Standard Caucasian Extramucosal Rhinoplasty Operative ... Stan.pdf · Standard Caucasian...

Standard CaucasianExtramucosal RhinoplastyOperative Sequence

My Point of V iew

Standard CaucasianExtramucosal RhinoplastyOperative Sequence

My Point of V iew

By Constantin STAN, M.D.The MEDICAL SERVICE Clinic - Bacau - Romania

Constantin STAN, M.D. – The MEDICAL SERVICE Clinic, Romania

Barcelona - 2001

D E F I N I T I O ND E F I N I T I O N

• the extramucosal approach maintains theintegrity of the mucosa preservingits valvular mechanismand normal physiologicfunctioning

•• the the extramucosal extramucosal approach maintains theapproach maintains the

integrity of theintegrity of the mucosa mucosa preserving preserving

its its valvular valvular mechanism mechanism

and normal physiologicand normal physiologic

functioningfunctioning

Barcelona - 2001

“La rinoplastica e una lezione costante diumilita.”

(Madeleine Lejour) “ L a rinoplastica sia la piu difficile operazione

da imparare, cosi come da insegnare….” (Sohn)

“ L a rinoplastica e un intervento solitario” (M icheli-Pellegrini )

“La rinoplastica e una lezione costante diumilita.”

(Madeleine Lejour) “ L a rinoplastica sia la piu difficile operazione

da imparare, cosi come da insegnare….” (Sohn)

“ L a rinoplastica e un intervento solitario” (M icheli-Pellegrini )

Barcelona - 2001

W hat is the “ideal” nasal shape ?W hat is the “ideal” nasal shape ?

The Caucasian “ standard nose” :

• slightly convex frontal bone• a moderate nasofrontal angle• a narrow bridge of uniform width• a tip of moderate thickness and projection• vertical-oblique nostrils with thin alae• an open nasolabial angle• skin of thin-to-moderate thickness

The Caucasian “ standard nose” :The Caucasian “ standard nose” :

•• slightly convex frontal bone slightly convex frontal bone

•• a moderate a moderate nasofrontal nasofrontal angleangle

•• a narrow bridge of uniform width a narrow bridge of uniform width

•• a tip of moderate thickness and projection a tip of moderate thickness and projection

•• vertical-oblique nostrils with thin vertical-oblique nostrils with thin alaealae

•• an open an open nasolabial nasolabial angleangle

•• skin of thin-to-moderate thickness skin of thin-to-moderate thickness

Barcelona - 2001

PREOPERATIVE NASA L V A L U A T I O N& SURGICAL PLANNING

• a successful rhinoplasty is l ike a successful workof architecture• a detailed preoperative evaluation and organized surgical plan• an amount of time showing the patient those areasI feel that I can improve• a realistic appraisal of the type of results• a diagrammatic notes of the discussion• a computerized imaging more user-friendly for an honest prediction of results

•• a successful a successful rhinoplasty rhinoplasty is l ike a successful workis l ike a successful work

of architectureof architecture

•• a detailed preoperative evaluation and organized a detailed preoperative evaluation and organized

surgical plan surgical plan

•• an amount of time showing the patient those areas an amount of time showing the patient those areas

I feel that I can improveI feel that I can improve

•• a realistic appraisal of the type of results a realistic appraisal of the type of results

•• a diagrammatic notes of the discussion a diagrammatic notes of the discussion

•• a computerized imaging more user-friendly for an a computerized imaging more user-friendly for an

honest prediction of results honest prediction of results

Barcelona - 2001

NASAL E V A L U A T I O NNASAL E V A L U A T I O N

• a successful preoperative evaluation is a good communication between the physician andpatient• a surgeon’ s communication skills are nearly as important as his surgical skills• a carefully analyzing a patient’ s anatomy andbasic psychological profile• a remarkable rhinoplastic surgery is unsuccessfulif the patient’ s expectations were different than theoutcome

•• a successful preoperative evaluation is a good a successful preoperative evaluation is a good

communication between the physician and communication between the physician and

patientpatient

•• a surgeon’ s communication skills are nearly as a surgeon’ s communication skills are nearly as

important as his surgical skills important as his surgical skills

•• a carefully analyzing a patient’ s anatomy and a carefully analyzing a patient’ s anatomy and

basic psychological profilebasic psychological profile

•• a remarkable a remarkable rhinoplasticrhinoplastic surgery is unsuccessful surgery is unsuccessful

if the patient’ s expectations were different than theif the patient’ s expectations were different than the

outcomeoutcome

Barcelona - 2001

T H E C O N SU L T A T I O NT H E C O N SU L T A T I O N

• the final measure of success in aesthetic surgery is the attainment of the patient’ s desires, withguidance from the surgeon

• a complete an honest prognosis

• enough information to make a proper informedconsent

• to not totally disregard function over aesthetics

•• the final measure of success in aesthetic surgery is the final measure of success in aesthetic surgery is

the attainment of the patient’ s desires, with the attainment of the patient’ s desires, with

guidance from the surgeonguidance from the surgeon

•• a complete an honest prognosis a complete an honest prognosis

•• enough information to make a proper informed enough information to make a proper informed

consentconsent

•• to not totally disregard function over aesthetics to not totally disregard function over aesthetics

Barcelona - 2001

SURGICAL PLANNINGSURGICAL PLANNING• an detailed planning to modify the form andfunction• a few general principle will assist in formingthe surgical plan• proper preparation and surgical background ofthe surgeon• the plan is for nasion, bridge and dorsum, tip,base, septum and turbinates• is very helpful to complete a detaileddiagrammatic plan before surgery• thorough planning makes intraoperativesurprises remarkably rare

•• an detailed planning to modify the form and an detailed planning to modify the form and

functionfunction

•• a few general principle will assist in forming a few general principle will assist in forming

the surgical planthe surgical plan

•• proper preparation and surgical background of proper preparation and surgical background of

the surgeonthe surgeon

•• the plan is for the plan is for nasionnasion, bridge and dorsum, tip,, bridge and dorsum, tip,

base, septum and base, septum and turbinatesturbinates

•• is very helpful to complete a detailed is very helpful to complete a detailed

diagrammatic plan before surgerydiagrammatic plan before surgery

•• thorough planning makes thorough planning makes intraoperativeintraoperative

surprises remarkably raresurprises remarkably rare

Barcelona - 2001

OPERATIVE PROCEDUREOPERATIVE PROCEDURE

• general anesthesia or e.v. sedation pluslocoregional infiltration with 0,5 % Bupivacainehydrochloride (M arcaine) with Epinephrine1:100 000• a modified sub-mucous resection of the inferior turbinate• intercartilagious incisions with freed of dorsum, superior third of the lateral nasal wall , andupper lateral cartilage segments• hemitransfixion of the membranous septum• skelotonization

•• general anesthesia or e.v. sedation plus general anesthesia or e.v. sedation plus

locoregionallocoregional infiltration with 0,5 % infiltration with 0,5 % BupivacaineBupivacaine

hydrochloride (hydrochloride (M arcaineM arcaine) with Epinephrine) with Epinephrine

1:100 0001:100 000

•• a modified sub-mucous resection of the inferior a modified sub-mucous resection of the inferior

turbinate turbinate

•• intercartilagious intercartilagious incisions with freed of dorsum,incisions with freed of dorsum,

superior third of the lateral nasal wall , and superior third of the lateral nasal wall , and

upper lateral cartilage segmentsupper lateral cartilage segments

•• hemitransfixionhemitransfixion of the membranous septum of the membranous septum

•• skelotonizationskelotonization

Barcelona - 2001

OPERATIVE PROCEDUREOPERATIVE PROCEDURE

• removal of the hump, or corrective procedure ofthe dorsum (great care to leave the mucose betweenthe septum und upper lateral cartilages intact)• correction of the septum (septoplasty) plus whennecessary excise of the caudal septal proeminence• osteotomies: - a 2 mm osteotomes and a step-wise fracturingfrom the inferior nasal-maxillary junction upward tothe medial canthal area (“ l ow-to-low” ) - infracturing and seven minutes of nasal compression to decrease bleeding and bruising• modeling of the tip and complementary procedure

•• removal of the hump, or corrective procedure of removal of the hump, or corrective procedure of

the dorsum (great care to leave the the dorsum (great care to leave the mucose mucose betweenbetween

the septum und upper lateral cartilages intact)the septum und upper lateral cartilages intact)

•• correction of the septum ( correction of the septum (septoplastyseptoplasty) plus when) plus when

necessary excise of the caudal necessary excise of the caudal septal proeminenceseptal proeminence

•• osteotomies osteotomies::

- a 2 mm - a 2 mm osteotomes osteotomes and a step-wise fracturingand a step-wise fracturing

from the inferior nasal-maxillary junction upward tofrom the inferior nasal-maxillary junction upward to

the medial the medial canthal canthal area (“ l ow-to-low” )area (“ l ow-to-low” )

- - infracturing infracturing and seven minutes of nasaland seven minutes of nasal

compression to decrease bleeding and bruising compression to decrease bleeding and bruising

•• modeling of the tip and complementary procedure modeling of the tip and complementary procedure

Barcelona - 2001

SU R G E R Y O F T H E N A SA L T I PSU R G E R Y O F T H E N A SA L T I P

• The non-delivery approach - cartilage-splitting - retrograde eversion2. The delivery approach (sequential)3. The external approach (open)

Indications depends on: - volume reduction - reconstruction - cephalic rotation - change of projection

•• The non-delivery approachThe non-delivery approach

- cartilage-splitting - cartilage-splitting

- retrograde - retrograde eversioneversion

2. The delivery approach (sequential)2. The delivery approach (sequential)

3. The external approach (open)3. The external approach (open)

Indications depends on:Indications depends on:

- volume reduction - volume reduction

- reconstruction - reconstruction

- cephalic rotation - cephalic rotation

- change of projection - change of projection

Barcelona - 2001

T he delivery approachT he delivery approachIndications:

- asymmetry- bifidity- extra cephalic tip rotation- diminishing of the tip rotation

A dvantages:- modifying the alar cartilage under directvision- remodeling alar cartilages by scoring and morselization- interdomal suturing to correct bifidity- interruption of alar cartilage (to reduce over- projected tip or enhance cephalic rotation)

Indications:Indications:

-- asymmetry asymmetry

-- bifidity bifidity

-- extra cephalic tip rotation extra cephalic tip rotation

-- diminishing of the tip rotation diminishing of the tip rotation

A dvantages:A dvantages:

-- modifying the modifying the alar alar cartilage under directcartilage under direct

visionvision

-- remodeling remodeling alar alar cartilages by scoring andcartilages by scoring and

morselization morselization

-- interdomal interdomal suturing to correct bifiditysuturing to correct bifidity

-- interruption of interruption of alar alar cartilage (to reduce over-cartilage (to reduce over-

projected tip or enhance cephalic rotation) projected tip or enhance cephalic rotation)

Barcelona - 2001

POSTOPERATIVE NASA L PACKINGand DRESSI N G S

• packing may be important to avoid bleeding, stenosis, synechiae and recurent airway obstruction• merocel nasal tampons provide soft but adequatepacking• postoperative tape, splints and dressings are helpful: - gentle pressure with patient’ s sense of security - stabilizing osteotomies and grafts - assist in decreasing edema• I prefer an individually-cut heat-treated plasticsplint covered with adhesive tape

•• packing may be important to avoid bleeding, packing may be important to avoid bleeding,

stenosis stenosis, , synechiae synechiae and and recurent recurent airway obstructionairway obstruction

•• merocel merocel nasal tampons provide soft but adequatenasal tampons provide soft but adequate

packingpacking

•• postoperative tape, splints and dressings are helpful: postoperative tape, splints and dressings are helpful:

- gentle pressure with patient’ s sense of security - gentle pressure with patient’ s sense of security

- stabilizing - stabilizing osteotomies osteotomies and graftsand grafts

- assist in decreasing edema - assist in decreasing edema

•• I prefer an individually-cut heat-treated plastic I prefer an individually-cut heat-treated plastic

splint covered with adhesive tapesplint covered with adhesive tape

Barcelona - 2001

V I D E O SCOPY AND RHINOPLAST YV I D E O SCOPY AND RHINOPLAST Y

• i t is helpful to identify and resects smallirregularities• important in secondary rhinoplasty of injurednoses• surgical correction of the septal cartilagedeformities and inferior nasal conchalhypertrophy• useful in teaching and learning in the operatingroom• it is an adjunct that allows a closed approach tosee what is sculptured

•• it is helpful to identify and resects small i t is helpful to identify and resects small

irregularitiesirregularities

•• important in secondary important in secondary rhinoplasty rhinoplasty of injuredof injured

nosesnoses

•• surgical correction of the surgical correction of the septal septal cartilagecartilage

deformities and inferior nasal deformities and inferior nasal conchalconchal

hypertrophyhypertrophy

•• useful in teaching and learning in the operating useful in teaching and learning in the operating

roomroom

•• it is an adjunct that allows a closed approach to it is an adjunct that allows a closed approach to

see what is sculpturedsee what is sculptured

Barcelona - 2001

C O N C L U SI O NC O N C L U SI O N

The extramucosal approach maintains:

• Integrity of internal nose• Preserve the respiratory airway and the smell• Reduce hemorrhage and edema with earlier

good results• Avoids excessive retraction of the internal

nose and ti ssue adhesion• L ess functional and aesthetic deformities

The The extramucosal extramucosal approach maintains:approach maintains:

•• Integrity of internal noseIntegrity of internal nose

•• Preserve the respiratory airway and the smellPreserve the respiratory airway and the smell

•• Reduce hemorrhage and edema with earlierReduce hemorrhage and edema with earlier

good resultsgood results

•• Avoids excessive retraction of the internalAvoids excessive retraction of the internal

nose and ti ssue adhesionnose and ti ssue adhesion

•• L ess functional and aesthetic deformitiesL ess functional and aesthetic deformities

Barcelona - 2001

Some A esthetic ResultsSome A esthetic Results

Barcelona - 2001

BEFOREBEFORE AFTER 7 DaysAFTER 7 Days

Barcelona - 2001

BEFOREBEFORE AFTERAFTER

Barcelona - 2001

Some A estheticResults

Barcelona - 2001

Thank YouFor Y ourA ttention!

Standard Caucasian Extramucosal Rhinoplasty Operative ... Stan.pdf · Standard Caucasian...

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