Rhinoplasty Dissection Manual - part 8 docx

Other Maneuvers 129 _ " z Y AA Figure 5, continued. The severely deviated component (U-W) is removed, along with pos- terior septum (X). The deviated septum is replaced with straight septal cartilage (Y-Z) har- vested posteriorly. A tip graft also was applied (AA). . . '",- ~ . . -f=: ", ~ 130 RHINOPLASTY DISSECTION MANUAL RIB CARTILAGE GRAFT RECONSTRUCTION OF SADDLE DEFORMITY: INTEGRATED DORSAL GRAFT/COLUMELLAR STRUT The severe saddle-nose deformity may be treated by using autogenous rib cartilage (8,9). Harvest of rib is . escribed later. The rib graft is carved into a dorsal graft and a columellar strut, which are interdigitated to recreate an intact L-strut (Fig. 6). This type of structural re- construction is particularly useful when there is complete loss of septal support . If an intact nasal septal L-strut is present, onlay dorsal grafting will be sufficient to correct the deformity. Great care must be taken to adhere to the principle of "balanced cross-sectional carving" to minimize the risk of graft warping. Once in position, the domes can be sutured over the graft with a transdomal suture. An external rhinoplasty approach allows exposure for facile place- ment of these grafts. A tip graft allows improved tip projection and definition. Figure 6. A, B: Severe saddle-nose deformity. Rib graft is fashioned into a columellar strut (secured to the medial crura) and a dorsal onlay graft that interdigitates with the columellar strut. C-EE: (slides) Preoperative (C-F) pho- tographs of a patient with a severe saddle-nose deformity. She underwent application of an iliac bone graft to her nasal dorsum in the past. Lack of an intact L-strut and in- adequate middle vault support resulted in descent of the graft, airway obstruction, and referral to our office for re- construction . Base view reveals the bone graft in the left nostril and a widened columellar scar. Other Maneuvers 131 c D E F Figure 6, continued. . , ~- =-~!!II. ;r-r, I' - ~"~ • _ ~~ ~J~TI 132 RHINOPLASTY DISSECTION MANUAL G H J Figure 6, continued. Graphic operative worksheet (G, H) illustrates the surgical high points. Rib graft was harvested (I, J), and exposure was achieved via the external rhinoplasty approach (K, L). A sutured-in- place columellar strut fashioned from rib graft was secured between the medial crura (M, N). A dorsal-on- lay graft was carefully carved (0, P) with a notch, allowing it to interdigitate with the columellar strut. r1j 'Iii -' • "~I Other Maneuvers 133 M N ;:;;;:::: L o p Figure 6, continued. :!'Oo . ~I - .~~ L ~II . IT 134 RHINOPLASTY DISSECTION MANUAL Q s R T Figure 6, continued. Other Maneuvers 135 u v w Figure 6, continued. The dorsal graft was placed and se- cured (0- T). Example from another patient illustrating in- terdigitation of strut and dorsal onlay graft (U). A tip graft was placed and covered with a layer of perichondri um to camouflage and soften the leading edge of the tip graft. (V, W). .'. ~ } -r . - -=-~.Jil . : ., . -;~:~ : 136 RHINOPLASTY DISSECTION MANUAL x z y AA Figure 6, continued. . 11'1 I ~; III '~ I • : I Other Maneuvers 137 BB cc DD EE Figure 6, continued. Preoperative (X, Z, BB, DO) and postoperative (Y, AA, CC, EE) side-by-side com- parison. 138 RHINOPLASTY DISSECTION MANUAL PEARLS · • When placing plumping grafts, the surgeon should overcorrect because the grafts tend to settle over time. Additionally, the pocket can be gently irrigated with an- tibiotic solution to minimize the incidence of infection. • When performing a caudal extension graft, the surgeon must take special care to set appropriate tip projection, rotation, length, and alar/columellar relation. Addi- tionally, the caudal margin of the graft must be in the precise midline. • The inferior border of the caudal extension graft should be stabilized on the pos- terior septal angle, soft tissue, or other supporting tissues to avoid postoperative counterrotation of the extension graft. . • Deviations of the caudal septum can usually be corrected by crosshatching the car" tilage and other conservative maneuvers described in the text. Many cases can be . corrected by accounting for excessive length of the L-strut. Inrare cases, subtotal septal replacement may be necessary. • When using an integrated columellar strut/dorsal graft, the surgeon must take spe- cial care to stabilize the columellar strut in the midline to avoid shifting or tilting of the columella. Placement of the dorsal graft into a precise dorsal pocket or su-: . ture fixation of the dorsal graft to the middle nasal vault will miriimize the chance . of the graft shifting to one side. • Symmetric carving of the costal cartilage graft will minimize the chance of the graft warping over time: REFERENCES I. Tardy ME, Becker DG, Weinb erger MS. Illusions in rhinoplasty. Facial Plast Surg 1995;11:117-1 38. 2. Tardy ME. Rhinoplasty: the art and the science. Philadelphi a: WB Saunders, 1997. 3. Tor iurni OM. Caudal septal extension graft for correction of the retracted columella. Opel' Tech Otolaryngol Head Neck Surg 1995;6:3 11- 318. 4. Beeson WH. The nasal septum. Otolaryngol Clin North Am 1987;20:743- 767 . 5. Toriurni DM, Ries WR. Innovative surgical management of the crooked nose. Facial Plast Surg Clin North Am 1993;1 :63-78. 6. Metzinger SE, Boyce RG, Rigby PL, Joseph JJ, Anderson JR . Ethmoid bone sandwich grafting for caudal sep- tal defects. Ar ch Otolaryngol H ead Neck Surg 1994;120 :1121-11 25. 7. Toriurni DM. Subtotal reconstruction of the nasal septum: a preliminary report. La ryn goscope 1994 ;104: 90 6-9 13. 8. Daniel RK. Rhinoplasty and rib grafts : evo lving a flexible operati ve technique. Plast Reconstr Surg 1992 ;94: 597 -6 11. 9. Wang TO . Aesthetic struct ural nasal augmentation. Opel' Tech Otolaryngol Head Neck Surg 1990. [...]... circumferential incision is shown here with a 6-0 nylon running vertical mattress suture (M-P) Alternatively, one may close the incision with in­ terrupted mattress sutures Place a bolster dressing of Telfa, dental roll, or other suitable material into the concha and suture it into position (0-T) to decrease the risk of hematoma .- , ~."~ -~ •• ~"3!' A 4-cm to 6-cm incision overlying the eighth rib allows... etic structural nas al aug men tat ion Opel' Tech Otolaryngol Head Neck Su rg 1990 5 Tardy ME Rhinoplasty: the a rt an d the scie nce Philadelphia: W B Saund ers, 1997 6 Chen ey ML, G licklicb RE The use of calvari al bone in nasal reconstruction Arch Otola ryng ol Head Neck Surg 1995; 121 :643 -6 48 - • - -ii , ~ = ­ ... used to har­ vest the grafts carefully (C, F-I) Narrower grafts are safer and easier to harvest -~ • l- T~!lJ! ' ~il- G Figure 3, continued Short , controlled taps on a sharp teotome (H) allow increased precision and help decre the risk of inner table penetration and dural tear PEARLS · • When harvesting auricular cartilage, the surgeon can simplify the dissection b performing local anesthetic injection... continued A-T: Injection hydrodissects the skin of the concha cavum and cymba from the underlying cartilage (A) The incision follows the outer edge of the cavum and cymba concha and is placed along the portion of the concha that is vertically oriented in re­ lation to the lateral aspect of the skull (B, C) Dissection proceeds by using appropriate scis­ sors, and also bluntly with cotton-tip applicators (D-G)... Frit sch MH Th e versat ile cartilage autogra ft in recon structi o n of the nose and face Laryngoscope 1 985 ;95:52 3- 532 2 Met zinger SE , Boyce RG, Rigb y PL, Jo seph JJ , Ande rson JR Ethm oid bone san dwich graf ting for caudal sep­ tal defects A rch Otol Head Neck Surg 1994 ; 120: 112 1-1 1 25 3 Dani el RK Rhin oplasty and rib gr afts: ev olvin g a fle xible o perative tech niqu e Plast Recon... cartilage Make the incision with a no 15 blade, and elevate the skin and perichondrium from the underlying cartilage Dissection proceeds by using appropriate scissors, and also bluntly with cotton-tip applicators Care should be taken not to damage the soft auricular cartilage, which can tear The dissection should stop short of the cartilage of the external auditory canal The radix helicis should be preserved... Cartilage is typically harvested from the eighth and ninth ribs A 4 cm to 6 cm incision overlying the eighth rib allows adequate expo­ sure (see also Chapter 11, Fig 6) Dissection proceeds to and then through the rib perichondrium Dissection around the rib is undertaken subperichondrially; the pleura is typically closely adherent to the perichondrium With the donor rib completely separated from surround­... piece of cartilage, and leave the underlying muscle behind (peri­ chondrium will remain adherent to the posterior surface of the cartilage), Avoiding deep dissection into the soft tissue minimizes bleeding Suture the circumferential incision with a 6-0 nylon running mattress suture Alterna­ tively, the incision may be closed with interrupted vertical mattress sutures Special care must be taken to avoid... identified, a pursestring suture closure dertaken around a red-rubber suction catheter The surgeon then requests a "Val salva " the anesthesiologist The red rubber is then removed and the suture tightened Saline be placed in the wound and another Valsalva undertaken while the surgeon careful spects for air bubbles A standard, layered soft-ti ssue closure without a drain is ac plished Skin edge eversion... allow proper angle for application of a chisel or powered oscillating saw to harvest the grafts fully Short controlled taps on a sharp osteotome allow increased precision and hel crease the risk of inner-table penetration and dural tear Patients must be cautioned preoperatively of the risk of possible dural tear and pos brain injury Any dural entry should elicit an immediate neurosurgical con sultation . the leading edge of the tip graft. (V, W). .'. ~ } -r . - - =-~ .Jil . : ., . -; ~:~ : 136 RHINOPLASTY DISSECTION MANUAL x z y AA Figure 6, continued. . 11'1 I. may be used to har- vest the grafts carefully (C, F-I). Narrower grafts are safer and easier to harvest. -~ • l- T~!lJ! '. . . ~il- 146 RHINOPLASTY DISSECTION MANUAL G H Figure. continued. Preoperative (X, Z, BB, DO) and postoperative (Y, AA, CC, EE) side-by-side com- parison. 1 38 RHINOPLASTY DISSECTION MANUAL PEARLS · • When placing plumping grafts, the surgeon should