Учебники / Rhinoplasty Dissection Manual Toriumi 1999

sesa moid,3f

upper lateral (ULC). See Upper lateral cartilage Cartilage-splitting approac h, 37, 38f-39f Cephalic trim, 77,11 0

Cervi cal point, IOf, I I, 157 Ch in altera tions

augment ation , 165f

alloplastic imp lant manufac turers, 172 Legan faci al-co nvexity angle, 15

Cleft lipnasal deformity, I67f, 167168 bilateral , 167f, 168

unilateral, 167, 167f Col umell a, 2f

cleft lip-nasal deform ity bilateral, 168 unilatera l, 167

hangin g columella deformity, septoplasty, 3 1

infilt rati ve anesthetic injec tion technique, 25, 26f, 28 retr acte d, 17

caudal extension grafts, 118, 118f-12lf plumpi ng graft , 1l7, 117f

rhino plasty analysis, fron tal view, l7 Co lumella-labial angle (junc tion), 2f Col umell ar artery, 4f

Columellar flap, 47, 47f-49f elevation of, 47, 49f

infiltrative anesthetic inject ion technique, 27f Columellar-labial confluence, 18

Co lumellar -lobular angle, 18 Columellar show

normal value, 15, 20

rhi noplasty analy sis, 15, 158

Columell ar strut cartilage graft, 56, 81-84

dorsal onlay graft interdigit ating with. See Sadd le nose deformity placem ent, 8184

endonasal approach, 8 1, 83f-84f external rhinoplas ty appro ach, 81, 82f

tripod concept, 155 Complic ations, 163 Compressor muscles, 4f

Com pressor narium minor, 4f

Computed tomography (CT scan), concha bullosa, 78, 78f Co ncha bullosa, 78, 78f

Co nchal cartilage . See Auricu lar cartilage Converse sc issors, nasal dissection, 5 Jf Co rrugator muscle , 4f

Crumley' s me thod, nasa l projection, 16, 159

Crus/crura, 3f. See also specific area

Cyanoacrylate ad hesive man ufactur er, 172 skin closure, 113

D

Delivery approach, 40-43

deli very of LLC, 41-42, 42f-43f intercarti lag inous incision , 40 , 40f marginal incision, 4 1, 4 lf

Depressor muscles, 4f Depresso r septi nasi, 4f

Derma bond. See Octyl-2-cya noa cry late Digital exercises, postoperat ive, 153 Dil ator muscle s, 4f

Dilator naris anterio r, 4f Dissection

auricular cartilage harvest ing, 139, 140 f-1 41 f delivery of LLC, 41-42, 42f-43f

external rhinop lasty app roach . See Ex terna l rhinop lasty approac dissecti on

retrograde, 50

rib cartilage harvestin g, 144 septoplasty, 31 , 32f, 33

Dome

divided, tip graft in, 101, 10If divis ion. See Na sal tip, surgery iden tification , 84

Dorsal nasal artery, 4f Dorsu m of nose

cartilagi nous, exposure and incisio n for hump removal, 59, 60f contour assessment, anes thetic injection and, 27

irre gularities, pos toperative, 163 rhinoplasty analysis, 11,20

Double break , 18-1 9

Dur al tear , parietal bone harvesting, 144

E

Edema, per sistent postoperative supratip edema, 152-1 53 Elevator mus cles, 4f

Endona sal approach

alar batten graft placement, 106f

columellar strut cartilage graft placement, 8 1, 83f84f incision closure, 152, 152f

nasal dissection, 56 spreader grafts, 7 1, 72f

Ethmoid bone

harve sting . 143, 147 perpendicular pla te, 4f

splinting (sand wich) gra fts, 122, 123f External rhinoplasty approach, 43-56

anes thesia injection techn ique, 2529, 26f-29f bac kgrou nd, 43

co lumellar strut carti lage graft placem ent, 8 1, 82 f dissecti on, 43

incisions for, 43 indications for, 170

integrated dorsal graft-co lumellar strut for saddle nose deformity marg inal incision, 43, 44f

colume llar extension, 45, 46f, 56 nasa l dissection, 43-47

defining columell ar flap, 47 , 47f-49f

elev atio n of per iosteum and expo sure of bony vault, 54-56, 55 exci sion of cephalic car tilage, 50

exposure of cartilag inous middle nasal vau lt, 54, 54f flap elevation, 47, 49f

incision marking, 43, 44 f lateral crus, 50, 5 1f

marginal incision, 43 , 44 f, 47 midcolumellar incisio n, 43 , 44 f, 45, 45f midline dorsal dissecti on, 52, 52f53f retrograde dissection , 50

three-poi nt countertraction, 50, 50f pearl s, 56

septoplasty, 33, 34f

spreader graft placeme nt, 7 1, 72f-75f transcolumellar (midcolu mella r) incision, 43

clo sure , 56

marking for, 43, 44f

F

Face

Frankfort plane, 12, 13f, 158

hori zontal facial thirds, 12, 12f, 158 surface measurem ent s, 22, 23f

Legan facial-conv exity angle, 14f, 15

mentocervica l angle, 14f, 15 nasofaci al angle, 12, 13f, 158 nasofrontal angle, 12, 13f, 158 nasolabi al angle, 15, 15f nasomental angle, l3f, 15, 158

surface angles, plane s, and meas urements, 12· ·16, 158-159 vertical facial fifths, 12, 12f, 158

Facet,2f

Flap, columellar, 47, 47f-49f Frankfort plane, 12, 13f, 158

G

Glabella, zr,9, 10f, 157 Gnathion, 10f, 11, 157

Goode's method, nasal projec tion, 15f, 16, 18,159 Grafts/grafting

alar batten graft, 105, 106f-l09f cap or buttress graft, 102, I02f-1 05f

caudal extension grafts, 118, 118f-1 21f, 138 colume llar strut cartilage gra ft, 56

ethmoid bone splinting (sandw ich) grafts, 122, 123f harvest of autogenous tissue, 139-147

calvarial bone, 144146

conchal (auricular) car tilage, 139-1 42 ethm oid bone, 143

rib graft , 143-144

integrated dorsal graft -columellar strut for saddle nose deformity, 130137

lateral crural grafts, I 10, II Of nasal tip, 98101

onlay cartil age wafer grafts, 77 plumping grafts, 117, 1l7f, 138 shield-shaped tip graft, 98 ··10I spreader grafts, 7 1-79

Greenstick fracture, in osteotomy, 68

H

Hanging columella deformity, septoplasty, 3 1 Hemitransfixion incision, septoplasty, 3 1, 32f "Hidden columella, " l7

Hump, 17

Hump excision, 5966

excision of bony hump, 59, 61f

expo sure and incision of cartilaginous dorsum, 59, 60f extramucosal reduction, 64

fine-tun ing modifications, 62 in high-risk patient , 76

in "narrow nose syndrome," 76

nasofrontal angle in, anesthesia considerations, 28 "open roof," 62

preop erative and postoperative views, 61f separation of ULC from dorsal septum, 64, 65f septoplasty and, 33

smoothing bony margin s, 62, 63f, 64f Hydrodissection, auricul ar cartilage harvesting, 139, 140f

I

Illusions, 22

Incisions, 160

alar base reduction surgery, 113 auricular cartilage harvesting, 139, 140f closure. See Wound clos ure

external rhinopla sty approach, 43-47 intercartilaginous, 38f, 40, 40f

closure, 152, 152f marg inal, 41 ,4 1f

clos ure, 152, 152f, 153

colum ellar extension, 45, 46f, 153

external rhinoplasty appro ach, 43, 44f midco lumellar

closure, 149, 150f-151f, 153

external rhinoplasty approach, 43, 44f , 45, 45f suture removal, 152

parietal bone harvesting, 144 rib cartilage harvesting, 144 septoplasty, 31, 32f transcartila ginous, 37, 38f

closure, 152, 152f Infratip lobule, 2f, 5

transdornal suture placement and, III Injection . See Anesthesia

Instrumentation rasps, 62, 63f

suggested surgical instrum ents for rhinopl asty, 171 manufacturers' address/phone numbers, 172

Intermediate crus, 3f anesthetic injection, 25, 26f

Internasal suture line, 3f, 6 Intranasal pack, 152

manufacturers, 173

"Inve rted V" deformity, 76, 163

K

Kenalog. See Triamcinolone aceto nide

Killian incision, septoplasty, 31, 32f

L

Labrale superiu s, 10f, II, 157 Lateral crus , 3f, 5

anesthetic injection, 25, 26f cephalic trim, 110

grafts, 110, II Of

lateral crural over lay, 96, 96f-97f reduction of volume and rigidity, 85, 85f transcartila ginous incision, 37

Lateral nasal artery, 4f

Lega n facial-convexity ang le, definition, 14f, 15, 158 Length of nose

central, 18 definiti on, 18 "ideal," 19 illusions, 22 lateral, 18

rhinoplasty analys is, 11, 18-1 9, 19f

surgical goa ls and options for achiev ing, 161-1 62 Levator labii alaequae nasi, 4f

Lidocaine , infiltrative anesthesia techniqu e, 25-29 Lipectomy , submental, 166f

Lips, rhinoplasty analysis , 14f, 15, 158 Literature recommendati ons, 174-175 LLC. See Lower lateral cartilage Lobule, 5

Lowe r lateral car tilage, 3f asymmetries, columellar strut for, 83f

cephalic resection of lateral crura, 85, 85f L-strut

integrated dorsal graft-c olumellar strut , 130-137 in septoplasty, 33, 33f

M

Mattress sutures

closure of auricular cartil age harvest site, 139, 142f closure of midcolumell a incision , 149, 150f-15If spreader graft stabilization, 75, 75f

Maxilla, ascendng process, 3f

Maxillary crest, 4f

Medial crural footplate, 3f Medial crus, 3f Mentocervical angle

definition, 14f, IS, 158

Powell-Humphries "aesthetic triangle," 16 Mentolabial sulcus, 10f, II , 157

Menton, 10f, II, 157

Midcolum ellar incisio n. See Incisions Mucoperichondrium , support function, 59, 62f Muscles, nasal, 4f

N

Naris, 3f

"Narrow nose syndrome," 22 hump removal in, 76

Nasal analysis. See Rhinoplasty analysis Nasal floor, cleft lip-nasal deformity

bilateral, 168 unilateral, 167

Nasal obstruction, 18 causes, 78

concha bullosa, 78, 78f spreader grafts for, 75-78

Nasal septum. See Septum Nasal spine, 3f, 4f

Nasal splint external, 152

application and removal, 153 manufacturers, 172-1 73

Nasal starting point, 20 Nasal tip, 9, IOf, 157

acce ntuating

cephalic edge leading caudal edge of lateral crus, 86, 93f

dome division with intact vestibular skin and suture reconstitution, 95f, 95-96, 96f

individual horizontal mattress domal suture technique, 86, 86f lateral crural overlay, 96, 96f-97f

lateral crural steal, 94f, 95

single transdo mal suture technique, 86, 89f-93f tip grafts, 98-10 1

transdomal surgical techniques for, 86-95 trapezoidal asymmetric tip, 89f-93f

trapezoida l tip and broad doma l angles, 87f-89f

anterior protrusion. See Rhinoplasty analysis, nasal projection asymmetry, 81, 83f

bifidity, 17

cleft lip-nasal deform ity bilateral, 168 unilateral, 167

deviated, 8I , 83f grafts

alar batten graft, 105, 106f109f, J II cap or buttress graft, 102, I02f-1 05f caudal extension grafts, 118, 118f-1 21f in divided domes, 101, IOIf

lateral crural grafts, 110, I IOf pearls, II I

shield-shaped tip graft, 98101

narrowing, transdomal surgical techniques for, 86

projection, surgical goals and options for achieving, 16 1. See also specific procedures

rhinoplasty analysis, I I frontal view , 17 lateral view, 18

rotation

lateral crura l steal, 94f, 95

surgical goals and options for achieving, 161. See also spec procedures

support

co lumellar strut cartilage graft. 56, 8184 major support mechanisms, 160

minor support mechanisms, 160

surgery, 81-1 11. See also specific procedure accentuate tip, 86-95

alar batten graft, 105, 106f-I 09f, II I cap or buttress graft, 102, 102f-J 05f caudal extension grafts, 118, 118f-1 21f

columellar strut cartilage graft placement, 81-84

dome division with intact vestibular skin and suture reconst 95f, 95-96, 96f

dome identi fication, 84 lateral crura l grafts, 110, 1JOf

lateral crural overlay, 96, 96f-97f lateral crural steal, 94f, 95 pearls, 110-1 11

reduction of crural volume and rigidity, 85, 85f refinement, 162

sculpting techniques, 160 shield-shaped tip graft, 98-10 I

placeme nt, 98, 99f

preoperative and postoperative views, 100f-IOlf size of, 98, 98f, I II

tip grafts, 98lOI tip-defining points, zr,3f tripod concept, ISS

Nasal valve, 75, 75f co llapse, 163

ajar batten graft, 105 Nasal valve area, 6, 75, 75f Nasal vault

bony, postoperative shifting, 153 middle

asymmetry , 77, 77f collapse, 76-77 excessive narrowing , 77 exposure, 54-56

width, assessment, 77 Nasion, 2f, 3f, 9, 10f, 157 Naso facial angle

definition, 12, 13f, 158 normal values, 12

Powell-Humphries "aes thetic triangle," 16 Nasofrontal angle, 2f

aesthetic ana lysis, II definition, 12, 13f, 158

in hump excision, anesthesia considerations, 28 length of nose and, J8, 19f

norma l values, ]2

Powell-Hum phries "aesthetic triangle," 16 Nasofrontal bone, osteotomy, 6

Nasofrontal suture line, 3f Nasolabial angle

aesthetic analysis, 11 definition, IS, 15f, 158 length of nose and, 18, 19f normal values, 15

obtuse, septo plasty, 31 Nasomaxi llary suture line, 3f Nasomental angle

definition, 13f, IS, 158

Powe ll-Humphries "aesthetic triangle," 16 Nasomental line, lip relationships, 14f, 15, 158

Nostri l(s)

cleft lip-na sal defo rmi ty

bilateral, 168 uni lateral, 167

rhinop lasty ana lys is, 18

Nostri l floo r, 3f

intern al nostril floor redu ction , 113, 114f wedge excision, 114, 114f

Nostr il sill, 2f

wedg e excision, 114, 114f

Notch defe ct, 149

o

Octyl-z-cyanoac rylate (Derrnabond)

man ufac ture r, 172 skin closure, 113

Onlay cartilage wafe r grafts, 77

Ope rative worksheet

integrated do rsal graft -columellar stru t for saddle nose deformity, 132f

sec on dary rhinoplasty patien t requiri ng alar batten graf ts, I08f trapezoidal asym metric nasal tip, 90f

Orbicularis or is muscle, 4f

Osseo cart ilagino us j unction , 2f, 3f , 6

Osteotomy, 67-69

anesthetic injection , 27, 28 inter mediate, 68

lateral, 67-68, 68f high-to-low, 67, 68f

high-to-low-to-high, 67 infracture of nasal bone, 67-68

med ial, 67, 68f nasofron tal bone, 6 pearls , 68

p

Packs/pack ing, intranasal, 152 man ufactu re rs, 173

Pain, postoperative, rib cartilage har vesting, 147 "Parenthesis" de formity, 22

Parietal bone, harvesting, 144, 144f146f, 147

Perich ondri um , rib cartilag e barves ting, 147

Phi ltrum , 2f

Photograp hy setup, 169f

Pleural leak (tear), rib carti lage harvesti ng, 144

Plumpi ng grafts, 117, 117f, 138

Pne umo tho rax , rib cartilage harves ting , 147

Pogon io n, 10 f, II , 157

Pollybeak defor mity, 22 , 59 , 163

Polydioxanone suture

inci sion c los ure, 149 spreader graft fixa tion, 7 1

Postope rative care, 152-1 53 digital exercises, 153

Q

Quadran gular cartilage, 4f

R

Radi x projection, 1920

Rasps, 62, 63 f

Rhin ion , 2f, 3f, 9, 10f, 157 sellion vs., 6

Rhi noplasty analysis, 9-23 base view, 17f, 17-18

guide line s, II , 156

co lume llar show , IS, 158 facial planes, 12, 12f, 158

horizo ntal facial thirds, 12, 12f, 22, 23f lower two thirds surface measurements, 23f vertical facial fifths, 12, 12f

Frank fort plane, 12, 13f, 158 frontal view, 17

guidelines, II, 156 general assessment, 16 guidelines, I I, 156

guide to, 11, 156

lab exercise: nasal analysis, II land mar ks, 157

points,9-1 1,I Of

surfac e ang les, plane s, and measur ements, 1216 lateral view , 1820, 19f, 2 lf

guidelines , II , 156

Leg an facial-conve xity angle , 14f, IS, 158 length of nose, 18-1 9 , 19f

lip relationships, 14f, 15, 158

me ntocerv ica l angle, 14f, IS, 158 nasal proj ection , 15f, 16, 159

asse ssment, 22

Byrd 's meth od, 16, 19, 159

Crumley's method , 16, 159

Goode's method, 15f, 16, 18, 22,159 normal values, 16

nasofacial angle, 12, 13f, 158 nasofrontal angle

definitions, 12, 13f, 158 guidelines, 11, 156

nasolabial angle definitions, IS , 15f, 158 guidelines , 11, 156

naso me ntal angle, de finitions, 13f, IS, 158 obliq ue view , 20

gui delin es, I I, 156 pear ls, 20, 22

photograph ic analysis, 16

physica l examination and anatomic analysis, 16-2 1 PowellHum phries "aes the tic trian gle," 16

ski n qu alit y, 11, 156

surface angles , planes, and measurement s, defini tions, 1216, 158159 Rib carti lage (gra ft)

harvesti ng, 143f, 143-144, 147 pos tope rat ive pai n, 147

integrated dorsal graft-columellar strut for sadd le nose deformity, 130-1 37

Rocker deform ity, 6, 163

Rotation. See Nasal tip

S

Saddle nose deformity, 17,22

integrated dorsal gra ft-colu mellar stru t for, 130-137 dorsal onlay graft, 133f

external rh ino plasty approach, 133f graft placem ent , 134 f

graft shifting, 138 operative workshee t, 132f pearls, 138

preoperative and postoperative view s, 136f137f preoperative views, 13 lf