Basic Open Rhinoplasty: Principles and Practical Steps for Surgeons in Training

Description

Expressly designed for surgeons in training who are new to nasal rhinoplasty, this textbook is written in a simple didactic style. A century after the first open rhinoplasty was performed by Dr. Aurel Réthi in Hungary, open rhinoplasty is now the most commonly used approach to aesthetic and reconstructive nasal surgery; the author’s decades of experience will safely guide the reader through her/his journey from the first contact with new patients to the postoperative analysis of clinical results. Instead of the usual classification of surgical techniques and anatomical regions, here the learning process is based on a sequence of steps, each of which addresses the most frequent problems that surgeons are likely to encounter in everyday clinical practice. In addition, the most relevant surgical instruments and electromedical devices are presented, together with their specific features and techniques, such as inclination and positioning during the procedure. Each step is richly illustrated and supported by a suggested reading list, as well as content on ethical and general principles. A specific chapter on radiological pre-evaluation assessment makes this book unique. Given its clear structure, its appealing didactic style and wealth of figures, Basic Open Rhinoplasty offers a much-valued step-by-step companion for postgraduate students, surgeons in training, and medical practitioners who deal with rhinoplasty in their clinical practice. Acknowledgments Contents 1: Introduction: Why this Book? 1.1 Recognizing One of Our Enemies 1.2 Is There Still Room for Improvements in Rhinoplasty? 1.3 The Spiral of Clinical Analysis 1.4 The Useful Limitations of a Book on Rhinoplasty Further Reading Books Articles 2: Approaching the Patient for Nasal Surgery 2.1 The Single Room Concept 2.2 The Interview Area 2.3 The Clinical Examination Area 2.4 The Clinical Photography Area 2.5 Approach to the First Consultation 2.6 The Interview 2.7 The Direct Clinical Examination 2.8 The Clinical Photographic Documentation 2.9 Final Communications and Remarks 2.10 The Time Spent in Organizing the Next Consultation 2.11 Approach to the Second (and Subsequent) Consultations 2.12 How to Enhance Patient/Physician Communication 2.13 The Single Operator Concept Further Reading 3: Techniques for Clinical Facial Photography 3.1 Professional Lighting Techniques for Clinical Facial Photography 3.2 Equipment and Technique 3.3 Point, Line, and Plane 3.4 A “Natural” Option 3.5 Problems with Two or More Lights 3.6 Avoid False Facial Asymmetry 3.7 The Importance of Soft Box Size 3.8 Advantages of Ceiling-Mounted Equipment 3.9 The Six Rules of Multiple Shots 3.10 A Portable and Inexpensive Alternative Further Reading 4: Views of Clinical Facial Photography for Nasal Surgery 4.1 Natural Head Position 4.2 How To Obtain Life-Size Photographs 4.3 The Poster “Views of Clinical Facial Photography” 4.4 Shooting a Complete Set of Clinical Facial Photographs for Rhinoplasty Further Reading 5: Facial and Nasal Clinical Analysis 5.1 Regions of the Face and Neck 5.2 Basic Qualitative Facial Analysis (Without Measurements) 5.3 Frontal View Analysis 5.4 Basal View Analysis 5.5 Oblique View Analysis 5.6 Profile View Analysis 5.7 The Facial Angles 5.8 The Supporting Skeleton Assessment 5.9 From Specific to General: A Reversed Approach to Basic Analysis 5.10 Points, Lines, and Subunits of the External Nose 5.11 Direct and Photographic Clinical Analysis for Nasal Deformities 5.12 Nasal Assessment: General Considerations 5.13 Nasal Upper Third Assessment 5.14 Nasal Middle Third Assessment 5.15 Nasal Lower Third Assessment 5.16 The Close Relationship Between the Nose and the Upper Lip 5.17 External Deformities and Nasal Airway Obstruction 5.18 Basic Facial Analysis: Preferred Terms 5.19 Nasal Analysis: Preferred Terms Further Reading 6: Dentofacial Analysis for Rhinoplasty Patients 6.1 Basic Assessment of Dental Occlusion 6.2 Upper Frontal Teeth Assessment 6.3 Lip Assessment 6.4 Smile Analysis 6.5 The Attractive Female Smile 6.6 The “No-Smile Patient” 6.7 Chin Assessment 6.8 The Basic Components of Dentofacial Deformities 6.9 Anterior Vertical Excess 6.10 Anterior Vertical Deficiency 6.11 Class III Sagittal Discrepancy 6.12 Class II Sagittal Discrepancy 6.13 Transverse Discrepancies and Asymmetry of the Jaws 6.14 The Immense Number of Combinations of Different Types and Grades of the Basic Components of Facial Deformities 6.15 Direct and Photographic Clinical Analysis for Dentofacial Deformities 6.16 The Youthful Neck 6.17 A Personal View on Radiographic Cephalometry 6.18 Essential Radiographic Cephalometry 6.19 Dental Cephalometric Analysis 6.20 Skeletal Cephalometric Analysis 6.21 Soft Tissue Cephalometric Analysis 6.22 Points, Lines, and Angles Difficult to Trace 6.23 The Maxillomandibular Complex Concept 6.24 Dentofacial Analysis: Preferred Terms Further Reading 7: Preoperative CT Scan for Nasal Surgery 7.1 Cone Beam Computed Tomography (CBCT) and Rhinoplasty 7.2 Nostrils and Columella Evaluation 7.3 Anterior Septal Deformities 7.4 Midline Cartilaginous Septal Deviation 7.5 Nasal Valve Analysis 7.6 Complex Septal Deviation 7.7 Anterior High Septal Deviation 7.8 Nasal Cycle and Inferior Turbinate Hypertrophy 7.9 Nasal Bony Vault and Walls 7.10 Evaluation of Secondary Cases Further Reading 8: The Rationale of Basic Open Rhinoplasty for Young Surgeons 8.1 Why Start with the Open Approach? 8.2 The Fourth Surgeon and the Missing Link in the Logical Evolution of the Open Approach 8.3 A Single Skin Incision Surgery 8.4 A Graduated Logical Approach to Surgical Steps 8.5 How to Communicate Your Surgical Approach to Patients 8.6 The Relationship Between What a Surgical Approach Offers and How Much a Surgeon Take Advantage of It 8.7 The Continuous Intraoperative Analysis 8.8 Working Under Direct Vision 8.9 A Still Valid Concept Further Reading 9: Rhinoplasty Treatment Plan: Basic Principles 9.1 Think in Terms of Angles 9.2 Think in Terms of Millimeters 9.3 Think in Terms of Vectors 9.4 Think in Terms of Volume (Volume Gain or Loss in One or More Specific Nasal Areas) 9.5 Think in Terms of Shapes 9.6 Think in Terms of Proportions and Balance (Avoid or Correct Any Disproportion) 9.7 Think in Terms of Disproportions (Maintain, Enhance, or Produce a Specific Disproportion) 9.8 Think in Terms of Symmetry (Maintain Symmetry or Reduce Asymmetry) 9.9 Think in Terms of Surgical Feasibility and Realistic Goals 9.10 Think in Terms of Surgical Preferences and Abilities 9.11 Think in Terms of Male/Female Differences 9.12 Think in Terms of Simplicity/Complexity of the Treatment 9.13 Think in Terms of Minimally Invasive Surgery 9.14 Think in Terms of the Patient’s Wishes 9.15 Think in Terms of the Patient’s Convenience 9.16 Think in Terms of the Patient’s Psychological Status 9.17 Think in Terms of Long-Term Results and Structural Support 9.18 Think in Terms of Functional or Esthetic Outcome 9.19 Think in Terms of Avoiding Surgical Stigmata (Natural, Not-Operated on Look) 9.20 Think in Terms of Small Incremental Adjustment 9.21 Think in Terms of Geometry 9.22 Think in Terms of Other Specialties 9.23 Think in Terms of Revision Rate 9.24 Refining the Surgical Treatment Plan According to Pareto’s Law 9.25 How to Use this Chapter Further Reading 10: Individual Treatment Plan for Rhinoplasty 10.1 Images Selection and Preparation 10.2 Realize One or More Simulation of the Nasal Profile 10.3 Realize a Printable File Containing the Standard Set of Photography for Rhinoplasty and Profile Simulations 10.4 Realize the Best Individual Treatment Plan 10.5 An Example of Handwritten Individual Treatment Plan Further Reading 11: Patient Preparation for Rhinoplasty 11.1 The Preoperative Checklist 11.2 Preoperative Visit and Exams 11.3 Meet the Patient Immediately Before Entering the Operating Room 11.4 In the Operating Room 11.5 Nasal Local Anesthesia: Initial Steps 11.6 Marking the Transcolumellar Incision 11.7 Columellar Local Anesthesia 11.8 Directional Terminology Further Reading 12: Basic Open Rhinoplasty: An Overview 12.1 Initial Exploratory Steps 12.2 Conservative Corrections 12.3 Non-conservative Corrections 12.4 Reconstructive Work 12.5 Finishing Steps 12.6 The BOR Sequence Further Reading 13: Basic Open Rhinoplasty: Incisions and Skeletonization 13.1 Columellar Skin Incision 13.2 Finishing the Columellar Skin Incision 13.3 Initial Flap Elevation 13.4 Marginal Incision in the Domal Area 13.5 Finishing the Marginal Incision and Lower Lateral Dissection 13.6 Dealing with the Ligaments of the Nasal Tip 13.7 Midline and Lateral Dorsal Dissection 13.8 Approaching the Septum with the “Tip Split” Technique 13.9 Initial Nasal Septum Skeletonization 13.10 Variations in the Extent of Septum Skeletonization 13.11 Splitting the Upper Lateral Cartilage from the Septum Further Reading 14: Basic Open Rhinoplasty: Intraoperative Analysis 14.1 Intraoperative Nasal Tip Analysis 14.2 Intraoperative Dorsum Analysis 14.3 Intraoperative Tip/Dorsal Profile Assessment 14.4 Intraoperative Septal and Inferior Turbinate Analysis Further Reading 15: Open Rhinoplasty: Initial Surgical Steps 15.1 Releasing the Depressor Septi Nasalis Muscle 15.2 Septal Work: Part I 15.3 Shaping the Anterior Nasal Spine 15.4 Conservative Inferior Turbinate Work 15.5 Dorsal Work: Part I 15.6 Limited Osteocartilaginous Hump Resection and Progressive Profile Adjustment 15.7 Partial Conservative Nasal Bone Resection and Conservative Profile Adjustment 15.8 Deepening the Nasal Radix with an Electric Power Burr 15.9 Lowering the Dorsal Profile of the Quadrangular Cartilage 15.10 Lowering and Refining the Nasal Bones 15.11 Take Another “Surgical Time Out” Further Reading 16: Basic Open Rhinoplasty: Intermediate Surgical Steps 16.1 Septal Work: Caudal Reshaping 16.2 Septal Work: Cartilage Harvesting 16.3 Straightening the Dorsal Septum 16.4 Spreader Grafts 16.5 Spreader Flaps 16.6 Trimming and Reattaching the Upper Lateral Cartilage 16.7 Septal Fixation to the Anterior Nasal Spine 16.8 Septal Extension Graft 16.9 Quilting Suture of Septal Mucosa 16.10 Temporary Nasal Packing 16.11 Nasal Osteotomies 16.12 Medial Oblique Osteotomies 16.13 Basal Osteotomies 16.14 Endonasal Basal Osteotomies 16.15 External Percutaneous Basal Osteotomies 16.16 Basal Osteotomies with Ultrasonic Instruments 16.17 Nasal Osteotomies: Refinements and Stabilization 16.18 Take Another “Surgical Time Out” 16.19 Columellar Reconstruction with Autologous Strut 16.20 Shaping the Lateral Crura 16.21 Shaping and Reinforcing the Lateral Crura 16.22 Creating New Surgical Domes 16.23 Domal Equalization Suture 16.24 Take a Special “Surgical Time Out” Further Reading Articles on Spreader Flaps (Autospreader) and Middle Vault Reconstruction Articles on Tip Surgery Articles on Lateral Crural Turn-in Flap 17: Basic Open Rhinoplasty: Final Surgical Steps 17.1 Excess of Lateral Crura Convexity 17.2 Over-Projected Nasal Tip 17.3 Under-Projected Nasal Tip 17.4 Nasal Thick Skin-Related Problems 17.5 Long Nose with a Narrow Nasolabial Angle 17.6 Camouflage Grafts 17.7 Composite Radix Graft 17.8 Soft Camouflage Grafts 17.9 Grafts Wrapped in Absorbable Hemostatic Gelatine Sponge 17.10 Plumping Grafts 17.11 Gel of Cartilage Grafts 17.12 Closure of the Marginal and Columellar Skin Incisions 17.13 George C. Peck on Tip Projection Further Reading Articles on Diced Cartilage Grafts 18: Basic Open Rhinoplasty: Alar Base Work and Final Nose Dressing 18.1 Approximation of the Footplates 18.2 Principles and Techniques of Alar Base Surgery 18.3 Removal of Bilateral Nasal Packing 18.4 Taping and Splinting Further Reading Books Articles on Alar Base Surgery 19: Chin Surgery for Rhinoplasty Patients 19.1 Clinical Analysis of the Lower Third of the Face 19.2 Cephalometric Analysis of the Lower Third of the Face 19.3 Elements of Surgical Anatomy of the Chin 19.4 Surgical Approaches to the Chin 19.5 Sliding Osteotomy Genioplasty 19.6 Alloplastic Chin Implant 19.7 Comparing Between Surgical Approaches to the Chin Further Reading Books 20: Cartilage and Fascia Harvesting for Rhinoplasty 20.1 Conchal Cartilage Harvest 20.2 Conchal Composite Harvest 20.3 Costal Cartilage Harvest 20.4 Temporal Fascia Harvest Further Reading Books Articles 21: Postoperative Care, Complications, and Unsatisfactory Results in Rhinoplasty 21.1 “Once the Operation is Over and You’re Fully Awake,..” 21.2 Before Discharging the Patient 21.3 The First Postoperative Visit 21.4 The Most Frequent Postoperative Complications 21.5 Hemorrhage 21.6 Infection 21.7 Persistent Structural Nasal Obstruction 21.8 Postoperative Septal Problems 21.9 Supratip Swelling 21.10 The Most Common Postoperative Visible Deformities 21.11 “THE MOST FREQUENT COMPLICATIONS” Explained to the Patient Further Reading Books Articles 22: A Clinical Practice Focused on Rhinoplasty 22.1 Boundaries 22.2 Prepare a Path of Self-Selection for New Patients 22.3 Orient Your Professional Communication to Patient Self-Selection 22.4 Orient Your First Direct Contact with a New Patient to PS-S 22.5 “WHY ISN’T THE FIRST CONSULTATION FREE?” and PS-S 22.6 Meet the Patient at Least Twice Before Surgery 22.7 Ask Your Patient About Three Important Points 22.8 Ask Yourself Three Questions 22.9 How to Maintain a Continuous Professional Relationship with Your Patient 22.10 Everything You Must Delegate 22.11 Everything You Can’t Delegate: A List 22.12 Time and Commitment: Related Numbers 22.13 Self-Discipline Matters 22.14 The Rule of Changing Rules 22.15 Read the Classics Again from Time to Time 22.16 Essential Equipment: Part I 22.17 Essential Equipment: Part II 22.18 Essential Equipment: Part III 22.19 Become Passionate about Portrait Photography 22.20 The Most Conservative Option Is Often the Best Choice 22.21 The More Conservative Option Should Not Be Confused with the Simpler One 22.22 A Reconstructive Approach 22.23 Two Honesty Tips 22.24 Be Less Responsive and More Understanding with Your Patients 22.25 Mentorship 22.26 How to Join a Private Practice Facility 22.27 Add Highly Professional Specialists to Your Extended Team 22.28 The Power of a Gift 22.29 Collect Your Patients’ Questions and Write Your Unique Book 22.30 Become Aware of the Passion Factor 22.31 One Day in Philadelphia Further Reading Books Articles