Учебники / Rhinoplasty Dissection Manual Toriumi 1999

Rhinoplasty Dissection

Manual

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Rhinoplasty

Dissection Manual

Dean M. Toriumi, M.D.

Associate Professor

Division ofFacial Plastic and Reconstructive Surgery

Departm ent of Otolaryngology-Head and Neck Surgery

University ofIllinois at Chicago

Daniel G. Becker, M.D.

Assistant Professor

Division ofFacial Plastic and Reconstructive Surgery

Department ofOtolaryngology-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 • Hong Kon g • Sydney · Toky o

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99-260 58 CIP

Acquisitions Editor: Danette Knopp

Developmental Editor: Sara Lau ber

Production Editor: Patrick Carr

Manufacturing Manag er: Tim Reynolds

Cove r 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 reproduced 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 copyright owner, except for brief quotat ions embodied in critica l article s and reviews . Material s appearin g 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.

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 index.
ISBN 0-7817 -1783-3
I . Rhinoplasty Handbooks, manu als, etc. 2.		Nose-Surgery
Handb ooks, manuals, etc. I. Becker, Daniel G.		II. Title.

[DNLM: 1. Rhinopla sty-methods Handbo oks. WV 39 T683 r 1999] RDII9.5.N67T67 1999

617.5' 230592---dc2 1 DNLMIDLC

for Library of Congress

Care has been take n to confirm the accuracy of the information pre sented and to descri be generally accepted practices. However, the authors, ed itors, and publisher are not responsible for errors or omis sions or for any consequences from application of the information in this book and make no

warra nty, expresse d or impli ed, with respect to the currency , completeness, or accura cy of the contents of the publication. Appli cation of this information in a particular situation rem ains the professional respon sibility 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

publ ication . Howe ver, in view of ongoing research, changes in govern ment regul ation s, and the con stant flow of inform ation relat ing to dru g therapy and drug reaction s, the reader is urged to check the package insert for each drug for any change in indic ation s and dosage and for added warnings and preca utions.

Thi s is particularly importan t when the recomm ended agent is a new or infrequently employed drug. Some drugs and med ical devices presented 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 device planned for use in their clinical practice.

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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.

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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-		12
	Definitions	.
	Rhinoplasty Analysis	.	16
Chapter 3:	Injection	.	25
	Infiltrative Anesthesia Technique	.	25
Chapter 4:	Septoplasty	.	31
	Nasal Dissection: Septoplasty with		31
	Cartilage Harvest	.
Chapter 5:	Incisions and Approaches	. 37
	Transcartilaginous or Cartilage-Splitting	. 37
	Approach
	Delivery Approach	. 40
	The External (Open) Rhinoplasty Approach	. 43
Chapter 6:	Removal of Bony-Cartilaginous Hump	. 59
Chapter 7:	Osteotomies	. 67
	Medial Osteotomies	. 67

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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: Tripod Concept Appendix B: Guide to Nasal Analysis Appendix C: Aesthetic Analysis

Appendix D: Surface Angles, Planes, and Measurement: Definitions

Appendix E Tip Support, Incision, and Approaches Appendix F: Achieving Surgical Goals: Selected Options . . Appendix G: Selected Complications of Rhinoplasty Appendix H: Adjunctive Procedures

Appendix I: Cleft Lip Nasal Deformity Appendix J: Photography Setup

Appendix K: Indications for External Rhinoplasty Approach

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Rhinoplasty

Appendix M: List of Selected Companies with AddresseslPhone Numbers

Appendix N: Selected Recommended Literature

Index

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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 onl y by ca reful foll ow-up of ope rated patients over time.

The genera l con cepts of nasal anatomy have been fun damentally clear for centuries , but on ly in recen t 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 suc h, 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

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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 avo major resections and vertical interruprion of the intact residual strip of lateral and m crus. Notching, pinching, alar cephalic retraction, over-rotation, and asymmetries a almost entirely eliminated in long-term healing when this conservative philosophy i 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 creat 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 distu these structures and area s when correcting (or gaining access to) anatomic compone need of correction . This philosophy further extends the surgeon 'sfavorable control ov 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 short 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 Plasti

Reconstructive Surgery

University of Illinois Medical Cen

Chicago, Illinois

Professor of Clinical Otolaryngolo

Indiana University School of Med

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