Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery

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3 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery The RHINO Workshop Guidelines Author and editor: Stefan MAAS With contributions from: Hans Rudolf BRINER Frank RIEDEL Axel SAUER

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5 Acknowledgments I express my sincere thanks to Dr. h.c. mult. Sybill Storz and her staff for their kind, generous, and always dependable support. I thank Prof. Wolfgang Elies for his intensive, forthright, persistent, demanding, and encouraging surgical training. Thanks to the participants and contributors at the RHINO Workshop and to the coauthors of these guidelines, who have consistently and constructively advanced the development of the RHINO Workshop. On behalf of the entire team at Elisabeth Hospital in Kassel, Germany, I thank our administrator, Mr. Albin Zimmermann, for his pleasant and trusting collaboration and for his solid support. I thank Dr. Katja Dalkowski for her professional handling of the illustrations and her constant willingness to help. Above all, I am grateful to my family: my brother Frank, who contributed his advice and talents to the RHINO Workshop from the beginning, and my wife Nicole, without whose patient, indulgent, and loving support I would not have been able to maintain a busy surgical practice or conduct the RHINO Workshop.

6 6 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery Illustrations by: Katja Dalkowski, M.D. Grasweg 42, D Buckenhof, Germany Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery The RHINO Workshop Guidelines Author and Editor: Stefan MAAS 1 With contributions from: Hans Rudolf BRINER 2 Frank RIEDEL 3 Axel SAUER 1 1 Plastic Fascial Surgery and Special ORL ORL Surgical Center at the Elisabeth Hospital, Kassel, Germany 2 ORL Center, Hirslanden Hospital, Zürich, Switzerland 3 Rhein-Neckar ORL Center, Mannheim, Germany Address for correspondences: Important notice: Medical knowledge is ever changing. As new research and clinical experience broaden our knowledge, changes in treatment and therapy may be required. The authors and editors of the material herein have consulted sources believed to be reliable in their efforts to provide information that is complete and in accord with the standards accepted at the time of publication. However, in view of the possibility of human error by the authors, editors, or publisher of the work herein, or changes in medical knowledge, neither the authors, editors, publisher, nor any other party who has been involved in the preparation of this work, warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from use of such information. The information contained within this brochure is intended for use by doctors and other health care professionals. This material is not intended for use as a basis for treatment decisions, and is not a substitute for professional consultation and/or use of peer-reviewed medical literature. Some of the product names, patents, and registered designs referred to in this booklet are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain. All rights reserved. No part of this publication may be translated, reprinted or reproduced, transmitted in any form or by any means, electronic or mechanical, now known or hereafter invented, including photocopying and recording, or utilized in any information storage or retrieval system without the prior written permission of the copyright holder. All rights reserved. No part of this publication may be translated, reprinted or reproduced, transmitted in any form or by any means, electronic or mechanical, now known or hereafter invented, including photo copying and recording, or utilized in any information storage or retrieval system without the prior written permission of the copyright holder. Dr. med. Stefan Maas Plastische Gesichtschirurgie und Spezielle HNO-Chirurgie Operative Schwerpunktpraxis am Elisabeth-Krankenhaus Kassel Obere Karlsstraße 2a Kassel, Germany Telephone: +49 (0) Fax: +49 (0) Internet: Tuttlingen, Germany ISBN , Printed in Germany P.O. Box, D Tuttlingen, Germany Telephone: / Fax: / Endopress@t-online.de Editions in languages other than English and German are in preparation. For up-to-date information, please contact Tuttlingen, Germany, at the address indicated above. Layout and image processing: Tuttlingen, Germany Printed by: Straub Druck + Medien AG Schramberg, Germany Co-Authors: KD Dr. med. Hans Rudolf Briner ORL-Zentrum, Klinik Hirslanden, Witellikerstrasse Zürich, Switzerland Internet: Prof. Dr. med. Frank Riedel HNO-Zentrum Rhein-Neckar Goethestraße 16a, Mannheim, Germany Internet: Dr. med. Axel Sauer Plastische Gesichtschirurgie und Spezielle HNO-Chirurgie Operative Schwerpunktpraxis am Elisabeth-Krankenhaus Kassel Obere Karlsstraße 2a Kassel, Germany

7 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 7 Table of Contents 1.0 Preface Before the Operation Patient Interview History and Physical Examination Indications Informed Consent Risk Disclosure Postoperative and Posthospital Instructions Cost Issues Postoperative Course Imaging Operation Positioning, Anesthesia, Medication Approach Closed Approach Open Approach with Medial Crural Protection (MCP) Individual Septal Reconstruction (ISR) Case Report 1 Crooked Nose Case Report 2 Crooked Nose and Alar Deformity L-Beam Traditional Costal Cartilage Graft Costal Cartilage Harvest and Wound Closure L-Beam Concept Similarities and Differences between the I-Beam and L-Beam Indication for the L-Beam L-Beam Fabrication L-Beam Implantation and Fixation Individual Septal Reconstruction (ISR) with the L-Beam Case Report 1 Saddle Nose Case Report 2 Cleft Lip and Palate Rhinoplasty without Osteotomy Case Report 1 Humped Nose Case Report 2 Humped Nose and Alar Deformity The I-Beam Surgical Concept Operating Technique Case Example Saddle Nose Perforated Septum Nasal Tip Correction Rhinophyma References Instruments for Complex Facial Plastic Surgery and Rhinosurgery Instruments for Complex Rhinosurgery Recommended Set acc. to MAAS and SAUER with depicted items Instruments for Costal Cartilage Harvest (L-Beam Technique) Recommended Set acc. to MAAS and SAUER without depicted items Instruments for Complex Rhinosurgery Recommended Set acc. to MAAS and SAUER with depicted items Instruments for Costal Cartilage Harvest (L-Beam Technique) Recommended Set acc. to MAAS and SAUER with depicted items Burrs and Irrigation Systems Basic Equipment for Videoendoscopic and Micro scopic-assisted Complex Rhinosurgery HD Video Camera Systems KARL STORZ Monitors Cold Light Fountains and Accessories for Video Documentation Data Management and Documentation RHINO Workshop Case Documentation

8 8 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 1.0 Preface The RHINO Workshop is a once-a-year continuing education symposium that is organized for office physicians and interested hospital-based physicians. The workshop consists of two parts. Part 1: Continuing Education on Wednesday Afternoon. An interdisciplinary team of experts presents reports on topics in facial plastic surgery and rhinology with the goal of fostering a common professional discourse. Part 1 usually ends with a practical exercise that addresses or expands upon the contents of a report. Part 2 of the RHINO Workshop, called Rhinosurgery Live, takes place on the Thursday and Friday after the Wednesday program. Part 2 involves the live, HD transmission of complex nasal operations such as open and closed techniques of nasal dorsum and tip correction, revision septorhinoplasties using auricular or costal cartilage, and the repair of septal perforations using auricular cartilage and bridgeflap techniques. One operation is transmitted live at any given time so that all aspects of the procedure can be discussed with the Workshop participants. The goal of the RHINO Workshop is dialogue. Performing a surgical procedure with technical precision does not always guarantee success. This particularly applies to complex procedures in functional, aesthetic, and cosmetic rhinosurgery. Issues relevant to practicing rhinosurgeons are addressed and discussed in a collegial atmosphere. 2.0 Before the Operation 2.1 Patient Interview As rhinosurgeons gain experience, the level of satisfaction of their patients will usually increase. There are three reasons for this: (1) Years of informed experience in rhinosurgery leads to better outcomes. (2) As surgeons become more familiar with the various personality structures of patients seeking rhinoplasty, they can more readily identify patients who will be unhappy with their surgery regardless of the outcome. (3) Detailed preoperative counseling and disclosure will enhance patient satisfaction by preparing the patient for typical peri- and postoperative sequelae. True to the motto Honesty is the best policy, fostering realistic expectations is the foundation for a trusting doctor-patient relationship. The interview is of key importance in the management of rhinoplasty patients. The importance of follow-up visits should also be explained so that surgeons can self-assess the quality of their long-term results. Follow-up visits should be maintained for as long as possible (at least 1 year, or at least 5 years in patients with costal cartilage grafts) and are an integral part of the treatment plan. 2.2 History and Physical Examination All signs and symptoms, even ones that patients deny, should be documented when the history is taken. Otherwise it cannot be determined if the physician forgot to ask about a particular symptom, or the patient denied a symptom, by looking at the patient s chart. Besides visual inspection, the physical examination includes palpation of the skin, cartilage, and nasal bones. It is common for examiners to forget the nasal bone. Its size, or rather lack of size, may assume tremendous importance in cases where lateral osteotomies are planned.

9 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery Indications There are various reasons in otorhinolaryngology to select patients for corrective surgery of the internal and external nose. Functional, aesthetic, and cosmetic indications are integral to our specialty, and an understanding of how function, aesthetics, and cosmetics are defined can be very helpful for the practice of rhinosurgery and for communicating with patients. In its guidelines on morphologic abnormalities of the internal and external nose, the German Association of Scientific Medical Societies defines these three terms as follows: 3 Function: The creation or restoration of a function (e.g., nasal breathing). Aesthetics: The creation or restoration of a normal form or symmetry (abnormal normal). Cosmetics: The correction of an inherently normal form (normal optimal = true cosmetic surgery). A good rule to follow for all indications is to wait until the patient is skeletally mature and longitudinal growth is complete. Exceptions are functional disorders in children that would compromise normal development. The highest priority in midfacial cosmetic surgery is to create a trusting relationship between doctor and patient. This relationship is almost always established by an attentive, patient, and honest counseling process. If not, the physician should not hesitate in referring the patient to a different rhinosurgeon. 2.4 Informed Consent Risk Disclosure Every surgical procedure constitutes a punishable bodily injury under the law, and only informed consent by the patient exempts the surgeon from liability. Informed consent, then, is a key legal concern for physicians. The requirements for informed consent are more rigorous for a medically unnecessary cosmetic procedure than for a medically indicated intervention. We use a standard information sheet that covers all potential risks and complications. These sheets are given to patients following their initial interview with the surgeon. This gives patients the opportunity to read about the operation and review its potential risks and complications even while at home. Approximately 1 2 weeks before the operation, the patient is scheduled for a second counseling and disclosure session with the surgeon and is given a customized information sheet (e.g., with a diagram showing where the incisions will be made). The possibility of an unsuccessful outcome should always be disclosed, especially in purely cosmetic operations. Years of informed experience in rhinosurgery are a key factor in achieving a high degree of patient satisfaction. But even very experienced rhinosurgeons will have patients who, for understandable reasons, are dissatisfied with the postoperative result. Even in cases of this kind, it is easier and less complicated to work with a patient who is well informed Postoperative and Posthospital Instructions Patients are routinely furnished with postoperative and posthospital instructions. We routinely give the instructions twice, especially at the time of discharge. Necessary precautions regarding exposure to sunlight, sports activities, nasal hygiene, etc. are reviewed with the patient Cost Issues Lately we have also been counseling our patients on possible out-of-pocket costs relating to surgical procedures that are not medically indicated. Patients may have to share in the financial costs of diseases that develop as a result of cosmetic surgery.

10 10 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery a 1 Patient before (a), shortly after (b) and 1 year after open revision rhinoplasty (c). b c a 2 Patient before (a), shortly after (b) and 1 year after open primary septorhinoplasty (c). b c a b c 3 Patient before (a), shortly after (b) and 1 year after open septorhinoplasty revision with a costal cartilage graft (c).

11 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery Postoperative Course Patients dissatisfied with their appearance will often enter recovery with a critical attitude. We therefore describe postoperative healing in realistic terms and, when in doubt, may even exaggerate potential discomforts to help our patients cope with the normal healing process. Healing after rhinoplastic surgery takes 6 to 12 months, and the healing process may vary significantly from one patient to the next. Figures 1 3 show patient photographs taken preoperatively, several weeks postoperatively, and at one year. As the follow-up pictures illustrate, an initially good result may become less favorable over time (Fig. 1a c). Conversely, a result that is less favorable initially may improve during the first year (Fig. 2a c). The third possibility is that the early postoperative result is essentially the same at one year (Fig. 3a c). A more technically complex procedure does not necessarily lead to delayed wound healing or an unstable result. Patient 3, for example (Fig. 3a c), underwent a long and demanding septorhinoplasty revision with costal cartilage grafting. 2.5 Imaging If imaging is indicated, it should consist of low-dose computed tomography with axial scan acquisitions and coronal reconstructions. CT will reliably detect coexisting paranasal sinus pathology, for example, and will provide essential imaging data in case the operation needs to be extended to the sinuses. Ultimately, further diagnostic studies are directed by the results of the history and physical examination. 3.0 Operation 3.1 Positioning, Anesthesia, Medication Rhinosurgery is often performed in the sitting position, so the patient is positioned with the neck slightly hyperextended and the head turned slightly to the right side. Infiltration anesthesia with articaine plus 1:100,000 epinephrine is administered with a cartridge syringe (Fig. 4). This type of syringe makes it possible to use smallgauge injection needles, and an injection volume of 1.7 to 3.4 ml is often sufficient. We administer an oral cephalosporin for antibiotic prophylaxis. Intra operative decongestion is aided by giving 100 to 250 mg prednisone approximately 20 minutes before the start of the operation, barring contraindications. Pledgets soaked in decongestant nose drops are packed into the nasal cavity to decongest the turbinates. 4 Cartridge syringe for infiltration anesthesia.

12 12 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 3.2 Approach A discussion of open and closed approaches in rhinosurgery alone could fill an entire book. Ultimately it is the decision of the operating surgeon. Our basic rule: If a closed approach can yield an equally good postoperative result, we prefer it over an open approach. There is no general consensus on this point because the decision is always based on the individual experience of the surgeon. The arguments for or against a closed or open technique are well known and need not be detailed here. The open approach is used for the great majority of cases presented at the RHINO Workshop Closed Approach The closed or endonasal approach is an option if a reasonably wide septal frame can be left along the nasal dorsum, and the caudal septal border can retain its natural attachment to the nasal spine (Fig. 5). If the caudal septal border must be mobilized, it should at least be possible to reattach it through an endonasal approach. The closed approach is also excellent for nasal tip modifications by the cartilage-delivery method, for example. 5 Lateral view of the nasal septum and its support by the anterior nasal spine. 6 Incision along the anterior septal border in the closed approach. The nasal speculum compresses the blood vessels and improves visualization of the anterior septal border. For the endonasal approach, a nasal speculum is placed to aid identification of the anterior septal border. The incision can then be made from above downward (Fig. 6). The tension exerted by the speculum on the mucosa over the anterior septal border will prevent significant bleeding. The subperichondrial and subperiosteal tunnels can then be developed.

13 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 13 a 7 Patient 4. Nasal skeleton fracture before (a, c, e) and after (b, d, f) treatment by closed septorhinoplasty. b c d e f

14 14 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery For nasal tip modification, an intercartilaginous incision (between the alar and lateral cartilages) and an infracartilaginous incision (along the inferior margin of the alar cartilage) is made on each side (Fig. 8). These incisions permit the alar cartilages to be mobilized and exteriorized for further treatment (Fig. 9). 8 Infra- and intercartilaginous incisions combined with the hemitransfixion incision. 9 Alar cartilages are mobilized and delivered through the infra- and intercartilaginous incisions Open Approach with Medial Crural Protection (MCP) The open approach can easily become a tedious, time-consuming, and traumatizing procedure unless a definite sequence of steps is followed. The modification shown is helpful and provides maximum safety and efficiency for both primary and revision procedures. First the incision (inverted V) is drawn across the narrowest part of the columella (Fig. 10). Then the skin is incised along the inferior margin of the alar cartilage with a No. 15 blade (Fig. 11). The skin incision is spread open with a scissors (Fig. 12), and the cephalic portion of the alar cartilage is exposed. Next the skin is incised along the anterior margin of the medial crus (Fig. 13). After these skin incisions have been made on both sides, the columellar skin is dissected from the anterior margin of the medial crus with a small, angled nasal scissors (Fig. 14). At this point we place a forceps handle between the columellar skin and medial crura to protect the crura from iatrogenic injury (MCP). The columellar skin can then be incised safely and without loss of time (Fig. 15). The steps are illustrated in Fig. 16 a f. 10 Incision of the columella. 11 Incision along the inferior margin of the alar cartilage.

15 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery Skin incision is spread open with a scissors. 13 Skin is incised along the anterior margin of the medial crus. 14 The skin is mobilized from the medial crura. 15 The medial crura are protected with a forceps handle (MCP) while the inverted-v incision is made through the columella. a 16 Incision along the inferior margin of the alar cartilage. b Skin incision along the anterior margin of the medial crus. c Columellar skin is mobilized with a small angled scissors. d Medial crura are protected with a forceps handle (MCP). e Completed inverted-v incision. f Example of the precise dissection allowed by this modified approach.

16 16 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 3.3 Individual Septal Reconstruction (ISR) Correction of the external nose is one of the most demanding types of facial plastic surgery. Significant deformities of nasal shape are often associated with functional disorders and may necessitate simultaneous corrections of the internal and external nose. Septoplasty is typically viewed as a procedure for junior surgeons. But proficient surgery of the nasal septum requires a detailed diagnostic workup, meticulous technique, and an experienced surgeon. Considerable effort may be needed to overcome the memory effect of the septal cartilage. Many surgeons do not fully appreciate the importance of the nasal septum for nasal form and function, or the complexity of septal corrections, until they have begun to learn rhinoplastic techniques. Our approach to apparently simple problems has become more complex over the years. Conversely, we follow the principle of less is more when dealing with seemingly complex problems (see Sect. 3.6, Rhinoplasty without Osteotomy). Correction and reconstruction of the nasal septum is central to our rhinosurgical work on the internal and external nose. We use proven surgical techniques to correct or reconstruct the nasal septum. We select the method that provides the greatest possible safety and efficiency with the least invasiveness. The goal is an individual septal reconstruction (ISR). An individual septal correction or reconstruction may be described as superselective, selective, subtotal, or total. It involves the use of incisions and suture techniques that are performed through a closed approach (with endoscopic assistance if needed) or an open approach, depending on technical complexity and required exposure. Grafts or implants are used as needed. The goal of the ISR concept is to achieve a complete, physiologic reconstruction of the nasal septum which: defines the position of the columella; defines the position of the nasal tip; defines the width, height, and alignment of the cartilaginous nasal dorsum without additional rhinoplastic measures; and creates an optimum nasal valve angle whenever possible (Fig. 27a f). 17 Soft-tissue elevation over the nasal dorsum. 18 Anterior septal border is exposed with the scalpel.

17 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 17 In some cases this may require a technically complex septal reconstruction like the Gubisch extracorporeal septoplasty. 11 This technique is illustrated by diagrams (Figs ) and intraoperative photographs (Fig. 28a n) in Patient 5 (see also Fig. 27a f). First the soft tissues over the nasal dorsum are undermined with a scissors and a No. 15 blade through an open approach (Fig. 17). Then the anterior septal border is exposed with the scalpel or scissors (Fig. 18). Next, subperichondrial and subperiosteal tunnels are developed on both sides of the septum. A suction dissector may be a helpful tool at this stage (Fig. 19). When both tunnels have been developed, the bony and cartilaginous hump can be taken down as needed. The cartilaginous portion is shaved with a No. 11 scalpel blade (Fig. 20). The bony portion of the dorsal hump is removed with a freshly sharpened osteotome (Fig. 21). 19 Use of the suction dissector. 20 Cartilaginous hump is shaved with the scalpel. 21 Bony portion of the dorsal hump is removed with an osteotome.

18 18 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery A slight bony excess may be left because the osteotomy will be smoothed with a coarse diamond burr. Any portions of the lateral cartilage still attached to the septal cartilage are released with a No. 15 blade (Fig. 22a). Paramedian osteotomies are now performed with an osteotome or Lindemann burr (Fig. 22b, c). The nasal septum is completely mobilized from the premaxilla, fractured through the anterior portion of the perpendicular plate (Fig. 23), and removed in one piece (Fig. 24). b a 22 Separation of the lateral cartilage from the septal cartilage. c Paramedian osteotomy with an osteotome (b) and Lindemann burr (c). 23 Perpendicular plate is fractured. 24 Nasal septum is removed.

19 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 19 Next the anterior nasal spine is grooved in the facial midline with the Lindemann burr (Fig. 25a), and a hole is drilled transversely through the spine (Fig. 25b). At this point the surgical site is packed with pledgets soaked in nasal decongestant drops to ensure a bloodless field during implantation and fixation of the reconstructed septum. The next step is to straighten the septum on the operating table. This may be done, for example, by doubling or layering the cartilage, sewing spreader grafts to the septal border, and reusing straight septal remnants. A variety of technical options are available. A good rule to follow: the simpler, the better. Gross straightening of the septal plate is followed by replantation. The reconstructed septum is fitted into the sagittal groove and secured with nonabsorbable suture material (Fig. 25c, d). The fixation may begin at the nasal spine or lateral cartilages. In many cases, initial fixation to the lateral cartilages will allow for fine trimming of the caudal septal border. Fixation to the anterior nasal spine is more technically demanding but is easier if the septal plate has already been fixed to the lateral cartilages. Fine trimming of the dorsal border can be done with a No. 11 blade and coarse diamond burr. If an open roof remains, it is closed by performing a lateral and transverse osteotomy (Fig. 26). The columellar incision is provisionally closed and the result is assessed to see if any fine corrections are still needed. a b c d 25 A sagittal groove is cut in the anterior nasal spine with the Lindemann burr (a). A transverse hole is drilled through the anterior nasal spine (b). The neoseptum is fitted into the sagittal groove (c) and secured with nonabsorbable suture material (d). 26 Osteotomy lines and skin incisions for the transcutaneous lateral and transverse osteotomies.

20 20 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery Case Report 1 Crooked Nose This patient (Fig. 27a f) had a septal deviation to the left, nasal deviation to the right, and asymmetric nostrils. An individual septal reconstruction was performed without a lateral or transverse osteotomy. The septal reconstruction was able to: define the position of the columella; define the position of the nasal tip; define the width, height and alignment of the cartilaginous nasal dorsum without additional rhinoplastic measures; and create an optimum nasal valve angle. a 27 b Patient before (a, c, e) and 11 months after the operation (b, d, f). c d e f

21 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 21 The steps of the operation are illustrated in Figs and Fig. 28a n. This procedure was performed through an open approach (Figs ) with soft-tissue elevation over the alar cartilages and the cartilaginous and bony nasal dorsum (Fig. 28a). Bilateral subperichondrial and subperiosteal tunnels were developed with a pointed scissors, suction tip, and standard dissector. The lateral cartilages were released from the septal cartilage (Fig. 28c), and bilateral paramedian osteotomies were performed (Fig. 28d, e). The septum was completely detached from the premaxilla, and the perpendicular plate was fractured with a chisel (Fig. 28f). a b c 28 d e f 28 Soft-tissue elevation over the cartilaginous and bony nasal dorsum (a). The caudal septal border is exposed with a small angled scissors (b). Lateral cartilages are detached from the septal cartilage with the scalpel (c). Paramedian osteotomy (d). Appearance after lateral cartilage detachment and paramedian osteotomy (e). Fracturing the perpendicular plate (f).

22 22 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery Next the cartilaginous septum was completely removed along with the attached piece of perpendicular plate (Fig. 28g). Before any further steps were done, a sagittal groove was cut in the anterior nasal spine in the facial midline, and a transverse hole was drilled through the nasal spine. While further work was being done on the septum, the surgical site was packed with pledgets soaked in decongestant nose drops. The removed septum is outlined on the operating table (Fig. 28i) to create a template for sizing the reconstructed septum (Fig. 28j). In this case the septum was additionally stabilized with PDS foil. g 28 The deviated septum viewed from above. h Anterior nasal spine with sagittal groove and transverse drill hole. Suture material has been passed tentatively through the drill hole. i 28 Template drawn on the operating table. j The straightened septum is grossly trimmed to match the template.

23 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 23 Spreader grafts were also sewn to the upper border of the septal plate with mattress sutures (Fig. 28k, l). After coarse trimming, the reconstructed septum was replanted and fixed to the lateral cartilages and anterior nasal spine with nonabsorbable suture material (Fig. 28m). Fixation to the anterior nasal spine is aided by looping the suture material through the transverse drill hole three times before tying. The last photograph shows the straightened nasal dorsum, which is completely closed by the spreader grafts (Fig. 28n). Final tailoring of the nasal dorsum was done with a coarse diamond burr. Since there was no open roof in this case, it was unnecessary to add lateral and transverse osteotomies. There was also no need to correct the alar cartilages, and the medial crura were simply reapproximated. Comparison of the pre- and postoperative photographs (Fig. 27a f) shows how the individual septal reconstruction reshaped the external nose without the need for additional rhinoplastic measures. k l 28 Reconstructed septum with spreader grafts and PDS foil. m n 28 Reconstructed septum is fixed to the anterior nasal spine (m). View of the nasal dorsum after straightening and smoothing with a coarse diamond burr (n).

24 24 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery Case Report 2 Crooked Nose and Alar Deformity This patient had a crooked (deviated) nose with aesthetic and functional impairment, septal deviation to the left, conspicuous columellar subluxation to the right, asymmetric nostrils, and asymmetry of the nasal tip (Fig. 29a, c, e). a 29 Patient before (a, c, e) and 11 months after the operation (b, d, f). b c d e f

25 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 25 Emphasis was again placed on achieving an individual septal reconstruction, in this case without PDS foil but with a unilateral spreader graft and unilateral strut to stabilize the caudal edge of the septum (Fig. 30a, b). Again, the reconstructed septum was fixed to the lateral cartilages and anterior nasal spine with the aid of a sagittal groove and transverse drill hole (Fig. 30c, d). The septal reconstruction was able to: define the position of the columella; define the position of the nasal tip; define the width, height and alignment of the cartilaginous nasal dorsum; and create an optimum nasal valve angle. An onlay graft was added in this case to restore symmetry of the alar cartilages (Fig. 30e). a 30 b Individual septal reconstruction with stabilization of the caudal septal border and a unilateral spreader graft. c 30 d Sagittal groove in the anterior nasal spine before and after fixation of the reconstructed septum with nonabsorbable suture material. e 30 Alar cartilage asymmetry corrected with an onlay graft.

26 26 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 3.4 L-Beam Traditional Costal Cartilage Graft Significant deformities may necessitate the use of a major graft such as a costal cartilage graft. Rhinoplasty with rib cartilage is a two-cavity procedure, giving rise to two sets of problems. Whenever possible, then, we try to avoid the use of costal cartilage. An elegant alternative is the I-beam made of auricular cartilage (see Sect. 3.7 I-Beam). A costal cartilage graft is necessary in patients with significant pathology and is often necessary after previous failed surgery. We will describe a harvesting technique with low donor-site morbidity along with a simple method (L-beam) for preparing and using costal cartilage. We try to avoid the traditional costal cartilage graft technique whenever possible. A very common technique is to reconstruct the nasal dorsum with an onlay graft supported by a columellar strut (Fig. 31). Another piece of costal cartilage is placed in the septal pocket if necessary. Shaping and positioning the costal cartilage is a demanding task, and even experienced rhinosurgeons find it difficult to estimate the force vectors that will tend to alter and distort the tissues over time. The procedure may become an ordeal for the patient and the surgeon. a 31 b Diagrammatic representation of a common traditional technique for costal cartilage use Costal Cartilage Harvest and Wound Closure The eighth rib is the most frequent source for costal cartilage grafts. The ninth rib is the first mobile rib that is not integrated into the costal arch (Fig. 32). It can be palpated in slender patients and, with practice, in heavier patients as well (Fig. 33). 32 Diagrammatic representation of the costal arch. The ninth rib is the first rib that is not integrated into the costal arch. 33 Palpation of the ninth rib permits indirect identification of the overlying eighth rib.

27 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 27 Whenever possible, the overlying soft tissues and muscle are divided by a single, deep incision with a large blade (Fig. 34a) to create one well-defined cut edge. The perichondrium is exposed (Fig. 34b) and incised to form two, fully intact perichondrial flaps (Fig. 34c, d). The rib cartilage is incised, and a segment of the eighth rib is elevated with a dissector (Fig. 34e, f). The perichondrium deep to the rib is carefully preserved (Fig. 34g). Finally a suction drain is inserted and the wound is meticulously closed in five layers (perichondrium, fascia, two subcutaneous layers, and the skin; Fig. 34i, j). a 34 Overlying soft tissues are incised to the eighth-rib perichondrium with a No. 19 blade. b 34 A single, deep incision produces clean cut edges. c Two intact perichondrial flaps can be cleanly reapproximated later with sutures. d e f The eight rib is elevated and a segment is removed. g Perichondrium deep to the rib remains intact. h Saline test to exclude leakage. i Diagram and intraoperative photograph of wound closure. j

28 28 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery L-Beam Concept Corrections of the internal and external nose are complex procedures, especially when a major graft is needed. Complex and difficult questions require a simple answer. In the case of rib cartilage, the answer is to combine the ISR concept with the principle of mutually canceling force vectors. 1 Individual septal reconstruction (ISR) + 2 neutralization of deforming forces (with a double-layer construct). Comment on 1: Comment on 2: Nomenclature: ISR means that a septum reconstructed with costal cartilage can define the position of the columella, the position of the nasal tip, and the width, height and alignment of the cartilaginous nasal dorsum while also creating an optimum nasal valve angle. Neutralization of deforming forces. As with the I-beam, deforming forces are neutralized by layering the graft construct (see also Sect. 3.7, I-Beam). The graft includes the outer segments of the cartilaginous rib, whose deforming force vectors are visible and palpable, especially after smoothing with a diamond burr. The concave sides of these outer pieces (which should have the same tension) are apposed and sewn together with mattress sutures to neutralize the deforming force vectors. A serviceable remnant of septal cartilage or another strip of rib cartilage is sandwiched between the two outer pieces of rib cartilage to create an L-shaped neoseptum. Analogous to the I-beam, the symmetrical layered structure of the construct gives it a constant, stable shape. This suggested the name L-beam. a b 35 Intraoperative photographs of Patient 7. Loss of cartilaginous support has caused a saddle nose deformity with sagging lateral cartilages and lateral crura protruding into the vestibule and nasal cavity (a). Note the collapsed lateral cartilages and inverted crura (b). Similarities and Differences between the I-Beam and L-Beam Beam is a term used in structural engineering to describe a highly stable load-bearing member a property that is shared by the I-beam and L-beam. Other common features are a stable shape achieved with layered cartilage strips and an essentially physiologic septal reconstruction. The I-beam provides a partial (caudal) septal reconstruction, while the L-beam reconstructs all portions of the septum with a supportive function. Hence the I-beam is also called a caudal septal extension graft while the L-beam is described as an individual septal reconstruction. The I-beam obtains its layered structure by apposing and suturing together the convex sides of a conchal cartilage graft. In the L-beam, the concave sides are sutured together. The I-beam is fabricated from a piece of conchal cartilage, while the L-beam consists of three separate pieces of rib cartilage or two pieces of rib cartilage plus one piece of septal cartilage. Indication for the L-Beam Pronounced saddle nose deformity is a classic indication for an L-beam reconstruction. Loss of cartilaginous support leads to collapse of the nasal dorsum with a widened nasal valve angle and inversion of the lateral crura. The configuration of the nasal roof resembles a flat-roof bungalow ( ballooning phenomenon). A rib cartilage graft placed on the nasal dorsum can improve the outer contour of the nose but will not correct the functional pathology (Fig. 35a, b). The goal, therefore, is to convert the flat-roof bungalow to a pitched roof. This is accomplished by mobilizing the lateral cartilages and fixing them higher up on the L-beam.

29 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery L-Beam Fabrication In most cases, a scalpel is used to slice curved outer strips from the harvested rib cartilage along with a straight piece from the center. The grafts are immersed in physiologic saline solution to retard warping after implantation (Fig. 36), but this does not guarantee that the construct will maintain its shape in situ. A proven technique for making a straight, stable strut from curved conchal cartilage is to approximate (layer) the two convex sides of the cartilage and suture them together to neutralize the opposing force vectors and create a straight construct (see also Sect. 3.7, I-Beam). This is the principle that underlies the stable shape of the L-beam. A straight piece of rib cartilage is obtained by separating the outer walls of the eighth rib with a scalpel (Fig. 37a c) and thinning them with a coarse diamond burr (Fig. 38). Then the two concave sides are approximated and sewn together with mattress sutures (Fig. 39a). If a serviceable remnant of septal cartilage is available, it is placed between the two outer strips of rib cartilage (Fig. 39b) so that the construct can be braced against the anterior nasal spine. This produces an L-beam composed of costal and septal cartilage. If a serviceable septal cartilage remnant is not available, the L-beam can be fabricated from three pieces of rib cartilage (Fig. 40a, b). 36 Central piece of rib cartilage and two outer strips are immersed in physiologic saline solution. a b c 37 Eighth rib cartilage is incised with a scalpel to obtain two outer segments and one central segment. 38 The rib cartilage is shaped with a coarse diamond burr. a 39 b Principle of mutually canceling force vectors. Apposing the two concave sides of the outer strips of rib cartilage cancels out the force vectors, yielding a construct with a stable shape (a). Provisional L-beam composed of two outer strips of rib cartilage and a serviceable remnant of septal cartilage (b). The construct is provisionally implanted before final trimming. c 39 Provisional L-beam assembly composed of two outer strips of rib cartilage and a serviceable septal remnant (Patient 7). a 40 b L-beam composed of two outer strips of rib cartilage and a piece of central rib cartilage.

30 30 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery L-Beam Implantation and Fixation To permit a secure fixation, the L-beam is attached with nonabsorbable suture material to the lateral cartilages (Fig. 42) and anterior nasal spine. Fixation to the nasal spine is done in several steps. First a sagittal groove is drilled into the anterior nasal spine. This groove should lie on the facial midline, so it may be placed off-center on the nasal spine or may even be oblique to the spine axis. Next a hole is drilled transversely through the nasal spine. Before implanting the securing the L-beam, the surgeon should make sure that the needle and suture material can pass easily through the transverse drill hole (Figs. 25, 28h and m). After coarse trimming of the L-beam, it is definitively fixed to the anterior nasal spine (Fig. 41) and lateral cartilages (Fig. 42). Then the nasal dorsum is trimmed to its final shape with a No. 11 blade and/ or coarse diamond burr. 41 Intraoperative endoscopic view in a patient 42 who underwent five previous rhinoplasties, two with rib cartilage (autologous and allogeneic). Due to the heavy scarring and decreased blood supply, fixation of the L-beam was done under endoscopic vision. This view shows the L-beam fixed to the nasal spine with nonabsorbable suture material. Fine trimming of the L-beam on the columellar side has not yet taken place. This should be done very carefully and may even require multiple steps since the lower edge of the L-beam defines the position of the columella. L-beam fixed to the lateral cartilages. 3.5 Individual Septal Reconstruction (ISR) with the L-Beam Case Report 1 Saddle Nose This patient had a posttraumatic saddle nose following multiple severe nasal injuries. The nasal valve angle was abnormally widened. The collapsed cartilaginous nasal dorsum (Fig. 35b) and inverted lateral crura (Fig. 35a) protruded into the nasal cavity. a b 43 L-beam positioned at a typical site in Patient 7. The lateral and alar cartilages require additional mobilization. The lateral cartilages can then be fixed as high on the L-beam as possible, and the alar cartilages can be reapposed.

31 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 31 Individual septal reconstruction was performed with an L-beam composed of two outer cartilage strips from the eighth rib (Figs. 37b, 39a and b) and a remnant of septal cartilage. At operation, the L-beam was securely fixed to the lateral cartilages (which were also raised as much as possible to improve the nasal valve angle) and to the sagittal groove in the anterior nasal spine. After removal of the septal splints, the patient reported a significant improvement in nasal breathing that was still stable at 20 months (Fig. 44b, d, f). a 44 Patient 7 before (a, c, e) and 20 months after the operation (b, d, f). b c d e f

32 32 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery Case Report 2 Cleft Lip and Palate Individual septal reconstruction with the L-beam is also suitable for patients with cleft lip and palate. The deformities in these patients include septal deviation and subluxation toward the healthy side and deviation of the external nose. Additionally, the columella and alar cartilages are shortened on the cleft side, and this is associated with weak projection and protection of the nasal tip (Fig. 45). Nasal breathing is consistently impaired. Surgical correction is difficult and has its limitations. A significant number of patients have already had prior surgery. 45 Typical features of unilateral cleft lip and palate, with septal deviation and subluxation toward the healthy side, deviation of the external nose, and asymmetric alar cartilages. 46 This photograph of Patient 8 shows three scars. The donor site for rib cartilage used in the previous operation starts just below the nipple. The donor site for the L-beam (3 months postoperatively) is on the costal arch. The third scar (\) is unrelated to the nasal operations. \

33 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 33 a 47 Patient 8 with unilateral cleft lip and palate following two previous nasal operations, which included the use of rib cartilage. Revision consisted of an individual septal reconstruction with an L-beam. The postoperative photographs (b, d, f) were taken at 21 months. The patient has had unrestricted nasal breathing since the operation. b c d e f

34 34 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 3.6 Rhinoplasty without Osteotomy The title of this section is short. A more descriptive title might be: Is closure of the open roof with extended spreader grafts, without transverse and lateral osteotomies, a reasonable alternative in selected cases? A key requirement in traditional rhinosurgery is closure of the open roof by osteotomies. The open roof is closed by mobilizing and repositioning the lateral nasal walls. But does a good postoperative result require closure of the open roof, or does it require osteotomies? Are lateral and transverse osteotomies just a means to an end, and are they one of several options for closing an open roof? We answer this question in the following two case reports, in which extended spreader grafts were used to close the open roof (Fig. 48). 48 Closure of the cartilaginous and bony open roof with extended spreader grafts. Onlay grafts can be placed on the lateral cartilage to optimize the brow-tip aesthetic line Case Report 1 Humped Nose In this patient (Fig. 49a f) the dorsal hump was removed through an open approach and the open roof was closed with extended spreader grafts (Fig. 48) while omitting lateral and transverse osteotomies. The patient is very pleased with the result. It is an acceptable result from a surgical standpoint. Lateral and transverse osteotomies may have yielded a better result in some circumstances. But performing these osteotomies does not guarantee a better outcome. As the degree of nasal framework mobilization increases, so does the risk of failure.

35 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 35 a 49 Patient before (a, c, e) and 14 months after the operation (b, d, f). The open roof was closed with spreader grafts. Transverse and lateral osteotomies were not performed. b c d e f

36 36 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery Case Report 2 Humped Nose and Alar Deformity This patient also had an open roof following dorsal hump removal. As in the previous case, it was closed with extended spreader grafts (Fig. 48). The nasal tip was corrected by incising and folding over the alar cartilage on each side. As with the L-beam made of costal cartilage, we cause the opposing force vectors to cancel out and restore a physiologic shape to the lateral crura. Folding the cartilage on itself also reinforces the lateral crura to prevent alar collapse and nasal valve stenosis (Fig. 50). The photographs (Fig. 51a f) show the patient before and 12 months after the operation. 50 The cephalic portion of each alar cartilage is incised while leaving the deep perichondrium intact. The cartilage is then folded lengthwise, apposing the perichondrial surfaces, and fixed with suture material.

37 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 37 a 51 This patient also had an open roof closure with spreader grafts. Transverse and lateral osteotomies were not performed. The patient is shown before (a, c, e) and 12 months after the operation (b, d, f). b c d e f

38 38 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 3.7 The I-Beam The caudal cartilaginous nasal septum is responsible for stabilizing the cartilaginous lower third of the nasal dorsum and also provides crucial tip support. Weakening of the septal cartilage in this area due to external trauma, previous septal surgery, or destructive inflammatory changes in the septal mucosa can compromise this supportive function. This leads to the saddling of the cartilaginous nasal dorsum and drooping of the nasal tip that are characteristic of this pathology. Besides the cosmetic impairment caused by the saddled cartilage, the ptotic nasal tip also leads to impaired nasal breathing. This results from a decrease in both the projection (height of the nasal tip) and protection of the nasal tip (resistance of the tip to external pressure). The loss of projection and protection causes narrowing of the nasal valve and impaired nasal breathing. Thus, reconstruction of the caudal nasal septum is necessary for the correction of cosmetically objectionable saddle nose and for the functional improvement of nasal breathing Surgical Concept Operating Technique Ideally, the caudal nasal septum is reconstructed with septal cartilage taken from more dorsal portions of the septum. Very often, however, there is not enough nasal septal cartilage available for this type of reconstruction. In these cases the caudal nasal septum can be reconstructed with a different material such as costal cartilage. But reconstruction with costal cartilage leads to a relatively stiff nose in the reconstructed area due to the higher elastic modulus of rib cartilage. Moreover, harvesting costal cartilage leaves a thoracic scar and may lead to prolonged and troublesome post operative pain. Auricular cartilage provides an elegant alternative for reconstructing the caudal nasal septum. Cartilage harvested from the auricular concha is elastic and is much like the cartilage naturally present in the nasal tip. The difficulty of septal reconstruction with conchal cartilage lies in the fact that the cartilage is relatively thin and not very stable. Another problem is its concave curvature. Both disadvantages can be offset by creating a double-layer conchal cartilage graft (Fig. 52). As with the L-beam (see Sect L-Beam Concept), suturing the two layers together will cancel out the force vectors that cause bowing of the cartilage. This increases the stability of the graft, and the mirror-image arrangement of the layers eliminates the curve, resulting in a straight implant. 52 I-beam principle with a double-layer conchal cartilage implant in the columella.

39 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 39 This double-layer conchal cartilage graft, also called the I-beam, is implanted between the medial crura of the lower alar cartilages in the columella to restore nasal tip projection and protection. The surgery is performed through an open rhinoplasty approach. The base of the conchal cartilage implant (I-beam) is positioned just in front of the anterior nasal spine and extends into the dome area of the nasal tip. This is possible because the entire choncha is harvested, yielding a I-beam length of up to 35 mm (Fig. 53a, b). The I-beam is placed into the columella and fixed with nonabsorbable sutures to restore original nasal tip projection and protection. The still-saddled portion of the cartilaginous nasal dorsum is now sutured to the stable, reconstruction nasal tip. If this fixation is not adequate, the sunken area of the nasal dorsum can be augmented with a conchal cartilage onlay graft. One ear will supply enough conchal cartilage in most cases; it is rarely necessary to harvest cartilage from both ears. Reconstruction of the caudal nasal septum with the double-layer conchal cartilage implant (I-beam) leads to stable long-term cosmetic and functional results and provides a nasal tip elasticity similar to the original state. If I-beam use is not an option, we use an L-beam instead. The techniques for safely harvesting rib cartilage with minimal pain and for fabricating and implanting the L-beam are described in Sections 3.4 and 3.5. a 53 Harvesting conchal cartilage. b Two strips of conchal cartilage are apposed to make a straight I-beam.

40 40 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery Case Example Saddle Nose a 54 Saddle nose deformity and ptotic nasal tip due to loss of caudal septal support following two nasal injuries and two septorhinoplasties. b Postoperative result 3 years after caudal septal reconstruction with an I-beam (b, d, f). c d e f

41 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery Perforated Septum The close of a perforated septum was long considered an operation with an uncertain outcome. Conventional advancement flaps or transposition flaps such as the turbinate flap have not proven effective for closing large septal perforations. The bridge flap technique described and established by Schultz-Coulon has proven very reliable. 17 We have had good results with it in our patients. We will describe the modification that we use. When performing the bridge flap technique, we make sure that the mucosa is mobilized sufficiently to allow a tension-free closure. We also avoid additional mucosal incisions so that once the septal perforation and access incision have been closed, a complete mucosal lining is obtained. This also shortens healing time. For these reasons, the modified bridge flap has become our standard technique for closing septal perforations (Fig. 55). Septal perforations can be repaired through a closed or open approach. If doubt exits we favor an open approach, especially when dealing with perforations that have a large vertical extent. Following the open approach, we first expose the anterior septal border with a No. 15 blade. Subperichondrial and subperiosteal tunnels are then developed with a pointed scissors, suction tip, and dissectors above and below the perforation site. Next the mucosal tunnels above and below the perforation are joined together. We now expose the piriform aperture and extend the lower mucosal tunnel to a point below a 55 Modified bridge flap technique without mucosal incisions. The mucosa is mobilized from the nasal floor and nasal roof to allow a tension-free closure. We generally use tragal or conchal cartilage for the cartilage graft, depending on the size of the defect. b 56 View of the piriform aperture (bottom of image), the anterior nasal spine (left side of image), and the mucosa, which has been mobilized to a point below the inferior turbinate on the left side (right side of image) (a). The mucosa on the left nasal roof is completely mobilized as far as the anterior nasal artery. (The anterior nasal artery is often mistaken for the first olfactory fiber, but the latter is located behind the anterior nasal artery.) Note also the complete separation of the mucosa from the nasal roof medially (septum) and laterally (lateral nasal wall) so that large mucosal flaps can be developed (b). the attachment of the inferior turbinate (Fig. 56a). The upper tunnel is then extended to the attachment of the middle turbinate. We have found that starting posteriorly will often make the dissection easier. It is important to respect the anterior nasal artery as the posterior limit of the dissection (Fig. 56b). Carrying the dissection farther posteriorly may lead to avulsion of the anterior nasal artery and the olfactory fibers located there. When the upper tunnels and upper mucosal flaps are developed properly (Fig. 56b), enough mucosa should be available for a tension-free closure of the septal perforation. This also requires adequate mobilization of the mucosa and upper mucosal flaps in the area of the lateral cartilage a step that can be technically demanding and may require the aid of a microscope. When the mucosa has been adequately mobilized on all sides of the perforation, tension-free closure of the mucosa is carried out.

42 42 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery The septal perforation is closed with three to six simple interrupted sutures placing the knots internally (Fig. 56c, d). We obtain a physiologic three-layered repair (mucosa-cartilage-mucosa) by implanting autologous tragal cartilage or, for larger defects, autologous conchal cartilage. The graft is fixed with absorbable suture material or fibrin glue. Generally we do not transfer posterior septal cartilage for a three-layered septal perforation repair to minimize the risk of a recurrent perforation or a new perforation at a different site. At the end of the operation, silicone septal splints with breathing tubes are inserted. They are shortened in height to allow for the temporarily decreased vertical dimension of the nasal cavity. A question often asked at the RHINO Workshop is whether the size reduction of the nasal cavity caused by mobilizing the mucosa is temporary or permanent. Figure 56e shows the obliterated nasal roof at the end of the operation, and Fig. 56f shows the site 12 months after surgery. We always address abnormalities of the cavernous tissues separately in a second procedure to avoid compromising the blood supply to the mucosal flaps. The possible need for a two-stage procedure should always be noted during informed consent. We recommend a nasal septal prosthesis for patients with a symptomatic perforation who refuse surgery or are likely to have a poor outcome. c 56 fd The needle is passed from inside to outside so that the knots can be placed internally (c). Tension-free closure of the mucosa (view into the left nasal cavity) (d). e 56 f Temporary reduction of nasal cavity size with obliteration of the nasal roof at the end of the operation. A normal configuration of the nasal roof is seen one year after surgery.

43 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 43 a 57 Patient with a perforated septum before (a, c, e) and 12 months after the operation (b, d, f) (open approach). b c d e f

44 44 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 3.9 Nasal Tip Correction Besides an individual septal reconstruction (ISR), control of nasal tip position is a key component of every successful rhinoplasty. The rhinosurgeon is often confronted with an overprojected nasal tip. Nasal tip projection is defined as the distance of the tip defining point (apex of the alar cartilage convexity) from the facial plane. In principle, an overprojected nasal tip may occur as an isolated phenomenon, creating a nasal deformity also known as the Pinocchio nose. An overprojected nasal tip is also found in cases where all portions of the nose are enlarged (rhinomegaly). 12 Nasal tip projection is evaluated on a profile photograph of the patient. In most cases an overprojected nasal tip is caused by hypertrophy of its anatomic subunits. Thus it is useful to distinguish among alar cartilage hypertrophy, septal cartilage hypertrophy, hypertrophy of the nasal spine, combined hypertrophy of multiple components, and iatrogenic hypertrophy. It may be assumed that an isolated overprojected nasal tip is based on hypertrophy of the alar cartilages alone. With a rhinomegalic nose, all nasal components are too large. 12,19 Often it is not sufficient in these cases to correct one anatomic component. The fact that many techniques for decreasing nasal tip projection have been described in the literature attests to the difficulties that are associated with this step. A standard method has not yet been devised. Any surgical alteration of the complex relationships of the alar cartilage segments requires careful preoperative planning. Various surgical principles can be applied to decrease nasal tip projection. One way to decrease projection is by the surgical reduction of oversized structures that support the nasal tip (tip support mechanisms). 5,12 Especially when dealing with a tension nose in rhinomegaly, it is important to release the supporting ligamentous structures and reduce the overdeveloped septum before correcting the nasal tip to see how much of the overprojection is caused by the septum. A second possibility is to normalize underdeveloped or malformed structures that border the nose and give the tip an overprojected appearance (pseudohypertrophy of the nose), such as saddling of the nasal dorsum, a protruding maxilla, or retrognathia with a retrusive lower jaw. A third way to decrease projection is by the surgical reduction of underdeveloped anatomic component(s), especially the alar cartilages. 14 The dynamics of the nasal alae can be understood in terms of the tripod concept described by Anderson in In this concept the lateral crura each form one leg of the tripod while both medial crura combine to form the third. Changing the length of one leg will cause the nasal tip position to move in various directions. Shortening the outer legs will lower the nasal tip and rotate it upward. Shortening the center leg will move the tip downward and decrease its projection. 2 Based on the tripod model, we can identify two ways in which the legs of the tripod can be surgically altered: with or without division of the alar circumference. Suture techniques provide a way to reduce projection without disrupting the anatomic framework. Suturing the medial crura to the caudal septal border can produce at least a small amount of deprojection. 14,20 Surgical division of the alar circumference was first described by Goldman in 1957, although this initial description involved a technique for increasing nasal tip projection. 9 He achieved this by dividing the alar cartilage just lateral to the dome on both sides and suturing the medial crura together. This created a strong medial unit with increased projection and greater medial support of the nasal tip. But tip projection could also be decreased by shortening the medial crura and trimming the lateral crura in patients with skin that is able to undergo contraction.

45 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 45 One disadvantage of the Goldman technique is that it creates a discontinuity in the alar cartilage. This could lead to postoperative tip irregularities, especially in thin-skinned patients. This is also why many surgeons have avoided dividing the alar cartilages. They tried to avoid these problems by dividing the cartilage in the dome while preserving the vestibular skin. 18 Constantinides published a modification of the vertical dome division in 2001, using the more anatomically correct term vertical lobule division since the division may be made anywhere along the alar lobule. 4 The alar cartilage can be divided just medial or lateral to the dome, and one end is overlapped over the other to decrease projection while rotating the tip upward or downward. Kridel and Konior described a similar technique in 1990 in which they resected the entire dome region after placing a suture at the level of the new dome. They preserved the vestibular skin by previously elevating it from the cartilage in the nasal tip area. 13 In dome resections where the cartilaginous circumference is restored by suturing the cut edges, care should be taken that the caudal margin of the lateral alar cartilage is not lower than the cephalic margin after the reconstruction. In some cases that can be achieved with nonparallel excisions (Fig. 58) Diagrammatic representation of the vertical lobule division technique.

46 46 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery Otherwise the functionally and aesthetically important curved contour of the free alar margin would be lost. To avoid tip irregularities in thin-skinned patients, coverage with a tip onlay cartilage graft is also recommended. 15,16,21 Figure 59a, b shows pre- and postoperative views of a patient in whom this technique was used to decrease nasal tip projection. Figure 60a, b shows the intraoperative appearance before and after deprojection. a 59 b This patient underwent primary functional-aesthetic septorhinoplasty for a slight dorsal hump and overprojected nasal tip. The hump was resected and the tip deprojected by the dome division technique. The nose was restructured with spreader grafts, a septal extension graft, and a tip onlay graft. a 60 b Intraoperative photographs of the same patient before (a) and after (b) deprojection. While Adamson also described excision techniques for deprojection initially, he refined his technique later by overlapping the alar cartilage. 1 This corresponds to the lateral crural overlay technique described by Foda and Kridel (1999), which increases tip rotation and decreases projection by dividing the lateral crus relatively close to its foot and overlapping the cut ends (Fig. 61) Diagrammatic representation of the lateral crural overlay.

47 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 47 This technique can be combined with a second division of the alar cartilage circumference in the medial crus either to shorten the columella or to correct a tip region (lobule) that is too long relative to the columella. The cut ends of the lateral crus are overlapped and sutured into place. In the medial crus, cartilage is resected but the ends are not overlapped. Instead, the medial crural segments are splinted to an interposed columellar strut that is sutured into place. 7 The lateral and medial shortening deproject the tip without changing its rotation. The same principle is 6, 10, 11 applied in the medial or lateral sliding technique described by Gubisch (Fig. 62). Conclusion: Besides an individual septal reconstruction (ISR), the control of nasal tip projection, rotation, and contours is the key component of a successful rhinoplasty. A variety of techniques are available for achieving this. Along with adequate stabilization of the nasal base, these techniques lead to good long-term results that preserve the nasal tip projection achieved by surgery. The successful nasal surgeon adapts his technique to individual patient anatomy in order to achieve reliable and stable long-term results. 62 Diagrammatic representation of the medial sliding technique.

48 48 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 3.10 Rhinophyma Rhinophyma is a lobular hyperplasia of the sebaceous glands that may or may not be associated with rosacea and occurs almost exclusively in males. Since surgical removal leaves islands of epidermal tissue deep within the hypertrophic sebaceous glands that will create a nidus for reepithelialization, this type of tumor can be effectively managed by cutting it off. We use three methods for this: Scalpel and scissors Dermabrasion Laser The first method is the most widely used. Its advantage is that the surgeon can accurately assess the depth of the excision by noting the amount of tissue above the knife or scissor blades. It is also easy to identify the base of the excision, which should never extend below the hypertrophic sebaceous gland. For heavy bleeding, we recommend a CO 2 laser coupled to a Sharplan flash scanner operated in SilkTouch mode (Lumenis GmbH, Dreieich-Dreieichenhain, Germany). Irregularities can be smoothed with a diamond wheel like that used for dermabrasion. After surgery we make a light pressure dressing with ointment-impregnated gauze, which may contain cortisone and antibiotic if desired. Reepithelialization takes from two to four weeks. Placing a finger in the nose is helpful for monitoring the depth of the excision and avoiding an overexcision that could cause cartilage damage. a b c 63 Diagrammatic representation of a rhinophyma patient before (a), during (b) and after surgical treatment (c). Some instruments are also shown (b).

49 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 49 a 64 Patient before and 11 months after the operation. b c d e f

50 50 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 4.0 References 1. ADAMSON PA. Refinement of the nasal tip. Facial Plast Surg 1988; 5: ANDERSON JR. The dynamics of rhinoplasty. In: Proceedings of the 9 th International Congress of Otolaryngology. 1969; International Congress Series 206. Excerpta medica, Amsterdam 3. AWMF (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fach gesellschaften e. V.). Formstörungen der inneren und äußeren Nase (mit funktioneller und/oder ästhetischer Beeinträchtigung). Stand: , gültig bis , Reg.-Nr , Klassifikation S2k 4. CONSTANTINIDES M, LIU ES, MILLER PJ, ADAMSON PA. Vertical lobule division in rhinoplasty: maintaining an intact strip. Arch Facial Plast Surg 2001; 3(4): DYER WK 2nd. Nasal tip support and its surgical modification. Facial Plast Surg Clin North Am 2004; 12: EICHHORN-SENS J, GUBISCH W. The sliding technique: a precise method for treating the overprojected nasal tip. HNO 2009; 57: FODA HM. Alar setback technique: a controlled method of nasal tip deprojection. Arch Otolaryngol Head Neck Surg 2001; 127(11): FODA HM, KRIDEL RW. Lateral crural steal and lateral crural overlay. An objective evaluation. Arch Otolaryngol Head Neck Surg 1999; 125(12): GOLDMAN IB. The importance of mesial crura in nasal-tip reconstruction. AMA Arch Otolaryngol 1957; 65(2): GUBISCH W, EICHHORN-SENS J. The sliding technique: a method to treat the overprojected nasal tip. Aesthetic Plast Surg 2008; 32: GUBISCH W. The extracorporeal septum plasty: a technique to correct difficult nasal deformities. Plast Reconstr Surg 1995; 95(4): KREUTZER C. Die Reduktion der überprojizierten Nasenspitze mit der Sliding- Technik: retrospektive Analyse zur Quantifizierung des Operationsergebnisses. 2006; Dissertation, Ruprecht-Karl-Universität Heidelberg ( 13. KRIDEL RW, KONIOR RJ. Dome truncation for management of the over projected nasal tip. Ann Plast Surg 1990; 24: PAPANASTASIOU S, LOGAN A. Management of the overprojecting nasal tip: a review. Aesthetic Plast Surg 2000; 24: PECK GC, PECK GC Jr., ADAMS WP Jr. Long-term follow-up of the onlay tip graft and umbrella graft. In: JP Gunter, RJ Rohrich, WP Adams Jr., Dallas Rhinoplasty: Nasal Surgery by the Masters, 1 st Ed. St. Louis, Mo.: Quality Medical Publishing 2002; P RIEDEL F, BRAN G. Cartilage grafts in functional and aesthetic rhinoplasty. HNO 2008; 56: SCHULTZ-COULON HJ. Experiences with the bridge-flap technique for the repair of large nasal septal perforations. Rhinology 1994; 32(1): SIMONS RL. Vertical dome division in rhinoplasty. Otolaryngol Clin North Am 1987; 20: TARDY ME Jr., WALTER MA, PATT BS. The overprojecting nose: anatomic component analysis and repair. Facial Plast Surg 1993; 9: TEBBETS JB. Sharing and positioning the nasal tip without structural disruption: A new systematic approach. Plast Reconstr Surg 1994; 94: TORIUMI DM. New concepts in nasal tip contouring. Arch Facial Plast Surg 2006; 8:

51 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery Instruments for Complex Facial Plastic Surgery and Rhinosurgery Otorhinolaryngology is one of the most challenging, diverse, and interesting specialties in surgery. This particularly applies to facial plastic surgery and rhinosurgery. A detailed knowledge of the often complex anatomy is as essential as knowing the overall architecture of the nose and the properties of different tissues and their interactions during wound healing. Years of intensive training combined with a critical self-assessment of long-term results will enable rhinosurgeons to manage their rhinoplasty patients with a high degree of confidence and reliability. A high level of patient satisfaction can be achieved only if the surgical concept and preoperative plan can be successfully put into practice on the operating table. This practical implementation relies critically on the use of high-quality, precise, ergonomic instruments. Quality equipment can avoid irregularities caused by imprecise cutting instruments and unnecessary tissue trauma. Not infrequently, one millimeter or less may decide the success or failure of a rhinoplastic procedure. An instrument-related failure or less-than-optimum result should be avoided whenever possible. By and large, it may be true that an experienced surgeon can get by with fewer instruments. But when it comes to a functional, aesthetic, or cosmetic nasal operation, maximum precision is essential and is best achieved with instruments that are optimally designed for the requisite surgical steps. Besides instrument quality, then, an adequate assortment of instruments is crucial for the practical realization of a surgical concept. Mistakes due to poor instrumentation are easy to avoid and, consequently, should never be a reason for failure.

52 52 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 5.1 Instruments for Complex Facial Plastic Surgery and Rhinosurgery Recommended Set acc. to MAAS and SAUER bl bm bn bo bp bq br bs bt bu cl cm cn el co cp cq cr cs ct cu dl dm dn do dp dq dr ds dt du em en eo fr ft gl ep eq er es et eu fl fm fn fo fp fq fs fu gm gn go gp

53 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery AA 1 HOPKINS Straight Forward Telescope 0, enlarged view, diameter 4 mm, length 18 cm, autoclavable, fiber optic light transmission incorporated, color code: green BA 1 HOPKINS Forward-Oblique Telescope 30, enlarged view, diameter 4 mm, length 18 cm, autoclavable, fiber optic light transmission incorporated, color code: red KILLIAN-STRUYCKEN Nasal Speculum, standard model, blade length 40 mm, length 13.5 cm Same, blade length 55 mm Same, blade length 75 mm COTTLE Nasal Speculum, blade length 55 mm, length 13 cm Same, blade length 75 mm HARTMANN Nasal Speculum, for adults, length 13 cm COTTLE Nasal Speculum, extra slender, without set screw, special matt finish, blade length 35 mm, length 13 cm bl BLAKESLEY Nasal Forceps, straight, size 1, working length 11 cm bm Same, size 3 bn HARTMANN Nasal Cutting Forceps, round, size 4, working length 11 cm bo RUBIN Septum Morcelizer, double action, straight, special matt finish, length 20 cm bp HEYMANN-KNIGHT Septum Forceps, straight, working length 11 cm bq BECKER-CAPLAN Septum Scissors, double action jaws, serrated, working length 9.5 cm br HEYMANN Nasal Scissors, medium, serrated blades, working length 9.5 cm bs JOSEPH Scissors, straight, length 14 cm bt Same, curved bu METZENBAUM Scissors, with tungsten carbide inserts, curved, length 14 cm cl WALTER Scissors, angled, length 10 cm cm FOMON Dorsal Scissors, angular, serrated blades, slender, working length 6.5 cm cn Scissors, curved, sharp/blunt, length 14.5 cm co WALTER Nasal Retractor, double-ended, one side with retractor, width of retractor blade 12 mm, length of retractor blade 45 mm, other side with two pronged retractor for nasal wings, length 12.5 cm cp COTTLE Retractor, narrow (standard model), length 14 cm cq JOSEPH Double Hook, sharp, width 2 mm, length 15 cm cr Same, width 5 mm cs Same, width 5 mm ct COTTLE Retractor, two prongs, sharp, with thimble, width 10 mm, length 5.5 cm cu COTTLE Crossbar Osteotome, graduated, double-edged grinding, straight, width 2 mm, length 18.5 cm dl Same, width 4 mm dm Same, width 9 mm dn WALTER Osteotome, flat, double-edged grinding, width 2 mm, length 19 cm SB 1 Osteotome, flat, double-edged grinding, with enlarged distal finger grip plate, width 2 mm, length 19 cm (not illustrated) do WALTER Osteotome, flat, double-edged grinding, width 3 mm, length 19 cm SB 1 Osteotome, flat, double-edged grinding, with enlarged distal finger grip plate, width 3 mm, length 19 cm (not illustrated) dp RUBIN Osteotome, flat, straight, double-edged grinding, rounded corners, with finger grip stabilizer, width 10 mm, length 16.5 cm dq Same, width 12 mm dr Same, width 14 mm ds Same, width 16 mm dt COTTLE Metal Mallet, length 18 cm du Hone, ARKANSAS oil stone, wedge-shaped, size 10 x 4 cm el TOLSDORFF Bone and Cartilage Crusher, round, to press pieces of bone up to 4 cm evenly extended in all directions em FREER Elevator, double-ended, semisharp and blunt, length 20 cm en MASING Elevator, double-ended, graduated, sharp and blunt, length 22.5 cm eo Suction Elevator, with stylet, length 19.5 cm SB 1 Suction Raspatory, length 19.5 cm (not illustrated) ep JOSEPH Elevator, slightly curved, special matt finish, width 4 mm, length 17.5 cm eq Elevator, heavy model, for the repositioning of nasal fractures, length 17 cm er BALLENGER Swivel Knife, bayonet-shaped, width 3 mm, length 19.5 cm es Nasal Knife, curved, roundly tipped blade, width 4.5 mm, length 13.5 cm et Rasp, diamond coated, rasp blade 6 x 10 mm, length 16.5 cm eu AUFRICHT Glabella Rasp, curved, cuts with pressure and traction, length 20 cm fl Nasal Rasp, double-ended, fine, length 21.5 cm fm Same, double-ended, coarse (rasp) fn JANSEN Nasal Dressing Forceps, bayonet-shaped, length 16.5 cm fo ADSON Tissue Forceps, 1x 2 teeth, length 12 cm fp ADSON-BROWN Tissue Forceps, atraumatic, fine side grasping teeth, length 12 cm fq Needle Holder, tungsten carbide inserts, length 13 cm fr RYDER Needle Holder, tungsten carbide inserts, extra delicate, length 17 cm fs AIACH Cartilage Graft Forceps, for grasping and preparation of cartilage and bone grafts, with slotted jaws, length 15 cm ft HALSTEAD Mosquito Artery Forceps, straight, length 12.5 cm fu HALSTEAD Mosquito Artery Forceps, curved, length 12.5 cm gl HALLE-BIRKETT Forceps, light model, straight, length 20 cm It is recommended to check the suitability of the product for the intended procedure prior to use.

54 54 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery gm Surgical Handle, Fig. 3, length 12.5 cm, for Blades , Blade, Fig. 10, sterile, package of 100 (not illustrated) Same, Fig. 11 (not illustrated) Same, Fig. 15 (not illustrated) gn go FERGUSON Suction Tube, with cut-off hole and stylet, LUER, 10 Fr., working length 11 cm 1 Same, 12 Fr Cup Medicine, 100 ccm, diameter 80 mm, height 30 mm (not illustrated) Same, 200 ccm, diameter 100 mm, height 50 mm (not illustrated) gp Bipolar Coagulating Forceps, insulated, bayonet-shaped, blunt, tip 1 mm, length 19 cm E 1 Bipolar High Frequency Cord, to KARL STORZ Coagulator B/C/D, B/C/D, B/C/D, B/C/D, AUTOCON system (50, 200, 350), AUTOCON II 400 system SCB (111, 113, 115) and Erbe-Coagulator, T- and ICC-row, length 300 cm INTRA Drill Handpiece, angled, length 12.5 cm, transmission 1:1 (40,000 rpm), for use with KARL STORZ EC micro motor and straight shaft burrs Tungsten Carbide Straight Shaft Burr, with cross cut, stainless, sizes 014, diameter 1.4 mm, length 7 cm, for use with High-Performance EC Micro Motor and Connecting Cable Same, size 023, diameter 2.3 mm Same, size 031, diameter 3.1 mm Same, size 050, diameter 5 mm Same, size 060, diameter 6 mm High Performance EC Micro Motor II, for use with KARL STORZ motor systems UNIDRIVE II/UNIDRIVE ENT/OMFS/NEURO/ECO and Connecting Cable , or for use with KARL STORZ motor systems UNIDRIVE S III ENT/ ECO and Connecting Cable Connecting Cable, to connect High-Performance EC Micro Motor to UNIDRIVE S III ENT/ ECO/NEURO/OMFS control units Rapid Diamond Burr, straight shaft, with coarse grit diamond coating for precise cutting by light hand pressure, length 70 mm, diameter 2.3 mm, for use with KARL STORZ High-Performance EC Micro Motor and Connecting Cable , color code: gold Same, size 027, diameter 2.7 mm Same, size 050, diameter 5 mm Same, size 060, diameter 6 mm Same, size 070, diameter 7 mm LINDEMANN Burr, conical, stainless, sterilizable, size 018, diameter 1.8 mm, length 7 cm Same, size 021, diameter 2.1 mm Same, size 023, diameter 2.3 mm Rack, for 36 straight shaft burrs with a length of 7 cm, can be folded out, sterilizable, size 22 x 11.5 x 2 cm Brush, for cleaning atraumatic jaws, sterilizable, package of B 1 Sterilizing and Storage Tray, provides safe storage of accessories for KARL STORZ drilling/ grinding systems during cleaning and sterilization, includes tray for small parts, for use with Rack , rack included 5.2 Instruments for Costal Cartilage Harvest (L-Beam Technique) Recommended Set acc. to MAAS and SAUER KILNER Scissors, curved, flat end, length 12.5 cm ADSON Dressing Forceps, serrated, length 12 cm ADSON Tissue Forceps, 1x 2 teeth, length 12 cm HALSTEAD Mosquito Artery Forceps, curved, length 12.5 cm WEITLANER Retractor, 3x 4 prongs, sharp, length 16 cm Same, length 20 cm KILNER-GILLIES Hook, one prong, small curve, length 17 cm Retractor, sharp, 1 prong, length 17 cm LANGENBECK Retractor, 28 x 14 mm, length 21 cm KOCHER-LANGENBECK Retractor, 55 x 11 mm, length 21.5 cm PLESTER Elevator, width 8 mm, length 18 cm FISCH Elevator, sharp, width 10 mm, length 15.5 cm McKENTY Elevator, width 4 mm, length 14.5 cm HENKE Dissector, width 11.5 mm, length 23.5 cm, (standard size) OD 1 Raspatory, for the mobilization of mucosa during the repair of palate defects and cleft palate surgery, double-ended, strongly curved, sharp and blunt, length 20.5 cm Redon Guide Needle, curved 90, knife tip, 14 Fr Cup Medicine, 100 ccm, diameter 80 mm, height 30 mm Same, 200 ccm, diameter 100 mm, height 50 mm Bipolar Coagulating Forceps, insulated, angled tip, blunt, tip 2 mm, length 19 cm, for use with Bipolar High Frequency Cords or A/E/M/V E 1 Bipolar High Frequency Cord, to KARL STORZ Coagulator B/C/D, B/C/D, B/C/D, B/C/D, AUTOCON system (50, 200, 350), AUTOCON II 400 system SCB (111, 113, 115) and Erbe-Coagulator, T- and ICC-row, length 300 cm

55 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery Instruments for Complex Facial Plastic Surgery and Rhinosurgery Recommended Set acc. to MAAS and SAUER Headlight KS60, with double lens system and Y-fiber optic light cable, >175,000 lux, illuminated area adjustable from mm with 40 cm working distance, including: Headlight KS60, with removeable and sterilizable Focus Handle Headband, fully adjustable, with Forehead Cushion , with cross band, including holder for Headlight Y-Fiber Optic Light Cable, with special protective casing for Headlight , length 290 cm Clip with Band, for attaching the fiber optic light cable to OR clothing

56 56 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 7230 AA BA 7230 AA HOPKINS Straight Forward Telescope 0, enlarged view, diameter 4 mm, length 18 cm, autoclavable, fiber optic light transmission incorporated, color code: green 7230 BA HOPKINS Forward-Oblique Telescope 30, enlarged view, diameter 4 mm, length 18 cm, autoclavable, fiber optic light transmission incorporated, color code: red KILLIAN-STRUYCKEN Nasal Speculum, standard model, blade length 40 mm, length 13.5 cm Same, blade length 55 mm Same, blade length 75 mm COTTLE Nasal Speculum, blade length 55 mm, length 13 cm Same, blade length 75 mm HARTMANN Nasal Speculum, for adults, length 13 cm COTTLE Nasal Speculum, extra slender, without set screw, special matt finish, blade length 35 mm, length 13 cm

57 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery BLAKESLEY Nasal Forceps, straight, size 1, working length 11 cm Same, size HARTMANN Nasal Cutting Forceps, round, size 4, working length 11 cm

58 58 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery RUBIN Septum Morcelizer, double action, straight, special matt finish, length 20 cm HEYMANN-KNIGHT Septum Forceps, straight, working length 11 cm BECKER-CAPLAN Septum Scissors, double action jaws, serrated, working length 9.5 cm

59 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery HEYMANN Nasal Scissors, medium, serrated blades, working length 9.5 cm JOSEPH Scissors, straight, length 14 cm Same, curved METZENBAUM Scissors, with tungsten carbide inserts, curved, length 14 cm WALTER Scissors, angled, length 10 cm FOMON Dorsal Scissors, angular, serrated blades, slender, working length 6.5 cm Scissors, curved, sharp/blunt, length 14.5 cm

60 60 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery SB SB WALTER Nasal Retractor, double-ended, one side with retractor, width of retractor blade 12 mm, length of retractor blade 45 mm, other side with two pronged retractor for nasal wings, length 12.5 cm COTTLE Retractor, narrow (standard model), length 14 cm JOSEPH Double Hook, sharp, width 2 mm, length 15 cm Same, width 5 mm Same, width 10 mm COTTLE Retractor, two prongs, sharp, with thimble, width 10 mm, length 5.5 cm COTTLE Crossbar Osteotome, graduated, double-edged grinding, straight, width 2 mm, length 18.5 cm Same, width 4 mm Same, width 9 mm WALTER Osteotome, flat, double-edged grinding, width 2 mm, length 19 cm Same, width 3 m SB SB SB Osteotome, flat, double-edged grinding, with enlarged distal finger grip plate, width 2 mm, length 19 cm SB Same, width 3 mm

61 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery RUBIN Osteotome, flat, straight, double-edged grinding, rounded corners, with finger grip stabilizer, width 10 mm, length 16.5 cm Same, width 12 mm Same, width 14 mm Same, width 16 mm COTTLE Metal Mallet, length 18 cm Hone, ARKANSAS oil stone, wedge-shaped, size 10 x 4 cm TOLSDORFF Bone and Cartilage Crusher, round, to press pieces of bone up to 4 cm evenly extended in all directions FREER Elevator, double-ended, semisharp and blunt, length 20 cm MASING Elevator, double-ended, graduated, sharp and blunt, length 22.5 cm Suction Elevator, with stylet, length 19.5 cm SB Suction Raspatory, length 19.5 cm SB

62 62 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery JOSEPH Elevator, slightly curved, special matt finish, width 4 mm, length 17.5 cm Elevator, heavy model, for the repositioning of nasal fractures, length 17 cm BALLENGER Swivel Knife, bayonet-shaped, width 3 mm, length 19.5 cm Nasal Knife, curved, roundly tipped blade, width 4.5 mm, length 13.5 cm Rasp, diamond coated, rasp blade 6 x 10 mm, length 16.5 cm AUFRICHT Glabella Rasp, curved, cuts with pressure and traction, length 20 cm Nasal Rasp, double-ended, fine, length 21.5 cm Same, coarse (rasp)

63 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery JANSEN Nasal Dressing Forceps, bayonet-shaped, length 16.5 cm ADSON Tissue Forceps, 1x 2 teeth, length 12 cm ADSON-BROWN Tissue Forceps, atraumatic, fine side grasping teeth, length 12 cm Needle Holder, tungsten carbide inserts, length 13 cm RYDER Needle Holder, tungsten carbide inserts, extra delicate, length 17 cm AIACH Cartilage Graft Forceps, for grasping and preparation of cartilage and bone grafts, with slotted jaws, length 15 cm HALSTEAD Mosquito Artery Forceps, straight, length 12.5 cm HALSTEAD Mosquito Artery Forceps, curved, length 12.5 cm HALLE-BIRKETT Forceps, light model, straight, length 20 cm

64 64 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery Surgical Handle, Fig. 3, length 12.5 cm, for Blades , Blade, Fig. 10, sterile, package of Same, Fig Same, Fig FERGUSON Suction Tube, with cut-off hole and stylet, LUER, 10 Fr., working length 11 cm Same, 12 Fr Cup Medicine, 100 ccm, diameter 80 mm, height 30 mm Same, 200 ccm, diameter 100 mm, height 50 mm bipolar Bipolar Coagulating Forceps, insulated, bayonet-shaped, blunt, tip 1 mm, length 19 cm E Bipolar High Frequency Cord, to KARL STORZ Coagulator B/C/D, B/C/D, B/C/D, B/C/D, AUTOCON system (50, 200, 350), AUTOCON II 400 system SCB (111, 113, 115) and Erbe-Coagulator, T- and ICC-row, length 300 cm

65 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 65 INTRA Drill Handpiece and Accessories ## Tool-free closing and opening of the drill ## Right/left rotation ## Max. rotating speed up to 40,000 rpm ## Detachable irrigation channels ## Lightweight construction ## Operate with little vibrations ## Low maintenance, machine-cleanable ## Safe grip INTRA Drill Handpiece, angled, length 18 cm, transmission 1:1 (40,000 rpm), for use with KARL STORZ EC Micro Motor and straight shaft burrs High Performance EC Micro Motor II, for use with KARL STORZ motor systems UNIDRIVE II/ UNIDRIVE ENT/OMFS/NEURO/ECO and Connecting Cable , or for use with KARL STORZ motor systems UNIDRIVE S III ENT/ECO and Connecting Cable Connecting Cable, to connect High-Performance EC Micro Motor to UNIDRIVE S III ENT/ECO/ NEURO/OMFS control units Tungsten Carbide Straight Shaft Burrs Tungsten Carbide Straight Shaft Burr, with cross cut, stainless, sizes 014, diameter 1.4 mm, length 7 cm, for use with High-Performance EC Micro Motor and Connecting Cable Same, size 023, diameter 2.3 mm Same, size 031, diameter 3.1 mm Same, size 050, diameter 5 mm Same, size 060, diameter 6 mm Rapid Diamond Burrs Rapid Diamond Burr, straight shaft, with coarse grit diamond coating for precise cutting by light hand pressure, length 70 mm, diameter 2.3 mm, for use with KARL STORZ High-Performance EC Micro Motor and Connecting Cable , color code: gold Same, size 027, diameter 2.7 mm Same, size 050, diameter 5 mm Same, size 060, diameter 6 mm Same, size 070, diameter 7 mm LINDEMANN Burrs LINDEMANN Burr, conical, stainless, sterilizable, size 018, diameter 1.8 mm, length 7 cm Same, size 021, diameter 2.1 mm Same, size 023, diameter 2.3 mm

66 66 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery Burrs Accessories Rack, for 36 straight shaft burrs with a length of 7 cm, can be folded out, sterilizable, size 22 x 11.5 x 2 cm Brush, for cleaning atraumatic jaws, sterilizable, package of B Tray for small parts included B Sterilizing and Storage Tray, provides safe storage of accessories for KARL STORZ drilling/grinding systems during cleaning and sterilization, includes tray for small parts, for use with Rack , rack included for storage of: Up to 6 drill handpieces Connecting cable EC micro motor Up to 36 drill bits and burrs Small parts

67 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery Instruments for Costal Cartilage Harvest (L-Beam Technique) Recommended Set acc. to MAAS and SAUER KILNER Scissors, curved, flat end, length 12.5 cm ADSON Dressing Forceps, serrated, length 12 cm ADSON Tissue Forceps, 1x 2 teeth, length 12 cm HALSTEAD Mosquito Artery Forceps, curved, length 12.5 cm WEITLANER Retractor, 3x 4 prongs, sharp, length 16 cm Same, length 20 cm KILNER-GILLIES Hook, one prong, small curve, length 17 cm Retractor, sharp, 1 prong, length 17 cm LANGENBECK Retractor, 28 x 14 mm, length 21 cm KOCHER-LANGENBECK Retractor, 55 x 11 mm, length 21.5 cm

68 68 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery OD PLESTER Elevator, width 8 mm, length 18 cm FISCH Elevator, sharp, width 10 mm, length 15.5 cm McKENTY Elevator, width 4 mm, length 14.5 cm HENKE Dissector, width 11.5 mm, length 23.5 cm, (standard size) OD Raspatory, for the mobilization of mucosa during the repair of palate defects and cleft palate surgery, double-ended, strongly curved, sharp and blunt, length 20.5 cm Redon Guide Needle, curved 90, knife tip, 14 Fr Cup Medicine, 100 ccm, diameter 80 mm, height 30 mm Same, 200 ccm, diameter 100 mm, height 50 mm bipolar Bipolar Coagulating Forceps, insulated, angled tip, blunt, tip 2 mm, length 19 cm, for use with Bipolar High Frequency Cords or A/E/M/V E Bipolar High Frequency Cord, to KARL STORZ Coagulator B/C/D, B/C/D, B/C/D, B/C/D, AUTOCON system (50, 200, 350), AUTOCON II 400 system SCB (111, 113, 115) and Erbe-Coagulator, T- and ICC-row, length 300 cm

69 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery Burrs and Irrigation Systems UNIDRIVE SIII ENT SCB/UNIDRIVE SIII ECO The multifunctional unit for ENT UNIDRIVE S III ENT SCB UNIDRIVE S III ECO Special Features: Touch Screen: Straightforward function selection via touch screen UNIDRIVE S III ENT SCB UNIDRIVE S III ECO l Set values of the last session are stored l l Optimized user control due to touch screen Choice of user languages Operating elements are single and clear to read due to color display One unit multifunctional: Shaver system for surgery of the paranasal sinuses and anterior skull base INTRA Drill Handpieces (40,000 rpm and 80,000 rpm) Sinus Shaver Micro Saw STAMMBERGER-SACHSE Intranasal Drill Dermatome High-Speed Handpieces (60,000 rpm and 100,000 rpm) l l l l l l Two motor outputs: Two motor outputs for simultaneous connection of two motors: For example, a shaver and micro motor l l Soft start function l Textual error messages l Integrated irrigation and coolant pump: Absolutely homogeneous, micro-processor controlled irrigation rate throughout the entire irrigation range Quick and easy connection of the tubing set Easy program selection via automated motor recognition l l l l Continuously adjustable revolution range Maximum number of revolutions and motor torque: Microprocessor-controlled motor rotation speed. Therefore the preselected parameters are maintained throughout the drilling procedure Maximum number of revolutions can be preset SCB model with connections to the KARL STORZ Communication Bus (KARL STORZ-SCB) Irrigator rod included l l l l l l l l

70 70 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery Motor Systems Specifications System specifications Mode Order No. rpm Shaver mode oscillating Operation mode: in conjunction with Handpiece: Max. rev. (rpm): DrillCut-X II Shaver Handpiece ,000* DrillCut-X II N Shaver Handpiece ,000* Sinus burr mode rotating Operation mode: in conjunction with Handpiece: Max. rev. (rpm): DrillCut-X II Shaver Handpiece ,000 DrillCut-X II N Shaver Handpiece ,000 High-speed drilling mode counterclockwise or clockwise Operation mode: in conjunction with: Max. rev. (rpm): High-Speed Micro Motor ,000/100,000 Drilling mode counterclockwise or clockwise Operation mode: in conjunction with: Max. rev. (rpm): micro motor ,000/80,000 and connecting cable Micro saw mode in conjunction with: Max. rev. (rpm): micro motor ,000/20,000 and connecting cable Intranasal drill mode in conjunction with: Max. rev. (rpm): micro motor ,000 and connecting cable Dermatome mode in conjunction with: Max. rev. (rpm): micro motor ,000 and connecting cable Power supply: VAC, 50/60 Hz [ ] [ ] [ ] [ ] Dimensions: (w x h x d) 300 x 165 x 265 mm Two outputs for parallel connection of two motors Integrated irrigation pump: Flow: adjustable in 9 steps * Approx. 4,000 rpm is recommended as this is the most efficient suction/performance ratio. UNIDRIVE S III ENT SCB UNIDRIVE S III ECO Touch Screen: 6.4" / 300 cd/m 2 Weight: 5.2 kg 4.7 kg Certified to: IEC CE acc. to MDD IEC Available languages: English, French, German, numerical codes Spanish, Italian, Portuguese, Greek, Turkish, Polish, Russian

71 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 71 UNIDRIVE S III ENT SCB UNIDRIVE S III ECO Recommended System Configuration UNIDRIVE S III ENT SCB UNIDRIVE S III ECO UNIDRIVE S III ENT SCB, motor control unit with color display, touch screen, two motor outputs, integrated irrigation pump and SCB module, power supply VAC, 50/60 Hz including: Mains Cord Irrigator Rod Two-Pedal Footswitch, two-stage, with proportional function Silicone Tubing Set, for irrigation, sterilizable Clip Set, for use with silicone tubing set SCB Connecting Cable, length 100 cm Single Use Tubing Set*, sterile, package of UNIDRIVE S III ECO, motor control unit with two motor outputs and integrated irrigation pump, power supply VAC, 50/60 Hz including: Mains Cord Two-Pedal Footswitch, two-stage, with proportional function Silicone Tubing Set, for irrigation, sterilizable Clip Set, for use with silicone tubing set Specifications: Touch Screen Flow Power supply UNIDRIVE S III ENT SCB: 6.4"/300 cd/m 2 9 steps VAC, 50/60 Hz Dimensions w x h x d Weight Certified to 300 x 165 x 265 mm 5.2 kg EC 601-1, CE acc. to MDD * mtp medical technical promotion gmbh, Take-Off GewerbePark 46, D Neuhausen ob Eck, Germany

72 72 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery UNIDRIVE S III ENT SCB UNIDRIVE S III ECO System Components Silicone Tubing Set Two-Pedal Footswitch U N I T S I D E PATIENT SIDE High-Speed Micro-Motor High-Performance EC Micro Motor II DrillCut-X II Shaver Handpiece, for use with UNIDRIVE S III ECO/ENT/NEURO DrillCut-X II N Shaver Handpiece, optional adaptability to Shaver Tracker, for use with UNIDRIVE S III ECO/ENT/NEURO High-Speed Handpiece INTRA Drill Handpiece Shaver Blade KN Intranasal Drill Shaver Blade, curved KN Sinus Burr DN

73 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 73 Optional Accessories for UNIDRIVE S III ENT SCB and UNIDRIVE S III ECO Universal Spray, 6x 500 ml bottles HAZARDOUS GOODS UN 1950 including: Spray Nozzle C Spray Nozzle, for the reprocessing of INTRA burr handpieces, for use with Universal Spray B * Tubing Set, for irrigation, for single use, sterile, package of 10 * mtp medical technical promotion gmbh, Take-Off GewerbePark 46, D Neuhausen ob Eck, Germany

74 74 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 6.0 Basic Equipment for Videoendoscopic and Microscopic-assisted Complex Rhinosurgery Exchange of ideas among participants and faculty of the RHINO work shops has shown, that the use of optical aids in rhinoplastic surgery is constantly gaining in popularity in the medical community. This, for instance, applies to the use of the operating microscope during sophisticated and challenging dissections in patients undergoing reoperation, and equally to the use of an endoscope for improved visualization during endonasal rhinoplasty. The quality of surgical outcomes, however, is not only subject to optimal visual ization. Nowadays, rhinosurgeons may also benefit from the straightforward intra operative documentation of findings via state-of-the-art digital image recording / storage, which has shown to be very helpful in terms of quality management, particularly when correlated with the results of long-term follow-up studies.

75 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery HD Video Camera Systems IMAGE1 S Camera System n Economical and future-proof ## Modular concept for flexible, rigid and 3D endoscopy as well as new technologies ## Forward and backward compatibility with video endoscopes and FULL HD camera heads ## Sustainable investment ## Compatible with all light sources Innovative Design ## Dashboard: Complete overview with intuitive menu guidance ## Live menu: User-friendly and customizable ## Intelligent icons: Graphic representation changes when settings of connected devices or the entire system are adjusted ## Automatic light source control ## Side-by-side view: Parallel display of standard image and the Visualization mode ## Multiple source control: IMAGE1 S allows the simultaneous display, processing and documentation of image information from two connected image sources, e.g., for hybrid operations Dashboard Live menu Intelligent icons Side-by-side view: Parallel display of standard image and Visualization mode

76 76 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery IMAGE1 S Camera System n Brillant Imaging ## Clear and razor-sharp endoscopic images in FULL HD ## Natural color rendition ## Reflection is minimized ## Multiple IMAGE1 S technologies for homogeneous illumination, contrast enhancement and color shifting FULL HD image CLARA FULL HD image CHROMA FULL HD image SPECTRA A * FULL HD image SPECTRA B ** * SPECTRA A : Not for sale in the U.S. ** SPECTRA B : Not for sale in the U.S.

77 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 77 IMAGE1 S Camera System n TC 200EN TC 200EN* IMAGE1 S CONNECT, connect module, for use with up to 3 link modules, resolution 1920 x 1080 pixels, with integrated KARL STORZ-SCB and digital Image Processing Module, power supply VAC/ VAC, 50/60 Hz including: Mains Cord, length 300 cm DVI-D Connecting Cable, length 300 cm SCB Connecting Cable, length 100 cm USB Flash Drive, 32 GB, USB silicone keyboard, with touchpad, US * Available in the following languages: DE, ES, FR, IT, PT, RU Specifications: HD video outputs Format signal outputs LINK video inputs USB interface SCB interface - 2x DVI-D - 1x 3G-SDI 1920 x 1080p, 50/60 Hz 3x 4x USB, (2x front, 2x rear) 2x 6-pin mini-din Power supply Power frequency Protection class Dimensions w x h x d Weight VAC/ VAC 50/60 Hz I, CF-Defib 305 x 54 x 320 mm 2.1 kg For use with IMAGE1 S IMAGE1 S CONNECT Module TC 200EN TC 300 TC 300 IMAGE1 S H3-LINK, link module, for use with IMAGE1 FULL HD three-chip camera heads, power supply VAC/ VAC, 50/60 Hz, for use with IMAGE1 S CONNECT TC 200EN including: Mains Cord, length 300 cm Link Cable, length 20 cm Specifications: Camera System Supported camera heads/video endoscopes LINK video outputs Power supply Power frequency Protection class Dimensions w x h x d Weight TC 300 (H3-Link) TH 100, TH 101, TH 102, TH 103, TH 104, TH 106 (fully compatible with IMAGE1 S) , , , , , , (compatible without IMAGE1 S technologies CLARA, CHROMA, SPECTRA*) 1x VAC/ VAC 50/60 Hz I, CF-Defib 305 x 54 x 320 mm 1.86 kg * SPECTRA A : Not for sale in the U.S. ** SPECTRA B : Not for sale in the U.S.

78 78 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery HD Imaging with Operating Microscopes Direct Adaption Direct adaption to the VARIO operating microscope from Carl Zeiss Meditec With the operating microscope the surgeon always has a perfect view of the operating field. Assistents, OR nurses and students, however, often experience poor video presentation, especially if FULL HD visualization is not available. KARL STORZ offers a one-stop-shop solution to upgrade any surgical microscope with state-of-the-art FULL HD imaging technology. To achieve optimal results, all components in the video chain from the camera system to the monitor must be of the highest quality. The most straightforward and professional connection between camera and microscope is the so-called direct adaption. Here the H3-M COVIEW microscope camera and the corresponding QUINTUS TV adaptor are directly connected to the microscope via the C-MOUNT connection.

79 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 79 IMAGE1 S Camera Heads n For use with IMAGE1 S Camera System IMAGE1 S CONNECT Module TC 200EN, IMAGE1 S H3-LINK Module TC 300 and with all IMAGE 1 HUB HD Camera Control Units TH 106 TH 106 IMAGE 1 S H3-M COVIEW Three-Chip FULL HD Camera Head, 50/60 Hz, IMAGE1 S compatible, progressive scan, with C-MOUNT thread for coupling to microscopes, 2 freely programmable camera head buttons, with detachable camera head cable, length 900 cm, for use with IMAGE 1 S and IMAGE 1 HUB HD/HD Keypad, for H3-M camera head, for convenient control of the most important H3-M camera functions, with PS/2 connector, cable length 1 m, alternative to a standard keyboard, for use with H3-M or H3-M COVIEW camera heads, only compatible with IMAGE 1 HUB HD, not compatible with IMAGE 1 S Specifications: IMAGE 1 FULL HD Camera Heads Product code Image sensor Dimensions w x h x d Weight Optical interface Min. sensitivity Grip mechanism Cable Cable length IMAGE 1 S H3-M COVIEW TH 106 3x 1 /3" CCD chip 45 x 50 x 60 mm 240 g C-MOUNT connection F 1.9/1.4 Lux C-MOUNT connection detachable 900 cm

80 80 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery HD Imaging with Operating Microscope System Components QUINTUS High-Performance TV Adaptor for Operating Microscopes Unleash the full performance of your operating microscope from CARL ZEISS MEDITEC with FULL HD imaging solutions from KARL STORZ. The new QUINTUS TV adaptor is the perfect interface between the operating microscope and the H3-M COVIEW FULL HD microscope camera head from KARL STORZ. The innovative features of QUINTUS are easy to use, making it one of the most flexible TV adaptors on the market. Product Features: l A rotating C-MOUNT connection at the QUINTUS TV adaptor allows immediate adaption of the camera orientation during mounting. l The focus control makes it possible to easily achieve parfocality (perfectly sharp camera and microscope images). l The iris control provides convenient and optimal adjustment of the depth of field. l Pan (X) function enables adjustment of the horizontal position of the camera image. l Tilt (Y) function enables adjustment of the vertical position of the camera image. The pan and tilt functions helps the surgeon to adjust the position of the camera image according to his individual needs. l The QUINTUS ZOOM model also features a variable focal length f = mm. This allows the surgeon greater flexibility in choosing the exact zone required for documentation. Focal length of the QUINTUS TV adaptor: The QUINTUS TV adaptor is available in the fixed focal lengths f = 45 and f = 55 mm or as a zoom model with variable focal length mm. This provides an optimal FULL HD image in 16:9 in conjunction with the H3-M COVIEW HD microscope camera head from KARL STORZ. 45 mm 55 mm mm Focal lengths: H3-M COVIEW camera image detail sing a QUINTUS TV adaptor with the fixed focal lengths of 45 and 55 mm. Variable focal length: Adjustable H3-M COVIEW camera image detail using a QUINTUS zoom adaptor with variable focal length of mm.

81 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 81 HD Imaging with Operating Microscope System Components QUINTUS TV Adaptor for operating microscopes from CARL ZEISS MEDITEC with fixed focal length QUINTUS Z 45 TV Adaptor, for CARL ZEISS MEDITEC operating microscopes, f = 45 mm, recommended for IMAGE 1 HD H3-M/H3-M COVIEW camera heads / QUINTUS Z 55 TV Adaptor, for CARL ZEISS MEDITEC operating microscopes, f = 55 mm, recommended for IMAGE 1 HD H3-M/H3-M COVIEW, H3, H3-Z as well as IMAGE 1 S1 and S3 camera heads QUINTUS Zoom TV Adaptor for operating microscopes from CARL ZEISS MEDITEC with variable focal length Z QUINTUS Zoom TV Adaptor, for CARL ZEISS MEDITEC operating microscopes, with variable focal length f = mm, for use with all KARL STORZ cameras (SD and HD) Z Further accessories for operating microscopes from CARL ZEISS MEDITEC Iris, for ZEISS Pentero, iris as a necessary extension between the QUINTUS TV adaptor and the operating microscope ZEISS Pentero Optical Beamsplitter 50/50, for use with ZEISS operating microscope or colposcope Note: Optical beamsplitters for other operating microscopes (i.e. LEICA or Möller-Wedel) are available directly from the manufacturers.

82 82 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery HD Imaging with Operating Microscope System Components QUINTUS TV Adaptor for operating microscopes from LEICA Microsystems with fixed focal length QUINTUS L 45 TV Adaptor, for LEICA Microsystems operating microscopes, f = 45 mm, recommended for H3-M microscope camera head / QUINTUS L 55 TV Adaptor, for LEICA Microsystems operating microscopes, f = 55 mm, recommended for IMAGE 1 HD H3-M/H3-M COVIEW, H3, H3-Z as well as S1 and S3 camera heads QUINTUS TV Adaptor for operating microscopes from LEICA Microsystems with variable focal length Z QUINTUS Zoom TV Adaptor, for Leica Microsystems operating microscopes, with variable focal length f = mm, for use with all KARL STORZ cameras (SD and HD) Z QUINTUS TV Adaptor for operating microscopes from Möller-Wedel with fixed focal length QUINTUS M 45 TV Adaptor, for Möller-Wedel operating microscopes, f = 45 mm, recommended for IMAGE 1 HD H3-M/H3-M COVIEW camera heads / QUINTUS M 55 TV Adaptor, for Möller-Wedel operating microscopes, f = 55 mm, recommended for IMAGE 1 HD H3-M/H3-M COVIEW, H3, H3-Z and S1, S3 camera heads Note: Optical beamsplitters for other operating microscopes (i.e. LEICA or Möller-Wedel) are available directly from the manufacturers.

83 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 83 IMAGE1 S Camera Heads n For use with IMAGE1 S Camera System IMAGE1 S CONNECT Module TC 200EN, IMAGE1 S H3-LINK Module TC 300 and with all IMAGE 1 HUB HD Camera Control Units TH 100 TH 100 IMAGE1 S H3-Z Three-Chip FULL HD Camera Head, 50/60 Hz, IMAGE1 S compatible, progressive scan, soakable, gas- and plasma-sterilizable, with integrated Parfocal Zoom Lens, focal length f = mm (2x), 2 freely programmable camera head buttons, for use with IMAGE1 S and IMAGE 1 HUB HD/HD Specifications: IMAGE1 FULL HD Camera Heads Product no. Image sensor Dimensions w x h x d Weight Optical interface Min. sensitivity Grip mechanism Cable Cable length IMAGE1 S H3-Z TH 100 3x 1 /3" CCD chip 39 x 49 x 114 mm 270 g integrated Parfocal Zoom Lens, f = mm (2x) F 1.4/1.17 Lux standard eyepiece adaptor non-detachable 300 cm TH 104 TH 104 IMAGE1 S H3-ZA Three-Chip FULL HD Camera Head, 50/60 Hz, IMAGE1 S compatible, autoclavable, progressive scan, soakable, gas- and plasma-sterilizable, with integrated Parfocal Zoom Lens, focal length f = mm (2x), 2 freely programmable camera head buttons, for use with IMAGE1 S and IMAGE 1 HUB HD/HD Specifications: IMAGE1 FULL HD Camera Heads Product no. Image sensor Dimensions w x h x d Weight Optical interface Min. sensitivity Grip mechanism Cable Cable length IMAGE1 S H3-ZA TH 104 3x 1 /3" CCD chip 39 x 49 x 100 mm 299 g integrated Parfocal Zoom Lens, f = mm (2x) F 1.4/1.17 Lux standard eyepiece adaptor non-detachable 300 cm

84 84 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 6.2 KARL STORZ Monitors 9619 NB 19" HD Monitor, color systems PAL/NTSC, max. screen resolution 1280 x 1024, image format 4:3, power supply VAC, 50/60 Hz, wall-mounted with VESA 100 adaption, including: External 24 VDC Power Supply Mains Cord 9619 NB 9826 NB 26" FULL HD Monitor, wall-mounted with VESA 100 adaption, color systems PAL/NTSC, max. screen resolution 1920 x 1080, image fomat 16:9, power supply VAC, 50/60 Hz including: External 24 VDC Power Supply Mains Cord 9826 NB

85 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 85 KARL STORZ Monitors KARL STORZ HD and FULL HD Monitors Wall-mounted with VESA 100 adaption Inputs: DVI-D Fibre Optic 3G-SDI RGBS (VGA) S-Video Composite/FBAS Outputs: DVI-D S-Video Composite/FBAS RGBS (VGA) 3G-SDI Signal Format Display: 4:3 5:4 16:9 Picture-in-Picture PAL/NTSC compatible 19" 9619 NB l l l l l l l l l l l l l 26" 9826 NB l l l l l l l l l l l l l Optional accessories: 9826 SF Pedestal, for monitor 9826 NB 9626 SF Pedestal, for monitor 9619 NB Specifications: KARL STORZ HD and FULL HD Monitors Desktop with pedestal Product no. Brightness Max. viewing angle Pixel distance Reaction time Contrast ratio Mount Weight Rated power Operating conditions Storage Rel. humidity Dimensions w x h x d Power supply Certified to 19" optional 9619 NB 200 cd/m 2 (typ) 178 vertical 0.29 mm 5 ms 700:1 100 mm VESA 7.6 kg 28 W 0 40 C C max. 85% x 416 x 75.5 mm VAC EN , protection class IPX0 26" optional 9826 NB 500 cd/m 2 (typ) 178 vertical 0.3 mm 8 ms 1400:1 100 mm VESA 7.7 kg 72 W 5 35 C C max. 85% 643 x 396 x 87 mm VAC EN , UL , MDD93/42/EEC, protection class IPX2

86 86 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 6.3 Cold Light Fountains and Accessories for Video Documentation Fiber Optic Light Cable 495 NCS Fiber Optic Light Cable, with straight connector, extremely heat-resistant, diameter 4.8 mm, length 250 cm 495 NA Fiber Optic Light Cable, with straight connector, diameter 3.5 mm, length 230 cm Cold Light Fountain XENON 300 SCB Cold Light Fountain XENON 300 SCB with built-in antifog air-pump, and integrated KARL STORZ Communication Bus System SCB power supply: VAC/ VAC, 50/60 Hz including: Mains Cord SCB Connecting Cord, length 100 cm Spare Lamp Module XENON with heat sink, 300 watt, 15 volt XENON Spare Lamp, only, 300 watt, 15 volt Cold Light Fountain Power LED 175 SCB Cold Light Fountain Power LED 175 SCB with integrated KARL STORZ Communication Bus System SCB, High Performance LED and one KARL STORZ light outlet power supply: VAC, 50/60 Hz including: Mains Cord SCB Connecting Cord

87 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery Data Management and Documentation KARL STORZ AIDA Exceptional documentation The name AIDA stands for the comprehensive implementation of all documentation requirements arising in surgical procedures: A tailored solution that flexibly adapts to the needs of every specialty and thereby allows for the greatest degree of customization. This customization is achieved in accordance with existing clinical standards to guarantee a reliable and safe solution. Proven functionalities merge with the latest trends and developments in medicine to create a fully new documentation experience AIDA. AIDA seamlessly integrates into existing infrastructures and exchanges data with other systems using common standard interfaces. WD 200-XX* AIDA Documentation System, for recording still images and videos, dual channel up to FULL HD, 2D/3D, power supply VAC, 50/60 Hz including: USB Silicone Keyboard, with touchpad ACC Connecting Cable DVI Connecting Cable, length 200 cm HDMI-DVI Cable, length 200 cm Mains Cord, length 300 cm WD 250-XX* AIDA Documentation System, for recording still images and videos, dual channel up to FULL HD, 2D/3D, including SMARTSCREEN (touch screen), power supply VAC, 50/60 Hz including: USB Silicone Keyboard, with touchpad ACC Connecting Cable DVI Connecting Cable, length 200 cm HDMI-DVI Cable, length 200 cm Mains Cord, length 300 cm *XX Please indicate the relevant country code (DE, EN, ES, FR, IT, PT, RU) when placing your order.

88 88 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery Workflow-oriented use Patient Entering patient data has never been this easy. AIDA seamlessly integrates into the existing infrastructure such as HIS and PACS. Data can be entered manually or via a DICOM worklist. ll important patient information is just a click away. Checklist Central administration and documentation of time-out. The checklist simplifies the documentation of all critical steps in accordance with clinical standards. All checklists can be adapted to individual needs for sustainably increasing patient safety. Record High-quality documentation, with still images and videos being recorded in FULL HD and 3D. The Dual Capture function allows for the parallel (synchronous or independent) recording of two sources. All recorded media can be marked for further processing with just one click. Edit With the Edit module, simple adjustments to recorded still images and videos can be very rapidly completed. Recordings can be quickly optimized and then directly placed in the report. In addition, freeze frames can be cut out of videos and edited and saved. Existing markings from the Record module can be used for quick selection. Complete Completing a procedure has never been easier. AIDA offers a large selection of storage locations. The data exported to each storage location can be defined. The Intelligent Export Manager (IEM) then carries out the export in the background. To prevent data loss, the system keeps the data until they have been successfully exported. Reference All important patient information is always available and easy to access. Completed procedures including all information, still images, videos, and the checklist report can be easily retrieved from the Reference module.

89 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery 89 Equipment Cart UG 220 UG 220 Equipment Cart wide, high, rides on 4 antistatic dual wheels equipped with locking brakes 3 shelves, mains switch on top cover, central beam with integrated electrical subdistributors with 12 sockets, holder for power supplies, potential earth connectors and cable winding on the outside, Dimensions: Equipment cart: 830 x 1474 x 730 mm (w x h x d), shelf: 630 x 510 mm (w x d), caster diameter: 150 mm inluding: Base module equipment cart, wide Cover equipment, equipment cart wide Beam package equipment, equipment cart high 3x Shelf, wide Drawer unit with lock, wide 2x Equipment rail, long Camera holder UG 540 Monitor Swifel Arm, height and side adjustable, can be turned to the left or the right side, swivel range 180, overhang 780 mm, overhang from centre 1170 mm, load capacity max. 15 kg, with monitor fixation VESA 5/100, for usage with equipment carts UG xxx UG 540

90 90 Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery Recommended Accessories for Equipment Cart UG 310 Isolation Transformer, 200 V 240 V; 2000 VA with 3 special mains socket, expulsion fuses, 3 grounding plugs, dimensions: 330 x 90 x 495 mm (w x h x d), for usage with equipment carts UG xxx UG 310 UG 410 Earth Leakage Monitor, 200 V 240 V, for mounting at equipment cart, control panel dimensions: 44 x 80 x 29 mm (w x h x d), for usage with isolation transformer UG 310 UG 410 UG 510 Monitor Holding Arm, height adjustable, inclinable, mountable on left or right, turning radius approx. 320, overhang 530 mm, load capacity max. 15 kg, monitor fixation VESA 75/100, for usage with equipment carts UG xxx UG 510

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