Rhinoplasty • dissection manual

• Rhinoplasty • Dissection Manual e;t DEAN M TORIUMI • DANIEL G BECKER ~ L1PPINCOTf WILLIAMS & WILKINS Rhinoplasty Dissection Manual - -_. - ~ , , ~~ '­ , \ - Rhinoplasty Dissection Manual Dean M Toriumi, M.D Associate Professor Division of Facial Plastic and Reconstructive Surgery Departm ent of Otolaryngology-Head and Neck Surgery University of Illinois at Chicago Daniel G Becker, M.D Assistant Professor Division of Facial Plastic and Reconstructive Surgery Departm ent of Otola ryngology-Head and Neck Surgery University of Pennsylvania Illustrated by Devin M Cunning, M.D 4~ LIpPINCOTT WILLIAMS & WILKINS • A Wolters Kluwer Company Philadelphia • Baltim ore • New York • London Bueno s Ai res • Hon g Kon g • Sydney · Toky o ~ - _-~ ~~I • • - ~ - ," ~ Ill' ~~ Acquisitions Editor: Danette Knopp Developmental Editor: Sara Lau ber Production Editor: Patri ck Carr Manufacturing Manag er: Tim Reynolds Cover Designer: Christine Jenn y Compositor: Maryland Co mposi tion Printer: Couri er Westford © 1999 by LIPPINCOTT WILLIAMS & WILKINS 227 East Wa shington Square Philadelphia, PA 19106-3780 USA LWW.com All rights reserv ed This book is protec ted by cop yright No part of this book may be re produced in any form or by any means, includ ing photocopying, or utiliz ed by any information storage and retrieval system without written permission from the cop yright owner, exce pt for brief qu otat ions em bodied in cri tica l article s and reviews Material s appearin g in this book prepared by individuals as part of their of ficial duties as U.S go vernment employees are not covered by the above-me ntioned copyright Illust rations © Dani el G Becker Photograph s © Dean M Toriumi Printed in the United States of America Library of Congress Cataloging-in-Publication Data Toriurni, Dean M Rhinopla sty dissection manu al/Dean M Toriumi, Danie l G Bec ker ; illustrated by Devin M Cu nning p em, Includes bibliographical references and ind ex ISB N 0-7817 -1783-3 I Rhinoplasty Handbooks, manu als, etc Nose-Surgery Handb ooks, manuals, etc I Becker, Dani el G II Title [DNLM: Rhinopla sty-meth ods Handbo oks WV 39 T683 r 1999] RDII 5.N67T 67 1999 617.5' 230592 -dc2 DNLMIDLC for Library of Congress 99-260 58 CIP Care has been take n to co nfirm the accuracy of the information pre sented and to descri be generally accepted practi ces However, the autho rs, ed itors, and publisher are not responsible for errors or omis sions or for any sequ ences from application of the information in this book and make no warra nty, expresse d or impli ed, with respect to the currency , completenes s, or accura cy of the contents of the pub licati on Appli cation of this information in a particular situation rem ain s the profe ssion al respon sibility of the practitioner Th e authors , editors, and publisher have exerted every effort to ensure that drug selectio n and dosage set forth in this text are in accordance with current recommendations and practi ce at the time of publ ication Howe ver, in view of ongo ing research, change s in govern ment regul ation s, and the stant flow of inform ation relat ing to dru g therapy and drug reaction s, the reader is urged to chec k the package insert for each drug for any change in indic ation s and dosage and for added warn ings and preca utions Thi s is particularly importan t when the recomm end ed agent is a new or infrequently employed drug Some drugs and med ical de vices present ed in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted rese arch settings It is the resp onsibil ity of the health care provider to asce rtain the FDA status of each dru g or de vice planned for use in their clinic al practic e 10 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 parent s 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 Chapter 2: Rhinoplasty Analysis Landmarks for Analysis Lab Exercise: Nasal Analysis 11 Surface Angles, Planes, and Measurements- Definitions 12 Rhinoplasty Analysis 16 Chapter 3: Injection Infiltrative Anesthesia Technique 25 25 Chapter 4: Septoplasty Nasal Dissection: Septoplasty with Cartilage Harvest 31 Incisions and Approaches Transcartilaginous or Cartilage-Splitting Approach Delivery Approach The External (Open) Rhinoplasty Approach 37 37 40 43 Chapter 6: Removal of Bony-Cartilaginous Hump 59 Chapter 7: Osteotomies Medial Osteotomies 67 67 Chapter 5: 31 vii ~ ~ ' :r-=­ J -v' • -~ ~ ' Lateral Osteotomies and Infracture Intermediate Osteotomies Chapter 8: Spreader Grafts Chapter 9: Surgery of the Tip Exercises Chapter 10: Alar Base Resection Internal Nostril Floor Reduction Wedge Excision of Nostril Floor and Sill Alar Wedge Excision Sliding Alar Flap Chapter 11: Other Maneuvers Plumping Grafts Caudal Extension Grafts Deviated Caudal Septum Rib Cartilage Graft Reconstruction of Saddle Deformity Chapter 12: Harvest of Autogenous Tissue Harvesting Conchal Cartilage Harvesting Ethmoid Bone Harvesting Rib Graft Harvesting Calvarial Bone Chapter 13: Incision Closure, Nasal Splint, Post-Operative Considerations Closure of Midcolumellar Incision Closure of the Marginal, Intercartilaginous, or Transcartilaginous Incision Placement of Intranasal Packs, Nasal Splint Postoperative Care Appendix A: Appendix B: Appendix C: Appendix D: Appendix E Appendix F: Appendix G: Appendix H: Appendix I: Appendix J: Appendix K: Tripod Concept Guide to Nasal Analysis Aesthetic Analysis Surface Angles, Planes, and Measurement: Definitions Tip Support, Incision, and Approaches Achieving Surgical Goals: Selected Options Selected Complications of Rhinoplasty Adjunctive Procedures Cleft Lip Nasal Deformity Photography Setup Indications for External Rhinoplasty Approach -:1 , ." , Appendix L: Appendix M: Appendix N: Suggested Surgical Instruments for Rhinoplasty List of Selected Companies with AddresseslPhone Numbers Selected Recommended Literature 171 172 174 Index 177 - , t" - - ,­ - - -­ ;z Foreword Exce llent surgical outcomes in rhinoplasty derive from two interrelated fac tors: (1) a de­ tailed understanding of the multiple nasal anatomic varian ts encountered, and (2) an ac­ qui red knowledge of the ulti mate long-term effects of surgical altera tions of these anatomic components-the evo lution of healing The first ski ll ca n be learned by detailed observation, enhanced by cadaver dissection; the second skill only by ca reful foll ow-up of ope rated patients over time The genera l cepts of nasal anatomy have been fun damentally clear for centuries , but on ly in recent decades have surgeons appreciated the fine ly det ailed nuances of nasal anatomic dynamic s that influence the surgical crea tion of a natural, plea sing rhinopl asty re­ sult, free of surgical stigmata A det ailed com prehension of nasal anatomy must therefore transcend knowledge of basic anatomic relationships Th e surgeo n must j udge , by inspec­ tion and pa lpation, the character of the ski n and subcutaneous tiss ues as they vary from nasal region to region , the influences of faci al mimetic musculature, the relative strength and support of the carti laginous and bony framework and substruct ure, and the lim itations imposed by the int err elation ship of all these struc tures upon the ultimat e fav orable result As important as the eva luation of what can reasonably be accomplished during rhi noplasty is the acqui red kno wledge and ski ll to assess what canno t be acco mplished This ju dgment is largel y pre dicated on the critical ana lysis of each pat ient's indivi dual anatomy, coupled with techn ical refin ements guided by experie nce, and generally requires years of personal surgic al result evaluation to beco me kee n In this diss ection manu al, Drs Becker and Toriumi have created a unique study guide and cadaver dissection manu al ded icated to guiding the learn er in a disciplined manner They admirably ex tend the tradit ion of the Universi ty of Illinois Departm ent of Oto laryn­ gology's leader ship in teaching anatomy and surgery in rhin oplasty Cadaver dissec tion cons titutes a privil ege not available to all, and, as such, this precious material must be wise ly and co nserva tive ly approached Experie nce teaches that a discipl ined, structured ap­ proach to dissecti on of the nose pro duces the best edu cational outcome An imp ortant fav orable develop ment in cont empo rary rhinoplasty is the appropria te con­ ce rn for conservative and subtle anatomic changes that by definition derives from a prese r­ vativ e attitude toward nasal tissues Commonly, rath er than excisional sacrifice of large segments of cartilage or bon e, a phil osophy of preservation and restoration oftissues is de­ ve loping that preclud es crea tion of unnecessary tissue voids whic h may heal and scar un­ xi , - - \ L ' -:H predictably Wise surgeons recognize that even a larger nose, well balanced to the rounding facial features, is always aesthetically preferable to a nose made over-sma radical surgery Conservation surgery thereby further extends the surgeon's control the final surgical result, as an appropriate equilibrium between the corrected nasal ske and soft tissue covering is more reliably achieved Con servative sculpture and volum duction of the alar cartilages clearly produce more favorable results, generally avoi major resections and vertical interruprion of the intact residual strip of lateral and m crus Notching, pinching, alar cephalic retraction, over-rotation, and asymmetries ar almost entirely eliminated in long-term healing when this conservative philosophy is braced A further striking example of conservatism is the preservation of a strong , high file in many patients, a distinct contrast to the dramatic retrousee pro files create decades past by sacrifice of over-generous segments of nasal bony humps Finally, thoughtful nasal surgeons, through accurate anatomic diagnosis , discern w portions of the nasal anatomy are pleasing and satisfactory, striving to avoid distur these structures and areas when correcting (or gaining access to) anatomic componen need of correction This philosophy further extends the surgeon 's favorable control ove timate healing Thoughtful cadaver dissection provides the learner with visual pathwa gain access to structures to be modified, while preserving normal tissues and relations Important tissue planes, vital in live surgery, can be appreciated best when viewed at le in the dissection laboratory This well-conceived work, properly employed, contributes substantially to shorte the steep learning curve characteristic of rhinoplasty M Eugene Tardy, Jr., M.D., F.A.C Profes sor of Clinical Otolaryngolo Director, Division of Facial Plastic Reconstructive Surgery University of Illinois Medical Cen Chicago, Illinois Professor of Clinical Otolaryngolo Indiana University School of Medi ~ - ':1 I'll ,,1 Medial cr ura short bilatera lly Latera l crura short bilaterally, caudally displaced Tip-defining points poorly defined and wide ly separated Columella: Short, with a wide base Nostri ls: Horizon tal orientation bilaterally Alar base : Laterally, inferiorly, and posteriorly disp laced bilatera lly Nasa l floor: Usually abse nt bilaterally REFERENCE J Sykes 1M, Senders CW, Wang T D Cook TA Use of the open approach for repai r of secondary cle defo rmity Facial Plast Surg ChI! North Am 1993 ; 1: 111- 126 Appendix J: Photography Setup (1) (Fig A-4) Came ra: 35-mm SLR (single light reflex camera) with 105-mm macro lens Lighting: dual elect ronic flash units; overhead kick er light adds a backlighting effect that improves picture quality and sof tens or elim inates background shadows Background: Nassau blue no 25 Film : Kodak Ekta chrome ASA 100 STANDARD RHINOPLASTY VIEWS 1:7, front al, base, lateral, oblique 1:5 and 1:3, close-up, base view Background ~ Overhead Kicker Light / I \\ Light Source Light Source Camera Figure Schematic photography setup REFERENCE I Tardy ME Brown R Principles ofphotog raphy in f acia l plastic surgery New Yor k: Th ieme Publishers 1992 ~ -.=~ ij: ~ ift: j~ Appendix K Indications For Extern Rhinoplasty Approac (1, Asy mmetric nasal tip Croo ked-nose deformity (lower two thirds of nose) Sadd le-nose deformity Cleft- lip nasal deformity Secondary rhinopla sty requ iring complex structural grafting Septal -perforation repair REFERENCES I l oh nson CM 1r, Toriumi DM Open structure rhinoplasty Ph iladelphia: WB Saunders 1990 T oriumi DM , l ohnson CM Open struc ture rhi nopla sty: featured technical point s and long-term follow cial Plast Surg Clin North Am 1993; I: 1-22 Appendix L: Suggested Surgical Instruments for Rhinoplasty 10 I I 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 Needle holder Bayonet forceps Mallet Takaha shi forceps Siegel retractor Converse retractor Hemostat (curved) Hemostat (straight) Small nasal speculum Large nasal speculum Small single skin hook Small double skin hook Small double skin hook Medium double skin hook Wide double skin hook Freer/Cottle elevator Joseph elevator Converse scissors Fomon scissors Straight Stevens scissors Curved Stevens scissors Curved Iris scissors Scalpel handle Scalpel handle Brow n-Adson forceps Brown-Adson forceps Bishop-Harmon forceps Bishop-Harmon forceps 2.0-mm unguarded osteotome 3.0-mrn straight unguarded osteotome 3.0-mm straight guarded osteotome 2.5-mm straight guarded osteotome Medical grade sharpening stone Dorsal (Rubin) osteotomes : small, medium, large Rasps with tungsten-carbide inserts: 1/2, 3/4, 5/6 Aiache cartilage crusher No 10 Frazier tip suction -II -=?i: =I • -4- U1 -".­ Appendix List of Select Companies wi Address/Phone Numbe RHINOPLASTY INSTRUMENT SETS Anthony Products , Inc., Indianapolis, IN 800 428-1610 Ell is Instruments, Inc., Madison, NJ 800 218-9082 Instruments Unlimited, Quakertown, PA 800 818-0094 Inv otec, Jacksonv ille, FL 800 998-8580 Lorenz Sur gical , Jacksonville, FL 800 874-7711 MicroFrance, St Aub in, Fran ce 800- 874-5797 Smith-Nephew-Richards, Madi son, WI 888 395-8060 Snowden Pencer, Tucker, GA 800 843-8600 Stor z Instrument s, St Louis, MO 800 325-9500 Xo med Surgical Produ cts, Jacksonville, FL 800 874-5797 ALLOPLASTIC CHIN IMPLANTS Allied Biomedical, Paso Roble s, CA 800 276-1322 Hanson Medi cal, Inc , Kingston, WA 800771-2215 Invotec , Jacksonville , FL 800 998-8580 Porex Surgical, Inc , College Park, GA 800521-8145 W L Gore & Associ ates, Inc., Flagstaff, AZ 800 528-8763 Xom ed Surgical Products, Jacksonville, FL 800 874-5797 ALLODERM LifeCell Corporation, The Woodlands, TX 800367-5737 DERMABOND (OCTYL-2-CYANOACRYLATE) Ethicon, Somerville, NJ 800 888-9234 RHINOPLASTY POWER INSTRUMENTATION Lin vatecIHall Surgical Products Group, Largo , FL 800 925-4255 United Ame rican Medical, McMinnville, TN 800 521-5002 Xom ed Surgical Products, Jacks onv ille, FL 800 874-5797 NASAL SPLINTS Invotec, Jacksonv ille, FL 800 998-85 80 Shippert Medical Technologies (Denver Splints), Englewood , CO 800 888-8663 Vision Medical (Thermoplast), Peoria, AZ 800 874-5797 Xomed Surgical Products, Jacksonville, FL 800 874-5797 INTRANASAL PACKS Invotec, Jacksonville, FL 800 998-8580 Xomed Surgical Products, Jacksonville, FL 800 874-5797 - - _J~ - : ~ -t-: ' ~, Appendix Selected Recommend Literatu Adamson PA Open rhinopla sty In: Papel lD, Nachlas NE, eds Facial plastic & reco nstructive sur Louis: Mosby Year Book , 1992:295-304 Anderson JR A reasoned approach to nasal base surgery A rch Otolaryn gol Head Neck Su rg 1984; 110:3 Becker DG, Toriumi DM , Gross CW , Tardy ME Powered instrumentatio n for dorsal nasal reduction Fac Surg 1997;13:291-297 Becker DG, Weinber ger MS, Greene BA, Tardy ME Clinical study of alar anatomy and surgery of the a Arc h Otolaryngo l Head Neck Surg 1997;123:789-795 ' Beeson WHoThe nasal septum Otola ryng ol Clin North Am 1987;20:743-767 Byrd HS, Andochick S, Copit S, Walton KG Septal ex tension grafts: a method of controlling tip projecti Plast Reconstr Surg J998 ; I00:999-1 I O Byrd HS, Hobar Pc Rhinoplasty: a practical guide for surgic al planning Plast Reconstr Surg 1993;9 I:6 d iscussion 655-656 Cheney ML , Glicklich RE The use of calvarial bone in nasal reconstru ction Arch Otola ryng ol Head N 1995; 12 1:643-648 Constantian ME The incomp etent ex ternal nasal valve: patbophysiology and treatment in primary and s rhinoplasty Plast Rec onstr Surg 1994;9 3:919-93 Constantian MB, Clardy RB The relative importance of septal and nasaJ valvular surgery in corre cting struction in primary and secondary rhinoplasty Plast Recons tr Surg 1996;98:38-54 Crumley RL , Lanser M Quantitative analysis of nasal tip projection Laryngoscope 1998;98:202-208 • Daniel RK Rhinoplasty and rib grafts: e volving a flexible operative tech nique Plast Reconstr Surg 597-61 I Farrio r RT The osteotomy in rhinoplasty Laryngoscope 1978;88: 1449 Goode RL Surgery of the incompetent nasal valve Laryngoscope 1985;95:546-555 Gunter JP The merit s of the open approach in rhinoplasty Plast Reconstr Surg 1997 ;99: 63~867 Gunter JP, Clark CP, Friedm an RM Internal stabilization of autogenous rib carti lage grafts in rhinoplas rier to cartilage warping Plast Recons tr Surg 1998; I00: 161-1 69 Gunter JP, Clark CP, Friedm an RM Internal stabilization of autoge nous rib cartilage grafts in rhinopla s rierto cartilage warping Plast Reconstr Surg 1997; J00: J6 1-169 Gunter JP, Friedman RM Lateral crural strut graft: techniqu e and clinical applications in rhinoplasty P constr Surg 1997;99:943-955 Gun ter JP, Rohrich RJ Management of the deviated nose : the importance of septal reconstruct ion Clin P 1988;15:43-55 Gunte r JP, Rohrich RJ Augmentati on rhinopla sty: dorsal onlay graft ing using shaped autogenous septal c Plast Reconstr Surg 1990;86:39 45 Gunter JP, Roh rich RJ, Friedman RM Classification and correc tion of alar-co lumellar discrepancies plasty Plast Reconstr Surg 1996;97:643-648 Johnson CM Jr, Godin MS The tension nose: open structure rhinoplasty approach Plast Reconstr Su rg 43- 51 Johnson CM Jr, God in MS The tension nose [Letter, comment] Plast Recons tr Surg 1996;97:246 Johnson CM Jr, Tor iumi DM Open structure rhinop lasty Phil adelphi a: WB Saunders, 1990 Kamer FM, Pieper PG Revision rhinoplasty In: Bailey B, ed Head and neck surgery otolaryngo logy P phia: Lippin cott, 1998:2663-2676 Kasperbauer JL, Facer GW, Kern EB Reconstructi ve surgery of the nasal septum In: Papal ID, Nachlas Facial plastic and reconst ruct ive surg ery Philadelphia: Mosb y Year Book , 1992:337-343 Konior RJ, Kridel RWH Controlled nasal tip position ing via the open rhinoplasty approac h Facial P Nort h Am 1993;1:53-62 Kridel RWH , Konior RJ Contro lled nasal tip rota tion via the lateral crural overlay techn ique A rch O Ne ck Surg /991;117:411 41 Larrabee WF Jr, Open rhinopl asty and the upper third of the nose Facial Plast Surg Clin Nonti Am 1993; Metzin ger SE, Boyce RG, Rigby PL, Joseph Jl , Anderson JR Ethmoid bone sandwich grafting for caud defects Arch Otol Head Neck Surg 1994; 120: 1/ 21- 1125 McCollou gh EG Surgery of the nasal tip Otolaryng ol Clin North Am 1987;20 :769-784 McCollough EG, Mang at D System atic approac h to correction of the nasal tip in rhinoplasty A rch Oto 1981;J07: 12- 16 Murakami CS, Cook TA, Guida RA Nasal reconstruction with articulated irradiated rib cartilage A laryn gol Head Neck 511rg 1991;117:327-330 Murak ami CS, Larr abee WF Comparison of osteot omy techniqu es in the treatme nt of nasal fractures Fac Surg 1992;8:209-21 Rohrich RJ, Hollier LH Rhin oplasty with advancing age: characteristics and management Clin Plast Su 23:281-296 Schwartz MS, Tardy ME Standardized photodocumentation in facial plastic surgery Facial Plast Surg 1990;7: 1-1 Sheen JH Spreader gra ft: a method of reconstructing the roof of the middle nasal vault follo wing rhinoplasty Pl ast Reconstr S urg 19 84 ;7 3:2 30 237 Sheen JH Tip graft: a 20 year retrosp ective Plast R econ str Surg 1993;91 :48- 63 Simon s RL Vertical dome division in rhinoplasty Otolaryngol Clin North Am 1987 ;20 :785-796 Sim ons RL, Gallo JF Rhinoplasty complications Facial Pl ast Surg Cl in North Am 1994; 2:521-529 Sykes JM , Senders CW, Wang TD , Cook TA Use of the ope n approach for repair of secondary cleft lip nasal de­ formity Facial Plast S urg Clin North Am 1993;1:111-126 Tard y ME Rhinopla sty in midlife Otolaryngol Clin North Am 1980 ;13:289-303 Tardy ME Ethics and integrity in facial plastic surgery : imperatives for the 21st cen tury, Facial Pla st S urg 1995 ; 11:111-1 15 Tardy ME Rhinoplasty: th e art and the s cience Philadelphi a: WB Saunders, 1997 Tard y ME, Becker DG, Weinberger MS Illusions in rhinoplasty Facial Plast Surg 1995;11:117-138 Tard y ME, Broadw ay D Graphic record-keeping in rhino plasty: a valuable self-learning device Facial Pla st Su rg 1989;6:108-112 Tardy ME, Brown R Surgical anatomy of the nose New York: Raven Press, 1990 Tardy ME, Brown R, Pr inciples of ph otography in fa cial plastic surge/Yo New York: Thieme Publi shers, 1992 Ta rdy ME, Cheng E Tran sdomal suture refinement of the nasal tip Facial Plast Surg 1987 ;4:317- 32 Tardy ME, Cheng EY, Jernstrom V Misadventure s in nasal tip surgery Otolaryn gol Clin No rth A m 19 87 ;20 : 797-823 Tardy ME, Denneny J, Fritsch MH The versatile cartilage autograft in reconstruction of the nose and face Laryn­ goscop e 19 85 ;95 :52 3- 53 Tardy ME, Genack SH, Murrell GL Aesthetic correcti on of alar-co lumellar disprop ortion Facial Pl ast S urg Cl in North Am 1995 ;3:395-406 Tardy ME, Heinrich JA, Linbeck EO Refinement of the nasal tip Facial Plast S urg Clin No rth A m 1994 ;2: 459-476 Tardy ME, Kron TK, Younger RY, Key M The cartilaginous pollybeak: etiology , prevention, and treatment Fa ­ cial Plast Surg 1989;6:113-120 Tard y ME, Patt BS, Waller MA Transdomal suture refinement of the nasal tip: long-term outco mes Facial Pla st S urg 1989 ;9:27 5-284 Tard y ME, Patt BS, Walter MA Alar reduct ion and sculpture: anatomic concepts Facial Pla st Su rg 1993 ;9: 295-305 Tardy ME , Schwartz M, Parras G Saddle nose deformity: autogenous graft repair Facial Plast S urg 1989;6: 121-134 Tardy ME, Thom as JR Facial aesthetic su rge ry Philadelphi a: Mosby, 1995 Tard y ME, Tor iumi DM Alar retraction: composite graft correction Facial Pla st Surg 1989;6:101-107 Tard y ME, Toriumi DM Philosoph y and princip les of rhinoplas ty In: Cummings CW, Fredri ckson JM, Harker LA, et al., eds Otolaryngology-head & neck surgery 2nd ed St Louis: Mosby Year Book, 1993:278-294 Tardy ME , Toriumi DM, Walter MA, Patt BS The difficult nasal tip In: Gates G., cd Current therapy in oto ­ laryngol ogy-h ea d & neck s urg ery 1993:170- 182 Tardy ME, Walter MA, Patt BS The overprojecting nose: anatomic component anal ysis and repair Fac ia l Pla st Surg 199 ;9:306-316 Tebb ett s JB Shaping and positioning the nasal tip without structural disruption: a new systematic approach Pla st ReconstrSurg 1994 ;94 :61-77 Tho mas JR Steps for a safer method of osteotomies in rhinoplasty Laryng oscope 19 87 ;97:746-747 Thomas JR External rhinoplasty: intact columellar approac h Laryngoscop e 1990;I 00(2 Pt 1):206-208 Thomas JR , Griner NR, Remml er DJ Step s for a safer method of osteotomies in rhinopl asty Laryn goscop e 19 87 ; 97:746-747 Thom as JR, Tardy ME Uniform photographic documentation in facia l plastic surgery Otolaryngol Clin North Am 1980;13:367-3 81 Toriumi DM Subt otal reconstruct ion of the nasal septum: a prelimin ary report Lary ngoscope 1994; I04:906-13 Toriu mi DM Caudal septal extension graft for correcti on of the retracted columella Oper Tech Otol aryn gol Head Ne ck Surg 1995 ;6:3 11-3 18 Toriumi DM Management of the midd le nasal vault: operative techniques in plastic & recon structive surge ry 1995;2:16-30 Torium i DM Surgi cal correction of the aging nose Facial Plast Su rg 1996; 12:205-214 Toriumi DM, John son CM Open structure rhinoplasty featured tech nical points and long-term follow-up Facial Plast Su rg Clin No rth Am 1993;1:1-2 Toriumi DM, John son CM Mana gement of the lowe r third of the nose open structure rhinopla sty technique In: Papel 10, Nachlas NE, eds Facial p last ic & recon stru ctive surgery 1992:305-31 Toriumi DM, Josen J, Weinberger MS, Tardy ME Use of alar batten grafts for correction of nasal valve collapse Arch Oto l Head Ne ck S urg J997;123:802-808 Toriumi DM Mueller RA, Grosch T, Bhauacha ryya TK , Larrab ee WF Vascular anatomy of the nose and the ex­ tern al rhinopla sty approach Arch Oto l Head Neck Surg 1996 ;122:24-34 Toriu mi DM, Ries WR Innovative surgical management of the crooked nose Facial Pla st Surg CUn North Am 1993; I:63- 78 Torium i DM, Syke s JM , Johnson CM Open structure rhinoplas ty for managem ent of the non-caucasian nose Op er Tech Otola ryngol Head Neck Surg 1990;1:225- 233 Toriumi DM, Tardy ME Cartilage suturing techn iques for correction of nasal tip deformitie s Op er Tech Oto­ laryngol Head Ne ck Surg 1995 ;6 :26 5-273 Toriumi DM, Josen J, Weinberger M, Tardy ME Use of alar batten grafts for correction of nasal valve collapse Arch Oto l Head N eck Surg 1997;123 :802-808 Wang TD Aestheti c structural nasal augme ntation Op er Tech Otolaryngol Head Neck S urg 1990 :- ~ ~_ ' I , ' ~-~ r III ' ~lIjl ­ Subject Index 1'" ,11,,1 { - - ' , - _U-' '" ~ Subject Index A page number fo llowed by f indicates a figure A Aesthetic ana lysis, I I, 157 Aes thetic/cosmetic issues ala r base red uction , 113 clo sure of midco lumellar incision, 149, 150f- 15 1f Aesthetic triang le, 16, 20 Airway obstruction See Nasal obstruction Ala, rhinoplasty ana lysis, 20 Alar base cleft lip-nasal deform ity bilateral, 168 unilateral, 167 resect ion, 113-11 alar wedge excision, 114, I ISf internal excis ions, 115 internal nostril floor reduction, 113, 114f pearls, l iS sliding alar flap, 114, 115f wedge excision of nostri l floor and sill, 114, 114f rhinoplasty ana lysis, 18 Alar batten graft, 105, 106f-I09f Alar-columella relationship, 20, 1f Alar-fac ial groo ve (junction), 2f, 3f Alar flare internal nostril floor reduction, 113, 114f wedge excision of nostril floor and sill, 114, 114f Alar lobule, 3f, 5, 20 Alar nasalis muscle, 4f Alar sidewa ll, 2f Anatomy of nose, 1- musc ulature, f nasal relationships, S, 7f nasal valve area , pearls, 5-6 sc roll region, septum, f soft tissue layer, surface anatomy, 2f-3f basal view, 2f frontal view, 2f lateral view, 2f oblique view , 3f surgical anatomy, 3f-5f basal view, 3f lateral view, 3f oblique view, 3f vasculature, 4f- 5f Anesthesia, infilt rative injecti on technique , 25-29 co lumella injection, 25, 26f, 28 intercartilaginous, transcartilaginous, or delivery approach , 27, 28f lateral wall of nose, 27 , 29f mul tiple injections along marginal inc ision area, 25, 26f for osteotomy, 27, 28 pearls, 27-28 soft -tissue, domal region, 25, 26 f Anomalous nasi, f Anterior septal angle, 3f Aquaplast cas t, application and removal, 153 Artery(ies), nasal, 4f-5f Auricular carti lage alar batten graft, 105 harvesting, 139, 140f-1 42f, 146-147 B Beve ling of skin edges, 45 Bifidity, nasal tip, 17 Bleed ing, septoplasty, 33 Blood vesse ls, f-5 f Bone infarction, Bo nes, nasa l, 3f, infracture du ring os teotomy, 67-68 medialization, 68 postoperati ve margins, smoo thing with rasps, 62, 63 f postoperati ve shifting, digital exe rcises for, 153 Bossa for mation, 22, 110, 163 Brow-tip aesthetic lines, 17 Bulbosity, 17 Buttress graft, 102, 102f-105f Byrd' s method, nasal projection, 16, 19, 159 C Calvarial bone, harvesting, 144, 144f-1 46f, 147 Ca p graft, 102, 102f- I05f Cartilage harvesting See Tissue harvesting lower lateral (LLC) See Lower lateral cartilage quadran gular, 4f 179 - ,:,_ ~-i Cartilage tcontd.i sesa moid,3 f upper lateral (ULC) See Upper lateral ca rtilage Cartilage-sp litting approac h, 37 , 38f-39f Ce phalic trim, 77,11 Cervi cal point, IOf, I I, 157 Ch in altera tions augment ation , 165 f alloplas tic imp lant manufac turers, 172 Legan faci al-co nvexity angle, 15 Cleft lip- nasal deformity, I67f, 167- 168 bilateral , 167f, 168 unilateral, 167, 167f Col umell a, 2f cleft lip-nasal deform ity bilateral, 168 unilat era l, 167 hangin g co lumella deformity, septo plasty, infilt rati ve an esthetic injec tion techniq ue, 25, 26 f, 28 retr acte d, 17 caudal ex tension grafts, 118, 118f-12lf plumpi ng graft , 1l7, 117f rhino p lasty analys is, fron tal view, l7 Co lumella-labial angle (junc tion), 2f Col umell ar artery , 4f Co lumellar flap , 47, 47f-49f elevation of, 47, 49f infiltrat ive anesthetic inject ion tec hniq ue, 27f Columell ar-labial confluence, 18 Co lumellar -lob u lar angle, 18 Columell ar show normal value, 15, 20 rhi noplasty analy sis, 15, 158 Columell ar strut ca rtilage graft, 56, 81-84 dorsal on lay graft interdigit ating wit h See Sadd le nose deformity placem ent, 81- 84 endonasal approac h, 1, 83f-84f external rhi noplas ty appro ach, 81, 82f tripod co ncept, 155 Com plic ations, 163 Compressor muscl es, f Com presso r narium minor , f Compute d tom ograph y (CT scan), concha bullosa , 78, 78f Co ncha bullosa, 78 , 78f Co nchal carti lage See Auricu lar cartilage Converse sc isso rs, nasal dissection, J f Co rru gator muscle , 4f Cru mley' s me thod, nasa l projecti on , 16, 159 Crus/crura, 3f See also specific area Cyanoacrylate ad hesive man ufactur er, 172 skin closure, 113 D Del ivery approac h, 40-43 deli very of LLC , 41-42, 42f-43f intercarti lag inous inc ision , 40 , 40f marginal incisio n, 1, lf Depressor muscles, 4f Depresso r septi nasi, 4f Derma bond See Octyl-2 -cya noa cry late Digital exercises, postoperat ive , 153 Dil ato r muscle s, 4f Dilator naris anterio r, f Dissection auricular cartilage harv est ing, 139, 140 f-1 41 f deli very of LLC, 41-42, 42f-43f external rhinop lasty app roach See Ex terna l rhinop lasty approac h dissecti on retrograde, 50 rib cartilage harvestin g, 144 septoplas ty, 31 , 32f, 33 Dome divided, tip graft in, 101, 10If divis ion See Na sal tip, surg ery iden tification , 84 Dorsal nasal artery , 4f Dorsu m of nose cartilagi nous, ex posure and inc isio n for hump rem oval, 59, 60 f co nto ur assessment, anes thetic inj ection and, 27 irre g ularities, pos topera tive, 163 rhi noplasty an alysis, 11,20 Double break , 18-1 Dur al tear , parietal bone harvesting, 144 E Edema, per sistent postoperative sup ratip edema, 152-1 53 Elevator mus cle s, 4f Endona sal approa ch alar batten graft placement, 106f columellar stru t cartilage gra ft placement, 1, 83f- 84f incision closure, 152, 152f nasal dissecti o n, 56 spreader grafts, 1, 72f Ethmoid bone harve sting 143, 147 pe rpendicular pla te, 4f splinting (sand wich) gra fts, 122, 123f External rhinoplasty approach, 3-56 anes thesia inje ction techn ique , 25- 29, 26f-29f bac kgrou nd, 43 co lumellar strut ca rti lage graft placem ent, 1, 82 f dissecti on , 43 incisions for, 43 indications for , 170 integrated dorsal graf t-co lumellar strut for saddle no se deformity marg inal incision, 43, 44f colume llar ex tension, 45, 46 f, 56 nasa l dissection , 43-47 defining columell ar flap, 47 , 47f-49f elev atio n of per iosteum and expo sure of bony vault, 54-56, 55 exci sion of ce phalic car tilage, 50 exposu re of cartilag ino us middle nasal vau lt, 54, 54 f flap elevatio n, 47 , 49f incisio n marking, 43, 44 f lateral cru s, 50 , 1f m argina l incision , 43 , 44 f, 47 midcol umellar incisio n, 43 , 44 f, 45, 45f midline dorsal dissecti on, 52 , 52f- 53f retrograde dissect ion , 50 three-poi nt counter trac tion, 50, 50f pearl s, 56 septoplasty, 33, 34f spreader graft placeme nt, 1, 72f-75f transcolumellar (midcolu mella r) incision, 43 clo sure , 56 marking for, 43, 44f F Face Frankfort plane, 12, 13f, 158 hori zontal facial thirds, 12, 12f, 158 surface measu rem ent s, 22, 23f Leg an faci al-conv exity angle, 14f, 15 mentocervica l angle, 14f, 15 nasofaci al angle, 12, 13f, 158 nasofrontal angle, 12, 13f, 158 nasolabi al angle, 15, 15f nasomental angle, l3f, 15, 158 surface angles, plane s, and meas uremen ts, 12· ·16, 158-159 vertical facial fifths, 12, 12f, 158 Facet ,2f Flap, co lumellar, 47, 47f-49f Frankfort plane, 12, 13f, 158 G Gla bella, 9, 10f, 157 Gnathion, 10f, 11, 157 Goo de 's method, nasal projec tion, 15f, 16, 18,159 Grafts/grafting alar batten graft, 105, 106f-l09f cap or buttress graft, 102, I02f-1 05f caudal extension grafts, 118, 118f-1 21f, 138 colume llar strut cartilage gra ft, 56 ethmoid bone splinting (sandw ich) grafts, 122, 123f harvest of autogenous tissue, 139-147 calvarial bone, 144- 146 conchal (auric ular) car tilage, 139-1 42 ethm oid bone, 143 rib graft , 143-144 integrated dorsal graft -columellar strut for saddle nose defo rmity, 130- 137 lateral crural grafts, I 10, II Of nasal tip, 98- 10 onlay cartil age wafer grafts, 77 plumping grafts, 117, l7f, 138 shield-shaped tip graft, 98 ··10I spreader grafts, 1-79 Greenstick frac ture, in osteotomy, 68 zr, H Hanging columella deformity, se ptoplas ty, Hemitransfixion inc ision, septoplasty, 1, 32f "Hidden colu mella, " l7 Hump, 17 Hump excision, 59- 66 excision of bony hump, 59, 1f expo sure and incision of cartilaginous dorsum, 59, 60f extramucosal reduction, 64 fine-tun ing modifications, 62 in high-risk patient , 76 in "narrow nose sy ndro me," 76 nasofrontal angl e in , anes thesia considerations, 28 "open roof," 62 preop erative and postoperative views, 61f se paratio n of ULC from dorsal se ptum, 64, 65f septoplasty and , 33 smoothing bony margin s, 62, 63f, 64f Hydrodissection, auricul ar cartilage harvesting, 139, 140f I Illusions, 22 Incisions, 160 alar base reduction surgery, 113 auricular cartilage harvesting, 139, 140f closure See Wound clos ure external rhinopla sty approach, 43-47 intercartil aginous, 38f, 40, 40f closure, 152, 152f marg inal, 41 ,4 1f clos ure, 152, 152f, 153 colum ellar extension, 45 , 46f, 153 external rhinop lasty appro ach, 43 , 44 f midco lumellar closure, 149, 150f-151f, 153 external rhinoplasty app roach, 43, 44f , 45 , 45f suture remo val, 152 parietal bone harvesting, 144 rib cartilage harvesting, 144 septoplasty, 31, 32f transcartila ginous, 37, 38f closure, 152, 152f Infratip lobule, 2f, transdornal sutur e placement and, III Injection See Anesthesia Instrumentation rasps, 62, 63f suggested surgical instrum ents for rhinopl asty, 171 manufacturers ' address/ phone numbers, 172 Intermediate crus, 3f anesthetic inject ion, 25, 26 f Internasal suture line, 3f, Int ranasal pack, 152 manufacturers, 173 "Inve rted V" deformit y, 76, 163 K Kenalog See Triamcinolone aceto nide Killian incision, septoplasty, 1, 32f L Labrale superiu s, 10f, II, 157 Lateral crus , 3f, anesthetic inj ection, 25, 26f ce phalic trim , 110 grafts, 110, II Of lateral crural over lay, 96 , 96f-97f reduction of volume and rigidity, 85, 85f transcartila ginous incision, 37 Lateral nasal artery, 4f Lega n facial-convexity ang le, definition, 14f, 15, 158 Length of nose central, 18 definiti on, 18 "ideal," 19 illusions, 22 lateral, 18 rhinoplasty analys is, 11, 18-1 9, 19f surgical goa ls and options for ac hiev ing, 161-1 62 Levator labii alaeq uae nasi, 4f Lid ocaine , infiltrative ane sthesia techniqu e, 25-29 Li pectomy , submental, 166f Lips, rhinoplasty analysis , 14f, 15, 158 Literature recommendati ons, 174-175 LLC See Lower lateral cartilage Lo bule, Lowe r lateral car tilage, 3f asy mmetries, columellar strut for, 83f cephalic resection of lateral crura, 85, 85f L-strut integr ated dorsal graft-c olumellar strut , 130-137 in septoplasty , 33, 33f M Mattress sutur es closure of auricular cartil age harvest site, 139, 142f closure of midcolumell a incision , 149, 150f-15If spreader graft stabilization, 75, 75f Maxilla, ascendng process, 3f ::-.::::c::"" -'r,-I­ r ; '~-~~ Maxillary crest, 4f Medial crura l footplate, 3f Medial crus, 3f Mentocervical a ngle definition, 14f, IS , 158 Powe ll-Humphries "aesthetic triangle," 16 Mentol abial sulcus, 10f, II , 157 Menton, 10f, II, 157 Midcolum ellar incisio n See Incisions Mucoperichondrium , support function, 59, 62f Muscles, nasal, 4f N Naris, 3f "Narrow nose syndrome," 22 hump removal in, 76 Nasal analysis See Rhinoplasty analysis Nasal floor, cleft lip-nasal deformity bilateral, 168 unilateral, 167 Nasa l obstruction, 18 causes , 78 concha bullosa, 78, 78f spreader grafts for, 75-78 Nasal septum See Septum Nasal spine, 3f, 4f Nasal splint external, 152 ap plication and removal, 153 manufacturers, 172-1 73 Nasal starting point , 20 Nasal tip, 9, IOf, 157 acce ntuating cephalic edge leading caudal edge of lateral crus, 86, 93f dome division with intact vestibular skin and suture recons titution, 95f, 95-96, 96f individual horizontal mattre ss domal suture tech nique, 86, 86f lateral crural overlay, 96, 96f-97f lateral crural steal, 94f, 95 single transdo mal suture technique, 86, 89f-93f tip grafts, 98-10 transdomal surgical techniques for, 86-95 trapezoidal asymmetric tip, 89f-93f trapezoida l tip and broad doma l angles, 87f-89f anterior protrusion See Rhinoplasty analysis, nasal projection asymm etry, 81, 83f bifidity, 17 cleft lip-nasal deform ity bilateral, 168 unilatera l, 167 deviated, I , 83f grafts alar batten graft, 105, 106 f- 109f, J II cap or buttress graft, 102, I02f-1 05f caudal extension grafts, 118, 118f-1 21f in divided domes, 101, IOIf lateral crural grafts, 110, I I Of pearls, II I shield-shaped tip graft, 98- 101 narrowing, transdomal surgical techniques for, 86 projection, surgical goals and options for achieving, 16 See also specific procedures rhinoplasty analysis, I I frontal view , 17 lateral view, 18 rotation lateral crura l steal, 94f, 95 surgical goa ls and options for achieving, 161 See also speci procedures support co lume llar strut cartilage gra ft 56, 81- 84 majo r support mechanisms, 160 minor sup port mechanisms, 160 surgery, 81-1 11 See also specific procedu re accentuate tip, 86-95 alar batten graf t, 105, 106f-I 09f, II I cap or buttress graft, 102, 102f-J 05f caudal extension grafts, 118, 118f-1 21f columellar strut cartilage graft placement, 81-84 dome division with intact vestibular skin and suture reco nsti 95f, 95-96, 96f dome identi fication, 84 lateral crura l gra fts, 110, 1JOf lateral crural overlay, 96, 96f-97f lateral crural steal, 94 f, 95 pearls, 110-1 11 reduction of crural volume and rigidity , 85, 85f refinement, 162 sculpting techniques , 160 shield-shaped tip graft, 98-10 I placeme nt, 98 , 99f preoperative and postoperative views, 100f-IOlf size of, 98, 98f, I II tip gra fts, 98- lOI tip-defining points, zr, 3f tripod conce pt, ISS Nasal valve, 75, 75f co llapse, 163 ajar batten graft, 105 Nasal valve area, 6, 75, 75f Nasal vault bony, postoper ative shifting, 153 middle asymmetry , 77, 77f collapse, 76-77 excessive narrowing , 77 exposure, 54-56 width, assessment, 77 Nasio n, 2f, 3f, 9, 10f, 157 Naso facial angle definition, 12, 13f, 158 normal values, 12 Powell-Humphries "aes thetic triangle," 16 Nasofrontal angle, 2f aesthetic ana lysis, II definition, 12, 13f, 158 in hump excision, anesthesia considerations, 28 length of nose and, J 8, 19f norma l values, ]2 Powell-Hum phries "aesthetic triangle," 16 Nasofrontal bone, osteo tomy, Nasofrontal suture line, 3f Nasolab ial angle aesthetic analysis, 11 definition, IS, 15f, 158 length of nose and, 18, 19f normal values, 15 obtuse , septo plasty, Nasomaxi llary suture line, 3f Nasomental angle definition, 13f, IS, 158 Powe ll-Humphries "aesthetic triangle," 16 Nasomental line, lip relat ionships, 14f, 15, 158 Nostri l(s) cleft lip-na sal defo rmi ty bilateral, 168 uni lateral , 167 rhinop lasty ana lys is, 18 Nostri l floo r, 3f intern al nostril floor redu ction , 113, 114f wedge exci sion, 114, 114f Nostr il sill, 2f wedg e excision, 114, 114f Notch defe ct, 149 o Octyl-z-cyanoac rylate (Derrnabond) man ufac ture r, 172 skin closure, 113 O nlay cartilage wafe r grafts, 77 Ope rati ve worksheet integrated rsal graft -colum ellar stru t for saddle nose deformi ty, 132f sec on dary rhinoplasty pa tien t requiri ng alar batten graf ts, I08f trapezo ida l asym metric nasal tip, 90f Orbicularis or is muscle, 4f Osseo cart ilagino us j unction , 2f, 3f , Osteotomy, 67-69 anestheti c injection , 27, 28 inter mediate, 68 lateral, 67-68, 68f high-to-lo w, 67, 68f high-to-low-to-h igh, 67 inf racture of nasal bone, 67-68 med ial, 67, 68f nasofron tal bo ne, pearls , 68 p Packs/pack ing, intranasal, 152 man ufactu re rs, 173 Pain , postoperative , rib cartilage har vestin g, 147 " Parenthesis" de formity, 22 Pari etal bone, harvesting, 144, 144f- 146f, 147 Pe rich o ndri um , rib cartilag e barves ting, 147 Phi ltrum , 2f Photograp hy setup, 169f Pleural leak (tear), rib carti lage harvesti ng, 144 Pl umpi ng grafts, 117 , 117f, 138 Pne umo tho rax , rib carti lage harves ting , 147 Pogon io n, 10 f, II , 157 Po llyb eak defor mi ty, 22 , 59 , 163 Pol ydioxanone suture inci sion c los ure, 149 sprea der graft fixa tion, Postope rative care, 152-1 53 d igital exercises, 153 per sisten t supratip edema, 152-153 suture rem ova l, 152 Po well-Humphries " aesthetic triangle," 16,20 Procerus mus cle , 4f Pseudohyperteloris m, 17, 22 Pyriform aperture , 3f in osteotomy, 67 Q Quadran gular cartilage, 4f R Radi x projection, 19- 20 Rasps, 62, 63 f Rhin ion , 2f, 3f, 9, 10f, 157 sellion vs., Rhi noplasty analysis, 9-23 base view , 17f, 17-18 guide line s, II , 156 co lume llar show , IS, 158 facial planes, 12, 12f, 158 horizo ntal facial thirds, 12, 12f, 22, 23f lower two third s surface measurements, 23f vertical facial fifth s, 12, 12f Frank fort plane, 12, 13f, 158 fro ntal view, 17 guidelines, II, 156 general assessment, 16 guidelines, I I, 156 guide to, 11, 156 lab exercise: nasal ana lysis, II land mar ks, 157 points,9-1 1,I Of surfac e ang les , plane s, and measur em ents, 12- 16 lateral view , 18- 20, 19f, lf g uide lines , II , 156 Leg an facia l-conve xit y angle , 14f, IS, 158 length of nose, 18-1 , 19 f lip relatio ns hips , 14f, 15, 158 me ntocerv ica l angle, 14f, IS, 158 nasal proj ection , 15f, 16, 159 asse ssment, 22 Byrd 's meth od, 16, 19, 159 Crumley's method , 16, 159 Goode's method, 15 f, 16, 18, 22,159 normal values, 16 nasofacial angle, 12, 13f, 158 nasofrontal angle definitions, 12, 13f, 158 guidelines, 11, 156 nasolabial angle definitions, IS , 15f, 158 g uidelines , 11, 156 naso me nta l angle, de finitions, 13 f, IS, 158 o bliq ue view , 20 gui delin es, I I, 156 pear ls, 20, 22 photograph ic analys is, 16 physica l examination and anatomic analysis, 16-2 Powell- Hum phries "aes the tic trian gle," 16 ski n qu alit y, 11, 15 surface angles , planes, and measurement s, defini tions, 12- 16, 158- 159 Rib carti lage (gra ft) harvesti ng, 143f, 143-144 , 147 pos tope rat ive pai n, 147 integrated dorsal graft-colume llar strut for sadd le nose deform ity, 130-1 37 Rocker deform ity, 6, 163 Rotation See Nasal tip S '., Saddle nose deformity, 17,22 integrated rsal gra ft-colu mellar stru t for, 130-137 dorsal onlay graft, 133f external rh ino plasty approach, 133f graft placem ent , 134 f graft shifting, 138 operative wo rkshee t, 132f pearls, 138 preoperat ive and postoperative view s, 136f- 137f preoperative view s, 13 lf - , ' : :-" ~, ~ ~-' ­ Scars/scarring See Aesthetic /cosme tic issues anest hetic injec tion, 25 , 26 f Scr oll reg ion, 6, 85 persistent postoperativ e edem a, 152-,153 Sur gical ex posu re, approaches, 160 See also specific approaches Sc ulpting techniques, 160 See also Nasal tip, surgery Su ture lines , 3f Sell ion , 6, 9, 10f, 157 Sutures/suturing Sept al angle(s) , 4f, auricular ca rtilage graft site, 139, l4 2f Septal devi ation buttress grafts, 102, 102f caud al, 18, 122-129 domal suture techn ique s ethmoid bon e splinti ng (sand wich) graft s, 122 individual hor izontal mattress dornal suture techn ique, 86, 86 scoring septal cartilage for, 122 infratip lobul e after tran sdornal suture placeme nt, III "swinging door" maneu ver for, 122, 122f singl e transd ornal sutur e technique, 86, 89f-93f dorsal, ethmo id bone splinting (sa ndwich) grafts, 122, 123f suture reapprox irnation of LLC after dome di vision, 95f, 95septal repl acem ent , 122, 123f-1 29f inc ision closure , 149-152 partial, 122, 123f-1 27f spreade r grafts, 7.1 , 75, 75 f, 78 total, l2 8f-129f Septoplasty, 6, 31-34 T anes thesia injection techn ique, 25, 27 Tension nose deformity , septoplasty, 31 harvesting of cartil age, 1, 33 Ti ssue harve sting hernitran sfi xion incision with anterio r septal tunnels, 31, 32f, 33 auricular cartilage, 139, 140f-142f pearJs,33 calvaria l bone, 144, I44f-14 6f, 147 Se ptorhin oplasty, 33, 34f e thmoid bone , 143 Septum , pearls, 146-1 47 anatomy , 4f rib cartilage , 143f, 143-J44 caudal, 3f septal cartilage, 31, 33 cleft lip-n asal deform ity, 167 Tr ansverse nasali s mus cle, 4f deviated See Septal de viation T riamcin olone aceton ide (Ken alog), for persistent postoper ative s Sesam oid cartilage , 3f edema , 153 Skin T richion , 9, lOf, 157 at rhinion, 20 Tripod co ncept, 155 rhinoplasty ana lysis, 11 lateral crural steal, 94f, 95 thickne ss and quality, 22 Tunn els Skin edges, beveling, 45 septal, 1, 33 Skin mark ing subperiosteal, prop osed osteo tomy path , 67 for osteotomy, 67 T wo-tap technique transcolu mellar (midcolume llar) incis ion, 43, 44f hump exc ision, 59, 6lf Skull , parietal bone harvestin g, 144, 144f-146f, 147 osteotomy, 67 Slidin g alar flap, 114, j 15f So ft tissue layer, ~ U Spl ints/spl inting JLC See Uppe r lateral cartilage ex terna l nasal spl int, 152, 153 Jpper lateral cartilage, 3f manufactur ers, J72- 173 disarticul ation , 54 Sp read er grafts, 1- 79 di vision from dorsal septum, sp reade r gra ft p lace me nt, 73f, 74f bilateral,74f / inferomedial collapse , 59, 62f cli nical indications, 76-78 separ ation from dorsa l septum, 64 , 65f endo nasa l approach, 1, 72 f ex terna l rhino plasty approac h, 1~, ~::: ,] 2:-:;.5 f_7 ::.:f~_ _ ~ _ V ove rwidening, 77 ' Vascul atur e,4f-5f pearl s, 78 placement ',.• , W endon asal approach, 71, 72f, 76 '.,'~ Wedg e resec tion ex pos ure of middl e nasal vault , 78 accentuating nasal tip, cephalic edge leading cauda l edge of late ex ternal rhinoplasty appro ach , 71, 72f- 75f, 76 86,93 f ration ale, 76 alar, 114, 115f size, 71 nostr il floor and sill, lJ4, 114f suture fixation, 78 Wid th of nose suture fixation (stab ilizatio n), 75, 75 f illusions , 22 Stornion, 10f, II , 157 rhinoplasty anal ysis, 11, 17 inferiu s, 10f, 11, 157 Wound clos ure superius, 10f, II, 157 auricula r cartilage har vesting, 142f Subnasale, 9, 10f, 157 closure of margin al, interc artila ginous, or transcartil agin ous inc Sub nasale-to-pogonion line , lip relationship s, 14f, 15, 158 152, 152f Suction drill, postoperative smoothing of bony margin s, 62, 64f closure of midc olum ella incisio n, 149 , 150f 15 If Supraalar crease , 2f pearls, 153 rib carti lage harvest ing, 147 Supr atip, 2f, 9, ior, 157 - ... LIpPINCOTT WILLIAMS & WILKINS • A Wolters Kluwer Company Philadelphia • Baltim ore • New York • London Bueno s Ai res • Hon g Kon g • Sydney · Toky o ~ - _-~ ~~I • • - ~ - ," ~ Ill' ~~ Acquisitions.. .Rhinoplasty Dissection Manual - -_. - ~ , , ~~ '­ , - Rhinoplasty Dissection Manual Dean M Toriumi, M.D Associate Professor Division... dissec tion manual is to provide practical infor mation about a wide range of surg ical techn iques in rhinoplasty The dissection ma nual guides the reader through a step-by-step dissection It