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Anatomy, Incisions and Approaches: Open and Closed Rhinoplasty

Posted by Daniel G. Becker on January 6th, 2011

Daniel G. Becker, MD FACS
Becker Nose and Sinus Center, LLC
400 Medical Center Drive, Suite B
Sewell and Princeton, New Jersey USA
856 589-6673
856 589-3443 fax
drbecker@therhinoplastycenter.com

Clinical Professor & Director of Facial Plastic Surgery
Department of Otolaryngology-Head and Neck Surgery
University of Pennsylvania Medical Center
Philadephia, Pennsylvania

Clinical Professor
Department of Otolaryngology-Head and Neck Surgery
University of Virginia Medical Center
Charlottesville, Virginia

Introduction

In the modern era of rhinoplasty, the introduction of external rhinoplasty was greeted by enthusiastic advocates and also met with spirited opposition.    Over time, however, the tenor of this debate has become more ecumenical.   Most surgeons now recognize the broad utility of both endonasal and external approaches. Most understand that there are situations when a given approach offers advantages and may be considered preferable. Most also agree that there is a large "grey area," where either the endonasal or the external approach would be appropriate, and the choice may be considered a "toss-up."  Most surgeons readily acknowledge that surgeon comfort with a procedure is an appropriately important factor. 

Open-Tip Rhinoplasty: Exposure, Step by Step.

Posted on January 6th, 2011

OPEN-TIP RHINOPLASTY: EXPOSURE, STEP BY STEP.

PRATAS R., MARÇAL N.

1. INTRODUCTION

History of rhinoplasty comes from many centuries ago, most probably from ancient cultures in Egypt. One of the most important steps in modern open-tip rhinoplasty history was taken in 1921 by Rethi, from Budapest, which described an external approach to expose alar cartilages and nasal dorsum only through a unique high columellar skin incision, connected with bilateral endonasal skin incisions along the caudal border of the alar cartilages.(1) The Rethi incision became the dictum for transcolumellar approach.

Later on, Haubenrisser(2) in 1956 modified the Rethi incision with propose of facilitating the flap elevation. He described the extension of the incision laterally to the alar facial junction, curving it in the crease of the alar facial junction over the external skin.

Anatomy dissection video

Posted by M Eugene Tardy, Jr on January 11th, 2011
Player goes here

The Rhinoplasty Consult- Patient Evaluation

Posted by Jacob D. Steiger on January 20th, 2011

Jacob D. Steiger, MD
Private Practice
Boca Raton, FL

Patients seeking rhinoplasty span a wide range of ages and ethnicities.  In addition, they may have an equally wide range of desired outcomes from the procedure.  The initial rhinoplasty consultation is an opportunity for the surgeon to assess the patient.   This assessment includes both that of the physical and psychological condition of the individual.  In doing so, the surgeon can determine if the patient is an appropriate surgical candidate. Once this is determined the surgeon can proceed to further prepare the patient for surgery and manage expectations.

Rhinoplasty Analysis

Posted by Daniel G. Becker on January 23rd, 2011

Daniel G. Becker, MD FACS
Becker Nose and Sinus Center, LLC
400 Medical Center Drive, Suite B
Sewell and Princeton, New Jersey USA
856 589-6673
856 589-3443 fax
drbecker@therhinoplastycenter.com

Clinical Professor
Department of Otolaryngology-Head and Neck Surgery
University of Pennsylvania Medical Center
Philadephia, Pennsylvania

Clinical Professor
Department of Otolaryngology-Head and Neck Surgery
University of Virginia Medical Center
Charlottesville, Virginia

Development of an operative plan that will achieve the desired outcome requires an understanding of the patient's wishes and selection of appropriate surgical maneuvers to effect the proposed changes. The surgeon must be able to identify anatomic constraints that will limit the ability to change contour (thick skin, weak cartilages, etc.). Experience with rhinoplasty over time has shown that detailed anatomic analysis of the nose is an essential first step in achieving a successful outcome. Accurate assessment of the anatomic variations presented by a patient allows the surgeon to develop a rational and realistic surgical plan.  Furthermore, recognizing variant or aberrant anatomy is critical to preventing functional compromise or untoward aesthetic results.  Failure to recognize a particular anatomic point preoperatively can contribute to a less than ideal long-term result.

Infiltrative Anesthesia Technique

Posted by Daniel G. Becker on January 28th, 2011

Daniel G. Becker, MD FACS
Becker Nose and Sinus Center, LLC
400 Medical Center Drive, Suite B
Sewell and Princeton, New Jersey USA
856 589-6673
856 589-3443 fax
drbecker@therhinoplastycenter.com

Clinical Professor
Department of Otolaryngology-Head and Neck Surgery
University of Pennsylvania Medical Center
Philadephia, Pennsylvania

Clinical Professor
Department of Otolaryngology-Head and Neck Surgery
University of Virginia Medical Center
Charlottesville, Virginia

Proper local anesthesia is critical to allow atraumatic dissection with minimal bleed­ing 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 nil 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 injected with a 5-ml syringe and 27 gauge (1.5 cm) needle along the site of injection in a cadaver specimen. Injection varies in some respects, based on the surgical approach se­lected; for example, the subdermal columellar injection may be omitted in an endonasal approach. A generalized approach to injection is described below. For a septoplasty, multiple 0.5-m1 to 1.0 ml 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 in­jected if the surgeon plans to elevate mucosa bilaterally. The injection will aid in the dis­section if placed in the subperichondrial plane. It is helpful to place an injection on the posterosuperior septum bilaterally to minimize bleeding from the sphenopalatine blood vessels.

The Endonasal Approach: Overview and Personal Philosophy

Posted by Cemal Cingi on February 5th, 2011

Cemal Cingi, MD
Professor, Department of Otorhinolaryngology, Osmangazi University Medical Faculty, Eskisehir, Turkey
E-mail: ccingi@ogu.edu.tr
Phone: 0090 532 2676616
Fax: 0090 222 2240424 

Murat Songu, MD
Department of Otorhinolaryngology, Izmir Ataturk Research and Training Hospital, Izmir, Turkey

ABSTRACT

Endonasal rhinoplasty has long been considered a reductive operation. With the advent of cartilage grafting and support and better understanding of nasal dynamics, endonasal rhinoplasty can be performed in a predictable manner. The advantages of shorter operative time, less prolonged postoperative swelling, and less postoperative skin contracture have allowed endonasal rhinoplasty to continue to serve a prominent role in addressing nasal deformities.

Open Rhinoplasty

Posted by Alwyn R. D'Souza on February 9th, 2011

Annabelle C. Leong and Alwyn R. D’Souza

Abstract

The tenets of rhinoplasty focus on restoring or maintaining the strength and support of the nasal skeleton while altering the contour to achieve the desired aesthetic result.  The debate continues unabated over the advantages and disadvantages of an open versus a closed endonasal approach. The open technique offers the obvious benefit of direct observation, which often outweighs the commonly-cited disadvantage of transcolumellar incision and scar.  The enhanced exposure is especially beneficial for work on the nasal tip, dorsum and septum and additionally, offers the best possible teaching tool for the trainee.  The goal of this chapter is to provide the reader a logical and systematic road map upon which to manage the surgical correction of nasal deformities with the open rhinoplasty approach.  

Surgical Treatment of Nasal Obstruction in Rhinoplasty

Posted by Ashley Cafferty on February 20th, 2011

Daniel G. Becker, MD FACS
Becker Nose and Sinus Center, LLC
400 Medical Center Drive, Suite B
Sewell and Princeton, New Jersey USA
856 589-6673
856 589-3443 fax
drbecker@therhinoplastycenter.com

Clinical Professor
Department of Otolaryngology-Head and Neck Surgery
University of Pennsylvania Medical Center
Philadephia, Pennsylvania

Clinical Professor
Department of Otolaryngology-Head and Neck Surgery
University of Virginia Medical Center
Charlottesville, Virginia

Abstract

Often, rhinoplasty patients present not just for aesthetic correction, but for improvement of their nasal breathing due to functional abnormalities or problems. Because the aesthetic and functional problems must be addressed together, an understanding of both the internal and external anatomy is essential. In this article, the authors review the differential diagnosis of nasal obstruction and the important components of a thorough examination. In this article, medical treatment options are not discussed, but just as an exacting aesthetic analysis leads to an appropriate cosmetic rhinoplasty plan, a thorough functional analysis will dictate the appropriate medical or surgical treatment.

The Bulbous Nasal Tip

Posted on February 23rd, 2011

Michael S. Godin, MD and Robert S. Schmidt, MD
Department of Otolaryngology-Head and Neck Surgery
Virginia Commonwealth University Health System

Introduction

Many patients presenting for rhinoplasty evaluation complain that their noses are too large. A subset of these patients complains of a bulbous shape to the end of their nose which they find unpleasing. They may also note nasal obstruction. Proper management of these patients requires identification of the anatomical factors contributing to the bulbous nasal tip and employment of individually tailored surgical techniques that focus on volume reduction and aesthetic refinement while preserving and, when necessary, enhancing tip support.