Rhinoplasty

Springer Science+Business Media, LLC

Rollin K. Daniel, MD

RhinoplastyAn Atlas of Surgical Techniques

With 295 Color Figures in 1420 Parts and a Clinical

[aye Schlesinger, MFA

Medical Illustrator

Springer

Rollin K. Daniel , MD1441 Avocad o Avenue, Suite 308Newport Beach, C A 926 60 , USARKDaniel@aol .comandC lin ical Professor of SurgeryDep artment of Plastic Surge ryUniversity of Califomia, IrvineIrvine , C A, U SA

Medical Illustrator:[aye Schlesinger, MFASc hool of Art and DesignUniversity of MichiganAnn Arbor, MI , USAjayes@um ich.edu

Cover illustration: From top to bot tom: Endonasal tip incisions; domal equalization suture (Fig. 3-110, p. 83 intext): graft insertion (Fig 3-18A, p. 97 in text) .

Library of Co ngress Cataloging in Publication OataOaniel, Rollin K.

Rhinoplasty : an atlas of surgical techniques / Rollin K. Oanie\.p. cm.

Includes bibliograph ical references and index.

I . Rhinoplasty-Atlases. I. Title.[ONLM: I. Rhinoplasty-meth ods atlases. WV 17Dl 84r 1999)

R0119.5.N67D36 1999617.5' 230592-<1c21ONLM/OLC 98-27807

Printed on acid-free paper.

Additional material to this book can bc downloaded from http://cxtras.springcr.com.

© 2002 Springer Science+Business Media New YorkOriginally published by Springer-Verlag New York Inc. in 2002.Softcover reprint of the hardcover 1st edition 2002

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ISBN 978-1-4757-4264-0 ISBN 978-1-4757-4262-6 (eBook)DOI 10.1007/978-1-4757-4262-6

T 0 Andrew N icholas Daniel

Son . .. Scholar .. . Climbing Partner

University of Califomia at Berkeley, BA, 1994

Honors in Philosophy and English

Krafft Scholarship

Oxford University, BA, 1996

Top First

Marshall Scholarship

University of Califomia at Berkeley

English PhO Program

Mellon Scholarship

The North Col, Mt. Everest , April 1998

v

Preface and DVDOverview

T he vast majori ty of plas tic surgeons do not read the preface whe n picking up a

new book. They usually go straight to their favo rite sub jec t, look at the techn ical

illustrations plus the quality of the cl in ical results, and then decide whether the

book is worth buyi ng . The preface is relegated to the author for justifying the pur­

pose of the book and to the reviewer to serve as a sco reca rd for evalua t ing it . Be­

cause Rhinoplasty: An Atlas of Surgical Techniques is an attempt to truly teach sur­

geons how to improve their rhinopl asty results, I will not hesit at e to use the preface

for that purpose. The content of this book is simply all the ana lyt ical and techni­

ca l informa tion that I would teach a Rhinoplasty Fellow ove r a six-rnon th period,

both in the operat ing room and in the examination roo m. It is not written in a

highly referenced did actic form. Rather, the style is a more personal explanat ion

of the thought processes and surgica l principles that I use in my clinical cases.

One will qui ckl y note the commitmen t to make the book highly readable. The

clean atlas forma t with its numerous illustrations and abse nce of constan t reference

or figure ci ta tions was a deliberate choice-a concession to the busy surgeon, but

hopefully acceptable to the scholar. The enclosed OYO with its introductory

"menu" will allow readers to go dir ectly to that part of the operat ive technique that

interests them . The grea tes t surprise and perhaps most confusing aspect of the book

is the del ay of an in-depth discussion of photographic analysis to the last chapter .

Why was this done ? This decision was based on my experience with prior publi­

cations and lectures in wh ich a glassy-eyed stupor follows the mere mention of nu­

mer ic ana lysis. It is my hope that this time I will get it right and that the reader

will appreciate and want to leam how to analyze difficult and secondary noses af­

ter see ing its role in the case studi es.

How You CanAchieve Better

RhinoplastyResults

vi i

viii

PREFA CE

So, how does the reader use this book to improve results? First, the reader should

realize the progressive and interrelated concept of the text. The book begins with

the four basic components of the external nose : radix, dorsum, tip, and base. The

"3As" of each component are discussed (anatomv, aesthetics, and analvsis) . Then,

the techniques that I use most frequently are presented in detail while explana­

tions are offered for rejected techniques. One is exposed to a graded surgical ap­

proach for dealing with minor, moderate, and major deformities. For example, in

the tip section, the reader learns to differentiate between intrinsic and extrinsic

factors, to analyze seven characteristics of the intrinsic tip, and to select the ap­

propriate operative technique based on the degree of severity. One quickly realizes

that each rhinoplasty operation is carefu11y planned based on detailed analysis of

the individual patient's deformity and desires. The emphasis must be equa11y on

preoperative planning and intraoperative execution, or failure will follow. For those

who have done more than 500 rhinoplasties, their "surgical eye" is sufficiently acute

to make observations that a110w evolution of the optimal operative plan for the in­

dividual patient. As an alternative, the beginning surgeon would do well to under­

stand and learn these first four fundamental chapters in depth, as preoperative analy­

sis and planning is the only alternative to experience. Once the reader realizes the

value of photographic analysis, then it would be appropriate to read the section on

analysis/operative planning in Chapter 9 and then each of the detailed case studies

in Chapter 7. In less than five minutes, one can obtain a11 the required "numbers"

either from examining the patient or patient photographs. Time spent on analysis is

never wasted. Ir leads to a more refined operative plan and a more confident surgeon.

Next come the functional factors of septum, valves , and turbinates. After a

prospective study of my own cases, I am absolutely convinced that at least 35% of

cosmetic patients who deny nasal obstruction do indeed have a significant preop­

erative anatomical deformity that, if uncorrected, will result in postoperative ob­

struction. Thus, one must do an in-depth nasal history and internal examination.

The surgery techniques recommended for dealing with septal deviation and defor­

mity are not a variation of the classic septoplasty. Based on extrapolation from cor ­

recting the failures of secondary cases, a progression is presented for primary cases

going from mobilization to resection to total replacement. The emphasis is on fix­

ing septal problems within the context of septorhinoplasty, not as an isolated septal

entity. In addition, a new classification and treatment strategy is presented für deal­

ing with the four nasal valves of the nose. Ultimately, one will be able to minimize

the incidence of postoperative nasal obstruction.

Without question, the greatest advance in secondary rhinoplasty has been re­

constructing the underlying framework using numerous grafts. Some would con­

sider that utilization of spreader grafts, radix grafts, colume11ar struts, and tip grafts

P R EF A CE

has had an equally dramati c impact on primary rhinoplasty. Each of the major donor

sites is d iscussed in depth, as is modification of the graft material for a wide vari­

ety of applicatio ns. A ltho ugh some would argue tha t tip grafts have been overuti­

lized, most experienced surgeons do not find a 75% inc idence of spreader grafts un­

usual. With the recent emphas is on ope n tip suture techniques, the columella strut

graft becomes a must learn tec hn ique. Many surgeons will be surprised to learn that

the rib graft has totally supplanted th e cranial bone graft for dorsal reconstruct ion.

Ultimately, the modern rhinoplasty surgeon must master the various grafts irre­

spective of the graft material ava ilable.

In primary cosmetic rhinoplasties, there is a natural tendency to want a stan ­

dard operation to serve as a foundation for incorporating other techniques. There­

fore, I have discussed the open rhinoplasty in a step-bv-step fash ion , with varia­

tion s for the closed and closed/open approaches. I am conv inced that there is no

open versus closed debate nor any correct percentage of application. I prefer the

closed approach for simpler cases in which the intrins ic tip is near ideal and th e

open approach for moderate deformities. I reserve the closed/open approach for the

most cha llenging cases. The actual percentage for an individual surgeon will reflect

hi s or her training, experie nce, and patient popul ation . Early in their practices,

man y surgeons will uti lize the basic operation th at they learned in their residen ­

eies and develop alternative approaches on ly as they gain confidence and experi­

ence, or encounter the inevitable poor result. The three approaches discussed in

detail in this book will allow th e younger surgeon to deal comfortably with 95% of

the primary noses encountered. Because many older surgeons are hesitant to learn

the open technique, it is important to realize that the closed/open approach can

serve as a "transition" from the closed approach to the open approach. Unfortu­

nately, rh inoplasty is too complex an operation and the pat ient population too di­

verse for a single approach.

After learning the fund amentals and applying thern in cosmetic cases, the ne xt

logical step is to progress to complex advanced rhinoplasties. This category includes

the major deformities of ove r- and und erproject ion and rotation, as well as severe

asymmetries, the posttraumatic deviated nose, skin enve lope problems, and cocain e

and cleft noses. Because the anatomy is no longer withi n the norm al range, a pre­

requisite for dealing with these cases is a maste ry of the fundamental techniques

used in primary cosmetic cases. Suddenly, one is dealing with severely deviated sep­

turns requ iring spreader grafts as splin ts, then asymmetric multiple osteotornies for

bon y vault correction, and even exeision of the domes followed by replacement

with a tip graft . These complex cases require a sequential execution of complex

man euvers with a minimal margin of error. Each of these deformities is discussed

in depth, as are the clinically reliable techniques for achieving the desired result.

ix

x

PREFACE

No attempt is made to be encyclopedic or pedantic. Only those procedures I use

on a regular basis are illustrated, both in the text and on the DYD.

Finally, one comes to secondary rhinoplasty, which is the most difficult of all

operations as the normal anatomy has been disrupted, the presence of scar tissue

adds additional deforming forces, and the need for grafts with alternative donor

sites is very real. T wo aspects of secondary rhinoplasty will illustrate its inherent

complexity, First, the 97% incidence of graft utilization means that the septum will

be explored in virtually all cases, a task that is complicated by a 75% incidence of

prior septal surgery. Dissecting the previously compromised septum can range from

simple to complex, while the paucity of graft material available requires imagina­

tion and mastery of conchal grafts. Second, the choice of approaches shows 85%

open, 12% closed/open, and only 3% closed. The open approach offers enormous

advantages for major secondaries, ranging from analysis and utilization of alar rern­

nants that minimizes graft requirements to total exposure of the septum and un­

paralleled access to dorsal deviations. Yet, one should not attempt these complex

cases until the requisite surgical judgment is gained-as always-from surgical ex­

perience that comes from one's good results and one's poor results.

In conclusion, I would state that the single greatest benefit of writing a book

is that it clarifies one's thoughts, expands one's knowledge, and makes one a much

better surgeon. There is no question but that I am a much better rhinoplasty sur­

geon now than I was when this cornpilation began. I sincerely hope that the reader

will be a better surgeon after reading this book. In that spirit, I offer the following

guiding principles:

• Rhinoplasty is the most difficult of all cosmetic operations for three reasons: (1)

nasal anatomy is highly variable, thereby precluding a simple standard opera­

tion, (2) the procedure must correct form and function, and (3) the final highly

visible result must meet the patient's high expectations. It is never an easy

operation.

• Few surgeons will do more than 1,000 rhinoplasties in their careers. Therefore,

a commitment must be made early on to maximize each case, from preoperative

planning to careful documentation of the operative procedure to frequent post­

operative follow-ups-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 apreoperative subclinical condition. One must

be willing to diagnose and treat problems in the septum, nasal valves, and

turbinates. There is no excuse for not doing a thorough preoperative internal

examination before and after decongesting the nose.

PR E F A CE

• One must accept th at th ere is no magie answer, no one operation for all noses,

and no perfect results. Each surgical maneuver has a learning curve. An opera­

tive sequence is the addi tio n of these surgical maneuvers. Unfortuna tely, the ma­

neuvers are addi tive, but their interactions and potential complications are geo­

rnetric. Keep the operation simple- maximum gain , minimum risk. Maste r what

you know; do not jump on each new bandwagon.

• Each surgical technique has a standard distribution of applications, results, and

problems. Yes, the mythical Master Surgeon can make tip sutures or multilay­

ered tip grafts work in every nose, but they are at their outer limits when they

do. For example, the parenthesis tip is easily corrected with sutures, while a mul­

tilayer tip graft requ ires excision of both the entire dome and lateral crura be­

fore inserti on of the grafts. Stay in the center of th e distribution curve, and you

will have fewer problems.

• Early in your pract ice, select n ice patients with obvio us deformities that you can

easily correct using procedures that you know. With experience, begin to add

new man euvers and then take on cases of greater difficulty. O perate withi n your

comfort zone.

• Understand your own limitations and follow a progression from easy to more dif­

ficult to advanced primary deformities before embarking on major secondaries.

The latter cases are technically more demanding and requ ire greater surgical ex­

pertise that can on ly be gained through experience. One is not elimina ting th e

negatives to reveal the underlying att ractive nose as in primary cases, but rather

rebuilding a destroyed framework using numerous grafts.

• The preoperative course is finite, but postoperat ive visits are infinite, so pick

your patients carefully. Postoperative problems are most often confirrnations of

intraoperative suspicions- if the tip did not look right during the case, it rarely

gets better later. 0 0 not cut corne rs. Once you opera te on a patient, it is your

result , regardless of how man y previous operations were done or how noncom­

pliant the patient. Select carefully.

• Once you ha ve a complication or poor result , admit it directlv to the patient

and discuss how it can be improved. 0 0 not pretend that it is not there or sha me

th e patient in to accepting a minimal improvement or make it financially im­

possible to correct the problem. T reat pat ients as family-at worst , they will be

disappointed, but not lit igious.

• Rhinoplasty is the most reward ing of all cosmetic operations, both for the pa­

tient and the surgeon. Few operations can make as great a cha nge in a young

person's appearance and self-confidence as a highly visible attractive nose. For

the surgeon , rhinoplasty is the ult imate in artistic three-dimensional sculpturing

xi

DYD Overview

xii

P R E F A C E

requ iring an almost perfect result whose flaws cannot be h idden. Technically, it

is pure pleasure, in which each step takes you toward your goa l, but with the

heightened reali ty that a mistake can occur at any t ime. Rhinoplasty is truly

worth the patient's risk and the surgeon's cornrnitmen t,

The DYD has 3 videos:

1) N asal Aesthetics and A na to my: A Cadav er Study

2) Cosmetic Rhinoplasty: Step-by-Step

3) Open Tip Graft in T win Pat ients

The in itial menu allows one to select the desired video. One can eithe r wat ch

the entire video or use the "scen e select ion" to view a spec ific sect ion relevant to

the text . I would suggest that the reader view the Aesthe t ics and Anatomy video

in conjunc tio n with read ing Chapters 1 to 4. The Step-by-Step video will be use­

ful throughout the book , but is especially relevan t to Chapte r 7. The in-depth il­

lustration of a tip suture tec hn ique and the closed/open approach may warrant re­

peated viewing by those leaming these techniques. Certainly, the O pen Tip Graft

video demonstrat es bo th a classical open approach and a dramatic open tip graft

with the added chall en ge of preserv ing identical twins, The reader will be able to

have the feel of being in th e ope rat ing room and yet rapidly accessi ng those areas

of in teres t thanks to the most recent adva nces in DYD technology.

Rollin K. Daniel, MD

Contents

Preface and DYD Overview vii

1 The Radix 1

2 Dorsum 23

3 Tip 59DYD: Open Tip Graft in Twin Patients

4 Nasal Base 139

5 Functional Factors 163

6 Grafts 227

7 Primary Rhinoplasty 279DYD: Cosmetic Rhinoplasty: Step by Step

8 Advanced Techniques for the Difficult Nose 351

9 Secondary Rhinoplasty 421

Index 527

xiii