the surgery than the ones who only listen to what their surgeons have to say. They are expected to have better postsurgical results for they know exactly what they don’t like about their looks and what to expect from the surgery. Patients who are less motivated for the surgery, the ones who have a lot of other unsolved issues in their lives, who are less intelligent, who see their surgeon because the members of their families or their friends told them so, are worse candidates for the surgery for they don’t really know what they want and expect their surgeons to do wonders for them. Patients who are well motivated for the surgery and who know what to expect after the surgery, are better postoperative patients and in larger numbers show that they are satisfied with postsurgical period [4].

55.3 Preoperative Analysis

When a nose surgery is indicated, it is necessary for the patient to have some blood tests done as well as an internist exam. A thorough presurgical examination of the nose and throat is needed for every catarrh, let alone pustular inflammation, are absolute counter indications for the surgery. There are other factors because of which we cannot perform the surgery such as conjunctivitis, vestibulitis, and herpetic changes in the upper lip area, columella, or nasal wings. These infections can spread onto sinus cavernosus hematogenously by anastomoses between facial vein and ophthalmic vein. All the mentioned infections require a long-term treatment regardless of patients’ pressure or patients’ friends and family’s pressure to perform the surgery as soon as possible [5].

It is necessary to perform a postsurgical nose examination both anterior and posterior, both profiles and the base of the nose as well as the face itself. Afterwards, it is necessary to do nose palpation as well as anterior and posterior rhinoscopy. In case of some vague results, it is necessary to do an endoscopic examination of the nose along with anemisation of nasal mucous membrane, measurements, functional examination of breathing function (rhinomanometry and acoustic rhinometry) [6]. It is necessary to do rhinomanometry and rhinometry before and after nasal mucous membrane anemisation because breathing difficulty can be the consequence of skeletal, mucous, or combined components. These tests can

significantly solve the dilemma on the cause of breathing difficulties. Also, it is recommended for every postsurgical patient to undergo an olfactory examination.

Before every rhinoplastic surgery, it is necessary to take at least three photos which would include: profile, base of the face as well as anterior and posterior. Some authors insist on profile photos from the left and from the right, as well as additional photos, but the first three are highly necessary. The photos are necessary to develop the best plan of the surgery, to estimate the process of postsurgical healing having also in mind legal matters in cases of postsurgical lawsuits.

Prior to the surgery itself, it is necessary to explain the procedure to the patient and what can be expected in postsurgical period. A good postsurgical care is very important for it is also a significant factor in surgical results. Thus, with carefully chosen patients, a good presurgical preparation, and an adequate surgical technique that diminishes postsurgical complications, the success of the surgery and patients’ satisfaction increase a lot.

Borges et al. [7] have found personality disorders in one-fifth of prospective rhinosurgical patients. There were no significant differences between the genders. Also, their findings state that one-half of surgical patients who underwent rhinoseptoplasty have experienced an increase in self-esteem, notably female patients.

55.4 Surgical Techniques

What we call rhinoplasty is an implementation of different surgical techniques aiming for aesthetic and functional nose change (Figs. 55.1–55.3). Surgical approach covers performing several intranasal or intranasal and extranasal incisions which enable reaching nasal infrastructure.

55.4.1 Incisions in Rhinoplasty

In order to get the easiest approach to nasal pyramid modeling, it is necessary to perform some incisions. The incision location depends on whether the surgery is open or closed. The most frequent nasal septum approach is done through hemitransfixion or transfixion incisions.

The difference between these two incisions depends on whether the whole thickness of septum in front of caudal edge of septic cartilage is cut or the incision is done only on one side of the septum. The right-handed people perform hemitransfixion incision on the right hand side, while the left-handed do it on the left hand side, although this routine could often be vice versa (Fig. 55.4).

Hemitransfixion incision is done from nasal dorsum toward spini nasalis anterior inferior. If intercartilaginous incision is done (Fig. 55.5), it is necessary to approach nasal dorsum. This incision is done in case of endonasal approach. The incision is performed on the link between alar and triangular cartilage in the area above nasal valvula in the so-called

cul de sac so that the incision starts right above the free edge of triangular cartilage laterally and spreads over medially.

When both-sided intercartilaginous incision is done, it is possible to separate suprastructure from infrastructure. This incision enables an easy preparation of cephalic end of alar cartilages. The disadvantage of this incision is that it does not enable the surgeons to work on bifid tip and nasus bullosus.

Approaching alar cartilage is possible through marginal incision (infracartilaginous incision) that is done 1–2 mm in the parallel process with the edge of alar cartilage. This incision is used while decortication of nasal pyramid by widening medial crus of alar cartilage.

Transcartilaginous incision is done through alar cartilage between intercartilaginous and marginal incisions. While performing this incision, a surgeon usually recesses the cephalic part of alar cartilage along with the patient’s skin.

Transversal incision of the columella is used in nasal decortication and is often done on the link between lower and medium third of columella.

Vestibular incision is often used by rhino-sur- geons who do not separate the complete suprastructure from infrastructure in order to perform lateral osteotomy.

Alar incision is used in cases when it is necessary to make the base of the nose narrow by recessing one part of nasal wing.

55.4.2 Osteotomies in Rhinoplasty

Osteotomy is a procedure in which bones are cut. Chisels and saws can be used. Modern rhinosurgery tends to cut a bone sharply leaving the least possible bone dust. Chisels are recommended for that purpose.

Osteotomies can be transcutaneous when Tardy chisels are used, sublabial when approached through upper vestibulum of the mouth, and endonasal that are most common.

According to the incision location of nasal pyramid, all osteotomies can be divided into: medial, paramedial, lateral, and transverse.

Medial osteotomy is usually performed in cases when the nasal hump is not to be removed. The chisel

two proections (a) Preoperative. (b) Postoperative

b1

a2

b2

is usually introduced by hemitransfixion incision to the beginning of suture between nasal bones so that the chisel separates nasal bones. The chisel can also be introduced by intercartilaginous incision and it is place at the beginning of the suture of both nasal bones.

Paramedial osteotomy is used in cases when it is necessary to remove the nasal hump or in cases with nasal bone fractures creating the need for the bones to be cut in two levels.

The chisel is usually introduced through intercartilaginous incision or nasal skeleton is reached after lifting of soft tissue in external approach. A wide flat chisel is usually used, with or without guide on both sides. The chisel passes through both nasal bones at a certain level depending on how much is needed to remove the nasal hump or through an old fractural line in case when nasal skeleton is cut in two levels.

Lateral osteotomies serve to close the open nasal roof after removing the hump or in case when nasal dorsum is symmetrical, so it is necessary to correct the height of the nose. Vestibular incision is often used as an approaching way or it is reached through upper vestibulum of mouth cavity, which is extremely rare. They can be low, medium, or high. The line of these osteotomies starts from pyriform aperture, cuts the frontal extension of the upper jaw, passes at about 2–3 mm more dorsal from lacrimal bones, and ends in the area of nasion.

Transversal osteotomies are used in cases when there is no linking between lateral osteotomies and medial or paramedial cuts. The chisel is introduced either through intercartilaginous or vestibular incision.

In transcutaneous osteotomies, the 2 mm skin incision is performed through which a microchisel is introduced

Fig. 55.4 Hemitransfixion incision

Fig. 55.5 Intercartilaginous incision

making perforation cuts on the frontal extension of the lower jaw and nasal bones following an imaginary line of osteotomies. Afterwards, the fracture is made and roof of nose is closed.

Depending on the kind of the incision, we have two basic surgical techniques, open and closed techniques. The close techniques are also called endonasal while open techniques are called decortications techniques.

Surgeon decides on the technique that is to be implemented during presurgical planning. It should be pointed out that both approaches have their advantages and disadvantages. It is necessary to be knowledgeable about both approaches in order to avoid possible mistakes. Some rhino-surgeons have their own preferences when it comes to choosing a technique.

Decortications or the open technique is characterized by a visible scar on columella. This technique was created by Rethi in the 1920s. Thanks to Padovan, it became popular in the USA. This technique enables surgeons to have a better insight during resection and modeling of the nose tip, and it provides a better overview on the nasal pyramid skeleton. Its drawback lies in the visible scar which is a problem in patients prone to keloid reaction. This technique solves all the deformities of nasal pyramid, although problems can arise in nasal septum. It is indicated in the problem of long noses (nasus longus), big noses (macrorhinia), big nasal tips (nasus bullosus), in nostril asymmetry, in nasal tip augmentation, nasal valve insufficiency, as well as in repeated surgeries.

The surgery begins with a “V” incision or stairway incision of the skin on the link between lower and medium third of columella. This incision is linked to marginal incision (infracartilaginous incision). Skin is carefully lifted until lower edges of medial crus of both lobular cartilages are seen. By following the lobular cartilages, nasal suprastructure is carefully lifted, and triangular cartilages and nasal bones are seen. When a complete insight into nasal pyramid is obtained, surgeons approach nasal septum from the upper and frontal sides. The lobular cartilages are divided and elevated submucosoperichondrial flap on both sides until maxillary spine and crest. All the necessary steps are done regarding correction and reaching the envisaged dimension. If necessary, a scalpel excision of the cartilage part of the hump is done, and then the flat chisel is used to remove the bone part of the hump. Lateral osteotomies on both sides are done. The alar cartilages are modeled. The cartilage grafts are placed, if needed. All nasal cartilages are sutured with Prolene of 5–0 or 6–0 dimensions. Columellar and marginal incisions are closed with interrupted 4–0 or 5–0 chromic gut suture. Nasal packing are placed on both sides and nasal pyramid is immobilized.

Endonasal approach covers incisions on the nasal cavity so that they are invisible. Joseph from Berlin was the first surgeon to solve nasal deformities by endonasal way, which was proven as a revolutionary

concept in treating nasal pathologies. He was the first to implement several surgical techniques and introduced several specific instruments in rhino-sur- gery. His followers in the USA were Aufricht, Safian, and Fomon. Fomon’s followers were Cottle and Goldman. Cottle introduced the term of transfixional incision and four tunnel concept in nasal septum preparation. The advantages are shorter postsurgical period, no visible scars, and shorter surgery time. The disadvantages are worse insight in nasal infrastructure and having more difficulty in correcting nasal tip deformity. It is convenient in correcting kyphotic and scoliotic nose.

Endonasal rhinoplasty means incisions to approach nasal septum as well as incisions that enable the approach to nasal suprastructure.

The incision of the authors’ choice, in order to approach nasal septum, is hemitransfixion incision, although certain authors prefer transfixion incision. The authors are of the opinion that hemitransfixion incision is better for the better position of the tip of septal cartilage.

It is possible to approach nasal infrastructure through intercartilaginous incision, marginal incision, or transcartilaginous incision. They are usually done with a Bard-Parker 15 blade.

In every rhinoplastic surgery it is highly necessary tosolvethenasalseptumpathology.Mucoperichondrium is carefully lifted after hemitransfixion incision is done. Septal cartilage is completely prepared (Fig. 55.6).

Nasal septum is modeled to make sure that normal nasal function is obtained. It is necessary to point out that a nasal septum deformity that is not entirely correct can result in further nasal pyramid deformities a couple of months after the surgery. It is necessary to be very careful during nasal septum resection. If nasal septum resection is too big, this can result in nasal tip lowering due to the loss of the support. The best solution is to tend to perform the least possible resection, but not at the expense of the surgery outcome. One of the reasons for postsurgical breathing difficulties is the left deformity of nasal septum. The tip of quadrangular cartilage is shortened if necessary.

After solving nasal septum pathology, one of the nasal suprastructure incisions is performed. The authors prefer intercartilaginous incision. After the incision has been done with fine scissors, nasal suprastructure is carefully lifted (Fig. 55.7).

When the bone part of the pyramid is reached, periosteum is elevated from the bone. When suprastructure is separated from infrastructure in the dorsum area,

Fig. 55.6 Preparation of caudal part of septum nasi

Fig. 55.7 Lifted nasal suprastructure

vestibular incisions are done and the tunnels, through which the chisel will pass during lateral osteotomy, are prepared through them.

In case of dealing with kyphosis scalpels or when scissors are used to remove the cartilage part of the hump, the flat chisel is used to remove the bone part (Fig. 55.8). A file is used to flatten the bone edges. Afterwards, both-sided low osteotomy is performed in order to solve the problem of the open roof. If necessary, it is possible to prepare cephalic end of the lateral crus