Rhinoplasty Dissection Manual

• Rhinoplasty •

Dissection Manual

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DEAN M. TORIUMI

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DANIEL G. BECKER

~ L1PPINCOTf WILLIAMS & WILKINS

Rhinoplasty Dissection

Manual

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Rhinoplasty

Dissection Manual

Dean M. Toriumi, M.D. Associate Professor

Division of Facial Plastic and Reconstructive Surgery

Departm ent of Otolaryngology-Head and Neck Surgery

University of Illinois at Chicago

Daniel G. Becker, M.D. Assistant Professor

Division of Facial Plastic and Reconstructive Surgery

Departm ent of Otola ryngology-Head and Neck Surgery

University of Pennsylvania

Illustrated by Devin M. Cunning, M.D.

4~ LIpPINCOTT WILLIAMS & WILKINS •

A Wolters Kluwer Company

Philadelphia • Baltim ore • New York • London Bueno s Ai res • Hon g Kon g • Sydney · Toky o

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Acquisitions Editor: Danette Knopp Developmental Editor: Sara Lau ber Production Editor: Patri ck Carr Manufacturing Manag er: Tim Reynolds Cover Designer: Christine Jenn y Compositor: Maryland Co mposi tion Printer: Couri er Westford

© 1999 by LIPPINCOTT WILLIAMS & WILKINS 227 East Wa shington Square Philadelphia, PA 19106-3780 USA LWW.com All rights reserv ed. This book is protec ted by cop yright. No part of this book may be re produced in any form or by any means, includ ing photocopying, or utiliz ed by any information storage and retrieval system without written permission from the cop yright owner, exce pt for brief qu otat ions em bodied in cri tica l article s and reviews . Material s appearin g in this book prepared by individuals as part of their of ficial duties as U.S. go vernment employees are not covered by the above-me ntioned copyright. Illust rations © Dani el G. Becker. Photograph s © Dean M. Toriumi. Printed in the United States of America Library of Congress Cataloging-in-Publication Data

Toriurni, Dean M. Rhinopla sty dissection manu al/Dean M. Toriumi, Danie l G. Bec ker ; illustrated by Devin M . Cu nning. p.

em,

Includes bibliographical references and ind ex.

ISB N 0-7817 -1783-3

I . Rhinoplasty Handbooks, manu als, etc. 2. Nose-Surgery

Handb ooks, manuals, etc. I. Becker, Dani el G. II. Title.

[DNLM: 1. Rhinopla sty-meth ods Handbo oks. WV 39 T683 r 1999] RDII 9 .5.N67T 67 1999 617.5' 230592---dc2 1 DNLMIDLC for Library of Congress 99-260 58 CIP Care has been take n to co nfirm the accuracy of the information pre sented and to descri be generally accepted practi ces. However, the autho rs, ed itors, and publisher are not responsible for errors or omis sions or for any con sequ ences from application of the information in this book and make no warra nty, expresse d or impli ed, with respect to the currency , completenes s, or accura cy of the contents of the pub licati on. Appli cation of this information in a particular situation rem ain s the profe ssion al respon sibility of the practitioner. Th e authors , editors, and publisher have exerted every effort to ensure that drug selectio n and dosage set forth in this text are in accordance with current recommendations and practi ce at the time of publ ication . Howe ver, in view of ongo ing research, change s in govern ment regul ation s, and the con stant flow of inform ation relat ing to dru g therapy and drug reaction s, the reader is urged to chec k the package insert for each drug for any change in indic ation s and dosage and for added warn ings and preca utions. Thi s is particularly importan t when the recomm end ed agent is a new or infrequently employed drug. Some drugs and med ical de vices present ed in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted rese arch settings. It is the resp onsibil ity of the health care provider to asce rtain the FDA status of each dru g or de vice planned for use in their clinic al practic e. 10 9 8 7 6 5 4 3 2

To my ever supportive wife, Colleen, and our two daughters, Hannah and Olivia, and to my parents who gave me encouragement to practice medicine. Dean M. Toriumi, M.D.

With special appreciation and love for my family-my parent s Bill and Merle, and my brothers and sisters-in-law, Richard and Rachel, Paul, Sam, and Jen. Daniel G. Becker, M.D.

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Contents

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

Preface xiii

Acknowledgments xv

Chapter 1:

Anatomy

Chapter 2:

Rhinoplasty Analysis . 9

Landmarks for Analysis . 9

Lab Exercise: Nasal Analysis . 11

Surface Angles, Planes, and Measurements-

Definitions . 12

Rhinoplasty Analysis . 16

Chapter 3:

Injection Infiltrative Anesthesia Technique

. 25

. 25

Chapter 4:

Septoplasty Nasal Dissection: Septoplasty with

Cartilage Harvest

. 31

Incisions and Approaches Transcartilaginous or Cartilage-Splitting

Approach Delivery Approach The External (Open) Rhinoplasty Approach

. 37

. 37

. 40

. 43

Chapter 6:

Removal of Bony-Cartilaginous Hump

. 59

Chapter 7:

Osteotomies Medial Osteotomies

. 67

. 67

Chapter 5:

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Lateral Osteotomies and Infracture Intermediate Osteotomies

Chapter 8:

Spreader Grafts

Chapter 9:

Surgery of the Tip Exercises

Chapter 10: Alar Base Resection

Internal Nostril Floor Reduction Wedge Excision of Nostril Floor and Sill . .. Alar Wedge Excision Sliding Alar Flap

Chapter 11:

Other Maneuvers . . . . . . . . . . . . . . . . . . . . . .. Plumping Grafts Caudal Extension Grafts Deviated Caudal Septum Rib Cartilage Graft Reconstruction of

Saddle Deformity

Chapter 12:

Harvest of Autogenous Tissue Harvesting Conchal Cartilage Harvesting Ethmoid Bone Harvesting Rib Graft Harvesting Calvarial Bone

Chapter 13: Incision Closure, Nasal Splint, Post-Operative Considerations Closure of Midcolumellar Incision Closure of the Marginal, Intercartilaginous,

or Transcartilaginous Incision Placement of Intranasal Packs, Nasal

Splint Postoperative Care Appendix A: Appendix B: Appendix C: Appendix D: Appendix E Appendix F: Appendix G: Appendix H: Appendix I: Appendix J: Appendix K:

Tripod Concept Guide to Nasal Analysis Aesthetic Analysis Surface Angles, Planes, and

Measurement: Definitions Tip Support, Incision, and Approaches Achieving Surgical Goals: Selected Options . . Selected Complications of Rhinoplasty Adjunctive Procedures Cleft Lip Nasal Deformity Photography Setup Indications for External Rhinoplasty

Approach

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Appendix L: Appendix M: Appendix N:

Suggested Surgical Instruments for Rhinoplasty List of Selected Companies with AddresseslPhone Numbers Selected Recommended Literature

. 171 . 172 . 174

Index

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Foreword

Exce llent surgical outcomes in rhinoplasty derive from two interrelated fac tors: (1) a de­ tailed understanding of the multiple nasal anatomic varian ts encountered, and (2) an ac­ qui red knowledge of the ulti mate long-term effects of surgical altera tions of these anatomic components-the evo lution of healing. The first ski ll ca n be learned by detailed observation, enhanced by cadaver dissection; the second skill only by ca reful foll ow-up of ope rated patients over time. The genera l con cepts of nasal anatomy have been fun damentally clear for centuries , but on ly in recent decades have surgeons appreciated the fine ly det ailed nuances of nasal anatomic dynamic s that influence the surgical crea tion of a natural, plea sing rhinopl asty re­ sult, free of surgical stigmata. A det ailed com prehension of nasal anatomy must therefore transcend knowledge of basic anatomic relationships. Th e surgeo n must j udge , by inspec­ tion and pa lpation, the character of the ski n and subcutaneous tiss ues as they vary from nasal region to region , the influences of faci al mimetic musculature, the relative strength and support of the carti laginous and bony framework and substruct ure, and the lim itations imposed by the int err elation ship of all these struc tures upon the ultimat e fav orable result. As important as the eva luation of what can reasonably be accomplished during rhi noplasty is the acqui red kno wledge and ski ll to assess what canno t be acco mplished. This ju dgment is largel y pre dicated on the critical ana lysis of each pat ient's indivi dual anatomy, coupled with techn ical refin ements guided by experie nce, and generally requires years of personal surgic al result evaluation to beco me kee n. In this diss ection manu al, Drs. Becker and Toriumi have created a unique study guide and cadaver dissection manu al ded icated to guiding the learn er in a disciplined manner. They admirably ex tend the tradit ion of the Universi ty of Illinois Departm ent of Oto laryn­ gology's leader ship in teaching anatomy and surgery in rhin oplasty. Cadaver dissec tion cons titutes a privil ege not available to all, and, as such, this precious material must be wise ly and co nserva tive ly approached . Experie nce teaches that a discipl ined, structured ap­ proach to dissecti on of the nose pro duces the best edu cational outcome . An imp ortant fav orable develop ment in cont empo rary rhinoplasty is the appropria te con­ ce rn for conservative and subtle anatomic changes that by definition derives from a prese r­ vativ e attitude toward nasal tissues. Commonly, rath er than excisional sacrifice of large segments of cartilage or bon e, a phil osophy of preservation and restoration oftissues is de­ ve loping that preclud es crea tion of unnecessary tissue voids whic h may heal and scar un­

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predictably. Wise surgeons recognize that even a larger nose, well balanced to the rounding facial features, is always aesthetically preferable to a nose made over-sma radical surgery. Conservation surgery thereby further extends the surgeon's control the final surgical result, as an appropriate equilibrium between the corrected nasal ske and soft tissue covering is more reliably achieved. Con servative sculpture and volum duction of the alar cartilages clearly produce more favorable results, generally avoi major resections and vertical interruprion of the intact residual strip of lateral and m crus. Notching, pinching, alar cephalic retraction, over-rotation, and asymmetries ar almost entirely eliminated in long-term healing when this conservative philosophy is braced . A further striking example of conservatism is the preservation of a strong , high file in many patients, a distinct contrast to the dramatic retrousee pro files create decades past by sacrifice of over-generous segments of nasal bony humps. Finally, thoughtful nasal surgeons, through accurate anatomic diagnosis , discern w portions of the nasal anatomy are pleasing and satisfactory, striving to avoid distur these structures and areas when correcting (or gaining access to) anatomic componen need of correction. This philosophy further extends the surgeon 's favorable control ove timate healing. Thoughtful cadaver dissection provides the learner with visual pathwa gain access to structures to be modified, while preserving normal tissues and relations Important tissue planes, vital in live surgery, can be appreciated best when viewed at le in the dissection laboratory. This well-conceived work, properly employed, contributes substantially to shorte the steep learning curve characteristic of rhinoplasty.

M. Eugene Tardy, Jr., M.D., F.A.C Profes sor of Clinical Otolaryngolo Director, Division of Facial Plastic Reconstructive Surgery University of Illinois Medical Cen Chicago, Illinois Professor of Clinical Otolaryngolo Indiana University School of Medi

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Preface

The successful rhinoplasty surgeo n' s operative plan is based on a clear understanding of the patient's desired changes, a care ful and accurate diag nosis of the patient's anatomy , and a wide armamentarium of surgica l techniques. Prior techniques and the surgeon's personal experiences with the array of surgical techniques are also primary factors in the decision for a particular operative approach. The successful surgeon's applicatio n of surgica l tech­ niques is designed to accom modate differences in anatomy and to account for varia nt anatomy. For example, noses with thin skin and noses with thick skin each present specific problems that must be considered when choosing techniques for altering nasal struc ture. Also, the effec ts of scar contracture vary from patie nt to patient and can significantly affec t the ultimate aesthetic and functional outcome . The rhinoplasty surgeo n must recognize that the healing process may distort the cha nges made at the time of surge ry, however ex pert ly they were accomplished. The surgeon's only recourse is to build a structurally sound nasal architecture that can withstand the force s of scar contracture and provide an acceptable suc­ cess rate. The importance of experience in rhinopl asty cannot be overemphasized. The experi­ enced rhinoplasty surgeon can anticipate the likelihood of a favorable outcome based on his or her experience using certain techniqu es with a specific deformi ty. Selec tion of the proper technique for each circ umsta nce should provide the opportunity for a high success rate. The purpose of this dissec tion manual is to provide practical infor mation about a wide range of surg ical techn iques in rhinoplasty. The dissection ma nual guides the reader through a step-by-step dissection. It focuse s on the execution of basic and advanced rhino­ plasty techniques and seeks to provide practical information that can be readily applied in surgery. The text is intended to be a procedurally oriented dissection manual and is orga­ nized to allow easy reference to a wide array of basic and advanced rhinoplasty techniques. Illustrations and intraoperative photograph s, along with detailed text, guide the reader through the step-by-step dissection. Important techn ical and clinical "pearls" are high­ lighted in each section. A progra mmatic cadaver dissection videotape acco mpanies the text. Before beginning the nasal dissection, review the chapter on nasal anatomy (Chapter 1) and the chapter on pre-operative rhinoplasty analysis (Chapter 2). Chapter 3 outlines local anesthesia injec tion techniqu es; the dissector is instructed to practice the injections prior to commenci ng the programm atic dissection. The dissection manual guides you through the following dissections: septoplasty, trans­ /'

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cart ilag inous or int er-cart ilaginous app roach , de livery approac h and an external rh ino approach. The remainder of the programmatic nasal dissection detai ls a number of plasty techniques and addresses a number of specific rhinoplasty pro blems. The man cuses primarily on the external rhinopl asty approach; how ev er, all approaches are co and ca n be perform ed sequentially, or the dissector may choo se to foc us on a speci proach. Appro priate targeted reference s for further readi ng are also pro vided . We recommend that the diss ector pro ceed with Chapters 1- 6 with the skin-so ft tiss velope intact. For the remai ning chapters, the dissector may wish to split the ski n dow midl ine for better exposur e. In this fashi on, the dissection can be performed withou t sista nt, and (except for a complete septopl asty) without a he ad light. The cadav er laboratory is the plac e to sharpen one ' s sur gical skills. This manual se provide the dissector with the opportunity to obtai n maximum benefit from performin co mp lex opera tion on cadaver specimens. Th e di ssecti on manual was "field tested " Unive rsity of Pen nsylvan ia Rhinoplasty Co urse : Aesthetic & Fu nction al Rh inopl asty ticipants, many of wh om professed relativel y limited rhinoplasty experience, und erto stepwise, programmatic dissection and work ed through the manu al (with the except rib or clav arial bone harvest) in a sin gle five-hour period. Rhinopl asty is an operatio n that requ ires co nstant thou ght , assimilation of inform and reac tion to unexpected fi ndi ngs . W ith this in mind, the authors strongly recomme vo lve me nt in as many advanced teaching encounters as possible. This ma y involve re time ly literature, attending adv anced rh inoplasty courses, observing other experience geo ns, or sharpening one's skills in the cadav er laboratory. We hope that use of th section manual will stim ulate thought and incite both the en thu siasm of the beginner a as experie nced rhinopl asty surgeons seeking to broaden their surg ical armamentariu

Dean M. Toriumi, Daniel G. Becker,

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Acknowledgments

We wish to thank the follow ing frien ds, colleag ues, and me ntors for their encouragement, support, and guidance . Dr. M. Euge ne Tardy, Jr., has been an inspirational men tor and friend , whose advice and enco uragement were instrumental in this project ' s development. Our mentors in Otolary ngology- Head & Neck Surgery and in Facial Plastic & Recon­ structive Surgery are a continuing source of inspiration and guidanc e. Depar tment Chairm en, Ed Appl ebaum at the University of Illinois at Chic ago, and David Kennedy at the Univ ersity of Penn sylvania, deserv e spec ial than ks for supporting and fa­ cilitating this undertaking. Devin M. Cunning deserves much appreci ation. His medical illu strations speak for them­ selves, but do not tell of the countl ess hour s of collaboration, hard work, and multiple re­ visions. Danette Knopp of Lip pincott Williams & Wi lkins provided publishing leadership from the very co nception of the project to its co mpletion. Sara Lauber of Lip pincott Willi ams & Wil kins play ed an instru mental role in guiding the manuscript through its fina l, critical stage . Patrick Carr deserves thanks for his outstandi ng work as Production Editor.

Dean M. Toriumi, M.D. Daniel G. Becker, M.D.

xv

Rhinoplasty Dissection

Manual

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1 Anatomy

Although the anatomy of the nose has been fundamentally understood for many years, only relatively recently has there been an increased understanding of the long-term effects of surgical changes on the function and appearance of the nose. A detailed understanding of nasal anatomy is critical for successful rhinoplasty. This chapter reviews the surface and structural anatomy of the nose, with an emphasis on important surgical anatomy. Accurate assessment ofthe anatomic variations presented by a patient allows the surgeon to develop a rational and realistic surgical plan. Furthermore, recognizing variant or aber­ rant anatomy is critical to preventing functional compromise or untoward aesthetic results. This chapter presents a limited diagrammatic overview of nasal anatomy. More detailed study of nasal and facial anatomy is recommended (1) (Figs. 1-10).

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Figure 1. Surface anatomy of the nose: Frontal view. 1, Glabella ; 2, nasion; 3, tip-defining points; 4, alar-sidewall ; 5, supraalar crease; 6, philtrum .

Figure 2. Surface anatomy of the nose: Base. 1, Infratip ule; 2, columella; 3, alar sidewall; 4, facet or soft-tissue tr gle; 5, nostril sill; 6, columella-labial angle or junction alar-facial groove or junct ion; 8, tip-def ining points .

Figure 3. Surface anatomy of the nose: Lateral. 1, Glabella; 2, nasion, nasofrontal angle ; 3, rhinion (osseocartilaginous junction) ; 4, supratip ; 5, tip-defining points; 6, infratip lobule ; 7, columella; 8, columella-labial angle or junction; 9, alar-facial groove or junction .

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Figure 4. Surface anatomy of the nose: Oblique. 1, Glabella; 2, nasion, nasofrontal angle; 3, rhinion; 4, alar sidewall; 5, alar-facial groove or junction; 6, supratip; 7, tip-defining points; 8, philtrum.

Figure 6. Nasal anatomy : Lateral (rotated slightly obliquely) . 1, Nasal bone; 2, nasion (nasofrontal suture line); 3, inter­ nasal suture line; 4, nasomaxillary suture line; 5, ascending process of maxilla; 6, rhinion (osseocartilaginous junction) ; 7, upper lateral cartilage ; 8, caudal edge of upper lateral carti­ lage; 9, anterior septal angle; 10, lower lateral cartilage , lat­ eral crus; 11, medial crural footplate; 12, intermediate crus; 13, sesamoid cartilage; 14, pyriform aperture.

Figure 5. Nasal anatomy : Oblique. 1, Nasal bone; 2, nasion (nasofrontal suture line); 3, internasal suture line; 4, naso­ maxillary suture line; 5, ascending process of maxilla; 6, rhin­ ion (osseocartilag inous junction); 7, upper lateral cartilage; 8, caudal edge of upper lateral cartilage ; 9, anterior septal an­ gie; 10, lower lateral cartilage , lateral crus; 11, medial crural footplate ; 12, intermediate crus; 13, sesamoid cartilage; 14, pyriform aperture .

Figure 7. Nasal anatomy: Base. 1, Tip-defining point; 2, in­ termediate crus; 3, medial crus; 4, medial crural footplate; 5, caudal septum; 6, lateral crus; 7, naris; 8, nostril floor; 9, nos­ tril sill; 10, alar lobule; 11, alar-facial groove or junction; 12, nasal spine.

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Figure 8. Nasal septum. 1, Quadrangular cartilage; 2, nasal spine ; 3, posterior septal angle; 4, middle septal angle; 5, an­ terior septal angle; 6, vome r; 7, perpendicular plate of eth­ moid bone; 8, maxillary crest , maxillary component; 9, maxil­ lary crest, palatine component.

Figure 9. Nasal musculature. A: Elevator muscles: 1 cerus; 2, levator labii alaequae nasi; 3, anomalous na Depressor muscles : 4, alar nasalis; 5, depressor septi C: Compressor muscles: 6, transverse nasalis; 7, com sor narium minor. D: Minor dilator muscles : 8, dilator nar terior . E: Other: 9, orbicularis oris; 10, corrugator.

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Figure 10. Nasal vasculature. 1, Dorsal nasal artery ; 2, l nasal artery; 3, angular vessels ; 4, columellar artery.

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PEARLS

The nose may be thought of in anatomic thirds . The upper third roughly corre­ sponds to the bony dorsum; the middle third roughly corresponds to the cartilagi­ nous dorsum; and the lower third generally corresponds to the tip. o When describing relationships of one structure to another in the nose, use the well­ . defined anterior/posterior or caudal/cephalic. (Fig. II). . o The nasal bones are usually small; the ascending process of the maxilla provides a significant contribution to the bony anatomy of the nose. o The alar lobule contain s fat and fibrous connective tissue, but it contains no carti­ lage. The lateral crus of the lower lateral cartilage takes on a more cephalic posi­ tion as it extends laterally and is not found in the alar lobule. o The lobule, alar lobule, and the infratip lobule are terms that designate three dis­ tinct anatomic areas of the nose. The lower third of the nose may be referred to as the lobule or tip. The alar lobule is a fibrofatty nasal subunit that is devoid of car- . tilage and compose s a portion of the lateral nasal sidewall . The infratip lobule o

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should comprise one third of the vertical length of the nose on base v columellar/lobule ratio). • The nasal valve area includes the cross-sectional area described by th and is affected by the inferior turbinate; the caudal septum, and the rounding the pyriform aperture. The nasal valve proper is bounded septum, the caudal margin of the upper lateral cartilage, and the floor and is considered to be the location of the least cross-sectional area in lateral osteotomies, care is taken to preserve a small triangle of bone form aperture to prevent medialization of the inferior turbinate, whi , promise the cross-sectional area of the nasal valve area. • Scroll region: The upper lateral cartilages and lower lateral cartilage in three different configurations. Most commonly, the cephalic edge lateral cartilage overlaps the caudal edge of the upper lateral cartilage region. Less commonly, the cephalic edge of the lower lateral cartila caudal edge of the upper lateral .cartilage. Rarely the cephalic edge lateral cartilage is overlapped by the caudal edge of the upper lateral • Internasal suture line: The nasal bones are fused inthe mid\ine at the i ture. When elevating the skin-softtissue envelope, decussating fibers vided (typically with scissors) from their attachment at the midline i ture to achieve the desired exposure. ' • The caudal margin of the nasal septum has a defined posterior septal a dle septal angle, and an anterior septalangle. This anatomy plays a sig in the shape of the nasal tip, including the infratip lobule, double supratip region . The surgeon attempting to create or allow for tip rota servative excision of a superiorly based triangle of caudal septum m of this anatomy, .', ' , • The septum is composed of contributions from a number of anatom (see Fig . 8). • In performing septoplasty, great care must be taken to preserve a gene to maintain support for the lower two thirds of the nose. Generally, mended that at least 15 mm caudally and 15 mm dorsally (after accou removal of dorsal hump) be preserved. • Rhinion versus sellion: The rhinion is the soft-tissue correlate of th , laginous junction of the nasal dorsum. The sellion corresponds to th ' .'' ' . ' laginous junction ~f the nasal dorsum. • Osteotomies should not extend into "the ha~d nasofront~l bone. When , extend too far cephalically into this thick, hard bone, a rocker deform suit. In a rocker deformity, infracture of the bone may displace th cephalic portion laterally. .

• Vascular supply and lymphatics are found superficial to the nasal mus The soft-tissue layers in .the nose are epidermis, dermis,subcutaneou contains blood vessels and lymphatics; and also a (typically) thin l muscle and fascia (musculoaponeurotic) plane, areolar tissue plane, a drium/periosteum. Dissection during rhinoplasty in the proper tissue olar tissue plane (i.e ., submusculoaponeuroticj] preserves nasal blood minimizes postoperative edema. ' . . • The astute surgeon will be able to anticipate 'the contour of the uppe lateral cartilages by studying the surface topography of the nose.

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REFERENCES 1. Tardy ME, Brown R. Surgical anatomy of the nose. New York: Rav en Press, 1990. 2. Toriu mi DM , Mueller RA, Grosch T, Bhattachary ya TK , Larrabee WF . Vascular anatomy of the nose and the external rhinoplasty approach. Arch 0101Head Neck Sur g 1996 ;122:24-34.

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2 Rhinoplasty Analysis

Development of an oper ative plan that will achieve the desired outcome requires an under­ standing of the patient' s wishes and selection of appropriate surgical maneuvers to effect the propo sed changes. Th e surgeon mu st be able to identify anatomic con straints that will limit the ability to change contour (thick skin, weak cartilages, etc.). Experi ence with rhino­ plasty over time has sho wn that detailed anatomic analysis of the nose is an essentia l first step in achieving a successful outc ome. Failure to recognize a particular anatomic point preoperatively will often lead to a less than ideal long-term result. After you have identified the various anatomic landmarks in Chapter 1, undertake a pre­ operative rhinoplasty analysis of your patient (cadaver specimen) . In this programmatic dissection, you will perform a number of incisions, approaches, and surgic al techniques, but it is also important to develop your skills in rhinoplasty analysis. Repe ated practice of rhinoplasty-analysis skills will improve your preoperative diagno stic abilit y. Therefore, in this exercise, determine what the best approach and techniques would be in your specime n. Follow the simplified rhinoplasty-analysis algorithm provided as you examine the face and nose. Also provided is a more detailed description of terms and a more detailed review of rhinoplasty analysis.

LANDMARKS FOR ANALYSIS (FIG. 1) (Appendix C) Points Trichion: Anterior hairline in the midlin e Glabella: Mo st prominent midline point of forehead , well appreciated on lateral view Nasion: Most posterior midline point of forehead, typically corres ponds to nasofrontal su­ ture Rhinion: Soft-tissue correlate of osse ocartilaginous junction of nasal dorsum Sellion: Osseocartilaginous junction of nasal dor sum Supratip: Point cephalic to the tip Tip: Ideally , most anteri orly projected aspect of the nose Subnasale: Junction of columella and upper lip

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Figure 1. Nasal analysis: Landmarks.

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Labrale superius: Border of upper lip Stomion: Central portion of interlabial gap Stomion superius: Lowest point of upper-lip vermilion Stomion inferius: Highest point of lower-lip vermilion Mentolabial sulcu s: Mo st posterior midline point between lower lip and chin Pogonion: Mo st anterior midline soft-tissue point of chin Menton : Most inferior point on chin Cervical point: Point of intersection between line tangent to neck and line tangent to sub­ mental region Gnathion: Point of intersection between line from subnasale to pogonion and line from cer­ vical point to menton

LAB EXERCISE: NASAL ANALYSIS General

Skin quality: Thin, medium, or thick Primary descriptor (i.e., why is the patient here): For example, "big," "twisted," "large hump "

Frontal View

Twisted or straight: Follow brow-tip aesthetic lines Width: Narrow, wide, normal, "wide-narrow-wide" Tip: Deviated, bulbous, asymmetric, amorphous, other

Base View

Triangularity: Good versus trapezoidal Tip: Deviated, wide, bulbous, bifid, asymmetric Base: Wide, narrow , or normal. Inspect for caudal septal deflection Columella: ColumelJarllobule ratio (normal is 2:1 ratio); status of medial crural footplates.

Lateral View

Nasofrontal angle: Shallow or deep Nasal starting point: High or low Dorsum: Straight, concavity, or convexity; bony, bony-cartil aginous , or cartilaginous (i.e., is convexity primarily bony , cartilaginous, or both) Nasal length: Normal, short, long Tip projection: Normal, decreased, or incre ased Alar-columellar relationship: Normal or abnormal Naso-labial angle: Obtuse or acute

Oblique View

Does it add anything, or does it confirm the other views?

Many other points of analysis can be made on each view, but these are some of the vital

points of commentary.

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SURFACE ANGLES, PLANES, AND MEASUREMENTS: DEFINITIONS (FIG (1-5) (Appendix D)

Facial thirds Upper third : Trichion to glabella Middle third: Glabella to subnasale Lower third: Subnasale to menton (Fig. 2A) Horizontal fifths: Five equally divided vertical segments of the face (Fig. 2B) Frankfort plane: Plane defined by a line from the most superior point of auditory cana most inferior point of infraorbital rim (Fig. 2C) Nasofrontal angle : Angle defined by glabella-to-nasion line intersecting with nasion-to line. Normal, 115 to 130 degrees (within this range, more-obtuse angle more favor in female , and more acute angle in male patients ; Fig. 2D) Nasofacial angle : Angle defined by glabella-to-pogonion line inter secting with nasion tip line . Normal, 30 to 40 degrees (Fig. 2E)

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A Figure 2. Surface angles, planes, and measurements. A: Horizontal facial thirds. B: Vertical facial fifths .

c Figure 2, continued. C: Frankfort plane . D: Nasofrontal angle.

E Figure 2, continued. E: Nasofac ial angle . F: Nasomental angle.

G

Figure 2, continued. G: Relationship of lips to subnasale-to-pogonion line. H: Relationship of lips to na somental line.

Figure 2, continued. I: Mentocervical angle. J: Legan's angle of facial convexity.

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K Figure 2, continued. K: Nasolabial angle. L: Nasal projection : method of Goode.

PEARL Normal projection with a "3-4-5" triangle described by Crumley (see later) gives a riasofacial angle of 36 degrees . Nasoment al angle : Angle defined by nasion-to-tip line intersecting with tip-to-p ogonion line. Normal , 120 to 132 degree s (Fig. 2F) Relation ship of lips To nasomentalline: Upper lip, 4 mm behind; lower lip, 2 mm behind line from nasal tip to menton (Fig. 2H) To subnasale-t o-pogonion line: Upper lip, 3.5 mm anterior; lower lip, 2.2 mm anterio r (Fig.2G) Mento cervical angle: Angle defined by glabella-to-pogonion line intersectin g with men­ ton-to-cervical point line (Fig. 21) Legan faci al-con vexity angle: Angle defined by glabella-to -subnasale line intersecting with subnasale-to-pogonion line; normal , 8 to 16 degree (Fig. 21)

PEARL Useful in assessing chin deficiency, candidacy for chin implant, chin advancement, or other chin alteration Nasolabial angle : Angle de fined by columell ar point-to-subn asale line intersecting with subnasale-to-Iabrale superius line; normal , 90 to 120 degre es (within this range, more obtuse angle more favorable in female, and more acute in male patient s; Fig . 2K) Columell ar show: Alar-columellar relationship as noted on profile view; 2 to 4 mm of col­ umell ar show is normal

Nasal projection: Anterior protrusion of nasal tip from face (Fig. 2L) Goode's method : A line is drawn through the alar crease, perpendicular to the F plane. The length of a horizontal line drawn from the nasal tip to the alar l point-to-nasal tip line) divided by the length of the nasion -to-nasal tip line . 0.55 to 0.60 (2,3) Crumley's method: The nose with normal projection forms a 3-4-5 trian gle [ point-to-nasal tip line (3), alar point-to-nasion line (4), nasion-to-nasal tip (4).

Byrd's method: Tip projection is two-thirds (0.67) the planned postoperative ideal) nasal length . Ideal nasal length in this approach is two-thirds (0.67) the cial height (5)

POWELL AND HUMPHRIES "AESTHETIC TRIANGLE" Nasofrontal: 115 to 130 degrees Nasofacial: 30 to 40 degr ees Nasomental: 120 to 132 degrees Mentocervical: 80 to 95 degrees (3)

RHINOPLASTY ANALYSIS

A thorough phy sical examination and accurate preoperative anal ysis are cr achieving the desired long-term postoperative rhinoplasty result. Some degree of organization assi sts in the execution of the physical examination. Visual examinat finger palpation are equally important in the nasal evaluation. Throughout the eva a mental image of the potential outcome and surgical limitations inherent in every ual should be visualized. In effect, the potential rhinoplasty operation is rehearsed the physical examination proceeds (1,6). Study of the stand ard preoperative photographic images for rhinoplasty (fronta lateral, oblique) allows a systematic, detailed anatomic anal ysis that complements th ical examination proce ss. Thi s chapter focuse s on analy sis of the four standard rhin photographic views (frontal, base, lateral , oblique). Emphasis is placed on ana to scriptions of structures and their relationships to other structures. Analysis begins by examining all four view s and making an assessment of the stature of the patient , the facial skin quality , and the symmetry of the face . The prin dividing the face into horizontal thirds and vertical fifths is a useful tool to obtain a sense of any incongruent areas of the face that may playa key role in nasal appeara the outcome of nasal surgery. It is essential that these incongruent areas or asymme recognized and discus sed with the patient. Thickness and quality of the facial skin taneous tissue complex must be determined, as it plays a critical role in dictating t tations of what can and cannot be accompli shed with aesthetic nasal surgery (1,6,7 After completing the general assessment, note and highlight the most striking ch istics of the nose. These are typically the characteristics that bring the patient fo plasty , such as excessive size, deviation , or a dorsal hump. These primary patient c must be recognized, highlighted, and addres sed above all else. As the surgeon reviews each photographic image, the major aesthetic and te points that can be evaluated on a given view are noted first. Subtleties in analysis a addressed. It is important to recognize both the characteristics of greatest concern to tient and the more subtle findings. The patient may not notice these other subtle ab ities if they are left unaddressed by the surgeon. Postoperatively, the scrutinizing may notice and point out these abnormalities. Stepwise, methodical analysis of the and the photographic view s allows the well-trained surgeon to identify significant an and aesthetic point s.

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Frontal View On frontal view, the observant surgeon first notes nasal width, any deviation from the midline , and characteristics of the nasal tip . Nasal width can be assessed in the upper, mid­ dle, and lower third of the nose. It is important to recognize that a saddle deformity of the bony or cartilaginous dorsum will contribute to the appearance of an overwide dorsum on front al view, whereas a hump will give the impression of a narrow dorsum. Simil arly, a low bony dorsum will create an illusion of a relatively wide upper third of the nose and wide in­ tercanthal distance or pseudohypertelorisrn (7). This appearance can be significantly im­ proved by augmenting the nasal dorsum . The width of the nasal base on frontal view should approximate the interc anthal distance. The contour of the curved aesthetic lines that follow the eyebrows, traverse the radix, and continue down along the lateral nasal dorsum to end at the tip-defining points (the brow-tip aesth etic lines) should be followed , and any asymmetries, twists , or dev iation s noted. The se brow-tip aesthetic lines should be smooth, unbroken , gentl y curved, and symmetric (1,6) . The nasal tip should be characterized on frontal view with regard to symmetry and def­ inition. Concavity or other anatomic findings of the alar sidewall are noted. Vertical and horizontal aspects of bulbosity should be recognized when present. Bifidity of the nasal tip may be visible on this view (but is typically best appreciated on base view) . The gentle "gull-in-flight" relationship of the nasal alae to the infratip lobule should be followed , and any asymmetry should be noted. Exaggeration of this curve is suggestive of alar retraction and/or a dependent infratip lobule. If the columella is not visible ("hidden columella") on frontal view, this also may indicate a retracted columella. The vertical position and sym­ metry of the alar insertions should be described on the front al view. Base View On base view, special attention should be given to triangularity, symmetry, columella/lob­ ule ratio, and width and insertion of the alar base. The nasal base should be configured as an isosceles triangle with a gently rounded apex at the nasal tip and subtle flaring of the alar sidewalls (Fig . 3) (4,8,9). Poor triangularity or trapezoidal configuration with broad domal angles may suggest abnormal divergence of the intermediate crura . The presence of asym­ metry of the tip may best be appreciated on this view. Often one can visualize the outline of

Figure 3. Nasal analysis : Base view. Give special attention to triangularity, symmetry , columellar/lobule ratio, and width and insertion of the alar base.

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the lower lateral cartilages beneath the thin skin of the columella and alar rim, metries or buckling can be noted . Overlong or short medial crura may be appar columella and flaring of the medial crural footplates should be noted when p should look into the nasal vestibule to identify possible recurvature of the later the lower lateral cartilage (lateral crura), which on occasion contributes to nasal or correlates with an alar concavity seen on frontal view. This recurvature of the can be accentuated with application of dome-binding sutures (transdomal sutur sulting in nasal airway obstruction. The caudal septum may be seen protruding tril. Asymmetric nostrils or protruding medial crural footplates may be a clue of dal septal deviation or asymmetry . Asymmetric orientation of the nostril api indicative of underlying abnormalities of the domal region of the lower lateral c The width of the alar base should be noted, with normal width generally bei vertical line dropped from the medial canthi. Variations in the appearance of w base view may be due to the variation in horizontal position of the alar insert face or in the flare of the alar sidewalls. The alar sidewalls themselves are ch with regard to thickness and flare. Alar base insertions are described by degree ture , with straight insertions going directly into the face (i.e., no nostril sill) , and recurved alae inserting directly into the columella (4,8,9) . The ratio of the columella to lobule should approximate a 2: 1 ratio, and the b the flare of the medial crural footplates should divide the alar base into halves. T are commonly oriented 30 to 45 degrees toward the midline and are pear-shape gated. The facets or external soft-tissue triangles are attractive when they are w but can detract if they are overly conspicuous (4,8,9).

Lateral View

The lateral view offers important information on tip projection, nasal length, do and alar-columellar relationship. The nasal tip should ideally project strongly from the the face and gracefu supratip dorsum, creating a modest supratip break. An identifiable but not over ated columellar double break typically marks the junction of the medial and in crus . Nasal tip projection is consistently assessed by using the method describe (see Fig. 2) (2,3). If the length of a line drawn from the tip-defining point perpe a tangent to the alar-facial junction is greater than 0.55 to 0.60 of the line draw nasion to tip-defining point, then the nose ma y be overprojected. However, whe tip projection, relationships between the nose and other aesthetic facial features jection, forehead contour, ethnic background, etc.) must be considered. Nasal length is complicated to define. The nasal length is compared with the thirds of the face and the overall stature of the patient to determine whether th appropriate length. However, the factors contributing to the appearance of nasa complex. The nose can be considered to have three lengths, with nasion to tip be trallength , and nasion to alar margin being the lateral lengths. A short or long la may reflect a retracted or hooded ala, respectively, whereas a ShOl1 or long cen may reflect an obtuse or acute nasolabial (columellar-labial) angle, respective more, a deep nasofrontal angle contributes to the illu sion of a short nose, and a sofrontal angle adds apparent length to the nose (10). In Fig . 4A, three diagram except for the nasofrontal angle illustrate the effect of the nasofrontal angle on ance of nasal length. Another three diagrams (Fig. 4B), identical except for the angle, illustrate the effect of the nasolabial angle on the appearance of length. The nature of the columellar-labial confluence and columellar-lobular ang break) also must be assessed. Webbing or tenting of the columellar-labial should be noted. An overly obtuse columellar- labial angle and/or an exaggera break will make the nose appear ShOI1, whereas the converse (acute columella gle and/or absent double break) will add apparent length. A posteriorly inclinin ficiency of the premaxilla may confound accurate measurement of the colum

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Figure 4. A deep nasofrontal angle and/or an obtuse nasolabial angle contributes to the ap­ pearance of a short nose , whereas a shallow nasofrontal angle and/or an acute nasolabial angle adds appa rent length . In the first three line drawings (A) , the nasolabial angle is the same, whereas the nasofrontal angle is altered to illust rate the effect of the nasofrontal an­ gie on the appearance of nasal length. In the next three drawings (B), the nasofrontal angle is con stant , whereas the nasolabial angle var ies.

angle . The relationship of the nose to other facial structu res also will influen ce nasal length ; for exampl e, a flat forehead will give the illusion of increased nasal length (l0). Byrd (5) described a useful method for determining appropriate aesth etic proportions for tip projection, nasal length , and radix projection. "Ideal" nasal length is two third s of the midfacial height and is equ al to chin vertical. Tip projection is ideall y two thirds of this planned or ide al nasal length. Radix projection may be measured from the junction of the nasal bones with the orbit and ideally should be one third of the calculated nasal length.

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Byrd recommended the plane of the cornea surface as a preferred reference po projection ; from this starting point, the radix projects 0.28 times the ideal nas Byrd's report, the radix projected 9 to 14 mrn from the plane of the cornea sur One should be famili ar with the aesthetic angles applied in facial analysis guidelines for standards of facial aesthetics and facial harm ony. Powell and aesthetic triangle (nasofacial, nasofrontal, nasom ental, and mentocervical ang nasolabial angle or conflu ence are a few of the more commonly cited measure Assessment of the dorsal contour should identify any concavity, convexity, o ity. A high dorsum with a slight concavity at the rhinion is generall y conside thetic ideal in the white female nose. A high dorsum that is straight or with a is ideal in a white male nose. Other notable comp onents of the dorsum includ start ing point, which is ideally positioned at the level of the superior palpebral f tip-supratip relationship, as previousl y mentioned. The ala is analyzed in detail on the lateral view. Insertion of the ala on the fac above the columella in the horizontal plane, as described by Crumley (4), is j normal. The contour of the alar rim in profile ideally approximates a "lazy S" should note if this is normal, exaggerated, or straight. The size of the alar lobu ficd as small , normal , or large. The alar-columellar relationship should be p scribed. The range of norm al columellar show is generally considered to be 2 to complexities of the alar- columellar relationship were categorized by Gunter who identified abnormal positioning of the ala and the columella in relationsh drawn through the long axis of the nostril. All patient s have a hangin g, normal , ala and a hangin g, normal , or retracted columella. Thu s nine possible anatom tions make up the alar-eolumellar relati onship (Fig. 5). On lateral view, the long axis ofthe nostril should rise at approx imately 10 to from a plane horizontal to the Frankfurt plane. This is a reliable determinant of operative rotation of the nasal tip (7). Oblique View

Although it offers the least amount of objective data, this is an important aesthe cause the nose is most often seen at oblique angles. Several aspects of nasal conto lighted on this view and should be assessed. The brow-tip aesthetic lines and th facets are especi ally prominent and should be carefull y assessed , as irregularit highlighted on this view. Furthermore, abnormalities of the lateral aspect of the n nasal length , dorsal height, and tip projection also may be highlighted on the ob Overview

There is no "standard" rhinoplasty. Each operation is unique in that it must be the specific anatomic components involved and the desires of the patient. By d consistent, meticulous routine in which the patient' s nose is analyzed with r anatomic comp onents and their complex interrelationships, the surgeon can sel incisions, approaches, and techniques to achieve the desired surgical outcome. ,,-

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• The soft-tissue point correlating to the osse~cartilaginous jtin~tion of t . dorsum is the rhinion , The skin at this location is relatively thin compared thicker skin of the nasion. This is importantto recognize when planning hump reduction. After hump reduction, this area must be very smooth to a ible or palpable irregularities (see Appendix G): . • The nasal starting point typically corresponds to the nasion. In female pa is ideally situated at the same level as the superior palpebral fold. n

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• The nasaltipshouid be the most anteriorly projecting portion oftbe nose. tip should ideally lead the supratip dorsum, creating a modest supratip b • A "pollybeak" is a postoperative situation in which the supratip lead Causes for a pollybeak include underresection of cartilaginous dorsum at rior septal angle, excessive scar tissue formation, and inadequate suppo~t causing postoperative loss oftip projection. . ... . • An identifiable but not overly exaggerated columellar double break usua the junction of the medial and intermediate crus. . • Nasal-tip projection may be consistently assessed by using the method by Goode. If the length of a line drawn from the tip-defining point perpen a tangent to the alar-facial junction is greater than 0.55 to 0.60 of the li from the nasion to tip-defining point , then the nose may appear overproj • Thickness and quality of the facial skin-subcutaneous tissue complex m termined, as it plays a critical role in dictating the limitations of what can not be accomplished with nasal surgery. • Thin skin, strong cartilages, and bifidity: an important anatomic triad. Th must recognize the need to approximate the tip-defining points to impro angularity. The surgeori must recognize the risk of bossa formation if exce eral crura is excised (see Appendix G). . . . • Facial analysis can describe vertical facial thirds: trichion-to-glabella, gl subnasale, and subnasale-to-menton.However.the hairline is variable, an the glabella is not always precisely identifiable. Another method cons lower two thirds of the face from the nasion to the menton. The.nasion-to-s distance is 47% of the total, whereas subnasale to menton is53% (Fig. 6 • The astute surgeon will be able to anticipate the contour of the lower lat lages by studying surface topography of the nasal tip; . • The basal view provides information about the shape of the lower lateral c A trapezoidal nasal base indicates a wide domal angle and indicates the n tip technique that will create a more acute dome angle (dome-binding sut • Cephalic positioning of the lateral crura is indicated by the "parenthesis" d and lack of lateral wall support. • The "narrow nose syndrome" is noted in patients with a projecting nose, s bones, and long upper lateral cartilages. These patients are at high risk for dial collapse of the upper lateral cartilages after dorsal-hump excision . Thes frequently need spreader grafts. The contour of the caudal margin of the m intermediate crura can frequently be assessed by close examination of the n

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ILLUSIONS IN RHINOPLAS.TY . .

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• · .A dorsal convexity or hump frequently gives the appearance of narrow frontal view . It also provides the illusion of relative decreased projection changing the relationship between the dorsum and tip can improve the ap of projection. .. . • • A low dorsum gives the appeai·ance of increased nasal width due to less ing along the lateral nasal wall. • A saddle deformity of the bony or cartilaginous dorsum will contribute t . pearance of an overwide dorsum on frontal view, whereas a hump will giv pression of a narrow dorsum. Similarly-a low dorsum will create an illu relatively wide upper third of the nose or pseudohypertelorism. This ap can be significantly altered by augmeriting the nasal dorsum . • A deep nasofrontal angle lends the appearance of a short nose, as does nasolabial angle or an accentuated double break. I

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Figure 6. Relationship of the lower two-thirds of the face.

REFERENCES I. Tardy ME. Rh inoplasty: the art and the science. Philad elphia: WB Saund ers, 1997. 2. Tardy ME, Walter MA , Patt BS. The overprojecting nose: anatom ic component analysis and repair. Facial Plast Surg 1993;9:306- 316. 3. Ridley MB. Aestheti c facial proportions. In: Papel ID , Nachl as NE, eds . Facial plastic and recons tru ctive surgery. Philadelphia: Mosby Year Boo k, 1992:99-109. 4. Crumley RL, Lanser M . Quan titative analysis of nasal tip projection. Laryngoscope 1998;98:202-208. 5. Byrd HS, Hobar Pc. Rhinoplasty: a practical guide for surgical planning. Plast Reconstr Surg 1993;91 : 642-656. 6. Tardy ME, Brown R. Surgical ana tomy ofthe nose. New York : Raven Press, 1990. 7. Johnson CM , Toriu rni DM . Open structu re rhinoplasty. Philadelphi a: Sau nders, 1990. 8. Ta rdy ME, Pan BS, Walter MA. Alar reduction and sculpture: anatomic concep ts. Facia l Plast Surg 1993;9 : 295-305. 9. Becker DG, Weinb erger MS, Gree ne BA, Tardy ME. Clinical study of alar anatomy and surgery of the alar base. Arch Otolaryngol Head Neck Sur g 1997 ;123:789- 795. 10. Tardy ME, Becker DG, Weinberger MS. Illusions in rhinoplasty. Facia l Plast Surg 1995; 11:117-138. I I. Gunter JP, Rohrich RJ, Friedman RM. Classification and correction of alar-columellar discrepan cies in rhinoplasty. Plast Recon str Surg 1996 ;97:643- 64 8.

3 Injection

INFILTRATIVE ANESTHESIA TECHNIQUE Proper local anesthesia is critical to allow atraumatic dissection with minimal bleed­ ing and edema. A total volume of less than 3 ml of 1 % lidocaine with 1: 100,000 epinephrine is typically used to attain anesthesia for rhinoplasty alone. When performing septorhinoplasty, as much as 10 ml of local anesthetic may be used. The anesthetic is al­ lowed to take effect for at least 15 minutes to maximize the vasoconstrictive effect of the epinephrine. To become familiar with a method of injection of local anesthetic agent, saline can be in­ jected with a 5-ml syringe and 27 gauge (1.5 ern) needle along the site of injection in your cadaver specimen. Injection varies in some respects, based on the surgical approach se­ lected; for example, the subdermal columellar injection may be omitted in an endonasal ap­ proach. A generalized approach to injection is described below. For a septoplasty, multiple 0.5-ml to 1.0 rnl injections are made in the subperichondrial and subperiosteal plane along the entire area of anticipated dissection . Injections also should be placed along the site of the proposed incision (Killian, hemitransfixion, etc.). Both sides of the septum should be in­ jected if the surgeon plans to elevate mucosa bilaterally. The injection will aid in the dis­ section if placed in the subperichondrial plane . It is helpful to place an injection on the pos­ terosuperior septum bilaterally to minimize bleeding from the sphenopalatine blood vessels. Inject local anesthetic into the subdermal plane in the midline of the columella from tip­ defining points to the nasal spine in preparation for the external approach (Fig. I). This in­ jection is limited to < 0.3 ml to prevent distortion of the columella or nasal base. For either endonasal or external approach, inject < 0.3 ml of local anesthesia into the soft-tissue be­ tween and around the domes of the lower lateral cartilages (Fig. 2). The injection extends up to the region of the anterior septal angle . After completing this injection, gently massage the domal region between the thumb and index finger of both hands to disperse the anes­ thetic throughout the tip region. Place multiple injections of 0.1 ml of local anesthetic along the caudal margin of the lateral and intermediate crura (along the planned marginal inci­ sion; Fig. 3). Overinjection will result in distortion of the nostril rim and soft-tissue trian­ gle. Inject