthal width. Anesthesia Anesthesia 19 Fig. 2.2 (a-c) Local anesthesia a b c Alar arcade Columellar br. Every surgeon who carries out rhinoplasty procedures will learn a great deal from this book. The beginner is guided through the performance of a standard rhinoplasty operation that can be expanded to incorporate the described advanced techniques as experience is gained. Here, the emphasis is on the routine case that is too frequently overlooked in favor of the esoteric. For the already proficient surgeon, on the other hand, the latest breakthroughs in the management of difficult cases, such as saddle nose, skin sleeve problems, and dorsal grafting, are clearly depicted. When appropriate, approaches developed exclusively by the author are presented. The lucid text is complemented by a wealth of color figures as well as by DVDs containing video clips that transport the reader into the operating room with the author while he performs live surgery and demonstrates the technique in question. Every surgeon who carries out rhinoplasty procedures will learn a great deal from this book. The beginner is guided through the performance of a standard rhinoplasty operation that can be expanded to incorporate the described advanced techniques as experience is gained. Here, the emphasis is on the routine case that is too frequently overlooked in favor of the esoteric. For the already proficient surgeon, on the other hand, the latest breakthroughs in the management of difficult cases, such as saddle nose, skin sleeve problems, and dorsal grafting, are clearly depicted. When appropriate, approaches developed exclusively by the author are presented. The lucid text is complemented by a wealth of color figures. Please note: DVDs are no longer included. Customers will receive a link to download the videos! Every surgeon who carries out rhinoplasty procedures will learn a great deal from this book. The beginner is guided through the performance of a standard rhinoplasty operation that can be expanded to incorporate the described advanced techniques as experience is gained. Here, the emphasis is on the routine case that is too frequently overlooked in favor of the esoteric. For the already proficient surgeon, on the other hand, the latest breakthroughs in the management of difficult cases, such as saddle nose, skin sleeve problems, and dorsal grafting, are clearly depicted. When appropriate, approaches developed exclusively by the author are presented. The lucid text is complemented by a wealth of color figures. The video clips are stored on ExtraMaterials (http://extras.springer.com).