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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_884_Библиотеки_им_академика_М_И_Перельмана
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2 Informed Consent in Aesthetic and Plastic Surgery
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Makdessian investigated the effectiveness of verbal informed consent
during plastic aesthetic procedures as opposed to written informed
consent. The study found that written informed consent is significantly
better than verbal informed consent.
In the German-language literature, Fengler published a study which
examined the formal legal framework of informed consent. One interesting aspect of informed consent regards financial perspectives. Moreover, Fengler once again emphasizes the importance of photo documentation as a central pillar of informed consen t.
In summary, it is established that informed consent plays an increasingly important role in aesthetic plastic surgery. Also, with regard to
the increasing number of medico-legal cases, it is apparent that surgeons who conduct rigorous informed consent practices can significantlyreducetheirriskofbecominginvolvedinlitigationrelatingto
informed consent.
At our institution, we follow a procedure of duplicate patient information whereby the patient receives an extensive explanation of the treatment procedure and associated risks during the first consultation. As a
rule, the first photo documentation is compiled at this meeting. On
patient admission, which is generally one day prior to surgery, the procedure is explained again in full and new photo documentation is compiled. Both explanations are documented in writing in a standardized
manner.
Posto peratively, a further detailed discussion between physician and
patient takes place in which details relating to the operation as well as
postoperative aftercare are discussed.
The specific risks associated with common procedures are listed below:
1. Liposuction: dimpling, thrombosis and embolism, con tour irregularities, small scars at liposuction insertion sites, allergic reactions
resulting from the tumescence solution, hypoesthesia in the aspirated areas
2. Thigh and buttock lift: broadening scars, conto ur irregularities, side
asymmetries, vascular and neural injuries
3. Abdominoplasty: preoperative ultrasound recommended to avoid
internal abdominal organs, impaired wound healing, hematoma and
seroma, malposition of the navel and umbilical necrosis, lateral
“dog-ears”
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4. Breast augmentation: sensory changes in the nipple region, impair-
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ment in breast feeding, necrosis of skin, capsular fibrosis, displacement of prosthesis, asymmetry
5. Rhinoplasty: asymmetry , dimpling of nasal skin, injury to adjacent
structures (teeth and dura at the roof), difficulties breathing, rhinitis
sicca.Forrhinoplastyinparticular,itismandatorytoperformspecific nasal examinations which should include:
Rhinoscopic examination of the nose, including the nasopharynx,
a)
with an endoscopic system
b) Rhinomanometry
c) X-ray of the nose in two planes (occipitomental and lateral)
d) Allergy tests
e) Odor and taste perception tests
f) Tube ventilation test
g) Adequate external examination of the nose, e.g., measurement
of the nasofacial and nasolabial angles
h) Facial morphometry
6. Rhytidectomy:facialnerveinjury,skindehiscenceandnecrosis,
asymmetry, visible scars, shift of hairline, alopecia areata, traction at
the ear lobes, hypopigmentation and hyperpigmentation
2 Informed Consent in Aesthetic and Plastic Surgery
7. Blepharoplasty: ectropion, asymmetry, blindness, keratitis sicca, visible scarring. It is imperative to apply ophthalmologic ointment into
the eye prior to the procedure
8. Fillers: conto ur irregularities, scars, surgical removal of injected
material,granuloma,allergicreactions,infections
9. Otoplasty: hematoma, shape asymmetry, nerve injuries, infections
Guiding Principles in the Informed Consent Discussion
1. Persons Obliged to Obtain Informed Consent
The physician is obliged to obtain informed consent; this task may not
be delegated to non-medical staff. The physician carrying out the procedure does not necessarily need to obtain the informed consent himself; however, he or she should ensure the suitability and specialist
qualifications of the physician obtaining the informed consent. If several physicians are taking part in a procedure, each is obliged to obtain
informed consent for their part.
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2. Informed Consent in Non -medically Indicated Procedures
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(Cosmetic Procedures)
In the case of cosmetic surgery, the patient must be given the opportunity to carefully consider the advantages and disadvantages of the procedure. He or she must decide whether undergoing a risk-associated
procedur e is preferable to his or her current situation.
3. Timing of the Informed Consent Discussion
The patient’s right to self-determination requires the informed consent
discussion to take place at an appropriate time. This should ensure the
patient freedom to decide without time pressure. In the case of outpatient surgery , informed consent on the day of the procedure is sufficient. For inpatients, informed consent should be given on the day
prior to the procedure.
2 Informed Consent in Aesthetic and Plastic Surgery
4. Informed Consent for Foreign-Language Speakers
It is particularly important that the person in question is able to understand the doctor’s explanation. Where necessary, an interpreter should
be made available.
5. Extent of the Informed Consent Discussion
The ph ysician must explain the main features of the treatment without,
however, going into details. Therefore, the extent of the informed consent depends upon the urgency and severity of the procedure and its
consequences, as well as the patient’s knowledge and level of education.
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3 Rhinoplasty
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Correction of Nasal Hump and/or “Long Nose”
with the Endonasal Eversion Method (Mang Technique)
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Introduction 15
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Anatomical Overview 17
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Instruments and Medication 18
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Duplicate Patient Instruction 22
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Nasal Examination 22
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Photographic Documentation 23
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Surgical Planning 23
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Tumescence Injection T echn iq ue 26
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Disinfection 28
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Suction and Surgical Planning 28
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Incision Line 30
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D´ecollement 32
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Correction of the Nasal Tip with the Eversion Method 34
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Nasal Shortening 38
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Bump Ablation 40
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Reshaping of the Tip 46
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Suturing of the Mucosal Incisions 48
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Resection of the “Mang Triangle” 50
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Osteotomies 52
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External Dressing 56
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Postopera ti v e Medication and Precautions 58
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Results 59
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Tips and Tricks 62
The symbol indicates parts of the procedures shown in the video
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Introduction
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Rhinoplasty procedures are among the most difficult and most controversial operations in the area of plastic and aesthetic facial surgery . To
achieve functional and aesthetic unity , the surgeon requires in-depth
knowledge of both internal and functional structures.
Experienced surgeons specializing in rhinoplasty usually have no problem using an endonasal approach, but inexperienced surgeons and
newcomers to aesthetic surgery may find that the extranasal approach
initially gives them a better overview. However, this advantage can be
rapidly negated by the unsatisfactory aesthetic results.
In the operations performed using an endonasal approach, we distinguish between the vestibular margin incision, the intercartilaginous
incision, and the intracartilaginous incision. For primary septorhinoplasty, the intercartilaginous and intracartilaginous approaches are
generally adequate; the length of the nasal tip and the degree of nasal
curvaturedesiredbythepatientareofdecisiveimportancehere.The
vestibular margin incision is made only when the luxation technique is
to be used. This technique is indicated for reoperations and for patients
with broad nasal tips (ballooning phenomenon).
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When the operation is performed on patients with long noses, it is
advisable to place the intracartilaginous incision as far as possible
toward the vestibular margin in order to achieve an optimal lifting,
shortening, and rotation of the nasal tip. If the surgeon has intimate
knowledge of the internal nasal valves and the mucosa are left intact,
large portions of the triangular and alar cartilage can be removed without compromising nasal function.
The entire cartilaginous and bony nasal framework can be pushed off,
dissected, and reshaped using the endonasal approach. Moreover, the
angle of the glabella can be exposed and corrected using this endoscopic approach. Likewise, cartilage pieces of many different shapes
and sizes can be reimplanted, incorporated by modeling to achieve a
more aesthetic nasal tip and dorsum, and fixed in place with fibrin
adhesive.
In our opinion, the main problems associated with the extranasal
method are the insufficient exposure of the supratip region, the heightened scar formation, and the distortions occurring in the nasal tip and
soft tissue until wound healing is completed after about 6 months.
Open rhinoplasty is necessary only in exceptional cases, e.g., pro-
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nounced cleft deformations, noses that have been largely destroyed by
repeated unsuccessful operations, and extremely fleshy nasal tips. The
majority (67%) of patients undergoing nose operations at our hospital
are female patients between 18 and 40 years who have a long nose with
abump.
Surgicalcorrectionofa“thin-skinned”longnosewithabumpisoneof
the most rewarding aesthetic procedures, as the results are excellent.
Patients usually feel much better in both their professio nal and their
private life and in general have a more positive outlook. We have therefore described the individual steps required for this type of nasal correction in great detail in this chapter.
The basic prerequisites for successful rhinoplasty are as follows: comprehensive and candid instruction of the patient, deflation of exaggerated expectations, qualified professional training, and the aesthetic
imagination of the surgeon.
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Anatomical Overview (Fig. 3.1)
1. Cartilage of nasal septum
2. Lateral nasal cartilages
3. Lateral crus of greater alar cartilage
4. Medial crus of greater alar cartilage
5. Vestibule of nose
6. Cartilage of nasal septum
7. Anterior nasal spine
8. Dilator muscle of naris
9. Upper lip
10. Depressor muscle of nasal septum
11. Infraorbital nerve
12. Piriform aperture
13. Levator muscleof upper lip
and ala of nose
14. Angular artery
15. Compressor muscle of naris
16. Accessory nasal cartilages
17. Nasomaxillary suture
18. Supratrochlear nerve
19. Infratrochlear nerve
20. Nasal bones
21. Frontonasal suture
22. External nasal branches
of anterior ethmoidal nerve
23. Procerus muscle
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Instruments and Medication (Fig. 3.2–3.4)
1 Nasal speculum (short)
2 Bayonet- shaped forceps
3 Tweezers Adson-Br own
4 Delicate surgical tweezers
5 Columella clamp
6 Scalpel handle
7 Turned nose scissors Mang
)
Scissors for suture material
8 Dissecting scissors Wullstein
9 Bone rongeur Luer
10 Nasal scissors Heymann
11 Raspatory sharp Dieter
12 Raspatory sharp/blunt Freer
13 Raspatory McKenty
14 Delicate long single-pronged wound retractor
15 Fine long two-pronged wound retractor
16 Retractor blunt
17 Fine wound retractor sharp
18 Mallet Cottle
19 Chisel 4 mm
20 Chisel 10 mm
21 Largebonefile
22 Aspirator
23 Rongeur Weil-Blakesley
)
Elevator
24 Needle holder small
25 Dissecting and ligature forcep (mosquito forcep)
)
Optical System (0 and 30 degrees)
)
Electrocoagulation forceps
)
Suture material (4/0 PDS, 4/0 Prolene, 6/0 Prolene)
)
Scandicaine 0.5% with epinephrine
(mepivacaine hydrochloride) 1 :200,000
)
Saline 0.9%
)
Xylometazoline hydrochloride solution
)
Compresses(10×10cm)
)
Nasal packing
)
Swabs
)
Brown steristrips
)
Leukosilk adhesive tape (w = 1.25 cm)
)
Plaster of Paris
)
Skin cleaning kit
)
10 ml Omnifix syringe with a long needle
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Fig. 3.2
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