• Rhinoplasty • Dissection Manual DEAN M. TORIUMI • DANIEL G. BECKER . e;t ~ L1PPINCOTf WILLIAMS & WILKINS Rhinoplasty Dissection Manual , , , I t - -_ - I 1 - ~ 7 . ~~ , , .'- , - \ Rhinoplasty Dissection Manual Dean M. Toriumi, M.D. Associate Prof essor Division of Facial Plastic and Reconstructive Surgery Departm ent of Otolaryngology -H ead and Neck Surgery University of Illinois at Chicago Daniel G. Becker, M.D. Assistant Pr of essor Division of Facial Plastic and Reconstructive Surgery Department of Otolaryngology -H ead and Neck Surgery University of Pennsylvania Illustrated by Devin M. Cunning, M.D. 4~ LIpPINCO TT WILLIAMS & WILKINS • A Wolters Kluwer Company Philadelphia • Baltim ore • New York • London BuenosAi res • Hong Kong • Sydney · Tokyo ~ 1 - _-~ • .~~I ~ • Ill' - ~ - . ," ~~ Acquisitions Editor: Danette Knopp Developmental Editor: Sara Lau ber Production Editor: Patrick Carr Manufacturing Manag er: Tim Reynolds Cover Designer: Christine Jenn y Compositor: Maryland Co mposi tion Printer: Couri er Westf ord © 1999 by LIPPINCOTT WILLIAMS & WILKINS 227 East Wa shington Square Philadelphia , PA 19106-3780 USA LWW.com All rights reserved. This book is protec ted by copyright. No part of this book may be reproduced in any form or by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews . Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-me ntioned copyright. Illustrations © Daniel G. Becker. Photograph s © Dean M. Toriumi. Printed in the United States of America Library of Congre ss Cataloging-in-Publication Data Toriurni, Dean M. Rhinopla sty dissection manu al/Dean M. Toriumi, Danie l G. Bec ker; illustrated by Devin M. Cunning. p. em, Includes bibliographical references and index. ISBN 0-7817 -1783-3 I. Rhinoplasty Handbooks, manuals, etc. 2. Nose-Surge ry Handbooks, manuals, etc. I. Becker, Daniel G. II. Title. [DNLM: 1. Rhinopla st y- methods Handbooks. WV 39 T683 r 1999] RDII 9.5.N67T67 1999 617 .5' 230592 dc21 DNLMIDLC for Library of Congress 99-26058 CIP Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expresse d or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation rem ains the professional responsibility of the practitioner. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication . Howe ver, in view of ongoing research, changes in government regulation s, and the con stant flow of information relating to drug therapy and drug reaction s, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and preca utions. This is particularly importan t when the recomm ended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibil ity of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice. 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 parents Bill and Merle, and my brothers and sisters-in-law, Richard and Rachel, Paul, Sam, and Jen. Daniel G. Becker, M.D. " ,' , , Contents Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Preface xiii Acknowledgments xv Chapter 1: Anatomy . 1 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 . 25 Infiltrative Anesthesia Technique . 25 Chapter 4: Septoplasty . 31 Nasal Dissection: Septoplasty with Cartilage Harvest . 31 Chapter 5: Incisions and Approaches . 37 Transcartilaginous or Cartilage-Splitting Approach . 37 Delivery Approach . 40 The External (Open) Rhinoplasty Approach . 43 Chapter 6: Removal of Bony-Cartilaginous Hump . 59 : Osteotomies . 67 Chapter 7 Medial Osteotomies . 67 ~ ~ ' :r-=- J • -~ . . ~ -v' .'. vii viii CONTENTS Chapter 8: Chapter 9: Chapter 10: Chapter 11: Chapter 12: Chapter 13: App endix A: Appendix B: Appendix C: Appendix D: Appendix E Appendix F: Appendix G: Appendix H: Appendix I: Appendix J: Appendix K: Lateral Osteotomies and Infracture 67 Intermediate Osteotomies 68 Spreader Grafts 71 Surgery of the Tip 81 Exercises 81 Alar Base Resection 113 Internal Nostril Floor Reduction 113 Wedge Excision of Nostril Floor and Sill . 114 Alar Wedge Excision 114 Sliding Alar Flap 114 Other Maneuvers . . . . . . . . . . . . . . . . . . . . . 117 Plumping Grafts 117 Caudal Extension Grafts 118 Deviated Caudal Septum 122 Rib Cartilage Graft Reconstruction of Saddle Deformity 130 Harvest of Autogenous Tissue 139 Harvesting Conchal Cartilage 139 Harvesting Ethmoid Bone 143 Harvesting Rib Graft 143 Harvesting Calvarial Bone 144 Incision Closure, Nasal Splint, Post-Operative Considerations 149 Closure of Midcolumellar Incision 149 Closure of the Marginal, Intercartilaginous, or Transcartilaginous Incision 152 Placement of Intranasal Packs, Nasal Splint 152 Postoperative Care 152 Tripod Concept 155 Guide to Nasal Analysis 156 Aesthetic Analysis 157 Surface Angles, Planes, and Measurement: Definitions 158 Tip Support, Incision, and Approaches 160 Achieving Surgical Goals: Selected Options . . 161 Selected Complications of Rhinoplasty 163 Adjunctive Procedures 165 Cleft Lip Nasal Deformity 167 Photography Setup 169 Indications for External Rhinoplasty Approach 170 :1 , . , " Contents ix Appendix L: Appendix M: Suggested Surgical Instruments for Rhinoplasty List of Selected Companies with AddresseslPhone Numbers . . 171 172 Appendix N: Selected Recommended Literature . 174 Index 177 - - ,- . . - - , - - t" - ;z Foreword Exce llent surgical outcomes in rhinoplasty derive from two interrelated factors: (1) a de- tailed understanding of the multiple nasal anatomic varian ts encountered, and (2) an ac- quired knowledge of the ultimate long-term effects of surgical altera tions of these anatomic compo nents- the evolution of healing. The first skill can be learned by detailed observation, enhanced by cadaver dissection; the second skill only by careful follow-up of operated patients over time. The general concepts of nasal anatomy have been fun damentally clear for centuries, but only in recent decades have surgeons appreciated the finely detailed nuances of nasal anatomic dynamics that influence the surgical crea tion of a natural, pleasing rhinopl asty re- sult, free of surgical stigmata. A detailed com prehension of nasal anatomy must therefore transcend knowledge of basic anatomic relationships. The surgeo n must judge, by inspec- tion and palpation, the character of the skin and subcutaneous tissues as they vary from nasal region to region, the influences of facial mimetic musculature, the relative strength and support of the cartilaginous and bony framework and substruct ure, and the limitations imposed by the interr elationship of all these structures upon the ultimate favorable result. As important as the evaluation of what can reasonably be accomplished during rhinoplasty is the acqui red knowledge and skill to assess what canno t be acco mplished. This judgment is largely predicated on the critical analysis of each patien t's individual anatomy, coupled with technical refinements guided by experience, and generally requires years of personal surgic al result evaluation to become keen. In this dissection manual, Drs. Becker and Tor iumi have created a unique study guide and cadaver dissection manual dedicated to guiding the learner in a disciplined manner. They admirably extend the tradition of the University of Illinois Department of Otolaryn- golog y's leadership in teaching anatomy and surgery in rhinoplasty. Cadaver dissection constitutes a privilege not available to all, and, as such, this precious mater ial must be wisely and conservatively approached. Experience teaches that a disciplined, structured ap- proach to dissection of the nose produces the best educational outcome. An important favorable develop ment in contempo rary rhinoplasty is the appropriate con- cern for conservative and subtle anatomic changes that by definition derives from a preser- vative attitude toward nasal tissues. Commonly, rather than excisional sacrifice of large segm ents of cartilage or bone, a philosophy of preservation and restoration of tissues is de- veloping that precludes creation of unnecessary tissue voids which may heal and scar un- - , - L ' -:H - \ xi xii FOREWORD predictably. Wise surgeons recognize that even a larger nose, well balanced to the sur- rounding facial features, is always aesthetically preferable to a nose made over-small by radical surgery. Conservation surgery thereby further extends the surgeon's control over the final surgical result, as an appropriate equilibrium between the corrected nasal skeleton and soft tissue covering is more reliably achieved. Conservative sculpture and volume re- duction of the alar cartilages clearly produce more favorable results, generally avoiding major resections and vertical interruprion of the intact residual strip of lateral and medial crus. Notching, pinching, alar cephalic retraction, over-rotation, and asymmetries are all almost entirely eliminated in long-term healing when this conservative philosophy is em- braced.A further striking example of conservatism is the preservation of a strong, high pro- file in many patients, a distinct contrast to the dramatic retrousee pro files created in decades past by sacrifice of over-generous segments of nasal bony humps. Finally, thoughtful nasal surgeons, through accurate anatomic diagnosis, discern which portions of the nasal anatomy are pleasing and satisfactory, striving to avoid disturbing these structures and areas when correcting (or gaining access to) anatomic components in need of correction.This philosophy further extends the surgeon 's favorable control over ul- timate healing. Thoughtful cadaver dissection provides the learner with visual pathways to gain access to structures to be modified, while preserving normal tissues and relationships. Important tissue planes, vital in live surgery, can be appreciated best when viewed at leisure in the dissection laboratory. This well-conceived work, properly employed, contributes substantially to shortening the steep learning curve characteristic of rhinoplasty. M. Eugene Tardy, Jr., M.D., F.A.C.S. Profes sor of Clinical Otolaryngology Director, Division of Facial Plastic and Reconstructive Surgery University of Illinois Medical Center Chicago, Illinois Professor of Clinical Otolaryngology Indiana University School of Medicine ~ - ':1 I'll ,,1 [...]... recommended (1) (Figs 1- 1 0) I' jJ;i - : ' \ _ ~~I =:ii=U,ll • -s-; - c ,tlill! I 4 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... 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 ,... Becker, M.D xv Rhinoplasty Dissection Manual ~~ j, I ~ - - - - - ' - ' ~ ~~! 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. .. commenci ng the programm atic dissection The dissection manual guides you through the following dissections: septoplasty, trans /' xiii - ~ \~ ~ - 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... 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 13 Figure 4 Surface anatomy of the nose: Oblique 1, Glabella;... 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... 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,... 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. .. junction; 12 , nasal spine ~ :-~ , , • \ '- , -_ -I 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... 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 . Numbers . . 17 1 17 2 Appendix N: Selected Recommended Literature . 17 4 Index 17 7 - - ,- . . - - , - - t" - ;z Foreword Exce llent surgical outcomes in rhinoplasty derive. (1) (Figs. 1- 1 0). 1 I' .jJ;i - .: ' ~~I =:ii=U,ll _ c ,tlill! . • -s-; - I 2 RHINOPLASTY DISSECTION MANUAL 4 Figure 1. Surface anatomy of the nose: Frontal view. 1, . • Rhinoplasty • Dissection Manual DEAN M. TORIUMI • DANIEL G. BECKER . e;t ~ L1PPINCOTf WILLIAMS & WILKINS Rhinoplasty Dissection Manual , , , I t - -_ - I 1 - ~ 7