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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4366_Библиотеки_им_академика_М_И_Перельмана
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Chapter Harvesting Autologous Gras for Primary Rhinoplasty 215
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7. Gunter JP, Cochran CS, Marin VP. Dorsal augmentation with autogenous rib cartilage. Semin Plast
Surg :-, .
8. Marin VP, Landecker A, Gunter JP. Harvesting rib cartilage gras for secondary rhinoplasty. Plast
Reconstr Surg :-, .
9. Cochran CS, Gunter JP. Secondary rhinoplasty and the use of autogenous rib cartilage gras. Clin
Plast Surg :-,
10. Chauhan N, Sepehr A, Gantous A. Costal cartilage autogra harvest: inferior strip preservation
technique. Plast Reconstr Surg :e-e, .
11. Daniel RK, Calvert JW. Diced cartilage gras in rhinoplasty surgery. Plast Reconstr Surg :, .
12. Daniel RK. Diced cartilage gras in rhinoplasty surgery: current techniques and applications. Plast
Reconstr Surg :-, .
13. Kelly MH, Bulstrode NW, Waterhouse N. Versatility of diced cartilage-fascia gras in dorsal nasal
augmentation. Plast Reconstr Surg :-; discussion -, .
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PART THREE
e Dorsum
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13
Evaluation and Surgical
Approach to the Nasal Dorsum:
Component Dorsal Hump Reduction
and Dorsal Reconstitution
Rod J. Rohrich Jamil Ahmad Jason Roostaeian
M
is commonly performed during rhinoplasty. is largely stems from the fact that
achieving an aesthetically pleasing dorsal nasal prole is one of the most common goals among patients seeking rhinoplasty. However, signicant morbidity
can result when dorsal hump reduction is performed without sucient emphasis on the anatomic and functional relationships of the dorsum. Some of the more
signicant adverse outcomes of dorsal hump reduction include the following:
Chapter excerpted from Rohrich RJ, Muzaar AR, Janis JE. Component dorsal hump reduction: the
importance of maintaining dorsal aesthetic lines in rhinoplasty. Plast Reconstr Surg :-,
discussion -, ; Roostaeian J, Unger J, Lee MR, Geissler PJ, Rohrich RJ. Reconstitution of
the nasal dorsum following component dorsal reduction in primary rhinoplasty. Plast Reconstr Surg.
Nov . [Epub ahead of print]; and Geissler PJ, Roostaeian J, Lee MR, et al. Role of upper lateral
cartilage tension-spanning suture in restoring the dorsal aesthetic lines in rhinoplasty. Plast Reconstr
Surg (in press).
anipulation of the nasal dorsum, and in particular dorsal hump reduction,
■
Long-term dorsal irregularities, commonly at the osteocartilaginous transition zone, secondary to uneven hump reduction
■
Overresection or underresection of the osteocartilaginous hump
■
Excessive narrowing and/or widening of the midvault secondary to aggressive hump reduction, nasal osteotomies, and improper reconstitution
of the upper lateral cartilages
■
Inverted-V deformity secondary to excessive resection or avulsion of the
upper lateral cartilages
■
Asymmetries and/or irregularities of the dorsal aesthetic lines secondary to nasal osteotomies and poor reconstitution of the nasal dorsum
, ,,
-
,,,
219
Part ree e Dorsum220
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ese potential complications can oen be avoided when the surgeon has a complete understanding of the anatomy of the nasal dorsum and its relationship to
nasal aesthetics and function. A component dorsal hump reduction technique
has been developed that takes into consideration anatomic, aesthetic, and functional relationships.
,
is technique emphasizes a graduated approach to nasal
hump reduction that is both adaptable and reproducible. Although preservation
of the upper lateral cartilages is a fundamental step when addressing the nasal
dorsum, it must be accompanied by proper restoration of the midvault and dorsal
aesthetic lines. erefore correct positioning and contour of upper lateral cartilages following their detachment from the nasal septum is also critical to avoid
functional and aesthetic complications.
,
A graduated approach is critical, with preservation and proper reconstitution of
upper lateral cartilages when reducing a dorsal hump.
ANATOMIC CONSIDERATIONS
Thinner skin
Thicker skin
e thickness of the skin of the nasal dorsum varies; it is thinner in the dorsum
and thicker in the supratip and tip regions. erefore a straight dorsal prole
must account for this variation in dorsal skin thickness by creating a slight underlying convexity of the osteocartilaginous framework in the cephalic area.
Chapter Component Dorsal Hump Reduction and Dorsal Reconstitution 221
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e underlying osteocartilaginous nasal framework consists of three separate
vaults: bony, upper cartilaginous, and lower cartilaginous. e bony vault is created by the paired nasal bones and the ascending frontal process of the maxilla,
constituting the proximal one third to one half of the nose. e nasal bones are
narrowest and thickest above the canthal level.
e nasal bones overlap the upper lateral cartilages typically for distance of to
mm at the keystone area, which should be the widest part of the dorsum. e
relationship of the upper lateral cartilages to the septum is critical both functionally and aesthetically. Maintaining the T-shaped contour of the dorsum prevents
internal valve collapse and inverted-V deformities. is contour of the nasal dorsum, in particular its keel-shaped segment, must be maintained or reconstructed
in rhinoplasty or nasal reconstruction.
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AESTHETICS OF THE NASAL DORSUM
On frontal view, the character of the nasal dorsum is largely dened by the dorsal aesthetic lines. ese lines should be carefully maintained or recreated when
performing dorsal reduction. e dorsal aesthetic lines originate at the supraorbital ridges passing along the lateral borders of the glabella staying just medial to
the medial canthal ligaments. ey then diverge at the keystone area and go on to
follow the junction between the nasal dorsum and sidewall, ultimately concluding
at the tip-dening points. Ideally, the dorsal aesthetic lines should be symmetric with a smooth and continuous contour that matches either the interphiltral
distance or tip-dening points in width. e upper lateral cartilages dene the
middle third of the dorsal aesthetic lines thereby playing an integral role in the
overall contour and aesthetic result.
,
Preservation or creation of dorsal aesthetic lines with a smooth, symmetrical,
continuous contour is critical in rhinoplasty.
is angle is created by the intersection of a line passing through
(G)
and a line drawn as a superior extension of the nasal dorsum
Typically varying from to degrees, the nasofrontal
angle is ideally degrees in females and degrees in males,
but can also vary with ethnicity. e apex of the angle should
lie between the upper lid eyelashes and the supratarsal fold. e
nasion should be approximately mm anterior to the medial
canthus or mm anterior to the corneal plane as measured on
e perceived length and projection of the nose on lateral view
If the radix
is positioned more anteriorly and superiorly than normal, the
nose will appear articially elongated, the nasofacial angle will be
(yellow
Conversely, if the radix is too posteriorly and/or inferiorly
positioned, the nose will be made to appear shorter and the tip
e nasofacial angle ideally should
measure to degrees and is dened by the junction of the
Chapter Component Dorsal Hump Reduction and Dorsal Reconstitution 223
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G
Naso-
N
frontal
angle
D
e shape of the radix is determined by the nasofrontal angle.
the so tissue nasion (N) tangent to the infrabrow glabella
(D).
a lateral view.
are directly inuenced by the position of the radix.
decreased, and the tip projection will appear diminished
line).
more projecting (red line).
dorsum with the vertical facial plane.
e radix is located between the supratarsal fold and the upper eyelid lashes,
and its position aects the apparent length and projection of the nose on the lateral view.
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e width of the bony base of the osteocartilaginous vault should be equal to
% to % of the intercanthal distance or normal alar base width. Osteotomies
are not indicated if this width is normal; however, when the bony base is wider
than % of the intercanthal distance, osteotomies may be required to narrow
the bony dorsum.
e width of the dorsum at the keystone area must be preserved. e width of the
bony base should be equal to 75% to 80% of the intercanthal distance or normal
alar base width.
Each of these aesthetic relationships must be carefully considered in the preoperative planning of the dorsal prole. e rst step is to determine the preferred
position of the nasofrontal angle on lateral view. Next, the desired amount of tip
projection and degree of tip rotation should be determined.
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