Bahman Guyuron Rhinoplasty Pdf Writer
This 25-year-old woman has voiced no specific complaint but is seeking improvement in the appearance of her nose.Dr. Griffin: Her radix is a little high, but she may be happy with it. She has a very strong dorsum. She has poor tip projection, and I would certainly address that problem. Her columella-labial angle is less than 90 degrees; with more tip projection, she would also improve this already relatively good angle. From the basal view, I can see that she needs alar base resections to bring the base of her nose into balance. Her nasal tip needs a columella strut as well as tip grafting.
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- Bahman Guyuron Rhinoplasty Pdf Writer Reviews
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I am glad to see that, overall, her skin is not oily and appears to be in very good condition. Griffin, MDDr. Stal, how would you approach this patient?Dr. Stal: I agree with everything that has been said. She has lower lateral cartilages that tend to diverge.
If you resect too much of her cephalic lower lateral cartilages or cause them to diverge at an inappropriate angle, you may precipitate external valve collapse. She has a high radix and a dorsal convexity; you have to be very careful with her dorsal profile. I agree with the need to increase tip projection, and I would augment her alar dome. Samuel Stal, MDDr. Griffin, how would you manage this patient?Dr.
Griffin: I do not usually reduce the nasion, but that is what I would do to correct this patient's profile. My first goal would be to get her tip in a good position, raised above the dorsal line. That maneuver would also achieve a second goal, which is to open her columella-labial angle. Then, hopefully, a third goal will be achieved: with the tip supported and slightly rotated, the nose will appear shorter on profile. Because she does have alar malposition, I would be very conservative in performing alar or cephalic trims.
In other words, my focus is to achieve better tip projection: raise the tip above the dorsal line, add a columella strut, and perform a conservative cephalic trim to make the nose appear shorter with a little more rotation at the tip. In addressing her somewhat narrow columella-labial angle, I would consider a premaxillary implant. Finally, I would perform an alar base resection. I would also consider a chin implant.Dr. Hoefflin, do you have anything to add?Dr. Hoefflin: I basically follow the same principles in dealing with ethnic noses, whether they are African-American or Asian. I think that communicating with the patient is extremely important.
I have found it very helpful to take a life-sized digital photograph of the face, Xerox it, then sit down with the patient and draw on it.In terms of management, I always tell the patient that a nasal operation like this usually requires both augmentation of the dorsum and tip alar base reduction. I always use autologous tissue. At times, in a virgin nose, a silastic dorsal implant may be acceptable.I also feel very strongly about postoperative, compressive, nighttime taping for an edematous tip. I also use 3 dilute Kenalog injections (Bristol-Myers Squibb Co., New York, NY), 2-and-a-half mg/cc to one-half cc into the tip at 3, 6, and 9 weeks.A maxillary implant for this patient would be helpful.
Her frontal and lateral views demonstrate some maxillary retrusion. I would probably perform a very minimal bridge rasping. A peapod tip graft would be of major benefit to this patient. I harvest the graft from a postauricular approach. I incise just inside the border of the concha. I take an entire piece of conchal cartilage and divide it in half lengthwise.
I then place the concave sides together, much like placing hands together in prayer. I then wrap it tightly with 4-0 clear nylon.
This makes a very good projecting strut from spine to tip. To get to the tip, I make a right rim incision anterior to the alar cartilage and medial footplate. I then dissect up into the tip and make a little pocket over the nasal spine, and then place the tip graft, making sure that it projects from the aesthetic tip projected point. The graft should be at least 1 × 3 cm. You can always cut down the tip graft but you cannot easily augment it. I use pullout sutures on either end of the graft for proper placement and stabilization.
In alar base excision, I will leave a fraction of a millimeter at the incised crease. It is a better area to suture and it looks much more natural than placement of the incision line directly in the crease.In reference to the amount of alar excision, on the basal view, looking at the nostril, I measure the size of the orifice. I then divide that in half, lateral to medial measure, and carry that to the alar wall—that is the maximum that I would ever excise. I will slide the open wound base of the alar towards the columella using some buried dermal PDS sutures. It moves the base medially. When sutured, it will achieve a concavity of the alar, not a triangulation. I agree totally with the idea of a chin implant.Dr.
Stal, what do you think?Dr. Stal: The key is to set her tip in position for exact projection and rotation. To achieve this I would extend the septum using autogenous cartilage. In some patients you can perform this as an extended spreader graft and set the tip to expand the acute columella-labial angle. A strut would work as an extension of the septum. Extending the septum will open up the columella-labial angle.
I could elevate the tip, placing it in a desirable position and point of rotation, and fix it. My approach would be through an open rhinoplasty.Dr. Guyuron: Would this patient's suboptimal intercanthal distance change your approach or technique in terms of augmentation, reduction, or osteotomy?Dr. Stal: I cannot tell how long or short her nasal bones are.
I would be careful about osteotomy in this patient. The only benefit may be from a basal osteotomy, which might improve the shadow lines at the base of the nose. But I think it might also eliminate some other lines. So I would recommend a homeopathic hump removal (bony or cartilaginous) with the goal of setting the tip and elevating it above the dorsal line.
You could also achieve tip narrowing with sutures. I would put off a decision about alar base narrowing until this work had been completed.Dr. Stal prefers an open procedure. What about the other panelists?Dr. Griffin: My preferred approach is endonasal. One reason is that it enables me to place tension on the skin. I have found it difficult to achieve adequate projection, particularly with large pieces of tip grafts and columella struts, using an open procedure.
So I would use a closed approach for a virgin nose such as this.Dr. Hoefflin: I would also use a closed approach because I would like an envelope of good vascular tissue around this tip graft.Dr. Guyuron: The next patient is a 41-year-old woman who complains that her nose is too wide.
Hoefflin, how would you describe her aesthetic problem? This 41-year-old woman requests a reduction of her nasal width.Dr. Hoefflin: She has a low, deep nasion, a flat dorsum, and a wide bridge. The alae are quite thick and wide.
She has a deep nasolabial angle and a retrusive chin.Dr. Stal, how do you see this patient?Dr. Stal: She has wide nasal bones at the base and a tip with inadequate projection, especially in profile in the distal third. She has a very nice columella-labial angle. In fact it is over-rotated. In the tip, you have to be careful about rotating her more because of increased projection and a minimally lower radix as well as some irregularity of her nasal bone width.Dr.
Griffin, what do you think?Dr. Griffin: I am not convinced that she needs a chin implant.
Looking at the basal view, I think she has a horizontal orientation to her nostrils, and a wide, boxy, almost “infantile” tip. I would expand the tip with grafts, expanding the tip-labial complex.Dr. Hoefflin, what type of anesthesia do you usually use for this type of procedure?Dr. Hoefflin: I would use general anesthesia. I have described my experience with general anesthesia in an article about using 23,000 consecutive general anesthetics with no significant anesthetic complications.Dr. Guyuron: Why soft tissue augmentation?Dr. Hoefflin: The dorsal skin is thin.
The patient will need only 2 to 3 millimeters of grafted tissue. I have found postauricular fascia to be ideal. Many surgeons use Alloderm (Lifecell Corporation, The Wood-lands, TX); I think they have had generally good results except for unpredictable absorption.Dr. Guyuron: By postauricular fascia, do you mean mastoid fascia?Dr. Hoefflin: Yes.
One can collect a significant piece of mastoid fascia for dorsal augmentation. You need to crush the edges and make sure they are trimmed and parallel. I always use a proximal and distal pull-out suture. I have used iliac, rib, and cranial grafts but have minimized their use because of late shape problems. In this patient, I would not use bone or cartilage but fascial soft tissue. One trick to minimize bruising and bleeding in osteotomies is to apply pressure for 4 to 5 minutes on the osteotomy site.
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If you put 3M foam tape (3M, St. Paul, MN) under the eyelids, with a little pressure, it makes a big difference. I would also reduce her alar base width if she complained about it.Dr. Guyuron: Would you perform an osteotomy on this patient?Dr. Hoefflin: Yes, her nose in the frontal view is unquestionably wide. It could be improved by a low osteotomy.
I would also perform the tip graft that I previously described.Dr. Stal, what will the nose look like if we augment the dorsum and perform an osteotomy to narrow the nose, but we do not narrow the alar bases?Dr. Stal: I think that will result in disharmony.
I think that if you do not remove the hump, you cannot safely perform lateral conservative basilar osteotomy of the ascending portion of the maxilla and try to achieve better lateral lines of the nose. I would agree with some very conservative dorsal augmentation.I like Alloderm (Lifecell Corporation, The Woodlands, TX) for a patient such as this just to get some subtle lines to elevate a few millimeters. She has an inadequate tip and I would concentrate on augmenting it but I would also perform an alar base resection.Dr. Guyuron: Do you augment the tip through an open or closed technique?Dr. Stal: I could create a pocket and augment her tip through an intracartilaginous incision.Dr.
Guyuron: So you are going to perform a tip augmentation using an onlay graft? Am I correct?Dr. Stal: Yes.Dr. Stal, what will happen to the nasolabial angle if you perform a tip augmentation?Dr. Stal: In this patient, since the upper third and the basal view are foreshortened, I think it would improve the relationship.Dr.
Griffin, the nasal bone appears somewhat short in this patient. Would you perform an osteotomy? And, if so, what precautions would you take in performing an osteotomy in someone who has short nasal bones?Dr. Griffin: In someone with short nasal bones, if you are not taking down a significant hump, you may be able to lateralize just the caudal end of the nasal bone, assuming that she does not have large turbinates. One of the dangers of this procedure is that you can lateralize the inferior turbinates into the airway, causing postoperative airway obstruction.Her main complaint is the width of her nose. My approach would be to raise the radix with septal cartilage, but without discernible edges because her skin is thin. I would want to achieve some definition; definition creates an illusion of thinness.
And I agree with alar base resection as well as the expansion of the infantile tip. The degree of alar base resection is varied according to nostril type, as shown in these outline drawings. Alar base resection for patients in, and is demonstrated here. An attempt has been made to maintain a graceful transition from the alar base to the nostril sill while avoiding a pinched appearance. Drawings courtesy of Bahman Guyuron, MD.Dr. Griffin, where would you place your incisions? Where do you perform an alar base resection in an African-American nose compared with a Caucasian nose?Dr.
Griffin: It depends on whether the problem is mainly intra alar distance or if there is an issue of alar height. In general, I try to keep the incision a millimeter above the groove, but not directly in the groove, and certainly not above the nasal alar crease, which could injure the lateral nasal alar artery. But there are patients in whom I perform an alar incision and excision.Dr.
Guyuron: The next patient is a 35-year-old woman who says that her nose is too flat and she would like more refinement. Stal, what aesthetic problems do you see? This 35-year-old woman says that her nose is flat, and she would like it to have a more refined appearance.Dr. Stal: She has a nicely proportioned oval face and the upper, middle, and lower thirds seem reasonably balanced.
Her skin appears relatively thin. The frontal view shows a dorsal deviation. On the side view, there is inadequate tip projection and an acute columella-labial relationship. On the basal view, you can see an inner flaring as well as a wide nostril sill. Her dorsal line is somewhat low.
I would talk to this patient carefully to elicit her desires and goals.Dr. Guyuron: She also has dentoalveolar protrusion.
Does that make any difference in terms of your overall management?Dr. Stal: It depends on the extent of her occlusion, her skeletal proportions, if she has had orthodontia, and what her dental relationships are. At age 35, I suspect we are considering only her nose, and we have to accept the bimaxillary protrusion. I would offer her a complete work up, cephalometric and dental; I would plan “the Whipple” of the face if she needs orthodontics and orthognathic surgery. And I would discuss performing nose surgery and dorsal augmentation only.Dr. Stal, would you perform a closed or open procedure? What type of anesthesia would you use?Dr.
Stal: I would use general anesthesia if I were planning to augment her tip and her dorsum. I use an open approach when there is a significant tip problem or deviation to correct. In this patient, I could use either an open or closed approach because she has mild deviation, but it is a tip with inadequate projection and a dorsal height problem.
I can deal with alar base excisions at the close.Dr. Guyuron: What would be your choice of material?Dr. Stal: I would use the mastoid fascia, which is 1 level up from AlloDerm, or I would use crushed cartilage wrapped in fascia—that is the third level. If you really want to go up to a ninth or tenth level, I would use a rib graft.Dr. Guyuron: Do you use crushed or diced cartilage?Dr.
Stal: I use diced, small fragments.Dr. Griffin, can you add to what has already been discussed by Dr. Stal about analysis and management of this patient's problem?Dr.
Griffin: The only thing I would add is that she does have a prominent forehead that makes her radix look weak and her dorsum appear low. I would address her dorsum with augmentation. I agree with Dr. Stal that there is inadequate tip projection, and I definitely would use Weir excisions. In her case, I may perform a skin-only, alar-based resection. I might consider this because her nostrils appear disproportionately large. Her basal complex may permit an incision through her nostril and skin, or vestibule and skin.Dr.
Guyuron: What do you use for augmentation?Dr. Griffin: That depends on how much I elevate the dorsum. In this patient, and in most of my patients, the septum is usually inadequate and the ears are typically small. I have been using irradiated rib cartilage and have been happy with it.Dr.
Hoefflin, do you have anything to add?Dr. Hoefflin: She has quite a deep, flat nasion; I would augment it with mastoid fascia. In addition, if she has not had prior surgery, I would augment the dorsum with a silastic implant. Other materials that would work well for a larger graft are rib, septal cartilage wrapped in postauricular fascia, or Alloderm.
I prefer fascia because her projection needs are minimal, only 1 to 2 mm. She does have some maxillary retrusion.
I would suggest a sized silastic implant.She would benefit from moderate alar cartilage reduction. You have to be very careful not to overdo it. I would add a projecting peapod tip graft. One trick to maintain good projection is to place a pull-out suture both superiorly and inferiorly, and, while taping the nose, pull the superior dorsal suture forward and then tape it so it holds a forward projection. Due to her acute angle, I would use some fascia plus cartilage to augment the nasal spine.
I would also perform an alar base resection. It would probably involve about a 3-mm alar excision. In both the alar cartilage and alar base excisions you have to be cautious and conservative to avoid notching or retraction.Dr. Hoefflin, what has been your experience with fascia graft? What percentage of resorption occurs?Dr. Hoefflin: I have been very pleased.
I feel it is especially beneficial in thin nasal skin because it does not show the irregularity or sharpness of cartilage. I see relatively minimal resorption. I would also use a closed approach.
I know what has been published about using AlloDerm but, in my hands, I have had too much absorption. I prefer autologous tissue.Dr. Hoefflin mentioned that you have to be careful about narrowing the alar base because there is already a little bit of retraction and notching. Do you have a specific technique that you use to avoid that notching, or if notching occurs, a technique to correct it in a nose like this?Dr. Stal: In this nose, I would perform almost no reduction, except for purposes of harvesting at the septum.
I would reposition her tip and consider alar rim grafts to stiffen the alar rim and to provide a good contour for both functional and aesthetic reasons.Dr. Stal, which approach would you use for your alar rim graft: an anterior or an alar base incision?Dr. Stal: I would do it either way, but since we are entering through the alar base, you can retrofit it in that way or you can do it through the rim incision and fix it with suturing through the skin with a 4-0 plain catgut suture.Dr. Guyuron: Compared to the first patient who has a narrow intercanthal distance, this patient has a wide intercanthal distance.
In fact, it appears that she may have hypertelorism. Griffin, does this make any difference in your management, especially in choosing whether or not to augment the dorsum or to perform an osteotomy?Dr. Griffin: Yes, and that is why I pointed out that this patient appears to almost have frontal bossing. I did not point out her borderline hypertelorism; that is why I would raise her dorsum. Raising the dorsum gives the illusion that the eyes are closer. I have also been very conservative in elevating the dorsum or the radix because I do not want to make the eyes look too close, and I have had that experience.Dr.
Hoefflin: With hypertelorism, you need to be cautious in performing osteotomies that narrow the nose, visually augmenting the hypertelorism. It is the opposite in someone with narrow eyes.Dr.
Guyuron: The next patient is a 52-year-old man who wants a more “refined” and better-looking nose. Griffin, what can be troubling about this patient? This 52-year-old man states that he would like his nose to have a more refined appearance.Dr. Griffin: Rhinoplasty patients are difficult, particularly male rhinoplasty patients. African-American male rhinoplasties are quite different and particularly difficult.
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I would be concerned about a gentleman who is 52 and wants some very vague improvements, like refinement of the nose. With older male patients, I have at least 3 to 4 preoperative visits, and I ask them for very specific goals because they tend to not verbalize their desires until after the procedure and then it can become violent, and that has been documented. I would be concerned about his age and what it is that brings him to this stage in his life in which he requests a change.
He looks like he had some nasal trauma, or just has a crooked nose, particularly at the dorsum. He has thick skin, which is very troublesome, and difficult to achieve definition with, and also oily skin. Overall, this would be a very difficult rhinoplasty in a patient who may be unsatisfied.Dr. Stal: I agree. He is thick-skinned and he has very little underlying structural support to lend any real definition.
Most people want definition, some sort of sculpted refinement of the nose, and he has none. He has a very wide nose.
You can narrow his nose, you can narrow the alar base, you can augment his nose to give him a little structural support, and you can give him a bigger nose. If he is willing to accept a larger nose, then you can give him stronger lines and a little bit more refinement. Obviously, you are not going to hit a home run, but I think there can be improvement.Dr. Stal, where would you make this nose larger?Dr. Stal: You have to place a dorsal solid graft, like a rib graft, to give him a strong dorsum. I would lower the dorsum appropriately in all anatomic areas, so whatever I put in will fit in a straight line, fitting all quadrants of the nose.
Using strong support in the dorsum and in the columella can put his tip in a slightly better position in terms of rotation and projection.Dr. Guyuron: What would you use to achieve more projection? Would you use a closed or an open incision?Dr.
Stal: I would use an open approach, because I would want to see the dorsum, level the cartilaginous septum, and place my graft appropriately, positioning and fixing it as needed to get the tip in the correct position. I see this as a tip and a dorsum problem.Dr.
Stal, would you use a columella strut here?Dr. Stal: Yes I would.Dr. Hoefflin: I have found it beneficial to have patients bring in magazine photographs of noses that they like and, even more importantly, photographs of noses they do not like. In looking at this patient's nose, I think this is why we all became plastic surgeons—we like challenges. The nasal bones are relatively short, but he has a very prominent, central dorsal cartilaginous hump. I would trim the dorsal septal area with a scalpel and then slide that graft cephalad in order to provide dorsal augmentation of the proximal nasal bones.
I very rarely use an open technique in ethnic noses. With tip grafts, I need the vascular envelope around the graft. I make only 1 incision on the right side, extending it from a rim incision down anterior to the medial crus.
A pocket is created with 3 sides intact. I would perform osteotomies due to the bony width.
Most men do not look at their profiles because they do not use mirrors for hairstyling and makeup. A patient like this looks at his frontal view and says, “I have a very wide nose.” He is not as aware that he also has a hanging columella. I would reduce or rotate the columella cephalad.
He has very little tip definition. I would use a projecting peapod tip graft from the conchal cartilage and perform an alar reduction. A conservative cephalic alar cartilage reduction would be beneficial. And that material can also be used as additional graft tissue.Dr. Griffin, would you have any concerns about performing an osteotomy on this patient?Dr. Griffin: I would definitely have concerns. My approach to this patient is more of a reconstruction.
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I would reconstruct his cartilaginous framework, reconstructing his dorsum and his cartilaginous septum with a strut. Then I would narrow his alar base.Dr. Guyuron: Would you defat the ala and, if so, where?Dr. Griffin: I would perform an alar base resection and then elevate the lateral alar wall and defat the fibro-fatty layer, taking care not to injure the subdermal plexus. Another reason why I like to perform these procedures closed is because many patients have a fairly significant fibrofatty layer that they wish to decrease.Dr. Griffin, the patient complains that when he smiles, the tip of his nose is pulled down very significantly. How would you correct this?
Would you do anything to the depressor septi nasi muscle?Dr. Griffin: In almost all these patients, I do address the depressor septi; I transect it. If I can find the depressor septi, I usually will dissect it through the endonasal approach but, occasionally, I have done it through an upper buccal sulcus incision.Dr. Stal, can you rely on the columella strut alone in a nose like this to lend enough support to avoid the tip being pulled down by the depressor septi nasi muscle? If not, what else would you do?Dr. Stal: You can if you have a strong enough piece of cartilage. If you have a good septal piece or if you have a rib graft or rib cartilage and fashion a strut made out of relatively thick cartilage, you could fight the forces pulling down the tip.
I would release everything in the normal cartilage septum dissection to free the muscle, but I would not do anything besides that. Because of the thick skin, you will have to structurally augment the nose dorsum and tip.Dr. Guyuron: One of the distinctive features of this nose is the supratip fullness. How do you make a differential diagnosis between a supra tip deformity versus a tip that is dislodged caudally and posteriorly?Dr.
Stal: The history of previous trauma in a patient like this could be akin to a “Polly Beak” deformity in which he has had previous trauma, crushed nasal bones, and the dorsal cartilage is higher. Tallapoosa ga 30176. It could be soft tissue alone or it could be malpositioned.Dr. Hoefflin, would the nature of a supratip deformity make any difference in terms of your management one way or the other?Dr. Hoefflin: Once you have completed your dissection, you can evaluate whether the supratip is due to a low dorsum, insufficient excision of dorsal-distal septal cartilage, fibrous scar tissue, large tip cartilage, etc. I would directly treat the anatomical problems.Dr.
Guyuron: I have heard you mention cortisone. Where do you inject, how much do you inject, and what do you watch for?Dr. Hoefflin: I have found it very useful to pinpoint the distal septal-upper lateral cartilage mucosal junction. That is one area that tends to swell and may cause supratip deformity. I will inject one half mL of 10 mg/cc of Kenalog (Bristol-Myers, New York, NY). I would use a 30 gauge needle and would balloon out the mucosal edges of the septal-upper lateral cartilage junction.
I will also inject into the soft tissue of the tip. If necessary, I will reinject at 3, 6, and 9 weeks and continue compressive nighttime taping.Dr. Guyuron: Could you clarify at what level you inject Kenalog: in the dermis, in the subdermal fat, or below that?Dr.
Hoefflin: I would have excised the subdermal fat because, when I do a bucket-handle alar cartilage deliverance, I use small curved scissors to go close to the dermis without injuring the subdermal plexus. That delivers a lot of fibrofatty tissue with the alar cartilage that can be removed. If I find that the skin is very thick, I certainly will inject into the edematous fibrofatty tissue, but as deeply as possible. The taping program that I use makes a huge difference. First, it gives the patient something to do that helps the swelling. Second, I think it really does work particularly well if you put a loop of tape from the lateral bony wall all the way around the tip tightly and then pinch the tip of the tape.
It should compress the nasal tip.