Учебники / Rhinoplasty Dissection Manual Toriumi 1999

Preface

The successful rhinoplasty surgeo n' s operative plan is based on a clear understanding of the patient's desired changes, a care ful and accurate diag nosis of the patient's anatomy , and a wide armamentarium of surgica l techniques. Prior techniques and the surgeon's personal experiences with the array of surgical techniques are also primary factors in the decision for a particular operative approach. The successful surgeon's applicatio n of surgica l tech­ niques is designed to accom modate differences in anatomy and to account for varia nt anatomy. For example, noses with thin skin and noses with thick skin each present specific problems that must be considered when choosing techniques for altering nasal struc ture . Also, the effec ts of scar contracture vary from patie nt to patient and can significantly affec t the ultimate aesthetic and functional outcome . The rhinoplasty surgeo n must recognize that the healing process may distort the cha nges made at the time of surge ry, however ex pert ly they were accomplished. The surgeon's only recourse is to build a structurally sound nasal architecture that can withstand the force s of scar contracture and provide an acceptable suc­ cess rate.

The importance of experience in rhinopl asty cannot be overemphasized. The experi­ enced rhinoplasty surgeon can anticipate the likelihood of a favorable outcome based on his or her experience using certain techniqu es with a specific deformi ty. Selec tion of the proper technique for each circ umsta nce should provide the opportunity for a high success rate.

The purpose of this dissec tion manual is to provide practical infor mation about a wide range of surg ical techn iques in rhinoplasty. The dissection ma nual guides the reader through a step-by-step dissection. It focuse s on the execution of basic and advanced rhino­ plasty techniques and seeks to provide practical information that can be readily applied in surgery. The text is intended to be a procedurally oriented dissection manual and is orga­ nized to allow easy reference to a wide array of basic and advanced rhinoplasty techniques. Illustrations and intraoperative photograph s, along with detailed text, guide the reader through the step-by-step dissection. Important techn ical and clinical "pearls" are high­ lighted in each section. A progra mmatic cadaver dissection videotape acco mpanies the text.

Before beginning the nasal dissection, review the chapter on nasal anatomy (Chapter 1) and the chapter on pre-operative rhinoplasty analysis (Chapter 2). Chapter 3 outlines local anesthesia injec tion techniqu es; the dissector is instructed to practice the injections prior to commenci ng the programm atic dissection.

The dissection manual guides you through the following dissections: septoplasty, trans­

/'

xiii

-

~

\~ .~---

cart ilag inous or int er-cart ilaginous app roach , de livery approac h and an external rh ino approach. The remainder of the programmatic nasal dissection detai ls a number of plasty techniques and addresses a number of specific rhinoplasty pro blems. The man cuses primarily on the external rhinopl asty approach; how ev er, all approaches are c and ca n be perform ed sequentially, or the dissector may choo se to foc us on a speci proach. Appro priate targeted reference s for further readi ng are also pro vided .

We recommend that the diss ector pro ceed with Chapters 1- 6 with the skin-so ft tis velope intact. For the remai ning chapters, the dissector may wish to split the ski n do midl ine for better exposur e. In this fashi on, the dissection can be performed withou t sista nt, and (except fo r a complete septopl asty) without a he ad light.

Th e cadav er laboratory is the plac e to sharpen one ' s surgical skills. This manual s provide the dissector with the opportunity to obtai n maximum benefit from performi co mp lex opera tio n on cadaver specimens . Th e di ssecti on manual was "field tested " Unive rsity of Pen nsylvan ia Rhinoplasty Co urse : Aesthetic & Fu nction al Rh inopl ast ticipants, many of wh om professed relativel y limited rhinoplasty experience, und erto stepwise, programmatic dissection and work ed through the manu al (with the excep rib or clav arial bone harvest) in a sin gle five-hour period.

Rhinopl asty is an operatio n that requ ires co nstant thou ght , assimilatio n of inform and reac tion to unexpected fi ndi ngs . W ith this in mind, the authors strong ly recomme vo lve me nt in as many advanced teaching encounters as possible . This ma y in vol ve r time ly literature, attending adv anced rh inoplasty courses, observing other experience geo ns, or sharpening one's skills in the cadav er laboratory. We hope that use of th section manual will stim ulate thought and incite both the en thu siasm of the beginner as experie nced rhinopl asty surgeons seeking to broaden their surg ical armamentariu

Dean M. Toriumi

Daniel G. Becker

. t

)f

." III1

Acknowledgments

We wish to thank the follow ing frien ds, colleag ues, and me ntors for their encouragement, support, and guidance .

Dr. M. Euge ne Tardy, Jr., has been an inspirational men tor and friend , whose advice and enco uragement were instrumental in this project ' s development.

Our mentors in Otolary ngologyHead & Neck Surgery and in Facial Plastic & Recon­ structive Surgery are a continuing source of inspiration and guidanc e.

Depar tment Chairm en, Ed Appl ebaum at the University of Illinois at Chic ago, and David Kennedy at the Univ ersity of Penn sylvania, deserv e spec ial than ks for supporting and fa­ cilitating this undertaking.

Devin M . Cunning deserves much appreci ation. His medical illu strations speak for them­ selves, but do not tell of the countl ess hour s of collaboration, hard work, and multiple re­ visions.

Danette Knopp of Lip pincott Wi lliams & Wi lkins provided publishing leadership from the very co nception of the project to its co mpletion.

Sara Lauber of Lip pincott Willi ams & Wil kins play ed an instru mental role in guiding the manuscript through its fina l, critical stage .

Patrick Carr deserves thanks for his outstandi ng work as Produ ction Editor.

Dean M. Toriumi, M.D.

Daniel G. Becker, M.D.

xv

Rhinoplasty Dissection

Manual

~~

j, I

~ ~

4

Figure 3. Surface anatomy of the nose: Lateral. 1, Glabella; 2, nasion, nasofrontal angle; 3, rhinion (osseocartilaginous junction) ; 4, supratip ; 5, tip-defining points; 6, infratip lobule; 7, columella; 8, columella-labial angle or junction; 9, alar-facial groove or junction .

\,.