Учебники / Rhinoplasty Dissection Manual Toriumi 1999
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Figure 4. A deep nasofrontal angle and/or an obtuse nasolabial angle contributes to the ap pearance of a short nose , whereas a shallow nasofrontal angle and/or an acute nasolabial angle adds appa rent length . In the first three line drawings (A) , the nasolabial angle is the same, whereas the nasofrontal angle is altered to illust rate the effect of the nasofrontal an gie on the appearance of nasal length. In the next three drawings (B), the nasofrontal angle is con stant , whereas the nasolabial angle var ies.
angle . The relationship of the nose to other facial structu res also will influen ce nasal length ; for exampl e, a flat forehead will give the illusion of increased nasal length (l0).
Byrd (5) described a useful method for determining appropriate aesth etic proportions for tip projection, nasal length , and radix projection. "Ideal" nasal length is two third s of the midfacial height and is equ al to chin vertical. Tip projection is ideall y two thirds of this planned or ide al nasal length. Radix projection may be measured from the junction of the nasal bones with the orbit and ideally should be one third of the calculated nasal length.
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Figure 5. Nine possible anatomic combina tions making up the alar-columellar relation ship.
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Figure 6. Relationship of the lower two-thirds of the face.
REFERENCES
I. Tardy ME. Rh inoplasty: the art and the science. Philad elphia: WB Saunders, 1997.
2.Tardy ME, Walter MA, Patt BS. The overprojecting nose: anatomic component analysis and repair. Facial Plast Surg 1993;9:306316 .
3.Ridley MB. Aestheti c facial proportions. In: Papel ID, Nachlas NE, eds . Facial plastic and recons tru ctive surgery. Philadelphia: Mosby Year Boo k, 1992:99-109.
4. Crumley RL, Lanser M. Quantitative analysis of nasal tip projection. Laryngoscope 1998;98:202-208.
5.Byrd HS, Hobar Pc. Rhinoplasty: a practical guide for surgical planning. Plast Reconstr Surg 1993;91 : 642-656.
6. Tardy ME, Brown R. Su rgical ana tomy ofthe nose. New York: Raven Press, 1990.
7.Johnson CM, Toriu rni DM . Open structu re rhinoplasty. Philadelphia: Sau nders, 1990.
8.Ta rdy ME, Pan BS, Walter MA. Alar reduction and sculpture: anatomic concepts. Facia l Pla st Surg 1993;9 : 295-305.
9.Becker DG, Weinb erger MS, Greene BA, Tardy ME. Clinical study of alar anatomy and surgery of the alar base. Arch Otolaryngol Head Neck Sur g 1997 ;123:789795.
10. Tardy ME, Becker DG, Weinberger MS. Illusions in rhinoplasty. Facia l Plast Surg 1995; 11:117-138.
I I. Gunter JP, Rohrich RJ, Friedman RM. Classification and correction of alar-columellar discrepan cies in rhinoplasty. Plast Recon str Surg 1996 ;97:64364 8.
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Injection
INFILTRATIVE ANESTHESIA TECHNIQUE
Proper local anesthesia is critical to allow atraumatic dissection with minimal bleed ing and edema. A total volume of less than 3 ml of 1% lidocaine with 1:100,000 epinephrine is typically used to attain anesthesia for rhinoplasty alone. When performing septorhinoplasty, as much as 10 ml of local anesthetic may be used. The anesthetic is al lowed to take effect for at least 15 minutes to maximize the vasoconstrictive effect of the epinephrine.
To become familiar with a method of injection of local anesthetic agent, saline can be in jected with a 5-ml syringe and 27 gauge (1.5 ern) needle along the site of injection in your cadaver specimen. Injection varies in some respects, based on the surgical approach se lected; for example, the subdermal columellar injection may be omitted in an endonasal ap proach. A generalized approach to injection is described below. For a septoplasty, multiple 0.5-ml to 1.0 rnl injections are made in the subperichondrial and subperiosteal plane along the entire area of anticipated dissection . Injections also should be placed along the site of the proposed incision (Killian, hemitransfixion, etc.). Both sides of the septum should be in jected if the surgeon plans to elevate mucosa bilaterally. The injection will aid in the dis section if placed in the subperichondrial plane . It is helpful to place an injection on the pos terosuperior septum bilaterally to minimize bleeding from the sphenopalatine blood vessels.
Inject local anesthetic into the subdermal plane in the midline of the columella from tip defining points to the nasal spine in preparation for the external approach (Fig . I). This in jection is limited to < 0.3 ml to prevent distortion of the columella or nasal base. For either endonasal or external approach, inject < 0.3 ml of local anesthesia into the soft-tissue be tween and around the domes of the lower lateral cartilages (Fig. 2). The injection extends up to the region of the anterior septal angle . After completing this injection, gently massage the domal region between the thumb and index finger of both hands to disperse the anes thetic throughout the tip region. Place multiple injections of 0.1 ml of local anesthetic along the caudal margin of the lateral and intermediate crura (along the planned marginal inci sion; Fig. 3). Overinjection will result in distortion of the nostril rim and soft-tissue trian gle. Inject <0.1 ml to raise a small bleb in the vestibular skin along the lateral aspect of the
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Figure 1. Inject < 0.3 ml of local anesthetic into the subdermal plane in the midline of the columella from tip-defining points to the nasal spine in preparation for the external approach. This injection of the col umella is necessary for the external approach but may not be necessary for most endonasal ap proaches.
Figure 2. Inject < 0.3 ml of local anesthetic into the soft tween the dome s of the lower lateral cartilages . Inject supratip is illustrated here as a percutaneous injection but a performed endonasally .
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Figure 3. Place multiple injections of 0.1 ml of local anesthetic along the caudal margin of the lateral and intermediate crura (along the planned marginal incision).
