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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_537_Библиотеки_им_академика_М_И_Перельмана
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structure of the outcomes we present in this work is similar to those
presented in [188–223].
2 Rhinoplasty
Rhinoplasty is considered one of the most challenging facial augmentation
procedures, as it incorporates reduction, relocation, and augmentation with
a variety of individual nasal deformities [1]. The first rhinoplasties focused
only on reduction of the dorsal hump and adjacent nasal structures. Surgical
advancements over the years have moved in the direction of a proportional
approach, incorporating grafting and minimally invasive techniques [2].
Today, there are a plethora of options available to patients, including filler
augmentation and ultrasonic nasal osteotomy [3]. The various
osseocartilaginous nasal structures are shown below, and the procedures
targeted to augment these structures will be discussed in detail throughout
the remainder of the chapter (Fig. 1).
Fig. 1 Osseocartilaginous nasal structures [9]
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Nasal symmetry and proportions directly impact facial beauty, and there
is no universal “ideal nose.” Rather, the ideal size and shape of the nasal
constituents is dependent on the individual’s surrounding facial
characteristics [2]. The physical appearance of the nose and any selfperceived deformities are a primary motivation for patients who pursue
aesthetic rhinoplasty. Satisfaction post-rhinoplasty for functional and/or
aesthetic deformities is shown to be largely reliant on appearance [4].
Dimensional alterations should be made carefully and critically to avoid
overcompensation and help ensure an ideal aesthetic appearance [5].
In addition to aesthetic improvement, nasal function should be a top
priority for surgeons performing rhinoplasty.
2.1 Review of Relevant Anatomy
The external nose can be examined from frontal, lateral, and basal
viewpoints. The bony and cartilaginous nasal structures in this outermost
region are best identified as part of the upper, middle, or lower nose. The
upper third of the nose is comprised mainly of the nasal bones, with minor
cartilaginous overlap. These are two paired bones which originate at the
frontal bone and extend both posteriorly and anteriorly, connected by a
bony suture along the midline of the face. This suture begins
superiorly/caudally at the radix to form the nasofrontal angle and continues
inferiorly/anteriorly to eventually form the rhinion (most inferior point).
Additional bony articulations extend laterally from the nasal bones,
including the lacrimal bones at the superior aspect and nasomaxillary
processes at the inferior aspect [6].
The middle vault is comprised of the paired rectangular upper lateral
cartilages (ULCs), which are the basis for the middle third of the nose. The
ULC fuses with the nasal septum superiorly and extends laterally to the
borders of the piriform aperture (pear-shaped opening of the skull below the
nasal bones). The middle cartilaginous vault helps to provide fibrous
support for the dorsum of the nose and nasal valves [6, 7]. Surgeons should
use extra caution at the keystone area, a location characterized by 4–5 mm
of nasal bone overlapping ULCs. This region is important in determining
the contour and aesthetics of the dorsal hump [2]. Paired lower lateral
cartilages (LLCs) form the basis of the lower third, making up the lateral,
middle, and medial crus. The nasal columella is composed of the medial
crurae, extending to the tip of the nose anterosuperiorly and upper lip
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inferiorly [8]. The structural relationship between LLCs and adjacent
cartilage/bone is the key determinant of nasal tip shape and size [2].
The nasal septum is ideally located in the midline of the nose and is
posteriorly composed of the vomer, maxillary/palatine bones (inferiorly),
and ethmoid bone. Quadrangular segments of irregular hyaline cartilage
form the anterior septum. This quadrangular cartilage inserts into the bony
nasal spine and nasomaxillary crest of the maxilla [6, 10].
Intranasally, the turbinates are bony outgrowths which constitute the
lateral nasal walls. Extensions from the ethmoid bone form the middle and
superior turbinates, while the inferior turbinate is a separate bony structure.
Functionally, they are responsible for the physiological processing of
inhaled air through humidification and warming of inhaled particles.
Drainage from the sinuses and lacrimal glands is continuous with these
turbinates, allowing for meatal communication [10].
The nose is mainly supplied through the supratrochlear (internal carotid
a. branch) and facial (external carotid a. branch) arteries. Anastomosis of
these arteries with branches of ascending columellar arteries forms a rich
vascular network, which allows for maintenance of nasal blood supply with
wide undermining. Kiesselbach’s plexus is comprised of anastomosed
ethmoid a. (anterior and posterior), sphenopalatine a., and superior labial
artery branches, vascularizing the nasal septum. The vasculature is
illustrated in Fig. 2 [8].
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Fig. 2 The vascular supply of the nose and its adjacent structures [11]
2.2 Preoperative Patient Assessment
The patient’s perception of their appearance should always be considered
by the surgeon, although with rhinoplasty, additional precautions should be
taken. Many individuals who pursue aesthetic rhinoplasty specify perceived
deformities that may not be detected by an observer, indicating an
underlying psychological disturbance. Body dysmorphic disorder often
presents around the time of pubertal onset in young adolescents and is
indicated by altered self-perceived attractiveness [12]. The nasal structure is
the second most common trigger for distress related to appearance,
preceded by acne. There is continued debate as to whether underlying body
dysmorphic disorder should prevent patients from undergoing elective
rhinoplasty [1, 13, 14].
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Patients who wish to correct alar flaring or malposition, drooping or
bulbous nasal tip, and the width/projection of the dorsum are indicated for
aesthetic rhinoplasty. Aging and ethnicity can affect the aesthetic
appearance of the nose, and these are some other common reasons listed by
patients when pursuing surgery. Functional defects such as saddle nose or
twisted nose deformities, vestibular stenosis, external/internal nasal valve
collapse, and cleft nose deformities can be corrected with functional and
aesthetic rhinoplasty [5].
The contraindications for aesthetic rhinoplasty are not set in stone, as
this is considered an elective procedure performed at the surgeon’s
discretion. If patients are unsatisfied with previous surgeries or have a
history of prior traumatic injury to the nose, they should be referred to a
plastic surgeon with sufficient experience in these areas. Dissatisfaction can
result from contour irregularities or asymmetry, nasal dysfunction, or
resultant postoperative deformities. In all cases, the patient’s aesthetic goal
should be considered, as this can help to ensure satisfaction after the
procedure [5].
The surgical care team is responsible for obtaining a thorough patient
history before they are considered for rhinoplasty. Past medical history
should be collected in detail to assess their overall physical health and
identify relevant contraindications. As discussed with previous surgeries,
impaired wound healing is anticipated in individuals with diabetes mellitus,
vascular insufficiency, and/or hypertension. Guidelines regarding use of
tobacco and blood-thinning pharmaceuticals or supplements apply here.
There are additional factors to be considered before rhinoplasty listed
below, which specifically impact the nasal structure and postoperative
complication risk.
Cocaine Abuse
– Nasal inhalation of cocaine causes chronic inflammation of the
mucosa, as well as severe vasoconstriction. Patients who specify
recreational drug use are indicated for additional exploration with
rhinoscopy to identify septal collapse or perforation. Reparative
septoplasty can be utilized to correct septal defects when necessary,
but these patients are contraindicated for aesthetic rhinoplasty [15].
Obstructive Sleep Apnea (OSA)
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– This condition may not present with obvious symptoms, but if OSA is
suspected, the diagnosis should be confirmed with polysomnography
(sleep studies). OSA increases the risk of anesthetic and postoperative
complications. Patients may still undergo aesthetic rhinoplasty at the
surgeon’s discretion, and in these cases, the use of a continuous
positive airway pressure (CPAP) device reduces breathing
complications [16].
Past Surgical History
– Past surgical history (especially previous rhinoplasty) can provide the
care team with a better idea of the underlying nasal structures and their
integrity. Revisional rhinoplasty after alloplastic nasal implants puts
patients at a higher risk for some complications, including infection,
extrusion, and challenges in maintaining nasal projection and dorsal
height. In some cases, autologous cartilage grafting is necessary to
meet the patient’s expectations and complete the procedure. Surgical
rhinoplasty performed after filler rhinoplasty may require additional
nasal reconstruction and/or debridement in the event of ischemia or
necrosis [17, 18].
The motivation to pursue rhinoplasty should be identified through the
assessment of the patient’s goals and the impact of cultural and
psychosocial factors on these goals [6].
Aesthetic appearance and function should both be considered to ensure
the best possible outcome of rhinoplasty. An intranasal examination from
the base view is performed to determine the integrity of the inferior
turbinates and nasal septum and valves [19, 20]. Surgeons use a speculum
to examine the inside of the nose for any symptoms of turbinate
hypertrophy, septal perforation/deviation, or external/internal nasal valve
collapse. Dynamic examination techniques are used to confirm valve
integrity if suspected; positive signs include collapse during inhalation and
assessment of congestion improvement with cheek retraction [21–23] (Fig.
3).
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Fig. 3 Nasal valve collapse can take on a varied appearance as shown in the images, depending on
the severity of damage and stability of surrounding nasal structures [24]
Skin characteristics can indicate how well the nose will heal and predict
stiffness of the postoperative nasal tip and upper lip. A superficial skin
examination is performed to assess thickness, laxity, and quality (dry vs.
sebaceous). Irregularities of nasal contour and shape may be more visible
with certain skin types. Palpation of the nasal bones and their surrounding
structures can reveal previous surgery or trauma and inform surgeons of
cartilage (lower lateral and septal) integrity. Any asymmetry or defects
should be noted as well [23, 25].
Photos are taken from different viewpoints (frontal, oblique, and base
profiles), which can be virtually remodeled to show patients the potential
augmentation results. The surgeon should lead this discussion and explain
the realistic changes that can be made. Virtual remodeling can be used as a
guide to help the surgeon understand each patient’s goals and expectations;
however, it should be made clear that the images produced are not
guaranteed results [6].
The surrounding structures of the face should be considered, as drastic
changes to the shape and size of the nose can lead to a “mismatched”
aesthetic appearance. For best results, the patient’s goals are used to
influence the surgeon’s reconstructive decisions as opposed to leading them
[6].
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After the general integrity and functional status of the nasal structures
and tissues are determined, the surgeon will visually assess the proportions
of the nose, using aesthetic guidelines to propose corrections which line up
with the patient’s goals. These are listed in Tables 1 and 2, along with the
potential deformities which are indicative of rhinoplasty [26–29, 30] (Fig.
4).
Table 1 Frontal view assessment
Frontal view assessment Ideal presentation Rhinoplasty
indications
Nasal length: measured from nasal
root to tip
Equal to the vertical distance between
the stomion (oral commisure) and
menton (bottom of chin)
Longer nasal length
Dorsal esthetic lines: curved lines
bordering the dorsum, originating
at the medial superciliary ridges
and terminating at the nasal tip
Bilateral symmetry
Smooth, continuous contour at the
nasal bone/ULC junction
Inverted V deformity
Visible/palpable
groove at the nasal
bone/ULC junction
Commonly
presents after prior
surgery
Suggests valve
collapse
Septum: medial line drawn through
septum from midglabellar angle to
menton
Symmetrical, linear Deviated septum
C- or S-shaped
curvature of line
drawn through
septum
Bony nasal base Measures 75–80% of the alar base
width
Wider bony base
Often
necessitates use of
bone mobilization
with dorsal
augmentation
Saddle deformity:
wider bony base from
frontal aspect
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Frontal view assessment Ideal presentation Rhinoplasty
indications
Alar base Equal to intercanthal distance
(measured between medial canthal
openings)
Alar flaring: alar base
resection is indicated
if flaring extends >2
mm
Larger interalar
width: indicates
nostril resection
Additional
exploration required
Alar rims Symmetrical, outward inferolateral
flare
Bulbous, boxy,
pinched, or drooping
alar rims/bases
Columella Gentle curvature, “seagull wing”
appearance of columellar and alar rim
outline
Alar retraction:
indicated by dramatic
and/or asymmetrical
curvature
Retracted columella:
externally invisible
Nasal tip: measured using 4 major
landmarks: supra-tip break,
columellar-lobule angle, and
bilateral tip termination (2 points)
Outlined landmarks form a diamond
shape, divided horizontally into two
symmetrical equilateral triangles at the
level of lateral tip termination
Bulbous nasal tip
Increased
distance between
nasal domes,
corrected with
reattachment/closure
Thicker skin
often corrected with
debulking
Lateral crura Cranial and caudal edges are level,
with cephalic margin facing
downward and caudal margin facing
upward
Bilateral symmetry
Supratip fullness
Results from
higher cephalic edge
Parenthesis-shaped
tip deformity
Results from
vertical
malpositioning of
lateral crurae
Table 2 Lateral view assessment
Lateral view assessment Ideal presentation Rhinoplasty indications
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Lateral view assessment Ideal presentation Rhinoplasty indications
Nasofrontal angle: measured
from the nasion to the glabella
superiorly and tip inferiorly
115–130 degrees
Nasion represents the deepest
point, located between
supratarsal crease and lash line
(eyelid)
Longer/shorter appearing noses
result from larger/smaller
nasofrontal angles, respectively
Dorsal profile Dorsum originates at superior
palpebral fold
Smooth, concave (generally
preferred in women)
Dorsal hump
Convexity of the dorsal
profile
May be preferred in male
patients
Radix Projects 9–14 mm from the
anterior corneal plane
Located vertically between
supratarsal crease and superior
lash line
Caudally positioned radix
Inferior to the superior
lash line
Emphasizes the
appearance of a wide nasal
base/large nasal tip
Low radix projection may
present externally as a nasal
hump
Nasal tip projection 50–60% of nose projected
anteriorly to upper lip
Pollybeak deformity: excessive
projection of nasal tip [26]
Nasolabial angle: measured
from base of columella to
upper lip and nasal tip
Obtuse angle preferred in
women
90 degree angle preferred
in men
Drooping or bulbous nasal tip
decreased nasolabial angle
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