Essentials of Septorhinoplasty

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Essentials of Septorhinoplasty von Hans Behrbohm, Eugene Tardy 1. Auflage Essentials of Septorhinoplasty Behrbohm / Tardy schnell und portofrei erhältlich bei beck-shop.de DIE FACHBUCHHANDLUNG Thematische Gliederung: Plastische, Rekonstruktive & Kosmetische Chirurgie Thieme 2003 Verlag C.H. Beck im Internet: www.beck.de ISBN 978 3 13 131911 1

VIII Contents 1 The Dual Character of Nasal Surgery... 1 Introduction... 2 Historical Review... 3 Origins of Plastic Nasal Surgery... 3 The Development of Plastic Surgery in Berlin and at the Charité Hospital from the 18th to 20th Centuries. 3 History of Surgery of the Internal Nose... 5 Phylogenesis... 7 The Nose as a Respiratory Organ... 7 The Nose as a Sensory Organ... 8 The Olfactory Sense... 8 The Vomeronasal Organ... 9 Prerequisites for the Concept of Functional Esthetic Nasal Surgery... 9 Septal Surgery with Functional and Esthetic Goals... 9 Principles of Submucous Septoplasty... 10 The Pediatric Nasal Septum... 10 The Nasal Valve... 10 Physiological Limits of Nasal Breathing... 11 Atraumatic, Structure-Conserving Techniques of Septorhinoplasty... 12 Functional Aspects of Septorhinoplasty... 12 Olfactory Disturbances... 12 Recurrent and Chronic Sinusitis... 13 Adjunctive Intranasal Measures... 16 Tympanic Ventilation Problems... 18 Rhinogenic Headache... 19 Nasal Surgery and Sleep-Disordered Breathing... 20 W. Pirsig Rhinophonia... 21 W. Seidner Esthetic Aspects of Septorhinoplasty... 22 Selecting an Approach for Septorhinoplasty... 24 Endonasal Approaches... 25 Open Approach... 28 References... 33 2 Contemporary Rhinoplasty: Principles and Philosophy... 37 M. E. Tardy, Jr. Introduction and Philosophy... 38 Indications... 39 Contraindications... 40 Alternative Techniques... 40 Preoperative Considerations... 40 Special Surgical Requirements... 41 Preoperative Analysis... 41 Surgical Techniques... 43 Surgery of the Nasal Tip... 43 Profile Alignment... 58 Bony Pyramid Narrowing and Alignment... 60 Alar Base Reduction... 62 Dressings and Bandages... 62 Key Technical Points... 62 Postoperative Care... 62 Complications... 62 Summary... 63 References... 63 3 Facial Proportions and Esthetic Ideals... 65 I. D. Papel, R. B. Capone Introduction... 66 Facial Proportions... 66 Standard of Reference... 67 Golden Proportion... 67 The Facial Angles... 68 The Face... 68 Analysis of Patients with a Nasal Deformity... 72 General Considerations... 72 Nasal Deformity... 73 Ethnic Variations... 73 The Caucasian Nose... 73 The African Nose... 73 The Asian Nose... 73 Summary... 74 References... 74 4 Physiology and Pathophysiology of Nasal Breathing... 75 G. Mlynski Introduction... 76 Preconditions for the Respiratory Function of the Nose. 76 The Correlation between Shape and Function of the Nose... 76 Inspiration... 76 Expiration... 79 General Remarks... 79 The Problem of Septal Deviation with Compensatory Turbinate Hyperplasia in Terms of Flow Dynamics... 79 Inspiratory Nasal Wing Collapse... 80

Contents IX Rhinological Functional Diagnostics... 80 Rhinomanometry... 80 Rhinoresistometry... 81 Acoustic Rhinometry... 82 Long-Term Rhinoflowmetry... 83 Combination of Rhinoresistometry, Acoustic Rhinometry, and Long-Term Rhinoflowmetry... 83 Concluding Remarks... 87 References... 87 5 Preoperative Management... 89 Evaluation of the Face and External Nose... 90 The First Impression... 90 The Preoperative Consultation... 90 Conducting the Consultation... 90 Analysis, Clinical Geometry... 91 Proportions and Symmetry... 91 The Face from the Front... 91 Skin and Connective-Tissue Type... 92 Profile Analysis... 92 Dentition and Profile... 93 The Nasal Base... 96 Palpation... 96 Manual Examination Techniques... 96 Nasal Endoscopy... 98 Principles of Nasal Endoscopy... 98 Technique... 98 Photographic Documentation... 99 D. Jaeger and Lighting... 100 Focal Length of the Lens... 100 Image Scale... 100 Framing the Image... 101 Background... 101 Film Material... 101 Informed Consent... 101 Personal Recommendations... 101 Psychological Issues in Rhinoplasty... 102 Potential Problem Patients... 102 Preoperative Workup... 102 Rhinological History... 102 Esthetic History... 102 Evaluation of the External Nose... 103 Endoscopic Examination... 103 Diagnostic Imaging... 103 Function Testing... 103 Laboratory Tests... 103 Photographic Documentation... 103 Informed Consent... 103 Planning the Operation... 103 Immediate Preoperative Preparations... 103 Positioning... 103 Local Anesthesia... 103 Marking the Operative Site... 105 Anesthetic Management in Rhinoplastic Operations... 105 M. Goldstein References... 106 6 Principles of Modern Septoplasty... 107 T. Hildebrandt Introduction... 108 Indications... 108 Contraindications... 108 Preoperative Considerations... 108 Preoperative Analysis... 109 Clinical Examination... 109 Function Studies... 109 Imaging Studies... 109 Structural Principles of the Nasal Skeleton and their Surgical Significance... 109 Surgical Technique... 112 References... 114 7 Open Structure Rhinoplasty... 117 D. W. Kim and D. M. Toriumi Introduction... 118 Indications... 118 Contraindications... 118 Alternative Techniques... 118 Preoperative Considerations... 118 Special Surgical Requirements... 119 Preoperative Analysis... 119 Surgical Technique... 121 Incisions Nuances and Technique... 121 Middle Vault... 122 Tip Base Stabilization... 123 Secondary Rhinoplasty... 129 Closure... 134 Key Technical Points... 134 Postoperative Care... 134 Complications... 135 References... 135 Suggested Reading... 135

X Contents 8 Endonasal Tip Approaches and Techniques... 137 S. Perkins Introduction... 138 Indications... 138 Contraindications... 138 Preoperative Considerations... 138 Preoperative Analysis... 139 Surgical Technique... 140 Case Studies... 144 Broad/Wide Tip... 144 Bulbous/Boxy Tip... 144 Bifid Tip... 144 Trapezoid Tip... 146 Asymmetrical Tip... 146 Postoperative Care... 148 Complications... 148 Bossa Formation... 148 Alar Retraction... 148 Tip Asymmetry... 148 Improper Projection... 148 Summary... 148 References... 148 Suggested Reading... 148 9 Alar Reduction and Sculpture... 149 R. Thomas and M. E. Tardy, Jr. Introduction... 150 Indications... 150 Contraindications... 151 Alternative Techniques... 151 Preoperative Considerations... 151 Special Surgical Requirements... 151 Preoperative Analysis... 152 Graduated Surgical Techniques... 154 Internal Nostril Floor Reduction... 154 Wedge Excision Nostril Floor and Sill... 155 Alar Wedge Excision... 155 Alar Flap... 156 Sliding Alar Flap... 156 Key Technical Points... 157 Postoperative Care... 158 Complications... 158 Conclusions... 159 References... 159 Suggested Reading... 159 10 The Deviated Nose... 161 S. S. Park Introduction... 162 Indications... 162 Contraindications... 162 Preoperative Considerations... 162 Age... 163 Preoperative Analysis and Diagnosis... 163 Normal Anatomy and Diagnosis... 163 Analysis of Aberrant Anatomy... 164 Surgical Correction... 168 Upper Third Deviations... 168 Middle Third Deviations... 170 Tip Deviations... 173 Functional Repair... 173 Principles of Postoperative Care... 173 Complications... 175 Conclusion... 175 Representative Cases... 175 Case 1: Mild Dorsal Deviation... 175 Case 2: Severe Dorsal Deviation... 175 Case 3: Fractured Dorsum and Twisted Tip... 176 Case 4: Functional Obstruction from Deviated Dorsum... 182 References... 182 11 The Functional Tension Nose, The Overprojected Nose... 185 Introduction... 186 Definition of Terms... 186 Measurement of Overprojection... 186 Indications... 187 Functional Indications... 187 Esthetic Indications... 189 Contraindications... 190 Functional Contraindications... 190 Esthetic Contraindications... 190 Preoperative Preparations and Prerequisites... 190 Inspection... 190 Palpation... 190 Function Studies... 190 Informed Consent... 190 Photographic Documentation and Computer Simulation... 191

Contents XI Laboratory Tests... 191 Postoperative Measures... 191 Preoperative Analysis... 191 Principles of Surgery for the Overprojected Nose and Tension Nose... 191 Principal Causes of Overprojection... 191 Operative Strategy... 197 Central Role of the Septum... 198 Intranasal Septal Resection... 198 Principles of Profile Correction and Hump Removal... 198 Complications... 199 Infection... 199 Bleeding... 199 Dislocations... 200 References... 200 12 The Saddle Nose Causes and Pathogenesis, Approaches and Operative Techniques, Principles of Tissue Replacement in the Nose... 201 Introduction... 202 Indications... 203 Functional Indications... 203 Esthetic Indications... 203 Contraindications... 203 Preoperative Preparations and Prerequisites... 203 History... 203 Inspection... 205 Nasal Endoscopy... 205 Palpation... 205 Laboratory Tests... 205 Preoperative Analysis... 205 Type I Pathogenic Mechanism of Saddle Nose... 205 Type II Pathogenic Mechanism of Saddle Nose... 206 Type III Pathogenic Mechanism of Saddle Nose... 206 Surgical Strategy... 207 Reconstruction for Minor Saddling of the Cartilaginous Dorsum with a Circumscribed Defect in the Cartilaginous Septum and Normal Tip Support. 207 Reconstruction for Deep Saddling of the Cartilaginous Dorsum with Extensive Cartilage Losses or Septal Perforations and Adequate Tip Support... 207 Harvesting the Donor Cartilage... 209 Reconstruction of the Nasal Dorsum with Severe Loss of Tip Support... 209 Guidelines for Tissue Replacement in the Nose... 211 Graft Requirements... 211 Synthetic Implants... 211 Autologous Grafts... 214 Allografts... 215 Fibrin Glue... 215 Principles of Implantology in the Nose... 215 Harvesting Graft Material... 216 Preparing the Recipient Bed... 216 Postoperative Care... 216 Complications... 217 References... 217 13 Nasal Trauma... 219 O. Kaschke Introduction... 220 Trauma-Relevant Anatomy of the Nose... 220 Classification of Nasal Trauma... 221 Isolated Central Nasal Fractures... 221 Naso-orbito-ethmoid Fractures... 223 Diagnostics... 224 Inspection and Palpation... 224 Intranasal Diagnostics... 224 Imaging Diagnostics... 225 Management of Nasal Traumas... 226 Chronological Procedure... 226 Anesthesia... 226 Management of Isolated Central Nose Fractures... 226 Management of Naso-orbito-ethmoid Fractures... 229 Management of Soft-Tissue Injuries to the Nose... 230 Long-term Complications Following Nasal Traumas... 231 References... 231 14 Postoperative Care and Management... 233 O. Kaschke Introduction... 234 Intraoperative Management... 234 Internal Dressing... 234 External Dressing... 236 Postoperative Management... 236 First Postoperative Day... 236 Early Postoperative Period... 236 Late Postoperative Period... 239 References... 241 Index... 243

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