mastering rhinoplasty
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Because many postoperative rhinoplasty problems are directly related to the techniques used, the following tips will help to minimize undesirable results.
Useful tips and pitfalls which will help to minimize postrhinoplasty problems:

  1. Preoperative judgement:
    • List obvious deformities:
      Hump, deviation, wide tip, short columella, depressions, etc.…
    • Do not confuse between true and false hump, true and false pollybeak.
      False hump: it is due to tip underprojection, therefore, when the tip is lifted up the dorsum becomes straight. (Fig. 8 – 36)
      False pollybeak: it is due to hump overcorrection, therefore, when the bony dorsum is lifted up the nose becomes straight. (Fig. 13 – 21)
    • Listen to what the patient likes and dislikes about his nose.
  2. Operative judgement:
    Judiciously performed rhinoplasty on properly selected patient will minimize the postoperative complications:
    Rhinoplasty is a multiple steps procedure, following each step think… re-think if next step is indicated. Remember, there is no standard rhinoplasty.
  3. Do not over-reduce the hump at the beginning of the procedure. Leave final refinement and adjustment of the dorsum profile until after tip plasty. Never trim the superior septal angle in a patient with a bony and cartilagenous hump, short columella and underprojected tip. Actually, in such patients the superior septal angle may need to be augmented during the procedure following hump reduction and tip plasty. (Figs. 6 – 4,15 an Fig. 8 – 2)
  4. Perform septal correction if needed.
  5. Use auto grafts:
    Septal or conchal.
  6. When indicated perform:
    1. Intermediate osteotomy to break the banana shape (concave and convex) nasal bones.
    2. Transverse osteotomy to correct nasal root deviation.
    3. Fully mobilize the nasal bones to avoid open roof deformity and crooked like nose.
  7. Check the supratip region:
    1. High: trim dorsum septum and upper lateral cartilage.
    2. Low: consider supratip grafts.
    3. Consider pressure taping to prevent collection of fluids, which may result in later fibrosis and pollybeak.
    1. Dorsum refinement:
      Make sure that there are no irregularities. Remove bone debris and avoid too much rasping. Use dorsum grafts or fascia if needed.
    2. In crooked noses:
      1. Do not remove the hump until after performing the osteotomy because the hump may be due to overlapping of the nasal bones and not due to extra bone. In many cases the deviated hump disappears after bone repositioning.
      2. Consider dorsum grafts as indicated:
        Grafts will treat dorsum collapse and smooth the dorsum.
    3. Never do endonasal transcartilagenous cephalic trimming of the lateral crus without compensatory supportive tip measures. The rhinoplasty routine incisions and excisions divide the anatomical factors maintaining the tip support. Therefore, tip supportive means are required in order to avoid the unpleasant postrhinoplasty problems such as dropped tip, pollybeak, asymmetry, hanging columella and wide nares. The recommended tip plasty manoeuvres are: new dome creation or the Bizrah modification of Goldman’s tip, suture fixation, columellar strut, tip graft and septocolumellar sutures.
    4. Preserve at least eight mm of vertical lateral crus.
    5. Leave alar wedge resection as the last step of rhinoplasty.
    6. Use a septo-columellar suture to preserve tip projection and rotation. Make sure that the desired dorsum to tip profile has been achieved before suturing the incisions. Do not rely on sutures to achieve the desired profile. The effects of this suture will diminish in the early postoperative period, as will any tip support afforded by them.
    7. Listen to what the patient dislikes about his nose but don’t let the patient direct you. For example, the patient with a hump and an underprojected tip, might tell you to only do the hump and not to touch the tip. If you do so, the results will be low narrow dorsum with wide underprojected tip and possible pollybeak. Of course the patient will be unhappy and will forget what he instructed you before operation and even if he remembers he’ll tell you that you are the surgeon and not him. This will give a poor reflection of your skills.
  1. Treat both sides of the nose equally and symmetrically. Allow time for equal alar delivery, cephalic trimming, suture fixation, columellar strut and accurate positioning of tip graft. In the author’s hands and following over 3,000 rhinoplasty it takes only twenty minutes to do the tip plasty. Your speed and accurate symmetrical manoeuvres will come in time. The more experience you have the more you will improve.
  2. Consider pressure taping by steri-strips to cut the dead space and prevent collection of blood and fluids that might later lead to fibrosis and persistent hump or pollybeak.
  3. Apply cast. Gypsona is very useful in preservation of the desired shape and keeping the dorsum graft in the middle and helps in applying pressure on the nose to prevent oedema and hematoma. (Fig. 17 – 26)
  4. If using general anaesthesia, special care should be paid to the recovery period. Make sure that no pressure is applied on the nose by the oxygen mask. Anaesthetist and recovery nurses should be well trained and familiar with these cases.
  5. Remove the bilateral nasal packs together at the same time, not one by one. Separate removal will cause septal deviation.
  6. Tell the patient not to pull out any sutures, particularly the marginal incision sutures which might cause alar collapse. If any suture hangs down it is only to be trimmed by scissors and not to be pulled out.
  7. Give the patient your postoperative instructions and make sure it is set in writing (booklet information).
  8. Improving your rhinoplasty skills and work to become a capable rhinoplasty surgeon:
    1. Train and be confident in septoplasty. Firstly, you should perform hundreds of septoplasty and become a skillful septal surgeon before considering a career in rhinoplasty.
    2. Do at least fifty tip cadaver dissections.
    3. Work with an experienced rhinoplasty surgeon for at least one year.
    4. Attend as many courses as possible and keep attending. In between courses try to gain as much experience in rhinoplasty as possible to identify your weak areas. Sometimes, it may be worthwhile travelling long distances purely to learn a small detail of technique. For example in 1995, the author went to Atlanta for a four day intensive course, most of which was not worthwhile, until the ten minutes of lateral crura overlay technique was presented by William Silver. This was the only new manoeuvre learned on that course, but it was enough to revolutionize his results, since many of his patients in this region present with long lateral crura (drooping tip), tip asymmetry and or supra-alar fullness.
      1. Rhinoplasty demands the highest level of surgical skills from an otolaryngologist and plastic surgeon. Therefore, surgeons willing to practise this surgery should consider the above mentioned measures. Many of the author’s rhinoplasties are revisions from inexperienced surgeons. Some results are disastrous, then, one should have a conscience and be honest to the profession. Since most patients are on a private basis, it is unfair to ask him to pay for unfortunate results and pay again for a staged revised procedure. If the rhinoplasty appears too demanding, then refer to a more experienced surgeon.

MASTERING RHINOPLASTY:
‘Always aim for perfection. You will never achieve that, but unless you aim for it, you will never come close’ (Dr. Unger’s text). This wisdom applies to all plastic surgery procedures. Rhinoplasty operation is an accumulation of experiences which build up gradually and this begins with performing hundreds of septoplasty followed by hump removal and osteotomy and then mastering the tip. Following thousands of rhinoplasty one may claim to be a master rhinoplasty surgeon but one can not claim perfection. The wound healing and tissue contracture in rhinoplasty are unpredictable in spite of good technical skills, since our results are affected by the nature and thickness of nasal tissue and by the healing power of the patient.

Perfection is sometimes claimed because there has been no close or long term follow-up, low patient and surgeon expectation, low ethical and functional standard or dishonesty. While performing rhinoplasty, think and judge every step and manoeuvre, consider the anatomy and how to achieve your objectives of surgery by reshaping, refining and supporting the anatomy, but not by blind cuts and excisions. Do not leave gaps or overexcise tissue, as healing and wound contracture will cause scarring and fibrosis presenting with retraction, collapse, depression, pinching and notching. Imagine the nose as a brick house that you are going to rebuild and support. Do not excise without considering supportive means to compensate for the loss of support caused by your incisions and excisions. At the end of the procedure make sure that there is a good structural bony and cartilagenous support below each square millimeter of the nasal skin and that the desired profile of the dorsum and tip is achieved before applying sutures. The more experienced the surgeon, the less that is left to chance. But even so the master may stumble. Remember, Dr. Gustave Aufricht’s wisdom, ‘Rhinoplasty appears to be an easy operation but it’s hard to produce consistently good results’.

 

 

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