RHINOPLASTY
Operative Techniques
M.B. Bizrah
Fig. 1 7 - 1. Septal graft set: (From left to right) Ballenger:S knife, blunt elevator, sharp elevator, 11 -blade knife, nasal speculum.
Fig. 17 - 2. Hump reduction instruments: (From left to right) Aufrichts retractor, mallet, twelve mm osteotome, dorsum scissors, Howarths elevator, coarse and smooth rasps.
Fig. 1 7 - 3. (A,CJ Coarse rasps are used on a larger hump or for initial hump removal on smaller humps. (BJ A more delicate rasp is used for providing the finishing touches and for rasping smaller bony irregularities.
Fig. 17 - 4. Osteotomy set: (From left to right) Mallet, right cuNed Masing'.s single guarded osteotome, left cuNed Masing'.s single guarded osteotome, two mm Cottle'.s osteotome. The cuNed Masing'.s the two mm guarded osteotomes are used in medial osteotomies. The two mm Cottle'.s osteotome is used in transverse, lateral and or intermediate osteotomies.
Fig. 1 7 - 5. Tip plasty instruments: (From left to right) Blunt double hook, sharp ended double hook, blunt scissors, sharp scissors, 1 1-blade holder, single retractors.
Fig. 17 - 6. Bone nippier. This is used for trimming of the overdeveloped nasal spine. Also used for creating a gap in the bony dorsum midline for correction of broad bony dorsum.
Fig. 17 - 7. Cartilage crusher. This is used to soften the tip and dorsum grafts in order to avoid demarcation and sharp edges.
Fig. 17 - 6. Instruments for the reduction of fractured nose. (A) Ashs forceps maybe used to straigthen the septum. (BJ Walshams forceps which is used for elevating the nasal bones.
Fig. 17 - 9. ( 1,2) The caudal septum and superior septal caudal angle following intercartilaginous and transfixion incision. (3,4) Septal grafts are obtained and are prepared to be used in tip plasty and for augmentation of the dorsum as required. (5) The curved and projecting caudal upper lateral cartilages. (6) The caudal portion and the fatty fibrous tissue on the upper lateral cartilages were excised. (7) The upper lateral cartilage looks very clean following trimming.
Fig. 17 - 10. (8, 9) Trimming of the projecting caudal septum. (10, 11 J Cartilagenous hump removal: the scissors is passed through all the three components of the cartilaginous hump, left and right upper lateral cartilages and the septum. ( 12, 13) Bony hump removal this is best removed on the conjunction with the cartilaginous component with twelve mm osteotome. (14, 15) The bony hump is removed in conjunction with the cartilaginous hump.
Fig. 17 - I I. (16, 17) Rasp may be used for smaller hump or following large hump removal for smoothing. Direction during rasping should be in an oblique and transverse manner across the nasal bone to avoid frontal oedema. ( 18, 19 ,20) Demonstration of the patient before hump removal, the removed hump, and after hump removal. Do not overtake the hump, look at the tip. (21,22) The same patient following tip plasty. There was no need for extra hump removal. (23) Residual bone and dust must be removed in order to avoid an unexplained hump or irregularity at a later date.
Fig. 17 - 12. (24) Marginal incision. (25,26) Bilateral alar delivery (27,28,29,30) ConseNative cephalic trimming of the lateral crus leaving at least eight mm of the vertical lateral crus.
Fig. 17 - 13. (31,32) Tip defattening using fully curved scissors. (33,34,35) New dome creation a tissue forceps is pushed under the bilateral flaps and elevated in order to achieve symmetry and create a more acute domal junction. (36,37,38) Vertical dome scoring: the newly created dome is scored vertically on each side w ith preservation of the vestibular skin and mucousa.
Fig. 17 - 14. (39,40,41,42,43) Suture fixation following vertical new dome scoring: A 4/0 PDS mattress or simple suture is passed through the intermediate and lateral crurajust one mm below the scored area in order to create a more acute domal angle and preserve a stable tripod structure of conjoined lateral and medial crura. (44) The obtained septa/ grafts are trimmed: columellar strut, tip graft, dorsum graft and spreader graft as needed. (45,46) Columellar strut is inserted between the two medial crura.
Fig. 17 - 15. 147,48,49,50,51,52) Suture-in place columellar strut: a precise pocket is dissected between two medial crura. Mattress sutures are used to fix the strut that lies between the two medial crura . Indication of columellar strut are obtaining tip projection, definition and refinement, preservation of tip projection, correction of hanging columella, buckled medial crura, retracted columella, bifid columella and correction of tip asymmetry
Fig. 17 - 16. (53,54,55,56,57,58,59) Suture-in place tip grafts a single crushed tip graft is use to increase tip definition, projection, refinement and contouring. The graft should be crushed and the edges are bevelled. The tip graft is positioned so that it projects one to two mm above the dome. A long tip graft is used to narrow the tip in a thick skinned patient, increase rotation, support the columella in retracted columella, weak medial crura and hanging columella, augment the acute nasolabial angle, correct tip and columella bifidity Double and triple grafts are used to achieve more tip projection, definition, refinement in a thick skinned patient and to increase the length of the over-rotated nose.
Fig. 17 - 1 7. (60,61,62,63,64) Lateral crura overlay technique, which is indicated for tip overprojection, drooping tip, broad tip and correction of unilateral or bilateral supra-alar fullness. It produces a more natural looking tip without excessive cartilage excision. (65) Medial crura overlay technique is indicated if correction of overprojection is still insufficient after the lateral crura overlay technique. (66) Preoperative photographs. (67) By the end of the operation, the drooping tip has been corrected by the manoeuvres of new dome creation, suture fixation, columellar strut, tip graft, lateral overlay technique and septocolumellar suture.
Fig. 17 - 18. (68) Outlining the sites of medial, lateral and intermediate osteotomies. (69) Outlining the sites of medial, intermediate and transverse osteotomies and the Masing:S single guarded osteotome which is used for medial osteotomies. (70) The Masing:S single guarded osteotome while performing medial osteotomy The left forefinger is controlling the procedure. (71 J The two mm osteotome (Cottle) which is used in lateral and intermediate osteotomies. Intermediate osteotomies are indicated in banana and spindle shaped lateral nasal walls. (72) The site of transverse osteotomies which are indicated when the deviation starts from the root of the nose, the two mm Cottle:S osteotome is used.
Fig. 1 7 - 19. (7 3) Division of frenulum: It is indicated in underprojected tip in order to release the tip tension and increase tip rotation and projection. Also indicated for the correction of a crowded lip when the frenulum is tight. Closure is achieved byV-Y procedure. (74,75,76) Nippling of the nasal spine: It is indicated in tip overprojection and in many severely crowded lips. Bone nippier is used to trim the overdeveloped nasal spine. (77,78) Partial trimming of allergic inferior turbinates. This, when indicated, is usually the last step of the rhinoplasty procedure.
Fig. 17 - 20. There are always adequate conchal and septa/ autografts that can be used. The author rarely uses synthetic materials. (79,80,81,82,83,84,85,86) These photographs show conchal and septa/ grafts w hich have been prepared, divided and reshaped for augmentation according to the authors needs.
Fig. 1 7 - 21. (87) A dorsum graft: the edge of the graft should be bevelled or trimmed in a triangular way to avoid step deformities or showing the sharp edges. (88,89, 90, 91) Dorsum and tip grafts: Septa/ or conchal or both are used to augment the nasal dorsum. The graft may be single, double or even triple as indicated. (92, 93, 94) The dorsum graft is sutured to the newly created dome at the back of the tip graft and then inserted into the dorsum with the tip graft. This is ideal for the correction of supratip collapse.
Fig. 17 - 22. (95) Dorsum conchal grah The edges are trimmed and bevelled. (96, 97, 98) Examples of Silicon implant. (99,100, 1 O 1,102) Suitably designed x-ray sheets are applied on the sides of the nose and fixed with steri-strips in order to stabilize and secure the dorsum grah to avoid mobilization.
Fig. 17 - 23. I 103,104) On operating table, pre and post cleft nose. fl 05, 106,107,108) Anchor grafts are very useful in tip deformity associated w ith cleft tip. The graft w ill help in achieving symmetry and to correct alar rim collapse and notching. Rim grafts are applied in mild rim notching f 1 09, 11 OJ Batten grafts: are considered to strengthen the lateral crura and provide symmetrical tip support
Fig. 17 - 24. (111) Canine graft in cleft nose patient: It is inserted through a sublabial incision in order to elevate the affected nostril and obtain nose symmetry. (112) Spreader graft: Best to be used as a septa/ graft. It is very useful in crooked noses to correct the C-shaped dorsum septa/ deviation by positioning and suturing the graft to the concave septa/ surface. Bilateral spreader grafts also correct cartilaginous dorsum narrowing and valve collapse. (113, 114) Severe leishmaniasis was corrected by postauricular skin graft. (115) Postoperative result.
Fig. 17 - 25. I 116, 117, 118, 119, 120, 121, 122, 123) Alar wedge excision: Modified Weir excision should be the last step of the septorhinoplasty procedure and it should be made in natural creases. Vestibular skin should be preserved to avoid notching. Indications are: to reduce flare of the rim, reduce wide nostril floor and reduce both flaring and wide floor.
Fig. 17 - 26. (124, 125) Closure of the alar wedge excision is obtained by 4/0 Dexon or 4/0 Vicryl. ( 126, 127, 128,129) At the end of the rhinoplasty procedure steri-strips and plaster of paris are applied on the nose. Properly applied nasal dressing plays a more important role in good rhinoplasty results than many surgeons realise. Steri-strips obliterates dead space and may help to prevent hematoma, oedema and later pollybeak formation. It also secures tip projection and rotation. The splint is moulded over the nose and secured in position with another layer of wider steri-strips. The nasal splint may help to stabilize and fix the nasal bones and reduce postoperative oedema.
Fig. 1 7 - 27. ( 130, 131, 132, 133, 134, 135, 1 36) External rhinoplasty approach: It may be indicated in revision rhinoplasty, severely crooked noses and cleft noses. Surgeons with outstanding skills rarely need to apply the external incision. It applies in only 2% of our cases. ( 135) Triple bridge graft for augmentation in severe saddling. The grafts are accurately sutured in place to the dorsum septum and upper lateral cartilages. (137) Reduction of an acute fractured nose: Do not try to push the fractured or depressed nasal bone towards the middle, because this manoeuvre will cause more depression of the fragments of the fractured bone and in addition the depressed bone will prevent any return to the midline. The essential step is to free the depressed fragments by elevating each nasal bone in turn (start with nondepressed bone then depressed bone) from within in an outwards direction.
The Bizrah Modification
of Vertical Dome Division
Fig. 17 - 28. (138, 139, 140, 141, 142, 143, 144, 145) Special modified technique for the underprojected tip /Bizrah:S technique) The principles are: vertical dome division, medial crus delivery and /-beam w ithout lateral crus delivery. (I) Marginal columellar incision from mid-columella and up to the level of the external soft triangle and junction of intermediate to lateral crura. There is no marginal incision along the caudal margin of the lateral crura. /2) Vertical dome division: the incision starts just lateral to the external soft triangle at a right angled backwards to just lateral to the internal soft triangle dividing the vestibular skin and cartilage. /3) The bilateral intermediate and medial crura are delivered to one side. /4) A pocket is created between the medial crura, then co/umellar strut is inserted and sutured to both medial crura. /5) Shield tip graft is positioned and sutured to the caudal margin of the intermediate and medial crus. Advantages: (I) Preservation of the entire alar rim of the alar sidewalls. Thus preventing alar retraction, notching, collapse dimpling and asymmetry. /2) Trimming of cephalic lateral crus is made more visible, more accurate and has better control. /3) Less postoperative oedema and crustation . /4) More natural looking alar sidewall. /5) Stretches the alar sidewalls and reduces the alar flare.
Fig. 17 - 29. (150,151,152,153) On the operating table, pre and immediate post operation photographs of patients w ith modification of Goldman:S tip technique (Bizrah:S technique).
Note: Tip projection, definition and refinement w ith symmetry of the nares.