Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4366_Библиотеки_им_академика_М_И_Перельмана
.pdf
Chapter Digital Imaging and Standardized Photography in Rhinoplasty 125
https://t.me/medicina_free
Smiling Frontal and Lateral View
e dynamics of smiling produce several changes in the anatomic relationships of
the nose, particularly the relationship of the tip and alar base. e smiling frontal
and lateral views highlight these changes and can help to identify an overactive
depressor septi nasi muscle. is can cause excessive tip and alar base movement,
resulting in a displeasing appearance.
THREE-DIMENSIONAL IMAGING
Currently, most rhinoplasty analysis is carried out using direct measurements
of two-dimensional photographs in the frontal, lateral, oblique, and basal views.
However, the nose is a three-dimensional structure, and subtle irregularities can
be dicult to visualize in two dimensions, particularly in the frontal view.
Variations in lighting and positioning with two-dimensional imaging can lead
to inconsistencies, including changes in the appearance of tip-dening points.
Despite the implementation of standardized protocols, a change of photographers can cause signicant variations in image acquisition and interpretation.
Furthermore, lenses typically used for rhinoplasty imaging ( and mm) provide maximum depth of eld to ensure that the whole face is in focus, but these
lenses can potentially distort the image.
,
To obtain absolute measurements with two-dimensional images, photographs
may require recalibration to actual life size with the use of manual measurement tools such as rulers or calipers, and measurements of known distances in
the two-dimensional image. Many of these obstacles can be overcome with
three-dimensional imaging that employs linear and spatial parameters in a precise manner to outline the shape of the nose. ese images are reproducible and
maintain the proportions of the face independent of technique, photographer,
camera, and lighting.
Part One Basic Perioperative Concepts126
https://t.me/medicina_free
In general, three-dimensional systems consist of an optical system, a computer,
and analytic soware. Several forms of three-dimensional imaging modalities
have been developed for anatomic study. CT, three-dimensional ultrasonography,
Moiré topography, laser scanning, and stereophotogrammetry are a few of these
techniques. By far, stereophotogrammetry is the safest and most commonly
used three-dimensional imaging modality that does not require laser beams and
radiation. is involves taking multiple synchronous photographs with cameras
at various angles. ese images are then digitally merged to generate a threedimensional image. Examples of these commercial imaging modalities available
today include Vectra D (Caneld Scientic, Inc.) and dMD System (dMD
Inc., Atlanta, GA). ese machines are easily placed in a small room in the oce
and do not require special lighting. Aer the images are captured and uploaded,
the key landmarks are selected on a three-dimensional model automatically or
manually. Uploaded images are analyzed with special soware, and image morphing and manipulation can be performed immediately with the patient. Various
nasal parameters such as nasolabial angle, tip shape, dorsal height, nasal length,
supratip break, alar shape, vertical and horizontal proportions, and nasal and
facial symmetry can be assessed and manipulated either with the patient present or at a later time using the saved images. Unlike two-dimensional imaging
soware tools, the image can be rotated and the degree of alteration visualized
in multiple planes in real time. Preoperative and simulated postoperative images
can be saved and printed for the patient or for intraoperative use.
Chapter Digital Imaging and Standardized Photography in Rhinoplasty 127
https://t.me/medicina_free
To verify alignment and fully conceptualize the operative changes, the soware
can alter the transparency of either the preoperative or postoperative images. Superimposition of these images allows precise evaluation of the operative changes.
e soware can also calculate volume changes. is
is done by color coding, which demonstrates areas of
volume change by way of a color gradient.
Part One Basic Perioperative Concepts128
https://t.me/medicina_free
Furthermore, rather than measure straight point-to-point distances, which is
possible with two-dimensional photographs, the distances from point to point
can be measured along the contour of the nose with three-dimensional imaging
soware. For example, postoperative changes in dorsal width performed via medial osteotomies or dorsal gras on a stable, wide nasal base will not yield visible
changes in a two-dimensional frontal image. However, with three-dimensional
imaging the topographic change in distance can be measured. erefore threedimensional scanning can help in preoperative planning by providing the insight
to anticipate the degree of resection necessary to achieve desired postoperative
changes.
Facial analysis using three-dimensional imaging in conjunction with twodimensional imaging may oer new potential for understanding and standardizing aesthetic proportions of the face and nose. Advanced imaging technology
is evolving rapidly and has allowed the use of four-dimensional systemsto create
unprecedented, realistic facial animation (DID; Dimensional Imaging, Glasgow,
Scotland). With this technology, angles and animations can be manipulated and
measured aer capture to aid in the analysis of the dynamic tip and the dynamics
of nostril movement before and aer rhinoplasty. Currently, these images take a
long time to generate aer capture, and more practical documentation of these
movements can be obtained with videography.
INTRAOPERATIVE IMAGING
Intraoperative images are essential for preparation of peer-reviewed presentations, resident education, and self-assessment. Although the portability of a
point-and-shoot camera oers convenience for intraoperative use, a DSLR is
preferable and will produce the most consistent images. Advantages of the DSLR
are compatibility with interchangeable lenses, and high-powered external ashes
for close-up images and optimal illumination.
Prime/xed focal length macrolenses are preferred over zoom lenses for intraoperative photography. is allows all settings to remain constant except for ne
focus when images need to be obtained rapidly during the procedure. A prime
lens with a focal length between and mm is preferable.
Chapter Digital Imaging and Standardized Photography in Rhinoplasty 129
https://t.me/medicina_free
An externally mounted macroash such as a ring ash can provide the portability, even lighting, and power necessary for intraoperative photography. Ring
ashes are powerful enough to facilitate the use of a small aperture, thus increasing the depth of eld and producing sharp close-up images. It may be necessary
to make minor adjustments to the shutter speed and lens aperture during an intraoperative photography session, particularly if shooting from various distances.
Bracketing, which is the practice of taking two to three shots at dierent adjacent
f-stop settings, is a helpful technique to ensure proper exposure.
Optimal intraoperative images are taken close up and framed with fresh surgical towels to provide a clean background. Care must be taken to keep the eld
free of blood, which absorbs a large amount of light and can aect exposure. e
use of hooks and retractors helps to provide a clean background and is highly
encouraged.
DIGITAL IMAGING AND MORPHING
Morphing soware can be an excellent tool for patient communication and education. Some examples of digital morphing soware include Adobe PhotoShop
(Adobe Systems, Inc., San Jose, CA) and Aperture (Apple, Inc., Cupertino, CA).
is allows a patient to point out areas of concern and communicate desired
aesthetic goals. At the same time, the surgeon can educate the patient about realistic goals and limitations. It is extremely important to be cautious and judicious when using morphing soware to avoid creating unrealistic expectations.
Patients need to be informed that morphed images are merely a simulation and
do not guarantee a result. Moreover, surgeons should not generate imprudent
or overzealous representations of postoperative outcomes. As is so oen stated:
“e surgeon must underpromise and overdeliver.” Communication facilitated
by digital imaging can alert surgeons to patients who have unrealistic expectations and may help to discourage these patients from undergoing surgery.
It is extremely important to be cautious and judicious when using morphing
soware to avoid creating unrealistic expectations. Patients need to be informed
that the morphed images are merely a simulation and do not guarantee a result.
Communication facilitated by digital imaging can alert surgeons to patients who
have unrealistic expectations and may help to discourage these patients from
undergoing surgery.
Part One Basic Perioperative Concepts130
https://t.me/medicina_free
LEGAL ISSUES
Clinical photographs have the potential to violate patient privacy. ey are considered part of the medical record and are protected by federal laws such as the
Health Insurance Portability and Accountability Act (HIPAA) and state privacy
laws. erefore it is critical to understand the legal and ethical issues involved
before undertaking clinical photography. Consent should be obtained for all photographs and should include consent for publication and display (see the sample
consent form in Chapter ). For publication in a journal, textbook, or Website,
specic expressed consent for the particular publication should be obtained in
addition to the standard consent form. Images published in these forums should
be devoid of all patient information. As part of the medical record, patient photographs should not be destroyed, until aer the legal medical record retention
period as elapsed. ese images should be stored on a secure server with password protection compatible with institutional guidelines. Storage of images on
personal computers that are not encrypted is highly discouraged.
If patient consultation includes digital imaging and morphing, it is imperative to
counsel patients and ensure that they understand that the images are a simulation
and in no way guarantee the actual surgical result. is information needs to be
included on all morphed images given to a patient. To ensure image legitimacy
and minimize image tampering, all images given to a patient should be authenticated with a time-date stamp or signature.
,
It is imperative to counsel patients and ensure that they understand that digital
images are simulations and in no way guarantee the actual surgical result. is
information needs to be clearly stated on all morphed images given to a patient.
CONCLUSION
High-quality, consistent imaging is an essential tool for rhinoplasty surgeons.
Standardized imaging fosters communication, education, documentation, planning, and mastery, thereby promoting patient and surgeon satisfaction alike.
ACKNOWLEDGMENT
We would like to thank the UT Southwestern Department of Plastic Surgery’s Medical Photographers
Patricia D. Aitson, Kara (Kate) M. Mackley, and Certied Medical Aesthetician Brandi Session for their
time and expertise in the preparation of this chapter.
Chapter Digital Imaging and Standardized Photography in Rhinoplasty 131
https://t.me/medicina_free
KEY POINTS
■
Portrait lenses are recommended for rhinoplasty. ey have a focal length range
of to mm and prevent barrel distortion that oen occurs with shorter
focal lenses.
■
Lighting is critical to the production of high-quality, standardized photographs
in rhinoplasty.
■
To prevent a projected shadow, the ash should be on the same side as the
anterior part of the patient, eectively casting the shadow behind the patient.
■
For high quality and consistency in rhinoplasty photography, we advocate the
quarter light system as a major studio system.
■
Most experts agree that a medium or light blue tone is ideal for the background, because these colors are nondistracting and generally complement all
skin tones.
■
e six standard views necessary to critically evaluate nasal anatomy and the
underlying nasal framework are the frontal, prole (le and right), oblique (le
and right), and basal views.
■
It is extremely important to be cautious and judicious when using morphing soware to avoid creating unrealistic expectations. Patients need to be
informed that the morphed images are merely a simulation and do not guarantee a result.
■
Communication facilitated by digital imaging can alert surgeons to patients
who have unrealistic expectations and may help to discourage these patients
from undergoing surgery.
■
It is imperative to counsel patients and ensure that they understood that digital
images are simulations and in no way guarantee the actual surgical result. is
information needs to be clearly stated on all morphed images given to a patient.
REFERENCES
1. Gorman A. Malpractice carriers urge caution in use of imaging. Plastic Surgery Newsletter -,
.
2. Galdino GM, Swier P, Manson PN, et al. Converting to digital photography: a model for a large
group or academic practice. Plast Reconstr Surg :-, .
3. Stal SM, Klebuc M. Advances in computer imaging for rhinoplasty. In Gunter JP, Rohrich RJ, Ad-
ams WP Jr, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters,ed . St Louis: Quality Medical
Publishing, .
4. DiSaia JP, Ptak JJ, Achauer BM. Digital photography for the plastic surgeon. Plast Reconstr Surg
:-, .
5. McClelland D, Eismann K. Real World Digital Photography. Berkeley: Peachpit Press, .
6. Galdino GM, Manson PN, Vander Kolk CA. e digital darkroom. II. Digital photography basics.
Aesthet Surg J :-, .
7. Adams J, Parulski K, Spaulding K. Color processing in digital cameras. IEEE Micro :-, .
8. Peck JJ, Roofe SB, Kawasaki DK. Camera and lens selection for the facial plastic surgeon. Facial
Plast Surg Clin North Am :-, .
Part One Basic Perioperative Concepts132
https://t.me/medicina_free
9. Nahai F, Homan WY. Photographic essentials in aesthetic surgery. In Nahai F, ed. e Art of Aes-
thetic Surgery: Principles & Techniques, ed . St Louis: Quality Medical Publishing, .
10. Swamy RS, Sykes JM, Most SP. Principles of photography in rhinoplasty for the digital photogra-
pher. Clin Plast Surg :-, .
11. Galdino GM, DaSilva, Gunter JP. Digital photography for rhinoplasty. Plast Reconstr Surg :-
, .
12. Daniel RK, Hodgson J, Lambros VS. Rhinoplasty: the light reexes. Plast Reconstr Surg :-;
discussion -, .
13. Ne LL, Humphrey CD, Kriet JD. Setting up a medical portrait studio. Facial Plast Surg Clin North
Am :-, .
14. Guyuron B. Precision rhinoplasty. I. e role of life-size photographs and so-tissue cephalometric
analysis. Plast Reconstr Surg :-, .
15. Davidson TM, Homan HT, Webster RC. Photographic interpretation of facial plastic and recon-
structive surgery. J Biol Photogr :-, .
Facial Plast Surg :-, .
17. DiBernardo BE, Adams RL, Krause J, et al. Photographic standards in plastic surgery. Plast Recon-
str Surg :-, .
18. Schwartz MS, Tardy ME Jr. Standardized photodocumentation in facial plastic surgery. Facial Plast
Surg :-, .
19. LaNasa JJ Jr, Smith O, Johnson CM Jr. e cephalic view in nasal photography. J Otolaryngol :-
, .
20. Toriumi DM, Dixon TK. Assessment of rhinoplasty techniques by overlay of before-and-aer D
images. Facial Plast Surg Clin North Am :-, .
21. Humphrey CD, Kriet JD. Intraoperative photography. Facial Plast Surg Clin North Am :-,
.
22. Muhlbauer W, Holm C. Computer imaging and surgical reality in aesthetic rhinoplasty. Plast Re-
constr Surg :-, .
23. Segal J, Sacopulos MJ. Photography consent and related legal issues. Facial Plast Surg Clin North
Am :-, .
24. Chavez AE, Dagum P, Koch RJ, et al. Legal issues of computer imaging in plastic surgery: a primer.
Plast Reconstr Surg :-, .
■ ■ ■ ■ ■ ■
https://t.me/medicina_free
8
Postoperative Management
of the Rhinoplasty Patient
Rod J. Rohrich Jamil Ahmad
P
ostoperative management of rhinoplasty patients is an important component
of rhinoplasty and an extension of what was performed in the operating room.
Successful postoperative care begins in the preoperative period with a thorough
review of the expected recovery with the patient. Patients should receive detailed
written and oral postoperative instructions. Review of these instructions prepares
patients for what is to be expected, claries and reinforces the details, minimizes
anxiety, and helps involve them in their own care. A clear understanding of what
activities are allowed and what restrictions should be followed in the postoperative period can help patients plan for the recovery period and may reduce the
occurrence of certain complications.
-
Patients should receive detailed postoperative instructions before surgery. Review
of these instructions prepares the patient for what is to be expected, claries and
reinforces the details of the procedure, minimizes anxiety, and helps involve patients in their own care.
Dressings, medications, and management of complications are the key elements
of the postoperative period. Our preferred postoperative management protocols
are outlined in this chapter.
POSTOPERATIVE INSTRUCTIONS
All patients undergoing surgery receive both general postoperative instructions
and postoperative instructions specic to the procedure that they are having.
ese instructions should be given to patients preoperatively so they have an
opportunity to review them and prepare accordingly.
133
Part One Basic Perioperative Concepts134
https://t.me/medicina_free
Patients should be given instructions as to when they should call their surgeon.
Warning signs of potential emergencies should be reviewed. is includes both
general problems such as fever nausea, vomiting, dizziness, shortness of breath,
rash, rapid heartbeat and rapid breathing, and specic problems related to rhinoplasty including excessive pain at the surgical incisions and bleeding. Patients
should be given specic instructions as to how to contact their surgeon and when
to seek emergency medical treatment.
Patients are routinely prescribed pain medication, anxiolytics, sleeping pills, and
antinausea medication. Postoperative instructions should describe when it is appropriate for the patient to take these medications. It is particularly important to
instruct patients to keep the head elevated and to apply cold compresses to the
eyes and cheeks frequently for the rst hours aer surgery to decrease postoperative swelling, which is normal and may not reach its peak until to hours
aer surgery. When doing this, it is important not to saturate and/or apply signicant pressure to the external splint, because this can lead to premature splint
removal or displacement. Most of the postoperative edema will be resolved by
weeks. However, complete resolution of edema generally occurs months to
year aer surgery, and this is part of the normal recovery process. In addition,
patients may notice increased edema when outside temperatures are warmer and
with high salt consumption or aer alcohol consumption. To avoid unnecessary
anxiety and premature evaluation of the results, patients should be told—initially
during the preoperative consultation and again as a reminder postoperatively—
about the time necessary for complete resolution of edema.
Patients must be instructed to keep the head elevated and to apply cold compresses to the eyes and cheeks frequently for the rst 48hours aer surgery. ese
measures are useful for decreasing postoperative swelling, which is normal and
may not reach its peak until 48 to 72hours aer surgery.
Patients should be informed of activity restrictions, because these restrictions
will oen inuence when they can return to their normal daily activities and to
work. Strenuous activities and exercise should be avoided for at least weeks after surgery. Normal activity should be gradually resumed starting hours aer
surgery. Strenuous activity and heavy liing of objects greater than to pounds
should be avoided for to weeks aer surgery. ere should be no trauma or
pressure on the nose for weeks postoperatively.
Patients should be informed of activity restrictions, because these restrictions will
oen inuence when they can return to their normal daily activities and to work.
Соседние файлы в папке Библиотека им академика М.И. Перельмана