Open rhinoplasty without skin-columella incision

For the last 4 years, the author has been using the open lower cartilaginous vault rhinoplasty, making an external cutaneous incision on the columella. After observing the improved results in patients with nasal tip, lateral crura, and medial crura difficulties, the author widely recommends the use of this procedure in selected patients. In addition to multiple advantages which have been reported useful in open-tip rhinoplasty in the past, the author has contributed two additional advantages: that it avoids scarring columella skin and that it can be extended to cope with defects of the entire lower cartilaginous vault. Disadvantages are some residual edema in some patients over a 6-months period and prolongation of operating time.     

Asymmetric incision for open rhinoplasty in cleft lip nasal deformity.

One of the problems in the correction of the unilateral cleft lip nasal deformity is the alar web deformity on the mediosuperior side of the nostril. A number of methods for the correction of the alar web deformity have been introduced, but no single procedure has been identified as the standard. In this report, the incision line of the open rhinoplasty was modified and the alar web deformity was corrected by using an incision and closure. Open rhinoplasty with the asymmetric incision was performed on 18 patients with unilateral cleft lip nasal deformity. The incision line used in the normal side was the usual intranasal rim incision line and that used for the columella was the transcolumella incision line. For the cleft side, an intranasal rim incision line was plotted after the rim was lifted upward with forceps to achieve symmetry of the nasal tip. After removal of the forceps, the incision line of the cleft side was displaced outside the nostril. After such an incision, the alar cartilage mobilization and suspension were performed with or without the conchal cartilage graft. All patients used nasal retainers for 6 months after the procedures. So far, satisfactory results have been obtained with the modification of the incision line for open rhinoplasty. This method is unique in designing the incision line, and its procedure is rather simple. The postoperative follow-up period has been 12 to 26 months. A long-term follow-up is still needed, especially in growing children.     

Nasal tip blood supply: confirming the safety of the transcolumellar incision in rhinoplasty

The transcolumellar incision in rhinoplasty has proven to be a safe and effective technique, even with simultaneous alar base resections. A sound appreciation of the blood supply to the nasal tip and adherence to the guidelines presented above will prevent vascular compromise of the nasal tip skin.     

Digital photography for rhinoplasty

Standardized, high-quality, preoperative photographs of the nose are critical for preoperative rhinoplasty planning, comparative postoperative assessment, and demonstration of surgical results. To produce these high-quality, reproducible photographs, it is essential to standardize lighting, to properly position the patient in standard views, to avoid lens distortion, and to maintain consistent camera-to-subject distances. Traditional photographic standards have been well documented in the literature; however, most do not address digital photography, and none address digital photography for rhinoplasty. Certain variables in digital photography that are not present in 35-mm photography can be critical to the appearance of the final image. Variables such as image color and contrast (which usually vary between digital cameras), focal length differences between 35-mm and most digital cameras, the effect of resolution and compression on image quality, and the effect of the printing method used can affect the appearance of the external anatomy of the nose in the final print or image. Lack of detail in the external nasal anatomy becomes an issue if the surgeon uses the photograph intraoperatively for reference, as the authors do. Initially, the authors experienced difficulties with observing subtleties in the tip-defining points and tip anatomy using digital photography when compared with our traditional methods of 35-mm photography. The lack of detail in the external anatomy was most prevalent in the frontal and basal views. Thus, the authors have since tailored their photographic methods to document the rhinoplasty patient to maximize the visual information of the external nasal anatomy in the photographic and the printed image. This article is intended to review the photographic principles for standardized rhinoplasty photography, address the additional considerations necessary when using digital photography, discuss the printing variables that can affect overall quality of the printed image, and discuss the authors' new method of photographing the rhinoplasty patient.     

Dynamics in rhinoplasty

Nasal dynamics were studied on 87 patients undergoing rhinoplasty of one zone or two distant nasal zones. Statistical analysis of the results revealed that reduction of the nasion area, besides setting the soft tissue back, gave the appearance of increased intercanthal distance and lengthened the nose. Reduction of the nasal bridge resulted in a wider appearance on frontal view and a cephalically rotated tip on profile. Augmentation of the bridge affected the nose reversely. Tip cephalad rotation was achieved by resecting one of the three areas: the cephalad portion of the lower lateral cartilages (affecting the rims more), the caudal septum (affecting the central portion more), and the caudal portion of the medial crura of the lower lateral cartilages (affecting the central portion only). Resection of the alar base not only narrowed the nostrils but also moved the alar rim caudally. Furthermore, it reduced tip projection when a large alar base reduction was done. Reduction of the nasal spine increased the upper lip length on profile and reduced tip projection when a large reduction took place. Significant reduction in caudal nose projection resulted in widening of the alar base.     

A different rasp for rhinoplasty

A new rasp for rhinoplasty is presented. It can be dismantled and has a renewable blade that looks like the one you find in a plane. The main advantage of this rasp is that it rasps the cartilaginous septum as well as the bony part of the hump.     

A model for planning rhinoplasty

A rhinoplasty model is detailed in which nasal shape is conceived as a dynamic system, the result of powerful expansive and contractile forces, of a skin sleeve in equilibrium with a dynamic skeleton, in which the alar cartilages are external to the remaining skeleton and support a large area of lower nasal skin. In this system, changes in one region have "global" effects. Consequently, one powerful way to control nasal shape is to maintain skin sleeve size and thus maintain the preoperative nasal equilibrium. The surgeon who controls the postoperative equilibrium controls the postoperative result.     

External approach for secondary rhinoplasty

A systematic approach, using the external rhinoplasty technique, is presented to aid the plastic surgeon in obtaining improved aesthetic and functional results in patients with postoperative nasal deformities. In over 100 external rhinoplasties, there were no problems with the stairstep transcolumellar incision used to provide complete visualization of the underlying nasal framework. The external approach allows for a more accurate intraoperative anatomic diagnosis and subsequent complete correction of the nasal deformity. Three case reports are presented to demonstrate the indications and versatility of the external approach in secondary rhinoplasty.     

A graphic record of intraoperative maneuvers in rhinoplasty: the missing link for evaluating rhinoplasty results

A pictorial system is introduced for documenting intraoperative maneuvers in rhinoplasty that can be used to advantage for relating the effect that different surgical techniques have on postoperative results and for describing to other surgeons the technical steps performed in the operation.     

Cosmetic rhinoplasty

Rhinoplasty is safe, relatively painless and, if patients are carefully selected, quite successful. Psychological and personal benefits amply justify the procedure. Frequent indications are feelings of social rejection or ridicule and racial discrimination. Psychoneurotic patients with severe complexes, however, are poor subjects for rhinoplasty and should not be operated upon. It is doubtful that rhinoplasty grossly changes the physiologic integrity of the nose. Psychological trauma to the patient during hospitalization is to be avoided, sedation properly gauged for each patient, and complete block anesthesia used to preserve the cough reflex. The operation is brief and a small splint is worn for a few days. Complications are rare.     

Male rhinoplasty

Rhinoplasty is one of the most complex and challenging operations in plastic surgery. This complexity is increased among male patients, because male patients tend to have relatively nonspecific complaints, are typically more demanding, and are regarded as being much less attentive during consultations. It is critical for the surgeon to verify that the male patient has realistic goals before he undergoes an operation, and the surgeon must confirm that the male patient has heard and understood all of the risks, benefits, and options. It is essential that masculine features be preserved for male rhinoplasty patients. Excessive dorsal reduction or tip refinement produces unsatisfactory results. A comprehensive discussion of proper evaluation of the male nose, surgical planning, intraoperative techniques, and postoperative treatment is presented. These tools should allow plastic surgeons to produce a balanced harmonious nose in relation to the rest of the face.     

Toward refinement in rhinoplasty

Three interrelated principles can help to achieve nasal refinement: creation of nasal planes, attention to lateral light reflexes, and maintenance of skin sleeve size. These principles are detailed and illustrated in primary and secondary rhinoplasty patients.     

On rhinomanometry in rhinoplasty

Changes in nasal obstruction, nasal airway resistance, and postoperative nose appearance were evaluated in 92 rhinoplasty patients. Fifty-six patients had a deviation of their nose from the midline preoperatively. They were improved according to rhinomanometry whether the rhinoplasty was combined with a functional septoplasty or with a submucous resection. Among the other 36 patients who did not have a deviation of the nose from the midline, 23 had a rhinoplasty combined with a functional septoplasty and 13 had no surgery on the septum at all. Rhinomanometrically, only patients operated on with the combined operation were improved; the rest became worse, even in terms of nasal obstruction. Among 58 patients from both groups with preoperative nasal obstruction, there was agreement for 76 percent between the subjective and rhinomanometric changes. The advantages of giving the rhinomanometric results in a polar coordinate system are discussed.