ATLAS OF OPERATIVE Vol.

3
OTORHINOLARYNGOLOGY
AND HEAD & NECK SURGERY

FACIAL PLASTICS, COSMETICS AND

RECONSTRUCTIVE SURGERY
 ATLAS OF OPERATIVE Vol. 3
OTORHINOLARYNGOLOGY
AND HEAD & NECK SURGERY

FACIAL PLASTICS, COSMETICS AND

RECONSTRUCTIVE SURGERY
Editors

Bachi T Hathiram
Professor and Head
Department of ENT and Head and Neck Surgery
Topiwala National Medical College and
BYL Nair Charitable Hospital
Mumbai, Maharashtra, India

Vicky S Khattar
Assistant Professor
Department of ENT and Head and Neck Surgery
Topiwala National Medical College and
BYL Nair Charitable Hospital
Mumbai, Maharashtra, India

Forewords
Jatin P Shah
Milind V Kirtane

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Atlas of Operative Otorhinolaryngology and Head & Neck Surgery:

Facial Plastics, Cosmetics and Reconstructive Surgery (Vol. 3)

First Edition: 2013

ISBN 978-93-5090-481-7
Printed at:
 Dedicated to

Shri Swami Samarth

My father, Adi Dinshaw Mistry—Who taught me the value of hard work and loyalty
My mother, Viloo Adi Mistry—For her selfless love and caring
Both my parents and mamma—For their blessings and encouragement
My husband, Tempton—Always loving, caring and encouraging
My miracle and happiness, Karishma and Khushi—For making life worthwhile
Rustom, Khushru, Firozee, Sharon, Jenaifer, Zenia,
Travis and Hazel—For believing in me and being with me
Bachi T Hathiram

My father, Subhash Chandra Gyanchand Khattar—My support

My mother, Veena Subhash Khattar—My encouragement
My grandparents, Gyanchand Khattar, Mohandevi Khattar,
Vas Dev Pawa, Tulsidevi Pawa—Who indulged me
Shalu, Sameer, Sehar and Sia—My indulgence
My family, friends, teachers and students
Vicky S Khattar
 Contributors

Ahmad Abu-Omar DOHNS MRCS Lynzee N Alworth PhD AuD Luca Autelitano MD
Educational Fellow in CCC-A F/AAA Maxillo-Facial Surgeon
Otolaryngology Assistant Professor of Audiology Smile House, San Paolo Hospital
Whipps Cross University Hospital University Audiology Associates University of Milan, via A. di Rudinì
London, UK University of Louisville Milan, Italy
Kentucky, USA
Bashar Abuzayed MD Gregor Bachmann-Harildstad MD PhD
Attending Neurosurgeron Danic Hadzibegovic Ana MD Akershus University Hospital/UIO
Department of Neurosurgery Department of Otorhinolaryngology Otorhinolaryngology
Cerrahpasa Medical Faculty and Maxillofacial Surgery Nordbyhagen, Norway
Istanbul University Istanbul, Turkey Medical School Osijek, University
Josip Juraj Strossmayer of Osijek Vincent Bachy
Rahul Agrawal Croatia Departement de Chirurgie
Department of ENT and ORL et Chirurgie Cervico-Faciale
Skull Base Surgery Miroslav Andrić DDS Msc Site Mont-Godinne: Avenue
Dr Balabhai Nanavati Hospital Clinic of Oral Surgery Docteur G Thérasse
Mumbai, Maharashtra School of Dentistry Yvoir, Belgium
India University of Belgrade
Belgrade, Serbia Mohamed Badr-El-Dine MD
Vikas Agrawal MS FCPS DORL Professor of Otolaryngology
Consultant ENT Surgeon Nebil Ark Consultant Otology
Speciality ENT Hospital, Kandivli Fatih University, Faculty of Medicine Neurotology and
Asian Heart Institue, Bandra Department of Otorhinolaryngology Skull Base Surgery
Sevenhills Hospital, Andheri Head and Neck Surgery Faculty of Medicine
BSES MG Hospital, Andheri Ankara, Turkey University of Alexandria, Egypt
Mumbai, Maharashtra President of the
India V Arora Egyptian Society of
Associate Professor Skull Base Surgery
RG Aiyer Department of ENT and Egypt
Professor and Head Head Neck Surgery
Department of ENT and University College of Yogesh Bajaj MS MD FRCS (ORL HNS)
Head and Neck Surgery Medical Sciences and Consultant ENT
Govt Medical College and GTB Hospital Barts Children’s Hospital and
SSG Hospital New Delhi, India Royal London Hospitals
Vadodara, Gujarat, India Honorary Lecturer
Katie L Austin AuD CCC-A F/AAA Anglia Ruskin University
KM Ajith Audiologist London, UK
Department of ENT Heuser Hearing Institute, and
SS Institute of Medical Sciences and Heuser Speech and Karthikeyan Balasubramanian
Research Center Language Academy Department of Surgical Oncology
Davangere, Karnataka Louisville Prince Aly Khan Hospital
India Kentucky, USA Mumbai, Maharashtra, India
 viii Facial Plastics, Cosmetics and Reconstructive Surgery

Maurizio Barbara Kofi DO Boahene James A Burns

ENT Clinic, Sant’Andrea Hospital Assistant Professor Massachusetts General Hospital
Sapienza University Facial Plastic and Division of Laryngeal Surgery
Rome, Italy Reconstructive Surgery Boston, Massachusetts, USA
Johns Hopkins Facial Plastic and
Brajendra Baser MS (AIIMS) DNB Reconstructive Surgery Center Giulia Carnevali MD
Professor and Head of ENT Minimally Invasive Skullbase Surgery
Maxillo-Facial Surgeon
Shri Aurbindo Institute of Microvascular Surgery
Department of Traumatology and
Medical Sciences (SAIMS Medical Department of Otolaryngology
Maxillo Facial Surgery
College) Head and Neck Surgery
Johns Hopkins Medical Institute, USA AOUC Hospital and University of
Director Akash Hospital
Florence Largo Palagi
Indore, Madhya Pradesh
Miriam Boenisch MD PhD Florence, Italy
India
Medicent Linz, Untere
BP Belaldavar Donaulände Giorgio Carrabba MD PhD
Department of ENT, KLE University’s Linz, Austria Neurosurgery
JN Medical College and Fondazione IRCCS Ca’ Granda
Consultant ENT Surgeon, KLES Mariano M Boglione MD Ospedale Maggiore Policlinico
Dr Prabhakar Kore Hospital Pediatric Surgeon University of Milano
Belgaum, Karnataka, India General Pediatric Surgery Division Milano, Italy
Chief of Lung Transplant Program
Michael S Benninger MD Hospital de Pediatría Ricardo L Carrau MD FACS
Prof Dr Juan P Garrahan Professor
Chairman, Head and Neck Institute
Buenos Aires, Argentina Department of Otolaryngology
The Cleveland Clinic
Professor of Surgery Head and Neck Surgery
Luis A B Borba MD PhD The Ohio State University
The Learner School of
Medicine of Case Western Professor Medical Center
Chief of the Neurosurgical West 10th Avenue
Reserve University
Department Cramblett Hall, Columbus
Euclid Avenue
Evangelic Universitary Hospital Ohio, USA
Cleveland, Ohio, USA
Curitiba, Paraná, Brazil.
Neurosurgeon of the Brain and Ali Diaz Castillejos
Abir K Bhattacharyya MS DNB FRCS
Heart Institute
FRCS(ORL) FACS
Curitiba, Paraná, Brazil Fellow of Cranial Base Surgery
Consultant Otolaryngologist and Evangelic Universitary Hospital
Head and Neck Surgeon Jennings R Boyette MD Curitiba, Paraná – Brazil
Associate Director of Department of Otolaryngology—
Medical Education (Surgery) and Head and Neck Surgery CW David Chang MD
Royal College Surgical Tutor University of Arkansas for Associate Clinical Professor, Facial
Whipps Cross University Hospital Medical Sciences Plastic and Reconstructive Surgery
London, UK Arkansas Children’s Hospital Residency Program Director
Little Rock, Arkansas, USA Department of Otolaryngology
Merill Biel Head and Neck Surgery
Department of Otolaryngology Ryan F Brown MD University of Missouri
University of Minnesota Department of Head and Neck One Hospital Drive
Minneapolis Surgery Kaiser Permanente Columbia
Minnesota, USA Denver Colorado, USA Missouri, USA
 Contributors ix

Dinesh K Chhetri MD Rajib Dasgupta Akshay P Deshpande

University of California— London, UK Resident, Department of Plastic
Los Angeles Surgery TN Medical College and
Department of Danic Davorin MD PhD BYL Nair Charitable Hospital
Head and Neck Surgery Department of Otorhinolaryngology Mumbai, Maharashtra, India
CHS 62-132, UCLA and Maxillofacial Surgery
School of Medicine Medical School Osijek Snigdha Devane
Los Angeles University Josip Juraj Resident—Department of ENT and
California, USA Strossmayer of Osijek, Croatia Head and Neck Surgery, TN Medical
College and BYL Nair
Chi-Yee Choi Matteo de Notaris MD PhD Charitable Hospital
Mumbai, Maharashtra, India
Division of Head and Neck Department of Neurosurgery
Reconstruction Surgery Hospital Clinic, Faculty of Medicine
PV Dhond MS (ENT) DORL
Department of Surgery Universitat de Barcelona
Laboratory of Surgical Honorary Consultant
United Christian Hospital Bhagwati Hospital
Hong Kong Neuroanatomy (LSNA)
Faculty of Medicine Mumbai, Maharashtra, India
SAR, China
Universitat de Barcelona
Sara R Dickie MD
Tam-Lin Chow Barcelona, Spain
Section of Plastic and
Division of Head and Neck Reconstructive Surgery
Alberto Deganello MD PhD
Reconstruction Surgery University of Chicago
Department of Surgery Head and Neck Surgeon
Department of Surgery
Assistant Professor in Otolaryngology
United Christian Hospital Chicago, Illinois, USA
SOD Otolaryngology 1
Hong Kong
Department of Surgical Sciences J Dings
SAR, China
AOU-Careggi, University of Florence
Department of Neurosurgery
Vle Morgagni, Florence, Italy
Yakup Cil MD Maastricht University Medical Center
Plastic Surgeon The Netherlands
Amir R Dehdashti MD FACS
Eskisehir Military Hospital
Geisinger Clinic Gilles Dolivet MD PhD
Department of Plastic Surgery Department of Neurosurgery, USA
Eskisehir, Turkey Head and Neck Surgeon
Otolaryngologist
C E Deopujari Head of the Surgical
Joseph Curry
Department of Neurosurgery Oncology Department
Department of Otolaryngology Bombay Hospital National Cancer Institute
Head and Neck Surgery Mumbai, Maharashtra, India “Alexis Vautrin”
University of Miami Miller School of Av. de Bourgogne
Medicine, Miami Daniel G Deschler Vandoeuvre-Les-Nancy
Florida, USA Director University of Nancy
Division of Head and Neck Surgery France
Sanket Dani Department of Otology and
Resident—Department of ENT and Laryngology Adam Donne
Head and Neck Surgery Massachusetts Eye and Ear Infirmary Consultant in Paediatric
TN Medical College and Associate Professor Otolaryngology Alder
BYL Nair Charitable Hospital Harvard Medical School Hey Children’s Hospital
Mumbai, Maharashtra, India Boston, Massachusetts, USA Liverpool, UK
 x Facial Plastics, Cosmetics and Reconstructive Surgery

Mark Domanski Audrey B Erman Lorenzo Gaini

Department of Otolaryngology— Department of Otology and Department of Otorhinolaryngology
Head and Neck Surgery Laryngology IRCCS Policlinico
The George Washington University Massachusetts Eye and Ear Infirmary University of Milano-Statale
USA Harvard Medical School Milano, Italy
Boston, Massachusetts, USA
Prgomet Drago Oreste Gallo MD
Clinics of Otorhinolaryngology Waleed F Ezzat Associate Professor in
Head and Neck Surgery Professor of Otolaryngology Head Otolaryngology
Clinical Hospital Centar Zagreb and Neck Surgery Head of the SOD Otolaryngology
Medical School Zagreb Ain- Shams University Department of Surgical Sciences
University of Zagreb, Croatia Cairo, Egypt AOU-Careggi
University of Florence
Yadranko Ducic MD FACS FRCS Leo FS Ditzel Filho Vle Morgagni
Clinical Professor Research Fellows Florence, Italy
Department of Otolaryngology— Department of Neurological Surgery
Head and Neck Surgery at the The Ohio State University Werner Garavello
University of Texas Southwestern Columbus, USA Department of Otorhinolaryngology
Medical Center, Dallas Texas San Gerardo Hospital
Baylor Neuroscience Skullbase Dan M Fliss MD University of Milano Bicocca
Program Dallas Fort Worth Texas Professor and Chairman Monza, Italy
Otolaryngology and Facial Plastic Department
Surgery Associates Fort Worth Otolaryngology Celeste C Gary MD
Texas, USA Head and Neck Surgery Department of Otolaryngology
and Maxillofacial Surgery Head and Neck Surgery
Jason Durel Tel-Aviv Sourasky Medical Center Louisiana State University Health
Resident Physician 6 Weizmann St, Tel-Aviv, Israel Sciences Center
Department of Otolaryngology— 533 Bolivar Street
Head and Neck Surgery Hossam MT Foda MD New Orleans, Louisiana, USA
Louisiana State University Professor and Chief of
Health Sciences Center Facial Plastic Surgery Jacques Gaudet
New Orleans, Louisiana, USA Otolaryngology Department Resident Physician,
Alexandria Medical School, Egypt Department of Otolaryngology–
Philippe Eloy Head and Neck Surgery,
Department of Otorhinolaryngology Arun K Gadre MD FACS MS(Bom) DORL Louisiana State University
University of Louvain (Belgium) HHI Professor of Otology and Health Sciences Center
Cliniques de Mont Godinne (Yvoir) Neurotology New Orleans, Louisiana, USA
Av Therasse Director of Otology, Neurotology and
Yvoir, Belgium Skull Base Surgery Panagiotis Gerbesiotis MD PhD
Associate Professor of Registrar—ENT Surgeon
Joaquim Enseñat MD PhD Otolaryngology—Head and Neck 2nd University Department of
Department of Neurosurgery Surgery Otorhinolaryngology
Hospital Clinic, Faculty of Medicine Department of Surgery Head and Neck Surgery
Universitat de Barcelona University of Louisville ATTIKON Hospital, Rimini 1
Barcelona, Spain Kentucky, USA Chaidari, Athens, Greece
 Contributors xi

Nurperi Gazioglu MD Arunesh Gupta Imtiyaz Hussain Hakeem

Professor in Neurosurgery Assistant Professor Resident
Department of Neurosurgery Department of Plastic Surgery Department of Internal Medicine
Cerrahpasa Medical Faculty TN Medical College and Florida Hospital Medical Center
Istanbul University BYL Nair Charitable Hospital Orlando, Florida, USA
Istanbul, Turkey Mumbai, Maharashtra, India
Bachi T Hathiram
Gianni Gitti MD PhD Ashok K Gupta Professor and Head
Otolaryngologist Professor and Head Department of ENT and
Centro Rieducazione Ortofonica Department of Otolaryngology Head and Neck Surgery
Piazzale della Porta al Prato (Unit II) TN Medical College and
Florence PGIMER, Chandigarh, India BYL Nair Charitable Hospital
Italy Mumbai, Maharashtra, India
Rahul Gupta
Haralampos Gouveris Biswajyoti Hazarika
Assistant Professor
Department of Otorhinolaryngology Department of ENT and Senior Consultant
The University of Head and Neck Surgery Department of Surgical Oncology
Mainz Hospitals and Clinics Govt. Medical College and Max Cancer Center
Langenbeckstr, Mainz, Germany SSG Hospital New Delhi, India
Vadodara, Gujarat, India
Cassio Zottis Grapiglia MD Barbara Henderson
Fellow of Cranial Base Surgery Mehmet Habesoglu Department of Biophysics/Cell
Evangelic Universitary Hospital Department of II-Otolaryngology— Stress Biology
Curitiba, Paraná – Brazil Head and Neck Surgery Roswell Park Cancer Institute
Haydarpasa Numune Education and Buffalo, NY, USA
Jorge Orlando Guerrissi Research Hospital, Turkey
Patrick T Hennessey MD
Head, Department of
Tulay Erden Habesoglu PGY-5 Resident
Plastic and Reconstructive Surgery
Head and Neck Surgery Department of II-Otolaryngology— The Johns Hopkins Hospital
Head and Neck Surgery Department of Otolaryngology—
Argerich Hospital
Haydarpasa Numune Education and Head and Neck Surgery, USA
Health Ministery of Ciudad
Research Hospital, Turkey
Autonoma de Buenos Aires
Argentina Björn Herman
Josef Haik MD MPH
Department of Otolaryngology
Assistant Professor of Plastic Surgery; University of Miami
Anish K Gupta
Deputy of the Division of Plastic and School of Medicine, USA
Sr Consultant Reconstructive Surgery
Department of ENT Director of the Intensive Care Burn
Fortis Hospital Yasuyuki Hinohira
Unit Sheba Medical Center
Mohali Tel-Aviv University Department of Otorhinolaryngology
Punjab, India Ramat Gan, Israel Showa University School of Medicine
Hatanodai, Shinagawa, Tokyo, Japan
Anuragini Gupta Arsheed Hussain Hakeem
Jr Resident Consultant Steven B Hopping
Department of ENT Department of Head and Neck Department of Otolaryngology—
Resident BSPH Surgery and Surgical Oncology Head and Neck Surgery
Bhilai Prince Aly Khan Hospital The George Washington University
Chattisgarh, India Mumbai, Maharashtra, India USA
 xii Facial Plastics, Cosmetics and Reconstructive Surgery

Takashi Horiguchi Narayan Jayashankar Gauri Kapre

Associate Professor Department of Otorhinolaryngology Consultant ENT surgeon
Department of Neurosurgery and the Skull Base Group Neeti Clinics, Nagpur
Keio University School of Medicine Department of ENT and Clinical Fellow
Japan Skull Base Surgery Bombay Hospital
Dr Balabhai Nanavati Hospital Mumbai, Maharashtra, India
K Hörmann Mumbai, Maharashtra, India
Head and Chair of the Department of Madan Kapre
ORL and Head and Neck Surgery Deya Jourdy Director Neeti Clinics, Nagpur
University Hospital of Mannheim Honorary senior surgeon
Department of Otolaryngology
Mannheim, Germany RST Cancer Hospital Nagpur
University of Miami School of
Medicine, USA Maharashtra, India
Gilad Horowitz
Department Otolaryngology Pornthep Kasemsiri
Javier Herrero Jover MD PhD
Head and Neck Surgery and
Plastic Surgery Department Research Fellows
Maxillofacial Surgery
Centro Medico TEKNON Department of Otolaryngology and
Tel-Aviv Sourasky Medical Center
Vilana, Barcelona, Spain Head and Neck Surgery
6 Weizmann St, Tel-Aviv, Israel
The Ohio State University
Akinobu Kakigi MD Columbus, USA
Sonna Ifeacho
Department of Otolaryngology Assistant Professor
Amin B Kassam
Great Ormond Street Hospital Department of Otolaryngology
London, UK Head and Neck Surgery Professor
Faculty of Medicine Department of Neurological Surgery
Shabbir Indorewala University of Ottawa
Tokyo University, Japan
Ottawa, Canada
Department of Otorhinolaryngology
and The Skull Base Group Mohan Kameswaran DSc MS FRCS (Ed)
Daniel F Kelly MD
Dr Balabhai Nanavati Hospital FAMS FICS DLO
Mumbai, Maharashtra, India Brain Tumor Center and Pituitary
Consultant ENT Surgeon
Disorders Program
Department of Implant Otology
Ankit Jain John Wayne Cancer Institute at Saint
Madras ENT Research Foundation
Resident—Department of ENT and John's Health Center
Raja Annamalaipuram, Chennai Santa Monica, California, USA
Head and Neck Surgery, TN Medical Tamil Nadu, India
College and BYL Nair
Charitable Hospital Guy Kenyon FRCS
Tolga Kandogan MD
Mumbai, Maharashtra, India Consultant ENT Surgeon
Associate Professor of Whipps Cross University Hospital
Yong Ju Jang Otolaryngology Head and Neck NHS Trust
Surgery 69 Harley Street
Professor
Izmir Bozyaka Teaching and London, UK
Department of Otolaryngology
Asan Medical Center Research Hospital
University of Ulsan College of Department of Otol Aryngology Vicky S Khattar
Medicine, Seoul, Korea Head and Neck Surgery Assistant Professor
Izmir Bozyaka, Turkey Department of ENT and
Sharan C Jayaram Head and Neck Surgery
Head and Neck Fellow Sunita Kanojia TN Medical College and
Department of Otolaryngology Department of ENT BYL Nair Charitable Hospital
New Queen Elizabeth Hospital Bombay Hospital Mumbai, Maharashtra
Birmingham, UK Mumbai, Maharashtra, India India
 Contributors xiii

Sunil Khot Murat Küçüktaş MD Guglielmo Larotonda MD

Resident—Department of ENT and Departments of Dermatology Resident in Otolaryngology, SOD
Head and Neck Surgery Nevşehir State Hospital Otolaryngology 1
TN Medical College and Nevşehir, Turkey Department of Surgical Sciences
BYL Nair Charitable Hospital AOU-Careggi, University of Florence
Mumbai, Maharashtra, India Melda Kunduk Vle Morgagni, Florence, Italy
Assistant Professor
Ji Heui Kim Department of Otolaryngology— Georges Lawson
Department of Otolaryngology Head and Neck Surgery Otolaryngology
Asan Medical Center Louisiana State University Head and Neck Surgery Department
University of Ulsan Health Science Center Louvain University Hospital of
College of Medicine New Orleans ­Mont-Godinne, Yvoir, Belgium
Seoul, Korea Louisiana, USA
Davide Lazzeri MD
Milind Kirtane Daniel B Kuriloff MD FACS Plastic Surgeon
Professor Emeritus Seth GS Director Plastic and Reconstructive Surgery
Medical College Center for Thyroid and Unit, Santa Chiara Hospital of Pisa
Hon Surgeon at KEM Hospital Parathyroid Surgery Via Roma Pisa, Italy
Hon Consulting ENT Surgeon at PD New York Head and Neck Institute
Hinduja National Hospital Lenox Hill Hospital Eugenijus Lesinskas MD PhD
Hon ENT Consultant to his Associate Professor Clinic of Ear, Nose
Excellency the Governor of Clinical Otolaryngology Throat and Eye Diseases
Maharashtra Head and Neck Surgery Medical Faculty
Hon ENT Consultant at Columbia University Vilnius University, Lithuania
Prince Aly Khan Hospital 110 East 59th Street
Mumbai, Maharashtra, India New York, NY, USA Andreas Leunig
Professor Dr. Med. Andreas Leunig
Janusz Klatka Balagopal Kurup HNO-Zentrum Starnberg
Department of Otolaryngology and Resident Prinzenweg 1
Laryngeal Oncology Department of ENT and Starnberg, Germany
Medical University of Lublin Head and Neck Surgery
Poland TN Medical College and Roman Liscak
BYL Nair Charitable Hospital Na Homolce Hospital
Masahiro Komori Mumbai, Maharashtra, India Prague, Czech Republic
Department of Otolaryngology
Head and Neck Surgery Zekayi Kutlubay MD Marco Locatelli MD PhD
Kochi Medical School Departments of Dermatology Neurosurgery,
Okatoyo, Nankoku İstanbul University Cerrahpaşa Fondazione IRCCS Ca’ Granda
Kochi, Japan Medical Faculty, İstanbul, Turkey Ospedale Maggiore Policlinico,
University of Milano,
Shenal Kothari MS Danielle de Lara Milano, Italy
Associate Professor of ENT Research Fellows
Department of ENT Department of Neurological Surgery Kevin Lollar MD
SAIMS Medical College The Ohio State University Private Practice
Indore, Madhya Pradesh, India Columbus, USA Hannibal, Missouri, USA
 xiv Facial Plastics, Cosmetics and Reconstructive Surgery

Jennifer L Long MD PhD Nayla Matar Sonal Modi

University of California-Los Angeles Otolaryngology Department of Otorhinolaryngology
Department of Head and Neck Head and Neck Surgery Department and the Skull Base Group
Surgery Hôtel Dieu de France Dr Balabhai Nanavati Hospital
UCLA School of Medicine Bellevue Medical Center Mumbai, Maharashtra, India
Los Angeles, California, USA Saint-Joseph University
Beirut, Lebanon Arash Mohebati
Claudio Macrì
Senior Fellow in Head and Neck
ENT Clinic, Sant’Andrea Hospital Nancy McLaughlin
Sapienza University Surgery
USA Memorial Sloan Kettering Cancer
Rome, Italy
Center New York, USA
Vishal Madan MBBS (Hons) MD MRCP Andrew J McWhorter
Consultant Dermatologist Assistant Professor Aliasgar Moiyadi
Laser and Dermatological Surgeon Director Associate Professor
Salford Royal NHS Foundation Department of Otolaryngology— Department of Neurosurgery
Trust Stott Lane Head and Neck Surgery Tata Memorial Center
Salford, Manchester, UK Louisiana State University Health Mumbai, Maharashtra, India
Sciences Center
Amit Magadum New Orleans Simonetta Monini
Resident—Department of Anatomy Louisiana, USA
ENT Clinic, Sant’Andrea Hospital
JN Medical College
Belgaum, Karnataka, India Madhuri Mehta Sapienza University
Rome, Italy
Department of Otorhinolaryngology
Dipesh J Malviya and the Skull Base Group
Resident—Department of Plastic Eric J Moore MD
Dr Balabhai Nanavati Hospital
Surgery, TN Medical College and Mumbai, Maharashtra, India Mayo Clinic Department of
BYL Nair Charitable Hospital Otolaryngology
Mumbai, Maharashtra, India Head and Neck Surgery
Jayakumar R Menon
200 First Street SW
Jaiganesh Manickavasagam Consultant Laryngologist, Kerala
Institute of Medical Sciences Rochester, Minnesota, USA
FRCS (ORL-HNS)
Royal Hallamshire Hospital Thiruvananthapuram, Kerala, India
KP Morwani
Sheffield, UK
Rajendra B Metgudmath Department of ENT and
Gauri Mankekar Consultant, Head and Neck Surgical Skull Base Surgery
Oncologist, KLES Dr Prabhakar Kore Dr Balabhai Nanavati Hospital
ENT Consultant
PD Hinduja Hospital Hospital and MRC Belgaum Mumbai, Maharashtra, India
Mahim, Mumbai, Maharashtra, India Associate Professor
Surgical Oncology (Head and Neck) Fabrizio Moscatiello MD PhD
Wolf J Mann JN Medical College, KLE University Plastic Surgery Department,
Department of Otorhinolaryngology Belgaum, Karnataka, India Centro Medico TEKNON
The University of Mainz Hospitals Vilana, Barcelona, Spain
and Clinics, Mainz, Germany Jignesh Mewa
Department of Surgical Oncology RS Mudhol
Alexander Margulis MD Prince Aly Khan Hospital Professor and Head, Department of
Senior Lecturer Mumbai, Maharashtra, India ENT, KLE University’s JN Medical
Hebrew University College and
School of Medicine Julie A Miller Consultant ENT surgeon, KLES
Head—Center for Pediatric and
Craniofacial Plastic Surgery Department of Surgery Dr Prabhakar Kore Hospital
Hadassah Medical Center Royal Melbourne Hospital and Belgaum, Karnataka
Jerusalem, Israel University of Melbourne, Australia India
 Contributors xv

Rajashekhar Myageri Jerzy Nyzio MD Giampiero Parrinello MD

Assistant Professor Intensive Care Unit Otolaryngologist, PhD Student
SDM Medical College St John Grande’s Hospital SOD Otolaryngology
Dharwad, Karnataka, India Kraków, Poland Department of Surgical Sciences
AOU-Careggi, University of Florence
Lalita Naik Matthew Old Vle Morgagni
Skull Base Surgery Team, Department of Otolaryngology and Florence, Italy
Dr Balabhai Nanavati Hospital Head and Neck Surgery
Mumbai, Maharashtra, India The Ohio State University Prashant Patil
Columbus, USA Associate Professor
Haralampos Gouveris JN Medical College
Department of Otorhinolaryngology, Peter D Oliver Belgaum, Karnataka
The University of Mainz Hospitals Department of Otolaryngology India
and Clinics, Mainz, Germany Head and Neck Surgery
Louisiana State University Health Amol Patil
Deepa Nair Sciences Center Department of Otorhinolaryngology
Assistant Professor Bolivar Street and The Skull Base Group
Department of Head and Neck New Orleans Dr Balabhai Nanavati Hospital
Surgical Oncology Louisiana, USA Mumbai, Maharashtra
Tata Memorial Center
India
Mumbai, Maharashtra, India
Goldan Oren MD
Attending Surgeon, Division of R N Patil
Amith Naragund
Plastic and Reconstructive Surgery Professor
Assistant Professor, Department of
Sheba Medical Center Department of ENT, KLE University’s
ENT, KLE University’s
JN Medical College and Tel-Aviv University JN Medical College and
Consultant ENT Surgeon, KLES Ramat Gan, Israel Consultant ENT surgeon, KLES
Dr Prabhakar Kore Hospital Dr Prabhakar Kore Hospital
Bradley A Otto Belgaum, Karnataka, India
Belgaum, Karnataka, India
Assistant Professor,
Chitra Nayak Department of Otolaryngology and Sultan A Pradhan
Associate Professor and Head Head and Neck Surgery Professor and Chief Oncologist
Department of Dermatology The Ohio State University Department of Surgical Oncology
TN Medical College and Columbus, USA Prince Aly Khan Hospital
BYL Nair Charitable Hospital Mumbai, Maharashtra, India
Mumbai, Maharashtra, India Sumeet Pahwa
Fellow, Surgical Oncology Rashmi Prashant
Nupur Kapoor Nerurkar
Prince Aly Khan Hospital Assistant Professor,
Laryngologist Mumbai, Maharashtra Department of ENT
Bombay Hospital
India DY Patil Medical College
Mumbai, Maharashtra, India
Pimpri, Maharashtra, India
Thomas P Nikolopoulos Prathamesh S Pai
Associate Professor—ENT Surgeon Associate Professor Alberto Prats-Galino MD PhD
2nd University Department of Department of Head and Neck Laboratory of Surgical
Otorhinolaryngology Surgical Oncology Neuroanatomy (LSNA)
Head and Neck Surgery Tata Memorial Center Faculty of Medicine
ATTIKON Hospital, Rimini 1, Mumbai, Maharashtra Universitat de Barcelona
Chaidari Athens, Greece India Barcelona, Spain
 xvi Facial Plastics, Cosmetics and Reconstructive Surgery

Daniel M Prevedello Marc Remacle H Sadick

Assistant Professor Otolaryngology Head and Chair of the Department of
Department of Neurological Surgery Head and Neck Surgery Department ORL and Head and Neck Surgery
The Ohio State University Louvain University Hospital of University Hospital of Mannheim
Columbus, USA ­Mont-Godinne, Yvoir, Belgium Mannheim
Germany
Ashutosh G Pusalkar Roberta Rehder MD
Emeritus Professor, Resident Program Dariusz Sagan
Padmashree Dr DY Patil Medical Evangelic Universitary Hospital
College, Honorary Consultant Department of Thoracic Surgery
Curitiba Medical University of Lublin
Lilavati Hospital and Medical
Paraná – Brazil
Research Center Poland
Mumbai, Maharashtra, India
Gresham T Richter MD
Lucel E Salvan DA
Ullas Raghavan FRCS (ORL-HNS) Department of Otolaryngology—
Secretary
Doncaster Royal Infirmary Hospital Head and Neck Surgery
ENT-Voice Center
Doncaster, UK University of Arkansas for
Medical Sciences Yanhee International Hospital
Arkansas Children’s Hospital Bangkok
S Raghunandhan MS DNB
MRCS (Ed) DOHNS Little Rock, Arkansas, USA Thailand
Consultant ENT Surgeon
Nestor Rigual Suresh Sankhla
Department of Implant Otology
Madras ENT Research Foundation Department of Head and Neck/ Department of Neurosurgery
Raja Annamalaipuram Plastic Surgery, Dr Balabhai Nanavati Hospital
Chennai, Tamil Nadu, India Roswell Park Cancer Institute, Mumbai, Maharashtra
Buffalo, NY, USA India
Kannan Rajan
Senior Oncosurgeon Supriya Rode Zoukaa Sargi
Department of Surgical Oncology Resident – Department of ENT and Department of Otolaryngology,
Prince Aly Khan Hospital Head and Neck Surgery Head and Neck Surgery,
Mumbai, Maharashtra, India TN Medical College and University of Miami Miller
BYL Nair Charitable Hospital School of Medicine
Reema Rai
Mumbai, Maharashtra, India Miami
Resident
Department of ENT and Florida, USA
Philippe Rombaux
Head and Neck Surgery
TN Medical College and BYL Nair Department of Otorhinolaryngology Tamer Seyhan MD
Charitable Hospital University of Louvain
Assoc. Prof. of Plastic
Mumbai Maharashtra, India Cliniques Saint Luc Brussels
Reconstructive and Esthetic Surgery
Av Hippocrate, Brussels, Belgium
Adana Numune Education and
Suthee Rattanathummawat MD ENT Teaching Hospital
Phramongkutklao Hospital Sabino Russo MD
Cukurova, Adana
Medical University Consultant in Otolaryngology
Turkey
Bangkok, Thailand Head and Neck Surgery
Department of Otolaryngology
Nishit J Shah
C Rayappa Head and Neck Surgery
Department of Head and Neck and National Cancer Institute Department of ENT
Skull Base Surgery Giovanni Paolo II Bombay Hospital
Apollo Speciality Hospital Vle Flacco Mumbai, Maharashtra
Chennai, Tamil Nadu, India Bari, Italy India
 Contributors xvii

Jatin P Shah MD MS (Surg) FACS Hon FRCS Murat Songu Girish Surlikar MS (opthal)
(Edin) Hon FDSRCS (London) Hon FRACS Department of Otorhinolaryngology DOMS FCPS DNB

Professor of Surgery —Head and Neck Surgery Ophthalmologist

EW Strong Chair in Head and Neck Dr Behçet Uz Children’s Private Practice
Oncology Hospital, Izmir, Department of Mumbai, Maharashtra
Chief Otorhinolaryngology Head and India
Head and Neck Service Neck Surgery, Izmir Ataturk
Memorial Sloan Research and Training Hospital Harumi Suzaki
Kettering Cancer Center Izmir, Turkey Department of Otorhinolaryngology
New York, USA Showa University
Jonathan E Sorrel School of Medicine
Hemant Sharma Department of Otolaryngology Hatanodai, Shinagawa
Resident Head and Neck Surgery Tokyo, Japan
Department of ENT and Louisiana State University Health
Head and Neck Surgery Sciences Center and Andrew C Swift
TN Medical College and School of Medicine
Consultant ENT Surgeon and
BYL Nair Charitable Hospital New Orleans, Louisiana, USA
Rhinologist
Mumbai, Maharashtra, India Aintree University Hospitals
Giuseppe Spinelli MD
Foundation NHS Trust
Atsushi Shiraishi Maxillo-Facial Surgeon Liverpool, UK
Department of Ophthalmology Chief of the Department of
Ehime University School of Medicine Traumatology and Taizo Takeda MD
Shitsukawa, Toon, Ehime, Japan Maxillo-Facial Surgery
Emeritus Professor
AOUC Hospital and
Kochi Medical School
A M Shivakumar University of Florence Largo Palagi
Florence, Italy Kochi, Japan
Professor and Head
Department of ENT Paul A Tennant MD
SS Institute of Medical Sciences and Ornouma Sriwanishvipat MD ENT
Yanhee International Hospital Resident in Otolaryngology
Research Center, Davangere, India
Bangkok, Thailand University of Louisville
Kentucky, USA
Shy Stahl MD
Attending Surgeon, Division of Milan Stankovic MD
David J Terris MD FACS
Plastic and Reconstructive Surgery Clinic for ORL
Medical Faculty University of NIS Porubsky Professor and Chairman
Sheba Medical Center, Tel-Aviv
University, Ramat Gan, Israel Serbia Department of Otolaryngology—
Head and Neck Surgery
Michael C Singer MD Andrzej Stepulak Medical College of Georgia, Georgia
Instructor Department of Biochemistry and
Molecular Biology Alok Thakar
Department of Otolaryngology—
Head and Neck Surgery Medical University of Lublin Department of Otorhinolaryngology
Medical College of Georgia, Georgia Poland All India Institute of Medical
Sciences (AIIMS)
PP Singh RJ Stokroos New Delhi, India
Director-Professor and Head Department of Otorhinolaryngology
Department of ENT and Head and Head and Neck Surgery Kiskumar Thankappan
Neck Surgery, University College of Maastricht University Amrita Institute of Medical Sciences
Medical Sciences and GTB Hospital Medical Center Elamakkara
New Delhi, India The Netherlands Kochi, Kerala, India
 xviii Facial Plastics, Cosmetics and Reconstructive Surgery

C Thomas MS FRCS FACS Gauri Vaidya Parag Watve

Senior Consultant and Department of ENT Resident
Head Plastic Surgery Bombay Hospital Department of ENT and
Service in Oman Mumbai, Maharashtra, India Head and Neck Surgery
TN Medical College and
Livnat Siman Tov MD Saurabh Varshney BYL Nair Charitable Hospital
Aesthetic and Reconstructive Professor and Head Mumbai Maharashtra
Plastic Surgeon, Jerusalem, Israel Department of ENT India
Himalayan Institute of Medical
Jagadish Tubachi Sciences, (HIHT University) Stephen Wetmore MD
Fellow Jolly Grant; Doiwala Professor and Chair
Department of Surgical Oncology Dehradun, Uttarakhand, India Department of Otolaryngology
Prince Aly Khan Hospital West Virginia University
Mumbai, Maharashtra, India B K Venkatesha School of Medicine
Department of ENT Morgantown, West Virginia, USA
Jumroon Tungkeeratichai SS Institute of Medical Sciences and
Assistant Professor Research Center Jeremy B White
Facial Plastic and Davangere, Karnataka, India Plastic Surgeon
Reconstructive Surgery ARC Plastic Surgery
Otolaryngology Head and Neck Giovanni André Pires Viana MD Stirling Road
Surgery, Faculty of medicine Cliniplast Hollywood, Florida, USA
Ramathibodi Hospital Al. Jauaperi
São Paulo, SP, Brazil Adele P Williams
Mahidol University
Bangkok, Thailand Department of Otolaryngology
Rohan R Walvekar MD Head and Neck Surgery
Prof Tuncay Ulug MD Associate Professor Louisiana State University
Department of Otolaryngology Health Sciences Center
Department of Otorhinolaryngology
Head and Neck Surgery Bolivar Street
Istanbul University-Istanbul
Louisiana State University New Orleans, Louisiana, USA
Medical Faculty
Capa, Istanbul, Turkey Health Sciences Center
Bolivar Street Eyal Winkler MD
New Orleans, Louisiana, USA Assistant Professor of Plastic Surgery
Hirohito Umeno MD
Director of the Division of Plastic
Associate professor and Reconstructive Surgery
Jeremy Warner MD
Otolaryngology Head and Sheba Medical Center
Division of Plastic Surgery
Neck Surgery Tel-Aviv University
North Shore University Health
Kurume University Ramat Gan
System, Central Street
School of Medicine Israel
Evanston, Illinois, USA
Asahi-Machi Kurume, Japan
JJ Waterval R Yadav MS (ENT) DORL FCPS
Abhishek D Vaidya Assosiate Professor
Department of Otorhinolaryngology
Fellow, Head and Neck Surgery and Head and Neck Surgery Rajawadi Hospital
Tata Memorial Hospital Maastricht University Medical Center Mumbai, Maharashtra
Mumbai, Maharashtra, India The Netherlands India
 Contributors xix

Kazunari Yoshida Alper Yüksel Diego Zanetti

Associate Professor Fatih University, Faculty of Medicine Department of Otorhinolaryngology
Department of Neurosurgery Department of Otorhinolaryngology San Gerardo Hospital
Keio University Head and Neck Surgery University of Milano Bicocca
School of Medicine, Japan Ankara, Turkey Monza, Italy

Ramzi Younis Olaf Zagólski MD PhD Maria Zisiopoulou

Department of Otolaryngology ENT Department of Otorhinolaryngology
University of Miami School of St John Grande’s Hospital The University of Mainz Hospitals
Medicine, USA Kraków, Poland and Clinics, Mainz, Germany
 Contents xxi

Foreword

In spite of significant advances made in the multidisciplinary treatment of diseases and neoplasia
in the head and neck region, surgery remains the mainstay amongst all therapeutic modalities
currently available for these conditions. Surgical techniques have however, undergone significant
evolution with major emphasis on preservation or restoration of form and function. This has resulted
in the development of minimally invasive techniques. Technological advances in endoscopic
instrumentation have ushered in the era of endoscopic surgery, replacing the well-established
techniques of open surgery of the nasal cavity and paranasal sinuses. Major strides in imaging
techniques over the past three decades, has facilitated accurate assessment of the extent of a
neoplasm and has facilitated development of computer-assisted surgical techniques with intraoperative navigation and
Robotic surgery. Thus, the surgical specialty of Otolaryngology and Head & Neck Surgery has dramatically changed over
the years, and remains a challenging and continuously evolving field.
The editors of this magnificent work, Drs Bachi T Hathiram and Vicky S Khattar have done a splendid job in putting
together a state-of-the art surgical atlas by recruiting specialists from all parts of the world who have contributed their
specific areas of expertise in demonstrating surgical techniques. The atlas is lavishly illustrated with operative pictures,
imaging studies, and superb artwork to accompany the procedural details and operative photographs. The rationale,
indications, step-by-step details of the procedure, and postoperative management and complications, makes this a
complete surgical treatise, equally useful to the trainee and the surgeon in practice.
This opus of operative surgery is presented in five volumes, covering a total of 195 operative procedures and their
variations. The compilation covers nearly all the operative procedures from the ‘Dura to Pleura’, in the repertoire of the
Otolaryngologist /Head and Neck Surgeon. This would be an essential textbook for a surgeon or surgeon in training, to
familiarize oneself with an operative procedure, and go prepared to the operating room to carry out a safe and successful
surgical procedure. The Editors and the Publishers of this excellent Atlas are to be commended for bringing about this
excellent book, and offering it at an affordable price to surgeons of all generations. I am confident that this book will be
an essential ‘read’, for Otolaryngologist / Head and Neck Surgeons, worldwide for years to come.

Jatin P Shah MD MS (Surg) FACS Hon FRCS (Edin)

Hon FDSRCS (London) Hon FRACS
Professor of Surgery
Elliot W Strong Chair in Head and Neck Oncology
Memorial Sloan Kettering Cancer Center
New York, USA
 Contents xxiii

Foreword

It is a pleasure to write the foreword for the Atlas of Operative Otorhinolaryngology and Head & Neck
Surgery. Today, the field of Medicine and especially the field of Otorhinolaryngology and Head &
Neck Surgery is advancing by leaps and bounds in expertise and technology. With evidence-based
medicine being at the forefront of our practice, mastering the skills of the surgical technique and the
rationale behind this is of equal importance to the surgeon. There are various centers of excellence
all over the world specializing in particular aspects of our field and it is common practice for the
trainee doctors as well as established surgeons to visit these from time to time to learn and to upgrade
their skills.
This exhaustive compilation by the editors, Dr Bachi T Hathiram and Dr Vicky S Khattar is an attempt to bring together
the best in the field of Otorhinolaryngology and Head & Neck Surgery under one title. With its five volumes on Otology
and Lateral Skullbase Surgery, Rhinology and Anterior Skullbase Surgery, Facial Plastics, Cosmetics and Reconstructive
Surgery, Voice and Laryngotracheal Surgery and Head & Neck Surgery, the editors have aimed to cover topics dealing
with routine procedures as also, those that are at the cutting edge of technology.
The Atlas comprises of 195 Chapters with intraoperative images and clear line diagrams/figures making it easy to
understand the surgical steps. There are contributors from all over the world, each a master in his/her own technique.
More than 30 countries have participated in this mammoth and prestigious venture thus, making it unique in our field
and one of a kind, lending to it a truly global perspective.
In addition to this pictoral step-by-step depiction of surgeries, there will follow a similarly exhaustive compilation of
teaching DVDs which will further enhance the learning process.
I am sure this academic venture will go a long way in benefitting not only the trainees but also established specialists.

Milind V Kirtane
Professor Emeritus Seth GS Medical College
Hon Surgeon at KEM Hospital
Hon Consulting ENT Surgeon at PD Hinduja National Hospital
Hon ENT Consultant to his Excellency the Governor of Maharashtra
Hon ENT Consultant at Prince Aly Khan Hospital
Mumbai, Maharashtra, India
 Preface

In today’s age of rapid advances in science and technology, there is no dearth of learning material available to the
avid learner. However, in the field of Otorhinolaryngology and Head & Neck Surgery, there seemed a lacuna between
undergoing surgical training at various places and understanding the concepts/rationale behind the surgical technique.
This book is a modest attempt by the editors to bridge this lacuna by going through each surgery in a simple step-wise
manner using intraoperative images and illustrated figures, wherever required, to help understand the technique of
surgery.
This is essentially an atlas and hence, the stress on learning through intraoperative images and illustrations, making
it easy for the trainee as well as the ENT consultant to follow the surgery. The authors are masters in the field and this is
a mammoth compilation from more than 30 countries from all over the world since knowledge cannot be bound by any
barriers.
We feel that it is never too late to learn and especially as surgeons, it is imperative to keep in touch with the recent
advances in our field and we hope to spread this message amongst our fraternity through this atlas. The Atlas discusses not
only routinely performed surgeries, such as tonsillectomy, septoplasty, tympanoplasty, thyroidectomy and tracheostomy
but also the latest advances in our field such as robotics, endoscopic skullbase surgery and sialoendoscopy. It is targeted
to young trainee surgeons as well as specialists in the field who would like to learn the techniques of surgery from the
masters.

Bachi T Hathiram
Vicky S Khattar
 Acknowledgments

We would like to express our gratitude to our publishers, M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi,
India, especially Shri Jitendar P Vij for having the vision and faith in us, Ms Chetna Malhotra Vohra for her patience,
perseverance and perfection, Ms Payal Bharti, Mr Arun Sharma and the entire team for their untiring efforts in
completing this book on time. Also, we would like to thank all our students who have taught us in addition to learning
from us; Reema Rai, Harshad Nikte, Parag Watve, Harshal Sonavane, Snigdha Devane, Anjoo Choudhary, Alok Nema,
Supriya Rode, Balagopal Kurup, Hemant Sharma, Sunil Khot, Sanket Dani, Ankit Jain, Diptarka Bhattacharya, Sobhana
Chandran and Lubna Sayed. They have all contributed to the making of this Atlas in significant ways. Most importantly,
our teachers who have not only taught us surgery but, given us the drive to teach and impart knowledge.
 Contents xxix

Contents

Vol. 1: Otology and Lateral Skullbase Surgery 1–366

(Chapters 1 to 44)
Vol. 2: Rhinology and Anterior Skullbase Surgery 367–794
(Chapters 45 to 88)
Vol. 3: Facial Plastics, Cosmetics and Reconstructive Surgery 795–1106
(Chapters 89 to 111)
Vol. 4: Voice and Laryngotracheal Surgery 1107–1324
(Chapters 112 to 148)
Vol. 5: Head and Neck Surgery 1325–1654
(Chapters 149 to 195)

Volume 3
89. Chemical Peels 797
Chitra Nayak (India)

90. Head and Neck Tissue Expansion 807

Livnat Siman Tov, Alexander Margulis (Israel)

91. The Surgical Technique of LASER Skin Resurfacing 818

Zekayi Kutlubay, Murat Küçüktaş (Turkey)

92. Hair Transplantation 834

Jumroon Tungkeeratichai (Thailand)

93. Surgery for Alopecia 844

Arunesh Gupta, Dipesh J Malviya, Akshay P Deshpande (India)

94. Upper and Lower Lid Blepharoplasty 853

Giovanni André Pires Viana (Brazil)

95. SMAS Rhytidectomy: Preoperative Evaluation, Surgical Techniques and Pitfalls 867
Jeremy B White, Mark Domanski, Steven B Hopping (USA)

96. Planning and Facial Analysis before Rhinoplasty 879

Fabrizio Moscatiello, Javier Herrero Jover (Spain)

97. A Color Atlas of Septorhinoplasty 887

Sonna Ifeacho, Rajib Dasgupta, Guy Kenyon (UK)
98. Augmentation Rhinoplasty 916
Yong Ju Jang, Ji Heui Kim (Korea)
 xxx Facial Plastics, Cosmetics and Reconstructive Surgery

99. The Surgical Management of the Crooked Nose 941

Yakup Cil (Turkey)
100. Surgical Techniques in Open Rhinoplasty Procedures 948
Tamer Seyhan (Turkey)
101. Rhinoplasty for Cleft Nasal Deformity 966
C Thomas (Oman)
102. Revision Rhinoplasty: The Lost Tip Support 988
Hossam MT Foda (Egypt)
103. Alar Struts in Rhinoplasty 993
Patrick T Hennessey, Kofi DO Boahene (USA)
104. Augmentation Rhinoplasty 997
Brajendra Baser, Shenal Kothari (India)
105. Alar Base Reduction 1009
Sara Dickie, Jeremy Warner (USA)

106. Esthetic Rhinoplasty—Ailed and Ailing Noses 1019

BP Belaldavar (India)

107. Cleft Lip and Palate 1044

G Spinelli, G Carnevali, D Lazzeri, L Autelitano (Italy)

108. Lip Reconstruction 1064

Jagadish Tubachi, Karthikeyan Balasubramanian, Sumeet Pahwa, Sultan Pradhan (India)

109. Operative Techniques in Mandible Fractures 1074

Rajesh R Yadav, PV Dhond (India)

110. Faciomaxillary Fractures 1091

Arunesh Gupta, Akshay P Deshpande, Dipesh J Malviya (India)

111. Orbital Floor Fracture 1100

Rajesh R Yadav, Girish Surlikar, PV Dhond (India)

Index I-i-vi
 The Surgical Technique of Otoplasty 797
CHAPTER

89 Chemical Peels
Chitra Nayak

DEFINITION Historical Timeline

• 1882: PG Unna, German dermatologist described the
Chemical peeling is defined as application of one or more use of resorcinol, salicylic acid (SA), phenol, trichloro-
chemoexfoliating agents to the skin resulting in destruc- acetic acid (TCA)
tion of portions of epidermis or/and dermis with resulting • 1903: Mackee (Chairman of Dermatology at New York
regeneration of new epidermal and dermal tissues.1 University) began using phenol for acne scarring.
• 1961: Baker and Gordon presented a peel formula with
one patient with a 3-month follow-up which became
HISTORY the standard formula.
• Egypt: • 1966: Baker published results in 250 patients.
– First evidence of exfoliants use.
– Sun-damaged skin was a sign of lower rank in
society.
PRINCIPLE
– Sour milk containing lactic acid, an alpha-hydroxy Chemical peeling is used to create epidermal/dermal
acid (AHA), is commonly used today1 (Fig. 1). wounding enough to stimulate regeneration from the
• Turks: Used fire to produce thermal exfoliation. appendages and dermis via wound healing.2

HISTOLOGY
Actinic Changes3
Photochemical effects of solar radiation exposure:3
• Disorderly arrangement of epidermis
• Degeneration of the elastic network
• Mottled pigmentation
• Lymphocytic infiltration
• Decrease in collagen
• Flattening of the dermal-epidermal junction
• Epidermal cell atypia
• Increased melanocytes, but they were unevenly distrib-
uted and contained variable amounts of melanin.

Peel Skin Histology4,5 (Figs 2 to 5)

• At 2 weeks:
– New collagen formation begins and may continue
up to 1 year
– New bands of dermis 2–3 mm thick
– Thin, compact and parallel collagen bundles
Fig. 1: An Egyption female using sour arranged horizontally along the epidermal-dermal
milk as a natural peel matrix.
 798 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 2: Chemical burn of the epidermis and Fig. 3: First 2–5 days: Regeneration from
the outer dermis follicular and eccrine duct epithelium

Fig. 4: Fresh, orderly and organized epidermis

Other Changes
• Melanocytes contain fine, evenly distributed
melanin granules
• Impaired melanin synthesis with a generalized
bleaching effect
• Decreased lymphocytic infiltration.

CLASSIFICATION1,2
• Brody’s classification
• Mark Rubin’s classification

Classification According to Depth of Peel

• Very superficial exfoliation
• Superficial (epidermal) Fig. 5: Dermal collagen and extracellular matrix
• Medium (papillary dermis) remodeling after deep peeling
• Deep (reticular dermis)

Very Superficial Peel

• Only stratum corneum is thinned out or removed • It is also known as “freshening peel”.
without creating wound below stratum granulosum • Solutions used: Resorcinol, Jessner’s solution, tretin-
i.e. general epidermal wounding. oin, AHA [glycolic acid (GA), lactic acid], SA, TCA 10%,
• It is suited for all skin types. CO2 slush, liquid nitrogen.
 Chemical Peels 799

Superficial Peel with normalized tissue thereby achieving better

• Necrosis of part or all of epidermis from stratum cosmic results.
granulosum to basal cell layer • Removal of stratum corneum results in stimulation of
• Solutions used epidermal growth.
– Trichloroacetic acid 15–20% • Inflammatory reaction in deep dermis activates medi-
– Glycolic acid 30–50% ators of inflammation resulting in angiogenesis and
– Resorcinol collagen remodeling; also increased production of
– Jessner’s solution. glycosaminoglycans in dermis (Fig. 5).
• Epidermal regeneration within 2–7 days. Heals
Factors influencing depth of peel: completely in 2 weeks.
• Peeling agents and concentration
• Priming/degreasing done before
• Mode of application: Painting/rubbing
INDICATIONS OF PEELS
• Current on-going medications: Isotretinoin • Photoaging: Actinic keratosis, solar elastosis,
• Location: Facial/non-facial peel solar lentigines, pigmentary alterations, fine
• Skin condition: Thin/thick, dry/oily. wrinkles.7
• Pigmentary disturbances: Melasma, postinflamma-
Medium Depth Peel tory hyperpigmentation, freckles, fixed drug eruption,
• Peeling up to papillary dermis lentigines.
• Solutions used: • Rhytids: Actinic, dynamic, sleep
– Trichloroacetic acid 35% • Others
– CO2 slush prior to TCA – Rough, oily skin
– Jessner’s solution prior to TCA – Dilated pores
– Glycolic acid applied and washed off prior to TCA. – Superficial scarring
– Radiation keratoses
Medium-Deep Depth Peel – Acne vulgaris and rosacea
• Solutions used: – Flat facial warts and milia
– Trichloroacetic acid 50% – Pseudofolliculitis barbae
– Combination of GA 50% + TCA 35%. – Xanthelasma and acanthosis nigricans

Deep Peel
• Peeling up to reticular dermal layer
CONTRAINDICATIONS
• Formula used: Baker’s/Gordon phenol formula. • Keloidal tendencies
• Active infection: Herpes/bacterial
• Open wounds
MECHANISM OF ACTION6 • Unrealistic expectations
• Creating wound/necrosis of epidermal cells leads to • Recent radiation treatment or surgery
repair mechanism wherein damaged skin is replaced • Warts
 800 Facial Plastics, Cosmetics and Reconstructive Surgery

IMPROVEMENT IN PHOTOAGING
(FIGS 6A AND B)

A B
Figs 6A and B: 20% TCA-peel. (A) Pre-peel; (B) Post-peel

PATIENT SELECTION Fitzpatrick Classification (Table 1)

• “The ideal patient is a thin-skinned female with fair Table 1: Fitzpatrick classification
complexion and fine rhytids.” • Fitzpatrick skin type I and type II are good candidates
• Skin type and the amount of photo damage • Type III and greater: Increased risk pigment
present. complications
• Fitzpatrick classified the skin types on the basis of color
and acute solar radiation response (Table 1). Table 1: Fitzpatrick classification of skin types
• The Glogau classification is based on the degree of
Type Color Tanning response
photoaging (Table 2).
I White Always burns, never tans
History Taking II White Usually burns, tans less than
• History of recent facial surgery/peels and outcome average
• Herpes simplex III White Sometimes burns mildly, tans
• Current medications about average
• Immunocompromised states/susceptibility IV Brown Rarely burns, tans more than
• Recent facial X-ray therapy average and with ease
• Recent isotretinoin V Dark brown Very rarely burns, tans very easily
• Keloids/hypertrophic scarring
VI Black Never burns, tans very easily
• Concurrent product/treatment used.
 Chemical Peels 801

Glogau Classification (Table 2)

Table 2: Glogau classification of photoaging

Group Classification Skin characteristics Peel

I Mild Little wrinking or scarring and no keratoses Superficial
II Moderate Early wrinkling, mid scarring, and sallow color with early Medium
actinic keratoses
III Advanced Persistent wrinkling, discoloration with telangiectasias and Medium
actinic keratoses
IV Servere Wrinkling—superficial to deep actinic keratoses ± skin cancer Medium to deep

EXAMINATION PRIOR TO PEELS • Enforce importance of post-peel care and treatment of

complications.
• General cutaneous examination
• Fitzpatrick skin type to predict pigmentary response to Preparation of Skin
peeling • Keratotic lesions: Seborrheic keratoses; warts to be
• Degree of photoaging removed 2 weeks prior to peeling
• Degree of sebaceous secretions • Priming: Topical retinoic acid in acne vulgaris
• Laxity of skin • Alpha-hydroxy acid in acne and pigmentary alterations
• Presence of keloid/hypertrophic scar • Hydroquinone and kojic acid in melasma and
• Presence of active dermatitis/infection in areas to be hyperpigmentation
peeled • Broad-spectrum sunscreen
• Antiviral in patients with history of herpes simplex
infection in areas to be treated.
ADVANTAGES OF PRIMING
• Reduces wound healing time: Speeds up Before Peel
re-epithelialization. • To wash face with soap and water to remove makeup
• More uniform penetration of peeling agent. and surface oils
• Decreased risk of postinflammatory hyperpigmen- • Wipe face dry
tation. • Remove contact lenses if
• Use of hydroquinone (HQ), kojic acid and azelaic acid • Hair should be secured off the face using clips/rubber
enhance skin lightening with dispersion of melanin band
granules throughout epidermis. • Place a fan 4 feet from patient’s face to help keep
• Enforces concept of maintenance regimen and helps the skin cool to reduce discomfort during pro-
to assess patient’s skin tolerability. cedure.

During Peel
PREPEEL PROCEDURES8 • Patient should sit in reclining position with 45° head
• Counseling elevation to avoid the acid pooling around unwanted
• Test peel: Postauricular areas.
• Photodocumentation • Degreasing of area: To remove excess of sebum,
• Written informed consent dirt, debris and allow better, uniform penetration of
peeling agent.
Counseling • Commonly used agents: Acetone, alcohol, chlorhex-
• Patient/physician expectations to avoid unrealistic idine gluconate (Hibiclens®).
expectations and disappointment • Gentle wiping of area unidirectionally with gauze or
• Need for multiple office visits for staged peeling and cotton ball as scrabbing causes friction and damages
improvement the skin.
 802 Facial Plastics, Cosmetics and Reconstructive Surgery

Precautions • Trichloroacetic acid + Tretinoin cream preoperative

• Position and postoperative
• Label checking to confirm strength and substance. • Trichloroacetic acid + 5-Fluorouracil (5-FU)
• Avoid dripping of solution into non-peel areas • Trichloroacetic acid + Microdermabrasion
• Never pass on open container of acid over patient’s • Trichloroacetic acid + Phenol
face to avoid accidental spilling • Trichloroacetic acid + Solid CO2
• Water prefilled syringe to flush eyes in case of • Resorcinol/spot peel
accidental spilling • Lactic acid, GA, resorcinol and SA.
• Stand in front of patient and watch for untoward
reactions Application Protocol
• Give adequate post-peel care instructions • Level 0: No frost.
• Apply petrolatum to any cuts, abrasions, creases of • Level 1: Irregular frosting giving skin a wispy appear-
mouth, nose and eyes. ance—superficial intraepidermal peel.
• Level 2: Skin shows white frost with pink red back-
ground colour—peel extends up to dermoepidermal
TRICHLOROACETIC ACID PEEL8 junction.
• It is used to treat aging and premalignant skin conditions. • Level 3: Solid intense white frost with no pink/white
• It destroys epidermis and upper dermis; causes background—peel up to papillary dermis.
necrosed skin to exfoliate within 2–3 weeks.
• Sloughed epidermis is replaced by new epidermis Postpeel Events
within a week while regeneration of dermis takes • Area is pink for first 2–3 days when calamine lotion is
2–3 weeks and remodeling of collagen continue for up applied to initiate exfoliation during next 2 days.
to 6 months. • Skin darkens by 5th day.
• Skin begins to peel and is complete in 10 days.
Preparation of Solution
• 10 g of TCA United States Pharmacopoeia (USP) crys- Postpeel Care
tals w/v in 100 cc distilled water = 10% TCA • Application of sunscreens or emollients immediately
• Brands: after peel
– Easy TCA • Not to peel, pick, scratch or scrape the skin.
– Obagi Blue Peel® • Not to expose the skin to sun/sauna.
– Compositum Peel • Interval between two peels is 2–3 weeks and concen-
– AcuPeel tration can be increased 5–10% with each peel.

Depth and Concentration

• Superficial peel (20%): Used for acne, photoaging,
ALPHA-HYDROXY ACID PEEL1,2
freckles, melasma, shallow complexion, vitiligo and • Most preferred
seborrheic melanoses (Figs 6A and B). • They are group of nontoxic organic acids present in
• Intermediate peel (35%): Used for lentigines, wrinkles natural foods such as fruits, so known as fruit acid.
and actinic keratoses. • Natural sources: Sugarcane (GA), sour milk (lactic
• Deep peel (50%): Used for xanthelasma, acne scars, acid), citrus fruit (citric acid), apple (malic acid),
severe photoaging and striae distensae (Fig. 7). grapes (tartaric acid).

Advantages
• Safe and inexpensive
• Few medical contraindications
• No systemic toxicity and allergic reaction
• Depth of peel is achieved by adjusting TCA
concentration
• No need to neutralize peel.

Trichloroacetic Acid in Combination Fig. 7: Trichloroacetic acid (TCA) peel. 50% TCA in acne
• Tape occlusion scars (three sittings)
 Chemical Peels 803

Preparation and Formulation Peels Timetable (Table 3)

• Solutions are made using water, alcohol and propylene
glycol. Advantages
• In practice, solution is made by bubbling carbon • Biweekly serial peels: Effective in treatment of atrophic
monoxide through formaldehyde. acne scars
• Glycolic acid formulations: Partially neutralized, buff- • Fifteen to sixteen peels effective in all types of acne
ered, esterified, free GA. including rapid improvement and appearance of
normal skin
Application Protocol • Rapid improvement in comedogenic acne
• Routine degreasing. • For papulopustular acne, average 6 applications.
• Time bound peel so time to be noted at beginning of • For nodulocystic acne, 8–10 applications.
peeling using stopwatch. • 50% GA peel/month for 3 months are sufficient for
• Application to be completed within 30 seconds to effective treatment in Indian women with melasma.
1 minute. • No systemic toxicity and well tolerated.
• At end, sodium bicarbonate should be sprayed to
neutralize action of acids. Bubbling and fizzing occurs
on surface of skin. Continue the application till fizzing
SALICYLIC ACID PEEL1 (FIG. 8)
stops. • It is also known as beta-hydroxy acid (BHA).
• Popular and inexpensive.
Postpeel Care • Superficial, facial and non-facial sites can be done.
• Neutralization is exothermic reaction which produces • Salicylic acid is a keratolytic agent because of its
heat making patient’s face more erythematous and lipophilic nature. It has strong comedolytic effect.
potentially inducing wounds, so immediately spray ice • It affects arachidonic cascade and thus acts as an
cold water. anti-inflammatory.
• Dry with towel
• Mild steroid cream: Hydrocortisone or an emollient to Advantages
apply • Minimal downtime
• Leave at least for 4 hours • More efficacious when treating fine wrinkles, photoag-
• Emollient application: I-------------I × 2–7 days to ing, keratoses, acne and depigmentation.
promote healing process
• Avoid products containing SA, AHA and retinoids until Formulations
normal skin comes back • 20–30% on w/v basis in hydroethanolic solution
• Avoid makeup for 24 hours after peel • 20% w/v: Treatment for facial skin
• Avoid sun exposure, scrubs, abrasive materials and • 30% w/v: Non-facial sites
artificial tanning devices • Brands:
– Beta-Lift
Postpeel Events – Bioglan pharmacy
• Stinging, redness, burning and tightness, may be some – Delasco
mild swelling, superficial scabbing and peeling. These
gradually disappear over period of week. Procedure
• Temporary darkening of skin. • Application with cotton tip applicator or wedge sponge.

Table 3: Biweekly peel shedule for acne scars (GA peel)

CONC % 20 20 20 35 35 35 50 50
PEEL 1st 2nd 3rd 4th 5th 6th 7th 8th
TIME (MIN) 2–3 3–4 4–5 2–3 3–4 4–5 2–3 3–4
 804 Facial Plastics, Cosmetics and Reconstructive Surgery

Indications
• Acne
• Photoaging
• Hyperpigmentation

Application
• 2 mL of product should be evenly applied with brush
Fig. 8: 25% salicylic acid (SA) peel in melasma or cotton bud in two coats one after other without any
(three sittings) rubbing. No frosting should occur. If accidental frost-
ing occurs, neutralization with sodium bicarbonate is
• After 30 seconds, stinging and burning starts, which done.
increases over next 2 minutes, reaches crescent at • Brand: Easy phytic solution—mixture of phytic acid
3 minutes and then rapidly decreases to baseline over with glycolic, lactic or mandelic acid.
next minute.
• As hydroethanolic acid evaporates, it leaves behind a Postpeel Care
white precipitate of SA termed as SA frost. • Mild stinging persist up to 1 hour. The peel should be
left on face 8–12 hours and then washed off.
Advantages • Three to four days later, skin sloughs off very little often
• Any area inadequately treated can be identified. not visible
• Timing is not necessary. • Sunscreens and moisturizers
• Risk of overpeeling is remote because once vehicle • Interval: Once a week till results are obtained or once
evaporate, little penetration of active agents takes place. a month as maintenance treatment between TCA
• Neutralization is unnecessary. peels.
• Easier to apply on larger areas but risk of salicylism
restricts their use.
TRETINOIN PEELS6
Postpeel Events and Care • Retinoids are group of molecules consisting of vitamin
• Tightness, smoothness, immediate postpeel peeling A and their synthetic analogues.
begins 2 days post peel and extends up to 5–7 days. • Topical application on daily basis causes keratini-
• Care: Regular use of emollients and sunscreens zation.
• Avoid sun exposure • Indications
• Avoid products containing AHA – Melasma
– Intrinsic and extrinsic skin aging.
Intervals
• Once in 2 weeks for 5–6 sessions for resurfacing photo- Product and Procedure
damaged facial skin moderately. • Solution containing 0.1 g of tretinoin solution solu-
• Excellent improvement in rough and oily skin with bilized by addition of 5 mL of ethanol and 5 mL of
skin type V and VI, enlarged pores propylene glycol.
• To avoid in pregnant and breast-feeding mothers, and • Degreasing of skin followed by application—skin
those allergic to aspirin acquires yellowish discoloration—leave in contact for
• Cautions in children, elderly and large body surfaces 6–8 hours then wash off.

Postpeel Care
PHYTIC ACID PEELS6 • After 2 days, skin begins to peel mildly and complete in
• Slow-release superficial peel for individuals who do 7 days with no discomfort.
not opt for visible desquamation. • One percent hydrocortisone along with sunscreens.
• Molecule of inositol hexaphosphoric acid shows anti- • Advantages: Safe and effective in improving skin
oxidant, antityrosinase and iron chelating effects. texture and appearance.
 Chemical Peels 805

Peels in Combination Complications of Peels

Glycolic acid with TCA (medium depth peel) (Fig. 9): 70% • Pigmentary changes (Figs 10 and 11)
GA was applied to the entire face and diluted with water • Scarring
after 2 minutes. Then, 35% TCA was applied over the same • Infections (e.g. Herpes simplex) (Fig. 12)
areas. It results in impressive improvement in pigmentary • Keratoacanthomas
dyschromia and actinic damage. • Textural changes
• Milia
Peel with Dermabrasion • Acne
• Fifty percent TCA application f/b dexamethasone
acetate (DMA) with cryoanesthesia (CO2 slush or Toxicity
liquid nitrogen). • Trichloroacetic acid or AHA have no systemic toxicity
• Indications: • Urticaria with 30% TCA (cholinergic)
– Acne pitting • Faint or lightheadedness (facial vasodilatation and
– Acne scarring tachycardia)
– Striae • Mottled hyperemia
• Allergic contact dermatitis (lactic acid)
Peel with LASER9 • Non phenols (resorcinol and SA) can not be used in
• First chemical peel followed by LASER resurfacing large area.
for eradication of wrinkles in perioral and periocular
regions. Resorcinol Toxicity6
• Forty percent for 3–4 months: Tremors, collapse and
Peel with Manual Dermasanding violet black urine, methemoglobinemia, hypothyroid-
• First TCA application followed by local dermasand- ism and syncope.
ing using sandpapers and gauze roll dipped in normal • Guidelines to prevent toxicity
saline until fine bleeding points are visualized. – Patch test
• Indication: Fine and moderate rhytids. – Perform resorcinol peeling with the patient lying
down, and have them get up slowly after peel.

Salicylism
• Rapid breathing, tinnitus, decreased hearing, nausea,
vomiting and abdominal pain.
• Rarely allergic reaction
• Guidelines to prevent toxicity
– Do not peel large area
Fig. 9: 70% glycolic acid (GA) peel in active acne – In kidney disease do small area
(three sittings) – After peel drink lot of water.

Fig. 10: Hyperpigmentation Fig. 11: Hypopigmentation

 806 Facial Plastics, Cosmetics and Reconstructive Surgery

CONCLUSION
• Chemical peeling is a technique that removes superfi-
cial lesions and improves the texture of skin.
• Careful patient selection and education are crucial
to both the patient’s final result and his or her
satisfaction.
• Learning the technique is a small part of the process;
postoperative care and close patient follow-up are
equally important.
• Clinical and histological changes are long-lasting
(15–20 years) and may be permanent for some patients.
• A complication can also be permanent.

REFERENCES
Fig. 12: Herpes outbreak
1. Brody HJ. Chemical Peeling. St Louis, Mo: Mosby-Year Book;
1992. pp. 1-5.
2. Brody HJ. Chemical Peeling and Resurfacing. St. Louis:
SEQUELAE Mosby; 1997. pp. 109-10.
• Pigmentary changes 3. Tse Y, Ostad A, Lee HS, et al. A clinical and histologic
• Persistence of rhytids evaluation of two medium-depth peels. Glycolic acid versus
• Prolonged erythema Jessner’s trichloroacetic acid. Dermatol Surg. 1996;22(9):
• Hypertrophic subepidermal healing 781-6.
• Milia 4. Kligman AM, Baker TJ, Gordon HL. Long-term histo-
• Skin pore prominence logic follow-up of phenol face peel. Plast Reconstr Surg.
• Increased prominence of telangiectasias 1985;75(5):652-9.
5. Stegman SJ. A comparative histologic study of the effects
• Darkening and growth of pre-existing nevi.
of three peeling agents and dermabrasion on normal
and sun-damaged skin. Aesthetic Plast Surg. 1982;6(3):
COMPLICATIONS 123-35.
6. Rubin M. Manual of Chemical Peels. Philadelphia:
• Skin infection Lippincott; 1995. pp. 120-1.
• Herpes simplex virus 7. Cummings C, Haughey B, Thomas R, et al. Management
• Pseudomonas organisms of aging skin. Otolaryngology: Head & Neck Surgery, 4th
• Staphylococcus/Streptococcus organisms edition. Mosby; 2005.
• Candida organisms 8. Halaas YP. Medium depth peels. Facial Plast Surg Clin North
• Ectropion Am. 2004;12(3):297-303.
• Cardiac arrhythmias 9. Monheit GD, Zeitouni NC. Skin resurfacing for photoag-
• Renal failure ing: laser resurfacing versus chemical peeling. Cosmet
• Facial scarring Dermatol. 1997;10:11-22.
 The Surgical Technique of Otoplasty 807
CHAPTER

90 Head and Neck Tissue Expansion

Livnat Siman Tov, Alexander Margulis

INTRODUCTION AND BIOLOGY OF decreased thickness and volume at the area under the
expander, and increased thickness at the periphery of the
TISSUE EXPANSION prosthesis.13 Despite that, the process does not induce
The expansion of skin was first reported in 1957 by craniosynostosis. Observations by Colonna et al. showed
Neumann,1 who used a rubber balloon with an external that underlying bone reacts to the presence of an expander,
port in reconstructing a traumatic ear defect. After almost but this reaction subsides within 9 months with moderate
20 years, Radovan2 presented his experience with breast sequela in the general bony architecture.14
reconstruction. In 1982, Austad and Rose3 described a
self-inflating expander.
Both animal and human studies have documented
TYPES OF IMPLANTS
histological changes in soft tissue undergoing expansion. Tissue expanders are available in a variety of shapes, sizes,
A mechanical force applied to skin influences numerous contours, and backing configurations and inflation ports.
aspects of cellular architecture and function.4-6 Jackson et al.15 have described their experience with tissue
Analysis of multiple sites of expanded flaps demon- expanders of the extremities and their successful use of
strated an increase in epidermal thickness. A few weeks external ports with only 6% of infection rate. Others, like
after the cessation of expansion and flap transposition the authors, are reluctant to the use of external ports due
epidermal thickness decreases, though not to pre-expan- to fear of infection.16
sion thickness.7 Hair follicles and skin appendages are
compressed but do not degenerated. During the expan-
sion, there is evidence of an increased melanocyte activity
INDICATIONS FOR THE SURGERY
that returns to normal a few weeks after the transposition The indications for tissue expanders are skin conditions
of the expanded flap. that need to be excised for medical or cosmetic reasons,
Dermal thickness decreases dramatically during and in which primary closure or recruitment of local tissue
expansion and is most pronounced at the first weeks flaps does not produce a pleasing esthetic result. These
of the process.8 On the other hand, collagen content in conditions include:
the dermis is increased with preservation of the relative • Burn scars and scar contractures
proportion of type I and type III collagen.9 A few week • Congenital pigmented nevi
after the placement of the expander, a dense fibrous • Sebaceous nevus
capsule is formed with gradual decrease in the number of • Cutis aplasia
cells within it. Mitotic activity of the capsule fibroblasts is • Hemangiomas and vascular malformations.
­maximal after 96 hours of pressure application by expan-
sion and decreases gradually thereafter.10
Significant muscle atrophy is evident during the expan-
SPECIFIC PREOPERATIVE
sion period, regardless of the plane in which the expander EVALUATION
is placed (above or below the muscle).11 Histological During the preoperative evaluation of the patient, the
examination shows ulceration, focal muscle fibers degen- amount of tissue needed to be excised and the amount
eration, mild fibrosis and disorganization of the myofibrils and type of tissue needed for reconstruction is assessed.
of the sarcomeres. Skeletal muscles regain normal archi- For skin lesions, that involve both hairy and non-hairy
tecture after the prosthesis is removed with normalization areas, two different tissue expanders should be used. The
of muscle mass.12 surgeon should decide on the type of reconstruction—
Tissue expansion effect on underlying bone changes using an expanded flap or expanded full-thickness skin
depending on the type of bone. Calvarial bone shows graft. Further assessment should be made regarding the
 808 Facial Plastics, Cosmetics and Reconstructive Surgery

number of procedures needed for the final result. It is on • The authors routinely use drains, with one drain placed
this phase that the surgeon determines the volume of the in each expander pocket. The drains are removed
tissue expander that would be used and where it would be 4–5 days after the surgery
inserted. • After insertion of the expander, the pocket is closed
with two layers of nylon sutures. The skin nylon suture
is not removed throughout the entire process of
ANESTHETIC CONSIDERATIONS expansion
The procedures are performed under general anesthesia • The authors continue antibiotic treatment until all
and special attention should be made for tube placement drains are removed
in a way that would not distort the adjacent esthetic units. • The wound is bandaged with xeroform, bacitracin and
The tube should be firmly secured, sometimes, using silk kerlix.
sutures to the alveolus in order to avoid accidental extuba- The inflation process is initiated a week after expander
tion while maintaining the surgeon’s ability to move the insertion and the injections are repeated on a weekly
head relatively freely. basis. The volume of expansion varies according to the
size of the expander and the anatomical site in which it
was implanted. Inspection of skin color, capillary refill
OPERATIVE TECHNIQUE and simple palpation are performed when administrating
Reconstruction, using tissue expanders, involves at least injections, and patient comfort is taken into consideration.
two separate surgical procedures. The first procedure is the Typically, 8–10 weeks are sufficient to fill the expanders.
insertion of the expander (or expanders) and the second Expanders are typically overinflated beyond the manufac-
is removal of the expander, excision of lesion and recon- turer’s recommended full capacity.17,18
struction with expanded flaps, expanded full-thickness
skin grafts, expanded free flaps, or expanded prefabricated Removal of Tissue Expanders
flaps. The latter flaps are used less frequently. All proce- • The patient is under general anesthesia
dures are performed under general anesthesia. Incisions • Intravenous dose of cefazolin is given 1 hour
for placement of the expanders are carefully planned, preoperatively
with the most important consideration being the visional • The surgical field is prepared with antiseptic solution
design of the final flap. • The tissue expander is removed and the expanded flap
is transposed over the skin lesion. Flap borders are
marked over the lesion. It is extremely important to
SURGICAL STEPS avoid tension over the flap
• The skin lesion is excised according to markings. The
Insertion of Tissue Expanders
skin lesion should not be resected until the extent of
• The patient is intubated and the surgical field is washed the transposition flap is determined
with antiseptic solution • Flap is transposed and sutured to place in layers
• Intravenous dose of cefazolin is given 1 hour • Drains are left under the flap, and are removed when
preoperatively the secretions decrease
• The skin is incised parallel and close to the lesion to • The wound is bandaged with xeroform, bacitracin gauz
be excised, and a subcutaneous pocket is prepared. and kerlix
The expander pocket should reflect the dimensions of • Antibiotic treatment is continued until the drains are
the expander to be placed, being 1–2 cm larger in each removed.
dimension, so that the tissue expander will lie comfort-
ably without sharp folds. Much care should be taken Head and Neck Reconstruction
when dissecting the pocket to minimize trauma to the
Scalp
skin flap being elevated
• The authors use internal remote injection ports in all Tissue expansion is a treatment modality of choice for
of their patients. The port should be low profile and reconstructing many scalp lesions.19,20 As surgical experi-
placed in areas where there is no potential pressure ence increase and planning improves, larger defects can be
on the overlying skin. Importantly, the port should reconstructed with fewer procedures and better restoration
be distanced from the expander to ensure that the of normal hair patterns.21-23 The expander is inserted in a
expander is not punctured when accessing the port subgaleal pocket, with the port placed at the preauricular
 Head and Neck Tissue Expansion 809

area. The location of the future expanded flap is planned Nevi and extensive scars of the cheek are best recon-
with consideration of axial arterial supply to the flap structed with expanded or non-expanded postauricu-
(based on the superficial temporal, postauricular, occipital lar flaps. Use of advancement cervical flaps, distal to
and supraorbital). Treatment starts with patients as early the cervicomental angle for reconstruction of cheek
as age 8 months, with some cranial molding expected by defects, is discouraged due to increased complication
the time the expanders are removed. No long-term cranial rate and increased possibility of secondary deformities
deformity has been observed. Colonna et al.8 showed that as ectropion, lower lip drooping and oral incompetence
the underlying bone reacts to the presence of an expander, (Figs 9 to 13).
but this reaction subsides within 9 months with moderate Expanded full-thickness skin grafts have been used
sequela in the general bony architecture (Figs 1 to 3). effectively for excision and reconstruction of nevi of the
periorbital, eyelid and occasionally the nasal areas.23 A
Face single, large, expanded full-thickness graft from the supr-
Large and giant nevi of the face and extensive facial scars aclavicular area can cover eyelids, the canthus and the
present some of the greatest challenges for the plastic­ region between eyelid and brow, without the multiple
surgeon. Facial reconstruction should be done with “seams” that follow use of multiple smaller grafts
respect to facial esthetic units. Facial lesions are usually (Figs 14 to 20).
treated with expanded local flaps whenever possible, with Expanded full-thickness skin grafts or expanded fore-
the addition of expanded full-thickness skin grafts for the head flaps can be used for nasal reconstruction as lining or
forehead, periorbital and eyelid areas and occasionally for for external coverage of nasal defects.
the nasal dorsum.24,25
Planning the expansion and reconstruction of the Neck
forehead must be directed at minimizing any possibility of Posterior and posterolateral neck defects can be success-
distorting the eyebrow and the normal distance from brow fully reconstructed with expanded flaps from the upper
to hairline (Figs 4 to 8). back and the shoulders.22 The flap is designed in such a

Fig. 1: A 5-month-old girl with congenital melanocytic nevus Fig. 2: Fully expanded tissue expander
involving the left occipitoparietal scalp and posterior aspect
of the left auricle
 810 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 3: Following removal of the tissue expander and left Fig. 4: A 3-year-old boy with congential melanocytic nevus
scalp reconstruction with expanded flap. Note residual nevus involving the scalp, forehead, right eyebrow and upper
on auricle eyelid

Fig. 5: Fully expanded scalp and Fig. 6: The nevus was excised and forehead and scalp
forehead tissue expanders reconstructed with expanded flaps
 Head and Neck Tissue Expansion 811

Fig. 7: Residual nevus at eyebrow and upper eyelid Fig. 8: Upper eyelid nevus was excised and lid reconstructed
with full-thickness skin graft. The eyebrow was shaped, a part
of the nevus was excised, and small part of the nevus was
left to mimic the eyebrow

Fig. 9: A 6-month-old child with congenital melanocytic Fig. 10: Fully expanded tissue expander
nevus involving the left cheek and lateral nasal sidewall
 812 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 11: The tissue expander was removed, cheek and part Fig. 12: Residual nasal sidewall nevus was excised and
of nasal sidewall nevus were excised and reconstructed with wound closed primarily
expanded flap

Fig. 13: Late result at 4 years of age Fig. 14: A 12-year-old boy with congenital melanocytic nevus
involving the left periorbital region—upper and lower eyelids
and left nasal sidewall
 Head and Neck Tissue Expansion 813

Fig. 15: Fully expanded forehead and scalp tissue Fig. 16: The cheek expander was removed, lower eyelid
expanders and nasal sidewall nevus was excised and reconstructed
with expanded flaps

Fig. 17: Upper eyelid was reconstructed with pedicled Fig. 18: The tubed flap is attached to its pedicle
tubed expanded flap

way that it can be wrapped around the neck, eliminating platysma. Incorporation of this muscle in the expanded
the “webbing” created by pure upward advanced flaps. flap exposes the marginal mandibular nerve to trauma.
With this design, the reconstructed neck has a better Tissue expansion is also very effective in treating ante-
contour and more favorable scar location. Care must be rior burn scar contractures of the neck. The expanders are
taken to avoid placement of the tissue expander under the placed in the unburned skin in the posterolateral neck or
 814 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 19: The tubed flap was separated and upper eyelid Fig. 20: Final result after fourth stage surgery in which the
reconstruction completed. Residual nevus at the nasal residual upper eyelid nevus was excised and reconstructed
sidewall was excised. Lower eyelid nevus was excised, and with full-thickness skin graft
eyelid reconstructed with full-thickness skin graft

the supraclavicular region. The flaps are designed as large reconstructive capabilities of the added tissue and distracts
transposition flaps, wrapped around the anterior neck from the surgeon’s ability to achieve the initial goal of
to release these challenging mentosternal contractures. reconstructive surgery. The cost of additional incisions
When no adjacent tissue is available for expansion, island is worthwhile in order to achieve a better final contour of
or prefabricated expanded flaps from the supraclavicular the reconstructed part, a reduced risk of anatomic distor-
areas can be transplanted into the anterior neck defect tion, a better position of the scars and a reduced risk of scar
(Figs 21 to 26). contracture.

Implant Exposure
COMPLICATIONS Implant exposure can occur early or late during the course
Tissue expansion has been associated with significant of expander inflation. Early exposure is attributed to inad-
complications since its inception. The risks have been equate pocket dissection, inadequate wound closure or
described in numerous studies and overall complication early inflation of the expander. Late exposure is usually
rates from 13% to up as high as 40% have been reported. attributed to overzealous inflation of the expander in a
Complication rates are higher among pediatric popula- short period of time.
tion. However, some of the minor complications will not Once exposure occurs, the expander should be
delay the process of expansion and reconstruction, in deflated; wound edges are debrided and sutured in layers.
contradistinction to major complications, such as infec- Antibiotic treatment is given for 5 days following the
tion or extrusion. procedure. In case of late exposure, if there is sufficient
amount of expanded flap, reconstruction can be carried
Infection out earlier than planned. If the expander was exposed
Careful patient selection and meticulous surgical tech- for over 24 hours and there is high-risk for infection, the
nique are the two most important factors for avoiding patient should be hospitalized, intravenous antibiotics
complications.6 should be administered, and one should consider remov-
One has to envision the expanded flap for the final ing the expander and reinserting it on a later date.
reconstruction during the expander’s placement and plan
the incisions and the pocket accordingly. In planning Expander Deflation
the design of the expanded flap, the authors found that Deflation of an expander is usually caused by accidental
there are significant advantages in using expanded puncture of the expander during its insertion or inflation.
transposition flaps over pure advancement. Restricting Rarely does it occur due to device failure. When deflation
the expanded flap design to advancement alone, in occurs, the expander should be removed and replaced by
order to minimize potential scarring, severely limits the another.
 Head and Neck Tissue Expansion 815

Fig. 21: A 26-year-old postburn patient with Fig. 22: Thoracoacromial vessels were separated and
anterior neck scar contracture implanted under supraclavicular expanded skin

Fig. 23: Fully expanded left supraclavicular flap Fig. 24: Prefabricated flap elevation. Enriched blood
vessels network is seen through capsule
816 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 25: Immediate result following anterior neck reconstruction

with prefabricated expanded flap

A B

Figs 26A to C: Improved anterior neck esthetics and range

C of motion
 Head and Neck Tissue Expansion 817

REFERENCES 13. Moelleken BR, Mathes SJ, Cann CE, et al. Long-term effects
of tissue expansion on cranial and skeletal bone devel-
1. Neumann CG. The expansion of an area of skin by progres- opments in neonatal miniature swine: clinical findings
sive distension of a subcutaneous balloon; use of the and histomorphometric correlates. Plast Reconstr Surg.
method for securing skin for subtotal reconstruction of the 1990;86(5);825-34.
ear. Plast Reconstr Surg (1946). 1957;19(2):124-30. 14. Colonna M, Cavallini M, De Angelis A, et al. The effects of
2. Radovan C. Adjacent flap development using expandable scalp expansion on the cranial bone: a clinical, histological,
silastic implant. Presented at the Annual Meeting of the and instrumental study. Ann Plast Surg. 1996;36(3):255-60;
American Society of Plastic and Reconstructive Surgeons. discussion 260-2.
September 27-October 2, 1976, Boston, MA. 1976. 15. Meland NB, Loessin SJ, Thimsen D, et al. Tissue expansion
3. Austad ED, Rose GL. A self-inflating tissue expander. Plast
in the extremities using external reservoirs. Ann Plast Surg.
Reconstr Surg. 1982;70(5):588-94.
1992;29(1):36-9; discussion 40.
4. Johnson TM, Lowe L, Brown MD, et al. Histology and
16. Iconomou TG, Michelow BJ, Zuker RM. Tissue expansion in
physiology of tissue expansion. J Dermatol Surg Oncol.
1993;19(12):1074-8. the pediatric patient. Ann Plast Surg. 1993;31(2):134-40.
5. Takei T, Mills I, Arai K, et al. Molecular basis for tissue expan- 17. Paletta C, Campbell E, Shehadi SI. Tissue expanders in chil-
sion: clinical implications for the surgeon. Plast Reconstr dren. J Pediatr Surg. 1991;26(1):22-5.
Surg. 1998;102(1):247-58. 18. Neale HW, High RM, Billamire DA, et al. Complications of
6. Steenfos H, Tarnow P, Blomqvist G. Skin expansion. Long controlled tissue expansion in the pediatric burn patient.
term follow up of complications and costs of care. Scand J Plast Reconstr Surg. 1988;82(5):840-8.
Plast Reconstr Surg Hand Surg. 1993;27(2):137-41. 19. Antonyshyn O, Gruss JS, Zuker R, et al. Tissue expansion
7. Simon PJ, Anderson LS, Manstein ME. Increased hair growth in head and neck reconstruction. Plast Reconstr Surg.
and density following controlled expansion of guinea pig 1988;82(1):58-68.
skin and soft tissue. Ann Plast Surg. 1987;19(6):519-23. 20. Bauer BS, Vicari FA. An approach to excision of congeni-
8. Johnson PE, Kernahan DA, Bauer BS. Dermal and epidermal tal giant pigmented nevi in infancy early childhood.
response to soft-tissue expansion in the pig. Plast Reconstr 1988;82(6):1012-21.
Surg. 1988;81(3):390-7. 21. Rivera R, LoGiudice J, Gosain AK. Tissue expansion in pedi-
9. Knight KR, McCann JJ, Vanderkolk CA, et al. The redistri- atric patients. Clin Plast Surg. 2005;32(1):35-44, viii.
bution of collagen in expanded pig skin. Br J Plast Surg. 22. Bauer BS, Margulis A. The expanded transposition flap:
1990;43(5):565-70.
shifting paradigms based on experience gained from two
10. Lew D, Fuseler JW. The effect of stepwise expansion on
decades of pediatric tissue expansion. Plast Reconstr Surg.
the mitotic activity and vascularity of subdermal tissue
2004;114(1):98-106.
and induced capsule in the rat. J Oral Maxillofac Surg.
1991;49(8):848-53. 23. Bauer BS, Corcoran J. Treatment of large and giant nevi. Clin
11. Gur E, Hanna W, Anderighetti L, et al. Light and electron Plast Surg. 2005;32(1):11-8, vii.
microscopic evaluation of the pectoralis major muscle 24. Gur E, Zuker RM. Complex facial nevi: a surgical algorithm.
following tissue expansion for breast reconstruction. Plast Plast Reconstr Surg. 2000;106(1):25-35.
Reconstr Surg. 1998;102(4):1046-51. 25. Bauer BS, Few JW, Chaven CD, et al. The role of tissue expan-
12. Kim KH, Hong C, Futrell JW. Histomorphologic changes sion in the management of large congenital pigmented nevi
in expanded skeletal muscle in rats. Plast Reconstr Surg. of the forehead in the pediatric patient. Plast Reconstr Surg.
1993;92(4):710-6. 2001;107(3):668-75.
 818 Facial Plastics, Cosmetics and Reconstructive Surgery The Surgical Technique of Otoplasty
CHAPTER

91 The Surgical Technique of LASER

Skin Resurfacing
Zekayi Kutlubay, Murat Küçüktaş

The desire for cosmetic enhancement of facial skin with ablative resurfacing. Neither nonablative nor fractional
minimal risk and rapid recovery has inspired LASER medi- resurfacing produces results comparable to ablative
ated means of wrinkle and photodamage reduction. In the LASER skin resurfacing, but both have become much
1980s and early 1990s, continuous-wave carbon dioxide more popular than the latter because of minimal risks
(CO2) LASERS were used to resurface photodamaged skin and acceptable improvement.1
in a procedure called “thermabrasion”; however, this abla-
tive procedure was associated with an unacceptably high
risk of scarring. The advent of short-pulsed, high-peak-
INDICATIONS FOR LASER
power and rapidly scanned, focused beam CO2 LASERS RESURFACING
and normal mode erbium:yttrium-aluminum-garnet LASER skin resurfacing has been employed to treat a large
(Er:YAG) LASERS, which remove photodamaged skin number of skin conditions, but the two most common
layers in a precisely controlled manner, revolutionized indications are photoaging and scarring. A primary indi-
skin rejuvenation and scar treatment. cation is photoaging, which includes rhytides, dyspig-
The prolonged recovery time and complication risk mentation (Figs 1 and 2), vascular changes, elasto-
of ablative LASER resurfacing prompted the develop- sis, actinic cheilitis, and actinic keratoses (Figs 3A to D)
ment of nonablative and, more recently, fractional resur- is highly responsive to LASER resurfacing.2
facing in an effort to further minimize risk and recov- Perioral and periorbital rhytides, which are resistant to
ery. Nonablative LASER resurfacing induces dermal- facelift procedures, are highly amenable to LASER resur-
thermal injury to improve rhytides and photodamage facing. Fine rhytides (particularly in the periorbital, perio-
without epidermal damage. Fractional resurfacing ral and cheek areas) may be completely eradicated with
thermally ablates microscopic columns of epidermal LASER resurfacing; deeper creases are also improved,
and dermal tissue in a regularly spaced array compris- probably secondary to a general tightening effect. Rhytides
ing a fraction of the skin surface. This intermediate and creases that appear with active movement and facial
approach increases efficacy as compared to nonabla- expression, such as glabellar and nasolabial folds, tend to
tive resurfacing and speeds recovery as compared to be more resistant to LASER resurfacing.1

Fig. 1A: Solar lentigines before the operation Fig. 1B: Immediately after operation
 The Surgical Technique of LASER Skin Resurfacing 819

Ablative LASER resurfacing is effective for scars, includ-

ing those caused by acne (Figs 4 to 6), trauma (Figs 7A to E)
and surgery. It is most effective for elevated or deep, disten-
sible acne scars (Figs 8A and B), in which the fibrotic tissue
can be removed or the shoulders of the scars ablated,
respectively. Ice-pick or bound-down scars are less respon-
sive, requiring a combined approach of subcision and
punch excision/grafting, followed by LASER resurfacing
6–8 weeks later. Varicella scars may be improved with
spot LASER resurfacing, with fresh scars (6–10 weeks after
varicella) responding more completely than older scars.
Postsurgical and traumatic scars may achieve dramatic
improvement, especially if resurfaced 6–10 weeks after the
surgery or injury. Resurfacing well-vascularized wound
Fig. 1C: One month after LASER procedure edges immediately after surgery, prior to suture place-
ment, may also improve cosmetic outcome.

Fig. 2A: Solar lentigine before the operation Fig. 2B: Seventh day post procedure

Fig. 3A: Ablative Er:YAG LASER resurfacing for actinic keratoses Fig. 3B: Immediately after LASER
(before the operation) procedure
 820 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 3C: Seventh day after operation Fig. 3D: Twenty-eighth day after operation

Fig. 4A: Acne scars treated by ablative mode of Er:YAG Fig. 4B: Seventh day after procedure
LASER (before the procedure)

Resurfacing performed at the same time or soon after

Other Indications facelifting or blepharoplasty increases the risk of skin
Since LASER resurfacing is relatively bloodless and allows necrosis and scarring due to the altered blood circulation
for controlled tissue removal with a low risk of scarring, of the undermined skin following these procedures. Hence,
it has also been used to treat rhinophyma, diffuse actinic LASER resurfacing of undermined skin should be deferred
cheilitis, actinic keratoses, benign neoplasms/hamarto- for at least 6 months after the original surgical procedure.
mas (e.g. angiofibromas, appendageal tumors), verrucae, Ablative LASER skin resurfacing with either CO2 or
and eyelid laxity (Figs 9A to D).1,2 Er:YAG LASER systems is a well accepted treatment for
The ideal LASER resurfacing candidate is a healthy, facial rejuvenation.3
lightly pigmented patient with realistic expectations. Carbon dioxide LASER resurfacing can achieve excel-
Patients with a history of keloids, radiation therapy to lent results in patients with mild-to-moderate surface
the area or scleroderma are not candidates. Diseases that texture changes and fine superficial or moderate static
exhibit Koebnerization, such as psoriasis and vitiligo, are wrinkles but not in those with deep furrows or severe
relative contraindications. dermatoheliosis.4
Prior isotretinoin therapy has been associated with Acne scars can be classified into three basic types:
atypical scarring after dermabrasion or chemical peel- (i) Shallow depressed scars, (ii) Wide-base atrophic
ing, even if the procedure were performed more than scars, and (iii) Ice-pick scars. The first two types of acne
1 year after isotretinoin treatment. Therefore, it is gener- scars generally are amenable to CO2 LASER resurfacing;
ally recommended that patients wait for at least 1–2 years however, fibrotic or ice-pick scars often require punch exci-
before undergoing this procedure. sion, punch grafts, or punch elevation. Scar base lifting
 The Surgical Technique of LASER Skin Resurfacing 821

and injection of filling substances for atrophic acne scars skin with detectable improvement of fine lines and wrin-
(performed as a separate procedure at a different time) kles, mottled dyspigmentation, rough-skin texture, and
can also be combined with LASER resurfacing for optimal solar lentigines (Figs 10A and B). CO2 LASER resurfac-
results.5 ing can eradicate precancerous growths such as actinic
Carbon dioxide LASER resurfacing has proved to be a keratosis, although prevention of future development of
valuable method for facial rejuvenation of photodamaged actinic keratosis has not been substantiated.

Fig. 5A: Preoperative photo of the patient with acne scars Fig. 5B: Seven days later after ablative Er:YAG

Fig. 6A: Before Er:YAG ablation Fig. 6B: Immediately after the LASER procedure
822 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 6C: One month later from the ablation Fig. 7A: Blade cut trace, before fractional CO2 LASER
Source: By the courtesy of Dr Şehriyar Nazari

Fig. 7B: Blade cut trace, 7 days later Fig. 7C: Blade cut trace, 15 days later

Fig. 7D: Blade cut trace, 20 days later from Fig. 7E: Blade cut trace, 30 days later from the
fractional CO2 LASER fractional CO2 LASER
 The Surgical Technique of LASER Skin Resurfacing 823

The Er:YAG LASER is a powerful tool in the cosmetic is particularly well suited for patients with darker skin
surgeon’s armamentarium that can have beneficial phototypes. Several studies have documented a lower
effects when used properly for the correct indication risk of pigmentary alterations as compared to CO2
(Sample video). Mild-to-moderate photo-induced LASER resurfacing. Although studies suggest modu-
rhytides, superficial pigmentation, atrophic scars, lated Er:YAG LASERS are associated with a lower risk
and a variety of epidermal and dermal lesions can be of pigmentary alterations than CO2 LASER resurfacing,
treated successfully with the Er:YAG LASER (Figs 11A long-term data regarding the risks of delayed hypopig-
to E). Treatment with the short-pulsed Er:YAG LASER mentation are not yet available.

Fig. 8A: Acne scars, before the Er:YAG ablation Fig. 8B: Seven days later (from the ablative procedure)

Fig. 9A: Eyelid laxity, before fractional CO2 LASER treatment Fig. 9B: Eyelid laxity, 7 days later from
Source: By the courtesy of Dr Şehriyar Nazari fractional CO2 LASER treatment
 824 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 9C: Eyelid laxity, 15 days later Fig. 9D: Eyelid laxity, 30 days later

Skin resurfacing with a short-pulsed Er:YAG LASER is postoperative crusting and edema, presumably by reduc-
most commonly used for the improvement of fine rhyt- ing the amount of thermal necrosis induced by the CO2
ides. For moderate photodamage and rhytides, modu- LASER.
lated Er:YAG LASER skin resurfacing results in greater Nonablative procedures are ideal for the younger
collagen contraction and improved clinical results as person who wishes to improve the quality, the tone, and
when compared to short-pulsed Er:YAG systems. Clinical the texture of his or her skin. It is a technique ideally suited
improvement of severe rhytides treated with a modulated for the individual with early photoaging, not for one with
Er:YAG LASER can be impressive. However, the improve- class III rhytides.
ment seen is not equivalent to that of pulsed or scanned
CO2 resurfacing, even when equal depths of ablation
are obtained. Newman et al.6 compared a variable pulse
SPECIFIC PREOPERATIVE
Er:YAG LASER to traditional pulsed or scanned CO2 resur- EVALUATION
facing for the treatment of perioral rhytides. Although a Patient expectation, skin type and medical history should
reduced duration of re-epithelialization was noted with be thoroughly assessed before initiation. An ideal patient
the modulated Er:YAG LASER (3.4 days vs 7.7 days with has reasonable expectations for cosmetic outcome.
CO2), the clinical results observed were less impressive Patients should understand the side-effect profile, as
than those following CO2 LASER resurfacing. discussed later, as well as being able to manage the neces-
Er:YAG LASER systems may greatly improve atrophic sary downtime following treatment.1
scars caused by acne, trauma, or surgery. In a series of The ideal patient is of Fitzpatrick skin type I through
78 patients, Weinstein7 reported 70–90% improvement IV, and has a primary concern cited or related to the indi-
of acne scarring in the majority of patients treated with a cations described above. Because certain histories can
modulated Er:YAG LASER. Pitted acne scars may require directly, and negatively, influence outcome, a patient’s
ancillary procedures, such as subscision or punch exci- medical history plays a critical role in patient selection.
sion, for optimal results. These procedures can be A patient with history of keloids should not undergo the
performed either prior to or concomitant with Er:YAG procedure, as the procedure may trigger another keloidal
LASER resurfacing. response. Similarly, patients with dermatologic diseases
A variety of benign epidermal and dermal conditions that demonstrate Koebnerization, such as vitiligo, lichen
respond favorably to Er:YAG LASER resurfacing, includ- planus, and psoriasis, should be cautioned and likely
ing sebaceous hyperplasia, eruptive hair cysts, adenoma dissuaded from undergoing ablation.
sebaceum, angiofibroma, hidradenoma, xanthelasma, Any suggestion of adnexal disease also serves as a
and syringomas. contraindication to ablative LASER resurfacing. Ablative
LASER surgeons can combine Er:YAG LASER and resurfacing relies on the repopulation of the epidermis
CO2 LASER to take advantage of the unique properties from stem cells found in skin appendages. A deficiency of
of each LASER. The addition of Er:YAG LASER follow- these appendages, as seen in morphea and scleroderma,
ing CO2 LASER resurfacing may decrease the duration of for example, serve as contraindications because of their
 The Surgical Technique of LASER Skin Resurfacing 825

Fig. 10A: Before fractional CO2 LASER treatment Fig. 10B: Fifteen days later from LASER treatment
Source: By the courtesy of Dr Şehriyar Nazari

Fig. 11A: Before Er:YAG LASER ablation Fig. 11B: Immediately after operation

Fig. 11C: Seventh day Fig. 11D: Twentieth day postoperatively

 826 Facial Plastics, Cosmetics and Reconstructive Surgery

ANESTHETIC CONSIDERATIONS
Prior to the procedure, the skin is cleansed with a mild
cleanser to remove any makeup, sunscreen, creams, or
lotions. Topical anesthetic cream is applied to the skin
60 minutes prior to treatment.
Options for anesthesia exist over a wide spectrum,
from topical agents and local infiltration to nerve blocks
and systemic agents.1 A variety of topical anesthetics
are available. Superficial LASER procedures are often
managed with topical agents, such as lidocaine and
prilocaine cream. However, with deeper and higher
density treatments, topical anesthetic cream alone is not
adequate to keep the patient comfortable during the treat-
ment.8 These can be combined with local infiltration of
anesthetic, particularly when treating a specific cosmetic
Fig. 11E: Four months after operation unit. When broadly treating the central forehead, median
cheek, nose, upper lip, lower lip, and/or chin, a variety of
blocks including supraorbital, supratrochlear, infraorbital,
diminished stem cell supply. Furthermore, while the and mental nerve blocks may be employed as appropriate.
number of sebaceous glands remains approximately the Blocks may be achieved simply using lidocaine 1–2% with
same throughout life, they tend to increase in size with 1:100,000 or 1:200,000 epinephrine, but can be enhanced
age, and therefore younger patients may not be as suited by bupivacaine 0.5%, 1:10 sodium bicarbonate (NaHCO3)
to this form of treatment. 8.4% to neutralize the pH and, subsequently, diminish pain.
Several iatrogenic conditions can also serve as Patients undergoing total face resurfacing and patients
contraindications. Skin treated with radiation therapy who are particularly sensitive may warrant the addition of
should not undergo ablation for the same rationale just systemic agents as well, including anxiolytics, narcotics,
cited: namely, a relative absence of adnexal structures to intramuscular sedation, or intravenous anesthesia.
repopulate the epidermis. If the edema is severe enough, oral corticosteroids
Recent treatment with isotretinoin also serves as may be prescribed over a short term. Cool compresses,
a contraindication, since atypical scarring has been head elevation, soaks in saline or water, and protection
reported in dermabrasion and chemical peeling follow- with a petrolatum ointment as well as bio-occlusive dress-
ing its use. Though not evidence based, many consider a ings are additional methods of caring for these patients
washout period of at least 1 year as adequate when treat- postoperatively.
ing patients who have been on isotretinoin. Ironically, Additionally, patients must be strongly advised to use
despite the contraindication to ablative LASER resurfac- sunscreen and practice sun-protective behavior to reduce
ing following systemic retinoid treatment, preoperative risks of postinflammatory hyperpigmentation.2
topical retinoids, often tretinoin, are often recommended.
Tretinoin is thought to prime the skin for more rapid heal-
ing after ablation.
SURGICAL STEPS
Finally, ablative resurfacing after extensive surgical Ablative LASER Resurfacing
procedures is also contraindicated.2
At the time of the consultation, patients are given Carbon Dioxide LASER
prescriptions for an oral antibiotic, oral antiviral prepa- LASER resurfacing for rejuvenation was first widely offered
ration.8 Oral antiviral and antibacterial prophylaxis is in the 1980s using ablative CO2 LASERS.2 The CO2 LASER
generally recommended to prevent herpes and secondary emits a 10.600 nm wavelength which is strongly absorbed by
bacterial eruptions.2 Fluconazole administered postop- tissue water (Table 1). The penetration depth is dependent
eratively between days 3 and 8 significantly promotes upon the tissue water content, but not the melanin or
re-epithelialization in patients undergoing full-face CO2 hemoglobin content. With a pulse duration of less than
LASER skin resurfacing. Fluconazole should be consid- 1 ms, CO2 LASER light penetrates approximately 20–30
ered prophylactically in addition to antibiotic and antiviral μm into the skin, and residual thermal damage can be
medications in patients undergoing full-face CO2 LASER confined to a 100–150 μm layer of tissue, although thermal
resurfacing.9 coagulation up to 1 mm has been reported.1
 The Surgical Technique of LASER Skin Resurfacing 827

Vaporization and removal of a surface layer of cells; time on any individual spot is less than 1 ms, while achiev-
coagulation necrosis of cells and denaturation of extra­ ing fluences above the ablation threshold.1
cellular proteins in a subjacent residual layer; and nonfatal
damage to cells in a deeper zone are all seen in CO2 LASER Erbium: YAG LASER
resurfacing. The entire epidermis and varying thickness The Er:YAG LASER was the next ablative LASER developed
of the dermis are removed, and the patient’s skin looks for skin resurfacing. It emits infrared (IR) LASER light with
smoother and tighter during healing due to heat-induced a wavelength of 2940 nm, which is close to the absorp-
shrinkage of collagen.10 tion peak of water and yields an absorption coefficient
The vaporization or boiling point of water at 1 atmos- 16 times that of the CO2 LASER (Table 1). Penetration
phere is 100°C. The fluence required to achieve pulsed- depth of the Er:YAG LASER is limited to about 1–3 μm of
LASER ablation of skin tissue is 5 J/cm2, with less energy tissue per J/cm2 versus the 20–30 μm observed with the
producing diffuse tissue heating without vaporization. At CO2 LASER. This provides more precise ablation of skin
these parameters, the skin temperature reaches approxi- with minimal thermal damage to the surrounding tissues;
mately 120–200°C. The diameter of the beam plays a role, the residual thermal damage is estimated to be 10–40 μm.
with small beams (100–300 μm in diameter) achieving Operating the Er:YAG LASER at a fluence of 5 J/cm2 vapor-
high fluences and rapid tissue vaporization; however, izes the epidermis in four passes, 8–12 J/cm2 achieves this
the beam must be moved rapidly across the skin surface after two passes.
to avert desiccation, charring and heat diffusion. Beam The Er:YAG LASER is almost totally absorbed by a very
diameters of greater than 2 mm induce nonvaporization thin, superficial layer of skin and can be used for precise
heating and increase the risk of deep thermal damage and superficial tissue ablation (Fig. 12). Additionally,
due to the need to apply low fluences for longer periods the wavelength of the Er:YAG LASER is very close to an
of time in order for visible vaporization to occur. Based on absorption maximum of collagen at 3030 nm. Therefore,
these findings, the pulsed or scanned CO2 LASERS were skin containing 70–80% water has an absorption coeffi-
designed to combine high peak powers with short pulses cient of approximately 8000–9000 cm-1 at 2940 nm.11
and/or rapid movement across the skin surface.
Two basic CO2 LASER systems have been utilized in
cutaneous resurfacing. The first type is the high-powered
pulsed CO2 LASER system, which delivers energy in indi-
vidual pulses of about 1 ms or less. This LASER produces
up to 500 mJ of energy in each individual 600 μs to 1 ms
pulse. Vaporization can be performed either with a 3-mm
spot size or by a computer pattern generator, which can
deliver various patterns of up to 80 pulses, each pulse
measuring 2.25 mm in diameter.
The second type of CO2 resurfacing LASER achieves
well-controlled tissue ablation by rapidly scanning the
focal spot of a focused continuous-wave CO2 LASER over
the skin. Computer-driven mechanical devices can scan
a 0.2-mm spot in a spiral manner, ranging in diameter
from 8–16 mm in several shapes at a constant velocity. No
individual spot is irradiated more than once and the dwell Fig. 12: Er:YAG LASER skin resurfacing

Table 1: Ablative LASER devices for rejuvenation and resurfacing

LASER/Device Target Advantages Disadvantages
Carbon dioxide Water Excellent efficacy for rhytides and 3-week recovery time, higher
(10.600 nm) LASER photoaging risk profile
Erbium:YAG Water Excellent efficacy for rhytides and 3-week recovery time, higher
(2.940 nm) LASER photoaging risk profile
Nitrogen plasma Cell membranes Moderate to excellent efficacy for 3-day to 3-week recovery
rhytides and photoaging time
 828 Facial Plastics, Cosmetics and Reconstructive Surgery

Overall efficacy of the Er:YAG is rather similar to the epidermis serving as a biologic dressing for the formation
CO2 LASER, although the CO2 LASER has been found to of a new stratum corneum and epidermis.
be superior in most comparative studies. Er:YAG LASER Ablative LASERS offer maximum clinical benefit with
ablation is more superficial and wounds heal more increased prevalence of dermal wounds and morbid-
quickly, but efficacy is less when fluences per pulse and ity while nonablative LASERS offer minimal clinical
number of passes similar to those of the CO2 LASER are benefit and minimal morbidity. This novel PSR system
used. Er:YAG LASER treatment also produces less dermal offers a compromise between the two treatments, provid-
collagen remodeling than the CO2 LASER.10 The varia- ing patients with ablative like clinical results as well
ble-pulsed Er:YAG LASER (pulse durations of 10–50 ms) as the minimal morbidity associated with nonablative
demonstrates immediate tissue contraction and a healing techniques.12
rate that is intermediate between the short-pulsed Er:YAG
(pulse durations of 250–350 μs) and CO2 LASERS. In Nonablative Resurfacing
comparative studies, the variable-pulsed Er:YAG LASER Nonablative LASER and light systems can be classified
was very effective in the removal of rhytides, although the into three main groups: (i) Vascular LASERS such as the
CO2 LASER was still found to be slightly more efficacious. pulsed dye LASER (PDL) and pulsed potassium titanyl
The Er:YAG LASER results in less severe side effects phosphate (KTP) LASER; (ii) Mid-IR LASERS targeting
of discomfort, erythema and edema, and overall healing the dermis; and (iii) Intensed pulsed light (IPL) (Table
times are faster than with the CO2 LASER. When compared 2). Initially, the Q-switched Nd:YAG LASER (1064 nm)
according to the depth of ablation performed, healing was shown to induce dermal remodelling. Subsequently,
times for the two LASERS have been similar. In contrast vascular LASERS such as the PDL and pulsed 532 nm
to the bloodless nature of CO2 LASER treatment (due to LASERS were employed but with minimal efficacy.
photocoagulation of blood vessels less than 0.5 mm in Longer-wavelength IR LASERS, which more effectively
diameter), bleeding increases with successive passes with target the mid dermis, have since become the most prom-
the Er:YAG LASER.1 inent nonablative LASERS, resulting in more consistent
mild improvement in rhytides. IPL improves dyspig-
Plasma Skin Resurfacing mentation and vascularity while at the same time emit-
Plasma skin resurfacing (PSR) is a relatively new ting near-IR wavelengths that target the dermis, thereby
non­ablative and fully ablative strategy.1 This novel device resulting in global improvement in photodamage. More
for ablative resurfacing works by passing radiofrequency recently, RF systems have been developed, delivering
(RF) energy into nitrogen gas. The “nitrogen plasma” causes electrical energy (with or without concomitant LASER
rapid heating of the skin with limited tissue ablation and or light) that results in more pronounced reduction of
minimal collateral thermal damage (Table 1). Preliminary skin laxity and rhytides. The mechanisms for nonabla-
reports indicate improvement in facial rhytides and scars tive rejuvenation involve photothermal and other effects
following treatment. However, PSR offers improvement resulting in collagen contracture and neocollagenesis.1
of moderately photodamaged skin of the neck, chest, The greatest advantage to nonablative LASERS over
and dorsal hands with limited side effects.12 Epidermal their ablative and fractional ablative counterparts is their
regeneration occurs by 7 days postoperatively, with more attractive side-effect profile. However, efficacy of a
neocollagenesis visible on histologic analysis at 90 days.1 single treatment may be considered less than ideal. It is
This technology is based on delivery of high-energy the responsibility of the physician to be certain that the
RF into nitrogen gas, which generates nitrogen plasma patient has reasonable expectations and may require a
targeted at the treatment area. Heat is transferred to the series of treatments to achieve desired outcome.2
skin, driving the collagen denaturation and subsequent Nonablative LASER procedures selectively injure the
neocollagenesis. Although promising, this technology has dermis but protect the epidermis by cooling during treat-
not yet been fully evaluated in comparison to the CO2 and ment. Like ablative LASERS, nonablative LASERS emit
Er:YAG LASERS.2 coherent light at wavelengths absorbed by water.1
A pulse of ultrahigh-energy RF from the device genera-
tor converts nitrogen gas into plasma within the hand- Fractional Resurfacing
piece. The plasma emerges from the distal end of the In 2004, the concept of fractional photothermolysis (FP)
device handpiece and is directed onto the skin area to be was introduced. In photothermolysis, only a specific frac-
treated. Rapid heating of the skin occurs as the excited gas tion of the epidermal and dermal architecture is treated.13
transfers heat to the skin. Fibroblast activity is increased The theory of fractional photothermolysis, pioneered by
during dermal regeneration, with the retained necrotic Anderson and colleagues, along with the technology of
 The Surgical Technique of LASER Skin Resurfacing 829

Table 2: Nonablative LASER devices for rejuvenation and resurfacing

LASER/Device Target Advantages Disadvantages
Vascular LASERS (532 nm pulsed KTP, Dermal vasculature Excellent safety, no recovery Minimal
585 and 595 nm pulsed dye) time, improvement in efficacy, multiple
telangiectasias treatments
necessary
Near-infrared LASERS (1310 nm diode, Dermal collagen and Excellent safety, no recovery Modest efficacy,
1320 nm long-pulsed Nd:YAG, 1450 water time, greater efficacy for multiple
nm diode, 1540 nm Er:glass) and light rhytides treatments
devices (1100–1800 nm) necessary
Intensed pulsed light source Dermal vasculature, Moderate safety, no Minimal to
pigment, collagen and recovery time, improvement modest efficacy,
water in telangiectasias and multiple
dyspigmentation treatments
necessary
Radiofrequency energy source Dermal collagen; dermal Excellent safety, no recovery Modest efficacy,
and subcutaneous time, greater efficacy for multiple
charged particles and rhytides and laxity treatments
water necessary

traditional ablative LASERS, has spawned the rise of the Histologic studies examining fractional ablative
field of fractional ablative therapy (Table 3).2 devices have demonstrated that typical microthermal
Fractional photothermolysis is based upon the scien- zones consist of a tapered ablative zone, surrounded by
tific concept of creating microscopic thermal wounds eschar and a thermal coagulation zone, with maximum
deep to the surface of the skin, which allow for tissue lesion depths ranging from 300 μm to over 1 mm and
contraction, stimulation of collagen, and rapid wound lesion widths of 140 μm to almost 300 μm. More recently,
healing. Fractionated LASERS drill microscopic holes into it has been reported that fractional ablative LASERS can
the dermis in a grid pattern. FP has been likened to aerat- achieve a depth of over 1.5 mm into the dermis at higher
ing a lawn. The “lawn plugs,” termed microscopic epider- energy levels (70 mJ). Furthermore, re-epithelialization was
mal necrotic debris, are expelled via a transepidermal shown to be complete in a matter of 2 days, with extru-
elimination process over 7–10 days. The consequences are sion of the coagulated tissue, or microepidermal necrotic
twofold: (i) Dermal conditions that have been approached debris.14
indirectly in the past via epidermal wounding are now Following full-face resurfacing with ablative fractional
directly wounded as portions of the normal dermis are photothermolysis (AFP), complete re-epithelialization
removed; and (ii) The remaining adjacent intact dermis is generally seen in 3–6 days. This is in contrast to the
and epidermis allow for rapid healing without relying 2–3 weeks of recovery following full-face resurfacing with
on the presence of adnexal structures to regenerate the traditional CO2 LASER systems. Rapid re-epithelialization
epidermis.8 after AFP treatment results in very few infections, which are
Fractionated 1.410-nm erbium-doped fiber, 2.940-nm further reduced with the use of prophylactic antiviral and
erbium: YAG and 10.600-nm CO2 LASERS have also been antibiotic therapy. Faster re-epithelialization also results in
developed.1 The first LASERS employing this concept patients requiring fewer days of occlusive ointment appli-
were the nonablative fractional technologies, such as the cation. This greatly reduces the rate of acneiform erup-
1.550-nm erbium-doped fiber LASER.2 A 1.550-nm tions, which are seen in up to 83% of patients treated with
erbium-doped fiber LASER causes cylindrical areas of traditional CO2 LASERS. The rapid recovery times seen
thermal damage to the epidermis and upper dermis, with fractionated CO2 LASER marks a significant improve-
which are spaced at a density of approximately 1.000–3.000 ment over traditional CO2 and Er:YAG LASER resurfacing.8
microscopic treatment zones of photothermolysis per cm2.
Each column or ‘microthermal zone’ is approximately Practical Tips for Treatment of LASER
70–150 μm in width with a vertical thermal injury depth Resurfacing
of 400–700 μm into the dermis. Approximately 15–25% Prior to treating patients with any of the available ablative
of the skin surface area is ablated per treatment session.1 LASER systems, it is important for the practitioner to have
 830 Facial Plastics, Cosmetics and Reconstructive Surgery

Table 3: Indications and parameters for fractional LASER resurfacing

Indication Energy/MTZ (mJ) Density (MTZ/cm2) Number of passes Total treatment density (MTZ/cm2)
Melasma
Skin types I–II 6 250 12 3,000
Skin types III–VI 6 250 8 2,000
Rhytides
Mild 12 125 12 1,500
Moderate 15 125 8 1,000
Severe 20 125 8 1,000
Acne scarring
Skin types I–II 15–20 125 8–12 1,500–1,000
Skin types III–VI 15 125 8 1,000
Photoaging
Skin types I–II 10 250 8 2,000
Skin types III–VI 8 250 8 2,000

an understanding of the extent of tissue injury produced densities increase the duration of edema and erythema
by the device at various settings and consider the thick- following treatment. It is prudent to use lower densities in
ness of the skin and the depth required to ablate the skin areas with lower density of hair follicles, such as the neck
abnormality, in order to choose safe and effective treat- and lower eyelid. Higher densities are necessary and can
ment settings. be used safely to treat deep rhytides in the perioral region.
Published histologic studies on the thickness of the In general, shorter pulse durations are desirable.
skin, and the depth and number of adnexal structures at Longer pulse durations result in more collateral heating
various anatomic sites, and histologic studies showing of the tissue. When using LASERS that have pulse dura-
the depth and width of tissue injury with varying LASER tions greater than 2 milliseconds, the authors recommend
parameters are helpful in guiding the clinician in the compensating for the increase in collateral tissue heating
choice of appropriate LASER settings. by using lower densities.8
When using AFP devices with small spot sizes, increas-
ing energy results in deeper tissue injury. Increasing
energy with both of these devices also increased the
COMPLICATIONS OF LASER SKIN
width of the zones of ablation and coagulation of tissue. RESURFACING
Treatments utilizing higher energies increase the time • Prolonged erythema
required for resolution of edema and erythema following • Acne and milia
treatment. In addition, deeper treatments result in more • Contact dermatitis
pinpoint bleeding during and following treatment. It is • Recall phenomenon
important to use lower energies when treating areas with • Infection
thinner skin, such as the eyelids and neck.1,2,8 • Pigmentary alteration
Spot sizes less than 200 µm allow for deeper penetra- • Eruptive keratoacanthomas
tion into tissue, whereas spot sizes greater than 300 µm • Hypertrophic scarring
result in a shallower depth of penetration at the same • Ectropion formation
energies. When superficial treatment is the goal, as in • Delayed purpura
treatment of dyschromia, the practitioner may choose a • Superficial erosions
larger spot size, whereas for treatment of skin conditions, • Anesthesia toxicity11,15-17
such as scars and rhytids, a small spot size will result in
deeper tissue injury required to achieve a clinical result. Prolonged Erythema
Density determines the distance between micro- Immediate post-treatment erythema (Figs 13A and B)
thermal zones (MTZs). Increasing the density decreases is an expected consequence of fractionated LASER
the distance between MTZs, resulting in treatment of a skin resurfacing that usually resolves within 3–4 days.
larger percentage of the skin surface. Treatments at higher Prolonged erythema is defined as post-treatment
 The Surgical Technique of LASER Skin Resurfacing 831

Fig. 13A: Post-treatment crusting. Five days later Fig. 13B: Post-treatment erythema and crusting.
Er:YAG ablation Four days later Er:YAG ablation

erythema that persists longer than 4 days with nonabla- administered when a prior history of facial HSV is docu-
tive resurfacing and beyond 3–4 months with ablative mented or if full-face ablative LASER procedures are
treatment.8,15 Flushing within the treated site upon physi- performed. In these patients, oral antiviral agents should
cal exertion or emotional stress may occur for up to 1 year be initiated concomitant with or 1 day before treatment
after resurfacing.1 and continued for 5–7 days.11,15 The agent of choice for HSV
Photomodulation with a 590-nm-wavelength LED prophylaxis remains acyclovir 400 mg orally twice a day,19
array can decrease the intensity and duration of postfrac- or famciclovir 250 mg or 500 mg twice day.20 Antiherpetic
tional LASER treatment erythema.18 In addition, given prophylaxis is recommended for all patients undergo-
its anti-inflammatory properties, topical ascorbic acid ing full-face or perioral LASER resurfacing regardless of
should be considered because a previous study reported past HSV history.20 Furthermore, fractional skin resurfac-
less severe and shorter postablative LASER resurfacing ing should not be performed on patients with active HSV
erythema with its use.15 infection, given the risk of HSV exacerbation.15
The rate of bacterial infection with traditional LASER
Infection vaporization tends to be low (0.5–4.5% of cases).15
Given that viral, bacterial, and fungal infections usually Prophylactic systemic antibiotics and appropriate topical
present during the first postoperative week, proper identi­ care are used to minimize the risk of bacterial infection.1
fication and treatment are essential to avoid further Excessive wound occlusion during the early postoperative
complications, including delayed wound healing, scar- period can enhance the likelihood of pathogen overgrowth,
ring, co-infection with other pathogens, and systemic primarily Staphylococcus aureus and Pseudomonas aerug-
dissemination. inosa.13 The increased prevalence of methicillin-resistant
Infection rate ranging from 6–8% for all patients is Staphylococcus aureus in the community (with carrier
treated with ablative resurfacing devices.19 The rate of rates as high as 40% in some regions) warrants the use of
Herpes simplex virus (HSV) infection, the most common topical mupirocin three times a day.19
type of infection after fractional LASER skin resurfacing, Disseminated infection, the causative agents and
has been reported in 0.3–2% of cases. In contrast, infection appropriate treatment are essential, especially in light
rates with traditional (nonfractionated) LASER treatment of possible methicillin resistant Staphylococcus aureus.
are higher, with 2–7% of cases developing HSV reactiva- Notwithstanding, controversy remains with regard to the
tion. Patients may not present with classic herpetiform use of prophylactic systemic antibiotics in all patients but
vesicopustules but instead may demonstrate only super- should be standard practice in patients at high risk, espe-
ficial erosions that develop during the first week after cially those who are immunosuppressed or have docu-
treatment. To minimize the risk of HSV reactivation with mented mitral valve prolapse with regurgitation or other
fractional resurfacing, antiviral prophylaxis should be valvular heart disease.15
 832 Facial Plastics, Cosmetics and Reconstructive Surgery

Acne and Milia Hypopigmentation is an extremely uncommon

Transient acneiform eruptions and milia are relatively complication of fractional LASER skin resurfacing. One
common after traditional nonfractionated LASER resur- reported case involved transient hypopigmentation
facing, with up to 80% of cases developing the former and 15 days after treatment that was attributed to the prophy-
more than 14% developing the latter. Although the rates of lactic use of topical tretinoin and hydroquinone.15
acneiform eruptions are significantly lower (2–10%) with
fractional skin resurfacing, the incidence of milia develop- Scarring
ment has been reported in as many as 19% of treated patients. Hypertrophic scarring is a known and rare complication of
Given that occlusive moisturizers and dressings can ablative skin resurfacing using CO2 and Er:YAG LASERS.15
exacerbate such eruptions, most authors recommend Focal areas of erythema and induration 2–4 weeks after
their avoidance or a change to noncomedogenic equiva- treatment are the first signs of potential scar formation.
lents. Disruption of follicular units during treatment and Nine of ten published cases involved fractional ablative
aberrant follicular epithelialization during healing may skin resurfacing of the neck, resulting in multiple vertical
further contribute to acne exacerbation. and horizontal hypertrophic scars.
In moderate to severe acne flares, short courses of Scarring after LASER therapy may be due to overly
oral tetracycline-based antibiotics have been advocated. aggressive treatments of insensitive areas (including exces-
Antibiotics can also be prescribed during subsequent sive energy, density, or both), lack of technical finesse, asso-
treatments to prevent future outbreaks.11,15 ciated infection, or idiopathic. Care should be taken when
treating sensitive areas such as the eyelids, upper neck,
Dermatitis and especially the lower neck and chest by using lower
Irritant contact dermatitis may be observed following energy and density. Postoperative infections may lead to
application of topical anesthetics; it does not correlate scarring and may be prevented by careful taking of history,
with patch test findings but resolves with appropriate vigilant postoperative monitoring and/or prophylactic
treatment (e.g., topical corticosteroids). This occurrence antibiotics.22
increases the likelihood of postoperative erythema and The neck is also a well-recognized site that is especially
hyperpigmentation. Irritant or allergic contact derma- susceptible to the development of scarring because of the
titis due to other etiologies (e.g. wound dressings, topi- small number of pilosebaceous units and poor vascula-
cal antibiotics) may also develop during the first 4 weeks ture in this region, which are essential for wound heal-
after treatment and also responds to mid to high-potency ing. In addition, the thin skin of the neck renders it more
topical corticosteroids. Perioral dermatitis is infrequently susceptible to thermal injury.15,23
observed 1–3 months after resurfacing of the perioral Other scar-prone anatomic locations that also require
region, and responds to oral doxycycline.1 more conservative treatment protocols include the perior-
bital and mandibular regions.15
Pigmentary Alteration
Postinflammatory hyperpigmentation (PIH) is much less Ectropion Formation
frequent with fractional LASER skin resurfacing than Cicatricial ectropion is a rare and serious complication
with other ablative procedures but is observed in 1–32% that has recently been reported after fractional CO2 LASER
of patients, depending on the system used, parameters treatment. The lower eyelid is typically involved. Careful
applied, and skin phototypes treated. Patients with darker intraoperative detection of excessive collagen contraction
skin phototypes (Fitzpatrick III–VI) have a higher likeli- and use of lower energy density settings help to minimize
hood of developing PIH.15 Both the density and energy of ectropion formation.15
the treatment determines the risk of PIH in dark-skinned
patients.21 Eruptive Keratoacanthomas
In general, fractional resurfacing of darker skin should Keratoacanthomas are low-grade malignant skin tumors
use higher fluencies, lower density settings, and longer that are known to arise over sites of trauma. Although
treatment intervals. To further minimize the risk of PIH, previously described in association with ablative LASER
patients should avoid sun exposure at least 2 weeks before treatment of the face,24 the development of multiple
and after fractional skin resurfacing. In contrast to tradi- eruptive keratoacanthomas after fractional resurfac-
tional nonfractionated LASER resurfacing, PIH is typically ing has more recently been reported on the legs of two
less intense and of shorter duration. patients.25
 The Surgical Technique of LASER Skin Resurfacing 833

Recall Phenomenon 9. Conn H, Nanda VS. Prophylactic fluconazole promotes

Heat-induced recall phenomenon has been observed after reepithelialization in full-face carbon dioxide laser skin
skin resurfacing with a combination (1.320/1.440 nm) resurfacing. Lasers Surg Med. 2000;26(2):201-7.
fractional LASER. After resolution of transient post- 10. Geronemus RG. Fractional photothermolysis: current and
future applications. Lasers Surg Med. 2006;38(3):169-76.
treatment wheal-like erythema, some patients experi-
11. Kutlubay Z, Gokdemir G. Treatment of atrophic facial acne
ence reappearance of erythematous patches after a hot
scars with the Er:YAG laser: a Turkish experience. J Cosmet
shower or prolonged exposure to direct sunlight, resulting Laser Ther. 2010;12(2):65-72.
in a ‘‘recall’’ phenomenon. The exact mechanism has not 12. Alster TS, Konda S. Plasma skin resurfacing for regeneration
been fully elucidated, but it appears that there is activa- of neck, chest, and hands: investigation of a novel device.
tion of neurogenic or histamine or mast cell-dependent Dermatol Surg. 2007;33(11):1315-21.
mechanisms responsible for high levels of molecules that 13. Manstein D, Herron GS, Sink RK, et al. Fractional photo-
produce erythema in the skin.15 thermolysis: a new concept for cutaneous remodeling using
The wavelengths or deep heating component of this microscopic patterns of thermal injury. Lasers Surg Med.
combination device might be responsible for the phenom- 2004;345):426-38.
enon through the activation of pathways or increased 14. Hantash BM, Bedi VP, Kapadia B, et al. In vivo histological
evaluation of a novel ablative fractional resurfacing device.
levels of molecules that produce erythema in the skin:
Lasers Surg Med. 2007;39(2):96-107.
histamine, 5-hydroxytryptamine, phospholipase A2,
15. Metelitsa AI, Alster TS. Fractionated laser skin resurfacing
cyclooxygenase, interleukin-1, and tumor necrosis factor. treatment complications: a review. Dermatol Surg. 2010;
However, in contrast to this line of thinking, a previous 36(3):299-306.
study assessing the wheal and flare reaction following 16. Fisher GH, Geronemus RG. Short-term side effects of frac-
treatment of human forearm skin with an argon LASER tional photothermolysis. Dermatol Surg. 2005;31(9 Pt 2):
demonstrated that the reaction could not be blocked by 1245-9.
pretreatment with acetylsalicylic acid or antihistamines, 17. Graber EM, Tanzi EL, Alster TS. Side effects and complica-
suggesting a neurogenic rather than a histamine or mast tions of fractional laser photothermolysis: experience with
cell-dependent mechanism.26 961 treatments. Dermatol Surg. 2008;34(3):301-7.
18. Alster TS, Wanıtphakdeedecha R. Improvement of postfrac-
tional laser erythema with light-emitting diode photomodu-
REFERENCES lation. Dermatol Surg. 2009;35(5):813-5.
19. Setyadi HG, Jacobs AA, Markus RF. Infectious complications
1. Armenakas MRA, Dover JS, Arndt KA. Laser therapy. after nonablative fractional resurfacing treatment. Dermatol
In: Bolognia JL, Jorizzo JL, Rapini Rp (Eds). Bolognia Surg. 2008;34(11):1595-8.
Dermatology, 2nd edition. Spain: Mosby Elsevier; 2008. pp. 20. Alster TS, Nanni CA. Famciclovir prophylaxis of herpes
2099-120. simplex virus reactivation after laser skin resurfacing.
2. Brightman LA, Brauer JA, Anolik R, et al. Ablative and frac- Dermatol Surg. 1999;25(3):242-6.
tional ablative lasers. Dermatol Clin. 2009;27(4):479-89; 21. Chan HH, Manstein D, Yu CS, et al. The prevalence and
vi-vii. risk factors of post-inflammatory hyperpigmentation after
3. Tanzi EL, Wanitphakdeedecha R, Alster TS. Fraxel laser fractional resurfacing in Asians. Lasers Surg Med. 2007;
indications and long-term follow-up. Aesthet Surg J. 2008; 39(5):381-5.
28(6);675-8. 22. Fife DJ, Fitzpatrick RE, Zachary CB. Complications of frac-
4. Sandel HD 4th, Perkins SW. CO2 laser resurfacing: still a tional CO2 laser resurfacing: four cases. Lasers Surg Med.
good treatment. Aesthet Surg J. 2008;28(4):456-62. 2009;41(3):179-84.
23. Avram MM, Tope WD, Yu T, et al. Hypertrophic scarring of
5. Avram MM, Tope WD, Yu T, et al. Hypertrophic scarring of
the neck following ablative fractional carbon dioxide laser
the neck following ablative fractional carbon dioxide laser
resurfacing. Lasers Surg Med. 2009;41(3):185-8.
resurfacing. Lasers Surg Med. 2009;41(3):185-8.
24. Gewirtzman A, Meirson DH, Rabinovitz H. Eruptive kerato-
6. Newman JB, Lord JL, Ash K, et al. Variable pulse erbium:YAG acanthomas following carbon dioxide laser resurfacing.
laser skin resurfacing of perioral rhytides and side-by-side Dermatol Surg. 1999;25(8):666-8.
comparison with carbon dioxide laser. Lasers Surg Med. 25. Mamelak AJ, Goldberg LH, Marquez D, et al. Eruptive kerato-
2000;26(2):208-14. acanthomas on the legs after fractional photothermolysis:
7. Weinstein C, Scheflan M. Simultaneously combined ER:YAG report of two cases. Dermatol Surg. 2009;35(3):513-8.
and carbon dioxide laser (derma K) for skin resurfacing. 26. Foster KW, Fincher EF, Moy RL. Heat-induced “recall” of
Clin Plast Surg. 2000;27(2):273-85. treatment zone erythema following fractional resurfacing
8. Tierney EP, Eisen RF, Hanke CW. Fractionated CO2 laser skin with a combination laser. Arch Dermatol. 2008;144(10):
rejuvenation. Dermatol Ther. 2011;24(1):41-53. 1398-9.
 834 Facial Plastics, Cosmetics and Reconstructive Surgery The Surgical Technique of Otoplasty 834
CHAPTER

92 Hair Transplantation
Jumroon Tungkeeratichai

The scalp contains approximately 100,000–125,000

INDICATIONS terminal hairs.5 Transverse or horizontal sections of the
scalp show that hair follicles are organized into follicular
Primary Alopecia units. Each unit contains one to four terminal hairs, one
• Genetic hair loss (85% are men)1 or two vellus hairs, nine sebaceous glands and arrector
pili muscle insertions and a perifollicular vascular plexus,
Secondary or Traumatic Alopecia neural net and connective tissue (Fig. 2).
• After trauma or surgery procedures such as endoscopic The scalp consists of five layers—SCALP; the outer
forehead facelifts, forehead facelift or facelifts layer is the skin. The subcutaneous layer contains fat,
• Previous hair transplantation to improve hairline and connective tissue, vessels, lymphatics and nerves. The
unnatural large plug grafts2,3 galea aponeurotica combines with the frontalis muscle
The hair follicles begin to develop between 9 weeks and anteriorly and the occipitalis muscle posteriorly. Loose
12 weeks of gestational age from ectodermal and meso- connective tissue lies between the galea and periosteum
dermal cells. The ectoderm gives rise to the hair matrix of the skull. The arterial supply to the scalp is provided by
cells and the melanocytes responsible for the pigmenta- five pairs of arteries: the supraorbital and supratrochlear
tion of hair. Two buds form off of this layer, one gives rise arteries in front, the superficial temporal and retroauricu-
to the sebaceous gland. Hair production can typically be lar arteries laterally and the occipital arteries posteriorly4
seen by 16–20 weeks of gestation4 (Fig. 1). (Fig. 3).
Hair growth can be divided into three phases. Anagen
is the active (growth phase), about 90% of hair follicles are
in the anagen phase and its duration is between 2 years
and 8 years. The catagen is the active loss (regression

Fig. 1: Hair follicle Fig. 2: Follicular units

 Hair Transplantation 835

phase), shortest of three phases and its duration between it affects the bitemporal and frontal hairline first, followed
2 weeks and 4 weeks, is characterized by separation of the by diffuse thinning of hair over the vertex. The dermal
hair shaft from the dermal papilla and migration toward papilla is most likely the target for these androgen-
the epidermis. The telogen follicles are in active and hair induced changes. As the follicle becomes smaller, hair
growth stop (resting phase) or resting phase, about 10% becomes finer and less pigmented. Also, the time of each
hair follicles are in this phase, which lasts 2–4 months, hair cycle spent in anagen becomes shorter while the telogen
shaft detaches from the dermal root resulting in the hair phase becomes longer. The ratio of time spent in anagen
falling out. Scalp hair growth occurs at a rate of approxi- compared to telogen reduces from 12:1 to 5:19 (Fig. 5).
mately 37–44 mm/day and normal scalp hair loss is 50–100 Both men and women are affected by AGA. It is trans-
hairs/day6-8 (Figs 4A and B). mitted in an autosomal dominant pattern. Approximately
33% of people with a positive family history of AGA will
be affected. In most patients, 30–50% of hair losses occur
ANDROGENETIC ALOPECIA before it becomes apparent. Thirty percent of white men
The term androgenetic alopecia (AGA), both androgens have AGA by age 30 years, 50% are affected by age 50 years
and genetic factors work together to produce hair loss and 40% of women are affected by age 70 years.
pattern. The most common form of hair loss is androge-
netic alopecia or male-pattern balding (MPB). Typically,
CLASSIFICATION
Many classification systems of hair loss in androgenetic
alopecia have been devised. Hamilton, in 1951,10 was the
first to publish such a schematic but his system was later
revised by Norwood in 1973. Today, the Norwood system
is most commonly used to classify MPB. Female andro-
genetic alopecia follows the Ludwig classification system
that was introduced in 19777 (Figs 6 and 7).

PATIENT EVALUATION FOR

SURGERY
Age is not a contraindication for hair replacement
surgery.11 It is important to emphasize that the hair
replacement techniques available today do not result
Fig. 3: Outer layer of the skin in new hair growth, but instead involve redistribution of

A B
Figs 4A and B: Hair cycle
 836 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 5: Androgen pathway

1. Testosterone (T) bound to circulating binding globulin (G)
2. T enters target cell.
3. Conversation of T to dihydrotestosterone (DHT)
5 alpha-reductase.
4. DHT binds to cytosol androgen receptor (AR).
5. DHT-AR complex enters cell nucleus.
6. DHT-AR complex binds to DNA, producing cell-spacific
mRNA.
7. Protein synthesis produces physiologic effect.
8. Direct binding of T to alternate cytosol AR.
9. T-AR complex enters cell nucleus.
10. Antiandrogen (A) binds to cytosol AR.

remaining hair. Therefore, in order to be a candidate for

these procedures, a patient must have adequate donor
hair at occipital and parietal scalps.

FOLLICULAR UNIT HAIR

TRANSPLANTATION Fig. 6: Norwood classification
In 1939 Okura, a Japanese dermatologist, was the first to
describe to using small full-thickness autografts of hair-
bearing skin to correct alopecia. In 1959 Orentreich, a
New York dermatologist, discovered the principle of donor
dominance. He harvested via 4 mm round punch grafts
from the occipital scalp.5
This provides grafts that typically contain 10–20 hairs/
punch depending on hair density of the donor site. Hair
distribution can be visualized and the remaining spaces
filled in with new grafts.12,13
Vallis was the first to describe strip grafting in 1964.
This technique involves a free composite graft of hair-
bearing scalp. The graft is harvested by creating two paral-
lel, horizontal incisions in the donor scalp, down to the Fig. 7: Ludwig classification
 Hair Transplantation 837

level of the galea. It is elevated in this plane and the donor

site closed.14
In 1980, Bobby Limmer began to transplant grafts that
were dissected along these natural cleavage planes. Thus
was born Total Follicular Unit Transfer.5
Follicular-unit transplantation is probably the most
widely used hair grafting method today. In this tech-
nique, large numbers of minigrafts (3–4 hairs/graft) and
micrografts (1–2 hairs/graft) are utilized to cover signifi-
cant areas of balding scalp. Several different methods of
follicular-unit transfer are described by various authors;
herein is the technique as outlined by Barrera. Donor hair
is harvested from the occipital scalp in one large ellipse,
the size of which is determined by hair density, scalp elas-
ticity and the area of alopecia to be covered. Graft dissec-
tion proceeds on a separate table under bright lighting
and magnification. The donor tissue is first cut into 2 mm
segments, aligning all incisions in the direction of follicle
growth. Then, a #10 blade is used to further dissect the
segments into micrografts and minigrafts, taking care to
preserve natural groupings of hair follicles. The grafts are
kept moist and cool while the recipient area is prepared.
The direction of grafted hair growth can be controlled by
Fig. 8: Horizontal role of third
changing the angle of the scalpel when creating the slits.
This is particularly important along the frontal hairline
where the direction of growth should be angled 45–60 contained 70–100 follicular units per square centimeter. If
degrees anteriorly. If there are residual native hairs in the surgeon needs 1,000 grafts, the projected numbers reflect
region being grafted, the slits should be placed parallel to 10 cm long by 1 cm wide strip of donor hair.15 Measurement
the existing hairs. Barrera advocates placement of a moist, of scalp laxity is done to estimate the maximal donor strip
light pressure dressing that is removed after 48 hours. width that can be safely removed during hair transplanta-
Patients are then instructed to shampoo daily and begin tion. Trim donor area to 2 mm with electric clippers from
applying minoxidil 2% topical spray twice daily.7 occipital protuberance medially to over ears laterally and
then the donor area has been planned out and marked
Six Steps for Hair Transplantation (Figs 9A and B).
1. Patient Preparation
2. Anesthesia 2. Anesthesia (Figs 10A and B)
3. Donor Strip Harvest • Oral sedation with Dormicum 15 mg; 1 tablet
4. Donor Strip Dissection 20 minute before surgery
5. Recipient Sites • Local anesthesia for donor and recipient sites
6. Postoperative Care – 1% Lidocaine with Epinephrine 1:100,000 (20 mL)
– +0.9% NSS (20 mL) + 0.5% bupivacaine (20 mL)
1. Patient Preparation – +7.5% sodium bicarbonate (3 mL)
Hairline design: The midpoint of the forehead is normally - Lidocaine for quick onset
8 cm from the glabella. Then, estimate the number of hair - Bupivacaine for increased duration
for transplantation after design of frontal hairline (Fig. 8) - Epinephrine for hemostasis and increased
• Average non-balding scalp has 100 follicular units per duration
square centimeter - Sodium bicarbonate to decrease stinging
• 50% of hair may be lost before noticeable thinning • Donor-recipient tumescent solution after injection of
• Aim density at approximate 30–40 units per square local anesthesia (Fig. 11)
centimeter – 1% Lidocaine (10 mL) + 0.9% NSS (100 mL) +
How many grafts must be harvested are based on epinephrine (0.3 mL)
donor hair density; typically donor density in mid-occiput – Purpose of injection tumescent solution is to :
838 Facial Plastics, Cosmetics and Reconstructive Surgery

A B
Figs 9A and B: Scalp laxity

A B
Figs 10A and B: Local anesthesia

3. Donor Strip Harvest

Donor area preparation: The donor area is shaved and
the ellipse is marked. The hair-bearing ellipse is cut with
an oblique angle parallel the hair axis angle to avoid
damaging the hair follicles. Just deep from hair follicle
not deeper than vessel The midline of the donor area
is determined by the landmark of the bony occipital
protuberance. The lateral limit of hair transplant is defined
by the auricle about two finger breadths or approximately
2 cm above the top of the ear. If width of donor strip more
than 1.5–2 cm subcutaneous suture with 3-0 vicryl suture
Fig. 11: Donor-recipient tumescent
is necessary for prevent scar. Before suture skin superior
edge of epithelium 1 mm is removed for trichophytic
wound closure,16-18 then suture skin with 4-0 nylon suture
- Increase follicular distance from blood vessels continuous locking fashion (Figs 12A to F).
and nerves
- Increase rigidity of donor area 4. Donor Strip Dissection
- Decrease bleeding To avoid follicular transection all graft dissections are
- Reduce total amount of anesthesia required under binocular stereo microscopic 10-power magnifi-
– The procedure starts with the patient sitting up or cation.19,20 Right now all graft dissections are under LED
in prone position for ring-block anesthesia and monitor that has more power magnification than binocu-
donor harvest lar stereomicroscopic. Preparing the follicular units: the
 Hair Transplantation 839

A B

C D

E F
Figs 12A to F: Donor strip harvest

hair-bearing ellipse is placed on a hard wooden and cut • 50% of hair may be lost before noticeable thinning
into several slices. The grafts are divided into two groups: • Aim density approximately 20–40 units per square
micrografts consisting of one or two hair follicles and centimeter
minigrafts consisting of three or four hair follicles.21 After • Keep recipient sites small, but large enough so that
the grafts have already been divided, they are soaked in grafts do not need to be forced in place
0.9% normal saline and kept under control temperature at • Visible scars are not produced by needles 18 gauge or
4° C (Figs 13A to F). less
• Recipient sites
5. Recipient Site (Figs14A to E) Instrument size guide equivalents
• Average non-balding scalp has 100 follicular units per 20 gauge = 1-hair unit
square centimeter 19 gauge = 2-hair and thin 3-hair units
840 Facial Plastics, Cosmetics and Reconstructive Surgery

A B

C D

E F
Figs 13A to F: Donor strip dissection. (A to D) Minigraft Unit; (E and F) Micrograft Unit
 Hair Transplantation 841

A B

C D

E Figs 14A to E: Recipient site

 842 Facial Plastics, Cosmetics and Reconstructive Surgery

18 gauge = 3-hair and 4-hair units suture, skin superior edge of epithelium 1 mm has been
Grafts placed at original growing angle removed for trichophytic wound closure.
• Hair anterior to vertex transition point should point
forward Donor harvesting: Blood vessel and nerve transection,
• Angle becomes more acute as it reaches the anterior hair transection and Prevention the tumescent solution
hairline subgaleal plane.18
There are two principle methods for recipient-site creation:
1. Pre-making recipient sites describe the method in Recipient Area
which the surgeon makes almost all of the recipient Surgical effluvium: Hair will fall out 2–3 weeks postopera-
sites after which the surgical assistant16 places the graft tively and regrow will occur in 3 months.
into these sites at the end of procedure (sites made
prior to graft insertion).5,22 Cysts, pustules: Burying of grafts by making the recipient
2. Stick-and-place describes a method in which the holes too deep.
surgeon makes a single site (stick) and immediately
followed by graft insertion (place). Right now we place Pitting and tenting: Grafts are placed too deeply in pitting
the graft under LED monitor to so that more precise and are placed too superficially in tenting.
and more graft can be inserted per square centimeter.
The transplanted hairs usually fall out within
3–6 weeks and hair growth will begin 3 months after
ACKNOWLEDGMENTS
surgery. The final result will be visible within 6–8 months. The authors are thankful to Prof Amnuay Thithapangha
Faculty of Medicine Ramathibodi Hospital, Mahidol
6. Postoperative Care University for advice during the preparation of this
Wash scalp with sterile water manuscript.
• Apply antibiotic ointment and pressure headband
dressing to donor
• Patient to have hair washed on postoperative day 3 to
REFERENCES
remove crusts 1. Fisher J. Management of alopecia. In: Guyuron B, Elof
• Pain medication and antibiotic for 1 week Eriksson, Murray JE, et al. (Eds). Plastic Surgery: Indication
• No strenuous activity for 1 week and Practice, volume 2. Philadelphia: Saunders; 2009. pp.
• Return to clinic in day 2 to remove dressing and day 10 1391-1408.
for stitch off donor site 2. Vogel JE. Correction of the cornrow hair transplant and
• Wait for at least 6–8 months between sessions other common problems in surgical hair restoration. Plast
Reconstr Surg. 2000;105(4);1528-36.
3. Epstein JS. Revision surgical hair restoration: repair of
COMPLICATION5,23,24 undesirable results. Plast Reconstr Surg. 1999;104(1);
222-32.
Donor Area 4. Nordstrom RE. Scalp, hair, baldness, and surgery. Facial
Plast Surg. 1985;2(3);173-7.
Effluvium: Hair in the anagen phase can suddenly be shed 5. Hair Transplant Preoperative 360. In: Lam SM (Ed). Hair
due to a temporary lack of oxygen during surgery. Hair will Transplant 360: For Physicians, volume 1. New Delhi: Jaypee
fall out 2–3 weeks postoperatively and regrow will occur Brothers Medical Publishers (P) Ltd.; 2011. pp. 1-45.
within 3 months. 6. Nigman AM. The human hair cycles. J Invest Dermatol.
Dehiscence: It occurs more when epidermis to epidermis 1959;33:307.
contact than dermis to dermis contact. 7. Barrera A. Hair Transplantation: The Art of Micrografting
and Minigrafting. St. Louis: Quality Medical Publishing Inc.;
Necrosis: When too wide, a donor strip is harvested,
2002.
extremely tight closure cause a massive compromise of the
8. Abell E. Embryology and anatomy of the hair follicle. In:
circulation and tissue death. Olsen EA (Ed). Disorders of Hair Growth, Diagnosis and
Excessive donor scarring: If the skin closed under strong Treatment. New York: McGraw-Hill Inc.; 1994.
tension, there is a high risk of scar widening. To prevent 9. Sinclair R. Male pattern androgenetic alopecia. BMJ.
scar widening, severe tension free technique is used by 1998;317;865-9.
sunbcutneous 3-0 vicryl suture, especially if the width 10. Norwood OT. A classification of male pattern baldness.
applying of donor strips is more than 1.5-2.0 cm. Before South Med J. 1975;68:1359.
 Hair Transplantation 843

11. Nordstrom RE. The initial interview. Facial Plast Surg. 19. Limmer BL. The history of follicular unit micrografting
1985;2(3):179-87. technique: A personal view. In: Unger W, Shapiro R (Eds).
12. Unger WP. Construction of the hairline in punch transplant- Hair Transplantation. New York: Marcel Dekker Publishers;
ing. Facial Plast Surg. 1985;2(3):221-30. 2004. pp. 383-8.
13. Vallis CP. Treatment of male pattern baldness by punches, 20. Limmer BL. Donor strip slivering and microscopic dissec-
strips, and flaps. In: Courtiss EH (Ed). Male Aesthetic tion. In: Haber RS, Stough DB, (Eds). Hair Transplantation.
Surgery, 2nd edition. St. Louis: Mosby; 1991. Philadelphia: Elsevier Saunders; 2006. pp. 87-9.
14. Vallis CP. The strip graft. Facial Plast Surg. 1985;2(3);
21. Pathomvanich D. Donor harvesting: a new approach to
245-52.
minimize transection of hair follicles. Dermatol Surg.
15. Hair transplant preoperative 360. In: Lam SM (Ed).
2000;26:345-8.
Hair Transplant: For Physicians, volume 1. New Delhi:
22. Pathomvanich D. Hair Transplantation in Asians. In: Haber
Jaypee Brothers Medical Publishers (P) Ltd.; 2011. pp.
47-126. RS, Stough DB (Eds). Hair transplantation. Philadelphia:
16. Frechet P. Donor harvesting with invisible scars. Hair Elsevier Saunders; 2006. pp. 149-56.
Transplant Forum Int. 2005;15:119-20. 23. Cooley JE. Complication of hair transplant. In: Unger
17. Marzola M. Trichophytic closure of the donor area. Hair W, Shapiro R (Eds). Hair Transplantation. 4th edition.
Transplant Forum Int. 2005;15:113-16. New York: Marcel Dekker Publishers; 2004. pp. 568-73.
18. Marzola M. Single-scar harvesting technique. In: Haber 24. Marzola M, Vogel JE. Complication: Haber RS, Stough
RS, Stough DB (Eds). Hair Transplantation. Philadelphia: DB, (Eds). Hair Transplantation. Philadelphia: Elsevier
Elsevier Saunders; 2006. p. 83. Saunders; 2006. pp. 173-85.
 844 Facial Plastics, Cosmetics and Reconstructive Surgery
CHAPTER

93 Surgery for Alopecia

Arunesh Gupta, Dipesh J Malviya, Akshay P Deshpande

• Fiber breakage
INTRODUCTION • Risk of carcinogenesis from deeply embedded bits of
The surgical treatment of alopecia includes: fibers
• Synthetic hair grafting • Pruritus.
• Hair transplant
• Scalp reduction surgery
• Scalp flaps
HAIR TRANSPLANT
• Expanded scalp flaps It is the redistribution/rearrangement of the existing hair
follicles in a particular pattern by various techniques
so as to cover the bald areas of alopecia and give a good
SYNTHETIC HAIR GRAFTINGS cosmetic camouflage. In this, a horizontal strip of scalp is
In this technique, synthetic hairs made up of polyethylene harvested from occipital area; its hair units with follicle
terephthalate (PET) are inserted percutaneously into the are separated under magnification and implanted over the
scalp. area of baldness under local anesthesia.

Requirements for Synthetic Hair Indications for Hair Transplant

The synthetic hair should have the following properties. • Male pattern alopecia
• It must not dissolve after placement • Female androgenic alopecia
• It must be completely removable without frag­men-­­ • Cicatricial alopecia
­tation • Reconstruction of eyebrows, eyelashes and side burns.
• It must have low potential for infection
• It must have no residual toxicity or mutagenicity after Contraindications
sterilization • Large bald area
• It must have long-term durability • Small donor area
• It must be heat stable • Low hair density
• It must have appearance of natural hair. • Progressive microscopic polyangiitis (MPA) in young
patient with strong family history
Advantages • Bleeding disorders
• Supply is infinite • Keloidal tendency
• Simple procedure • Systemic debilitating disease
• Variety of hair styles can be achieved. • Patient with unrealistic expectation.

Disadvantages Preoperative Evaluation

• Chances of infection exist • Whether or not the donor site has adequate hair
• Not all grafted hair are permanently fixed, thus requires • To design a hair pattern that is appropriate not only as
follow-up sittings patient ages but also on the basis of progressive hair loss
• Facial swelling • Patient’s family history specially from maternal side
• Loss of natural hair • Classification of hair loss: Norwood classification
• Foreign body reaction (Fig. 1)
 Surgery for Alopecia 845

Fig. 2: Frontotemporal angle

Fig. 1: Norwood classification Table 1: Requirement of follicles

The recommended number of follicular unit grafts for Norwood class Follicular units
hair transplantation is indicated in Table 1. III 800–1,000+
• Type of hair: Color, texture, density, curling, straightness III Vertex 800–1,000+
• Assessment of frontotemporal angle (Fig. 2)
IIIA 1,300–1,600+
• Medical history
• Drug history: Aspirin, anticoagulants, etc. should be IV 1,100–1,400+
discontinued 2 weeks prior IVA 1,700–2,100+
• Alcohol, caffeine, smoking should be avoided V 1,500–1,800+
• Number of sittings required VA 2,200–3,000+
• Previous procedures like scalp reduction, etc.
VI 2,000–3,200+
• Informed consent
• Premedications VII 2,000–3,500+
– Minoxidil lotion/foam Local Application at
bedtime (should be stopped 1 week before surgery)
– Tab. Finasteride 1 mg OD classification, strip of scalp is excised with width of
– Multivitamin tab. I OD. around 1–1.5 cm.
• Shampooing
• Trimming Anesthesia
• Preoperative photographs. Procedure is done under local anesthesia. (for average
Assessment of density of hair and dimension of strip to 70 kg adult). Tumescent solution is prepared by mixing:
be harvested—photo of 1 × 1cm square from donor site 20 mL 2% xylocaine
is taken and hairs are counted. This gives density of hairs. 10 mL sensorcaine
According to the requirement of grafts based on Norwood 2 mL adrenaline
 846 Facial Plastics, Cosmetics and Reconstructive Surgery

70 mL ringer lactate. superior border is according to posterior border of balding

102 mL- total zone generally 11–12 cm above posterior hairline, inferior
Infiltration – Occipital region for strip harvest - 20 mL border 4 cm above posterior hairline. Light trimming of
Frontal hairline – 20 mL hairs is done over the area to be excised (Fig. 3).
Supratrochlear and supraorbital block – 2 mL + 2 mL Betadine is applied. Local anesthetic preparation is
50 mL of remaining solution + 50 mL ringer lactate for injected. Strip of scalp of 0.5–1.5 cm width and 10–20 cm
tumescent infiltration over recipient area. length is harvested with No. 10 blade (Figs 4 and 5). The
Some patients require light sedation. incision should be parallel to the direction of hairs to avoid
cutting the bulb. The strip is raised in supragaleal plane
Steps of Surgery just below the hair follicles and fat. The harvested strip
with intact hair follicles and shaft is shown in Figure 8.
Preparation of Donor Site and
Donor site is closed with prolene 4-0 continuous sutures/
Harvesting of Strip staples (Fig. 6).
Donor site is approximately marked as follows. Lateral Tricophytic closure—A new “trichophytic” donor
border at a line perpendicular to external auditory canal, site closure technique (“tricho”) provides improved

Fig. 3: Donor site preparation Fig. 4: Donor strip harvesting

Fig. 5: Donor strip harvesting completed Fig. 6: Donor site closure completed
 Surgery for Alopecia 847

camouflage of a linear donor scar in Follicular Unit hair graft inserted in the incision with follicle down and
Transplantation. Normally, in FUT, the surrounding hair simultaneously needle is withdrawn. Grafts should be
easily covers the scar. For some patients with very short placed from front to back and should snugly fit in the inci-
hairstyles, the resulting donor scar may be visible. With the sion (Fig. 13).
trichophytic closure technique, one of the wound edges Direction of grafts — frontal region- forward
(upper or lower) is de epithelised , allowing the edges to Parietal region — downward and forward
overlap each other and the hair to grow directly through Vertex — radiating and spiral manner
the donor scar. This can significantly improve the appear- Occipital region — downward
ance of the donor area in patients who wear their hair very No dressing is applied, antibacterial ointment is
short and who had previous transplant surgery. applied. Follicular Unit transplant has been completed
(Fig. 14). Patient is kept under observation for 2 hours
Graft Preparation and discharged with antibiotics, analgesics. Finasteride
Slices containing 1 to 3 follicular units( FUs) are separated and minoxidil are continued postoperatively.
from harvested strip under magnifying glass or loupes
(Fig. 10). This process is called “slivering” (Fig. 9). The Complications
grafts and strip are always kept in cold saline in petri dish
Donor site
to prevent desiccation (Figs 7 and 11).
• Hypertrophic scar and keloid
Recipient Site Preparation • Infection
Recipient area is anesthetized with prepared solution by • Wound dehiscence
supratrochlear and supraorbital blocks and tumescent • Hematoma, neuroma
infiltration .Marking is done as discussed with patient • Cyst formation.
(Fig. 12).
Incisions are made 0.5–2 mm apart, more closely over Recipient site
frontal and central scalp, either by 18 G/19 G needle or • Poor graft survival
miniblades. In needle and stick technique, after punctur- • Chronic folliculitis
ing the scalp, about 5 mm deep or till the beveled edge of • Elevated or depressed grafts
needle just disappears, needle is slightly withdrawn, the • Changes in hair texture.

Fig. 7: Scalp strip kept in cold saline Fig. 8: Close up view of strip with visible hair
shafts and follicles
848 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 9: Slivering of strip Fig. 10: Follicular units (FUs) with 1, 2 and 3 FU grafts

Fig. 11: Follicular unit (FU) grafts kept in cold saline in Fig. 12: Marking on recipient site
petri dish till grafting is done

Fig. 13: Simultaneous incision with needle and grafting Fig. 14: FU transplant completed
 Surgery for Alopecia 849

Special Instruments • Secondary procedures required

• Exposure of scars.
The following special instruments, used in surgery for
alopecia, are given in Figures 15 to 19.
SCALP FLAPS
In this technique, scalp tissue having hairs is transposed
SCALP REDUCTION and redistributed to bald area.
SURGERY
It is defined as the surgical excision of redundant tissue Types
from one or more areas of scalp alopecia. There are 1. Temporo-parieto-occipital flap
different types of scalp reduction techniques that can be 2. Temporo-occipital flap
performed (Figs 20A to H). The design of triple advancement transposition flap is
given in Figure 21.
Indications
• Extensive baldness with limited donor site Advantages
• Patient with large circular bald spots over crown or at • Immediate results with dense frontal hairline
the back of scalp. • Useful for treatment of vertex.

Advantage Disadvantages
• Immediate results in limited alopecia. • Unnatural appearance of frontal hairline
• Inadequate coverage
Disadvantages • Incorrect hair direction
• Stretch back phenomenon • Scarring
• Widening of scars • Necrosis.

Fig. 15: Petri dish Fig. 16: Wooden sticks

 850 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 17: Curved microforceps, scalpel

Fig. 18: Magnifying glass with light

Fig. 19: Needles—smaller caliber needles are used in the

front of the area to be grafted and preferably FU containing
single hair are grafted. As we go posteriorly, FU containing
2 or 3 hairs are grafted to increase density and larger caliber
needles are used

A B C D

E F G H
Figs 20A to H: Different types of scalp reduction techniques. (A) L pattern; (B) Mercedes Benz pattern; (C) Y-shaped
pattern; (D) S-shaped pattern; (E) J-shaped pattern; (F) Midline reduction pattern; (G) Lateral pattern; (H) U-shaped pattern
 Surgery for Alopecia 851

EXPANDED HAIR BEARING FLAPS Figure 25) is inserted into the surrounding hair bearing
area of scalp in subgaleal plane.
It is a staged procedure. A patient with post burn alope- Stage 2 - Serial expansion is done till adequate size of flap
cia over scalp reconstructed by this method is shown in is achieved: approximately 1.5 to 2 times the capacity of
Figure 22. expander (Fig. 23)
Stage 1 – Appropriate size and shape of tissue expander Stage 3 - Expander removal and advancement of scalp
(for e.g. crescentric shaped tissue expander shown in flap. (Figs 24 A and B)

Fig. 21: Design of triple advancement transposition flap Fig. 22: Patient with post-burn scalp alopecia
over left parietal region

Fig. 23: Tissue expander inserted below the hair bearing

scalp in subgaleal plane and serial expansion done
 852 Facial Plastics, Cosmetics and Reconstructive Surgery

A B
Figs 24A and B: Postoperative results of patient after Fig. 25: Crescentric shaped tissue expander
excision of alopecia segment with coverage using expanded
scalp flap

Few words about female alopecia—Hair loss in females These are candidates of hair transplant. Unlike male
is often of diffuse nature which frequently results in pattern, they maintain low frontal hairline. In female
lack of donor area. However a subgroup of females candidates of hair transplant Finasteride is not
show male pattern which has familial predisposition. used.
 The Surgical Technique of Otoplasty 853
CHAPTER

94 Upper and Lower Lid

Blepharoplasty
Giovanni André Pires Viana

HISTORICAL PERSPECTIVE later, he published before and after photographs of his

procedure.1,2 Madame Noël, a French female surgeon, was
The history of periorbital surgery has been traced as far the first to stress the importance of before and after photo-
back as the 18th century BC, when Hammurabi’s code graphs in cosmetic surgery.1
detailed the contract between a surgeon and patient The modern concept of blepharoplasty and detailed
undergoing the lancing of an infected lacrimal sac.1 The anatomy of the orbital fat compartments were described by
medical therapy of eye disease was documented through- Castanãres in 1951.4 In the years between 1951 and 1967,
out ancient Egyptian times between 1550 BC and 3000 Castanãres described seven treatable cosmetic eyelid
BC.1 It is in the Edwin Smith papyrus that the earliest deformities and their treatments: (i) Blepharochalasis,
known description of stitching the eyebrow is found.1 (ii) Dermatochalasis, (iii) Hypertrophy of the orbicularis
The eyelid surgery was described in an Indian docu- muscle, (iv) Protusion of intraorbital fat, (v) Combination
ment, the Susruta, more than 2000 years ago.2 The recorded of these conditions, (vi) Hooding of upper eyelid skin due
history of blepharoplasty dates back to the first century to brow ptosis, and (vii) Lid cheek bags.1-3
when the Roman Aulus Cornelius Celsus described exci- Over the past 40 years, surgeons have generally moved
sion of skin for “relaxed upper eyelids” in his compendium away from traditional techniques of the subtractive
De Re Medicina (25–35 AD).1,3 As early as the 10th century, approaches, described by Castanãres, to a more conserva-
Avicenna devised ways to excise skin folds in the upper tive approach.
eyelid that impaired vision.1-3 Ambroise Paré described In upper blepharoplasty, the “anchor blepharoplasty”
the functional correction of excess eyelid skin in the 16th described by Flowers in the 1970’s represented the esthetic
century.2 ideal, but this approach has fallen into disfavor with many
The term blepharoplasty itself is derived from Greek surgeons and recently, a more conservative, reconstruc-
term “blepharon”, meaning “eyelid,” and “plastos,” mean- tive surgery with attention to the repair of anatomic defects
ing “formed”, and was initially used by Carl Ferdinand von from levator aponeurosis to replacement of lost fat volume
Graefe in the early 19th century when reporting a recon- in the lateral brow has become popular.5,6
structive technique for defects caused by resection of cancer In lower eyelid surgery, Raul Loeb was one of the first
in the eyelids.1-3 Jules Sichel, in 1844, provided the first surgeons to preserve adipose tissue during the lower lid
accurate description of herniated orbital fat in association blepharoplasty, but since de la Plaza and Arroyo described
with skin excess, to which he attributed decreased move- their approach for lower lid hernia repair, there has been
ment of the lid and overhanging of the eyelid margin.1-3 a great deal of interest in fat-preservation techniques in
Ernst Fuchs observed that the excess skin fold was caused lower lid blepharoplasty.7-9
by weakening of the fascial attachments of the skin and
the tendon of the levator muscle.1
In 1907, Charles Conrad Miller wrote the first book on
SPECIFIC PREOPERATIVE
cosmetic surgery and also published the first photography EVALUATION
depicting a marking of upper and lower eyelid surgery that
was similar to those used today.1,3 Frederick Kolle was Preoperative Assessment
the first to stress the importance of preoperative meas- Preoperative patient evaluation for blepharoplasty should
urements and markings of excess skin.1 Julian Bourguet include lifestyle history (smoking, exercise tolerance,
reported separate fat compartments in the eyelids and and alcohol use), history of chronic illness, hyperten-
was the first to describe a transconjunctival approach to sion, diabetes, cardiac disease, bleeding and/or clotting
the resection of herniated periorbital fat in 1924. One year disorders, thyroid disturbances, or previous operations.
 854 Facial Plastics, Cosmetics and Reconstructive Surgery

Medications, including aspirin and other anticoagu- In contrast to dermatochalasis, blepharochalasis is diffi-
lants, should be listed and withheld for at least 2 weeks cult to correct and likely to recur.2,3,10,11,13
pre­operatively. Dietary supplements should be listed as Upper eyelid ptosis should be evaluated by the rela-
they may affect clotting; for instance, Dong Quai (antico- tion of the eyelid margin to the superior limbus in neutral
agulants effects), omega 3-fatty acids in fish oil, ajoene in gaze, since it can be corrected simultaneously. The normal
garlic, ginger, Ginkgo, and vitamin E (antiplatelet proper- position of the upper lid margin covers 2–3 mm of the
ties), Fucus (heparin-like activity), Danshen (antithrom- superior limbus but does not cover any aspect of the pupil.
bin III-like activity and anticoagulant bioavailability), and Pseudoptosis, the excess lateral skin and hooding of the
St. John’s Wort and American Ginseng (interference with upper lid, can be differentiated from true ptosis by elevat-
drug metabolism).2,3,10 ing the lateral brow.14
Ophthalmologic history should be obtained, including Evaluation of the upper eyelid must include an evalu-
vision, correction lenses, trauma, glaucoma, allergic reac- ation of the eyebrow.2,3,10,11,13,15 In the male patient, the
tions, excess tearing, and dry eyes. Specific history pertain- brow should be at the superior orbital rim, whereas the
ing to LASER-assisted in situ keratomileusis (LASIK) and female brow should be above the rim with the arch apex
other refractive surgery should be documented, as they inline with lateral limbus.16,17 Brow ptosis should be
predispose the patient to postblepharoplasty dry eye corrected to achieve repositioning of heavy eyebrow skin,
exposure and visual changes. No cosmetic surgery of the which may be compensated by frontalis contraction to
periorbital region should be performed for a minimum of keep the eyebrows above the orbital rim. Once the visual
6 months following corneal refractory surgery and when obstruction has been removed by eyelid skin resection,
in doubt, clearance from the refractive surgeon should be the brows may look even heavier since elevation is no
obtained. Schimmer’s test should be considered if there is longer needed for the visual field. This results in a more
a history of dry eyes.2,3,10-13 aged appearance.2,3,10-13,15-17 This should be performed
before upper blepharoplasty so that correct brow posi-
Physical Examination tion is ensured before upper lid skin excision. Asymmetry
Evaluation of the patient for blepharoplasty should in upper and lower eyelids and brow position is common
include a general physical examination, including blood and should be appreciated individually. Correction to
pressure, height, and weight of the patient. Visual acuity attain exact symmetry is unreasonable.
should be registered. Pupillary response and extraocular The pathogenesis of aging within the lower eyelid is
muscles including evaluation for amblyopia and an intact multifactorial, and varies among patients. Periorbital
Bell’s phenomenon should be documented. The evalua- age-related changes include crow’s feet and lower eyelid
tion of the periorbital area should take into account skin rythides, scleral show, infraorbital hollowing, herniated
quality and quantity, underlying soft-tissue positioning, fat pads, excess or laxity of lower lid skin, festoons, and
and skeletal support.2,3,10-13 eyelid hooding. Common complaints include eyelid bags,
Dermatochalasis is the loss of elasticity and support in circles under the eye, wrinkles around the eye or a tired
the skin. In the upper eyelid, this can create a fold of excess look. Lower eyelid fat becomes more prominent in upgaze
skin, which can impair the function of the eye, specifically, and less prominent in downgaze.4,7-11 In addition, attenu-
by superior and lateral visual field obstruction. Lower ation of the lateral canthal tendons results in loss of the
eyelid should be assessed for skin excess secondary to youthful architecture of the eye secondary to a decrease
dermatochalasis. Age-associated changes in the orbicu­ of the esthetically pleasing upward tilt. The change in the
laris oculi muscle are attributable to increased muscle lateral canthal complex position is functionally important,
relaxation and ligamentous attenuation. This can cause as its changes contribute to lower eyelid laxity, which may
lower lid malposition and, in association with malar ptosis, result in rounding of the lateral commissure and narrow-
can result in inferior muscle border prominence, creating ing of the palpebral fissure.9-11,18
a festoon or malar crescent. Fat herniation can accentuate Lower eyelid displacement with anterior traction
lower eyelid fullness. This may be attributed to weakening (distraction test) can precisely determine the degree
of the lower eyelid septum and can be localized to one or of laxity and guide lower eyelid canthal repositioning;
all three fat pads (medial, central, lateral).2,3,10,11,13 greater than 6 mm of anterior distraction from the globe
Blepharochalasis is a recurrent, intermittent, inflam- indicates significant lid laxity, which may require lateral
matory condition of the eyelids resulting in edema, canthal repositioning. The anatomical relationship of
erythema, and thin skin excess eyelid secondary to hista- the orbital region should also be evaluated secondary to
mine response and related to increased immunoglobulin E. the direct effect of lower blepharoplasty. The posterior
 Upper and Lower Lid Blepharoplasty 855

displacement of the orbital rim in relation to the anterior A simple upper or lower eyelid blepharoplasty, where
cornea and lower lid margin, a negative vector, should be only skin or fat is excised, can be performed under local
appreciated preoperatively. Proeminent or deep-set eyes anesthesia with small volume of 2% lidocaine with
should be documented. A more detailed analysis can be epinephrine, and may be combined with intravenous
performed using exophthalmometry with Hertel or Lued sedation. Other more invasive procedures, such as lower
exophthalmometer (Fig. 1), which measures the posi- blepharoplasty combined with fat repositioning, mid-face
tion of the globe relative to the lateral orbital rim (normal lifting or endoscopic browlift, may need intravenous seda-
range: 16–18 mm). Malar anatomy should be evaluated tion with local anesthetic infiltration or general anesthesia.
for tear trough deformities or prominent nasojugal folds, The modality of anesthesia should be discussed preopera-
which may guide lower eyelid operative plans.9-11,18 tively with patient, surgeon and anesthesia provider.
Complications during anesthesia should be diagnosed
Photography Documentation and treated promptly. Changes in vital signs or end-tidal
All patients should be submitted to a preoperative photo carbon dioxide may be early warning signs of impen­ding
evaluation. Standardized digital photographs should be complications. Events, such as laryngospasm, hypoten-
taken as following, one frontal (eyes opened, neutral- sion, or hypertension, may occur at anytime during the
gaze), one frontal (eyes closed), one frontal (upgaze), one perioperative period. Close monitoring of the patient
frontal (downgaze), and lateral views (neutral-gaze). should persist during the postoperative period, as cardiac
arrhythmias, cardiac standstill, fluid overload, and pulmo-
nary edema may manifest hours after surgical procedure
ANESTHETIC CONSIDERATIONS is complete.10
The surgeon must consider the risk factors associated with
each blepharoplasty procedure when deciding whether
such procedures should be performed in a hospital or an
SURGICAL STEPS
office-based setting. The postblepharoplasty patient may Upper Eyelid Blepharoplasty
have temporary decreased visual acuity and limited visual
fields. This may be secondary to temporary tarsorrhaphy Preoperative Marking
sutures, edema, and chemosis, which may require hourly
care. Patient assistance in postoperative period should be Preoperative marking should be made with the patient
part of the preoperative plan and may dictate the location sitting upright in neutral gaze with the brow properly posi-
of the operation and postoperative care. tioned. The eyelid crease is situated above ciliary margin
Blepharoplasty may be performed under different approximately 8–9 mm in women and 7–8 mm in men
anesthesia modalities, depending upon the surgical plan, (Fig. 2).11 The lower limit of excision should be along the
patient and surgeon preference, and need for concomitant eyelid crease, and lateral extent of the marking should
operations. be limited by an imaginary line joining the lateral end of

Fig. 1: Exophthalmometry with Lued exophthalmometer Fig. 2: Measuring the eyelid crease with caliper
 856 Facial Plastics, Cosmetics and Reconstructive Surgery

the brow to the lateral canthus, because a poorly planned pinch test can confirm the preoperative markings (Fig. 5).
incision in this location can be noticeable, especially A minimum of 20 mm of vertical lid height should be
in male patients and patients with thick skin. Similarly, preserved for normal eye closure (Figs 6A and B). The
the medial markings should not be extended medial to location of fat should be determined and marked preop-
medial canthus for larger resections because extensions eratively, with the patient in upgaze, downgaze, and
onto the nasal sidewall result in webbing. The extent of medial and lateral ranges of motion, with photographic
the excision should be at least 10 mm from the inferior documentation.
border of the brow, so as to not include any brow skin,
making a pattern of skin excision as shown in Figure 3. The Surgical Technique
pattern of skin excision should be lenticular in the younger The upper lids should be injected superficially to avoid
patient and more trapezoid-shaped laterally in the older any subcutaneous or intraorbicularis hematoma forma-
patient (Fig. 4). Using the midpupil line as the reference tion, with 2% lidocaine with epinephrine using a 30-gauge
point, more skin is excised laterally and less medially. A skin needle (Fig. 7). Incisions are made superficially with a
fresh No. 15 blade through the epidermis only, and the
premarked strip of skin is resected with fine curved scis-
sors, scalpel or a needle-point Bovie (Fig. 8). If definition
of the supratarsal fold is desired, some surgeons recom-
mend that a small strip of orbicularis be resected, as
described by Baker et al.19 Hemostasis is obtained using
pinpoint cautery (Fig. 9). Conservative fat excision can be
performed as part of upper lid blepharoplasty. There are
two fat compartments—medial or nasal (white fat) and
central (yellow fat)—that can be accessed through small
incisions in the septum, teased out, and resected using
pinpoint cautery (Figs 10A to D). Of the medial and central
fat, only the fat that comes easily into the wound is excised.
It is important not to aggressively pull fat from the orbit
to avoid injury to neurovascular structures or extraocular
muscles and lead to a “hollowed-out” appearance.
Retro-orbicularis oculi fat can be accessed beneath
the lateral orbicularis oculi muscle overlying the supe-
rior orbital rim.20 Resection has been described to help
Fig. 3: A careful evaluation and particular attention to precise decrease heaviness of the upper lid and lateral brow.
incision planning can lead to a more accurate and youthful
Supratarsal fixation at the conclusion of an upper lid
result
Source: Adapted from Fagien S. Advanced rejuvenative upper blepharoplasty can secure the pretarsal orbicularis oculi
blepharoplasty: enhancing aesthetics of the upper periorbita. Plast muscle or dermis to the levator mechanism to reconstitute
Reconstr Surg. 2002;110(1):278-91 and define the supratarsal fold.21

Fig. 4: Upper eyelid skin resection increases in size both vertically and laterally as the periorbital area ages: young (left),
middle age (center), and old (right)
Source: Adapted from Fagien S. Advanced rejuvenative upper blepharoplasty: enhancing aesthetics of the upper periorbita. Plast Reconstr
Surg. 2002;110(1):278-91
 Upper and Lower Lid Blepharoplasty 857

The skin incision can be closed using running subcu-

taneous 6-0 nylon suture or interrupted sutures with
6-0 nylon sutures to achieve an esthetic outcome (Fig. 11).
Bandage strips are applied at the end of bilateral proce-
dure (Fig. 12).
In male blepharoplasty, a more natural look is
preferred, and the “operate look” will not be tolerated well
by most male patients. Men will typically not be wear-
ing cosmetics, so all scars must be carefully concealed.
The lateral incision should only infrequently be extended
beyond the later orbital rim. In men with heavy brows,
resection of upper eyelid skin will only result in profoundly
ptotic brows. Therefore, one should counsel combined
brow surgery with upper blepharoplasty. Often, conserva-
tive eyelid resection is all that is required.
In Asian patients, blepharoplasty represents a unique
Fig. 5: Skin pinch test set of challenges. The eyelid anatomy, esthetic goals

A B
Figs 6A and B: Final marking. (A) Schematic figure; (B) Real patient

Fig. 7: Local anesthetic infiltration Fig. 8: Skin resection with scalpel

 858 Facial Plastics, Cosmetics and Reconstructive Surgery

and surgical techniques are vastly different from that of

Caucasian patients. Approximately 50% of Asians have an
upper lid crease, which can be complete, partial or inter-
mittent. Many patients requesting blepharoplasty desire
the formation of a crease or a double eyelid. A common
misconception is that the endpoint of Asian blepharo-
plasty is the creation of a more “Westernized” appearance.
In Asians, the primary goal is to create an eyelid crease to
enhance their natural Asian features.

Postoperative Care
Methylcellulose eye drops are recommended while the
patient is awake, and lubricating ointment for night-
use for several days postoperatively. The patient’s head
should remain elevated to reduce edema and ophthalmic
Fig. 9: Hemostasis pressure. Patients are advised to avoid strenuous lifting,

A B

C D
Figs 10A to D: Both fat compartments and respectively fat pads exposed through small incisions. (A) Central fat pad;
(B) Central and medial fat pads; (C) Schematic figure showing the fat being placed in the tips of the clamp, the fat
being removed with either scissors, knife or pinpoint cautery. Then, the stump is coagulated with bipolar cautery to obtain
hemostasis and, after hemostasis is obtained, the instruments are withdrawn; (D) After excision (both eyelids)
 Upper and Lower Lid Blepharoplasty 859

Fig. 11: Final upper blepharoplasty closure Fig. 12: Bandage strips

bending, and vigorous activities for 2 weeks following the 90–120 minutes of ischemia leads to irreversible blind-
procedure. Lagophthalmos is usually secondary to peri- ness.2 All dressings should be removed and sutures need
orbital edema and resolves in 1–2 weeks. The patient is to be released. An ophthalmologic consultation should
advised to return to full activities 2 weeks following upper be obtained immediately. The patient should be given
blepharoplasty. Suture removal is performed 5 days mannitol 20% 1.5 g/kg to 2 g/kg intravenously (with the
postoperatively, and bandage strips may be removed first 12.5 g over a 3-minute period and the remainder over
on the first postsurgery visit, which is usually 1–3 days a 30-minute period), 95% oxygen/5% carbon dioxide to
following surgery. dilate intraocular vessels, methylprednisolone 100 mg
intravenously (Solu-Medrol), Betaxolol Hydrochloride
Complications Ophthalmic Suspension (Betoptic) one drop imme-
Thorough preoperative planning and meticulous surgical diately, then twice daily. These actions should be taken
technique will avoid or decrease the risk of serious compli- as the patient is being taken back to the operating room
cations in upper blepharoplasty. The surgeon should focus for re-exploration and evacuation of hematoma, as well
intraoperatively on executing the surgical plan, emphasiz- as possible lateral canthotomy and release of the arcus
ing conservative skin excision maintaining symmetry of marginalis.2,3,10,23,24
the lid crease and managing any intraoperative findings, Visual changes, including diplopia, are generally
such as levator dehiscence. The most common compli- temporary and can be attributed to wound reaction,
cation of cosmetic surgery is failure to meet the patient’s edema, and hematoma. Damage to extraocular muscles
expectations. and nerves may cause permanent strabismus. The most
Post surgery mild pain, ecchymosis, eyelid edema, common structures damaged in blepharoplasty are the
lagophthalmos, blepharoptosis, subconjunctival hemor- inferior oblique muscle and superior oblique muscle.
rhage, and diminished sensitivity of the eyelids should Conservative management is recommended, though
resolve within the early postoperative period. Other refractory cases should be referred to an ophthalmologist.
complications, such as persistent fat, skin or textural irreg- Vision loss can also result from globe perforation during
ularities may require minor secondary procedures. infiltration with local anesthetic.10,25 This is extremely rare
The major complications of blepharoplasty are blind- and along with corneal abrasion, can be prevented with
ness, hematoma, and globe injury. Visual loss due to corneal protectors.
retrobulbar hematoma is the most feared complication;
fortunately, the occurrence is rare.10,22 Acute retrobul- Lower Eyelid Blepharoplasty
bar hematoma may compress neurovascular structures, Lower eyelid rejuvenation is more complex and has several
leading to ischemia of the retina, central artery, and optic treatment options, such as blepharoplasty, fillers and skin
nerve. Symptoms include severe pain, visual changes, resurfacing. Most surgeons have developed a customized
including hemianopia or amaurosis fugax, and scintillat- approach to eyelid surgery in which the specific anatomic
ing scotomas. Examination will often reveal a tense and problems are identified and the operation is individual-
protuberant periorbital area with diminished or absent ized to address these problems.
extraocular movements. Once the diagnosis is made, The approach to the lower eyelid remains a contro-
treatment should be implemented immediately because versial issue within plastic and oculoplastic surgeons.
 860 Facial Plastics, Cosmetics and Reconstructive Surgery

A B
Figs 13A and B: Subciliary incision. (A) Schematic figure; (B) Real patient

The evolution of lower eyelid blepharoplasty has resulted

in divergent concepts; some authors favor the mainte-
nance of the fat bags, others are against touching the
orbicularis oculi muscle and still, others recommend
muscle cutaneous flaps and ample undermining of the
orbicularis oculi muscle.9

Transcutaneous Lower Eyelid Surgery

Traditional transcutaneous lower blepharoplasty corrects
multidimensional aspects of periorbital aging through
tightening of the lower eyelid skin and muscle and manip-
ulation of orbital fat.

Preoperative Marking
The incision should be marked with the patient in the
supine position. The scar in the lower eyelid will become Fig. 14: Local anesthetic infiltration
less visible when placed just beneath the lashes and
restricted to the lateral canthus, and certainly extending no
further than the orbital rim (Figs 13A and B). The amount
of skin and fat in excess should be noted previously. through a subciliary incision with the skin elevated off the
orbicularis to the level of the infraorbital rim. Redundant
Anesthesia skin can be removed conservatively and redraped without
No matter which kind of approach may be performed in disturbing the underlying orbicularis oculi muscle.10,11
the lower lid, different anesthesia modalities would be The more aggressive skin-muscle flap method is again
done and in all cases, lower eyelid is anesthetized with 2% approached through a subciliary incision with dissection
lidocaine (Fig. 14). through skin and orbicularis oculi muscle. The pretarsal
orbicularis fibers should remain intact and the skin and
Operative Technique preseptal orbicularis are elevated as one flap (Figs 16A
The skin flap method of lower blepharoplasty has the to C). Dissection can be continued along the orbital septum
advantage of maintaining the integrity of the orbicularis to the level of the orbital rim. Periorbital fat is approached
(Figs 15A and B). It is ideal for skin laxity alone with no through small incisions in the septum. Orbicularis oculi
fat prolapse. The amount of skin to be resected can be muscle fibers and skin can be excised at closure; however,
estimated with a skin pinch between forceps and usually damage to the muscle may lead to lower eyelid malposi-
represents 3 mm of tissue. The technique is approached tion and muscle denervation (Figs 17A and B).9-11
 Upper and Lower Lid Blepharoplasty 861

A B
Figs 15A and B: Skin flap figure. (A) Schematic figure; (B) Undermining with curved scissors

A B

Figs 16A to C: Skin-muscle flap. (A) Dissection through

skin and orbicularis oculi muscle with curved scissors;
(B) The curved scissors used; (C) After complete dissection
C of the skin-muscle flap
 862 Facial Plastics, Cosmetics and Reconstructive Surgery

A B
Figs 17A and B: Skin excision. (A) Marking the amount to be excised; (B) After skin excision

Separate skin and muscle flaps are developed to maxi- 6-0 nylon sutures to achieve an esthetic outcome (Fig. 19).
mally preserve the pretarsal orbicularis oculi fibers on Bandage strips are applied at the end of bilateral proce-
the tarsal plate. This leaves the orbicularis-tarsus rela- dure (Fig. 12).
tionship intact and possibly preserves innervation to the
muscle. Periorbital fat, muscle and skin can be addressed Transconjunctival Lower Eyelid Blepharoplasty
separately.9-11,26 Surgery is performed through an incision made several
It is important to remember that three fat compart- millimeters below the tarsal plate through conjunctiva
ments are associated with the lower eyelid. The medial and lower eyelid retractors (Fig. 20). This incision would
and central fat pads are separated by the inferior oblique be continuous or discontinuous. This can be done by
muscle. However, an isthmus of fat generally lies anterior sharp dissection with scissors, radiofrequency mono­
to the muscle belly. Its course makes it susceptible to injury polar cautery or LASER. Gentle pressure on the eyeball
during surgical dissection of the surrounding fat pads. The prolapses the fat compartments and aids in identification
medial and lateral fat pads are separated by the arcuate of the medial, central and lateral fat pads. Conservative
expansion, a fascial band extending from the capsulo- fat removal is achieved using radiofrequency monopolar
palpebral fascia to the inferolateral orbital rim. Notably, or bipolar cautery (Fig. 21). Care is taken not to damage
the inferolateral orbital septum inserts 2 mm outside the inferior oblique muscle that separates the medial from
the orbital rim, creating the recess of Eisler, allowing the central fat pocket. The end point for excision is reached
lateral fat pad to just spill over the orbital rim.20 If neces- when gentle pressure on the globe results in the anterior
sary, fat pads can be accessed through small incisions aspect of the orbital fat being flush with the orbital rim.
in the septum, teased out, and resected using pinpoint The transconjunctival incision is left unclosed, but the
cautery (Fig. 18). Only the fat that comes easily into the inferior and superior edges of the conjunctival epithelium
wound is excised. It is important not to aggressively pull are well apposed to avoid overlap. The incision usually
fat from the orbit to avoid injury to neurovascular struc- heals within a week.10,11,26,27
tures or extraocular muscles and lead to a “sunken eyes” The advantage of the transconjunctival approach is
appearance. not violating the middle lamella. Lower eyelid skin can
The skin incision can be closed using running subcu- be addressed with a conservative “pinch” excision or
taneous 6-0 nylon suture or interrupted sutures with through skin resurfacing with chemical or LASER peels.
 Upper and Lower Lid Blepharoplasty 863

Fig. 18: Inferior fat pads Fig. 19: Final upper and lower lid closure

Fig. 20: Transconjunctival incision at the Fig. 21: Fat pads compartments through
inferior edge of the tarsus transconjunctival approach

The disadvantage of this approach is a limited exposure, Fat repositioning surgery includes release of the arcus
leading to inadequate fat removal and possible injury to marginalis and advancement of the orbital fat beyond the
lower extraocular muscles.10,26,27 infraorbital rim underneath the orbicularis oculi muscle
with the help of temporary exteriorized sutures. The fat
Lower Eyelid Fat Repositioning can be placed either in the subperiosteal or supraperi-
Transposition of periorbital fat from the retroseptal posi- osteal plane, with no apparent effect on esthetic results.
tion to redrape over the arcus marginalis can be used This technique camouflages the lower orbital rim anat-
to fill out the nasojugal deficiencies and soften lower omy and provides more youthful rejuvenation of the mid-
eyelid depressions.7,9,28,29 Advantages to this technique face.7,9,28,29 This procedure is difficult secondary to the
include the ability to use a pedicle, vascularized fat graft limited exposure and delicate septal tissues. It should be
to precisely fill out a depression, though in reality, the performed only by an experienced surgeon prepared for
periorbital fat is delicate and difficult to reliably secure the frequent complications of ectropion and lower lid
in position. malposition.
 864 Facial Plastics, Cosmetics and Reconstructive Surgery

Other methods suggested to correct tear through defor­ treatment can include simple massage exercises as advo-
mity include orbital fat removal, fat injections or grafts and cated by Carraway, lateral canthal repositioning, vertical
temporary soft-tissue fillers, such as hyaluronic acid.7,28,30 skin recruitment and spacer grafts.9,10,31-36
Severe complications, such as visual loss from
Postoperative Care orbital hemorrhage, orbital injection or posterior optic
Methylcellulose eye drops are recommended while the nerve infarction are extremely rare, but have been
patient is awake, and lubricating ointment for night use for described.23,24,26,37 Other possible complications are
several days postoperatively. The patient’s head should lagophthalmos, corneal exposure and acquired strabis-
remain elevated to reduce edema and ophthalmic pres- mus (Fig. 22B). Among the potential risks with lower eyelid
sure. Patients are advised to avoid strenuous lifting, fat repositioning are temporary skin irregularities from fat
bending, and vigorous activities for 2 weeks follow- and edema, fat granulomas, restricted ocular motility or
ing the procedure. Suture removal is performed 5 days new-onset diplopia.23,24,26,37,38
postoperatively, and bandage strips may be removed on
the second postsurgery visit, which is usually 5–7 days
following surgery.
GENERAL COMPLICATIONS

Complications Early Complications

Historically, the most common complication follow- Dry eye syndrome is a clinical diagnosis. Symptoms
ing lower lid blepharoplasty is lower eyelid malposi- include itching, foreign body sensation, burning, mucoid
tion, with published complication rates ranging from secretions, frequent blinking, and conjunctival infec-
5% to 90%.9,10,24,31 Causes include excessive skin, fat or tion. Pre-existing dry eyes may be aggravated by peri­
muscle removal, scar contracture, intramuscular hema- operative lagophthalmos. Abnormal preoperative ocular
toma, orbicularis oculi muscle paralysis, adhesions in the history, such as documented dry eyes, history of dry eyes,
middle lamella, uncorrected lower lid laxity, and proptosis LASIK surgery and/or history of frequent eye drop use,
(Fig. 22A). The most prevalent etiological factor in post- and abnormal orbital and periorbital anatomy, such as
blepharoplasty lid malposition is vertical deficiency of lower eyelid laxity and a negative vector, are all predictors
the anterior or posterior lamella in the setting of tarso­ of postoperative dry eye complications.10,11,24,26 Ocular
ligamentous laxity.9,10,24,31 To avoid the typical deformity protection with patches, temporary tarsorrhaphy, and/
seen after this procedure, canthopexy and canthoplasty or lateral canthopexy/canthoplasty should be combined
have been adopted into cosmetic surgery, as the presumed with aggressive corneal lubrification, warm compresses
rationale for correction of (or prophylaxis of ) lower lid and edema control.
malposition in an attempt to optimize vertical eyelid posi- Infection is a rare complication of blepharoplasty.
tion by tightening or shortening the lower eyelid hori- Dry eye syndrome may predispose the cornea to super-
zontally.9,24,31-34 In general, all methods of canthopexy/ infection. It can be treated with topical and/or systemic
canthoplasty correct tarsoligamentous laxity, thereby antibiotics. A fluid collection, if present, should be
coun­teracting the downward forces of healing.9,24,31-34 Its drained.

A B
Figs 22A and B: Complications. (A) Lower eyelid malpositioning (ectropion—OD) after blepharoplasty. The surgery was
performed at another hospital by another surgeon; (B) Acquired strabismus after lower blepharoplasty (40 days). However,
the etiology of this case was Lambert-Eaton syndrome
 Upper and Lower Lid Blepharoplasty 865

Chemosis is a common complaint after blepharoplasty CONCLUSION

that is caused by lymphatic disruption of the eyelid, with
development of milky conjunctival and corneal edema. This chapter briefly describes the techniques of stand-
Corneal injury and infection should be ruled out. It can be ard upper and lower blepharoplasty. Blepharoplasty
limited by atraumatic dissection, protective tarsorrhaphy, is most of all about anatomy, and once the surgeon
and edema-limiting maneuvers, such as cold compresses, understands the surface anatomy of the eyelid complex
elevation, massage, and corneal lubrification. It is and its deep underpinnings, the surgeon is prepared to
usually self-limiting and resolves spontaneously, though assess the individual patient and formulate an individ-
prolonged chemosis can be treated with topical steroids. ual surgical plan.
Asymmetry is a common complication that can be Practically, rejuvenation of this complex anatomical
addressed with revision procedures once edema and area requires a combination of therapies including fat
inflammation resolve completely. excision, repositioning or transfer, simultaneous brow or
Iatrogenic ptosis can result from injury to the leva- midface lift, and adjunctive treatment for skin resurfacing
tor aponeurosis during the inferior skin muscle excision and periorbital hollows.
upper lid blepharoplasty. Other causes include local anes- Physicians should be receptive to patient feedback and
thetic, edema, intramuscular hematoma, and traumatic continually evaluate their results to ensure patient satis-
operative technique. If levator injury is recognized intra- faction and safety. Refinements can be based on construc-
operatively or postoperatively, it should be repaired. Mild tive criticism and can be incorporated into the entire
cases may resolve spontaneously. blepharoplasty process.

Late Complications
Lagophthalmos can be caused by upper eyelid edema,
REFERENCES
iatrogenic orbital septal elevation or excessive skin resec- 1. Espinoza GM, Holds JB. Evolution of eyelid surgery. Facial
tion. It usually resolves spontaneously, as edema resolves Plast Surg Clin North Am. 2005;13(4):505-10.
and muscles relax. Treatment is conservative with patient 2. Rohrich RJ, Coberly DM, Fagien S, et al. Current concepts
reassurance, light massage, taping and proper nocturnal in aesthetic upper blepharoplasty. Plast Reconstr Surg.
lubrification. If conservative treatment fails, surgical treat- 2004;113(3):32e-42e.
ment includes upper lid scar release with full-thickness 3. Gentile RD. Upper lid blepharoplasty. Facial Plast Surg Clin
interposition skin grafting. North Am. 2005;13(4):511-24.
Undercorrection of upper lid skin can be treated with 4. Castanãres S. Blepharoplasty for herniated intraorbital fat;
secondary excision if necessary or, if pseudoptosis is the anatomical basis for a new approach. Plast Reconstr Surg
cause, lateral brow elevation. 1951;8(1):46-58.
Excess fat removal can result in hollowing of the socket. 5. Flowers RS. Upper blepharoplasty by eyelid invagination.
Fat transposition or soft-tissue fillers along the orbital rim Anchor blepharoplasty. Clin Plast Surg. 1993;20(2):193-207.
may help mask this complication. 6. Fagien S. The role of the orbicularis oculi muscle and
Inadequate fat resection, usually medial fat compart- the eyelid crease in optimizing results in aesthetic upper
ments, may be amenable to secondary transconjunctival blepharoplasty: a new look at the surgical treatment of mild
resection. Residual lower lid rhytides can be treated with upper eyelid fissure and fold asymmetries. Plast Reconstr
resurfacing modalities such as, chemical peels and abla- Surg. 2010;125(2):653-66.
tive LASER resurfacing and/or soft-tissue fillers. 7. Loeb R. Fat pad sliding and fat grafting for leveling lid
depressions. Clin Plast Surg. 1981;8(4):757-76.
8. de la Plaza R, Arroyo JM. A new technique for the treatment
REOPERATIONS of palpebral bags. Plast Reconstr Surg. 1988;81(5):677-87.
Secondary blepharoplasty is a challenging and demand- 9. Viana GA, Osaki MH, Nishi M. Comparison between two
ing procedure. It should not be performed until more than surgical techniques for lower eyelid rejuvenation: safety
3 months after the previous operation. Patients, who are to analysis and outcomes. Graefes Arch Clin Exp Ophthalmol.
undergo secondary surgery to correct eyelid irregularities, 2010;248(4):555-63.
should be evaluated carefully and counseled to ascertain 10. Trussler AP, Rohrich RJ. MOC-PSSM CME article:
a concurrent goal for surgery. Blepharoplasty. Plast Reconstr Surg. 2008;121(1 Suppl):1-10.
 866 Facial Plastics, Cosmetics and Reconstructive Surgery

11. Naik MN, Honavar SG, Das S, et al. Blepharoplasty: an over- 25. Schechter RJ. Management of inadvertent intraocular injec-
view. J Cutan Aesthet Surg. 2009;2(1):6-11. tions. Ann Ophthalmol. 1985;17(12):771-5.
12. Lima CGMG, Siqueira GB, Cardoso IH, Sant’Anna AEB, 26. Goldberg RA, Charonis GC, Baylis HI, et al.Upper and lower
Osaki MH. Avaliação do olho seco no pré e pós-operatório eyelid blepharoplasty. In: Nesi FA, Lisman RD, Levine MR
da blefaroplastia (Evaluation of dry eye in before and after (Eds). Smith’s Ophthalmic Plastic and Reconstructive
blepharoplasty). Arq. Bras. Oftalmol. 2006; 69:227-32. Surgery. St Louis: Mosby; 1998. pp. 416-35.
13. Brazzo BG, Nesi FA. Evaluation of the cosmetic patient. In: 27. Baylis HI, Long JA, Groth MJ. Transconjunctival lower
Nesi FA, Lisman RD, Levine MR (Eds). Smith’s Ophthalmic eyelid blepharoplasty. Technique and complications.
Plastic and Reconstructive Surgery. Mosby, St Louis. 1998; Ophthalmology. 1989;96(7):1027-32.
411-5. 28. Goldberg RA. The three periorbital hollows: a para-
14. Beard C. Examination and evaluation of the ptosis digm for periorbital rejuvenation. Plast Reconstr Surg.
patient. In: Nesi FA, Lisman RD, Levine MR (Eds). Smith’s 2005;116(6):1796-804.
Ophthalmic Plastic and Reconstructive Surgery. Mosby, St 29. Hamra ST. The role of the septal reset in creating a youthful
Louis. 1998; 339-44. eyelid-cheek complex in facial rejuvenation. Plast Reconstr
15. Viana GP, Viana GAP. Approach to eyebrow ptosis through Surg. 2004;113(7):2124-41.
the modified technique of Castanãres. Indian J Plast Surg. 30. Viana GA, Osaki MH, Cariello AJ, et al. Treatment of the tear
2009; 42:58-62. trough deformity with hyaluronic acid gel filler. Arg Bras
16. Feser DF, Gründl M, Eisenmann-Klein M, Prantl L. Oftalmol. 2011;74(1):44-7.
Attractiveness of eyebrow position and shape in females 31. Codner MA, Wolfi JN, Anzarut A. Primary transcutaneous
depends on the age of the beholder. Aesth Plast Surg 2007; lower blepharoplasty with routine lateral canthal support:
31:154-60. a comprehensive 10-year review. Plast Reconstr Surg.
17. Knize DM. Anatomic concepts for brow lift procedures. 2008;121(1):241-50.
Plast Reconstr Surg. 2009; 124:2118-26. 32. Flowers RS. Canthopexy as a routine blepharoplasty compo-
18. Jelks GW, Jelks EB. The influence of orbital anatomy and nent. Clin Plast Surg. 1993;20(2):351-65.
eyelid anatomy on the palpebral aperture. Clin Plast Surg. 33. Jelks GW, Glat PM, Jelks EB, et al. The inferior retinacular
1991; 18:183-95. lateral canthoplasty: a new technique. Plast Reconst Surg.
19. Baker TJ, Gordon HL, Mosienko P. Upper lid blepharoplasty. 1997;100(5):1262-70.
Plast Reconstr Surg. 1977;60(5):692-8. 34. Lessa S, Sebastiá R, Flores E. Uma cantopexia simples. Rev
20. Zide BM, Jelks GW. Surgical anatomy of the orbit. New York: Bras Oftal. 1999;58:779-86.
Raven; 1985. 35. McCord CD Jr. The correction of lower lid malposition
21. Sheen JH. A change in the technique of supratarsal fixa- following lower lid blepharoplasty. Plast Reconstr Surg.
tion in upper blepharoplasty. Plast Reconstr Surg. 1999;103(3):1036-9.
1977;59(6):831-4. 36. Carraway JH, Mellow CG. The prevention and treatment of
22. Callahan MA. Prevention of blindness after blepharoplasty. lower lid ectropion following blepharoplasty. Plast Reconstr
Ophthalmology. 1983;90(9):1047-51. Surg. 1990;85(6):971-81.
23. Wolfort FG, Vaughan TE, Wolfort SF, et al. Retrobulbar 37. Trelles MA. Sight lost after lower lid laser blepharoplasty.
hematoma and blepharoplasty. Plast Reconstr Surg. Ann Plast Surg. 2000;45(6):678-9.
1999;104(7):2154-62. 38. Goldberg RA, Yuen VH. Restricted ocular movements
24. Lowry JC, Bartley GB. Complications of blepharoplasty. following lower eyelid fat repositioning. Plast Reconstr Surg.
Surv Ophthalmol. 1994;38(4):327-50. 2002;110(1):302-5.
 CHAPTER
SMAS Rhytidectomy: Preoperative
95 Evaluation, Surgical Techniques
and Pitfalls
Jeremy B White, Mark Domanski, Steven B Hopping

INDICATIONS FOR THE SURGERY surgery. If the patient is relying on this surgery to get a new
job, find a new spouse and completely change his or her
Subcutaneous dissection with Superficial Muscular life, one must be cautious. Any dissatisfaction with these
Aponeurotic System (SMAS) rhytidectomy is indicated additional expectations postoperatively may be associated
for patients who have developed jowls and cervical skin with surgeon failure in the patient’s mind. It is therefore of
laxity and wish to restore a more youthful appearance. The utmost importance to establish a bond of trust and under-
midface is not fully resuspended with this procedure so standing between the physician and patient at this first
alternative approaches or adjunct procedures should encounter.
be considered if this result is desired. Treatment of the A second preoperative consultation is often necessary
midface can be accomplished by a combination of meth- to solidify this relationship, to answer any questions, and
ods, including, but not limited to filler or fat injections to to make sure that the patient’s and surgeon’s expectations
the midface, malar implants, and extended supra-SMAS, are similar. Risks of the surgery should be reviewed thor-
midface, deep plane or subperiosteal rhytidectomies. oughly at this time to enhance the patient’s understand-
The ideal candidate is one who is in the early forties ing of the surgical complexity and to minimize patient
to late fifties, has minimal sun damage to the skin, mild- resentment towards the surgeon if complications do
to-moderate skin laxity and mild-to-moderate jowls. The occur. One should proceed with particular caution if the
thickness of the skin and soft tissues is important since patient has had multiple cosmetic surgeries and still is not
those who have thicker, heavier tissues may experience satisfied with the results. This may mean that the previ-
decreased longevity to the lift due to the gravitational ous surgeries were poorly executed, expectations were
effect over time. A strong bony structure is also crucial not shared by both the surgeon and patient preopera-
as this will provide the platform upon which skin redrap- tively, the patient has some impediment to optimal heal-
ing will occur and the most pleasing results are usually ing, or that the patient has a psychiatric disorder, such as
obtained when mandibular and malar angularity can be body dysmorphia. In these situations, one should strongly
restored. Some patients may require implants to achieve consider obtaining an official psychiatric evaluation. If the
this effect. Along the same line, a patient with a low lying patient has such a disorder, he or she will likely continue
hyoid bone and microgenia is not ideal since tightening to be dissatisfied with any further procedures that are
the SMAS alone may not restore a sharp cervicomen- conducted, as will the surgeon.
tal angle. This anatomic problem can be aided, to some In addition to the psychological evaluation, the physi-
effect, by submental liposuction and chin augmenta- cian should take a complete medical history. This should
tion, if necessary. If the patient has platysma bands, it is include a list of any dermatologic diseases, such as
often necessary to make a separate submental incision to uncontrolled lupus or propensity to develop keloids that
remove excess platysma and reapproximate the edges in the patient may have. These problems will have negative
the midline. effects on the patient’s healing process. Moreover, if the
patient has significant medical problems, such as diabetes
or peripheral vascular disease, which can impact wound
SPECIFIC PREOPERATIVE healing and skin flap survival significantly, the surgeon
EVALUATION should consider performing a less extensive procedure
Patients often present for facial rejuvenation consulta- and limiting the adjunct procedures.
tions because they desire to recapture their youth. During A full list of medications should be obtained, but
the preoperative assessment, it is important to gain a particular attention should be paid to patients who are
thorough understanding of the patient’s motivations for taking anticoagulants, long-term steroids, which can
 868 Facial Plastics, Cosmetics and Reconstructive Surgery

cause wound healing complications and any alternative Even after extensive discussion and patient evaluation,
medicines that the patient might not have remembered the preoperative dialogue is not complete without taking
to mention. Retinoids should not be used perioperatively patient photographs. This should be performed against a
as isotretinoin has been demonstrated to delay healing light blue background in the Frankfort horizontal plane,
and the wound contraction response in animal models.1,2 which is parallel to a line that extends from the supratragal
Certain herbal medicines and vitamins, such as vitamin E, notch to the infraorbital rim. Frontal and bilateral lateral
feverfew, ginkgo, ginseng, ginger, garlic and green tea can and oblique views should be obtained, however, addi-
cause an increase in intraoperative and postoperative tional photos should be taken if there are plans to perform
bleeding either directly or via interactions with other other adjunctive surgery. Examination of these photo-
medications. These medicines should be discontinued graphs with the patient gives the opportunity to address
two weeks before surgery. Any history of propensity to any further concerns from the patient and to finalize
bleed should prompt obtaining a CBC and coagulation preoperative documentation.
profile.
Most importantly, the patient should not smoke Categories of Subcutaneous SMAS Facelifting
tobacco for at least two to four weeks before and after Anterior scar, short flap (S-Lift): Patients who are in their
surgery. Rhytidectomy skin flap necrosis has been shown 30s or 40s and have early jowl and neck laxity.
to occur anywhere between four and 12.5 times more Anterior scar, long flap (S-PlusLift): Patients who are in
frequently in smokers than in nonsmokers.3,4 Urine anaba- their 40s to 60s and have moderate jowl, neck and midface
sine, which does not test positive with nicotine replace- laxity.
ment product use and serum or urine cotinine measure- Posterior scar (Neck Lift): Patients who are in their 30s to
ments can be obtained to confirm the patient’s smoking 60s, often men with moderate-severe neck laxity.
status. Given the added risk to this elective procedure, if Platysmaplasty: Patients are of any age, but demonstrate
the patient continues to smoke despite having received platysma bands at rest.
extensive counseling, one should consider either limiting
the extent of flap undermining or canceling the surgery
altogether.
ANESTHETIC CONSIDERATIONS
The consultation should then continue with the physi- Excellent anesthesia management is essential since it sets
cal examination. The surgeon should begin with a careful the tone for the entire surgical experience. Patients often
assessment of the facial skin for color, thickness, evidence view cosmetic surgery as a venture without risks and it is
of solar damage, scars and any lesions that are concerning therefore most important to educate the patient regarding
for neoplasia. Rhytids, jowls, deepened nasolabial folds, these real risks without contributing excessively to his or
platysma bands and areas of particular laxity should be her anxiety. Once this has been done, the anesthesiologist
identified with the patient in front of a mirror to enable or CRNA must make certain key assessments to give the
a shared understanding of the most problematic regions highest probability for a safe surgery. First, the surgeon
to target. Moreover, the surgeon should discuss areas of and anesthesia provider must decide on the appropriate
hollowing where the malar fat pads have begun to atrophy setting in which the surgery should be performed, whether
and displace inferiorly. Midface descent can be treated in the office, at an outpatient ambulatory facility, or on a
with a lift, but is often in need of volume restoration as well. 23-hour observation status at a hospital. If the patient has
Autologous fat injection and other fillers can be extremely sleep apnea or is obese, strong consideration should be
useful to accomplish this task. In the lower third of the given to admit the patient postoperatively. Patients with
face and neck, the cervicomental angle should be exam- sleep apnea, which is often undiagnosed, can be more
ined with respect to the hyoid bone. It may be more diffi- difficult to intubate if the necessity arises and are more
cult to restore a youthful neck profile and a well-defined sensitive to narcotics than patients without sleep apnea.
jaw in a patient with a low hyoid and an obtuse cervico- The latter factor is crucial since narcotics can depress their
mental angle. Adjunctive procedures, such as conserva- respiratory drive postoperatively so these patients may
tive midline cervical skin excision and submental lipo- require continuous pulse oxygen monitoring overnight.
suction may be necessary to achieve the best outcome in If the patient is over 50 years old, an electrocardio-
these cases. Incision lines should be drawn on the patient gram should be performed. Preoperative medical clear-
to communicate where scars will be placed and hidden. ance should be obtained from the appropriate physi-
In planning these incisions, the surgeon must pay heed to cian if the patient has any significant medical problems.
the temporal hair line position as this may influence the Anticoagulants, such as aspirin and coumadin should
optimal location of the incision. be stopped one to two weeks prior to surgery. A urine
 SMAS Rhytidectomy: Preoperative Evaluation, Surgical Techniques and Pitfalls 869

pregnancy test is conducted on the day of surgery for all SPECIAL INSTRUMENTS USED FOR
premenopausal women as general anesthesia can have
significant consequences for a fetus. Patients are asked not
THE SURGERY
to eat or drink after midnight the night before surgery. If Instrumentation for rhytidectomies can vary widely from
patients do not adhere to this and surgery proceeds with surgeon to surgeon.
some level of sedation, the patient is at risk for aspiration A basic facelift set would include:
pneumonia. • Blunt facelift scissor
Patients who will receive general anesthesia or IV • Curved, sharp scissor
sedation are also at risk for deep vein thrombosis, partic- • Suture scissor
ularly if the procedure is long and combined with other • Skin hook, two prong
surgeries, such as abdominoplasty. There is additional • Deaver retractor
cause for concern in patients who smoke, take oral contra- • Scalpel
ceptive hormones, or have hypercoagulability disor- • Adson forceps with teeth
ders. Sequential compression devices are placed on the • Needle holder
patient’s lower extremities to minimize this risk of DVT • Hemostats
and pulmonary embolus. Considering the precision that • Bipolar or unipolar cautery Unit
is required to perform this operation well, every attempt Additional Instruments:
should be made to maintain a blood-free surgical field. • Flap demarcator
This can be aided by giving the patient 0.2 mg of cloni- • Facial liposuction cannulas
dine fifteen minutes prior to surgery, unless preoperative • Lighted facelift retractor
blood pressure is quite low. Intraoperative blood pressure
should be maintained at the low range of normal for that Operative Technique
patient while allowing for occasional raises in pressure Modified tumescent anesthesia (1000 cc saline, 100 cc 1%
due to stimulation or pain. lidocaine plain, 2 cc epinephrine 1:1000) is infiltrated into
In the senior author’s practice (SBH), patients are the subcutaneous-supra SMAS tissue planes utilizing a
given IV sedation anesthesia intraoperatively with combi- 20 gauge spinal needle. Approximately 200 mL is infused
nations of versed, diprivan, fentanyl and ketamine. Some into the neck and 100 mL into the anterior face. The face
patients prefer only oral-versed sedation. The patient’s is then prepped with betadine and a light massage of the
head is elevated just above the heart. A helpful method to facial tissues is performed for 5 minutes to diffuse the
optimize the surgical field is to instill tumescent local anes- tumescent solution evenly into the tissues.
thesia solution subcutaneously over the SMAS ten minute Five stab incisions are made with a No. 15 blade: one
prior to dissection. This will not only aid in hemostasis, but submental, two supra-auricular and two infra-auricular.
also increase the ease of operation with hydrodissection of Criss-cross liposuction is performed with 1 or 2 mm blunt
the surgical plane. To avoid postoperative bucking, which cannulas with the openings down, away from the skin. Criss-
can lead to bleeding and hematoma, dexamethasone and crossing tunnels helps to maximize skin tightening (Fig. 1).
ondansetron are provided intraoperatively. Lastly, there Starting on the patient’s right, incisions are made with
should be good communication between the surgeon and a No. 15 blade from the infra-auricular ear to the supra-
anesthesia provider towards the end of the case. This will auricular area, with extensions horizontally into the
help to ensure that the sedation agent is titrated off at the temporal hairline, designed to preserve pretemporal hair.
appropriate time, leading to a smooth wakeup. A preauricular strip for improved exposure is optional
(Fig. 2). The incision is retrotragal in women and pretra-
gal in men, if there is a history of nicotine use, however,
SURGICAL STEPS a pretragal incision is favored because of concerns about
Contemporary facelifting involves reversing the aging distal flap viability. The incision is beveled towards the
effects of atrophy and gravity by lifting the skin and SMAS SMAS keeping the distal flap as full thickness as possible.
of the face in a superior and posterior direction. Incisions Next, a two-pronged skin hook provides counter traction
are hidden anterior and posterior to the ears and in the as the flap is extended anteriorly 2–3 centimeters using
hairline. Facelifts involve subcutaneous dissection, SMAS the beveled No. 15 blade. Face-lift scissors are now utilized
plication or imbrication, and sometimes deep plane to extend the flap widely inferiorly and anteriorly. As the
(beneath SMAS) or subperiosteal dissection. The follow- dissection extends anteriorly beyond the parotid gland, be
ing will discuss the senior author’s (SBH) technique for sure to remain in the subcutaneous plane to avoid injury
superficial plane SMAS rhytidectomy. to deeper facial nerve branches (Fig. 3).
 870 Facial Plastics, Cosmetics and Reconstructive Surgery

In patients with fatty or heavy necks, open liposuction ESP (extended SMAS platysma) tissue allows dramatic
with a 3 mm spatula cannula is now performed. tightening of the neck when the purse-string suture is
Next, purse-string SMAS plication sutures are placed tightened. A second purse-string suture (“O suture”) is
starting at the fixed fascial tissues overlying the zygomatic placed if lifting of the jowl is desired. A 2-0 Ethibond suture
arch extending inferiorly to the platysma SMAS tissues at is used for the purse string SMAS plication and the knot
the angle of the mandible (“U suture”). A firm bite in this is buried using a horizontal mattress suture of 3-0 Vicryl
(Figs 4A and B). Any redundant tissue bunching that is
created by the purse-string sutures is trimmed flat with
the scissors. The skin flap is pulled superolaterally and
held in position with a temporary surgical clip in the pre-
auricular area. Other plication sutures can be placed to lift
the jowl or midface as indicated. While the senior author
has experienced excellent results using the purse string
suture technique, there are many ways of plicating the
SMAS, some of which have been evaluated in biomechan-
ics studies.5
The same maneuvers are now performed on the
patients left side.
Once the left side plication is completed, return to the
right side and irrigate the flap with jets of saline from a
10 cc syringe. Complete hemostasis is obtained with
bipolar forceps.
Superior rotation of the facelift flap skin is then
performed. Measuring with a flap demarcator, the
maximum tension of the closure is placed at the supra-
auricular point of the anterior incision using a 3-0 vicryl,
horizontal mattress suture to secure the flap to the fixed
SMAS tissues below (Fig. 5).
At this point, tissue redundancy is created by the supe-
Fig. 1: Liposuction of neck, jowl and face. A 1 mm cannula rior flap rotation. The horizontal, temporal hair preserv-
is used for pretunneling and liposuction after tumescent ing incision is extended utilizing sharp scissors. If exces-
anesthesia infusion sive redundancy is present, the incision is curved sharply

Fig. 2: Anterior facelift incision. Pre-excision strip can be Fig. 3: Scissor elevation of facelift flap is best
performed for improved exposure prior to flap elevation performed under direct vision
 SMAS Rhytidectomy: Preoperative Evaluation, Surgical Techniques and Pitfalls 871

A B
Figs 4A and B: SMAS plication sutures secured to fixed fascial tissues above the zygomatic arch

Fig. 5: Flap demarcator assists in calculating extent of skin Fig. 6: The vector of pull is superolaterally as depicted.
excision. The point of maximum tension is just above the ear Note the excess skin superior to the ear

superiorly into the temporal hair. Redundant tissue (scalp) perichondrium of the ear to prevent inferior migration
is removed and the superior “dog-ear” is corrected with a of the scar and a “pixie ear” deformity. The anterior skin
cut back into the temporal hair (Fig. 6). incision is closed with subcuticular 5-0 monocryl (Fig.
Having resolved the superior redundancy issue, the 7). Surgical clips are used to close all scalp incisions. Any
flap demarcator assesses the amount of preauricular postauricular incisions are closed loosely with interrupted
skin to be excised. No tension should be present in this 4-0 chromic suture. This allows easy egress of fluid or
anterior-inferior portion of the closure. Correct any infra- blood from beneath the flaps.
auricular redundancy or dog-ear as necessary. Generally, A light compressive dressing is applied for 24 hours.
the extreme superior rotation of the flap minimizes redun- The patient is seen the next day and the dressing is
dancy in the infra-auricular area. replaced with a velcro head band, which is worn intermit-
Closure of the subcutaneous tissues is accomplished tently throughout the day and during sleep for one week.
with 3-0 vicryl interrupted sutures. This includes a tight The surgical clips in the temporal and occipital hairline are
adhesion of the infra-auricular flap to the conchal cartilage removed on postoperation day 9 or 10.
 872 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 7: Incision closed anterior to ear without tension. Note Fig. 8: Postauricular M-plasty to handle
redundant skin left over the tragus to prevent postoperative postauricular skin excess
tragal retraction

Fig. 9: Closure with extended postauricular and scalp skin Fig. 10: Temple lift incision for superior
excision, often needed for cases of excess neck laxity temple scalp advancement

provides a safe plane away from the facial nerve branches,

Special Considerations which lie within the temporoparietal fascia. Advance the
If excessive skin redundancy exists postauricularly after temple tissues superiorly by attaching the temporopari-
superior rotation of the anterior flap, the incision should etal fascia to a more superior level on the temporalis fascia
be extended into the postauricular sulcus and posterior using a 3-0 Vicryl horizontal mattress suture (Fig. 10).
hair as necessary. A postauricular M-plasty is useful for If excessive or redundant SMAS tissues exist, perform
small skin redundancies (Fig. 8). For more excessive skin SMASectomies to debulk excess SMAS before closure with
excess as in cases with advanced neck laxity, the incision purse-string sutures (Figs 11 and 12).
must be extended into the postauricular sulcus and poste- If excessive midface laxity exists, extend the midface
rior scalp (Fig. 9). dissection to the level of the infraorbital neurovascular
If excessive redundancy exists in the temple area after bundle and plicate up the mobile malar soft tissues to
flap rotation, perform a temple lift by widely undermin- the fixed orbicularis muscle fascia 1 cm below the lateral
ing in the sub-SMAS plane between the temporoparietal canthus. Use two or three 3-0 vicryl interrupted sutures
fascia and the superficial layer of the temporalis fascia. This with the knots buried (Figs 13 and 14).
 SMAS Rhytidectomy: Preoperative Evaluation, Surgical Techniques and Pitfalls 873

Fig. 11: Intraoperative photo showing planned Fig. 12: SMASectomy defect closure. Note superior
SMASectomies movement of the distal midface tissues

A B
Figs 13A and B: Preoperative (A) oblique view of the face demonstrating the presence of jowls and a slightly obtuse
cervicomental angle. She underwent SMAS rhytidectomy with autologous fat grafting to the midface; (B) and had significant
improvement in these areas

If excessive submental fullness exists after lateral backcuts on the platysma muscles at the level of the
flap tightening or if there are platysma bands at hyoid bone. Approximate the cut edges of the platysma
rest, the neck should be opened by extending the with interrupted 3-0 vicryl sutures with knots buried
horizontal submental incision to 3 cm and remove completing the platysmaplasty. Wide undermining of
the soft tissue excess in the midline with scissors. the skin of the neck is necessary to prevent postoperative
Liposuction any excessive subplatysmal fat. Perform irregularities.
874 Facial Plastics, Cosmetics and Reconstructive Surgery

A B

C D
Figs 14A to D: Preoperative (A and C) and postoperative (B and D) anterior and lateral views of a patient who
underwent SMAS rhytidectomy with autologous fat grafting to the midface
 SMAS Rhytidectomy: Preoperative Evaluation, Surgical Techniques and Pitfalls 875

COMPLICATIONS Infection
As with any surgical procedure, rhytidectomy has its own Infection is a risk in any surgery. Patients at increased risk
complications. If a complication occurs, early recognition for infection include those that are at risk for poor wound
and proper treatment is paramount to salvage a success- healing, such as diabetics and smokers.
ful outcome. Moreover, if an adverse event occurs and the Prevention of infection is focused on the minimiza-
patient becomes upset, it is essential to see this patient tion of bacterial load. The patients should be instructed to
more often, rather than distance oneself. This will help to shower and shampoo the morning of surgery. Some cent-
maintain good rapport between the surgeon and patient. ers recommend that patients bathe with hexachlorophene
(Phisohex) before elective surgery. The theory is that this
Hematoma decreases bodily bacterial load and thus decreases wound
The most common complication of rhytidectomy is infections. Phisohex should not be used around the eyes.
hematoma, which is reported to occur in 0.3–8.1% of The role of preoperative antibiotics continues to
cases.6 Avoidance of hematoma begins in the preopera- evolve. Preoperative parenteral antibiotics given within
tive setting by discontinuing anticoagulants and avoiding one hour of skin incision has been shown in the general
herbal supplements that can contribute to bleeding, as surgery literature to decrease wound infections. Common
mentioned previously. If a patient has a medical condition antibiotics include cefazolin or clindamycin.
that requires a blood thinner, the patient’s internist should Routine use of postoperative oral antibiotics after
evaluate the risks of discontinuing the medication prior to facial plastic surgery is common, but varies considerably
surgery. between practitioners. Many practitioners like to apply
Intraoperative avoidance of hematoma requires metic- bacitracin or mupirocin ointment to wound edges after
ulous technique. Common practice involves preoperative closure. This theoretically decreases bacterial exposure to
injection of lidocaine with epinephrine into the planned the wound while maintaining tissue moisture. However,
incision sites. While this allows for better intraoperative such ointment may actually prevent adequate cleans-
hemostasis, this may mask blood vessels that may bleed ing of the wound edge by trapping sloughed skin and
postoperatively. Intraoperative dissection in the appropri- debris next to the wound. Therefore, some practitioners
ate surgical planes will minimize bleeding. Bipolar coagu- recommend daily removal of clots from the wound with
lation of bleeding vessels is performed. Bipolar cautery is q-tips and hydrogen peroxide. Regardless of the method
more focused and precise than monopolar cautery and recommended, much about postoperative wound care
thus carries less risk to nearby structures, such as nerves. is more empiric than evidence based.
Cauterization of the skin flap should be performed only If postoperative infection is suspected, antibiot-
where necessary as to minimize the risk of flap necrosis. ics should be started. The antibiotic coverage should
Prevention of hematoma continues postoperatively. be broadened if the patient is already on antibiotics. If
Gentle emergence from anesthesia is paramount to purulence is expressed from the wound edge, the wound
prevent patient bucking and associated rises in blood should be opened, cultured and irrigated. Treatment
pressure. A gentle pressure dressing in the form of a head should be tailored to the extent of the patient’s infection.
wrap is placed on the wound site at the end of the proce-
dure. Appropriate postoperative pain management helps Skin Slough/Flap Loss
to control blood pressure and potentially reduces the risk Skin slough or flap loss occurs when the blood supply is
of hematoma. For this reason, the patient should have inadequate to support live tissue. This has been reported
their postoperative prescriptions filled prior to the date of to occur in 1–3% of rhytidectomies. Blood supply can
surgery to avoid any medication access problems. become compromised if the skin flap is too thin or the
If they occur, hematomas usually present within the flap is placed on excessive tension. If hair follicles are
first 24 hours postoperatively. Symptoms can include visible on the undersurface of the skin flap, the flap is
pain that is greater than expected, swelling or increased too thin. Hematoma can cause increased tissue pres-
drain output. It should be emphasized that drains prevent sure and thus lead to reduced blood flow and flap loss.
seromas not hematomas. Evacuation of the hematoma Similarly, infection compromises capillary blood flow.
is important to ensure skin flap survival. The wound site Smokers and diabetics have impaired microcirculation
should be irrigated with saline to attempt to locate the and are at increased risk of flap loss. Smokers should
source of bleeding. Unfortunately, the bleeding vessel cease smoking at least two weeks prior to the surgery.
often will remain elusive. Small hematomas may only Since nicotine also causes vasoconstriction, nicotine
present after facial edema has decreased and, at times, gum and other cigarette substitutes should be avoided
may be treated by repeat needle aspiration. as well.
 876 Facial Plastics, Cosmetics and Reconstructive Surgery

Initial treatment of partial thickness loss involves of the facial nerve exit the parotid gland anteriorly and
dressing changes and observation. Many partial thick- travel along the parotidomasseteric fascia. The facial
ness losses will re-epithelialize with little noticeable nerve lies deep to the superficial musculoaponeurotic
cosmetic impairment. Skin flap re-advancement can system and innervates the muscles of facial expression
be considered for more noticeable losses. The surgeon from the deep surface except for the buccinator, leva-
should be aware that blood supply is compromised each tor anguli ori and mentalis muscles, which receive their
time tissue is advanced. Therefore, readvancement of innervation on their superficial surfaces. The concept
the skin flap should be performed only once the wound here is that the facial nerve lies deep in the lateral face
is stable and the vasculature of the skin flap has accom- but becomes more superficial toward the midline.
modated to having been advanced previously. The most commonly injured branch of the facial nerve
is the buccal branch. The buccal branch runs in close prox-
Great Auricular Nerve Injury imity to Stensen’s duct (the parotid duct). Due to signifi-
Impairment to the sensation of the ear can be very cant cross innervations of the buccal branch, injuries are
significant to females, especially those that wear often not disfiguring. The marginal and temporal branches
earrings. Sensation to the earlobe and helix is provided of the facial nerve have few cross-innervating arcades and
by a branch of the great auricular nerve. This nerve injury to these branches is more obvious postoperatively.
arises from the second and third cervical spinal root- There is controversy in the medical literature as to which
lets and travels posterior to the sternocleidomastoid of these two branches is injured most often. The tempo-
muscle. It then wraps around the posterior edge of the ral branch of the facial nerve is particularly vulnerable to
sternocleidomastoid muscle at Erb’s point to course injury because of its superficial location as it crosses the
anteriorly and superiorly along the superficial aspect midportion of the zygomatic arch.
of the muscle. This portion is typically encountered If a facial nerve branch is transected during surgery, it
approximately 6.5 cm below the external auditory should be repaired immediately using a small suture, such
meatus. The great auricular nerve then gives off several as 9-0 nylon. A microscope or high powered loupes will be
branches, one of which courses superiorly toward the required. If there is a weakness from a traction injury, high
earlobe. dose steroids, such as dexamethasone (10 mg IV) followed
One can prevent greater auricular nerve injury by by an oral taper may reduce inflammation and thus reduce
avoiding deep dissection at the level of the sternocleido­ neuropraxia.
mastoid muscle. Some surgeons prefer to identify the
nerve during dissection and then preserve it. Either Pixie Ear Deformity
way, most rhytidectomy patients experience some Reattachment of the facial cheek skin to the ear can result in
postoperative anesthesia to the earlobe and helix that an elongated earlobe, which obliterates the definition of the
is usually transient. Patients must be counseled to this lobule. This is often referred to as a pixie ear or satyr earlobe
fact. deformity.
Prevention of this deformity centers around mini-
Facial Nerve Injury mizing skin tension at the lower earlobe upon closure.
Facial nerve injury is the most devastating complication A generous amount of perilobular skin flap should be
of rhytidectomy. An understanding of facial nerve anat- left around the earlobe. Closure of the infra-auricular
omy is critical to avoid such a complication. The facial flap to the conchal cartilage perichondrium or mastoid
nerve exits the temporal bone at the stylomastoid fora- fascia reduces skin tension. The pull on the SMAS in
men. The main nerve trunk can be found one centim- this region should also help to redistribute the forces
eter deep, anterior and inferior to the tragal pointer. from the skin.
There is no need to be this deep in a face-lift and thus Pixie ear deformities may not manifest for some time
injuries to the main branch of the facial nerve are rare. after surgery. If present, it can be repaired with a V to Y
The facial nerve travels through the parotid gland, advancement flap. The drawback of this procedure is a
which is divided by this into a superficial and deep small scar that presents anterior to the earlobe. Another
lobe. This division is somewhat arbitrary as there is option is to perform a platysmaplasty or neck lift to
no fascial plane dividing the parotid into lobes. The resuspend the SMAS and thus remove tension from the
facial nerve divides within the parotid gland at the pes skin. If this is a revision platsymaplasty, little skin needs
anserinus (“goose’s foot”) into a superior and inferior to be excised other than the original incision since the
division and then into smaller branches. The branches problem is tension forces and not redundant skin.
 SMAS Rhytidectomy: Preoperative Evaluation, Surgical Techniques and Pitfalls 877

Unhappy Patient to TCA application to increase penetration depth. These

In order to succeed, one must first identify the problem, treatments are repeatable with minimal risk of scar or
conceive an achievable goal, and then design and execute pigmentation problems. TCA concentrations higher
a tenable plan. Failure anywhere along this pathway will than 20% can provide deeper peels, but there is more
preclude success and result in an unhappy patient. concern for scar formation and pain with more concen-
Patients have various motivations for rejuvenating trated formulas over 35%. Phenol-based solutions,
procedures. This motivation may not have to do with which typically contain croton oil, can produce deep
any objective physical deformity and therefore, address- chemical peels. These should be used with caution as
ing physical appearance will not lead to patient satisfac- they cannot only lead to hypopigmentation and scar,
tion. If a patient seeks facial rejuvenation because they but can cause cardiac arrhythmias, particularly, if the
are distraught over their recent divorce, rhytidectomy will treatment is not distributed slowly over an hour. It is
not change the divorce. The desire to create an external because of this last concern that cardiac monitoring
appearance commensurate with the patient’s internal should be employed during phenol peels.
vigor is reasonable.
Rhytidectomy cannot make someone look like they did Dermabrasion
twenty years ago, but it can reduce the stigmata of aging Dermabrasion is a useful adjunct to rhytidectomy to
and create a more youthful appearance. This difference is smooth fine rhytids, particularly around the mouth.
subtle, but extremely important. In the end, the problem This should not be performed on cervical skin since
of the unhappy patient is best managed preoperatively by there is an increased risk of hypertrophic scar and
making sure to establish a trusting bond with the patient hypopigmentation due to thin dermis. Use of a powered
and establishing realistic expectations with goals that can be dermabrader has the disadvantage of causing a hazard-
accomplished. ous splatter. Sandpaper can be used instead to avoid
this exposure while accomplishing this result, but it
can occasionally cause adverse healing and scarring.
OTHER TREATMENT OPTIONS Potential complications include hypopigmentation,
AVAILABLE FOR THE SAME scar, milia, acne flare-ups, infection, photosensitivity
CONDITION and erythema.

“It is tempting, if the only tool you have is a hammer, to LASER Resurfacing
treat everything as if it were a nail.” In this regard the facial LASER resurfacing with CO2 or Er:YAG LASER is indicated
plastic surgeon should think beyond surgical rhytidec- for fine and moderate rhytids. Discoloration from previous
tomy as the sole solution for facial rejuvenation. Patients scars, acne, trauma or surgery can also be improved.
sometimes may not be emotionally or fiscally ready to Facial resurfacing uses LASERS with wavelength
undergo extensive cosmetic surgery. Other times, they ranges that allow absorption by water. The Er:YAG
simply cannot spare the time off from work that is required LASER is considered more conservative and fosters
for recovery. There are multiple rejuvenation therapies faster recovery, while the CO2 LASER can produce
that can be offered to these patients, many of which can be greater smoothing and tightening of the skin. LASER
used as adjuncts to rhytidectomy. resurfacing works by creation of a zone of revers-
ible thermal damage that allows for collagen contrac-
Chemical Peels tion and remodeling. The facial skin is rich with skin
Chemical peels are commonly used to treat rhytids appendages that are thought to be responsible for a low
of various depths. This technique can be used at the incidence of scarring. In contrast, the neck, with a lower
same time as the rhytidectomy, but one must be care- concentration of skin appendages, is at higher risk of poor
ful to consider the possibility of an increased risk in flap healing and scaring.
necrosis.7 Nonetheless, superficial peels can be a safe Contraindications to LASER resurfacing include
adjunct to surgery as long as the flap is not made exten- isotretinoin (Accutane) use within 12 months of the
sively thin.8 Pretreatment with tretinoin can accelerate procedure. Isotretinoin increases the risk of hypertrophic
the healing process and increase the peel penetration scarring. Radiation therapy or collagen disorders, such as
depth.9-11 For fine wrinkles, superficial peeling agents, Ehlers-Danlos are also contradictions to resurfacing. A
such as lactic acid, glycolic acid and 10–20% TCA formu- history of prior resurfacing procedures (LASER, chemi-
las can be used. Jessner’s solution is another popular cal peel or dermabrasion) may predispose the patient
agent that can be used alone for a superficial peel or prior to prolonged healing and possible scarring. Previous
 878 Facial Plastics, Cosmetics and Reconstructive Surgery

Table 1: Injectable fillers and their effects permanent surgical procedure. Autologous fat is used very
commonly in the senior author’s practice to rejuvenate
Injectable Brand Composition Effect the face in a 3D manner at the time of rhytidectomy. This
Name can be a permanent filler, but only approximately 50% of
Artefill Polymethylmethacrylate Permanent the fat survives after each injection, thereby necessitating
Evolence Porcine collagen Temporary overinjection and repeated treatments. Some of the inject-
Juvéderm Hyaluronic acid Temporary able fillers are given in Table 1.
Radiesse Calcium hydroxylapatite Temporary
Restylane Hyaluronic acid Temporary REFERENCES
Sculptra Poly-L-lactic acid Temporary
1. Arboleda B, Cruz NI. The effect of systemic isotretinoin on
wound contraction in guinea pigs. Plast Reconstr Surg. 1989;
83(1):118-21.
blepharoplasy will predispose the patient to eyelid 2. Zachariae H. Delayed wound healing and keloid formation
malpositioning. Previous facial herpetic infections and following argon laser treatment or dermabrasion during
smoking are not absolute contraindications but should isotretinoin treatment. Br J Dermatol. 1988;118(5):703-6.
be noted and, in the former situation, should be treated 3. Riefkohl R, Wolfe JA, Cox EB, et al. Association between
cutaneous occlusive vascular disease, cigarette smoking,
prophylactically with valacyclovir.
and skin slough after rhytidectomy. Plast Reconstr Surg.
The ideal candidate for LASER facial resurfacing has 1986;77(4):592-5.
fine to moderate rhytids. Those with facial soft tissue ptosis 4. Rees TD, Liverett DM, Guy CL. The effect of cigarette smok-
or laxity will benefit more from surgical rhytidectomy, ing on skin-flap survival in the face lift patient. Plast Reconstr
which addresses larger wrinkles. Previous LASER resur- Surg. 1984;73(6):911-5.
facing does not preclude surgical rhytidectomy. Some 5. White JB, Barraja M, Mengesha T, et al. Avoiding early
surgeons caution that LASER resurfacing may increase the revision rhytidectomy: a biomechanical comparison of
risk of wound complications when done concurrently with tissue plication suture techniques. Laryngoscope. 2008;
surgical rhytidectomy.12 This has been shown not to be the 118(12):2107-10.
case in a more recent study and meta-analysis with the 6. Baker DC. Complications of cervicofacial rhytidectomy.
right balance between LASER settings and amount of flap Clin Plast Surg. 1983;10(3):543-62.
7. Hayes DK, Stambaugh KI. Viability of skin flaps subjected
undermining.13 Despite this controversy, most surgeons
to simultaneous chemical peel with occlusive taping.
agree that LASER facial resurfacing can safely be used as a Laryngoscope. 1989;99(10 Pt 1):1016-9.
touch up procedure after all the healing from surgical rhyt- 8. Dingman DL, Hartog J, Siemionow M. Simultaneous deep-
idectomy has occurred. plane face lift and trichloroacetic acid peel. Plast Reconstr
Surg. 1994;93(1):86-93.
Fillers 9. Hevia O, Nemeth AJ, Taylor JR. Tretinoin accelerates heal-
Injectable fillers may be useful to augment the lips and to ing after trichloroacetic acid chemical peel. Ach Dermatol.
reduce prominent creases, such as nasolabial folds or fore- 1991;127(5):678-82.
head lines. The patient incurs minimal to no bruising and 10. Vagotis FL, Brundage SR. Histologic study of dermabrasion
social recovery time. In the context of surgical face lifting, and chemical peel in an animal model after pretreatment
the most important concept is that most injectables are with Retin-A. Aesthetic Plast Surg. 1995;19(3):243-6.
11. Kim IH, Kim HK, Kye YC. Effects of tretinoin pretreatment
temporary and thus their behavior in the context of a surgi-
on TCA chemical peel in guinea pig skin. J Korean Med Sci.
cal rhytidectomy is unpredictable. If a patient received an 1996;11(4):335-41.
injectable a month prior to undergoing surgical rhytidec- 12. Spira M, Gerow FJ, Hardy SB. Complications of chemical
tomy, the facial plastic surgeon will not be able to account face peeling. Plast Reconstr Surg. 1974;54(4):397-403.
for how the face will look after the injectable has been 13. Koch BB, Perkins SW. Simultaneous rhytidectomy and
reabsorbed. Therefore, it may be advantageous to wait full-face carbon dioxide laser resurfacing: a case series and
until the injectable has worn off before proceeding with a meta-analysis. Arch Facial Plast Surg. 2002;4(4):227-33.
 The Surgical Technique of Otoplasty 879
CHAPTER

96 Planning and Facial Analysis

before Rhinoplasty
Fabrizio Moscatiello, Javier Herrero Jover

The nose is the most prominent feature of the human face to be situated 1–2 mm within these lines. A widened nasal
and is significantly involved with the perception of beauty. base could require a partial resection of the nostrils (Fig. 3).
Although the canons of beauty can vary according to the In the frontal view, the nasal dorsum is made of two
fashions, attractive faces follow having precise propor- parallel or concave lines, starting from the eyebrow and
tions and relations. Leonardo da Vinci studied in detail the ending in the nasal tip. The width of the nasal dorsum is
relationships of beauty. similar to the distance between the two lateral tip defining
points. A surgeon has to evaluate the symmetry and the
width of the dorsum. If the dorsal width is approximately
INDICATIONS FOR THE SURGERY 80% in length (or more) of the alar base, nasal pyramid has
to be narrowed.
Facial Analysis
It is very important to study the tip defining points
In the frontal view, the face can be divided in five equal according to the thickness of the skin and the presence of
parts by the aid of four vertical lines that intersect the sebaceous glands. A very thick skin could be not adequate
medial and lateral canthus. The medial intercantal coverage and could require fat removal, cartilage grafts or
distance has to be equal in length to the eye width (Fig. 1). other corrective procedures. With thin skin, the nasal tip
In the same frontal view, the face can be divided in will show three defining points that correspond to the alar
three equal thirds with segments between four horizontal doms in the upper part and the junction of the medial with
lines that run through the chin, the base of the columella, inferior crura in the lower part.
the glabellar area and the hair line (Fig. 2). In the lower part of the nasal tip, a small portion of the
The width of the alar base is evaluated with the aid of two columella has to be visible. An increased or decreased
vertical lines from the two medial canthus. Alar edges have projection of the columella has to be corrected.

Fig. 1: Anthropometric measures in frontal view Fig. 2: Anthropometric measures in frontal view
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 880 Facial Plastics, Cosmetics and Reconstructive Surgery

In the lateral view, with the head in a vertical position, a thirds correspond to the length of the nasal orifice or the
horizontal line is marked from the upper part of the tragus columella, the remaining third is the length of the nasal
until to the inferior orbital rim. This line corresponds to lobule (from the superior margin of the nasal orifice until
the Frankfort horizontal plane. to the end of the nasal tip) (Fig. 7).
To evaluate the facial convexity, a vertical line from the In the basal view, the length and the width of the colu-
glabellar area is traced. In a well-proportioned face, this mella are recorded. The inferior third of the columella has
vertical line intersects the upper lip at the base of colu- to be wider than the upper thirds. If its width is excessive,
mella. With the aid of this vertical line, the authors are able the internal crura will be reduced, sutured and defatted.
to measure the nasolabial angle, that can vary in a woman
between 90° and 110°, in a man between 80° and 90° (Fig. 4).
In the lateral view, the columella has to be 4 mm
SPECIFIC PREOPERATIVE
approximately lower than the alar edge. It is very impor- EVALUATION
tant for the columello-alar relationship. As suggested by
Gunter, the larger axis of the nasal orifice has to divide, in Clinical Evaluation
equal parts, the distance from the nostrils until to the colu- It is essential that the surgeon and the patient communi-
mellar edge. Alterations in these relationships can corre- cate thoroughly and realistically concerning the aesthetic
spond to an excessive or retracted columella, to an exce­ goals before entering the operating room. Communication
ssive or retracted ala, or to a combination of both defects. is the basis of preoperative analysis and planning for
Each problem can require different surgical techniques. rhinoplasty.
In the lateral view, frontonasal angle is also examined. From the patient’s point of view, a surgeon’s commu-
This 4–6 mm depression (named nasion) is between the nication skills are nearly as important as his or her surgical
superior edge of the tarsus and the upper lid rim (Fig. 5). skills. In addition to carefully analyzing a patient’s anatomy
If a straight line is marked between the nasion and and basic physiological profile, it is paramount that the
the nasal tip, nasal dorsum has to be 2 mm approximately physician understands the patient’s emotional goals and
behind this line. Nasal length corresponds to the distance motivation.
from the nasion and the nasal tip. Nasal projection is the During the first visit, there are a lot of characteristics
length between nasal tip and alar groove in the cheek. An that the surgeon has to explore in detail: facial propor-
adequate ratio between nasal length and projection is tions; nasolabial and nasofrontal angles; height, width
1:0.6 (Fig. 6). and length of the nasal dorsum; the width and the projec-
In the basal view, the nose has to appear as an equilat- tions of the nasal tip; the tip defining points; thickness and
eral triangle that can be divided in three equal thirds. Two texture of the skin.

Fig. 3: In the frontal view, alar base width is evaluated Fig. 4: Nasolabial and nasofrontal angles
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 Planning and Facial Analysis before Rhinoplasty 881

Fig. 5: Relationship between columella and nasal ala Fig. 6: Nasal length/tip projection ratio
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IT Systems (Barcelona, Spain) IT Systems (Barcelona, Spain)

With the aid of a nasal speculum, alterations in the

nasal anatomy, that could affect the vestibule, the nasal
valve, the septum and the turbinates, have to be evaluated.
The patient should be informed about the possible
outcome and the risks of the suggested treatment and it
is very important to use every instrument that helps to
improve communication with patients.

Photographic Study
Photographic documentation is indispensable in the
planning of rhinoplasty and in the postoperative period
to value the results of the authors’ work. Usually, six static
photos (frontal, left oblique, right oblique, left profile,
right profile, basal) and two dynamic photos (frontal and
profile) with the patient smiling are taken.
Patient photos are required also in the surgical theatre
during the operation. They have to be of adequate size and Fig. 7: Anthropometric measures in the basal view
Courtesy: Image has been produced by the aid of the software Alma
in each profile (frontal, lateral and basal), it can be useful IT Systems (Barcelona, Spain)
to write the desired modification both with the surgical
planning.
In a lot of cases, the lateral profile image is the most diagnostic tests, that can clearly demonstrate the inner
important. In this profile, the authors advocate considering anatomy of the nose and avoid, intraoperatively, unex-
in detail: nasal length/projection ratio, nasofrontal angle, pected anatomic alterations, can be a useful tool for the
supratip region, nasolabial angle, columelloapical angle, positive outcome of the operation.
relationship between the columella and the nasal orifice. A complementary important method of preopera-
tive evaluation is the nasosinusal fibroendoscopy. This
Complementary Exams method allows directly viewing the nasal fossas, posterior
The development of the surgical technique in rhinoplasty septal deviation, rhinopharynx alterations, rhinosinusitis
is, these days, accompanied by the progress in more and and other sinus pathologies.
more sophisticated diagnostic methods. Modern rhino- These days, although rhinomanometry can be used
plasty has to achieve a natural aesthetic result without in the preoperative period, it is not useful in studying the
affecting the respiratory physiology. All preoperative internal nasal valve. Rhinomanometry can register flow
 882 Facial Plastics, Cosmetics and Reconstructive Surgery

and resistance alterations but cannot allow identifying the sections of anatomic regions are generated through volu-
anatomic defect. To solve this problem, arose the acoustic metric and sequential acquisitions. This allows a safer and
rhinomanometry that allow understanding the anatomic more precise evaluation than conventional and helicoidal
region of the nasal cavity where flow and resistance are scan, with a final better quality (Fig. 11).
altered.
Multidetector CT scan is a very useful method to preop- Computer Imaging
eratively study a patient that will undergo an aesthetic or Personal computer is a very useful instrument when
functional rhinoplasty. CT scan allows valuing, in detail, adequately used. In the XXI century, it is not allowed that
the nasal and paranasal anatomy, identifying all the possi- a surgeon does not use this resource in his or her daily
ble alterations that have to be corrected during the opera- activity. Patients prefer the aid of computer imaging during
tion (Fig. 8). the preoperative consultations rather than simple photos
Through static and dynamic details, it establishes
a correlation between the different planes: superficial
(skin), intermediate (subcutaneous and cartilages) and
deep (bones) (Fig. 9).
CT scan can be considered the main test in detecting
inflammatory rhino and sinusopathies, nasofacial trau-
mas, planning primary, secondary or tertiary rhinoplasty
(aesthetic, functional and posttraumatic) (Fig. 10).
The authors ask for a preoperative CT scan also in
patients that do not complain respiratory difficulty.

CT Scans
Nowadays, there are different types of tomography:
conventional, helicoidal and multislice. The use of differ-
ent windows in tomography allows the study of the bones,
discerning between cortical and medullar bone, and of the
soft tissues, discriminating between skin, subcutaneous
tissue and cartilages. Multislice CT scan, also known as Fig. 9: Close-up view of cartilaginous structures
multidetector CT scan, is the imaging diagnostic method Courtesy: Image has been produced by the aid of the software Alma
that uses between 2–256 detector channels where thin IT Systems (Barcelona, Spain)

Fig. 8: This patient has a complete cleft of the superior Fig. 10: 3D facial reconstruction
maxillary bone. An osteal graft could be considered during Courtesy: Image has been produced by the aid of the software Alma
rhinoplasty IT Systems (Barcelona, Spain)
Courtesy: Image has been produced by the aid of the software Alma
IT Systems (Barcelona, Spain)
 Planning and Facial Analysis before Rhinoplasty 883

and schemes. They had become aware of computer imag- • The nasal tip (including tip shape, definition or lack of
ing and frequently asked for it when making an appoint- definition of the tip, presence of surface defects, rela-
ment by telephone. tionship of the columella to the alar rims, and nasal
Although the simulation (morphing) of a possible base width) (Fig. 14).
postoperative result by common imaging software can be • Profile characteristics (including position of the radix,
very effective during the preoperative period in impress- slope of the dorsum, dorsal irregularities, presence or
ing patients and convincing them to undergo surgery, it is absence and location of a supratip break, amount of tip
not an advisable procedure. In the postoperative period, projection, nasal length, columellar/labial angle, colu-
patients cannot be satisfied with the final outcome due to mellar/lobular angle, nostril height and shape, promi-
unclear expected result. nence of the columella, length and relative position of
Informatic items, dedicated to rhinoplasty, can help crura, and nasal spine) (Fig. 15).
in the following: record pre, post, intraoperative images; • Basal characteristics (including nostril size, symme-
comparative study of results; improving patient-surgeon try, nasal width, columellar width, alar position and
relationship; recording files for medicolegal purposes; symmetry, and tip definition) (Fig. 16).
and technical planning of rhinoplasty. • Inner characteristics (including nasal valve morpho­
logy, septal deviations, cornet malformations, and
3D Radiologic Viewer in the Office sinus pathologies) (Fig. 17).
A 3D radiologic viewer, in the authors’ hands, has proved • Close-up of anatomic elements (Fig. 18).
to be a sophisticated instrument for communicating with In addition, full facial views, to determine the rela-
the patient during consultation. Imaging in front of the tive size of the nose and its relationship with other
patients, that offers them the possibility of accurately stud- facial features, are possible. By determining preopera-
ying their own anatomy and planning their own surgical tively which structures need modification, stress can be
procedure, is very impressive and helpful. With this imag- reduced for the surgeon who can now go directly, with
ing, patients better understand the anatomy, the proce- confidence, to change an already ‘‘known’’ nasal subunit,
dures, and the possible results. The authors think that the both functionally and aesthetically, without wasting time.
3D radiologic viewer increases the patients’ trust in their Furthermore, it has become a marketing tool that should
operations (Fig. 12). not be underestimated (Fig. 19).
The 3D viewer allows for preoperatively studying the
following clearly: SURGICAL STEPS
• The nasal dorsum (including any deviation, charac-
teristics of the nasal bones, relative height of the nasal Surgical Planning
bridge, width of the dorsum and bony base, and transi- Surgical planning starts when patient and surgeon agree
tion into the nasal tip) (Fig. 13). about the aesthetic modifications of the nose and when

Fig. 11: Detail of septum, turbinates and maxillary sinus Fig. 12: 3D facial reconstruction
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IT Systems (Barcelona, Spain) IT Systems (Barcelona, Spain)
 884 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 13: A dorsal bone graft of several years of evolution Fig. 14: The same patient of Figure 8 with a scar retraction
Courtesy: Image has been produced by the aid of the software Alma of the whole nasal tip and a complete occlusion of right nostril
IT Systems (Barcelona, Spain) Courtesy: Image has been produced by the aid of the software Alma
IT Systems (Barcelona, Spain)

Fig. 15: Nasal tip right deviation Fig. 16: A cocaine nose with left ala retraction and necrosis
Courtesy: Image has been produced by the aid of the software Alma of columella and anterior septum
IT Systems (Barcelona, Spain) Courtesy: Image has been produced by the aid of the software Alma
IT Systems (Barcelona, Spain)

the patient understands the surgical process. This first The process starts with a dynamic vision of the 3D model
evaluation with the patient is very important because that can be rotated 360° in each plane. Anteroposterior,
the basic surgical principles about patient’s demand and caudal, lateral and intermediate views can be studied
surgical options will be established. whenever the surgeon considers convenient.
With the aid of the surgical model (SM), the authors Once the first examination of the nasal pyramid has
are able to quantify, objectify, estimate and customize been made, the SM allows taking all the anthropometric
the habitual workflow of the rhinoplasty to each patient. measures the surgeon considers useful.
The SM, obtained from patient radiological images, allows Surgical planning follows with the evaluation of the risk
the authors to make a surgical planning more precise and points. These are peculiar for each patient and can influ-
structured, clarifying possible doubts both of the patient ence or modify the authors surgical strategy, i.e. secondary
and the surgeon (Fig. 20). nose, abnormal osteal structures, complex nasal tip, etc.
 Planning and Facial Analysis before Rhinoplasty 885

Fig. 17: Nasal septum perforation Fig. 18: With special windows, it is possible to evaluate the
Courtesy: Image has been produced by the aid of the software Alma distribution of cartilaginous elements
IT Systems (Barcelona, Spain) Courtesy: Image has been produced by the aid of the software Alma
IT Systems (Barcelona, Spain)

Fig. 19: Facial 3D reconstructions are very useful to explain Fig. 20: Close-up view of osteocartilaginous structures
the anatomy Courtesy: Image has been produced by the aid of the software Alma
Courtesy: Image has been produced by the aid of the software Alma IT Systems (Barcelona, Spain)
IT Systems (Barcelona, Spain)

The SM also allows evaluating the nasal soft tissue, defect to be filled. In frontal, oblique and lateral views, it
like fat and muscles. Thickness of subcutaneous tissue is possible to decide where to perform the lateral osteoto-
can influence, sometimes, the surgical strategy due to the mies, if needed, according to the osteal morphology and
cartilage grafts’ visibility in the skin or due to the inefficacy preview fractures.
of the work in a nasal tip with a very thick skin. Once established—the dorsal projection and the width
At this moment, it is useful to study the upper lateral of the pyramid—it is mandatory to plan the total length of
cartilages, nasal septum and columella morphology. the nose and the nasolabial angle. In the nasolabial angle,
Projection, width and length of the nasal pyramid are the authors are able to clearly look at all structures to be
three sizes that will be evaluated all together due to the modified, like columella, nasal spine and septum.
tight relation between the three parameters. SM will be In the basal view, it will be possible to evaluate the
useful to evaluate the nasal dorsum structures, bones and length of the columella and of the nasal lobule, the width
cartilages, and to calculate the excess to be removed or the of the nasal orifice and the width of the nasal ala.
 886 Facial Plastics, Cosmetics and Reconstructive Surgery

Surgical model is very useful also in functional opera- To improve nasal dorsum projection, adequate solu-
tions. It allows to study, in detail, the internal valve, turbi- tions can include the use of autologous cartilage grafts—
nates, septum and the whole internal nasal cavity with a costal, septal or auricular. Bone grafts can also be consid-
complete understanding of all the structures to modify. ered but have a great quote of reabsorption.
Increasing the projection of the tip is performed in
Reduction Rhinoplasty different steps according to the desired result and the anat-
The nasal pyramid can be reduced in all its structures— omy of the patient. Shortly, to obtain tip projection, one of
both osteal and cartilaginous. The amount of tissue to the easiest and first procedures consists of conservative
remove has to be evaluated according to: total length of modifications (i.e. suturing) of the domal cartilages. If it is
the nose, length/projection ratio, nasolabial angle, upper not enough, a strut cartilage graft is put on the nasal spine
lip height. and between the two inferior lateral cartilages in order to
create a support and an augmentation of the tip. As last
Augmentation Rhinoplasty option, if needed, a small cartilage graft can be sutured
Nasal dorsum, tip or both, can need increasing their size in over the domal cartilage. Grafts above the domal cartilages,
terms of projection, width or length, according to the facial in few years, can become visible through the skin (unless it
anthropometric measures. is very thick), so the graft has to be cut very carefully in size.
 TheASurgical Technique
Color Atlas of Otoplasty 887
of Septorhinoplasty
CHAPTER

97 A Color Atlas of Septorhinoplasty

Sonna Ifeacho, Rajib Dasgupta, Guy Kenyon

PREOPERATIVE PLANNING
Patient Selection
The key to successful outcomes in rhinoplasty and
septorhinoplasty is careful patient selection.
Managing the patient’s expectation is of paramount
importance. Patients undergoing septorhinoplasty must
have realistic expectations of what can be achieved with
surgery. Details of past trauma, previous surgery and the
relevant past medical history should all be meticulously
recorded prior to surgery.

Clinical Examination
The clinical examination seeks to combine the patient’s
concerns with an objective assessment of the nose and
face. The face as a whole must be assessed from an esthetic
and symmetry point of view to identify sources of general-
ized asymmetry and deformity that may impact the nose.
For example, there may be an apparent, but not true,
distortion of the nasal profile in asymmetrical hemifacial
microsomia or a perceived over-projection of the nose
relative to a retrognathic mandible.
Fig. 1
General facial esthetics are assessed using fixed bony
points and ideal facial proportions. A symmetrical face
when viewed with the Frankfort plane parallel to the floor
face is divided into equal horizontal thirds:
• From radix to nasion (Fig. 1) This initial examination will provide a generalized
• From nasion to columella assessment of the individual’s facial esthetics, skin qual-
• From collumella to menton ity and identify gross facial asymmetry that may give an
The face is further assessed for symmetry by dividing it illusion of nasal asymmetry. Operating on the latter may
into vertical fifths: result in unsatisfactory results due to poor preoperative
• From the outer ear to the ipsilateral lateral canthus of planning.
the eye Nasal examination follows the basic principles of
• From the lateral canthus to the ipsilateral medial inspection and palpation. The following are key areas to
canthus assess:
•� From
����� the
���� ipsilateral
������������ medial
������� canthus
�������� to
��� the
���� contralat-
����������
eral medial canthus Inspection of the Frontal View
• From the medial canthus to the ipsilateral lateral Follow the brow-tip esthetic (also known as the dorsal
canthus esthetic) line on each side and assess for smoothness.
• From the lateral canthus to the ipsilateral outer ear Assess the width of the nose, deviation of the dorsum and
(Fig. 2) assess the nasal tip for bulbosity or asymmetry (Fig. 3).
 888 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 2 Fig. 3

Inspection of the Lateral View

Assess the position of the nasofrontal angle, the nasal
dorsum, nasal length, tip projection and rotation, nasola-
bial angle and degree of columella show.

Inspection of the Basal View

Inspection of the nose in the caudal and cranial planes
provides further information. From the basal view the
alar base should be equal to the intercanthal distance. Tip
asymmetry is also assessed (Fig. 4).

Assessment of the Skin

Assess the skin for thickness. Very thick skin is sebaceous
and will hide minor irregularities of the underlying bony
and cartilaginous framework. Thin skin is less forgiving
and must be handled with great care during surgery.
Palpate the nose for superficial irregularities.
• Assess
������� ����
the �������
dorsum ���
of ����
the �����
nose �����
with ��������
respect ���
to ������
devia-
tions. Divide the nose into horizontal thirds to locate Fig. 4
the cause of the deviation. Deviations of the upper
third are usually due to a problem with the nasal bones,
middle third deviations due to septal or upper lateral • Tip projection: Apply Goode’s formula (Fig. 5). Assess
cartilage (ULC) deviation or asymmetry and lower for over or under-projection.
third deformity are due to deformities of the lower • Dorsum: Assess from the front and while standing
lateral cartilages (LLC) caudal septum or alar base. behind the patient.
 A Color Atlas of Septorhinoplasty 889

Fig. 5 Fig. 6

• Tip-defining points: Medial crura-, supra- and infra- The bird’s eye view is another helpful view.5 Attention to
tip-defining points. Assess the size and shape of the patient positioning, lighting and accurate color printing is
alar cartilage, asymmetry, bifidicity and rotation. essential for producing photographs that are an accurate
• Assess the nasolabial angle (Fig. 6). replication of the patient’s face.6
• Assess columella show: This should be approximately
3–5 mm. Consent
• Assess the alar base: It should be equal to the intercan- The procedure to obtain consent for a septorhinoplasty
thal distance. starts at the first consultation and culminates in a preop-
• Inspect the internal nose: The septum by palpation of erative appointment where the necessary consent forms
the anterior margin if necessary and by direct vision are signed. It is important to ensure that the sources of
using anterior rhinoscopy and then nasendoscopy. patient’s dissatisfaction are understood and that these are
Assess the turbinates, the internal valve and assess the addressed. If they cannot be addressed then the reasoning
nose for any alar collapse. Nasendoscopy adds further behind this should be explained to the patient. Agreement
information regarding the more posterior septum, at this stage and a written plan of the proposed procedure
postnasal space and turbinates. (which the patient should understand) avoids potential
Lopez et al. have published a stepwise approach to embarrassment, at least, and litigation, at worse. Providing
assessment for rhinoplasty, highlighting the likely surgical as much information as possible is crucial to obtain
correction needed for various deformities.1 informed consent. Written information in the form of a
leaflet is a useful adjunct to promote retention and under-
Clinical Photographs standing of information; there is published evidence to
Standardized preoperative photographs aid planning suggest this is more useful amongst the female population.7
and postoperative comparative assessment. The lateral Some of the points that should be discussed during the
photographs must be taken in the Frankfort plane if a consent process are:5
false sense of over or under-projection of the nose is to be • Bleeding
avoided.2 The standard views required are frontal, lateral, • Infection
profile, lateral obliques (left and right) and basal views.3,4 • Nasal blockage
 890 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 7 Fig. 8

• Septal hematoma
• Septal perforation
• Graft migration/extrusion/resorption
• Skin necrosis
• Scars (keloid, hypertrophic and pigmentatory changes)
• Dissatisfaction
• Failure
• Possibility of further procedures
• Bruising
• Time off work
• Dressings and splints, and the length of their
application.

SETUP OF THE OPERATING THEATER

General Theater Layout
Photograph shows an optimum theater setup that is
acceptable to the surgeon, anesthetist and theater nurse.
The equipment trolley and theater nurse’s positions
promote smooth passage between the surgeon and the
nurse—who should be aware of the normal stages of the
operative process and who should be able to anticipate the
surgeon’s needs (Fig. 7).

Instruments (Figs 8 and 9)

The basic instruments required are:
• Alar retractors
• Sharp dissecting scissors
• An Aufricht’s retractor
Fig. 9
 A Color Atlas of Septorhinoplasty 891

• A range of osteotomes Theater Lighting

• Rasps Visualization during rhinoplasty is of great importance.
• Tissue holding forceps Therefore it is beneficial to use both a headlight and the
• Needle holders overhead theater lights. Individual preferences vary but
• Suture cutting scissors. a battery operated headlight and loupes permits greater
ease of movement around the operating table and is the
Mounting Clinical Photographs senior authors preferred option (Figs 10 to 13).
The preoperative clinical photographs (all views) must be
displayed in the operating theater in an easily accessible Position of the Patient and Surgeon
location so the photographs may be referred to during It is traditional to stand at the right hand side of the patient.
the procedure. They serve as a general reminder of the The patient lies prone, on a headrest, at elbow height with a
preoperative status, but can also provide guidance for degree of upward head tilt to aid visualization and reduce
specific areas e.g. intraoperative assessment of the nasal bleeding from venous congestion (Figs 14 and 15).
tip. This is particularly helpful once intraoperative swelling
has intervened and once the nasal bones have been Patient Preparation (Fig. 16)
fractured and repositioned, and the original anatomy has The patient requires eye protection, there are several
been altered (Fig. 10). options including Lacrilube© ointment, eye tape or eye
pads (Figs 17 and 18).

Fig. 10 Fig. 11

Fig. 12 Fig. 13
 892 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 14 Fig. 15

Fig. 16 Fig. 17

The nasal skin and surrounding areas are prepared SURGICAL STEPS
using a water-based skin preparation solution that is
nontoxic to the cornea of the eyes (Figs 19 and 20). Local Anesthetic
It is imperative that, as far as possible, the orientation
of the patient is preserved. Therefore the head should Adequate infiltration of local anesthetic affords dissec-
not be tilted at setup and the drapes should be secured tion with minimal bleeding and swelling. Lignocaine
so that they cross in the midline (Figs 21 and 22). In with adrenaline in dental cartridges is the senior authors
like manner the endotracheal tube should be centrally preferred choice of local anesthetic (2% lignocaine and
placed. 1:80000 adrenaline). Infiltration of local anesthetic into
A bipolar diathermy is setup with the cable and the correct tissue planes promotes hemostasis of the surgi-
diathermy forceps resting on the operating table and cal field and improved visualization. It also contributes to
secured to the drapes with the sucker. pain control in the early postoperative period.
 A Color Atlas of Septorhinoplasty 893

Fig. 18 Fig. 19

Fig. 20 Fig. 21

Local anesthetic is injected into the proposed site of

incision for the septoplasty (Killian’s or hemitransfix-
ion) with a more widespread subperichondrial infiltra-
tion to the remainder of the septum (Fig. 23). Infiltration
produces a degree of hydrodissection which aids flap
elevation during the septoplasty. Further infiltrations are
performed in the mid-columella region, (Fig. 24) marginal
incision sites (Figs 25 and 26), intranasally to the dorsum
of the nose (Fig. 27) and externally at the sites of any
proposed osteotomies (Fig. 28).
The photographs below depict the points of infiltra-
tion. Care must be taken not to inject excessive amounts.
In total 6 mL of local anesthetic volume should suffice. It is
imperative that sufficient time is given for the anesthetic to
take effect. During this waiting period the clinical photo-
Fig. 22 graphs are reviewed and the necessary surgical steps are
894 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 23 Fig. 24

Fig. 25 Fig. 26

Fig. 27 Fig. 28
 A Color Atlas of Septorhinoplasty 895

visualized in the mind. It is often helpful to discuss these that the perpendicular plate of the ethmoid. The cartilage
points with nursing staff or surgical trainees since they can is freed posteriorly and is also divided inferiorly toward
then appreciate what is anticipated and where appropriate the maxillary crest. A “swing-door” of the quadrilateral
prepare for this. cartilage is then created. It is important to leave dorsal and
caudal struts as supporting structures. The bony maxillary
Vibrissae Trimming crest can then be dissected free of mucosa so that it can,
Many surgeons appear to inject the local anesthetic and if necessary, be removed. For this maneuver it is consid-
then reach almost immediately for a scalpel. However, erably easier to commence the mucosal dissection poste-
the local anesthetic needs time to act and this time can be riorly and work forward toward the maxillary spine since
profitably spent removing the nasal vibrissae since they the mucosa is not so adherent posteriorly. This approach
frequently act to obstruct a good view of the nasal vestibule minimizes the risk of mucosal tears. Selective cartilage and
and they may obscure the incision line if a marginal inci- bone excision is then undertaken and, if required, bone or
sion is to be performed. Scissors that are not required for cartilage can be harvested to use during the reconstructive
any other steps of the rhinoplasty are to be preferred and procedure.
if these are coated with Vaseline or passed over a Jelonet
dressing they will be sticky and hence catch the nasal
vibrissae as they are trimmed. Care must be taken not to
cut skin as this may predispose to infection or contribute
to unwanted scarring (Figs 29 to 31).

Septoplasty
The septoplasty is normally the first surgical step in
septorhinoplasty and, if the surgery is being performed
following trauma, this part of the operation is often the
most difficult part of the entire procedure. It is prefer-
able to perform a septoplasty through a hemitransfixion
incision. The mucosa is incised using a no. 15 blade on
the same side as the leading edge of the septum and a
mucoperichondrial flap is then elevated and the septum
exposed—dissection must be in the subperichondrial
plane. The bony-cartilaginous junction is identified and
a chondrotomy is undertaken just anterior and parallel to Fig. 30

Fig. 29 Fig. 31
 896 Facial Plastics, Cosmetics and Reconstructive Surgery

If the caudal septum is deviated then this must Endonasal Approach

normally be repositioned. Excision is not recommended The endonasal approach to the nose normally starts
unless the preoperative photographs suggest that the with an intercartilaginous incision on each side using a no.
columella is truly “hanging”. An assessment of the ala- 15 blade. This incision follows the caudal border of the
columella esthetics therefore needs to be made if exci- ULC and is normally continued over the septal angle (the
sion is to be accomplished without adverse postoperative anterosuperior corner of the quadrilateral cartilage) such
sequelae.8 It is important to anchor the anteroinferior part that it then joins a hemitransfixion incision at the caudal
of the septum to the maxillary spine in order to ensure margin of the nasal septum (Figs 32 to 34).
adequate fixation of this part of the septum.9 This can be The skin and the soft tissues of the SMAS are then
accomplished by suturing with a suture such as 3/0 PDS. elevated over the ULCs and the bony pyramid on each
side and are joined over the dorsum such that the whole
Rhinoplasty: Endonasal versus skin envelope is raised from the underlying tissues. Sharp
External Exposure dissection using the scalpel blade and McIndoe, or other
The nasal skeleton may be approached by a variety of similar scissors, is required to effect this. It is important
differing incisions (trans-collumellar, marginal, inter- during this dissection that every attempt is made to remain
cartilaginous and transcartilaginous) and there is
frequently a robust discussion regarding the merits of an
“open” as opposed to a “closed” approach—in truth such
arguments are sterile since both can damage the skin and
supporting mechanisms of the nose. While the added
“insult” of an external skin incision is real it is somewhat
over-rated since, if the incision is closed carefully, the
wound is only rarely visible. The real risks of the external
approach are of increased soft tissue swelling and of some
transient numbness of the nasal tip, which can last up to
6 months. The patient should therefore be warned of this
during the consenting process if an external approach is
contemplated.
The external approach is to be preferred in patients
who have had trauma and is also very helpful in those in
whom the middle third is deformed, as insertion of grafts
to correct deviation here is otherwise difficult. It is also to
be recommended in revision cases. Fig. 33

Fig. 32 Fig. 34
 A Color Atlas of Septorhinoplasty 897

close to the underlying bones and cartilages. The skin Marginal incisions (Fig. 36): This should be done with great
over the keystone area is the thinnest of the dorsum and care as mistakes here are difficult to rectify. The caudal
particular care must be taken in this area, especially border of the LLC is identified by elevating the vestibu-
where there has been previous trauma. The soft tissues lar rim. If there is doubt as to the position of the leading
are elevated to provide a midline tunnel exposing the edge then the caudal margin of the lower lateral can be
ULCs, the keystone area and the bony vault. It is impor- palpated using a blunt instrument. An incision is made
tant not to extend this dissection too far laterally as the using a knife and the lower edge of the cartilage is identi-
soft tissues play a supporting role and prevent the nasal fied. The margin is at the junction of the nonhair and hair
bones collapsing when they are in-fractured. A Howarth’s bearing skin margin and is usually readily identified, espe-
elevator is then used to elevate the periosteum from the cially when wearing loupes. It runs closer to the vestibular
dorsal aspect of the nasal bones and a small postage stamp rim as it is developed medially and care should be taken
shaped piece of ribbon gauze can then be temporarily to avoid transgressing the skin edge toward the nasal tip.
inserted to reduce any minor bleeding. The gauze also acts Columella flap elevation: A no. 15 blade is used to incise
to remove any small pieces of adherent soft tissues from the skin having first marked it with a marker pen. Elevation
the underlying nasal skeleton. of the columella skin by sharp dissection is then under-
taken taking care not to notch the medial crura of the
External Approach underlying LLC, which will support the incision during
healing and help prevent a depressed scar. If an assistant
Skin Marking
gently holds the tip elevated by insertion of an alar retractor
The columella incision is either a stepped or inverted ‘V’ to the domes of the lower laterals the dissection can
incision. The external approach is joined to a marginal proceed by lifting the skin under direct vision and by the
incision on each side and the incisions are then joined to use of a single skin hook. An alternative to sharp dissection
lift the skin of the lower third of the nose before elevation is a pair of converse scissors. The paired columella arteries
is developed over the ULCs and the bony pyramid in a are usually encountered and are cauterized using bipolar
manner that is entirely similar to the endonasal approach. diathermy (Figs 37 to 42).
Columella incision: The columella incision is marked out Dorsal nasal flap elevation/SMAS layer elevation: The
using either a stepped (Gunter) or inverted ‘V’ incision.10 columella flap is joined to the marginal incisions. The
The incision is marked over the narrowest aspect of the skin is then elevated in continuity from the lateral crura
columella. A Gunter incision has one arm which is verti- of the LLCs staying in the supraperichondrial layer. Once
cally placed and is easily camouflaged. It has proved reli- the cephalic margins of the lower laterals are identified
able in over X cases for such cases over a number of years an Aufricht’s retractor is inserted and further dissection
with only 3% visible at 6 months (Kenyon—unpublished is readily accomplished in the midline (and then later-
data) (Fig. 35). ally) using scissors and sharp dissection up to the nasion.

Fig. 35 Fig. 36
898 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 37 Fig. 38

Fig. 39 Fig. 40

Fig. 41 Fig. 42
 A Color Atlas of Septorhinoplasty 899

This dissection is entirely similar in effect to the endonasal and then through the junction between the upper lateral
approach (Figs 43 to 47). and dorsal septum. It is imperative that the dissection is
kept as close as possible to the upper part of the carti-
Hump Reduction laginous septum to avoid leaving a T-shaped segment.
A dorsal hump is formed either of cartilage or bone, and In an open approach rhinoplasty, it is easy to dissect the
is in most instances a mixture of the two. Full exposure upper laterals from the dorsal septum under direct vision.
allows identification of the appropriate site of reduction. Particularly, if it is anticipated that spreader graft will be
Using a no. 15 blade the cartilaginous hump is reduced required it is important to leave within “mucosal trench”
initially. Prior to doing this, it is necessary to separate the between the upper lateral and the septum so that the graft
ULCs from the dorsal septum. In an endonasal approach, will lie parallel to the dorsum and create a satisfactory
an incision is made through the mucosa beneath the ULC dorsal esthetic line.

Fig. 43 Fig. 44

Fig. 45 Fig. 46
 900 Facial Plastics, Cosmetics and Reconstructive Surgery

Once the cartilaginous elements of the dorsum have is symmetrical then the osteotome is kept level as the
been separated, the cartilaginous dorsum can be lowered hump reduction proceeds. If the bones are skewed then
up to the keystone area. The ULCs can then be lowered an asymmetrical removal should be attempted leaving a
sequentially inline with the new dorsum but it is prob- slightly greater bony height to the bone that is the more
ably better to delay doing this initially until the bony vertically placed (Fig. 48). If this is not done then there
hump has been removed. It is particularly important to will be residual asymmetry after an in-fracture has been
realize that is Aufricht’s elevator is being inserted under performed (Figs 49 and 50).
the skin, the ULCs can be elevated as the skin is raised. After the bony hump has been divided from the under-
The danger is that the ULCs can be over-resected once the lying bones a fine artery forceps is inserted to grasp the
skin is elevated and the surgeon should be aware of this caudal end of the excised hump. After an initial cephalic
possibility and be as conservative as possible when lower- movement, to free any soft tissue strands, the forceps are
ing the ULCs. pulled caudally to remove the hump from the attached soft
Once the cartilaginous dorsal is satisfactory, the bony tissues (Figs 51 to 53).
hump is then identified at the keystone area and a 7 mm A rasp is then used to smooth the dorsal surface of
osteotome is inserted to remove the bone. If the hump the bones. In doing this the surgeon should keep the
elbow elevated and use small strokes of the rasp in order
to smooth the bone while avoiding trauma to the overlying
skin. Initially a number 1 or 2 rasp is used and the final
smoothing is undertaken with a number 5 or 6. A rasp
cleaned of all debris and everted may serve to remove all
minor bony fragments from the underlying skin at the end
of this process. All fragments must be removed and it is also
helpful to wash the affected area with some saline from
a syringe with a quill attached in order to ensure that all
minor pieces of debris are removed (Figs 54 and 55).
Overzealous rasping can cause detachment of the ULCs
from the bone above. Bilateral disarticulation produces
an inverted V deformity with a poor esthetic outcome,
and unilateral disarticulation also produces disfigure-
ment with asymmetry in the middle third of the nose. In
each case a spreader graft is then required to correct the
deformity (vide infra). Once the hump has been reduced
further adjustments to the septum and ULCs may also be
Fig. 47 necessary.

Fig. 48
 A Color Atlas of Septorhinoplasty 901

Fig. 49 Fig. 50

Fig. 51 Fig. 52

Fig. 53 Fig. 54
 902 Facial Plastics, Cosmetics and Reconstructive Surgery

Osteotomies: Medial and Lateral the risk that cephalic margin of the bone moves laterally,
so creating a “rocker” deformity (Fig. 56).
Medial Osteotomy To effect the osteotomies place a sharp 4 mm oste-
Medial or paramedian osteotomies are not always required otome at the junction of the nasal bones and the septum
if an “open book” deformity is created after dorsal hump and use a controlled double tap technique to progressively
reduction.11 If they are required then it should be remem- incise the nasal bones. The position of the osteotome
bered that the bone above the intercanthal line is too should be continually monitored via external palpation as
thick to fracture with accuracy and the osteotomy should the osteotome moves under the skin. So it is imperative an
not continue above this line—continuation in a cephalad assistant performs the tapping of the osteotome. The oste-
direction also risks breaching the skull base. If the oste- otomy should fade laterally at the upper end and should
otomy creates a cephalic fracture in the thicker part of the end when the note of the tap changes which signifies that
frontonasal junction then, after in-fracture, there is also denser bone has been reached (Figs 57 and 58).

Fig. 55 Fig. 56

Fig. 57 Fig. 58
 A Color Atlas of Septorhinoplasty 903

Lateral Osteotomy (Fig. 59) aperture is preserved to reduce the risk of iatrogenic nasal
The lateral osteotomies can be marked on the skin to aid blockage via medial displacement of the attachment of
accurate results. Lateral osteotomies are used to close an the inferior turbinate and narrowing of the internal nasal
open book deformity following hump reduction, correct valve. At the level of the medial canthus, turn the oste-
asymmetrical lateral wall deformity or narrow a widened otome and direct it toward the nasion. Now an in-fracture
vault.12,13 Stab skin incisions are made using a no. 11 blade, of the bones is performed. The bones usually move with
marking points near the pyriform aperture and midway minimal manual pressure but if incomplete fractures have
between the medial canthus and the nasion. Using a taken place then instrumentation may be required, such
controlled double tap technique and a 2 mm osteotome as a Hill’s elevator, to complete the fracture. Osteotomes
bony perforations are created initially heading cephali- rapidly lose their sharpness with repeated use; however,
cally and posteriorly just above the pyriform aperture, professional sharpening has been reported to only restore
then heading toward the ipsilateral medial canthus in a rasps to a state similar to that of an osteotome that has
high-low-high manner13 (Figs 60 to 66). It is of great impor- been used between three to six times.14 They should there-
tance that a triangular piece of bone above the pyriform fore be replaced regularly.

Tip Surgery
Alterations of the nasal tip generates considerable anxiety
in the neophyte surgeon and a basic understanding of the
underlying anatomy is necessary if the desired effects are
to be achieved. In this respect understanding the anatomy
and the relevant connections of the LLCs to the skin and
the surrounding structures is imperative.

Fig. 59 Fig. 60

Fig. 61 Fig. 62
 904 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 63 Fig. 64

Fig. 65 Fig. 66

The LLCs themselves consist of medial, intermediate the supra tip area. Lowering of the dorsum in this area
and lateral crura. Together with the accessory cartilages reduces this support.
(which are of little practical importance) they form the • The fibrous connections of the lateral crura to the
framework for the nasal tip and the shape and position ULCs. This support is compromised by an intercarti-
of these cartilages, and the thickness of the overlying laginous incision.
skin, are the factors which determine the appearance of • The abutment with the pyriform aperture gives support
the tip. to the tip and resists backward movement.
While the shape is dependent on the size, strength and
curvature of the cartilages, their position is determined by The Tripod Concept
the fibrous attachments to the adjacent anatomical struc- The tripod concept was popularized by Anderson.15 The
tures. The lateral crural complexes are supported by: tripod is envisaged with the lower leg representing the
• The suspensory ligament of the tip which rests on the medial crura and with each upper leg formed by the lateral
septal angle. The ligament joins the cephalic margins crural complex on each side. The tip of the tripod corre-
of the lateral crura as they diverge from one another in sponds to the nasal tip.
 A Color Atlas of Septorhinoplasty 905

Shortening or removal of the lower leg should move sutured between the medial crura of the LLCs. This can
the tip downward and backward: be effected either through a transfixion incision as part
• Shortening of the upper legs should move the tip of an endonasal approach or insertion as part of an open
upward and backward approach rhinoplasty is easier. A strut can improve tip
• Shortening of all three legs should result in backward support and projection and also help to straighten the
an upward movement of the tip caudal septum or the medial crura of the LLCs.
• Lengthening of the lower leg should move the tip A pocket is dissected between the soft tissue that lies
upward and forward between the medial crura to house the strut of cartilage,
• Lengthening the lower leg and shortening the upper which then sits above and in the plane of the anterior
leg should accentuate upward movement of the tip nasal spine. Sutures are used to secure the strut in place.
A notch in the lower end of the graft helps the lower end
to sit astride the nasal spine and avoids movement; more
TIP MODIFICATION dramatically the graft can be stabilized against the under-
Many techniques have been described to modify the tip lying nasal spine using a K wire. The long-term results of
cartilages and the profusion of descriptions can be confus- this graft have recently been emphasized.16 The objection
ing. Basically there are six different reasons for modifying to the strut is that it tends to widen the columella and it
the tip: also limits the mobility of the nasal tip.
1. Changing tip projection A tip graft will also produce tip projection.17 A flat shield
2. Altering tip rotation shaped graft is used which is notched at the center leaving
3. Decreasing the distance between the tip-defining the corners 6–8 mm apart to form two tip-defining points.
points Shield grafts have to be secured by suturing, and for these
4. Reducing tip fullness reasons are more readily used during open rhinoplasty.
5. Creating a supra-tip break
6. Altering the relationship between the columella and Decreasing Projection
alar rims. A complete transfixion incision destroys the support
provided by the attachments of the feet of the medial crura
Changing Tip Projection to the caudal septum allowing the feet to settle toward the
premaxilla. The shorter the medial crura and the further
Increasing Projection
the feet are from the premaxilla, the more the tip can move
In practice this is one of the most frequently required and backward. Interruption of the suspensory ligament elimi-
desired maneuvers. nates the support provided by the dorsal septum and also
Where there is a moderate degree of flare of the medial allows backward movement of the LLCs.
or intermediate crura a limited amount of tip projec- However, the strength and stability of the lateral crura
tion can be achieved by suturing the medial walls of the is important. If these are strong and firmly adherent to the
domes to each other. This is simple to effect using an open pyriform aperture then they will resists backward move-
approach and gives a 2–3 mm of additional projection—a ment of the tip. In such circumstances, if the vestibular
modest amount. skin is mobilized and the crura vertically transacted, then
Vertical transfixion of the lateral crura and dissec- they will move backward. The overlying segments can be
tion off the underlying vestibular skin with closure re-sutures with 4/0 Vicryl rapide in order to re-establish
of the lateral segments of the domes with a horizon- support of the lateral alar wall.
tal mattress suture (the Goldman tip) also increases The medial crura can also be transacted and re-sutured
tip projection. The senior author has never under- if they are too long. The transaction is normally performed
taken this as the disadvantage of this approach are midway between the tip-defining points and the
that it may predispose to collapse of the alar rim and columella-lobular angle after undermining vestibular skin
may give a pinched appearance to the tip. In addi- in that area.
tion a single tip-defining point is produced in a more Reducing tip projection tends to result in flaring of
cephalad position than normal with increased infra- the alar. This may be desirable in a narrow nose but when
lobular show, which are rarely desired outcomes. there is a normal contour the increased flaring then has
An alternative is that a columella strut of autologous to be reduced, either by bilateral crural incision or by alar
cartilage can be inserted. A rectangular cartilage graft is based resection.
 906 Facial Plastics, Cosmetics and Reconstructive Surgery

Altering Tip Rotation can be trimmed in situ. A senior also prefers a rim inci-
The elements that resist rotation of the tip are: sion in this respect since this gives the full exposure to the
• The fibrous attachments of the ULCs to the lateral crura whole of the LLC and allows us a direct inspection of the
•� The
�� �����������������������������������������������������
abutment of the lateral crural complex to the pyri- whole structure rather than a part thereof (Figs 68 and 69).
form aperture or long ULCs
• The caudal septum
• A high septal angle
• Adherence of the skin to the lateral crura, ULCs and
nasal bones.
The resistance offered by the attachments of the lateral
crura to the ULCs is eliminated by an inter-cartilaginous
incision or by resection of the cephalic margin of the lateral
crus. When rotation is desired a portion of the cephalic
margin of the lateral crura is usually resected (Fig. 67).
High attachments of the lateral crus to the pyriform suture
will cause resistance to rotation, which rarely may have
to be reduced by transection of the lateral crus. In spite
of this the tip may still not rotate if the caudal end of the
septum interferes with upward movement of the medial
crura. Trimming of the septum anteriorly will therefore
allow rotation. The skin attachment cephalad to the tip will
resist upward movement of the LLCs and any rotation will
therefore involve undermining and redraping of the skin
of the lower dorsum.
In particular terms, rotation of the LLCs can normally
be achieved by removal of some of the cephalic margins.
This can be done endonasally through a cartilage splitting
incision or fashioning a rim incision. The cartilage is then
dissected free from the overlying skin and everted, often
on a Hill’s Elevator or other such instrument, such that it Fig. 68

Fig. 67 Fig. 69
 A Color Atlas of Septorhinoplasty 907

In open approach rhinoplasty removal of the cephalic Decreasing the Distance

margin of the lower lateral is relatively simple as this struc- between the Tip-Defining Points
ture is immediately visible. If the nose appears wide because of an increase distance
Whichever way is chosen it is important to realize that between the tip-defining points, suturing the medial walls
the resection of the upper border of the LLC defiles some of the domes toward each other with permanent sutures
of the important support mechanisms for the lateral crus. will reduce the gap.
Resection should always be conservative and it is a In certain cases the distance can also be reduced
good maxim always to “leave more than you take away”. by resection of the cephalic margins of the medial wall
A more important problem is rotation of the tip down- of the domes and the anterior medial crura. This is
ward to increase the length of the nose. The forces resist- because, as the cartilages curve away from the dome
ing this the adherence of the skin to the underlying frame- area toward the columella (the intermediate crura),
work, fibrous attachments of the lower to the ULCs and they flare such that the caudal margins are separated.
adherence of the mucosa and vestibular skin to the nasal Resection of the cephalic rim eliminates this abutment
bones, upper and LLCs and septum. This can be overcome and allows the tip-defining points to move closer together
by an extended spreader graft. (Figs 70 to 74).

Fig. 70 Fig. 71

Fig. 72 Fig. 73
 908 Facial Plastics, Cosmetics and Reconstructive Surgery

Altering the Alar-Columellar Relationship

The relationship between the alar and columella is most
frequently described from the lateral view but it is also
important to look at the nose from the front and to ensure
that this relationship is correct. Gunter et al. have written
of an analysis of several hundred patients and have found
that it is possible to divide the end of the nose by three
horizontal planes through, respectively, the tip-defining
points, the highest point of the alar rims and the columella
lobular angle.18
The same relationship was found on the lateral view
but they found that the most common and valuable find-
ing was that the outline of the nostril should simulate a
complete oval. The alar rooms form the upper half of this
oval and the lower half is formed by the columella rim at
Fig. 74
the junction of the external skin with the vestibular skin.
A line drawn through the most anterior and posterior
points of the oval represents the long axis of the nostril
and divides it into an upper and lower half. By using the
Reducing Tip Fullness distance from this long axis to alar rim superiorly (AB) and
the columella rim inferiorly (BC) they have categorized
Decreasing fullness of the tip usually requires partial alar-columella relationships into one of six groups. Class
resection and/or weakening of the lateral crura. Resection one is normal and shown opposite. In this diagram the
of the cephalic segments of the lateral crura will decrease alar rim (AB) and the columella (BC) are both equal.
tip fullness but the remaining caudal segments may In the literature the common method described for
remain flared giving the nose a bulbous appearance. To correction of an abnormality in this area is resection of
overcome this, the lateral crura can be attenuated by inter- part of the membranous columella or part of the caudal
digitating incisions which are made through the cartilage septum together with resection of the caudal margins of
only avoiding damage to the underlying vestibular lining. the medial crura. To this these authors have added partial
The risk is that the lateral crura may subsequently collapse removal of the medial crus on each side with suturing of
on inspiration. the ages together and insertion of composite grafts and
A better way to reduced flare is to place 5/0 sutures removal of tissues at the alar rims. The paper should be
in the dome area. This can be done on both sides and if it consulted for details regarding these removers which allow
is also necessary to narrow the distance between the tip- infinite adjustments of the alar-columella relationships.
defining points then, if one suture is left long on each side
and then tightened, the desired effect can be achieved.
Any such maneuver can cause medial migration of the
SPECIALIST TECHNIQUES
lateral crus and cause alar intrusion to the airway. Spreader Grafts
Creating a Supra-Tip Break Spreader grafts were first described by Sheen in 1984, and
It is usually desirable, especially in female patients, to act as spacers in the internal nasal valve region. This region
create a break immediately above the tip. This is accom- is bounded medially by the caudal septum and later-
plished by lowering the dorsal septum just above the ally by the inferior turbinate.19 Spreader grafts improve
septal angle. nasal airflow in the internal valve area and are also useful
The skin in this area is thicker than that which in correcting middle nasal vault asymmetry. They also
covers the intermediate dorsum. If it is very thick then restore the dorsal esthetic lines.
it is possible to remove some fat and loose tissue on the Spreader grafts are placed in a subperichondrial
under surface of the skin. However this must be done pocket that lies between the ULCs and the septum. A
with great care and only that tissue which is loosely pocket is created in a horizontal plane starting from the
attached should be removed in order to avoid damaging anterior septal angle and heading in a cephalic direction
the underlying dermis. Dimpling or even necrosis of the and ending at the keystone area. This pocket can be created
skin may then result. by sharp dissection using a no. 15 blade scalpel and can be
 A Color Atlas of Septorhinoplasty 909

further developed using a Freer’s elevator. The ULCs are silicone, Gore-Tex (expanded polytetrafluorethylene) or
dissected free from the septum preserving, as far as possi- Medpor (high density polyethylene). All such materials
ble, the underlying mucoperichondrium. A rectangular have their proponents and early studies have suggested
cartilage graft of approximately 1–3 mm thickness and 2–3 favorable outcomes using these materials.24 However, in
cm length that extends from the keystone area to the ante- most instances long-term outcomes are not known.
rior septal angle is then inserted and the grafts are secured
in situ with horizontal mattress sutures (5/0 Vicryl rapide) Closure and Dressings
above and below. The aim of early postoperative care including the use of
dressings is for:
Alar Batten, Alar Strut and Rim Grafts • Reduction of swelling by the elimination of dead space
The terms alar batten and alar strut grafts are used inter- • Maintenance of a patent nasal airway
changeably with some confusion. Batten grafts were first • Stabilizing the osteotomized nasal bones
described by Toriumi in 1997 and are cartilage grafts used • Protection from external trauma
to augment the alar rim and hence alter the elasticity of • Pain control.
the external nasal valve.20 A batten graft is placed deep to Intranasal incisions are best closed using 3/0 Vicryl
the lateral crus in the space between the lateral crus and rapide (Fig. 75). Closure is important in order to avoid
the vestibular mucosa. Maximum support is achieved by asymmetry during healing. In external approach rhino-
placing the alar graft over the bone of the pyriform aper- plasty the skin is closured with an absorbable mattress
ture. They are best secured with sutures and in order to suture such as 5/0 Vicryl (Figs 76 to 82). The marginal and
maintain position, and it is easier to insert these utilizing hemitransfixion incisions are also closed with a nonab-
an open approach rhinoplasty. sorbable suture (4/0 Vicryl rapide) (Figs 84 and 85).
A strut is placed over the lateral crus to reinforce it At then end of the procedure, the nasal cavity and
and to prevent collapse and a pinched look. This graft is dorsal skin is gently cleansed to avoid disturbing the new
particularly useful if the lateral crus is naturally concave position of the nasal bones, and any grafts. Intranasal
to the nasal vestibule and is producing a deformity in the packs (e.g. Merocel©) soaked with an antibiotic ointment
supra-alar crease. A gentle curve to the graft aids optimal and then inflated with antibiotic solution provides extra
placing and an external approach rhinoplasty permits the internal support for up to 6 hours as the patient gently
best access for this graft. If the deformity of the underly- recovers full consciousness (Figs 85 to 88).
ing cartilage is severe then excision of the concave part Friars Balsam/Benzoin compound tincture is lightly
of the lateral crus and reversing it and reattaching it prior painted over the skin lateral to the dorsum of the skin to
to attaching an overlying graft will facilitate correction. ensure the skin tape dressing remains in situ until the
The graft should not be too thick or excessive rigidity and follow-up appointment (Fig. 89). Skin tapes (Steristrips)
thickening of the alar is achieved which is undesirable. are applied in a horizontal fashion from the radix
Alar rim grafts, also known as alar contour grafts, are to the nasal tip with a long U-shaped strip placed to
placed in the most caudal aspect of the nasal ala in an
effort to prevent a pinched nose appearance. They can be
inserted through a stab incision.

Dorsal Augmentation
The dorsum of the nose may be altered using onlay grafts.21
These may formed from autologous cartilage sources such as
the septum, upper or LLCs, conchal bowl or costal cartilage.
Alternatively irradiated homograft cartilage can be used.
A newer technique of using cartilage that has been
diced and wrapped in fascia can remain malleable in the
early postoperative period should further correction be
necessary.22 Autologous soft tissue may also be used, such
as subcutaneous fat, temporalis fascia or SMAS or even
hard tissue such as bone.23 The latter is associated with
rather high levels of reabsorption. Research is needed into
the long-term behavior of materials such as processed
fascia lata (Tutoplast) and synthetic materials such as Fig. 75
910 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 76 Fig. 77

Fig. 78 Fig. 79

Fig. 80 Fig. 81
 A Color Atlas of Septorhinoplasty 911

Fig. 82 Fig. 83

Fig. 84 Fig. 85

Fig. 86 Fig. 87
 912 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 88 Fig. 89

Fig. 90 Fig. 91

support the nasal tip (Figs 90 to 96). A piece of trans- POSTOPERATIVE CARE
parent Transpore© tape is then applied to add further
soft tissue protection. Finally, a plaster of Paris cast is Patients may be discharged the same day after a suitable
cut and shaped to fit the patient, moistened with warm period of observation.
water and carefully molded to fit the dorsum of the nose. • Analgesia: It has been reported that postoperative pain
The plaster cast must lie over the dorsum of the nose is at its worst during the first 3 days.25 Suitable anal-
and the sites of the lateral astronomies (Figs 97 and 98). gesics in clued paracetamol and a nonsteroidal anti-
Flesh-colored micropore tape secures the plaster in inflammatory such as voltarol.
place. • Antibiotics: There are no published guidelines on the
A temporary bolster dressing placed over the inferior use of antibiotics in this patient group. However, a
aspect of the nose to absorb any minor nasal bleeding or survey reported 72% of surgeons prescribed antibiotics
secretions in the immediate postoperative period. The in the intraoperative and postoperative period.26 This
patient should be nursed 30���������������������������
°��������������������������
head-up in order to mini- seems especially appropriate if free cartilage grafts
mize tissue edema (Figs 99 and 100). have been inserted.
 A Color Atlas of Septorhinoplasty 913

Fig. 92 Fig. 93

Fig. 94 Fig. 95

Fig. 96 Fig. 97
 914 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 98 Fig. 99

• Saline nasal drops: These have been reported to signifi-

cantly reduce the symptoms associated with the stasis
of secretions and crust formation which occurs as a
result of the reduced mucociliary function in the first
three postoperative weeks.31,32
• Ephedrine nasal drops: It helps to advance nasal
patency in the early postoperative period. These are
routinely prescribed.
• Antibiotic ointment helps to prevent secondary infec-
tion of the crusting that inevitably forms around the
nares.
• The patient should be advised not to blow nose and
to try and sneeze through an open mouth in order to
try and avoid separation of the tissue flaps. Removal
of sutures and plaster of Paris occurs at 1 week. The
Fig. 100 patients are then reviewed at 1 month and then at
4 months with postoperative clinical photographs.

• Low dose oral steroids: There is conflicting data on

the use of steroids, but short courses are beneficial
REFERENCES
in patients with no medical contraindications.26 A 1. Lopez MA, Michaelson PG, Westine JG. A systematic
single dose of steroid is beneficial to reduce perior- approach for preoperative rhinoplasty planning. Am J
bital edema and ecchymosis for up to 2 days postop- Otolaryngol. 2008;29(4):265-9.
eratively.27 Three doses provide a benefit for up to a 2. Ahluwalia S, Veer V, Kenyon GS. Lateral photography of the
week.28 Further evidence shows that postoperative nasal tip: what is acceptable and can it be improved? Plast
edema is reduced for up to 2 weeks when a single intra- Reconstr Surg. 2010;126(5):250e-2e.
3. Krugman ME. Photoanalysis of the rhinoplasty patient. Ear
operative dose is followed up by a 5 day oral course.29
Nose Throat J. 1981;60(7):328-30.
There is evidence to suggest a trend toward long-term 4. Staffel JG. Photo documentation in rhinoplasty. Facial Plast
reduction of edema and bruising when steroids are Surg. 1997;13(4):317-32.
given for 3 days.30 The senior author ensures that the 5. LaNasa JJ, Smith O, Johnson CM. The cephalic view in nasal
patient is given intraoperative Dexamethasone (8 mg) photography. J Otolaryngol. 1991;20(6):443-5.
and that this is followed by the same drug in a dose of 6. Galdino GM, DaSilva And D, Gunter JP. Digital photography
2 mg qds by mouth for 5 days. for rhinoplasty. Plast Reconstr Surg. 2002;109(4):1421-34.
 A Color Atlas of Septorhinoplasty 915

7. Makdessian AS, Ellis DA, Irish JC. Informed consent in facial 21. Lee MR, Unger JG, Rohrich RJ. Management of the nasal
plastic surgery: effectiveness of a simple educational inter- dorsum in rhinoplasty: a systematic review of the literature
vention. Arch Facial Plast Surg. 2004;6(1):26-30. regarding technique, outcomes, and complications. Plast
8. Rettinger G. Risks and complications of rhinoplasty. Reconstr Surg. 2011;128(5):538e-50e.
Laryngorhinootologie. 2007;86(Suppl 1):S40-54.
22. Erol OO. The Turkish delight: a pliable graft for rhinoplasty.
9. Gunter JP, Rohrich RJ, Friedman RM. Classification and
Plast Reconstr Surg. 2000;105:2229-41.
correction of alar-columellar discrepancies in rhinoplasty.
Plastic Reconstr Surg. 1996;97:643-8. 23. Toriumi DM, Larrabee WF, Walike JW, et al. Demineralized
10. Kenyon GS, Kalan A, Jones NS. Columelloplasty: a new bone: implant resorption with long-term follow-up. Arch
suture technique to correct caudal septal cartilage disloca- Otolaryngol Head Neck Surg. 1990;116:676-80.
tion. Clin Otolaryngol Allied Sci. 2002;27(3):188-91. 24. Reiffel AJ, Cross KJ, Spinelli HM. Nasal spreader grafts: a
11. Gunter JP, Rohrich RJ. External approach for secondary comparison of medpor to autologous tissue reconstruction.
rhinoplasty. Plast Reconstr Surg. 1987;80(2):161-74. Ann Plast Surg. 2011;66(1):24-8.
12. Most SP, Murakami CS. Nasal osteotomies: anatomy, plan- 25. Szychta P, Antoszewski B. Assessment of early postoperative
ning, and technique. Facial Plast Surg Clin North Am. 2002;
pain following septorhinoplasty. J Laryngol Otol. 2010;124
10(3):279-85.
13. Rohrich RJ, Minoli JJ, Adams WP, et al. The lateral nasal oste- (11):1194-9.
otomy in rhinoplasty: an anatomic endoscopic comparison 26. Cochran CS, Ducic Y, DeFatta RJ. Current concepts in the
of the external versus the internal approach. Plast Reconstr postoperative care of the rhinoplasty patient. South Med J.
Surg. 1997;99:1309-12. 2008;101(9):935-9.
14. Murakami CS, Larrabee WF. Comparison of osteotomy tech- 27. Kara CO, Gökalan I. Effects of single-dose steroid usage on
niques in the treatment of nasal fractures. Facial Plast Surg. edema, ecchymosis, and intraopertive bleeding in rhino-
1992;8:209-19. plasty. Plast Reconstr Surg. 1999;104:2213-8.
15. Bloom JD, Ransom ER, Antunes MB, et al. Quantifying the 28. Kargi E, Hoşnuter M, Babucçu O, et al. Effect of steroids on
sharpness of osteotomes for dorsal hump reduction. Arch
edema, ecchymosis, and intraoperative bleeding in rhino-
Facial Plast Surg. 2011;13(2):103-8.
16. Anderson JR. A personal technique of rhinoplasty. plasty. Ann Plastic Surg. 2003;51:570-4.
Otolaryngol Clin North Am. 1975;8:599-62. 29. Hoffman DF, Cook TA, Quatela VC, et al. Steroids and rhino-
17. Rohrich RJ, Hoxworth RE, Kurkjian TJ. The role of the colu- plasty. A double-blind study. Arch Otolaryngol Head Neck
mellar strut in rhinoplasty: indications and rationale. Plast Surg. 1991;117:990-3.
Reconstr Surg. 2012;129(1):118e-25e. 30. Hatef DA, Ellsworth WA, Allen JN, et al. Perioperative ster-
18. Sheen JH. Achieving more tip projection by the use of a oids for minimizing edema and ecchymosis after rhino-
small autogenous vomer or septal cartilage graft. A prelimi- plasty: a meta-analysis. Aesthet Surg J. 2011;31(6):648-57.
nary report. Plast Reconstr Surg. 1975;56(1):35-40. 31. Tomooka LT, Murphy C, Davidson TM. Clinical study
19. Sheen JH. Spreader graft: a method of reconstructing the
and literature review of nasal irrigation. Laryngoscope.
roof of the middle nasal vault following rhinoplasty. Plast
Reconstr Surg. 1984;73:230-9. 2000;110:1189-93.
20. Toriumi DM, Josen J, Weinberger M, et al. Use of alar batten 32. Shone GR, Yardley MP, Knight LC. Mucociliary function
grafts for correction of nasal valve collapse. Arch Otolaryngol in the early weeks after nasal surgery. Rhinology. 1990;28:
Head Neck Surg. 1997;123:802-8. 265-8.
 916 Facial Plastics, Cosmetics and Reconstructive Surgery The Surgical Technique of Otoplasty 916
CHAPTER

98 Augmentation Rhinoplasty
Yong Ju Jang, Ji Heui Kim

nose with the overall surrounding structure is important.

INDICATIONS FOR THE SURGERY Also, excessive augmentation and lengthening of the nose
Dorsal augmentation is a surgery that is performed for the can always result in disasters, such as the extrusion of the
purpose of elevating the nasal dorsum using an autologous implant. Therefore, any request by the patient for an exces-
tissue or an alloplastic implant when the nasal dorsum has sive augmentation must be rejected outright.
been lowered by a congenital cause, trauma, inflamma-
tion, or reduction rhinoplasty. Hump
It is advisable to properly remove even the slightest hump
and then perform dorsal augmentation. In most cases,
SPECIFIC PREOPERATIVE EVALUATION more problems are caused by inadequate removal rather
than from an excessive removal of the hump. Thus, the
Analyzing and Making Reference of the
removal of the hump (whether it is a bony hump or carti-
Preoperative Photographs of the Patient
lage hump) should be accurately ascertained if a nasal
Length of the Nose dorsum is to take correct shape (Figs 1A and B).

Determining the length of the implant also determines the The Relationship to the Chin
length of the nose. Thus, it is important to make the correct Although a close relationship exists between the chin and
decision regarding the suitable length of the patient’s nose. the nasal tip surgery and between the chin and dorsal
For patients with a round shaped face and small eyes and augmentation, it is often disregarded. The chins of Koreans
mouth, a shorter nose is more suitable than a longer nose. are generally retruded so that if just a dorsal augmentation
Conversely, for patients with an elongated and angled is performed, it would in many cases make the chin look
face, a long and elevated nose with a clear definition is even more retruded. If patients with a low nasal dorsum
more suitable than a small nose. Likewise, harmony of the and tip as well as a pre-existing microgenia or retrognathia

A B
Figs 1A and B: (A) A cartilage hump and; (B) Bony hump being removed
 Augmentation Rhinoplasty 917

undergo surgery to elevate the low nasal dorsum and tip, it ANESTHETIC CONSIDERATIONS
will result in the lip and chin being repositioned relatively
further backward. Thus, to maintain the symmetry of the Before selecting the types of anesthesia to be used, the
face, it is desirable to perform genioplasty concurrently or surgeon must make it a standard practice to examine the
subsequently (Figs 2A and B). following factors.

Verifying Physiological or Anatomical The Condition of the Patient

Problems within the Nasal Cavity Most patients prefer general to local anesthesia because of
Should septal deviation, turbinate hypertrophy, or their fear of surgery and pain. However, most rhinoplasty
sinusitis exist within the nasal cavity, the patient may can usually be performed using conscious sedation or local
complain of an increased nasal obstruction despite being anesthesia. Nevertheless, if patients express excessive fear
highly satisfied cosmetically. Thus, it is advisable to always of surgery or pain, if the patient is a child, when there is a
be fully aware of any problems within the patient’s nasal severe case of saddle nose, in case of a total reconstructive
cavity prior to surgery. Particular attention is required surgery of the nose, or when harvesting costal cartilage,
when there is infection within the nasal cavity as the risk the inhalational general anesthesia is recommended. As
of infection following dorsal augmentation increases in some patients react negatively to the inhalational general
such a case. In addition, in case the patient is diagnosed anesthesia because of mistaken popular belief that in may
with chronic inflammation due to allergic rhinitis so that adversely affect the memory function, doctors need to
blowing or touching the nose is unavoidable, there is a provide proper guidance for patients.
high risk that scarring will occur at the incision area or that
the implant will migrate. In such a case, medication, such Familiarity of the Anesthesia to the Surgeon
as antihistamine, needs to be prescribed. There is always the possibility of the unexpected happen-
ing as a result of anesthesia. Thus, it is always best for the
Considering the Occupation and the surgeon to select the anesthesia that he is familiar with
Circumstances Surrounding the Patients as it is the fastest means for the surgeon to properly and
The general population or housewives generally prefer a rapidly respond to an emergency situation.
natural looking but slightly augmented nose while enter-
tainers or those working in service-oriented fields prefer
robust looking features and relatively high nose. Therefore,
SURGICAL STEPS
deciding the extent of dorsal augmentation based on Various implant materials have been used for dorsal
patient’s occupation can reduce possible discontent that augmentation. Materials used in rhinoplasty can be
may arise later on. divided largely between biologic tissues (autologous and
homologous tissue) and the alloplastic materials. In the
rhinoplasty for Caucasian, use of alloplastic implant, espe-
cially silicone, on the nasal dorsum has been condemned.
In Asian rhinoplasty, however, alloplastic implants still
play a role due to the differing anatomical characteris-
tics of Asians, such as thick skin and poorly developed
cartilaginous framework, compared with Caucasians.
Alloplastic implants generally need to be biocompatible,
nontoxic, chemically safe, and nonimmunogenic. They
must also not induce infection, cancer or produce toxic
substances within the body. Additionally, during recovery,
these implants should maintain their original size, shape,
and hardness. At present, the most commonly used allo-
plastic implants that meet these conditions are silicone,
Gore-Tex, and Medpor.

A B Autologous Tissue
Figs 2A and B: (A) A preoperative image of a patient with The advantage of autologous material for the dorsal
a micrognathia and; (B) An image showing a patient whose augmentation of the nose cannot be questioned as these
chin seems more drawn back following tip projection surgery implants are well-tolerated and carry the least risk of
 918 Facial Plastics, Cosmetics and Reconstructive Surgery

infection. However, if any autologous tissue other than about 10 mm from the dorsum of the nasal septum
septal cartilage is selected, the additional operative time (Figs 6A and B).
required to harvest the graft and donor site morbidity • After applying a full-thickness incision vertically,
become limiting factors. Common autologous tissues used 10 mm from the caudal margin of the nasal septum,
for dorsal augmentation include septal cartilage, conchal dissect the perichondrium on the opposite side
cartilage, costal cartilage, fascia, and dermofat. (Figs 7A and B).
• While dissecting the perichondrium from the opposite
Septal Cartilage side, using a Freer elevator, separate the connection
As it is easy to harvest and shape the septal cartilage, it between the septal cartilage and the partially attached
can be used to moderately elevate the nasal dorsum, to vomer and maxillary crest (Figs 8A and B).
camouflage a partial concavity on the dorsum, and for
nasal tip surgery. Since Asian patients have relatively small
noses, it is practically difficult to harvest enough amount
of cartilage, leaving at least 1-cm width of the L-strut, suit-
able for a full-length dorsal graft (Fig. 3).

Technique of harvesting the septal cartilage

• After incising the mucosa, use a Freer elevator to
perform dissection on one side of the nasal septum.
During the elevation of the mucoperichondrium, if the
cartilage takes on a blue-gray color and the hemorr­
hage is minor, it can be determined that the dissection
is successful (Figs 4A and B).
• At junction area between the cartilaginous area of
the cartilaginous septum and the bony septum,
apply proper pressure to the elevator and sepa-
rate the septal cartilage and the junctional area
of the perpendicular plate, vomer of the ethmoid
bone. When separating the septal cartilage with
the perpendicular plate, try to preserve the upper
10 mm belonging to the keystone area (Figs 5A and B).
• While preserving about 10-mm width of the L-strut
septal cartilage, apply full-thickness incision on the
cartilage parallel to the nasal dorsum—a distance of Fig. 3: Septal cartilage harvest area

A B
Figs 4A and B: (A) Modified Killian incision; (B) Elevation of the mucoperichondrium
 Augmentation Rhinoplasty 919

A B
Figs 5A and B: (A) Separating the septal cartilage and the perpendicular plate; (B) Vomer

A B
Figs 6A and B: Using D-knife, perform a full-thickness incision parallel to the nasal
dorsum while keeping a 1-cm cartilage strut

A B
Figs 7A and B: (A) Maintaining a 10-mm distance from the caudal most part of the septum, perform a full-thickness
incision parallel to the caudal margin of the septum and then; (B) Dissect out perichondrium on the opposing side
 920 Facial Plastics, Cosmetics and Reconstructive Surgery

A B
Figs 8A and B: (A) Dissect the perichondrium on the opposite side through the incision area and;
(B) Detach the connection to the vomer and maxillary crest

A B
Figs 9A and B: (A) Harvesting the septal cartilage with care using nasal forceps;
(B) Photo of an extracted septal cartilage

• Harvest the separated septal cartilage with care using part layer upon layer while suturing them in order to
a nasal forceps (Figs 9A and B). After suturing the inci- determine the thickness (see Fig. 27). However, the edge
sion site, perform a through-and-through running of the implant must be made as slim as possible if a protru-
quilting suture with vicryl or PDS in the area from sion free nasal dorsum is to be created.
which the septum is harvested.
Augmentation using a septal cartilage
Trimming the septal cartilage (Figs 10A and B) Although it is difficult to augment the nasal dorsum
To perform an augmentation using a nasal septum, as significantly with a septal cartilage, it is a suitable mate-
much cartilage as possible must be harvested. And, it is rial for minor augmentation or when the patient is seek-
useful to also harvest the bony part. When trimming the ing a dorsal augmentation using the autologous tissue.
cartilage, the absorption rate can be reduced by sparing However, to use the septal cartilage to perform augmen-
one side of the perichondrium when the cartilage is used tation, a relatively large quantity of septal cartilage to
by folding it into a shape of a hinge. First of all, after over- perform augmentation, a relatively large quantity of septal
lapping the cartilage slices two-fold to obtain a certain cartilage and bone need to be harvested. Also, if the size
level of thickness, stack the remaining cartilage and bony and width of the harvested cartilage is small, it can lead to
 Augmentation Rhinoplasty 921

A B
Figs 10A and B: Trimming the septal cartilage

the nasal dorsum looking narrow or protruding. Because advantage of hiding the scar from the frontal view but
the septal cartilage frequently migrates after being grafted, many pose difficulties for a beginner to accurately locate
it is useful to fixate it to the nasal dorsum with a suture or the area in the front of the ear using a needle. In harvesting
needle and, more than anything else, it is important to from the front of the ear, it is easy to verify the location of
dissect a proper-sized pocket (Figs 11A to D). the cartilage to be harvested so that harvesting the cartilage
is simple. However, it can lead to problems, such as scar-
Various uses for septal cartilage ring. Whenever possible, harvesting the conchal cartilage
It is easy to harvest and carve the septal cartilage into a with the perichondrium attached on one side can increase
straight shape, which allows for it to be used for various its survivability after being transplanted. Also, the crust of
purposes, such as tip graft, strut, and septal extension the helix, which is also called the support framework of the
graft. ear, must be left untouched. It is preferable that the cymba
concha in the upper area and the cavum concha at the
Conchal Cartilage lower area be harvested separately (Figs 12A to C).
Unlike septal cartilage, conchal cartilage has an intrinsic
curvature that hampers its routine use in a dorsal augmen- Application of the conchal cartilage
tation in its original shape. Rather, in surgery on Asian Because of its intrinsic curvature, it is difficult to use the
noses, conchal cartilage is more frequently used for nasal conchal cartilage for dorsal augmentation. However, it can
tip surgery, to camouflage a partial concavity, or to cover be used for tip graft, camouflage grafting, etc. The biggest
the tip of the silicone implant to prevent extrusion. In addi- advantage of a conchal cartilage is that it can be harvested
tion, the conchal cartilage is frequently too small to yield in a composite graft so that the cartilage can be harvested
a cartilage piece suitable for one piece dorsal augmenta- with the skin. This composite graft can be applied usefully
tion. To reduce the visibility and migration of the septal to correct an alar retraction (Figs 13A to C).
cartilages, and to overcome the limitation in the size, the
authors prefer to place the septal cartilage onto the nasal Costal Cartilage
dorsum after gentle crushing using a cartilage crusher. Although costal cartilage is difficult to harvest and is asso-
Also, when using conchal cartilage, it may be necessary ciated with more serious donor site morbidity, such as
to overlap pieces of cartilage in their opposite direc- pneumothorax, as well as the problem of warping, it is the
tions of curvature to neutralize their intrinsic curvature. most useful autologous cartilage for substantial augmen-
tation or in patients who have experienced complications
Technique of harvesting the conchal cartilage with alloplastic implants. Although strongly advocated
The technique of harvesting the conchal cartilage can be by some surgeons of its routine use for Asian rhinoplasty,
divided largely between harvesting from the front of the during the primary rhinoplasty, however, it is very difficult
ear. Each technique has its own merits and demerits. In to persuade Asian women to use costal cartilage because
the case of harvesting from the back of the ear, it has the the harvesting procedure leaves scars on the chest. One
 922 Facial Plastics, Cosmetics and Reconstructive Surgery

A B

C D
Figs 11A to D: Example of an augmentation being performed on a patient with a slight saddle nose using a septal cartilage.
(A) After harvesting the septal cartilage, overlap it three-fold and trim it to match the depression area. After performing a
marginal incision (B); undertake a cephalic resection and tip plasty (C). (D) Insert the septal cartilage graft and fixate it with
a needle to prevent any movement

A B C
Figs 12A to C: (A) Region for harvesting the conchal cartilage; (B) Technique of harvesting from
the front of the ear and; (C) From the rear
 Augmentation Rhinoplasty 923

C
Figs 13A to C: (A) A patient presenting a blunt tip and alar retraction prior to surgery; (B) Appearance of the blunt tip and
alar retraction improved using a composite graft (conchal cartilage and skin) and septal extension graft; (C) Photographs
of the surgery
 924 Facial Plastics, Cosmetics and Reconstructive Surgery

other critically important limitation of autologous tissue the skin must be minimized and, due to the restricted
is that, except for only a few highly-experienced surgeons, view, a thorough hemostasis is needed. Additionally,
most rhinoplasty surgeons have difficulty using these in case of patients with a thick fatty layer, excision part
implants to form an esthetically pleasing nose, resulting in of the fatty tissue for re-insertion, after the cartilage is
a high revision rate. harvested, can prevent a postsurgical wound depres-
sion or seroma formation (Figs 14A and B).
Techniques of harvesting the costal cartilage • After the fascia of the external abdominal oblique
• Select the location of the cartilage to be harvested. In muscle is exposed, do not excise the muscle but, rather
case of a woman or when the breast is large, it is fine carefully, dissect in between the muscle. While doing
to harvest the fourth or fifth costal cartilage. But when this, damage to the fascia and the muscle must be
harvesting in large quantity or in case of a beginner, it minimized in order to minimize the postoperative pain.
is preferable to harvest from the broad cartilage area In addition, as oozing can occur from the dissected
of the sixth or seventh rib. Once the cartilage to be muscle, a thorough hemostasis is necessary to obtain
harvested is chosen, as it is often difficult to verify the a good exposure and to prevent the occurrence of a
exact position of the costal cartilage once it has been postoperative hematoma (Figs 15A and B).
draped, it is advisable to premark the position while • Dissecting between the external abdominal oblique
tracing from the eleventh costal cartilage onward. muscle will allow the perichondrium of the costal
When there is an assistant who will harvest the cartilage cartilage to be inspected. After exposing the superfi-
during surgery, it is preferable for the cartilage to be cial part of the perichondrium of the cartilage, make
harvested from the left. When the surgeon is operating an incision line at the perichondrium with a knife
from the right, harvesting the cartilage by himself, it is and then perform dissection using a periosteal eleva-
best to harvest the cartilage from the right. tor or Freer elevator. All following manipulation must
• It is desirable for the size of the incision to be small be performed on the inside of the perichondrium
but, when it is overly small, it can restrict the surgi- for it to be safe. Dissecting the perichondrium at the
cal exposure and, by forcing the skin to be overly superficial part of the cartilage is relatively easy but
retracted during the incision, often cause scarring. the upper and lower area is so firmly attached that it
Thus, an incision line of about 3–4 cm is suitable. The is best to dissect this area carefully, a la slowly strip-
incision should always be performed in concert with ping the onion. And, although it is proper to dissect
frequent efforts to verify the costal cartilage area with the whole length of the cartilage, rather than force-
the fingers in order to accurately confirm the surgical fully perform dissection while the surgical exposure is
plane. If this is difficult due to excessive amount of poor, it is better to dissect just two third of the radius.
fat, using a needle to verify the location of the costal In particular, the surgeon must be particularly careful
cartilage can be helpful. While doing this, damage to not to exert too much force while dissecting in order

A B
Figs 14A and B: (A) After marking the incision line at the seventh costal cartilage area;
(B) Dissect all the way down the fatty layer of the superficial fascia
 Augmentation Rhinoplasty 925

A B
Figs 15A and B: (A) After the fascia of the external abdominal oblique muscle is exposed; (B) Use a mosquito
forceps to carefully spread the muscles by dissecting in between the muscles

A B
Figs 16A and B: (A) Surgical photos showing a perichondrium being dissected and; (B) After the dissection is performed

to prevent the surgical instrument from entering too (Figs 17A and B). The pleura can be torn slightly when a
deeply and tearing the pleura (Figs 16A and B). particularly string force is exerted during the dissection
• After the perichondrium is dissected to some extent, so that the instrument enters too deeply. In such a case,
make a partial incision line at the junction between the the torn area can be sutured while the lung is expanded.
bone and the cartilage, and likewise make an incision However, if the tear is too large, first insert a nelaton
at the edge of the cartilage to be harvested. Cutting the catheter into the thoracic cavity and, while the suction
cartilaginous area in increments rather than at once can is placed in position, suture the circumference of the
prevent pleural damage by the blade. By hooking one nelaton catheter with a vicryl 3-0 so that the peri­meter
side of the Dorian elevator to the cartilage and lifting of the nelaton can be closed in a pulse-string shape.
up the costal cartilage by dissecting it from one side, the Then, if the suture is swiftly performed as the nelaton is
cartilaginous area attached to the perichondrium will fall being removed, the chest tube need not be inserted after
off naturally, enabling it to be harvested. It is important surgery (Figs 18A and B).
that the edge of the Dorian elevator be inserted in a care- • After the costal cartilage is harvested, it is deemed
ful manner so that it does not stick to the pleura. The risk essential that a saline solution should be poured in and
of damaging the pleura is greatest during this maneuver the chest pressed down to verify the existence of air
 926 Facial Plastics, Cosmetics and Reconstructive Surgery

A B
Figs 17A and B: (A) Photos of a cartilage being excised using a knife and then; (B) Being lifted using a Dorian elevator

A B
Figs 18A and B: (A) After connecting a suction to the nelaton, perform a purse-string suture around the nelaton and
then; (B) Suture the laceration area rapidly while pulling out the nelaton

bubbles due to pneumothorax followed by saline irriga- warping occur, and perform careful carving after a certain
tion and hemostasis. If needed, bone wax can be used time elapsed (Fig. 21A). To reduce the risk of warping,
for the hemostasis (Figs 19A and B). When repairing the the authors prefer to use costal cartilage in a laminated
cartilage harvest area, each layer must be sutured sepa- form (Fig. 21B). So, harvested costal cartilage was cut into
rately and if there isn’t any particularly severe oozing, several vertical strips and placed in saline solution during
placement of a drain is not necessary and the stitch-out initial warping.
is usually performed on the seventh day.
Dorsal augmentation using a costal cartilage
Trimming the costal cartilage
Costal cartilage is one of the best autologous implants,
Warping, graft visibility, and unnatural looking noses are in cases where a substantial amount of augmentation is
common complications of augmentation using costal needed, where a previous graft is causing a rejection or
cartilage (Figs 20A and B). To avoid warping, it is best to infection, or where a patient requests for an augmentation
soak the cartilage in saline solution to let the maximal using an autologous implant (Figs 22A to C).
 Augmentation Rhinoplasty 927

A B
Figs 19A and B: (A) An image showing the wound filled with saline solution after the costal cartilage has been
harvested to check for air bubbles and; (B) A harvested costal cartilage

Figs 20A and B: Patients showing cartilage warping (A);

and visible graft contour (B), years after dorsal augmentation
A B using autologous costal cartilage

A B
Figs 21A and B: (A) To avoid warping, it is best to soak the cartilage in saline solution to let the maximal warping occur,
and to perform careful carving after a certain time has elapsed; (B) Laminated costal cartilage graft for nasal dorsum
 928 Facial Plastics, Cosmetics and Reconstructive Surgery

A B

Figs 22A to C: A case where a patient with a lowered

nasal dorsum requested for an autologous implant surgery
and received a dorsal augmentation and nasal tip surgery
using the costal cartilage; (A) Preoperative; (B) Postoperative
C and; (C) Extracted costal cartilage

Application of the conchal cartilage tissue also requires additional incision distant from the
The greatest advantage of a costal cartilage is an autolo- main operative field. Nonetheless, in rhinoplasty, fascia
gous implant that is relatively solid and has a low rate of lata could be used for dorsal augmentation, especially
resorption. Therefore, it can be used variously, in areas in secondary rhinoplasty for the correction of a failed
requiring hardness and volume. It is particularly useful alloplastic implant. One other advantage of fascia is that
in cases where a strong tip support is needed due to the this material, placed right underneath the skin and over
contracture of the nose resulting from a previous surgery the crushed or morselized cartilage, or used after wrapping
or accident and when a strong tip projection is needed up the morselized cartilage, can nicely camouflage the
(Figs 23A and B). irregular contour of diced cartilage or crushed cartilage,
maximizing the full use of the small pieces of autologous
Autologous Fascia tissues left behind after other procedures, and making it
Autologous fascia, including temporalis fascia, can an alternative method of dorsal augmentation (Fig. 24).
be used in rhinoplasty as radix graft or dorsal onlay Studies have shown that diced cartilage-fascia
grafts. However, harvesting autologous fascia requires wrapped grafts survived and demonstrated normal carti-
an additional incision and hence, is associated with lage survival.
additional morbidity. Furthermore, it is not always
possible to harvest sufficient fascia of reasonable thickness, Dermofat
because harvested fascia shrinks in volume as it dries, Dermofat, harvested from various locations, can also be
and when wet, it is hard to manipulate. Comparing with used in dorsal augmentation. Although dermofat can be
the temporalis fascia, fascia lata can provide a sufficient harvested in great quantities, its absorption is difficult
amount of connective tissue with significant thickness to predict, making it unsuitable for substantial dorsal
suitable for dorsal augmentation. However, harvesting this augmentation. However, dermofat can be useful for
 Augmentation Rhinoplasty 929

A B
Figs 23A and B: Columellar strut and tip graft from a costal cartilage

Fig. 24: Dorsal augmentation using fascia A

with crushed cartilage

patients with thin skin or contracture of the nose due to

complicated primary rhinoplasty.

Harvesting the dermofat

Though it is possible to harvest the dermis-fat from vari-
ous regions, it is mostly harvested from the buttock below
the coccyx or from the inguinal area (Figs 25A and B).
However, although this area offers the advantage that the
dermofat can be harvested in large quantity, it also has
the disadvantage that the surgical area will be broad and
performing dressing after surgery will be difficult. It is best
to minimize the incision during harvesting and the damage
to the dermofat from forceps if the absorption rate is to
be reduced. Also, this area being in frequent friction, the B
skin suture should be performed with the greatest preci- Figs 25A and B: (A) Harvesting dermofat from coccygeal
sion to prevent the dehiscence of the skin. Furthermore, area and; (B) Harvested dermofat
 930 Facial Plastics, Cosmetics and Reconstructive Surgery

A B
Figs 26A and B: Postauricular dermofat and Gore-Tex was used to perform a dorsal augmentation as well as tip surgery

Tutoplast Processed Fascia Lata

Tutoplast processed fascia lata (TPFL) is commercially
available homograft fascia that has been successfully used
as human tissue grafts for physical support procedures,
such as slings for stress incontinence, filler material, facial
paralysis or congenital ptosis. The author has used TPFL
in rhinoplasty for dorsal and radix onlay grafts. TPFL can
be used for smoothening grafts for dorsal irregularity
following correction of a deviated nose, as additional
graft material when an inadequate amount of septal or
conchal cartilage is available for dorsal augmentation, in
patients who dislike using of alloplastic material for dorsal
augmentation, for complicated revision surgery in which
silicone has been used on the dorsum. The soft contour
of TPFL means that it can be nicely blended with the
Fig. 27: Various shapes of prefabricated silicone implants overlying skin soft tissue envelope.

Silicone
a thorough hemostasis is of an utmost importance. In the Nasal dorsal augmentation with silicone rubber is the
case of the author, the use of a postauricular dermofat is most popular rhinoplasty procedure in Eastern Asia.
usually favored because of such advantages as the donor Due to its stable chemical structure, silicone has several
site being within the same surgical field of head and neck advantages including its lack of tissue reaction and ease
area, and that it is easy to perform disinfection with limited of handling. Moreover, the availability of readymade
scarring (Figs 26A and B). products makes application convenient and the rela-
tive hardness of silicone makes it suitable for fashioning
Homologous Tissue or Tissue Allograft the desired nasal shape for Asians with a thick skin. The
skin of Asians is thicker than that of Caucasians, so there
Homologous Costal Cartilage
is a lower risk of an implant extrusion after surgery. The
Homologous costal cartilage can be used in revision prefabricated products can be divided largely into L-and
rhinoplasties requiring structural reconstruction of the I-shaped implants (Fig. 27). Because the nasal tip area is
nasal framework, but in which patients resist harvesting an area that is always exposed to exterior stimulation, the
their own costal cartilage. use of L-shaped silicone carries a higher risk of extrusion,
 Augmentation Rhinoplasty 931

regardless of the thickness of nasal subcutaneous tissue in inserting silicone, one must be mindful of the following
Asians. Thus, a placement of I-shaped implant at the nasal aspects:
dorsum area, and tip plasty using an autologous material • The subperiosteal placement of silicone implant may
(septal cartilage, conchal cartilage) at the nasal tip area, is lead to the resorption of the underlying nasal bone by
the preferable surgical method. exerting too much pressure. However, if it is inserted
above the periosteum, the implant can shift when
Trimming the Silicone touched and become visible. Therefore, the implant
• In most cases, problem arises from trying to remove must be inserted within the subperiosteal space and,
too much quantity all at once using a #15 blade or even with the risk of bone resorption, in reality that is
#11 blade, so that the desired length fails to materi- not a problem because a relatively thick fibrous capsule
alize or the silicone becomes torn so that a new sili- gets formed around the implant (Figs 28A and B).
cone becomes needed. Therefore, if the surgeon is To create a precise pocket, make a small incision
a novice, he should give up trying to carve the sili- at an area 5–6 mm lateral to the midline of the keystone
cone cleanly all at once but rather concentrate on area using a Joseph knife and then insert a periosteal
trimming the silicone slowly and with care. Also, he elevator into the subperiosteal space, and gradually
should prefabricate the silicone to some extent and create a pocket towards the midline.
keep it sterilized. • The size of the pocket should be made slightly larger
• Most readymade products are 4.5–5.0 cm × 8–10 mm than the implant, with just enough space for the implant
in size and the decision regarding the length of the and a surgical tool holding the implant to be jammed
silicone should be based on the distance between the through. Also, a space needs to be created evenly on
nasion or nasal root to the supratip area. Also, it should either side. If not, and one side is made larger than the
preferably be about 3.5–4.0 cm long, about 8 mm wide, other, the implant can break away from the center and,
and the edge should be made as thin as possible. At if a hematoma occurs within the pocket, the implant
this point, it is convenient to have the line, between the can incline towards one side.
eyelashes of the upper eyelid and the supratarsal fold, • The nasal dorsum and the base of silicone should be
act as a starting point of augmentation. trimmed to the point that they almost adhere closely
together. Otherwise, the implant will become detached
Method of Inserting the Silicone and a seesaw phenomenon occurs after surgery, caus-
To insert the silicone, an open rhinoplasty approach or an ing a hematoma to form and the implant to become
endonasal approach is used. As with other implants, when deviated and show through the skin.

A B
Figs 28A and B: After incising the junctional area between the bone and the cartilage with a Joseph knife (A);
carefully perform dissection with an elevator (B)
 932 Facial Plastics, Cosmetics and Reconstructive Surgery

A B
Figs 29A and B: (A) Method of suturing a Gore-Tex sheet together and; (B) Additionally fastening the sheets to the
area requiring partial insertion of Gore-Tex

Gore-Tex implants are porous inducing the surrounding

tissue to grow inward through the pore, and have the
advantages of increased stability and lower incidence
of capsule formation. In addition, the risk of extrusion is
lower with Gore-Tex than with silicone. The soft texture of
Gore-Tex reduces patient discomfort and the occurrence
of unnatural visible graft contours through the skin. One
important disadvantage of Gore-Tex is that it decreases in
volume after insertion. In addition, it is more difficult to
remove a Gore-Tex implant than a silicone implant.

Method of Trimming and Inserting Gore-Tex

According to Each Individual Type
• Sheet-shaped Gore-Tex
– Trimming a sheet-shaped Gore-Tex: Sheet-shaped
Gore-Tex is 2 mm thick and usually, according
to the intended degree of augmentation, a sheet
8 mm wide should be multilayered with two-fold
(4 mm) to three-fold (6 mm) and used. While doing
this, suture both ends with nylon or PDS to prevent
Fig. 30: Method of inserting a sheet-shaped Gore-Tex the sheet from opening up and then the supratip
using a thread side must be trimmed as thin as possible into a
triangular shape while the end of the nasion area
• Deviated nose must be corrected prior to inserting the must also be trimmed and made as thin as possible
silicone. (Figs 29A and B).
• It is preferable to use an autologous cartilage when – Technique of inserting a sheet-shaped Gore-Tex:
operating on the nasal tip to avoid inflammation and Because Gore-Tex sheet, unlike silicone, is soft and
silicone extrusion. has a low solidity, care must be taken to prevent it
from folding while it is being inserted. Method of
Gore-Tex insertion can be divided largely between two types
Gore-Tex (expanded polytetrafluoroethylene:ePTFE), next as shown in the Figures 30 and 31, and it is all right
to silicone, is the most widely used alloplastic implant for the surgeon to choose the method of his choice.
in Asian noses and currently, its use is on the increase. Only, make sure to feel for the nasal dorsum
 Augmentation Rhinoplasty 933

A B C
Figs 31A to C: (A) Method of inserting a sheet-shaped Gore-Tex using a bayonet forceps. After grasping the front part of
a sheet-shaped Gore-Tex with a bayonet forceps, start inserting it in a slightly lifting manner; (B) When the implant reaches
the correct position, fixate it to the bone by penetrating a needle through the skin of the nasal dorsum and the implant so
that it does not slip away from the desired location when the forceps is withdrawn; (C) Subsequently, the nasal dorsum
must be felt with fingers to check for any bent areas and then use an elevator to straighten it. As occasion demands, it is
sometimes sutured to the lower lateral cartilage to make it secure

with fingers for any bent area after the implant is As in trimming silicone, the decision regard-
inserted and do not forget to use an elevator to ing the length should be based on the distance
straighten it out. In the case of Gore-Tex, although between the nasion or nasal root to the supratip
there is a lesser risk of extrusion than silicone, and preferably should be about 3.5–4.0 cm long,
an autologous tissue must always be used at the and about 8 mm wide. Also, the edge should be as
nasal tip. thin as possible.
• Block-shaped (Reinforced) Gore-Tex – Insertion technique: The insertion technique of
– Trimming: Unlike the sheet-shaped Gore-Tex, the a block-shaped Gore-Tex, same as in inserting
block-shaped Gore-Tex has a certain level of hard- silicone, can either be an open rhinoplasty
ness, so it is easy to carve with a blade. Similar to app­roach (Figs 33A to D) or an intranasal approach
silicone, a block-shaped Gore-Tex needs to be (Figs 34A to P).
pretrimmed to approximately match the patient’s
nose using an appropriately sized block (a rectan-
gular parallelopipedon which is about 3–5 mm
NEW TECHNIQUES IN THE SURGERY
thick, 8–10 mm wide, 5–6 cm long). Then, it must Crushed Cartilage-TPFL Grafting
be prepared for surgery by gas sterilization. During
surgery, a blade should be used to adjust it to the Crushed cartilage-TPFL grafting to the nasal dorsum
patient’s nasal dorsum and then applied to the was used in patients who disliked the use of alloplastic
patient. Currently, there are readymade nasal material for dorsal augmentation, and in revision surgery
augmentation products in the market which are cases involving complications following the use of
relatively easy to carve and use. silicone implants on the nasal dorsum. All rhinoplasties
In most cases, either a #15 blade or #11 blade is were performed via an external approach after making
used for trimming. And, because the block-shaped a transcolumellar incision. Intravenous antibiotics,
Gore-Tex has a softer quality than silicone, instead usually a second generation cephalosporin, were
of forcing the blade, it is best to trim it in a softly injected 1 hour prior to incision. TPFL was rehydrated
twirling manner. In addition, when trimming the in a saline solution for at least 5 minutes before use
dorsal part of the implant, it is useful to use a razor (according to the manufacturer’s instructions) and then
that is rolled in a carved shape (Figs 32A and B). cut to the desired size. The technique used has been
 934 Facial Plastics, Cosmetics and Reconstructive Surgery

A B
Figs 32A and B: Trimming a block-shaped Gore-Tex

A B

C D
Figs 33A to D: After grasping the Gore-Tex with the bayonet-shaped forceps capable of clamping (A); insert the Gore-
Tex into the dissected pocket (B). (C) To prevent the implant from slipping out with the forceps when it is withdrawn, fixate
it with a needle; (D) The fastened needle can be maintained until the casting is removed after surgery. Cut or adjust the
position of the implant so that the end of the implant is positioned at the supratip break area
 Augmentation Rhinoplasty 935

A B

C D

E F
Figs 34A to F
936 Facial Plastics, Cosmetics and Reconstructive Surgery

G H

I J

K L
Figs 34G to L
 Augmentation Rhinoplasty 937

M N

O P
Figs 34A to P: Technique of performing a Gore-Tex augmentation rhinoplasty using an intranasal approach

previously published.6 Cartilage was preferentially used cartilage complex. Postoperative antibiotics were pres­
for tip surgery and reconstruction of the septal cartilage cribed for 2 weeks after the operation.
framework. Any remaining cartilage fragments or bones
were gently crushed using a cartilage crusher. The crushed Silicone Sheeting
cartilage and/or bone were then placed onto the nasal The author has used silicone sheeting for nasal dorsal
dorsum under direct vision, considering a differential augmentation, which is more versatile but without
augmentation along the length of the dorsum (see Fig. 24). an increased risk of complications (Figs 35A and B).
A stack of multilayered (two or three layers) TPFL at the In trimming the silicone, it should preferably be about
desired thickness was inserted onto the dorsum. When 3.5–4.0 cm long and about 8 mm wide, and the edge
further augmentation of the nasal dorsum was required, should be as thin as possible. To insert the silicone, an
a little more remaining crushed cartilage was inserted open rhinoplasty approach or an endonasal approach
deep to the TPFL. The nose was then taped and external is used. The size of the pocket should be made slightly
nasal splinting, using Aquaplast (WFR/Aquaplast Corp, larger than the implant, with just enough space for
Wyckoff, NJ), was placed for 6 days after the surgery to insertion of the implant and a surgical tool holding the
prevent lateral displacement of the fascia and crushed implant at the same time.
 938 Facial Plastics, Cosmetics and Reconstructive Surgery

A B A B
Figs 35A and B: (A) Patient before and; (B) After Figs 36A and B: (A) Patient before and; (B) After under­
undergoing dorsal augmentation using silicone sheeting going rhinoplasty using Tutoplast processed fascia lata for
management of contracted nose caused by infection due to
silicone implant

COMPLICATIONS impending extrusion, and infection. Early infections can

be prevented by the use of aseptic techniques and prophy-
Autologous Cartilage lactic antibiotics. Infection can also be treated by implant
Although autologous cartilage has the lowest risk of infec- removal, antibiotic administration, and delayed rein-
tion among graft materials, autologous cartilage includ- sertion. Extrusion of the implant can occur through the
ing costal cartilage is associated with a significant risk of nasal skin or mucosa, with tension over the implant being
revision surgery, with rates as high as 15.5%. The primary the most common cause of extrusion. The most likely
reasons for this high revision rate is that autologous tissue cause of implant displacement is supraperiosteal place-
is usually used to treat more difficult cases and use of these ment of implants. Thus, implant displacement can be
implants is associated with unpredictable scarring, warp- reduced by placing it immediately below the periosteum
ing and, at times, visible graft contours (see Figs 20A and B). (Figs 36A and B).

Homologous Costal Cartilage Gore-Tex

The use of homologous costal cartilage in rhinoplasty has Reports of a delayed inflammation are increasing and
shown conflicting results regarding the degree of resorp- outcome data are not adequately accumulated to date.
tion and warping. In the authors’ own experience, a signifi- One must be cautious when using Gore-Tex in the pres-
cant number of patients had unpredictable complications, ence of inflammation within the nasal cavity (sinusitis,
such as resorption, warping, and graft visibility, when this vestibulitis, and active acne). Moreover, when perform-
cartilage was used as full-length dorsal graft. The high ing operations that may create microcommunication
complication rate associated with homologous cartilage with the nasal cavity (e.g. osteotomy or septal reconstruc-
may limit its utility for dorsal augmentation. tion), there is an increased risk of infection. It has been
recommended that patients be treated with antibiotics
Homologous Fascia prior to inserting the Gore-Tex as well as after surgery,
Although TPFL has very low risks of infection, displace- and it is essential to soak the Gore-Tex in saline solu-
ment and extrusion, but an unpredictable degree of tion containing Betadine or antibiotics before use. Also,
resorption could be a problem. before handling the Gore-Tex, surgical personnel should
wash their gloves to remove powder or other foreign
Silicone substances. It has been reported that infection rate in
Revision rhinoplasty after silicone implants may be needed primary surgery is 1.2%, while infection rate in secondary
for implant deviation, floating, displacement, extrusion, surgery is 5.4%.
 Augmentation Rhinoplasty 939

SPECIAL INSTRUMENTS USED FOR

THE SURGERY
Figures 37 to 40 show the instruments used for the surgery.

Fig. 37: Gouge (right), Joseph nasal knife (middle), and

Freer septum elevator (left)

B C
Figs 38A to C: Razor blade
 940 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 39: Cartilage crusher Fig. 40: Grid

BIBLIOGRAPHY facial soft-tissue suspension, augmentation, and recon-

struction. J Long Term Eff Med Implants. 1998;8(1):19-42.
1. Baeck SI, Joung DH, Min YG. Rhinoplasty. In Min YG (Ed). 12. Maas CS, Gnepp DR, Bumpous J. Expanded polytetrafluo-
Clinical Rhinology, 1st edition. Seoul: Ilchokak Publishing roethylene (Gore-Tex soft-tissue patch) in facial augmen-
Co; 1997. pp. 507-63. tation. Arch Otolaryngol Head Neck Surg. 1993;119(9):
2. Bateman N, Jones NS. Retrospective review of augmentation 1008-14.
rhinoplasties using autologous cartilage grafts. J Laryngol 13. Maas CS, Monhian N, Shah SB. Implants in rhinoplasty.
Otol. 2000;114(7):514-8. Facial Plast Surg. 1997;13(4):279-90.
3. Byrd HS, Andochick S. Copit S. et al. Septal extension graft: 14. McCurdy JA Jr. The Asian nose: augmentation rhino-
a method of controlling tip projection shape. Plast Reconstr plasty with L-shaped silicone implants. Facial Plast Surg.
Surg. 1997;100(4):999-1010. 2002;18 (4):245-52.
4. Daniel RK, Calvert JW. Diced cartilage grafts in rhinoplasty 15. Slavin SA, Rees TD, Guy CL, et al. An investigation of bacte-
surgery. Plast Reconstr Surg. 2004;113(7):2156-71. remia during rhinoplasty. Plast Reconstr Surg. 1983;71
5. Erlich MA, Parhiscar A. Nasal dorsal augmentation with (2):196-8.
silicone implants. Facial Plast Surg. 2003;19(4):325-30. 16. Stucker FJ, Shaw G. Ephrat M. Biologic tissue implants. In:
6. Ghoniem GM. Allograft sling material: is it the state of the Papel ID (Ed). Facial Plastic and Reconstructive Surgery,
art? Int Urogynecol J Pelvic Floor Dysfunct. 2000;11(2): 2nd edition. New York: Thieme; 2002. pp. 73-8.
69-70. 17. Tham C, Lai YL, Weng CJ, et al. Silicone augmentation rhino-
7. Godin MS, Waldman SR, Johnson CM Jr. Nasal augmenta- plasty in an oriental population. Ann Plast Surg. 2005;54
tion using Gore-Tex: a 10-year experience. Arch Facial Plast (1):1-5.
Surg. 1999;1(2):118-21. 18. Toriumi DM, Swartout B. Asian rhinoplasty. Facial Plast
8. Guerrerosantos J. Nose and paranasal augmentation: Surg Clin North Am. 2007;15(3):293-307.
autogenous, fascia, and cartilage. Clin Plast Surg. 1991;18 19. Wang JH, Lee BJ, Jang YJ. Use of silicone sheets for dorsal
(1):65-86. augmentation in rhinoplasty for Asian noses. Acta
9. Jang YJ, Song HM, Yoon YJ, et al. Combined use of crushed Otolaryngol Suppl. 2007;(558):115-20.
cartilage and processed fascia lata for dorsal augmenta- 20. Welling DB, Maves MD, Schuller DE, et al. Irradiated homol-
tion in rhinoplasty for Asians. Laryngoscope. 2009;119 ogous cartilage grafts. Long-term results. Arch Otolaryngol
(6):1088-92. Head Neck Surg. 1988;114(3):291-5.
10. Jang YJ, Wang JH, Sinha V, et al. Tutoplast-processed fascia 21. Yang SJ, Kim BS, Kim JH. Secondary augmentation rhino-
lata for dorsal augmentation in rhinoplasty. Otolaryngol plasty with dermofat graft. J Korean Soc Plast Reconstr Surg.
Head Neck Surg. 2007;137(1):88-92. 1998;25:152-60.
11. Lewis RP, Schweitzer J, Odum BC, et al. Sheets, 3-D strands, 22. Yeo NK, Jang YJ. Rhinoplasty to correct nasal deformi-
trimensional (3-D) shapes, and sutures of either reinforced ties in postseptoplasty patients. Am J Rhinol Allergy.
or nonreinforced expanded polytetrafluoroethylene for 2009;23(5):540-5.
 The Surgical Technique of Otoplasty 941
CHAPTER

99 The Surgical Management of the

Crooked Nose
Yakup Cil

INTRODUCTION Step 1
The primary goal of the crooked nose management is The patient under general anesthesia, the nasal septum
straightening the nose symmetrically without collapse or and the external nose were infiltrated with 1% xylocaine
relapse. Collapse or relapse occurs frequently due to weak with 1:100,000 epinephrine. Time has been allowed for the
structural support. Conventional septal surgery may not vasoconstrictive effect of the infiltration solution to take
be adequate to prevent recurrences. The aim of this chap- place and number-15 blade was used to perform nasal
ter is to present the author and associates’ current princi- incision for open rhinoplasty approach. Nasal structures
ples of correcting the crooked nose with iliac bone graft.1 were exposed through standard transcolumellar incision
and two marginal incisions. The hump resection with
mucosal preservation was performed primarily to conserve
OPERATIVE TECHNIQUE the vertical nasal height. Then, septal dissection began
between medial cruras of both lower lateral cartilages, and
Indications
septum was separated from two mucoperichondrial flaps
Iliac bone graft is indicated for the patients who have (Fig. 2).
crooked nose; if their cartilaginous septum is seriously
destructed and/or their deformity includes both upper Step 2
lateral cartilage and cartilaginous septum. After septal separation, iliac bone donor site’s skin area
was infiltrated with 1% xylocaine with 1:100,000 epineph-
Preoperative Planning rine. A block of bone 3 × 2 × 0.5 cm in size was harvested
Successful management of the crooked nose surgery is from right iliac crest medial wall (right or left could be
best achieved through careful analysis of the problem and used) with electrical saw (Fig. 3).
clear communication with the patient regarding expecta-
tions of surgery. The crooked nose should be considered Step 3
as an osseocartilaginous unit in which all components The bone graft was shaped as L-strut by electrical saw and
may potentially play a role. The external examination thinned by abrasion (Fig. 4).
concludes with an assessment of the shape and position
of the nasal bones and the upper and lower lateral carti- Step 4
laginous vault. Photographic documentations should be The septum was resected leaving a 0.8–1 cm dorsal and
performed in all cases before surgery. caudal L-strut. Deviated caudal portion of the septal carti-
lage was straightened by medialization. L-strut bone graft
Patients was stabilized by the nasal septal cartilage (Fig. 5). Lateral
Treatments of the crooked nose with iliac bone graft and medial osteotomies were performed. Residual irreg-
were performed in the author and associates’ clinic since ularities on the dorsum were camouflaged with Turkish
February 2005. All the patients had severely distorted delight and operation was completed.2
septum with cosmetic nasal problems. All surgeries were
performed under general anesthesia. Postoperative Care
After nasal packing, external bandage and cast plaster
Case Presentation for Technique were applied. The packing was removed after 4 days. The
Twenty-three-year-old male who had crooked nose due plaster nasal splint was replaced with another one at
to blunt trauma at childhood is presented here (Fig. 1). 7 days postoperatively. The second splint was removed
Clinical examination revealed osseocartilaginous devia- 1 week after. Donor site was closed appropriately with
tion with severely distorted septum. mini Hemovac drain, which was removed within 3 days
 942 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 1: Preoperative view of the patient with crooked nose

postoperatively. Patient had a straight nose with a natural graft (Fig. 9). Lateral antecubital nerve, flexor, and exten-
appearance at 13-month follow-up (Figs 6 and 7). sor muscles were protected during bone graft harvesting
procedure.
Results Fibular bone graft was accessed from the lateral leg
The mean operation time was 4 hours (3–4.5 hours). All region, and bone graft was taken from the lateral side
patients healed uneventfully. The grafts have shifted in any of fibular bone for L-strut framework (Fig. 10). Lateral
case, and have not developed unsightly irregularities over muscles were protected during bone graft harvesting
time. Absorption of the grafts was not seen in the follow- procedure.
up (Fig. 8). All patients had a straight nose with a natural
appearance at follow-up. Discussion
Various techniques have been described for the correc-
Alternative Bone Graft Sources for tion of the crooked nose. Problems can be localized in the
L-Strut Frame upper (bony) and lower (cartilaginous) portions or both
Radial and fibular bone may also be used for crooked nose (osteocartilaginous).3 According to these localizations,
treatment. Bone graft was harvested from the lateral side of surgical algorithm for the management of the crooked
radial bone and L-strut framework was prepared with this nose may differ. Only the osteotomies may be performed,
 The Surgıcal Management of the Crooked Nose 943

Fig. 2: Deviated nasal septum, intraoperatively Fig. 3: Bloc bone graft was taken from iliac crest

Fig. 4: The bone graft was shaped as L-strut by electrical saw and thinned by abrasion

if bony deviation is present.4 Dorsal hump resections,5 prevent redeviation, the author and associates aimed to
a variety of modified osteotomies,6-8 septal cartilage mani­ use rigid iliac bone grafts instead of flexible and relatively
pulations,9 suture correction,10 and spreader grafts11,12 weak cartilage to maintain the support of the corrected
have been recommended. However, the problem still chal- deformity.
lenges with high recurrence and revision rates because of The most popular method to maintain long-term
unpredictable behavior of cartilage even after correction. support is reinforcement of corrected septum with sprea­
Besides straightening the septum, maintaining its support der grafts.11,13 The spreader grafts restore the integrity of
is also crucial for long lasting results. Conventional septal septal L-struts. These splinting grafts resist the memory of
surgery may not be adequate to prevent recurrences. To the septal cartilage and prevent relapse of the curvature.14
 944 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 5: Deviated septal cartilage was straightened by medialization and L-strut bone graft was stabilized
by the nasal septal cartilage

Unilateral spreader graft,3 unilateral spreader-extension memory of the previous position. There was no significant
grafts,11 asymmetric spreader grafts4 were also described. contour deformity at the donor site.
However, the graft obtained from severely deviated carti- In conclusion, L-strut iliac bone graft could be very
laginous septum is relatively weak and cannot produce usable in selected patients who have crooked nose.
adequate support. Bony-cartilaginous spreader stents may
also fail even if they are combined.4 It is also technically Surgical Tips
difficult to harvest long and straight pieces of spreader • Clear communication with the patient regarding his or
grafts from a severely distorted osseocartilaginous septum. her expectations from the surgery.
In addition, flexible cartilage has unpredictable tendency • Careful analysis of the nasal problem.
to retain its curvature attributed to its memory. A more • Open rhinoplasty approach is preferable.
rigid framework is necessary against deforming forces • Deviated portion of the septal cartilage should be
during the healing period. Some authors12 have preferred straightened by medialization before L-strut bone graft
using alloplastic materials as spreader grafts in respect of stabilization.
more rigid stabilization. The author and associates consid- • The bone graft should be harvested from medial iliac
ered to use an autolog material that is more rigid from region in order to minimize donor site morbidity.
cartilage and more reliable than alloplasts. Medial side of • Shaping the bone graft as L-strut framework should be
iliac crest provides a source of straight bone when shaped done carefully.
properly. L-strut shaped medial crest graft supports the • Camouflage grafts could be used for dorsal smooth-
realigned caudal-dorsal septum despite the cartilaginous ness, and hide minor residual deviations.
 The Surgıcal Management of the Crooked Nose 945

Fig. 6: Preoperative (left), postoperative 1 month (middle), 13 months (right) view of patient
946 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 7: Preoperative (left), postoperative 1 month (middle), 13 months (right) inferior view of patient

Fig. 8: Radiologic appearances of L-strut bone graft

Fig. 9: Radial bone graft alternative to L-strut graft source (RA: Radial artery; UN: Ulnar nerve; MN: Median nerve)
 The Surgıcal Management of the Crooked Nose 947

Fig. 10: Fibular bone graft alternative to L-strut graft source

8. Fanous N. Unilateral osteotomies for external bony devia-

REFERENCES tion of the nose. Plast Reconstr Surg. 1997;100(1):115-23.
1. Cil Y, Ozturk S, Kocman AE, et al. The crooked nose: the use 9. Park DH, Kim TM, Han DG, et al. Endoscopic-assisted
of medial iliac crest bone graft as a supporting framework. J correction of the deviated nose. Aesthetic Plast Surg.
Craniofac Surg. 2008;19(6):1631-8. 1998;22(3):190-5.
2. Erol OO. The Turkish delight: a pliable graft for rhinoplasty. 10. Calderón-Cuéllar LT, Trujillo-Hernández B, Vásquez C,
Plast Reconstr Surg. 2000;105(6):2229-41. et al. Modified mattress suture technique to correct anterior
3. Boccieri A, Pascali M. Septal crossbar graft for the correction septal deviation. Plast Reconstr Surg. 2004;114(6):1436-41.
of the crooked nose. Plast Reconstr Surg. 2003;111(2):629-38. 11. Byrd HS, Salomon J, Flood J. Correction of the crooked nose.
4. Rohrich RJ, Gunter JP, Deuber MA, et al. The deviated nose: Plast Reconstr Surg. 1998;102(6):2148-57.
optimizing results using a simplified classification and algo- 12. Mendelsohn M. Straightening the crooked middle third
rithmic approach. Plast Reconstr Surg. 2002;110(6):1509-23.
of the nose: using porous polyethylene extended spreader
5. Constantian MB. An algorithm for correcting the asymmet-
grafts. Arch Facial Plast Surg. 2005;7(2):74-80.
rical nose. Plast Reconstr Surg. 1989;83(5):801-11.
13. Guyuron B, Uzzo CD, Scull H. A practical classification
6. Jameson JJ, Perry AD, Ritter EF. High septal osteotomy
in rhinoplasty for the deviated nose. Ann Plast Surg. of septonasal deviation and an effective guide to septal
2006;56(1):40-5. surgery. Plast Reconstr Surg. 1999;104(7):2202-9.
7. Bracaglia R, Fortunato R, Gentileschi S. Double lateral 14. Kim DW, Toriumi DM. Management of posttraumatic nasal
osteotomy in aesthetic rhinoplasty. Br J Plast Surg. deformities: the crooked nose and the saddle nose. Facial
2004;57(2):156-9. Plast Surg Clin North Am. 2004;12(1):111-32.
 The Surgical Technique of Otoplasty 948
CHAPTER

100 Surgical Techniques in Open

Rhinoplasty Procedures
Tamer Seyhan

HISTORY Table 1: Medical conditions generally corrected

with an open rhinoplasty approach
Historically, the first rhinoplasty procedure was performed
by using a midline dorsal external incision in the 1850s.1 Revision rhinoplasties
Subsequently, Jacques Joseph popularized the endona- Severe alar and upper lateral cartilage deformities
sal approach for rhinoplasty in the 1930s.2 In a 1948 issue Severe nasal valve problems
of “Plastic and Reconstructive Surgery,” Rethi, a Hungarian Severe septal deformities and septal perforations
surgeon, described the transcolumellar incison (vertical V) Nasal deformity with severe breathing problems
and renewed interest in the external (open) rhinoplasty Cleft lip nose deformity
approach.3 It was Goodman, who devoted the entire issue
of the “Canadian Journal of Otolaryngology” to the exter-
nal (open) rhinoplasty approach and increased interest in preference, management of some conditions requires an
the external approach among North Americans during the open approach. Such conditions generally corrected with
1970s.4 Although the controversy of “open versus closed” the open approach are summarized in Table 1.
rhinoplasty approach is still an ongoing issue among The author prefers the closed approach for “simple”
surgeons, the external approach has gained proponents cases that require simple tip and dorsal surgery.
increasingly.5,6 Younger surgeons perform open rhino-
plasty more frequently than older surgeons.6 SPECIFIC PREOPERATIVE
EVALUATIONS
INDICATIONS FOR THE SURGERY A specific preoperative evaluation is necessary for the
Proponents of the open rhinoplasty approach cite patient who demands a rhinoplasty. Patient expecta-
supporting points in favor of the open technique.6 First of tions are noted and those which are surgically correct-
all, direct visualization of the nasal cartilages and handling able or require secondary and other operations should
and grafting of the nasal cartilages are easier with the open be discussed openly with the patient. The patients with
approach rhinoplasty than the closed approach rhino- body dysmorphic disorder and unrealistic expecta-
plasty. Management of a deviated bony and cartilaginous tions should be identified during the preoperative inter-
septum and management of nasal septal spurs are easier view.9-12 Cosmetic surgery should not be performed in
in the open approach rhinoplasty. Finally, low revision such patients, who are then referred to a psychiatrist.
rates for primary open rhinoplasty have been reported.7,8 A detailed history should be obtained and a physical
Except for the difficulty of secondary revision procedures, examination of the patient should be performed and all
following open rhinoplasty, the disadvantages of the open findings recorded in a printed examination form or as
approach are minimal, such as prolonged tip edema, computer data. Important points of this form are demon-
extended operation time and scarring. With respect to strated below (Table 2). Also, signed informed consent
the final transcolumellar scar, it is acceptable in most should be obtained from the patient. An informed consent
cases. In the beginning of my practice, the ratio of open- form for rhinoplasty can easily be found on the internet
to-close approaches was 50:50. After 10 years of experi- (Appendage 1).
ence and approximately 1,000 rhinoplasties that ratio
was 90:10, favoring the open approach. In addition to the
aforementioned advantages, the author believes that the
ANESTHETIC CONSIDERATIONS
longevity of the results of an open approach exceed the The majority of operations, except minor revisions, are
closed approach. Although the choice of open or closed performed under general anesthesia, supplemented with
approach rhinoplasty is generally related to the surgeon’s 7 mL of 0.5% bupivacaine and 3 mL of physiologic serum
 Surgical Techniques in Open Rhinoplasty Procedures 949

Table 2: Some important points taken into consideration during the examination of a rhinoplasty patient

Brief history Prior nasal trauma or nasal surgery?

Identifying the body-dysmorphic patient If some clues are detected during the interview, use a
screening questionnaire or refer for psychiatric counseling!
The use of herbal medicine (potential for increased bleeding) Such as garlic, ginseng, ginger, ginkgo biloba and echinacea
should be discontinued 2 weeks before surgery.
Questions in relation to hemorrhagic diatheses Table 3
History of smoking Patients should quit smoking for at least 4 weeks before
surgery.
Allergies Allergic rhinitis? Allergies to any medications or plaster?
Prior operations under general anesthesia Any problems related to general anesthesia?
Primary complaint of the patient Breathing (which of the areas? Right, left or both?), aesthetic
concerns or both?
Nasal physical examination Nasal skin (thin, thick and oily or mixed); nasofrontal angle;
nasolabial angle; hump (cartilaginous, bony or both); nasal
tip projection; nasal tip width; nasal tip asymmetry; upper
lip height (narrow or long); nasal spine hypertrophy (yes
or no); smiling deformity (yes or no); nasal radix (low or
high [requires wedge excision]); alar base (narrow or large
[requires wedge excision]); nostril asymmetry (yes or no);
Examination of the nasal valve (Cottle test); speculum exam
(septum, inferior and middle concha and concha bullosa?);
nasal passage exam (prior and after vasoconstrictor, such as
xylometazoline and oxymetazoline gut)
CT examination of paranasal sinuses If history of severe headache, suspected concha bullosa or
any reason that explains breathing problem on physical
examination is not present.
Impression and any specific explanations to the patient The probability of second or third operations, continuing
breathing problems due to surgically insoluble problem
(allergy)
Operation plan Specific procedures based on the above findings
(e.g., median osteotomy with wedge excision, alar base
narrowing, nasal spine reduction, asymmetric spreader
graft, spur resection, concha bullosa resection, functional
endoscopic sinus surgery, concha resection or lateralization.
Surgical procedure Gunter rhinoplasty diagrams13

Table 3: Clues for hemorrhagic diathesis during with epinephrine (1 : 100,000). Nasal packing soaked in
preoperative evaluation oxymetazoline and xylometazoline is inserted in the nasal
passages 5 to 10 minutes before surgery. A throat pack is
• History of excessive bleeding after previous surgical or
then placed in the oropharynx after oral intubation, which
nonsurgical trauma.
reduces postoperative nausea from swallowed blood. The
• History of excessive bruising, epistaxis, intramuscular or
columella and nasal lobule are infiltrated first and then
intraarticular bleeding episodes.
hydrodissection of the septal mucosa is infiltrated and
• Family history remarkable for a coagulopathy.
hydrodissected with a local anesthetic. Infiltration to the
• Petechiae, purpura and ecchymotic areas.
lateral osteotomy site is performed 7 to 10 minutes before
• History of menorrhagia (heavy and prolonged menstrual perforating lateral osteotomies. If turbinate surgery or
periods), severe preeclampsia, eclampsia and repeated
radiofrequency ablation is planned under general anes-
abortus.
thesia, topically decongest the turbinates with application
• Spontaneous abortus during previous pregnancies.
of a decongestant on nasal pledgets. If a concha bullosa
 950 Facial Plastics, Cosmetics and Reconstructive Surgery

resection is performed under general anesthesia, the Hewlett, NY, USA; Fig. 2A). Coagulation mode (partially
conchae are infiltrated with local anesthetic solution after rectified waves) is selected. The power is adjusted to 3.
vasoconstrictor-containing nasal packing. The Bayonette Turbinate Electrode needles are placed
in the hypertrophic inferior turbinate approximately
2 to 3 mm into the turbinate tissue (Figs 2B to D). The
SURGICAL STEPS current is used until visual blanching occurs at the
hypertrophied site.
Surgical Technique
• A winged inverted-V incision of Goodman4 is made
• The patient is prepped and draped. The back of the using a No. 15 blade at the narrowest distance between
patient is elevated, and then adjusted in a manner the nostrils with special care not to damage the under-
such that the head of the patient is parallel to the floor lying medial crura. The columellar part of the marginal
(Fig. 1). incision should be placed 1.5 to 2 mm inside the vesti-
• Radiofrequency cauterization or anterior turbino- bulum. The alar part of the incision should be placed
plasty is performed in case of hypertrophied turbinate. 1.5 to 2 mm inside the alar rim, at the apex and follow
The author uses a 3.8, 140 watt MHz Surgitron EMC the cranial edge of the alar cartilages (Fig. 3A). The soft
high frequency radiosurgical unit (Elman Corporation, tissue envelope (the columellar skin over the incision,
distal nasal skin over the upper and lower lateral carti-
lages and the skin over the bony pyramid) is raised
subperichondrially and subperiosteally, using a skin
hook and fine dissecting scissors (Figs 3B to E). The
transected columellar arteries are coagulated with fine
bipolar cautery. The elevation over the bony pyramid
should not be very far laterally, but only to the area of
the hump to be resected. Thick supratip subcutaneous
tissues can be thinned very conservatively. The shape,
size and volume of the alar cartilages are evaluated.
As a rule, the excess cephalic part of the lateral crus
of the alar cartilages is excised by leaving a 6 to 8 mm
caudal strip of the cartilages (Fig. 3F). The manage-
ment of other deformities of the lateral crura have
been described before.14
• Approach a deviated quadrangular septum, bony
septal spurs, deviated vomer and caudal septum with
Fig. 1: Preoperative positioning of the patient the tip split and dorsal split techniques.4,15 Dorsal and

A B
Figs 2A and B
 Surgical Techniques in Open Rhinoplasty Procedures 951

C D
Figs 2A to D: The view of Surgitron EMC high frequency radiosurgical unit and the
Bayonette Turbinate Electrode needles and its usage

Fig. 3A: The view of winged-inverted V incision and

A marginal incision of columella and alae

B C
Figs 3B and C
952 Facial Plastics, Cosmetics and Reconstructive Surgery

D E
Figs 3B to E: Raising of the soft tissue envelope with fine dissecting scissors and skin hooks

Fig. 3F: Excision of excess cephalic alar cartilages leaving

F a 6 to 8 mm caudal strip

base deviations of the septum are easily handled with

these approaches. Also, placement of caudal strut
grafts between the medial crura is easy with a tip split
approach. The medial crura of the alar cartilages are
separated to expose the septum and bilateral septal
submucoperichondrial dissections are performed.
Both sides of the cartilaginous and bony septum are
exposed (Fig. 4A). The upper lateral cartilages are
separated from the septum (Fig. 4B). The septum is
detached from its base and from the bony septum.
The deviated septal parts, including the septal spurs,
are resected, leaving at least a 0.8 to 1 cm dorsal and
caudal L-shaped strip of cartilage (Fig. 4C). Graft mate-
rials for the columellar strut and spreader grafts are
harvested from the base of the septum without damag- A
ing the anterior nasal spine (Figs 4C and D). A reverse Fig. 4A: The view of the tip split approach
 Surgical Techniques in Open Rhinoplasty Procedures 953

B C
Fig. 4B: The view of the dorsal split approach Fig. 4C: Resection of the deviated septal parts

D E
Figs 4D and E: (D) Harvested graft material from the base of the septum; (E) Tip rotation maneuver by
resecting reverse triangular segment of the caudal septum

triangular segment of the caudal septum is resected to • Use the transoral lateral osteotomy both for saddle
achieve tip rotation (Fig. 4E). nose deformity and nasomaxillary depression.16
• The caudal end of the upper lateral cartilages are Perform external/percutaneous perforating lateral
grasped with a clamp and pulled to facilitate the intra- osteotomies with a 2 mm straight chisel to reduce post-
mucosal dissection of the dorsal edges. The excess operative ecchymoses and edema.17 External/percuta-
dorsal part of the upper lateral cartilages and septum neous perforating lateral osteotomies are begun at the
are conservatively lowered before hump reduction midportion of the lateral osteotomy line after piercing
(Figs 5A to C). with a 2 mm osteotome (Fig. 7A). The tip of the oste-
• The septal hump is lowered using a knife and the otome leans against the bone with pressure at an angle
bony hump is lowered using a tungsten carbide rasp between 30º and 45º (Fig. 7B). Perforations are barely
to open the roof. A straight rasp is used for the caudal made through the bone. Adjacent punctures are placed
hump and a curved rasp is used for lowering the radix a few millimeters apart and terminated at the level of
(Figs 6A and B). Prefer not to use the hump osteotome the medial canthus. Digital pressure to the bony nasal
for hump reduction. pyramid at the canthal level produces a greenstick
954 Facial Plastics, Cosmetics and Reconstructive Surgery

A B

Figs 5A to C: The resections of the excess dorsal part of

C the upper lateral cartilages and septum

A B
Figs 6A and B: A straight rasp used for the caudal hump and a curved rasp used for lowering the radix
 Surgical Techniques in Open Rhinoplasty Procedures 955

A B
Figs 7A and B: The view of the external percutaneous perforating lateral osteotomy

Fig. 7C: The view of 15º medial osteotomies of the nasal

C root with 5 mm sharp unguarded osteotomies

fracture. Fifteen-degree medial osteotomies of the provides columellar lengthening and supports the
nasal root are performed with 5 mm sharp unguarded nasal tip (Fig. 9B). Horizontal mattress interdomal
osteotomes for patients with thick nasal bone or a sutures, sandwiching the columellar strut are used to
deviated bony pyramid (Fig. 7C). Removal of the bone increase the lobular projection. Horizontal mattress
wedge between the nasal bone and the bony septum at transdomal sutures are used to narrow the lobular
the radix nasi region prior to the medial osteotomy is width (Figs 9C and D). Suture between the medial
performed in patients who have a wide nasal root. crura and septum is used if columella-lobular rotation
• The dorsal septum is straightened and nasal valve is inadequate (Fig. 9E). Other suture techniques which
collapse is prevented using bilateral spreader grafts can be used for the nasal tip have been described in
prepared from the septal graft (Figs 8A and B). detail before.18
• A columellar strut graft is inserted between the medial • The transcolumellar incision is closed using 6 to 0
crura of the alar cartilages and accurate alignment polypropylene suture and marginal incisions are
can be achieved by skewering the medial crura with closed using 5 to 0 rapid polyglactin 910 sutures
No. 27 needles (Fig. 9A). The columellar strut graft (Figs 10A to C).
956 Facial Plastics, Cosmetics and Reconstructive Surgery

A B
Figs 8A and B: The placement of bilateral spreader grafts

A B
Figs 9A and B: (A) The view of a columellar strut between the medial crura. (B) The columellar strut is
sandwiched between the medial and middle crura with sutures

C D
Figs 9C and D
 Surgical Techniques in Open Rhinoplasty Procedures 957

Figs 9C to E: (C and D) Interdomal and transdomal sutures

used to increase lobular projection and narrow the lobular
width. (E) Suture between medial crura and septum is used,
if columellar-lobular rotation is inadequate. It was not used
in this patient because the columellar-lobular rotation was
E adequate

A B

Figs 10A to C: The view of the patient after all the

C incisions are closed
 958 Facial Plastics, Cosmetics and Reconstructive Surgery

A B
Figs 11A and B: The postoperative view of the patient after nasal packing and splinting

A B
Figs 12A and B: The preoperative view of the patient

• The nose is draped with layered tapes and an external • The patient is reexamined following the operation at
thermoplastic splint is applied. A split merocel impreg- first, third, sixth month and 1 year after the operation
nated with lidocaine-prilocaine cream in a clear glove (Figs 12A to D).
finger is used as a nasal packing (Figs 11A and B).19 An • In conclusion open approach in rhinoplasty provides
intranasal silastic septal splint (Bivalve Nasal Splint, a direct inspection of the osteocartilaginous vault and
large; Boston Medical Products, Westborough, MA, corrections of anatomical deformities by grafting and
USA) is applied and fixed by transseptal sutures in suturing techniques. Its disadvantages are minimal
patients who have had severe septal deviation inter- and for this reason it has become popular all over the
vention or undergone inferior turbinate resection. world. The only absolute contradiction to open rhino-
• The septal splints and a dorsal nasal splint are removed plasty is patient refusal regarding a potentially percep-
after 10 days. tible scar.
 Surgical Techniques in Open Rhinoplasty Procedures 959

C D
Figs 12C and D: The postoperative view of the patient

12. Jakubietz M, Jakubietz RJ, Kloss DF, et al. Body dysmorphic

REFERENCES disorder: diagnosis and approach. Plast Reconstr Surg.
2007; 119(6):1924-30.
1. McDowell F. History of rhinoplasty. Aesthetic Plast Surg. 13. Gunter JP. A Graphic Record of Intraoperative Maneuvers
1978; 1:321-48. in Rhinoplasty: The Missing Link for Evaluating
2. Joseph J. Nasen Plastik und Sonstige Gesichts Plastik. Rhinoplasty Results. Plast Reconstr Surg. 1989; 84(2):
Leipzig, Germany: Verlag C. Kabitsch; 1931. 204-12.
3. Rethi A. Right and wrong in rhinoplastic operations. Plast 14. Whitaker EG, Johnson CM. The evolution of open struc-
Reconstr Surg (1946). 1948; 3(3):361-70. ture rhinoplasty. Arch Facial Plast Surg. 2003; 5(4):
4. Goodman WS. External approach to rhinoplasty. Can J 291-300.
Otolaryngol. 1973; 2(3):207-10. 15. Adamson PR. Rhinoplasty-Our Past. Fac Plast Surg. 1988;
5. Gentile P, Bottini DJ, Nicoli F, et al. Open-tip approach: evolu- 5:93-6.
tions in rhinoplasty. J Craniofac Surg. 2008; 19(5):1323-9. 16. Seyhan T. Correction of major saddle nose deformities with
6. Adamson PA, Galli SK. Rhinoplasty approaches: current nasomaxillary depression by using an intraoral and exter-
state of the art. Arch Facial Plast Surg. 2005; 7(1):32-7. nal open rhinoplasty approach. Aesthetic Plast Surg; 2010.
7. Kamer FM, McQuown SA. Revision rhinoplasty: analysis [Epub ahead of print].
and treatment. Arch Otolaryngol Head and Neck Surg. 1988; 17. Gryskiewicz JM, Gryskiewicz KM. Nasal osteotomies: A
114(3):257-66. clinical comparison of the perforating methods versus
8. Bagal AA, Adamson PA. Revision rhinoplasty. Facial Plast the continious technique. Plast Reconstr Surg. 2004;
Surg. 2002; 18:233-44. 113(5):1445-56.
9. Veale D, De Haro L, Lambrou C. Cosmetic rhinoplasty in 18. Guyuron B, Behmand RA. Nasal Tip Sutures part
body dysmorphic disorder. Br J Plast Surg. 2003; 56(6):546-51. II: the interplays. Plast Reconstr Surg. 2003; 112(4):
10. Hodgkinson DJ. Identifying the body-dysmorphic patient in 1130-45.
aesthetic surgery. Aesthetic Plast Surg. 2005; 29(6):503-9. 19. Seyhan T. A comfortable and practical nasal packing
11. Andretto Amodeo C. The central role of the nose in the face method: Tied merocel in clear glove finger impregnated
and the psyche: review of the nose and the psyche. Aesthetic with lidocaine-prilocaine cream. Plast Reconstr Surg. 2010;
Plast Surg. 2007; 31(4):406-10. 125(3):111e-2e.
 960 Facial Plastics, Cosmetics and Reconstructive Surgery

Appendage 1

Informed Consent – Rhinoplasty Surgery

INSTRUCTIONS disorders may not require surgery on the exterior of the
nose. Risks and potential complications are associated
This is an informed consent document that has been with alternative surgical forms of treatment.
prepared to assist your plastic surgeon inform you
concerning rhinoplasty surgery, its risks, and alternative
treatment.
RISKS OF RHINOPLASTY SURGERY
It is important that you read this information carefully Every surgical procedure involves a certain amount of risk
and completely. Please initial each page, indicating that and it is important that you understand these risks and the
you have read the page and sign the consent for surgery as possible complications associated with them. In addition,
proposed by your plastic surgeon and agreed upon by you. every procedure has limitations. An individual’s choice to
undergo a surgical procedure is based on the comparison
of the risk to potential benefit. Although the majority of
GENERAL INFORMATION patients do not experience the following complications,
Surgery of the nose (rhinoplasty) is an operation frequently you should discuss each of them with your plastic surgeon
performed by plastic surgeons. This surgical procedure to make sure you understand the risks, potential compli-
can produce changes in the appearance, structure and cations and consequences of rhinoplasty.
function of the nose. Rhinoplasty can reduce or increase
the size of the nose, change the shape of the tip, narrow Bleeding
the width of the nostrils or change the angle between the It is possible, though unusual, to experience a bleeding
nose and the upper lip. This operation can help correct episode during or after surgery. Intraoperative blood trans-
birth defects, nasal injuries and help relieve some breath- fusions may be required. Should post-operative bleeding
ing problems. occur, it may require an emergency treatment to drain the
There is not a universal type of rhinoplasty surgery accumulated blood or blood transfusion. Hypertension
that will meet the needs of every patient. Rhinoplasty (high blood pressure) that is not under good medi-
surgery is customized for each patient, depending on his cal control may cause bleeding during or after surgery.
or her needs. Incisions may be made within the nose or Accumulations of blood under the skin may delay healing
concealed in inconspicuous locations of the nose in the and cause scarring. Do not take any aspirin or anti-inflam-
open rhinoplasty procedure. In some situations, cartilage matory medications for ten days before or after surgery,
grafts, taken from within the nose or from other areas of as this may increase the risk of bleeding. Non­prescription
the body may be recommended in order to help reshape “herbs” and dietary supplements can increase the risk
the structure of the nose. Internal nasal surgery to improve of surgical bleeding. Hematoma can occur at any time
nasal breathing can be performed at the time of the following injury. If blood transfusions are necessary to
rhinoplasty. treat blood loss, there is the risk of blood-related infections
The best candidates for this type of surgery are indi- such as hepatitis and HIV (AIDS). Heparin medications
viduals who are looking for improvement, not perfection, that are used to prevent blood clots in veins can produce
in the appearance of their nose. In addition to realistic bleeding and decreased blood platelets.
expectations, good health and psychological stability are
important qualities for a patient considering rhinoplasty Infection
surgery. Rhinoplasty can be performed in conjunction Infection is unusual after surgery. Should an infection
with other surgeries. occur, additional treatment including antibiotics, hospi-
talization or additional surgery may be necessary.
ALTERNATIVE TREATMENT Scarring
Alternative forms of management consist of not undergo- All surgery leaves scars, some more visible than others.
ing the rhinoplasty surgery. Certain internal nasal airway Although good wound healing after a surgical procedure
 Surgical Techniques in Open Rhinoplasty Procedures 961

is expected, abnormal scars may occur within the skin and Pain
deeper tissues. Scars may be unattractive and of different You will experience pain after your surgery. Pain of varying
color than the surrounding skin tone. Scar appearance intensity and duration may occur and persist after rhino-
may also vary within the same scar. Scars may be asym- plasty. Chronic pain may occur very infrequently from
metrical. There is the possibility of visible marks in the nerves becoming trapped in scar tissue.
skin from sutures. In some cases scars may require surgi-
cal revision or treatment. Allergic Reactions
In rare cases, local allergies to tape, suture materials and
Damage to Deeper Structures glues, blood products, topical preparations or injected
There is the potential for injury to deeper structures, agents have been reported. Serious systemic reactions
including nerves, tear ducts, blood vessels, muscles and including shock (anaphylaxis) may occur to drugs used
lungs (pneumothorax) during any surgical procedure. The during surgery and prescription medications. Allergic
potential for this to occur varies according to the type of reactions may require additional treatment.
rhinoplasty procedure being performed. Injury to deeper
structures may be temporary or permanent. Delayed Healing
Fracture disruption or delayed wound healing is possible.
Change in Skin Sensation Some areas of the nose may not heal normally and may
It is common to experience diminished (or loss) of skin take a long time to heal. Areas of skin may die. This may
sensation in areas that have had surgery. There is the require frequent dressing changes or further surgery to
potential for permanent numbness within the nasal skin remove the non-healed tissue. Smokers have a greater
after rhinoplasty. The occurrence of this is not predictable. risk of skin loss and wound healing complications.
Diminished (or loss) of skin sensation in the nasal area
may not totally resolve after rhinoplasty. Skin Sensitivity
Itching, tenderness, or exaggerated responses to hot or
Asymmetry cold temperatures may occur after surgery. Usually this
The human face is normally asymmetrical. There can be a resolves during healing, but in rare situations it may be
variation from one side to the other in the results obtained chronic.
from rhinoplasty. Additional surgery may be necessary to
attempt to revise asymmetry. Nasal Septal Perforation
Infrequently, a hole in the nasal septum will develop. The
Skin Discoloration/Swelling occurrence of this is rare. Additional surgical treatment
Some bruising and swelling normally occurs following may be necessary to repair the nasal septum. In some
rhinoplasty. The skin in or near the surgical site can appear cases, it may be impossible to correct this complication.
either lighter or darker than surrounding skin. Although
uncommon, swelling and skin discoloration may persist Nasal Airway Alterations
for long periods of time and, in rare situations, may be Changes may occur after a rhinoplasty or septoplasty
permanent. operation that may interfere with normal passage of air
through the nose.
Seroma
Fluid accumulations infrequently occur in between the Surgical Anesthesia
skin and the underlying tissues. Should this problem Both local and general anesthesia involve risk. There is the
occur, it may require additional procedures for drain- possibility of complications, injury and even death from
age of fluid. all forms of surgical anesthesia or sedation.
 962 Facial Plastics, Cosmetics and Reconstructive Surgery

Substance Abuse Disorders general anesthesia. Pulmonary and fat emboli can be life-
Individuals with substance abuse problems that involve threatening or fatal in some circumstances. Air travel, inac-
the inhalation of vasoconstrictive drugs such as cocaine tivity and other conditions may increase the incidence of
are at risk for major complications including poor healing blood clots traveling to the lungs causing a major blood clot
and nasal septal perforation. that may result in death. It is important to discuss with your
physician any past history of blood clots or swollen legs that
Skin Contour Irregularities may contribute to this condition. Cardiac complications
Contour irregularities may occur. Residual skin irregulari- are a risk with any surgery and anesthesia, even in patients
ties at the ends of the incisions or “dog ears” are always a without symptoms. If you experience shortness of breath,
possibility and may require additional surgery. This may chest pains, or unusual heart beats, seek medical attention
improve with time, or it can be surgically corrected. immediately. Should any of these complications occur, you
may require hospitalization and additional treatment.
Sutures
Most surgical techniques use deep sutures. You may notice
these sutures after your surgery. Sutures may spontane-
ADDITIONAL ADVISORIES
ously poke through the skin, become visible or produce Skin Disorders/Skin Cancer
irritation that requires removal.
Rhinoplasty is a surgical procedure to reshape of both
Unsatisfactory Result internal and external structure of the nose. Skin disorders
Although good results are expected, there is no guarantee and skin cancer may occur independently of a rhinoplasty.
or warranty expressed or implied, on the results that may
be obtained. You may be disappointed with the results Long-Term Results
of rhinoplasty surgery. This would include risks such as Subsequent alterations in nasal appearance may occur as
asymmetry, loss of function, structural malposition, unac- the result of aging, weight loss or gain, sun exposure, preg-
ceptable visible or tactile deformities, unsatisfactory surgi- nancy, menopause, or other circumstances not related to
cal scar location, poor healing, wound disruption, and loss rhinoplasty surgery. Future surgery or other treatments
of sensation. It may be necessary to perform additional may be necessary.
surgery to attempt to improve your results.
Female Patient Information
Shock It is important to inform your plastic surgeon if you use
In rare circumstances, your surgical procedure can cause birth control pills, estrogen replacement, or if you believe
severe trauma, particularly when multiple or extensive you may be pregnant. Many medications including antibi-
procedures are performed. Although serious complications otics may neutralize the preventive effect of birth control
are infrequent, infections or excessive fluid loss can lead to pills, allowing for conception and pregnancy.
severe illness and even death. If surgical shock occurs, hospi-
talization and additional treatment would be necessary. Intimate Relations after Surgery
Surgery involves coagulating of blood vessels and
Cardiac and Pulmonary Complications increased activity of any kind may open these vessels
Surgery, especially longer procedures, may be associ- leading to a bleed, or hematoma. Activity that increases
ated with the formation of, or increase in, blood clots in your pulse or heart rate may cause additional bruising,
the venous system. Pulmonary complications may occur swelling, and the need for return to surgery and control
secondarily to both blood clots (pulmonary emboli), fat bleeding. It is wise to refrain from sexual activity until your
deposits (fat emboli) or partial collapse of the lungs after physician states it is safe.
 Surgical Techniques in Open Rhinoplasty Procedures 963

Smoking, Second-Hand Smoke Exposure, surgeon for further instructions. If the reaction is severe,
Nicotine Products (Patch, Gum, Nasal Spray) go immediately to the nearest emergency room. When
taking the prescribed pain medications after surgery, real-
Patients who are currently smoking, use tobacco prod- ize that they can affect your thought process and coordina-
ucts, or nicotine products (patch, gum, or nasal spray) tion. Do not drive, do not operate complex equipment, do
are at a greater risk for significant surgical complica- not make any important decisions, and do not drink any
tions of skin dying, delayed healing and additional scar- alcohol while taking these medications. Be sure to take
ring. Individuals exposed to second-hand smoke are your prescribed medication only as directed.
also at potential risk for similar complications attribut-
able to nicotine exposure. Additionally, smoking may
have a significant negative effect on anesthesia and
PATIENT COMPLIANCE
recovery from anesthesia, with coughing and possibly Follow all physician instructions carefully; this is essen-
increased bleeding. Individuals who are not exposed to tial for the success of your outcome. It is important that
tobacco smoke or nicotine-containing products have the surgical incisions are not subjected to excessive force,
a significantly lower risk of this type of complication. swelling, abrasion, or motion during the time of healing.
Please indicate your current status regarding these Personal and vocational activity needs to be restricted.
items below: Protective dressings and splints should not be removed
unless instructed by your plastic surgeon. Successful post-
_________ I am a non-smoker and do not use nicotine operative function depends on both surgery and subse-
products. I understand the risk of second-hand smoke quent care. Physical activity that increases your pulse or
exposure causing surgical complications. heart rate may cause bruising, swelling, fluid accumula-
tion and the need for return to surgery. It is wise to refrain
_________ I am a smoker or use tobacco/nicotine prod- from intimate physical activities after surgery until your
ucts. I understand the risk of surgical complications due to physician states it is safe. It is important that you partici-
smoking or use of nicotine products. pate in follow-up care, return for aftercare, and promote
your recovery after surgery.
It is important to refrain from smoking at least 6 weeks
before surgery and until your physician states it is safe to
return, if desired.
HEALTH INSURANCE
Most health insurance companies exclude coverage for
Mental Health Disorders and cosmetic surgical operations or any complications that
Elective Surgery might occur from cosmetic surgery. If the procedure
It is important that all patients seeking to undergo elective corrects a breathing problem or marked deformity after
surgery have realistic expectations that focus on improve- a nasal fracture, a portion may be covered. Many insur-
ment rather than perfection. Complications or less than ance plans exclude coverage for secondary or revisionary
satisfactory results are sometimes unavoidable, may surgery. Please carefully review your health insurance
require additional surgery and often are stressful. Please subscriber-information pamphlet.
openly discuss with your surgeon, prior to surgery, any
history that you may have of significant emotional depres-
sion or mental health disorders. Although many individu-
FINANCIAL RESPONSIBILITIES
als may benefit psychologically from the results of elective The cost of surgery involves several charges for the services
surgery, effects on mental health cannot be accurately provided. The total includes fees charged by your doctor,
predicted. the cost of surgical supplies, anesthesia, laboratory tests
and possible outpatient hospital charges, depending on
Medications where the surgery is performed. Depending on whether
There are many adverse reactions that occur as the result the cost of surgery is covered by an insurance plan, you
of taking over-the-counter, herbal, and/or prescription will be responsible for necessary co-payments, deducti-
medications. Be sure to check with your physician about bles and charges not covered. Additional costs may occur
any drug interactions that may exist with medications should complications develop from the surgery. Secondary
which you are already taking. If you have an adverse reac- surgery or hospital day surgery charges involved with revi-
tion, stop the drugs immediately and call your plastic sionary surgery would also be your responsibility.
 964 Facial Plastics, Cosmetics and Reconstructive Surgery

disease or condition along with disclosure of risks and

ADDITIONAL SURGERY NECESSARY alternative forms of treatment(s), including no surgery.
There are many variable conditions that may influence The informed-consent process attempts to define prin-
the long-term result from rhinoplasty surgery. Secondary ciples of risk disclosure that should generally meet the
surgery may be necessary to obtain optimal results. Should needs of most patients in most circumstances.
complications occur, additional surgery or other treat- However, informed-consent documents should not be
ments may be necessary. Even though risks and compli- considered all inclusive in defining other methods of care
cations occur infrequently, the risks cited are particularly and risks encountered. Your plastic surgeon may provide
associated with rhinoplasty surgery. Other complications you with additional or different information which is based
and risks can occur but are even more uncommon. The on all the facts in your particular case and the current state
practice of medicine and surgery is not an exact science. of medical knowledge.
Although good results are expected, there is no guarantee Informed-consent documents are not intended to
or warranty expressed or implied, on the results that may define or serve as the standard of medical care. Standards
be obtained. In some situations, it may not be possible to of medical care are determined on the basis of all of the
achieve optimal results with a single surgical procedure. facts involved in an individual case and are subject to
change as scientific knowledge and technology advance
and as practice patterns evolve.
DISCLAIMER It is important that you read the above information
Informed-consent documents are used to communicate carefully and have all of your questions answered before
information about the proposed surgical treatment of a signing the consent on the next page.
 Surgical Techniques in Open Rhinoplasty Procedures 965

CONSENT FOR SURGERY/PROCEDURE or TREATMENT

1. I hereby authorize DR. …............. and such assistants as may be selected to perform the following procedure or
treatment:

RHINOPLASTY SURGERY
I have received the following information sheet:

INFORMED CONSENT—RHINOPLASTY SURGERY

2. I recognize that during the course of the operation and medical treatment or anesthesia, unforeseen conditions
may necessitate different procedures than those above. I therefore authorize the above physician and assistants or
designees to perform such other procedures that are in the exercise of his or her professional judgment necessary
and desirable. The authority granted under this paragraph shall include all conditions that require treatment and are
not known to my physician at the time the procedure is begun.
3. I consent to the administration of such anesthetics considered necessary or advisable. I understand that all forms of
anesthesia involve risk and the possibility of complications, injury, and sometimes death.
4. I acknowledge that no guarantee or representation has been given by anyone as to the results that may be obtained.
5. I consent to be photographed or televised before, during, and after the operation(s) or procedure(s) to be performed,
including appropriate portions of my body, for medical, scientific or educational purposes, provided my identity is
not revealed by the pictures.
6. For purposes of advancing medical education, I consent to the admittance of observers to the operating room.
7. I consent to the disposal of any tissue, medical devices or body parts, which may be removed.
8. I consent to the utilization of blood products should they be deemed necessary by my surgeon and/or his/her
appointees and I am aware that there are potential significant risks to my health with their utilization.
9. I authorize the release of my Social Security number to appropriate agencies for legal reporting and medical-device
registration, if applicable.
10. I understand that the surgeons’ fees are separate from the anesthesia and hospital charges, and the fees are agree-
able to me. If a secondary procedure is necessary, further expenditure will be required.
11. I realize that not having the operation is an option.
12. IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:
a. THE ABOVE TREATMENT OR PROCEDURE TO BE UNDERTAKEN
b. THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT
c. THERE ARE RISKS TO THE PROCEDURE OR TREATMENT PROPOSED

I CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED ITEMS (1 – 12).
I AM SATISFIED WITH THE EXPLANATION.

_______________________________________________________________________________________________________

____________________________________________________________ Patient or Person Authorized to Sign for Patient.

Date: __________________________ Witness: ______________________________

 966 Facial Plastics, Cosmetics and ReconstructiveThe Surgical Technique of Otoplasty
Surgery
CHAPTER

101 Rhinoplasty for Cleft Nasal

Deformity
C Thomas

• Real or apparent maxillary deficiency.

INTRODUCTION • Circumference of the naris is greater on the cleft side.
There is significant improvement in the results of cleft lip • Naris on the cleft side is retrodisplaced.
repair in the present decade but nasal deformity is the • Columella is shorter in the anteroposterior dimension
greatest corrective challenge and which is more obvious on the cleft side.
once the lip has been repaired. • Medial crus is displaced on the cleft side.
The nasal deformity varies in • Columella is positioned obliquely with its base toward
• Unilateral cleft lip the non-cleft side.
• Bilateral cleft lip • Absence of the nasal floor.
• Hypertrophy of the inferior turbinate on the cleft
side.
UNILATERAL CLEFT LIP NASAL • Vestibular web: Within the cleft side of interior nostril.
DEFORMITY
The nasal deformity has characteristic features, but the
severity varies and is related to the extent of the lip deform-
BILATERAL CLEFT LIP NASAL
ity and alveolar cleft. DEFORMITY
It is a characteristic nasal deformity which is usually
Etiology symmetric, hence reconstruction is much easier than that
It may be the result of the following: of a unilateral cleft lip nasal deformity.
• Tissue deficiency of the cleft lip
• Deficiency of the maxilla Etiology: Several Hypotheses
• Abnormal muscular pull on the nasal structures. • Lateral traction on the alar bases and lowering of the
ala due to abnormal muscle insertions
Components • Overgrowth of the mesoderm at the vomeropremax-
Defects of the illary suture due to lack of restraint by the nonunited
• Alar cartilage orbicularis oris muscle
• Nasal septum • Incorporation of prolabium into the lip repair.
• Columella
• Nasal tip Pathologic Anatomy
• Entire nasal pyramid • A short columella with encroachment of the lip tissue,
• Abnormal orbicularis muscle attachments especially in a protruded premaxilla
• Hypoplastic maxilla. • Medial crura of the alar cartilages are displaced inferi-
orly with lowering of the alar domes
Pathologic Anatomy • Alar domes are laterally displaced on a hypoplastic
• Nasal tip is deflected toward the cleft side. maxilla resulting in a widened nostril sill
• The dome on the cleft side is retrodisplaced. • Prominent vestibular skin webs and buckling of the
• The angle between the medial and lateral crura is lateral crura produce a collapsed nasal contour
excessively obtuse. • The caudal septum and underdeveloped anterior nasal
• Alar buckles inward on the cleft side. spine are displaced inferiorly or laterally depending on
• Alar-facial groove on the cleft side is absent. the degree and asymmetry of the cleft.
 Rhinoplasty for Cleft Nasal Deformity 967

MANAGEMENT Advantages
Neonatal splintage prior to lip repair may be helpful to • Identification and proper repositioning of the lower
correct these deformities but difficult to practice because alar cartilages by accurately placed sutures under
it needs prolonged nasal splintage and noncompliance by direct vision.
the parents. • Approach of this procedure through the hidden rim
incisions without any residual scars.
• Septal cartilage can be easily dislocated and relocated
SURGICAL CORRECTION into normal position without any resection.
• Easy procedure comparable to the closed technique
Timing of the Surgery
with a shorter operating time.
• Primary rhinoplasty, if nasal deformity is corrected • It is a procedure of choice where there is no preopera-
along with the lip repair. Otherwise it is known as tive orthodontic treatment or nasoalveolar molding.
secondary rhinoplasty, which could be done during
the school going age (5–6 years), early adolescence
(10–12 years) or in adult age (above 18 years).
SURGICAL TECHNIQUE
• Primary rhinoplasty can be done by closed approach, Primary Rhinoplasty by Open Approach with
semi-open approach or open approach.
Repair of Unilateral Complete Cleft Lip
Primary Cheilorhinoplasty—Open Approach The markings are made showing a modification of the
• Proper reconstruction of the clefted musculoap- Millard rotation-advancement technique and Harashina
eneurotic complex by a subperiosteal dissection and open rhinoplasty technique as shown in Figures 1 and 2. A
placing the muscles in their proper anatomic and triangular flap of 2 mm is incorporated at the advancement
physiologic orientation after detaching from their flap (Millard B flap) near the vermillion to break the scar
abnormal insertions with adequate mobilization. and subsequent scar contraction. Addition points (phil-
• Muscle repair is the “key” for the establishment of a tral-columellar points) are also marked at the junction of
normal nasolabial complex. the columellar and the philtrum on both the cleft and the
• Primary rhinoplasty by delicate dissection and accu- non‐cleft side. Millard C flap is drawn at the mucocutane-
rate repositioning of the lower alar cartilages during ous junction of the rotation flap (Millard A flap) at the level
the primary lip repair enhances normal nasal shape of the philtral-columellar angle with its base in continuity
and breathing. with the mucosal lining of the septum as mucocutaneous

Fig. 1: Preoperative markings for unilateral complete cleft Fig. 2: Repair after the operation
lip and palate repairs along with primary rhinoplasty by the
open approach
 968 Facial Plastics, Cosmetics and Reconstructive Surgery

flap. From the philtral-columellar points, the incisions are are approximated to reconstruct a nostril tube. The C flap
extended in the nose as standard rim incisions through is incorporated into the nostril sill, which is an important
the edge of the columella, extending through the inside step to avoid stenosis of the nostril. Lip repair is carried
margins of the nostril rim up to its middle on the cleft and out in the conventional manner as in the Millard rotation‐
non‐cleft side. advancement technique. The length of the rotation flap A
Orbicularis oris muscles are radically mobilized from (A1 + A2 + A3) is equal to the length of the advancement flap
the vestibular nasal lining down to the edge of the bony B (B1 and B2). The role of the triangular flap is mentioned
cleft. The lateral nasal mucosa is elevated upward subpe- earlier. Union of the orbicularis muscle from the cleft and
riosteally up to the inferior turbinate. The medial nasal non-cleft sides without tension should be given adequate
septal mucosal flap is raised and extended posteriorly as emphasis.
a vomerine flap. Subperiosteal dissection of the cheek is The columellar skin is retracted with the skin hook. This
performed widely from the anterior maxilla, respecting maneuver tends to symmetrically align the alar cartilages.
the inferior orbital nerve, to allow tension‐free advance- Four to five 5/0 Vicryl (Ethicon) sutures are used to suture
ment of the soft tissue across the bony cleft. Columellar the medial crura of the alar domes. The cranial edges of
skin is dissected upward along the rim incision to expose the lateral crura are sutured, securing the upward rota-
the medial crura of the alar domes. Care is taken to free the tion of the lateral crura on the affected side (Figs 3 and 4).
fibrofatty tissue between the domes of the alar cartilage Finally, the nasal and the columellar incisions are sutured.
and to leave attached to the overlying skin. The nasal skin is Transparent thin steri-strips are applied over the
dissected widely over the nasal skeleton to allow redraping suture lines in the lip, followed by the application of the
over the reconstituted nasal tip. The nasal septum is dislo- nostril conformers. Skin sutures and nostril conformers
cated from its base to provide a symmetrical appearance are removed after a week under a short general anesthesia.
of the nostrils. Suturing begins with the repair of the ante- Nostril conformers encourage proper nasal contours
rior palate. The vomerine flap and lateral nasal mucosa and keep the patency of the nostrils for breathing.

Fig. 3 Fig. 4
 Rhinoplasty for Cleft Nasal Deformity 969

Surgical Technique—Unilateral Complete Cleft Lip

Figures 5 to 11 illustrate sequential operative steps of the
surgery.

Fig. 5: Skin markings Fig. 6: After dissection with marginal incisions of nostrils

Fig. 7: Muscle repair with the C flap at the nostril sill Fig. 8: Deformed lower alar cartilage at the cleft side
 970 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 9: Correction of the deformed lower alar Fig. 10: Corrected symmetrical appearance of the nostrils
cartilage with 5/0 Vicryl stitches

Fig. 11A: Postoperative frontal view after 1 year Fig. 11B: Postoperative nasal view after 1 year

Primary Rhinoplasty by Open Approach with philtrum. The width of the prolabium is made the same
Repair of Bilateral Complete Cleft Lip as the width of the columella from the philtral-columel-
Presurgical orthodontic correction by means of strapping lar points. These prolabial incisions are extended into the
is given to bilateral cleft lip with protruded premaxilla. nose as standard rim incisions through the edges of the
The markings are made showing a modification of the columella extending through the inside margins of the
Millard rotation‐advancement technique and Harashina nostril rim up to its middle. The remaining prolabial skin is
open rhinoplasty technique as shown in Figures 12 left attached to the skin of the membranous septum as two
and 13. Additional points (philtral-columellar points) nasal septal mucosal flaps (Figs 12 and 13). Orbicularis
are also marked at the junction of the columella and the oris muscles are radically mobilized from the vestibular
 Rhinoplasty for Cleft Nasal Deformity 971

Fig. 12: Preoperative markings for bilateral complete cleft

lip and palate repairs along with primary rhinoplasty by the
Fig. 13: Repair after the operation
open approach

nasal lining down to the edge of the bony cleft from the the mucosa followed by the muscle repair. Union of the
lateral lip elements. The lateral nasal mucosa is elevated orbicularis oris muscle from both lateral elements across
upward subperiosteally up to the inferior turbinate. The the premaxilla should be given adequate emphasis. The
medial nasal septal mucosal flap is raised and extended columellar skin is retracted with a skin hook, and this
posteriorly as a vomerine flap. A central strip of the nasal maneuver tends to symmetrically align the alar carti-
septal mucosa at least approximately 1 cm in width is to be lages. Three to four 5/0 Vicryl (Ethicon) sutures are used to
kept intact to preserve the blood supply of the premaxilla. suture the medial crura and the alar domes. Cranial edges
Subperiosteal dissection of the cheek is performed widely of the lateral crura are sutured securing the upward rota-
from the anterior maxilla, respecting the inferior orbital tion of the lateral crus. The skin suturing is carried out with
nerve, to allow tension‐free advancement of the soft tissue the prolabium to the lateral elements up to the philtral-
across the bony cleft (see Fig. 3). columellar angle. Care should be taken to create an obtuse
The prolabial flap is reflected along with columellar angle at the philtral‐columellar junction by accurately
skin by careful dissection especially at the base of the colu- placed sutures. The nasal and columellar skin incisions
mella to dissect all fibrofatty soft tissue from the medial are sutured.
crura of the alar cartilages up to the dome and then from Cupid’s bow of the philtral column is formed by the
off the lateral crura, the septum, and upper lateral carti- advancement of the vermillion flaps from both lateral
lages. Thus, the fibrofatty soft tissue is left attached to the elements. The length of flap A (A1 to A2) is equal to the
elevated skin of the nose, which is dissected back to the length of advancement flap B (B1 to B2). Transparent thin
dorsum of the nasal skeleton. The nasal skin is dissected steri-strips are applied over the suture lines in the lip
widely over the nasal skeleton to allow redraping over the followed by the application of the nostril conformers. Skin
reconstituted nasal tip. sutures and the nostril conformers are removed after a
Suturing begins with the repair of the anterior palate. week under a short general anesthesia.
The vomerine flap and the lateral nasal mucosa are Nostril conformers encourage the proper nasal
approximated to reconstruct a nostril tube on both sides. contours and keep up the patency of the nostrils for
Lip repair is carried out in the conventional manner—first, breathing.
 972 Facial Plastics, Cosmetics and Reconstructive Surgery

Surgical Technique—Bilateral Complete Cleft Lip

Figures 14 to 18 illustrate sequential operative steps of the
surgery.

Fig. 14: Skin markings Fig. 15: After dissection, to show both lower alar cartilages
by elevating the prolabium and columella by a skin hook

Fig. 16: Correction of the deformity of the lower alar Fig. 17: Application of steri-strips at the
cartilages and recreation of columella end of the operation

Fig. 18A: Postoperative frontal view after 1 year Fig. 18B: Postoperative nasal view after 1 year
 Rhinoplasty for Cleft Nasal Deformity 973

NOSTRIL CONFORMERS (FIGS 19 TO 21)

Nostril conformers, recently introduced, encourage the
proper nasal contours and keep up the patency of the
nostrils for breathing.

Fig. 19: Silicon nostril conformers Fig. 20: Nostril conformers—sizing set

A B
Figs 21A and B: Application of nostril conformers
after cleft lip repair
 974 Facial Plastics, Cosmetics and Reconstructive Surgery

PREOPERATIVE AND
POSTOPERATIVE PHOTOGRAPHS
OF CONSECUTIVE PATIENTS WITH
LONG-TERM FOLLOW-UP
Unilateral Complete Cleft Lip (Figs 22A to G)
• Middle column: Postoperative anteroposterior and
Directions for Figures nasal views with 1 year follow‐up of the same patient.
• First column: Preoperative anteroposterior and nasal • Last column: Postoperative anteroposterior and nasal
views. views over 12 years follow‐up of the same patient.

A
Fig. 22A
 Rhinoplasty for Cleft Nasal Deformity 975

C
Figs 22B and C
976 Facial Plastics, Cosmetics and Reconstructive Surgery

E
Figs 22D and E
 Rhinoplasty for Cleft Nasal Deformity 977

G
Figs 22A to G: Unilateral complete cleft lip long-term follow-up photographs
 978 Facial Plastics, Cosmetics and Reconstructive Surgery

• Middle column: Postoperative anteroposterior and

Bilateral Complete Cleft Lip (Figs 23A to G) nasal views with 1 year follow‐up of the same patient.
Directions for Figures • Last column: Postoperative anteroposterior and
• First column: Preoperative anteroposterior and nasal nasal views over 12 years follow‐up of the same
views patient.

B
Figs 23A and B
 Rhinoplasty for Cleft Nasal Deformity 979

D
Figs 23C and D
980 Facial Plastics, Cosmetics and Reconstructive Surgery

F
Figs 23E and F
 Rhinoplasty for Cleft Nasal Deformity 981

G
Figs 23A to G: Bilateral complete cleft lip long-term follow-up phtographs

SECONDARY RHINOPLASTY Skeletal Corrections

It should be tailored to suit each patient. It may be soft Skeletal corrections may be as follows according to the
tissue, cartilage or skeletal corrections. deformity and appropriate correction.
• Bone grafting of the alveolar clefts
Soft Tissue Corrections • Augmentation of the maxilla
Soft tissue corrections, such as columellar lengthening • Cantilever bone grafts for nose
by V‐Y advancement flaps, fork flap or Cronin flaps, lip • Skeletal base correction by osteotomies
reinforcements by Abbe flap from the lower lip, nasal • Correction of malocclusion by orthodontics and
sill narrowing by wedge resections and so on. orthognathic surgery
• Rhinoplasty.
Cartilage Corrections
Cartilage dissection, alar repositioning and suspension
nasal and columellar augmentation by grafts and tip plasty.
982 Facial Plastics, Cosmetics and Reconstructive Surgery

SECONDARY SEPTORHINOPLASTY IN
CLEFT LIP AND PALATE (FIGS 24 TO 29)
Clinical Photographs

Fig. 24: Frontal view showing the nasal deformity and the
vermillion notch

A B
Figs 25A and B: Correction of the vermilion notch by Z-plasty and the septorhinoplasty by open approach
 Rhinoplasty for Cleft Nasal Deformity 983

A D

B E

C F
Figs 26A to F: (A to C) Preoperative views; (D to F) Postoperative views
984 Facial Plastics, Cosmetics and Reconstructive Surgery

A C

B D
Figs 27A to D: (A and B) Preoperative views; (C and D) Postoperative views
 Rhinoplasty for Cleft Nasal Deformity 985

A D

B E

C F
Figs 28A to F: (A to C) Preoperative views; (D to F) Postoperative views
986 Facial Plastics, Cosmetics and Reconstructive Surgery

A D

B E

C F
Figs 29A to F: Postoperative bilateral complete cleft lip with septorhinoplasty.
(A to C) Preoperative views; (D to F) Postoperative views
 Rhinoplasty for Cleft Nasal Deformity 987

BIBLIOGRAPHY 6. Thomas C, Mishra P. Open tip rhinoplasty along with the

repair of the cleft lip in cleft lip and palate cases. Br J Plast
1. Cutting CB. In: Mathes SJ (Ed). Plastic Surgery, 2nd edition. Surg. 2000;53:1-6.
7. Thomas C. Primary rhinoplasty by open approach with
Philadelphia, PA: Saunders; 2006. pp. 217-47.
repair of bilateral complete cleft lip. J Craniofacial Surg.
2. Harashina T. Open reverse-U incision technique for
2009;20;1715-18.
secondary correction of unilateral cleft lip nose deformity.
8. Thomas C. Primary rhinoplasty by open approach with
Br J Plast Surg. 1990;43:557-64.
repair of unilateral complete cleft lip. J Craniofacial Surg.
3. Matsuo K, Hirose T. A rotational method of bilateral 2009;20;1711-14.
cleft lip nose repair Plast Reconstr Surg. 1991;87: 9. Trott JA, Mohan NA. A preliminary report on one stage open
1034-40. tip rhinoplasty at the time of lip repair in bilateral cleft lip
4. Millard DR. Refinements in Rotation-Advancement Cleft Lip and palate: the Alor Setar experience. Br J Plast Surg. 1993;
Technique. Plastic Reconstr Surg. 1964;33:26-38. 46:215-22.
5. Tajima S, Maruyama M. Reverse “U” incision for second- 10. Trott JA, Mohan NA. A preliminary report on open tip rhino-
ary repair of cleft lip nose. Plastic Reconstr Surg. 1977;60: plasty at the time of lip repair in unilateral cleft lip and palate:
256-61. The Alor Setar experience. Br J Plast Surg. 1993;46:363-70.
 The Surgical Technique of Otoplasty
CHAPTER

102 Revision Rhinoplasty: The Lost

Tip Support
Hossam MT Foda

INDICATIONS FOR THE SURGERY A strong caudal septum replacement graft (Fig. 1) is
designed to reconstruct the caudal septum and provide
Revision rhinoplasty is a very complex and technically good support to the weak buckled medial crura (Fig. 2)
demanding procedure. One of the main challenges, in in order to correct the functional and aesthetic problems
revision cases, is to rebuild the weakened or lost nasal tip resulting from the lost tip support.
support.1 Loss of tip support results mainly from excessive
excisions or resorption of the caudal septum, alar carti-
lages or anterior nasal spine.
SPECIFIC PREOPERATIVE
The lost tip support is responsible for most of the EVALUATION
functional and aesthetic problems encountered in The poor tip support can be detected by preoperative
revision case; this is mainly due to the fact that the loss examination and confirmed by the intraoperative findings:
of support leaves the tip weak and unstable so it can be I. Digital palpation to evaluate the degree of tip support
easily displaced backwards, by the weight of the thick a. Rolling tip skin between index and thumb to detect
lobular skin and downwards by the constant pull of its relative thickness
gravity, leading to loss of tip projection and rotation, b. Lifting of nasal tip upwards and testing for any
resulting in a depressed droopy nasal tip with pollybeak improvement in breathing
deformity and acute nasolabial angle. Additionally, the c. Pressing on nasal tip to detect amount of cartilage
weak unsupported tip cartilages can be easily displaced support and degree of recoil
by the contracture forces of healing leading to tip d. Pressing upwards on the columella to detect any
contour irregularities, alar notching or collapse, retracted caudal septum deficiency
columella, and shortened nose with an over-rotated e. Pressing inwards on the nasolabial junction to
tip.1-3 evaluate the premaxilla and anterior nasal spine.

Fig. 1: Intraoperative view of a large caudal septum Fig. 2: Intraoperative view of a revision case with total loss of
replacement (CSR) graft tip support showing weak buckled medial crura and deficient
caudal septum due to partial resection and resorption
 Revision Rhinoplasty: The Lost Tip Support 989

II. External nasal analysis for signs of loss of tip support SURGICAL STEPS
(Fig. 3 left, below)
a. Depressed underprojected nasal tip An external rhinoplasty approach was used to reconstruct
b. Droopy inferiorly rotated nasal tip the lost support using a cartilaginous caudal septum
c. Acute nasolabial angle replacement (CSR) graft combined with premaxillary
d. Retrodisplaced nasolabial junction augmentation using Mersilene mesh.
e. Posteriorly inclined upper lip
f. Retracted columellar base Premaxillary Augmentation
III. Intraoperative findings in revision cases with lost tip A pocket is dissected between the footplates of the
support: medial crura till reaching the premaxilla and the ante-
a. Premaxillary bony deficiency due to previously rior nasal spine, which is either previously resected or
resected or partially resorped anterior nasal spine partially resorped. In such cases, dissection is continued
b. Caudal septal cartilage deficiency from previous on both sides of the spine to create a pocket for premaxil-
excisions or resorption lary augmentation, which is done using Mersilene mesh4
c. Medial crura may be weak, fractured, twisted, (Ethicon, Somerville, NJ, USA) after rolling it tightly and
buckled or partially missing marking it, at the midpoint, with a 5/0 silk suture. The
roll of mesh is trimmed to an average length of 2 cms
(range, 1–3 cms) and its lateral ends tapered. The thick-
ness of the roll depends on the extent of premaxillary
deficiency. The prepared roll of mesh is then soaked in
Gentamicin solution and introduced into the premaxil-
lary pocket making sure the silk suture rests strictly in the
midline to ensure central placement of the implant.

Caudal Septum Replacement Graft

Graft Harvest
Donor cartilage for the CSR graft can be obtained from
multiple sources, the first and most preferable choice
is autogenous septal cartilage, followed by autogenous
conchal cartilage and finally the last choice is autogenous
or irradiated costal cartilage homograft. The dimensions
of the graft depend mainly on the size of the missing
caudal segment and the aesthetic goals of the operation.
The length (anteroposterior dimension) of the graft is
determined by the amount of tip projection needed, the
width (cephalo-caudal dimension) ranged from 7-13 mm
depending on the extent of caudal septum deficiency,
the thickness of the graft ranged from 2-4 mm for autog-
enous grafts and from 3–6 mm when irradiated cartilage
homograft is used. On using septal cartilage, an inferior
mucoperiostium tunnel is elevated off the maxillary crest
and the flap elevation is continued upwards to expose
the ventral part of the septal cartilage that is attached to
the maxillary crest. This is the best part to use for a CSR
graft as it is the thickest part of septal cartilage and it is
Fig. 3: Left: Preoperative schematic illustration and
photograph of a patient with caudal septal and premaxillary
usually found intact even in revision cases with near-total
deficiency showing a depressed droopy tip, acute nasolabial absence of septal cartilage. On using conchal cartilage, it
angle, retrodisplaced nasolabial junction and posteriorly is harvested through an anterior approach using a curved
inclined upper lip. Right: The same patient postoperatively incision parallel to the antihelix but a few millimeters
after using a CSR graft and a roll of Mersilene mesh for below it to allow the scar to be hidden by the curve of
premaxillary augmentation the antihelix and its inferior crus. In order to change the
 990 Facial Plastics, Cosmetics and Reconstructive Surgery

thin concave conchal cartilage into a thick and straight ingrowth that leads to early fixation of the implant. The
CSR graft; a vertical partial-thickness cut is made on the presence of the roll of mesh in the premaxilla proved to be
concave surface of the cartilage, which is then folded on very helpful to the CSR graft; it provides a soft cushion on
itself in a back-to-back fashion and sutured into a double which the base of the CSR graft will rest thus stabilizing the
layer using 6/0 Prolene mattress sutures. graft and preventing any side-to-side movement, which
in absence of the mesh, may cause a “click” against the
Graft Placement and Fixation premaxillary bone. Another advantage of the roll of mesh
The extent of missing caudal septum is evaluated by is that it would guard against any upward displacement
instrument palpation. Occasionally, the membranous of the graft thus avoiding potential overriding between
septum may be found stiff on palpation, giving the impres- the inserted graft and the septum. Another factor that
sion that some cartilage is present, but on exploration only prevented overriding is that a few millimeters of membra-
thick scar tissue is found from the previous surgeries. The nous septum were left undissected thus preventing any
medial crura are pulled apart and the thick scar tissue is direct contact between the graft and the caudal edge of the
excised using sharp dissection with No. 15 blade then a remaining septum (Fig. 4).
fine tenotomy scissors is used to continue the dissection
cephalically making sure to stop a few millimeters before
reaching the edge of the remaining septal cartilage, thus
COMPLICATIONS
keeping the created membranous septal pocket isolated The CSR graft and premaxillary augmentation with
from the septum proper. The dissected pocket is then Mersilene mesh was used in over 200 patients with follow-
extended posteriorly between the footplates of the medial ups for up to 14 years and proved to provide an excellent
crura till reaching the premaxillary mesh. The base of the amount of support to the nasal tip allowing it to maintain
graft is beveled in a concave fashion, to accommodate its position, over the long-term follow-up period, with
the roll of Mersilene mesh; the caudal border of the graft no loss in the achieved degree of projection or rotation.
is left longer than the cephalic one (Fig. 3 right, above) to Functionally, 85% of the cases with preoperative nasal
prevent any upward displacement of the graft. The graft obstruction reported a significant improvement in breath-
is then introduced into the membranous septum pocket ing (Figs 5 and 6).
and pushed downwards till it is tightly pressed against the No cases of infection, displacement or extrusion of the
premaxillary mesh. The graft is fixed, in that position, to CSR graft were encountered. However, partial extrusion
the medial crura using 5/0 Prolene sutures in a horizon- of the Mersilene mesh occurred in six cases (2%); four of
tal mattress fashion. Three sutures are used; the first at which had associated anterior septal perforations and
the level of the medial crural footplates, the second in the the remaining two patients had a unilateral cleft-lip nasal
columellar segment of medial crura and the third in the deformity. Accordingly, it is better to avoid using Mersilene
lobular segment of the medial crura (Fig. 3 right, above).
Finally, the degree of tip projection is assessed and any
excess length of the graft is trimmed to allow approxima-
tion of domes to be done above the level of the anterior
end of the graft.

TECHNICAL CONSIDERATIONS IN
THE SURGERY
In one of our previous studies,5 it was found that over 75%
of cases with caudal septal deficiency were associated with
some degree of premaxillary deficiency where the premax-
illa and/or the anterior nasal spine were found to be previ-
ously resected or partially resorped and the premaxillary
fat and soft tissue are atrophied and scarred-down as
a result of surgical trauma. In such cases, premaxillary
augmentation should be performed before attempting any
caudal septal reconstruction, we found Mersilene mesh to Fig. 4: Intraoperative view showing the minimum distance
be an ideal augmentation material for the premaxilla.4 It is that should be left undissected between the septum and the
soft, pliable and its lattice-like structure allows host tissue CSR graft
 Revision Rhinoplasty: The Lost Tip Support 991

Fig. 5: A revision patient who had a previous septal surgery Fig. 6: A revision patient who had a previous septorhinoplasty
with resection of caudal septum and anterior nasal spine. with an over-resected dorsal and caudal septum. Left:
Left: Preoperative views of the patient. Right: Postoperative Preoperative views. Right: Postoperative views of the patient
views of the patient 3 years after reconstruction with an 1 year after reconstruction with a costal cartilage CSR graft
auricular cartilage CSR graft and premaxillary augmentation and premaxillary augmentation with Mersilene mesh
with Mersilene mesh

mesh in the premaxilla in cases with anterior septal perfo- and conchal cartilage requires stacking it in layers, which
rations. In cleft-lip noses, it is mandatory to exclude the is technically difficult to stabilize. Autogenous bone graft
presence of any hidden bony or mucosa fistula that may can be used but it is more difficult to shape and carries a
predispose to contamination and extrusion of the mesh. significantly higher resorption rate.11
Due to the difficulties and limitation associated with
the use of autogenous grafts; many types of implants
OTHER TREATMENT OPTIONS were recommended to provide premaxillary augmenta-
AVAILABLE FOR THE SAME tion. Silastic was one of the first implants to be used in
CONDITION the premaxilla,12,13 however, due to its smooth surface, it
does not adhere to the surrounding tissues and is associ-
Premaxillary Deficiency ated with a high incidence of migration and extrusion.14-16
Unlike Silastic, Proplast17,18 (Vitek, Houston, TX) and
Various kinds of grafts and implants were used to provide Gore-tex19 (W.L. Gore & Co., Flagstaff, AZ) are highly
premaxillary augmentation; cartilage, which is the most porous thus inviting early tissue ingrowth and stabiliza-
widely used graft material in rhinoplasty, was used tion, however, they are more difficult to carve and insert
successfully in the premaxilla.8-10 However, as usually a and leaves the patient with a rigid unnatural feeling of
large amount of cartilage is required to provide adequate the solid implant. Mersilene mesh which was used in
premaxillary augmentation; the limited thickness of septal our technique, shares the advantages of other implants,
 992 Facial Plastics, Cosmetics and Reconstructive Surgery

being readily available in any quantity and not associated 9. Guerrerro-Santos J. Cosmetic repair of the acute columellar-
with any donor-site morbidity. However, unlike the solid lip angle. Plast Reconstr Surg. 1973; 52(3):246-9.
implants, the lattice-like composition of the mesh makes it 10. Lewis JR. Rhinoplasty and the nasolabial area. Clin Plast
soft in consistency and easily infiltrated by host tissue thus Surg. 1988; 15(1):115-24.
leading to early fixation and assures a natural feeling of the 11. Adams JS. Grafts and implants in nasal and chin augmenta-
tion: A rational approach to material selection. Otolaryngol
implant in the lower mobile part of the nose.4,20,21
Clin North Am. 1987; 20(4):913-30.
Another major advantage of Mersilene mesh over
12. Caronni EP. A new method to correct the nasolabial angle in
all other grafts and implants is the pliability of the mesh rhinoplasty. Plast Reconstr Surg. 1972; 50(4):338-40.
implant that allows it to be introduced through a small 13. Fanous N, Yoskovitch A. Premaxillary augmentation: adjunct
entry opening and to conform well and fill-out the under- to rhinoplasty. Plast Reconstr Surg. 2000; 106(3):707-12.
lying asymmetric areas of bony deficiencies as in cleft-lip 14. Davis PK, Jones SM. The complications of silastic implants.
noses.7 Br J Plast Surg. 1971; 24(4):405-11.
15. Deva AK, Mertin S, Chang L. Silicone in nasal augmentation
Caudal Septum Deficiency rhinoplasty: a decade of clinical experience. Plast Reconstr
Many types and shapes of septal extension grafts were Surg. 1998; 102:1230-7.
used successfully to replace the missing or weak caudal 16. Proter JP. Grafts in Rhinoplasty: alloplastic vs autogenous.
septal cartilage. The major problem of these septal exten- Arch Otolaryngol Head Neck Surg. 2000; 126(4):558-61.
sion grafts is the unnatural rigidity and stiffness of the 17. Kridel RWH, Kraus WM. Grafts and implants in revision
nasal lobule, which results from fixing the graft to the nasal rhinoplasty. Fac Plast Surg Clin N Am. 1995; 3:473-86.
18. Cook TA, Wang TD, Brownrigg PJ, et al. Significant premaxil-
septum either directly by suturing or via cartilage grafts.22-28
lary augmentation. Arch Otolaryngol Head Neck Surg. 1990;
In our technique, the pocket for the CSR graft is kept sepa-
116(10):1197-201.
rated from the septum by leaving an intact part of the 19. Schoenrock LD, Reppucci AD. Correction of subcutaneous
membranous septum to intervene between the septum facial defects using Goretex. Fac Plast Surg Clin North Am.
and the graft,6 which allowed preserving some of the natu- 1994; 2:373-88.
ral mobility of nasal lobule (Fig. 4). 20. Beekhuis GJ. Mersilene mesh to augment the nasal bridge.
Am J Cosm Surg. 1986; 3(2):49-53.
REFERENCES 21. McCollough EG, Weil C. Augmentation of facial defects
using Mersilene mesh implants. Otolaryngol Head Neck
1. Foda HM. Rhinoplasty for the multiply revised nose. Am J Surg. 1979; 87(4):515-21.
Otolaryngol. 2005; 26(1): 28-34. 22. Slavit DH, Bansberg SF, Facer GW, et al. Reconstruction
2. Foda HM. External rhinoplasty for the Arabian nose: a colu- of caudal end of septum: A case for transplantation. Arch
mellar scar analysis. Aesthetic Plast Surg. 2004; 28(5):312-6. Otolaryngol Head Neck Surg. 1995; 121(10):1091-8.
3. Foda HM. Management of the droopy tip: a comparison of 23. Pirsing W, Kern EB, Verse T. Reconstruction of anterior
three alar cartilage-modifying techniques. Plast Reconstr nasal septum: Back-to-back autogenous ear cartilage graft.
Surg. 2003; 112(5):1408-17. Laryngoscope, 2004; 114(4):627-38.
4. Foda HM. Mersilene mesh in premaxillary augmentation. 24. Naficy S, Baker SR. Lengthening the short nose. Arch
Aesthetic Plast Surg. 2005; 29(3):169-73. Otolaryngol Head Neck Surg. 1998; 124(7):809-13.
5. Foda HM. The Caudal Septum Replacement Graft. Arch 25. Gruber RP. Surgical correction of short nose. Aesthetic Plast
Facial Plast Surg. 2008;10(3):152-7. Surg. 2002; 26: Suppl 1: S6.
6. Foda HM, Magdy EA. Combining rhinoplasty with septal 26. Guyuron B, Verghai A. Lengthening the nose with a
perforation repair. Facial Plast Surg. 2006; 22(4):281-8. tongue-and-groove technique. Plast Reconstr Surg. 2003;
7. Foda HM, Bassyouni K. Rhinoplasty in unilateral cleftlip 111(4):1533-9.
nasal deformity. J Laryngol Otol. 2000; 114(3);189-93. 27. Toriumi DM. New concepts in nasal tip contouring. Arch
8. Cinelli JA. Correction of combined elongated nose and Facial Plast Surg. 2006; 8(3):156-85.
recessed nasolabial angle. Plast Reconstr Surg. 1958; 28. Toriumi DM, Pero CD. Asian rhinoplasty. Clin Plast Surg.
21:139-42. 2010; 37(2):335-52.
 The Surgical Technique of Otoplasty 993
CHAPTER

103 Alar Struts in Rhinoplasty

Patrick T Hennessey, Kofi DO Boahene

INDICATIONS FOR THE SURGERY placement of alar rim grafts provides additional rim
support and corrects the alar notching typically seen.
Alar rim contour and strength plays an important role in Alar flaring is a common complaint in patients seeking
nasal tip esthetics and function. Contour deformities and cosmetic nasal tip rhinoplasty. It can be either congenital
alar rim collapse may result from congenital weakness or secondary to deprojection of an overprojected nasal
or malposition of the lower lateral cartilages (LLCs). In tip. Alar flaring has traditionally been addressed with alar
addition, alar pinching and valve collapse may occur wedge resection.6 The authors have previously shown
as a result of overzealous cephalic trimming of the LLC, that alar flaring can be improved by either rim graft alone
when compensatory maneuvers are not performed during or in combination with wedge resection without any
rhinoplasty. Alar asymmetries may be noticed in the early increased risk of infection or graft loss.7 The analogy of
postoperative period or as a delayed complication due to a collar stay applies here, whereby the placement of a
scar contracture. More recently, an increased emphasis has stiff alar rim graft straightens a flared alar or minimizes
been placed on nasal tip grafting and suturing techniques the degree of secondary flaring resulting from nasal tip
instead of cartilage excision which has allowed for more deprojection.
predictable control of the alar contour. Traditionally, Additional indications for alar rim grafting include
structural and contour deformities of the alar rim have alar rim collapse, often seen in revision cases when the
been addressed with batten grafts, strut grafts, composite LLC was overresectioned, and congenital weakness of
grafts, and suture techniques.1-3 A less conventional, the LLC. Alar rim grafts may also be used to correct alar
but equally effective graft is the alar rim graft placed in a margin asymmetries, mild notching, and retraction. The
nonanatomic fashion along the alar margin. use of alar rim grafts in the correction of alar notching
In the authors’ experience, the two most common or retraction is a viable option in mild cases (those
indications for placement of alar rim grafts are cephalic with approximately 3–4 mm of retraction) when there
malposition of the LLC and correction of alar margin is adequate lining and skin elasticity to allow stretching
flare. Cephalic malposition of the LLC was first described and unfurling of the retracted rim.8 Alar rim grafts can
by Sheen4 as displacement of the alar cartilage at also be used to reduce the relative alar retraction that
the midpoint of the alar rim toward the medial occurs when septal extension grafts are used to lengthen
canthus instead of laterally toward the lateral canthus. short noses. For more severe cases of notching or
Clinically, the alar rim appears notched and boxy, an retraction, more aggressive maneuvers, including the use
appearance classically described as the parenthesis sign of composite grafts, alar batten grafts, and lateral crural
(Figs 1A to D). From a series of measurements made in strut grafts, may be needed.
50 consecutive patients, Daniel5 noted that the location
of the caudal margin of the lateral crus of the LLC, 7 mm
or more from the mid-alar margin, highly correlates with
PREOPERATIVE EVALUATION
malpositioning of the LLC. Cephalic malpositioning of The ideal alar rim transitions smoothly from the nasal tip
the LLC leaves more of the ala without rigid support. defining point to the nasofacial insertion as a gentle line
Preoperatively and intraoperatively, it is important to with a slight convexity (Fig. 2). The contour and strength
identify this variant of LLC orientation, especially when of the alar rim is primarily determined by the semirigid
cephalic trimming is being considered. Injudicious lateral crus of the LLC. As the LLC transitions from the
cephalic trimming in a malpositioned LLC has the intermediate crus to the lateral crus, it diverges away
potential to leave a weakened LLC, which over time will from the alar margin to a more cephalad position. Thus,
succumb to the forces of scar contracture. Prophylactic the posterior half of the ala is devoid of any rigid support
 994 Facial Plastics, Cosmetics and Reconstructive Surgery

A B

C D
Figs 1A to D: Alar rim grafting for alar margin support and contour correction in a patient with cephalic malpositioned
lower lateral cartilages and “boxy” nasaltip. (A) Preoperative front view; (B) Postoperative front view; (C) Preoperative basal
view; and (D) Postoperative basal view

of the ala without rigid support (Fig. 3B). Overzealous

resection of the cephalic margin of the LLC reduces its
support of the alar rim. The lack of rigid support along
most of the alar rim leaves it vulnerable to inevitable
scarring following trauma or rhinoplasty. A weak lateral
crus will result in static or dynamic collapse of the alar
rim during inspiration. As recently demonstrated,9 the
aesthetically pleasing nasal tip highlights the nasal
tip defining points, transitioning smoothly to the alar
margin without an interrupting shadow. Dome suturing
techniques commonly used in narrowing broad nasal tips
often interrupt the alar margin and may result in a pinched
nasal tip with an isolated nasal tip lobule. Analogous to a
shirt collar stay, the alar rim graft is placed along the alar
Fig. 2: The ideal alar rim transitions smoothly from the nasal margin and is capable of directly altering the contour
tip defining points to the nasofacial insertion as a gentle and strength of the alar margin and therefore improving
curve without a clear demarcation between the nasal tip and the function and esthetic harmony of the nasal tip
alar lobules (Figs 4A to C).

(Fig. 3A). The anatomic relationship between the LLC

and the alar margin has several structural implications.
ANESTHETIC CONSIDERATIONS
A greater degree of cephalic rotation of the lateral crus, As in other rhinoplasty techniques, meticulous injection
as seen in congenital LLC malposition, leaves more with local anesthesia containing epinephrine is necessary
 Alar Struts in Rhinoplasty 995

to ensure hydrodissection and maximal vasoconstriction for hydrodissection and vasoconstriction. The marginal
to allow for excellent visualization during the procedure. incision and alar margin are then exposed with a wide,
This is especially important if performing the procedure in double-pronged retractor. With the rim everted, a precise
an awake or lightly sedated patient in the clinic setting. tunnel is dissected along the alar margin beginning from
the medial end of the marginal incision to the alar base.
Care is taken to avoid penetrating the alar skin. A precise
SURGICAL PROCEDURE alar tunnel can be safely created with a narrow-tipped
After opening the nose in the standard fashion with trans- scissor and Cottle dissector (Figs 4A to C).
columellar and marginal incisions, the alar margin is The authors’ most commonly fashion alar rim grafts
infiltrated with a 1% lidocaine with 1:100,000 epinephrine from harvested quadrangular septal cartilage, but other
sources of cartilage may be used. The dimensions of the
rim graft are first determined by measuring along the
alar margin, the region that requires spanning. The rim
graft is tailored on a case-by-case basis and measures
2–3 mm wide and 15–25 mm long. The edges of the rim
graft should be beveled or contoured to reduce their
profile and palpability. The medial edge of the rim graft is
softened by gentle crushing with a Brown-Adson forceps
or a cartilage morselizer.
Creating a tight and precise pocket minimizes
migration of the alar rim graft. To further immobilize the
rim graft, a 5.0 fast-absorbing suture is placed around
the rim graft, fixing it to adjacent subcutaneous tissue at
its medial end. Placing the suture through the thin rim
graft often leads to cartilage fracture. After placement,
the marginal incisions are closed using 3–4 interrupted
A B 5.0 fast-absorbing sutures.
Figs 3A and B: (A) As the lower lateral cartilage transitions
from the intermediate crus to the lateral crus, it diverges COMPLICATIONS
away from the alar margin to a more cephalad position. Thus,
the posterior half of the alar is devoid of any rigid support. Although rare, potential complications include graft
(B) With cephalic rotation of the lower lateral crus, a greater extrusion, persistence of external naval valve collapse,
portion of the alar is left without rigid support infection, and poor cosmetic outcome. Graft extrusion

A B C
Figs 4A to C: The alar rim graft (green) is placed directly along the alar margin to effect contour changes and provide
resilience. (A) Basal view; (B) Front view; and (C) Profile view
 996 Facial Plastics, Cosmetics and Reconstructive Surgery

can be managed with local wound care and debridement 3. Toriumi DM, Josen J, Weinberger M, et al. Use of alar batten
in clinic as needed. Persistence of external nasal valve grafts for correction of nasal valve collapse. Arch Otolaryngol
collapse can occur when an insufficient quantity or poor Head Neck Surg. 1997;123(8):802-8.
quality of cartilage is used in grafting. Infection and 4. Sheen JJ. Aesthetic Rhinoplasty. St. Louis: Mosby; 1978. pp.
264-5.
poor cosmetic outcome can be avoided by proper tissue
5. Daniel RK. Discussion: the two essential elements for plan-
handling and meticulous skin closure.
ning tip surgery in primary and secondary rhinoplasty:
observation based on review of 100 consecutive patients.
SPECIAL INSTRUMENTATION Plastic and Reconstructive Surgery. 2004;114:1582-5.
6. Constantian MB. The two essential elements for planning
This procedure can be performed with standard rhino­ tip surgery in primary and secondary rhinoplasty: obser-
plasty instrumentation. vations based on review of 100 consecutive patients. Plast
Reconstr Surg. 2004;114(6):1571-81; discussion 1582-5.
7. Boahene KD, Hilger PA. Alar rim grafting in rhinoplasty:
REFERENCES indications, technique, and outcomes. Arch Facial Plast
1. Gunter JP, Friedman RM. Lateral crural strut graft: technique Surg. 2009;11(5):285-9.
and clinical applications in rhinoplasty. Plast Reconstr Surg. 8. Brissett AE, Sherris DA. Changing the nostril shape. Facial
1997;99(4):943-52; discussion 953-5. Plast Surg Clin North Am. 2000;8:433-45.
2. Kamer FM, McQuown SA. Minicomposite graft for 9. Toriumi DM, Checcone MA. New concepts in nasal tip
nasal alar revision. Arch Otolaryngol Head Neck Surg. contouring. Facial Plast Surg Clin North Am. 2009; 17:
1987;113(9):943-9. 55-90, vi.
 The Surgical Technique of
Augmentation Otoplasty 997
Rhinoplasty
CHAPTER

104 Augmentation Rhinoplasty

Brajendra Baser, Shenal Kothari

on septum by the surrounding bones and skin determines

INTRODUCTION its shape and therefore for achieving proper correction of
Augmentation is necessary for both esthetic and func­ septum, these forces are also to be corrected at the same
tional indications, such as the upper or lower lateral carti­ time. Certain factors that need to be evaluated for best
lages. Traditionally, depressed nose results in diminished results are as below:
social acceptability in India. A prominent nose is consid­ • Etiological factors: The etiology of saddle nose plays
ered as a symbol of prestige. Saddle nose is the common­ an important role as in cases of granulomatous disor­
est deformity requesting correction in clinical practice. ders. The basic etiological factor should be treated
Saddle nose deformity results from lack of support to first. For example, in patients with saddle nose due
the bony or cartilaginous nasal dorsum. Columellar retrac­ to leprosy, the disease should be under control and
tion and collapse of the nasal side walls further worsen not in active phase or in atrophic rhinitis. The nose
the cosmoses. Functional reason for augmentation rhino­ must be crust-free in atrophic rhinitis. Similarly, for
plasty includes providing structural support for areas defi­ patients requiring a revision rhinoplasty, a period of
cient of material weakened cartilaginous support formed 6 months to 1 year should have elapsed after primary
in the internal nasal valve area. surgery. Watch for collapsing ala during inspiration.
This is because of external valve collapse and is seen
Causes for Saddle Nose in patients who had undergone aggressive reductio
• Congenital: Nasomaxillary hypoplasia, frontonasal rhinoplasty.
dysplasia, congenital syphilis • Degree and site of required augmentation: The length
• Traumatic: Unreduced nasal bone and septal fract­ of the nasal dorsum and its proportion to the rest of the
ures, untreated septal hematoma/abscess nasal skeleton is important to plan the degree and site
• Iatrogenic: Complication of septorhinoplasty and of correction. Cases with disproportionately low radix
submucous resection (SMR), over reduction of nasal or loss of support in cartilaginous dorsum are difficult
hump (open roof deformity) to augment and such patients need to be accordingly
• Secondary: Granulomatous disorders i.e. leprosy, counseled. Cartilage grafts are the grafts of choice in
syphilis, tuberculosis most situations; septum, concha and rib in order of
• Congenital or racial shortness deformity preference. Occasionally the membranous bones of
• Acquired shortness deformity calvarium are used for nasal augmentation; the last
• Childhood trauma of these procedures is not practiced nowadays. The
• Congenital deformities: Cleft lip nose, Binder’s newer technique for augmentation is diced cartilage in
syndrome fascia lata. This can be prepared as per the requirement
• Dorsal irregularities such as in crooked noses both in respect to size and shape of the recipient area.
The nasal bones gain support from the maxilla and the
nasal process of the frontal bone. In a bony saddle not
SPECIFIC PREOPERATIVE only is the dorsum flat but also the side walls which
EVALUATION require support.
It is true that minor defects meticulously corrected are • Status of the columella and nasal tip: Nasal tip augmen­
not as well appreciated as gross defects converted to a tation is required for patients with retracted columella
less severe deformity. Therefore it is important to be real­ and when the tip support is lost. The concept of equi­
istic and make the patient understand as to what can be lateral rhomboid of nasal tip must be kept in mind for
or cannot be achieved postoperatively. The forces applied all rhinoplasties.
 998 Facial Plastics, Cosmetics and Reconstructive Surgery

• Condition of septal cartilage: The condition of septal (synthetic implants), allogenous materials (obtained
cartilage of nasal septum is assessed. We need to eval­ from cadavers), or autologous implants (harvested
uate as to whether it is available for grafting, both in from the patient’s own tissue). Each has advantages
terms of support and availability as a graft material. In and disadvantages.
conditions like septal abscess or hematoma or follow­
ing SMR operation there may be complete resorption Esthetics
of septal cartilage whether there is a true septal devia­ The esthetics of the profile must be analyzed critically. No
tion or it is because of unilateral collapse of cartilage. single ideal profile exists, because each individual has his
Pseudodeviation should also be ruled out. or her own tastes and priorities.
• Condition of nasal skin: Nasal cavities must be free Some considerations for ideal profile are as follows:
of any crust or infection. Nasal skin type varies from • The nasion should be positioned at the level of the
individual to individual and varies depending on the supratarsal crease.
racial factors as well. It is important as it has a bearing • The forehead and glabella must be adequately
on the anticipated tissue reaction, wound healing and projected to create an appropriately defined nasofron­
surgical outcome. This evaluation is important as in a tal angle.
thin-skinned patient the graft outline may be visible. • A relatively straight dorsum with a slight convexity at
Thick-skinned patient would require more aggres­ the rhinion is most natural and pleasing.
sive augmentation. Similarly, connective tissue type • The tip should project slightly, with the supratip area
becomes significant. It affects skin wrinkling, tissue composing the leading edge of the nasal profile.
tension, elasticity and mobility of skin. Post-traumatic
scarring; puckered skin following infective conditions
or following implant extrusion requires special care.
ANESTHETIC CONSIDERATION
• Degree of nasal obstruction: Evaluation of septal Although local anesthesia works well especially for small
relationship to turbinate is necessary as compen­ cases, it is preferred to use general anesthesia for major­
satory turbinate hypertrophy may lead to nasal ity of the patients. To achieve a clear bloodless field, it is
obstruction. The internal nasal valve is formed by important to inject xylocaine 2% with adrenaline at certain
junction of quadrangular cartilage, anterior end points. A competent anesthetist with controlled hypoten­
of inferior turbinate and floor of nose. This valve sive anesthesia is idle.
should be between 10° and 15°. If the valve is less
than 10°, it produces sense of nasal obstruction.
Positive Cottle’s test is indicative of internal nasal
CHOICE OF GRAFT MATERIAL
valve collapse. A complete internal nasal exami­ The properties of an ideal graft material for augmenta­
nation repeated with aid of topical decongestant tion rhinoplasty includes the following:
and nasal endoscopy allows better visualization of • The graft is tolerated by the host without any immu­
posterior and dorsal septum. nological rejection.
• Photographic documentation is important in diagno­ • The shape and size of material should not change
sis and planning surgery. Postoperative photographs with time and forces of healing.
serves to document immediate outcome and func­ • The material is reasonably malleable to carve or
tion as a historical record to follow surgical changes. mold into the desired shape.
The photographs are taken in following standard • The material is easily obtainable and adequate
views viz. frontal, right and left lateral, oblique supply of the material is available with minimal
and basal. The possible outcome is discussed with donor site morbidity.
patient using preoperative photographs. The nose
is analyzed in relation to entire face. These photo­ Graft Harvesting
graphs help us to understand detailed facial analysis • Septum: In patients without extensive removal of
and in diagnosing structural nasal pathology. Facial septal cartilage in the past, abundant quadrangular
esthetic units (vertically divided into five equal cartilage is apt to be available for harvest. Maintaining
parts and horizontally into three equal parts) are 1.5 cm of the dorsal and caudal septum should be
evaluated separately and in conjunction with nasal sufficient. An intact L-shaped septal strut is necessary
dorsum, nasal tip, sidewalls, nasal alae, columella to provide support to the lower two thirds of the nose
and soft tissue triangle. (Figs 1A to C).
• A number of materials are available to the rhinoplastic • Concha: Auricular cartilage grafts may be harvested
surgeon to augment the nose. These include alloplasts from either a posterior incision or an anterior incision.
 Augmentation Rhinoplasty 999

As long as the anti-helical fold is preserved, the form peripheral pieces, and (4) soak the prepared segment in
of the auricle is not significantly altered with removal saline for 10 minutes to identify any acute warping before
of the entire cavum conchae and cymba conchae implantation. The diced rib cartilage is virtually unlimited
complex. Maintaining the vertical component of supply of graft material for most situations.
the conchal bowl is advised to preserve lateral ear
projection. Hydraulic dissection of the subcuta­ Allograft
neous plane with the injection of local anesthetic The most commonly used allograft materials include
aids in the ease of harvest. The anterior skin is more silicone, Medpore and Gortx. Alloplastic materials have
adherent, although some surgeons prefer to harvest numerous advantages. They are readily available with an
composite grafts from a posterior incision. At times we unlimited supply, they are easy to fashion into the desired
harvest all the available cartilage from both the ears shape, they resist warping and resorption, and they have
(Figs 2A and B). no donor-site morbidity. They are especially popular in
• Ribs: The confluence of the 6th and 7th ribs and the southeast Asian countries where nasal augmentation is a
confluence of the 9th and 11th ribs have been used very common procedure.
successfully for grafting. Care is taken to avoid entrance However, alloplastic implants have been noted to have
into the pleural cavity. higher rates of infection and extrusion (Figs 3A and B).
Rib cartilages have a strong memory and are very prone Infection of the implant may leave the patient with perma­
to curl. This warping can be limited by taking following nent damage to the overlying skin. The use of alloplast in
steps: (1) remove perichondrium completely, (2) symmet­ revision cases, septal perforation and the situations where
ric carving of the costal cartilage from the straightest rib septal support is lacking can be disastrous; the authors
segment, (3) use only the core part of the rib discarding the prefers to use autologous material only.

A B

Figs 1A to C: The septal strut support for dorsum. (A)

L-shaped strut prepared from septal cartilage (needle is used
to fix the two parts); (B) L-shaped strut prepared from septal
cartilage, two parts being sutured; (C) L-shaped septal strut
C ready to use
1000 Facial Plastics, Cosmetics and Reconstructive Surgery

Figs 2A and B: Harvesting cartilage from both conchae

for major augmentation. (A) Severe depression; (B) Cartilage
A B harvested from both conchae

A B
Figs 3A and B: Alloplastic material resulting in extrusion. (A) Infection; (B) Displacement

SURGICAL STEPS The steps are:

As we describe the steps of rhinoplasty in all such cases, Step 1: Painting and Draping
few points must be remembered: Like all operations, standard painting and draping
• Open rhinoplasty approach is preferred as it gives a technique is adopted. The vibrissae are trimmed to get a
complete view of asymmetry. better visualization of the operative field.
• The septum is completely exposed as per the need.
• Care should be taken to avoid perforation of mucoper­ Step 2: Incision
ichondrial flap. Various incisions are described to get access to the recipi­
• Osteotomies are done sometime to reduce the width ent area like intercartilaginous incision (between upper
of the nasal dorsum, however, the authors does not and lower lateral cartilages), cartilage splitting incision (or
recommend it routinely. intracartilaginous) and the marginal incision (along the
• Due importance should be given to the cartilaginous lower margin of the ala) for graft insertion. Currently for all
framework and maintain their anatomical position minimal or major nasal augmentation we use the Rethi-
using spreader graft and positioning sutures. Goodman external rhinoplasty incision (Fig. 4). This has
 Augmentation Rhinoplasty 1001

several distinct advantages: easy access, direct visualiza­ is also sewed to prepare a bag open at one end. Cartilage
tion of the operative field to allow creation of symmetrical harvested from concha/septum or rib are made into very
pockets and elevation of nasal bone periosteum and bone small pieces and filled in the tuberculin syringe (Figs 13A
to bone contact is assured. Graft shifting is avoided since to C). The cartilage pieces are pushed inside the facial
the dissected pocket is in mid-line. Lesser risk of extrusion bag by pushing with the help of the plunger, the syringe is
through the incision site is avoided, the incision site being withdrawn while pushing the diced cartilage filled previ­
away from the recipient area. Also, augmentation of the ously in the syringe. Thus a malleable pillow of diced carti­
side walls is possible through the same incision. lage is formed ready to be used for desired augmentation.
Diced cartilage wrapped in facial tube has distinct advan­
Step 3: Elevation of Dorsal Skin Flap tages, like it is simpler procedure, bigger piece of cartilage
Now the skin along with the subcutaneous tissue is is available and graft material is autogenous. Grafts can be
dissected with the help of a scissors such that the plane prepared as per the desired length, shape and size to fit the
of dissection is kept close to the nasal cartilage and bone. specific defect as they are highly malleable. Complications
However, while we are using a bone graft the dissection is like step deformity and extrusion rarely occur and can be
subperiosteal (Fig. 5). easily managed. Over correction and graft visibility are not
usually met with.
Step 4: Preparation of Recipient Site
A symmetrical pocket of the size slightly larger than the Step 7: Positioning the Graft in Place
width of the graft to be inserted is dissected in the mid-line Once the graft is ready, it is pushed into the recipient site
to avoid migration of graft and subsequent irregularities. A and secured in place.
critical point is the preservation of an adequate soft-tissue
envelope during preparation of the pocket for implanta­ Graft Placement
tion of the graft. The dissection should be performed deep • Radix: The placement of a graft to the radix to correct
to the subdermal plexus, which not only preserves an an overly deep nasofrontal angle can restore a high,
adequate thickness of overlying soft tissue but also mini­ strong profile. The graft also produces the appear­
mizes subsequent fibrosis and unpredictable healing. ance of lengthening the nose. A precise pocket is
produced deep to the procerus muscle, and the graft
Step 5: Supporting Graft is placed. Often, the recipient bed is too large, and
In post-traumatic and revision cases where septal support the graft should be fixed by placing an absorbable
to the nasal dorsum is lost, it is important to remake the suture through the graft and bringing it out through
septal support. A L-shaped frame is made with conchal the skin. It is fixed at this point with a steri-strip for
/septal or rib cartilage (Figs 6 and 7).This frame is fixed several days. Alternatively, percutaneous K-wires
with nasal bone and the maxillary spine and the upper can be placed to secure the graft to the radix and are
lateral cartilage. This is called as the supporting graft. On removed in the office 3 weeks postoperatively. In the
top of this another esthetic layer of cartilage is placed to authors’ experience of utilizing this technique over
give continuity to the dorsum. Figures 8 and 9 demon­ the last 10 years, all costal bone grafts have had stable
strate these procedures in the patients. Figures 10 and 11 bony fusion.
show the method of fixing the graft. This supporting frame • Nasal dorsum: If an endonasal approach is chosen and
provides stable foundation and prevents posterior pulling if the recipient pocket can be created precisely, the
of the dorsal onlay graft, because of the fibrosis in between graft may be introduced without the need for fixation.
the septal mucoperichondrial flaps. Otherwise, fixation is necessary. Multiple options can
be used to stabilize the graft. If possible, multiple point
Step 6: Diced Cartilage in Facial Tube fixations are performed. Polydioxanone (PDS) may be
This is a very elegant method of nasal augmentation used to stabilize the graft to the underlying cartilages.
described by Rollin Daniel and is very useful in post-trau­ In addition, sutures passed through the skin and left in
matic and revision cases where a large amount of graft place for several days are helpful. In addition, suturing
material is required or when the skin covering is very tight of the upper lateral cartilages to the dorsal graft helps
with scarring. support the airway.
A fascial tube is prepared (Figs 12A to D) by harvest­
ing temporalis fascia or fascia lata. The sheet of fascia is Step 8
spread around the tuberculin syringe. The two opposite Finally the skin is closed, nasal packing is done and plaster
parallel borders are stitched together and then the base cast is applied.
1002 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 4: Columellar incision Fig. 5: Creating a symmetrical recipient pocket of the size
slightly larger than the width of the graft to be inserted

A B
Figs 6A and B: Use of L-shaped support from septal cartilage and bilateral conchal cartilage

A B
Figs 7A and B: Use of L-shaped support from septal cartilage
 Augmentation Rhinoplasty 1003

A B C D

E F
Figs 8A to F: Augmentation using bilateral conchal cartilages

A B C

D E F
Figs 9A to F: Use of septal cartilage for augmentation
1004 Facial Plastics, Cosmetics and Reconstructive Surgery

A B
Figs 10A and B: Use of supporting frame to provide stable foundation and placing the dorsal onlay graft. (A) Fixing the
supporting frame with nasal bone and the maxillary spine and the upper lateral cartilage; (B) An esthetic layer of cartilage
placed on the supporting L-shaped cartilage

Fig. 11: Fixation of supporting frame with nasal bone and the
maxillary spine between the upper lateral cartilage in a cadaver
 Augmentation Rhinoplasty 1005

A B

C D
Figs 12A to D: Preparation of fascial tube. (A) Measure the length to be augmented; (B) Harvest the required area of
fascia lata; (C) Cut the tip of tuberculin syringe; (D) Prepare the fascial tube

A B
Figs 13A and B
1006 Facial Plastics, Cosmetics and Reconstructive Surgery

C D
Figs 13A to D: Preparation of diced cartilage graft pillow. (A and B) Cartilage harvested from concha/septum or rib made
into very small; (C) Filled in the tuberculin syringe, the cartilage pieces are pushed inside the fascial bag; (D) A malleable
pillow of diced cartilage

This should be clearly explained to the patient before

Step 9 surgery. A particularly relevant adverse outcome of
An L-shaped support is created from the septal cartilage augmentation rhinoplasty is warping and resorption of the
remnant and the cartilage bag placed between the two grafts, especially with allografts. Asymmetries can occur,
upper lateral cartilages into the desired recipient pocket. despite ideal alignment of the tissues during surgery.
In difficult cases where the graft support is inadequate, These result from asymmetric resorption, warping, and the
we use a large L-shaped graft which rests in nasal spine. formation of scar tissue and can occur as long as several
A columellar strut is used in patients where the caudal months after surgery.
septum is deficient. Additional cartilage graft is used for An inadequacy or overabundance of the augmented
tip augmentation if required. area may become apparent postoperatively. However,
some patients may require revision to achieve a better
outcome.
POSTOPERATIVE DETAILS Infection may occur. The infection may cause extru­
The immediate postoperative care is the same as that for sion of the implant. Removal is then necessary, particu­
primary rhinoplasty. Patients are instructed to leave any larly with alloplasts.
splints or tape undisturbed for 1 week. Head elevation is Changes may occur in the skin overlying the graft mate­
encouraged in the immediate postoperative period. The rial. These include persistent erythema, telangiectasias,
gentle application of ice on the 1st day minimizes swell­ and contour irregularities due to dermal or subdermal
ing and ecchymosis. The avoidance of strenuous activ­ fibrosis. Graft visibility may be a problem in thin-skinned
ity is advised for the 1st week. Particular care to avoid patients.
any manipulation of the nose, including nose blowing,
is stressed for the 1st week. Eyeglasses are not rested on
the bridge of the nose but possibly taped to the forehead.
DIFFICULTIES AND SOLUTIONS
The external rhinoplasty sutures are removed on the 7th Partial or Complete
postoperative day; we recommend use of plaster for 10–15
Absorption of Graft Material
days.
• Whenever possible, prefer cartilage over bone.
• Prefer autologous material over homograft; place the
COMPLICATIONS bone grafts subperiosteally to assure a bone to bone
Complications and adverse outcomes occur in augmenta­ contact.
tion rhinoplasties. A certain percentage of patients inevita­ • Proper immobilization of bone grafts. Make the recipi­
bly require future procedures to achieve a desirable result. ent area free of stress
 Augmentation Rhinoplasty 1007

• Remove scar tissue from the recipient site. This can Septum
produce contraction and stress over the graft. A deficient septal foundation produces a poor frame­
• Infection, hematoma and edema in recipient bed work and this is taken care by using L-shaped dorsal
should be avoided. support.
• Make the recipient pocket in mid­line through external
approach.
• Pocket should be made just to accommodate the graft.
GRAFT MATERIAL
Avoid extensive skeletalization. Historically a wide variety of graft materials has been used
to rebuild the nasal dorsum. These include ivory, metals,
Graft Visibility homograft, allograft, xenograft, bone and cartilage and
Graft outline may be visible in a thin-skinned patient. irradiated rib cartilage. Autografts such as temporalis
• Dissect the pocket close to perichondrial and peri­ fascia, denna fat, septal, costal and conchal cartilage, bone
osteal plane from the iliac crest, calvarium, rib, tibia and olecranon.
• Crushed cartilage may be sutured over the dorsal
surface of bone graft or wrapped in fascia. Choice of Graft Material
• Temporalis fascia can be used to cover the dorsal The surgeons’ choice for selection of graft material in a
surface of bone graft. particular case is as follows:
• Minor augmentation: Septal cartilage. If this is not
Dorsal Irregularities available, conchal cartilage
Cartilage grafts have tendency to curl, especially the rib • Moderate augmentation: Septal cartilage or conchal
cartilage, producing late dorsal irregularities. To minimize cartilage. Layers of septal and conchal cartilage
recurling of cartilage graft, carve off the graft by trimming combined or rib cartilage.
the graft in balanced cross section. • Major augmentation: For severe deformities which
require large amount of graft material, calvarial bone
Soft Tissue Deficiency graft, rib cartilage or iliac crest bone graft is used. In
A generous pocket for the implant is essential to prevent present day practice, diced cartilage in fascia lata gives
graft extrusion and to allow a natural red raping especially the best results.
in post-traumatic or secondary rhinoplasty cases where • Columellar retraction: Septal or conchal cartilage strip
the tissue is scarred. or tip of 9th rib.

A B C

D E F
Figs 14A to F: Augmentation rhinoplasty. (A to C) Preoperative images; (D to F) Postoperative images
1008 Facial Plastics, Cosmetics and Reconstructive Surgery

A B C

D E F
Figs 15A to F: Augmentation using conchal cartilage in a girl with nasomaxillary hypoplasia (Binder’s syndrome)

Few preoperative and postoperative pictures of other 6. Gunter JP, Rohrich RJ. Management of the deviated nose.
patients are given in Figures 14 and 15. The importance of septal reconstruction. Clin Plast Surg.
1988;15:43-55.
7. Gurlek A, Ersoz-Ozturk A, Celik M, et al. Correction of the
BIBLIOGRAPHY crooked nose using custom-made high-density porous
1. Achauer BM, VanderKam VM, Celikoz B, et al. Augmentation polyethylene extended spreader grafts. Aesthetic Plast Surg.
of facial soft-tissue defects with Alloderm dermal graft. Ann 2006;30(2):141-9.
Plast Surg. 1998;41(5):503-7. 8. Holt GR, Garner EI, McLarey D. Postoperative sequelae and
2. Aufright G. Rhinoplasty and face. Plast Reconstr Surg. 1969; complications of rhinoplasty. Otolaryngol Clin North Am.
43:219. 1987;20:853-76.
3. Baser. B. Aesthetic and Functional Rhinoplasty, 2nd edition. 9. Watzinger F, Wutzl A, Wanschitz F, et al. Biodegradable poly­
2004. mer membrane used as septal splint. Int J Oral Maxillofac
4. Bernstein L. Surgical anatomy in rhinoplasty. Otolaryngol Surg. 2008;37(5):473-7.
Clin North Am. 1975;8:549-58. 10. Wright MR, Management of patient dissatisfaction with
5. Fanous N. Unilateral osteotomies for external bony devia­ results of cosmetic procedures. Arch Otolaryngol Head
tion of the nose. Plast Reconstr Surg. 1997; 100 (1):115-23. Neck Surg. 1980;106:466-71.
 The Surgical Technique Otoplasty 1009
Alar BaseofReduction
CHAPTER

105 Alar Base Reduction

Sara Dickie, Jeremy Warner

basal view the nose should be approximately the shape of

INDICATIONS FOR THE SURGERY an equilateral triangle. Alar margins are relatively straight
The soft tissues of the nasal tip, ala and nostrils are an as they travel from the tip of the nose to the alar bases.
integral to the success of rhinoplasty surgery and there- Nostrils should be ovoid in shape and canted off midline
fore need to be evaluated in every rhinoplasty consult so the inferior aspect is more laterally displaced compared
and plan. The primary aims of operating on the alar soft- to the superior.
tissues are to achieve an esthetic balance and natural The standard of keeping the width of the nose within
appearance. This is accomplished by maintaining natural the intercanthal distance should be used as a guideline
borders, preventing revision surgery and attaining accept- instead of a fixed criterion. The width of the lower third of
able scars. There are many techniques described in the the nasal tip should be a relative perceptive value depend-
literature.1-6 Unfortunately, the most effective or appro- ing on the size and shape of the nasal tip rather than an
priate strategy to achieve superior outcomes can at times absolute. One must exercise caution to avoid excessive
remain elusive. The goal of this chapter is to provide the narrowing of the columellar-alar base distance as this may
tools necessary to manipulate the alar soft-tissues, includ- give the appearance of an overly bulky tip. Understanding
ing an algorithmic approach to evaluate and treat various this concept is necessary to achieve the appropriate
anomalies. We will also provide detailed descriptions of balance. Confounding variables such as ethnic differ-
the techniques used to alter and improve the appearance ences and patient preference should affect the approach
of the nasal tip and alar base. Ultimately, these techniques to achieve visual harmony of the face.8
will offer the potential to transform a good result into an
exceptional result, ensuring both facial harmony and a Excessive Width of the
satisfied patient.7 Lower Third of the Nose
Increased Collumellar-Alar Base Distance and
SPECIFIC PREOPERATIVE Large or Asymmetric Nostril
EVALUATION There are two surfaces to the ala that affect the width and
Some alar base irregularities are apparent on preoperative contour of the alar base.9 The cutaneous, or the external
examination. However, many only become apparent after surface refers to the distance between the columella and
intraoperative manipulation of the nasal tip. Therefore, the alar base. The vestibular, or the internal surface refers
tip and base assessment should continue throughout the to the nostril diameter. If these are considered indepen-
operative course. The surgical planning should not be dently one can maintain or narrow the width of the alar
considered complete without an initial assessment and base and maintain or narrow the nostril size separately.
an intraoperative reassessment of the nasal soft-tissue The first step in planning an alar base reduction is
esthetics. Patients should be evaluated from anterior- deciding whether to perform an external base reduction,
posterior, lateral and basal views. If using an open rhino- internal base reduction or both. If the columellar-alar base
plasty approach, the analysis of the base width, appreciat- distance (the width of the lower third of the nose) is exces-
ing both the external and internal components should be sive then typically an external base reduction is warranted
performed with the nose completely closed. (Fig. 3). If the columellar-alar base distance is within the
The ideal nose parameters on anteroposterior (AP) normal range, then a decision needs to be made whether
view are shown in Figure 1. The width of the lower third of the nostril diameter needs to be decreased to reduce
the nose should be approximately that of the intercanthal nostril width (Fig. 4). Some patients may require both
distance. The basal view is shown in Figure 2. From the internal and external base reduction.
1010 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 1: The ideal nasal proportions as seen from the antero­ Fig. 2: The ideal nasal proportions as seen from the basal
posterior view. The width of the lower third of the nose is view. The surfaces of the nose approximate an equilateral
approximately equal to the intercanthal distance triangle (shown in red). Alar margins are relatively straight
from tip to base. Nostrils should be ovoid in shape and
canted off midline

Fig. 3: Intraoperative anteroposterior (AP) view of a patient Fig. 4: The same patient from Figure 3 from basal view.
after open rhinoplasty with columellar incision closed. Note Note the nostril diameter is too wide and the nostrils are
the width of the lower third of the nose is too wide. This is round. This is an indication for internal base reduction. This
an indication for an external base reduction patient also exhibits nasal flaring as the lateral wall of the
ala bows outward beyond the alar-facial groove
 Alar Base Reduction 1011

Excessive Alar Flaring for other surgical procedures of the nose, this can easily be
Alar flaring is best evaluated from the basal view done in the office under local anesthesia alone.
(Fig. 4). The alae should be relatively straight as they For local anesthetic we prefer 1% lidocaine with
travel from the tip to the alar base. Flaring is seen when 1:100,000 epinepherine. We are not concerned with tissue
the lateral aspect of the ala extends significantly beyond ischemia of the nasal tip using epinephrine.11 The dura-
the alar-facial groove, thus forming a very round nostril. tion of vasoconstriction is short lived and the nasal tip has
Following the algorithm described below, the sequence of a robust blood supply which will protect these delicate
alar flare analysis takes place after alar base reduction. At tissues from necrosis. Using a 27 gauge or smaller needle,
this point the alar base has been set and the majority of the we infiltrate 2–3 cc at the base of the columella and ala,
dissection has already been carried out. It is very common both internally and externally along the alar margins.
to see flaring when the nose has been deprojected For the anesthetized patient, proper neck and head
(Fig. 5). Evaluation of nasal flaring should always be support is important. One should ensure that the drapes
performed in this circumstance to address the possible do not prevent free movement of the neck, should turn-
need for flare reduction. ing the head become necessary for access or visualization.
Ensure that the endotracheal tube and any other tubing
Excessive Alar Hooding is free from the drapes, so any head movement will not
Alar hooding is best evaluated from the lateral view. It dislodge the tube. In patients who are undergoing alar
is present when the most caudal curve of the ala hangs base reduction under local anesthesia alone, make sure
excessively low. This can occur from either excess the patient is comfortable and the head well supported
alar bulk or from a caudal alar insertion. Hooding before getting started. We prefer to cover the eyes with
obscures the columella from view in the lateral position moist gauze in order to protect the patient from the surgi-
(Fig. 6). This deformity can be diagnosed using an assess- cal field and the intensity of the surgical lighting.
ment described by Gunter et al. Looking from the lateral
view, a line is drawn through the center of the long axis
of the visible nostril.10 If the alar rim is within 1.5–2.0 mm
SURGICAL STEPS
of this line, then alar position is acceptable. If the distance Alar Base Reduction
is less than 1.5 mm or if the nostril is not visible a hang-
ing or hooding ala is present. The amount of hooding can External Alar Base Reduction
be relative and change depending on columellar show.
However, an absolute analysis is more accurate and External alar base reduction decreases the columellar-alar
should be used when deciding whether to reduce bulk of base distance and reduces the apparent width of the lower
the ala. Intraoperatively, analysis of alar hooding should third of the nose on AP and basal views. It is best performed
be performed after the columellar-alar and tip-alar base in the nasal sill. If the goal is to reduce only the columel-
distances are set. lar-alar width, then an external reduction is planned. In
the external reduction the excision is wide at the bottom
Algorithm of the sill and tapered in an “inverted V” pattern (Fig. 8).
We have included an algorithm to provide an overview of This allows a narrowing of the base without changing the
the aforementioned analysis and the sequence of correc- circumference of the nostril. Patient marking begins with
tive procedures (Fig. 7). This algorithm should simplify the the columellar midline followed by the base of one of the
decision-making process. The rhinoplasty surgeon can nostril sills (Fig. 9). This distance is measured and used to
sequentially determine the need for each step and then mark the opposite sill. Using calipers mark the intended
apply the surgical techniques which follow for each indi- area of excision staying medial to the first mark as not to
cated procedure. encroach on the ala. The excision is then carried out with a
No. 11 blade (Fig. 10). In most cases of alar base reduction,
we find it necessary to create a true advancement-rota-
ANESTHETIC CONSIDERATIONS tion flap of the entire alar base to prevent notching. The
Most alar base reductions will be performed simultane- flap is planned with a 0.5 mm mark above the alar-cheek
ously with rhinoplasty and therefore will likely take place junction. The incision along the alar base is carried up to
under general or twilight anesthesia. In these cases an a line drawn halfway between the nasal alar base and the
oral-ray tube is most effective in maintaining the airway alar groove marking the extent of the superior incision in
and avoiding interference with the operative field. In cases order to prevent blood supply compromise to the nasal tip
where alar base reduction is indicated without the need and superior columellar flap.12,13 After incision, the alar
1012 Facial Plastics, Cosmetics and Reconstructive Surgery

base is undermined and freed to allow advancement to the appropriate amount of resection is marked at the top of
medial excisional edge (Fig. 11). The flap allows for a more the sill and at the bottom. These marks are connected
natural curve and reduces tension along the suture line. and define the total area of excision (Fig. 15). The
It also optimizes scar outcome. In patients with an obtuse remainder of the surgical steps are identical to those
alar-cheek junction, patients with a predisposition to poor detailed in the external alar base reduction section.
scarring, and patients with limited isolated internal base
reduction we forgo the advancement flap. A single 6-0 Alar Flare Reduction
nylon suture holds the advancement flap in place to allow If alar flare reduction is indicated, the amount of the
assessment of nasal flaring (Figs 12A and B). lobule to resect is planned and marked (Fig. 16). The
When the base reduction is complete the wounds are planned incision will be from the nasal sill around the
completely closed with 6-0 nylon sutures. Edges of all inci- alar base. It is important to preserve the natural alar-
sions should have a well-everted closure which reduces risk cheek junction with this incision, so care should be
of notched scarring in the nasal sill. Rarely, a V-Y closure may taken to stay just above this line. Also, do not extend
become necessary (Fig. 13). No deep sutures are necessary. the incision outside of the superior alar crease in order
Most of the cutaneous sutures are removed on postopera- to avoid the lateral nasal artery which is just beyond
tive day 4, with the exception of the central sill suture and the this margin. Excision is performed at the lateral base
more cephalad sutures on the inner portion of the sill, which of the ala, just above the ala-cheek junction. The free
are left in for 6 days. Sterile skin closure strips (Steri-Strips; edge of the base is grasped with forceps and held
3M, St Paul, Minnesota) are placed for an additional 4 days taught for wedge-shaped excision using a No. 11 blade
once the sutures are out. (Fig. 17A). This excision simply shortens the tip–alar
base distance. If flair reduction is carried out simulta-
Internal Alar Base Reduction neously with alar base reduction the incision will be
For internal alar base reduction one must address only the continuous with that of the medially located alar base
vestibular alar surface. For this, the sill excision is wide at incision along the nasal sill (Fig. 17B). Once the resec-
the top of the sill and tapered in a “V” pattern at the base tion is performed, the incisions are completely closed
of the sill (Fig. 14). This allows narrowing of the circumfer- with 6-0 nylon sutures (Fig. 18).
ence of the nostril but prevents any change in the columel-
lar-alar base distance. The surgical steps to carry out the
internal alar base reduction are the same as for the exter-
nal alar base reduction (detailed in the preceding section).

Combination
If pre or intraoperative assessment indicates a need for
both internal and external alar base reductions, then the

Fig. 5: When the nose is surgically deprojected the alar Fig. 6: Direct lateral view showing alar hooding. The
base widens and alar flaring is increased caudal curve of the ala obscures the columella
 Alar Base Reduction 1013

Fig. 7: Algorithm for the analysis and treatment of the alar base
1014 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 8: Excision pattern for external alar base excision Fig. 9: Markings for alar base excision. Start with the columellar
midline followed by the base of one nostril sill. Measure the
distance and use this to mark the opposite sill. Using calipers
measure the intended area of excision on both sides

A B
Figs 10A and B: (A) Using a No. 11 blade excise the wedge of tissue at the nasal sill;
(B) Shown is a combination of internal and external alar base excision
 Alar Base Reduction 1015

Fig. 11: Advancement-rotation flap to close the alar base

excision

A B
Figs 12A and B: (A) A stay-suture is placed to allow assessment of nasal flaring and contralateral reduction;
(B) Note how the base reduction has caused an increase in nasal flaring on the patient’s left

Fig. 13: V-Y closure may be necessary to avoid notching Fig. 14: Excision pattern for internal alar base excision
1016 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 15: Excision pattern for combination alar base excision Fig. 16: Excision pattern for alar flare reduction

A B
Figs 17A and B: (A) For alar flare reduction a wedge of tissue is resected from the alar base.
(B) The wedge resection is continuous with the alar base incision at the nasal sill
 Alar Base Reduction 1017

Fig. 18: Completion of alar base and alar flare reduction Fig. 19: The ideal visual boarder of the ala is a gentle curve
on both sides of nose

The wedge of tissue is excised from the inner ala and the
wound closed with a running 6-0 nylon suture. The suture
line often falls within the visual border of the ala. However,
it also occurs in a natural plane, and because of this we
have not found healing along this line to be a problem.
Sutures are removed on postoperative day 4.

COMPLICATIONS
Scars following the use of these techniques heal excep-
tionally well. While the possibility of each incision should
be discussed with patients preoperatively, reassurance
can be given that the scars typically heal well and will
result in a more balanced overall rhinoplasty result. Other
studies also support low complication rates and good scar
outcomes.14 For alar base excisions requiring an advance-
ment flap, note that excisions carried out too far laterally
along the natural curve of the ala may result in an unnatu-
ral curve, a notch, or unnatural insertion of the alar base.
It is vitally important not to disrupt the natural curve of the
Fig. 20: Excision pattern for alar hooding. Elliptical alar base.
excisions closed along the natural alar border
There is a risk of over correction when resecting the
alar base. It is important to recognize that small excisions
Alar Hooding Reduction can make a significant difference, and one should always
This resection is planned using a direct lateral view. excise less when there is doubt. Placing a trial stitch
The visual border of the ideal alar curve is marked allows the surgeon to make decisions regarding further
(Fig. 19). An ellipse is drawn on the inner portion of the resection (which should only be a millimeter at a time).
ala matching the outer visual border. This incision should You can always cut a board sorter, but you cannot
curve gently to avoid distortion of the nasal ala (Fig. 20). cut it longer.
1018 Facial Plastics, Cosmetics and Reconstructive Surgery

SPECIAL INSTRUMENTS USED FOR 3. McKinney PW, Mossie RD, Bailey MH. Calibrated alar
base excision: a 20-year experience. Aesthetic Plast Surg.
THE SURGERY 1988;12(2): 71-5.
A rhinoplasty tray containing fine toothed forceps and 4. Gilbert SE. Alar reductions in rhinoplasty. Arch Otolaryngol
Castroviejo calipers should be available. We also use a No. 11 head Neck Surg. 1996;122(7): 781-4.
blade knife , a fine marking pen, and 6-0 Nylon suture. 5. Becker DG, Weinberger MS, Greene BA, Tardy ME Jr.
Clinical study of alar anatomy and surgery of the alar base.
Arch Otolaryngol Head Neck Surg. 1997;123(8): 789-95.
A MENTION OF OTHER 6. Guyuron B, Behmand RA. Alar Base abnormalities: classifi-
TREATMENT OPTIONS AVAILABLE cation and correction. Clin Plast surg. 1996;23(2): 263-70.
7. Adamson PA. Alar base reduction. Arch Facial Plast Surg.
FOR THE SAME CONDITION 2005;7(2):98.
Excessive alar hooding is a relatively rare problem, and 8. Porter JP. The average African American male face: an
there are multiple ways to correct this deformity surgi- anthropometric analysis. Arch Facial Plast Surg. 2004:6(2):
78-81.
cally. Some authors prefer to keep the elliptical excision
9. Sheen JH. Alar Resection and Grafting: Dallas Rhinoplasty.
inside the nose, bringing the caudal alar border more
2nd ed. St Louis, MO: Quality Medical Publishing;
cephalad. Others have advocated conservative resection
2007:553.
of the caudal border of the lateral crus without mucosa,
10. Gunter JP, Rohrich RJ, Friedman RM. Classification and
elevating the caudal alar border.10,15-17 We prefer to use
correction of alar-coumellar discrepancies in rhinoplasty.
a direct external excision of the caudal border of the ala
Plast Reconstr Surg. 1996; 97(3): 643-8
along the ideal visual border. This approach has been
11. Hafner HM, Rocken M, Breuninger H. Epinepherine-
described in cleft nasal surgery. It benefits the surgeon by supplimented local anesthetics for ear and nose surgery:
allowing accurate determination of the visual border and clinical use without complications in more than 10,000
to set it as determined.18-20 We have found that these scars, surgical procedures. J Dtsch Dermatol Ges. 2005;3(3):
even if they are larger, heal just as well as the columellar 195-9.
and alar base incisions and restore and ideal visual border 12. Bafaqeeh SA, Al-Qattan MM. Simultaneous open rhino-
in the ala. plasty and alar base excision: is there a problem with the
The alar soft-tissue excision techniques presented in blood supply of the nasal tip and columellar skin? Plast
this chapter are based on three principles. First, excision of Reconstr Surg. 2000;105(1): 344-7.
the vestibular sill and rim reduces the outer alar perimeter 13. Rohrich RJ. Simultaneous open rhinoplasty and alar
and narrows the nostril diameter. By angling the excisions base excision: is there a problem with the blood supply
in the sill, the surgeon can manipulate the columellar-alar of the nasal tip and columellar skin? Plast Reconstr Surg.
distance and the nostril diameter independently, or use 2000;105(1): 348-9.
a combination of both. Second, a wedge resection along 14. Kridel RWH, Castellano RD. A simplified approach to alar
the rounded caudal margin of the alar lobule decreases base reduction: a review of 124 patients over 20 years. Arch
the amount of alar flare. Third, in the lateral view there Facial Plast Surg. 2005;7(2): 81-93.
is a natural curve and position of the ala. It should not 15. McKinney PW, Stainecker ML. The hanging ala. Plast recon-
hang excessively and obscure the view of the columella. str Surg. 1984; 73(3): 247-430.
Understanding these principles will allow the rhinoplasty 16. Brown JB, McDowell F. Plastic surgery of the Nose. 2nd ed.
surgeon to manipulate these variables and achieve supe- Springfield, IL: Charles C Thomas; 1951: 118-9, 134-5.
rior esthetic success. 17. Guyuron B. Alar rim deformities. Plast Reconstr Surg.
2001;107(3): 856-63.
18. Ellenbogen R, Blome DW. Alar rim raising. Plast Reconstr
REFERENCES Surg. 1992; 90(1): 28-37.
1. Adamson PA, Oakley S, Tropper GJ, et al. Analysis of alar 19. Millard DR Jr. alar margin sculpturing. Plast Reconstr surg.
base narrowing. Am J Cosmetic Surg. 1990;7(4): 239-43. 1967; 40(4): 337-42.
2. Farkas LG, Hreczko TA, Deutsch CK. Objective assessment 20. Dibbell DG. Cleft lip nasal reconstruction: correcting the
of standard nostril types –a morphometric study. Ann Plast classic unilateral defect. Plast reconstr Surg. 1982;69(2):
Surg. 1983;11(5): 381-98. 264-71.
 The Surgical Technique of Otoplasty 1019
CHAPTER

106 Esthetic Rhinoplasty—Ailed and

Ailing Noses
BP Belaldavar

suffered. And also nature of outcome of the results depends

INTRODUCTION on the intensity, frequency and duration of the ailment.
We, the human beings, are in pursuit of beauty from Therefore, it is essential to discuss and elaborate differ­
the ancient days of ignorance and illiteracy to the ent types of ailments and how to account them in relation
present days of evolved intellectual multimedia. It is to philosophy of treating such noses esthetically.
true with perceptive of both the subjective and the treat­
ing surgeon. The shape and functions of the nose have
been dictated with very complex and organized suppor­
AILED ASSOCIATED NOSES
tive architectural and associated supportive factors. To Ailed noses are the one that have already suffered or had
achieve expected goal these are to be respected and if been abused in one or other form and now there is no
violated in treatment with overjealous unrealistic expec­ prevailing active pathology or disease. So for all practi­
tations, leads to jeopardy and imperfections1. Thus cal purposes the architectural structures and the covering
patient evaluation and selection for esthetic rhinoplasty envelope of the nose are settled well for the surgical explo­
goes beyond assessment of anatomical indications. One ration and correction. All possible etiological factors can
of the accepted principles of surgeries is greater reliance cause the deformities and contribute for the ailed noses
on established rhinoplasty principles of repair and long (Figs 1 to 28). And this in turn adds up to eccenterated
term healing concepts.5 situation in corrective rhinoplasty.2,3,5,6,9,10,14,17,18
The human nose is subject to wide array of deformities,
abnormalities and anatomical variations. Deformities like Congenital Deformities (Figs 1 to 7)
congenital, traumatic, postinfections or growth. Abnor­
malities which cause pathological anatomical change Major congential deformities are often associated with
frequently implies functional disturbance. Anatomical other subtle deformities which need to be identified.
variations many of which to a certain extent dependent on
race, gender or age and have therefore to be considered
within the normal range.1,3,5,6
The behavior and outcome of the esthetic results of the
nose definitely skeptical and does depend on status and the
condition of the nose when the cosmetic or the functional
surgery is contemplated. In fact both the end results are
complementary to each other. Therefore it is ethical and
also sensible in terms of surgical concepts to evaluate clini­
cally and, if needed, with relevant investigations to assess
and to know the status and condition of nose in relations
to whether is it ailed or ailing nose. The esthetic surgery
should be under­taken only after proper diagnosis of the
ailment, its assessment and appropriate treatment.2,9
All the constituents forming the nose, like the skin and
its components, fibromuscular envelope bony skeleton
and the lining of inside of nasal cavities behave differently
to the surgical assault depending on the type and chronic­
ity of ailment2,3,5,6,9,10,14,17,18 they are being suffered or had Fig. 1: Poly deformity
1020 Facial Plastics, Cosmetics and Reconstructive Surgery

Congenital Deformities (Figs 1 to 7)

These are compound poly deformities and such and palpation so as to identify all deformities for
noses are to be evaluated in detail by inspection correction.

Fig. 2: Congenital Poly deformity Fig. 3: Small tension nose

Fig. 4: Short columellar deformity Fig. 5: Small nose with deep NF angle
 Esthetic Rhinoplasty—Ailed and Ailing Noses 1021

Fig. 6: Big deformed nose with Fig. 7: Thick, short and broad columella
excessive lax and thick skin

Fig. 8: Large crooked nose Fig. 9: Skewed nose

Developmental Deformities (Figs 8 to 12)

influence of some of the factors through the development
These types of noses are associated with variant inter- of the nose. It is ideal to contemplate the surgery after age
related abnormalities which are due to the continuous of of 18 years in males.
1022 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 10: Long deformed nose Fig. 11: Broad nose

Fig. 12: Septal caudal dislocated nose

 Esthetic Rhinoplasty—Ailed and Ailing Noses 1023

Traumatic Deformities (Figs 13 to 17)

It is suggested that the acute traumatic deformities are after the optimum period of 6 months.These deformities
corrected within 2-3 weeks, if not the correction is done are difficulty to address

Fig. 13: Saddle nose Fig. 14: Broad nose with saddle

Fig. 15: Chop injury of ala nose Fig. 16: Big amorphous nose
1024 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 17: Caudal dislocated septum in a child

Fig. 18: Post septoplasty Fig. 19: Post submucosal resection of septum

Iatrogenic Deformities (Figs 18 to 22)

Sometimes nasal deformities do occur because of surgical process. But, with due care during surgical correction of
interventions to correct the nasal disease or the deformi­ primary problems the deformities can be reduced to some
ties. These could be intentional or non-intentional. extent. The revision surgery is done after 6 months to
Invariably these are unavoidable because of disease correct the deformities.
 Esthetic Rhinoplasty—Ailed and Ailing Noses 1025

Fig. 20: Post septal abscess Fig. 21: Post submucosal resection septal perforation

Fig. 22: Post submucosal resection columellar retraction

1026 Facial Plastics, Cosmetics and Reconstructive Surgery

Skin Conditions (Figs 23 to 25) especially of the face. It is all the more important in open
Rhinoplasty to avoid flaring of the disease and also to
Before undertaking corrective surgery of nose it is always prevent the wound infection which may lead to unsightly
wise to diagnose and treat the primary skin diseases scars

Fig. 23: Acne rosacea Fig. 24: Thick sebaceous skin

Fig. 25: Lipoid proteinosis—Fine shining yellowish nodules

 Esthetic Rhinoplasty—Ailed and Ailing Noses 1027

Chronic Diseases (Figs 26 and 27) to cure the chronic disease before undertaking the correc­
Because of long lasting disease process it takes quite a long tive surgery of nose to achieve acceptable, reliable and
time to make the chronic disease to heal and it is worth sustainable results.

Fig. 26: Atrophic rhinitis – causing Saddle and Broad nose Fig. 27: Burnt out rhinoscleroma – Conjoint l
lip Columella and nasal lobule

Associated Deformities
So the satisfactory outcome of surgical results is possi­
ble only after thorough evaluation and understanding
of the exact nature of the tissue healing and associated
problems and addressing the same with extra care during
corrective surgery of the nose.
Rhinoplasty in the aging nose is distinctly different
entity, whose unique characterization must be appreci­
ated by the rhinoplasty surgeon to optimize the functional
and esthetic results.11
Early surgeries before patients have reached puberty
when properly performed will not alter nasal develop­
ment and normal nasal growth, even after medial and
lateral osteotomies, cartilage repositioning and conserva­
tive septoplasty.14
Fractures of the nasal complex are the most common
facial fractures. This is because it is most prominent, made
up of composite structures and less force is required. It
is always a rule and mandatory to allow minimum of 6
months time before the definitive corrective surgery on
Fig. 28: Hypertrophied masseter muscle – Dysharmonic such noses to allow all the tissues to settle and edema to
esthetic face subside completely.3,4,12,14
1028 Facial Plastics, Cosmetics and Reconstructive Surgery

AILING ASSOCIATED NOSES as the tissue healing process will be bizarre and unpredict­
Many of the time noses get affected by active disease or able. Infact, operating on such noses is unphilosophical,
diseases (ailing nose) (Figs 28 to 41). In such noses, the unethical and unwarranted3,4,6,8,15,20
tissues forming the nose are edematous, fragile and render
the nose more ugly looking. Therefore the esthetic surger­ Infections (Figs 29 to 36)
ies on such noses are definitely not undertaken for the Acute infections whether mild or fulminant are to be
obvious known reasons. By operating on such actively treated energetically then only patient is operated for
ailing noses one will end up with most disastroussituation, esthetic correction of nose.

Fig. 29: Nasal vestibulitis—Farunculosis Fig. 30: Cavernous sinus thrombophlebitis

Fig. 31: Erysipelas Fig. 32: Herpes zoster—vesicles

 Esthetic Rhinoplasty—Ailed and Ailing Noses 1029

Fig. 33: The wart—lesions Fig. 34: Rhinosporidiosis—mass

Fig. 35: Molluscum contagiosum lesions Fig. 36: Syphilis lesions

1030 Facial Plastics, Cosmetics and Reconstructive Surgery

A B

C D
Figs 37A to D: Rhinoscleroma noses—mild to florid lesions

A B
Figs 38A and B: Fungal diseases—involving the sinus and adjacent structures
 Esthetic Rhinoplasty—Ailed and Ailing Noses 1031

A B
Figs 39A and B: Human bite and its correction with auricular graft

Fig. 40: Acanthoma Fig. 41: Dacryocystitis

The primary modality of managing such ailing it leads to inefficient local anesthesia, excessive oozing
noses is proper accurate diagnosis of the disease, peroperatively and loss of tissue planes. And postop­
investigating the same and treating it appropriately. eratively exaggerated tissue edema, delayed healing,
The esthetic surgery is contemplated only after the more pain and sometimes may get infected and lead­
primary disease is completely cured and sufficient time ing to unexpected results of the surgery and permanent
is allowed for complete healing of the tissues. Otherwise morbidity.
1032 Facial Plastics, Cosmetics and Reconstructive Surgery

ASSOCIATION-EVALUATION of deformity and the site of correction or rectification

are also appreciated. The optimum timing for surgery is
(FIGS 42 TO 47)3,6,8,13,16 6 months to 1 year in chronic and traumatic noses.
Whether the nose is ailed or ailing the proper evalua­tion Special conditions, like atrophic rhinitis, rhinoscle­
is done with paramount care and precision, in relation roma, fungal diseases and skin conditions, are to be
to nasal skeleton and its envelope. The sensitivity of the taken care of and are to be addressed. Diagnostic, and
skin is examined for the easy bruising and ecchymosis. if needed functional endoscopy is done either concur­
The condition of the nasal mucosa and skin along with rently or at different interval depending on the need of
the status of the septal cartilage is noted. The degree the same.

Fig. 42: Acnetic skin and sensitive skin Fig. 43: Peroperative ecchymosis of skin

Fig. 44: CT scan evaluation—Chronic sinus disease

 Esthetic Rhinoplasty—Ailed and Ailing Noses 1033

A B

C D
Figs 45A to D: Nasal endoscopy-showing DNS, Spur, Hypertrophied turbinate and Secretions respectively

Fig. 46: Inspection and palpation of obvious and

subtle structures
1034 Facial Plastics, Cosmetics and Reconstructive Surgery

Apart from routine, patients are subjected for special The architectural balance between tension and
investigations like nasal endoscopy and, if needed, some­ compression get affected in such ailments leading to
times CT scan as well. The manual palpation for subtle deformities. Restoration of this balance is necessary for
details, even for minimum tissue details, is quite useful stable reconstruction. The corrective rhinoplasty is done
for proper planned surgery to avoid unexpected situations with basic concepts with permutation and combinations
peroperatively and for the good results. of various complimentary procedures and grafts in the
form of fillers, spreaders, suspensors, plums, battens,
shields, umbrellas and various modified sutures (Figs 48A
HOW TO RECTIFY2,3,6,8,9,11,14,15,18 and B).
As it is appreciated, the basic challenge in esthetic surgery
in ailed and ailing noses is the influence of the disease
process directly or indirectly on the architectural and skin
SOME OF THE EXAMPLES OF AILED
soft tissue envelope of the nose. This effects the diagno­ AND AILING NOSES BEFORE AND
sis, management, surgical evaluation, procedure, healing AFTER ESTHETIC SURGERY
process and thus directly on the result and the morbidity.
If this entity is not taken into consideration and compro­ Some of the examples of ailed and ailing noses before
mised, it leads to cosmetic as well as functional morbidity and after esthetic surgery are depicted in Figure 49 (two
and many a time it leads to psychosomatic disorder. columns).

A B

C D
Figs 47A to D: (A and B) Showing the tip and dome configuration; (C and D) Showing the dedirected
inspired air currents in saddle nose and anterior septal angle respectively
 Esthetic Rhinoplasty—Ailed and Ailing Noses 1035

A B
Figs 48A and B: Grafts in the form of fillers, spreaders, suspensors,
plums, battens, shields, umbrellas and various modified sutures
1036 Facial Plastics, Cosmetics and Reconstructive Surgery

Before Esthetic Surgery After Esthetic Surgery

C
Figs 49A to C
 Esthetic Rhinoplasty—Ailed and Ailing Noses 1037

Before Esthetic Surgery After Esthetic Surgery

F
Figs 49D to F
1038 Facial Plastics, Cosmetics and Reconstructive Surgery

Before Esthetic Surgery After Esthetic Surgery

I
Figs 49G to I
 Esthetic Rhinoplasty—Ailed and Ailing Noses 1039

Before Esthetic Surgery After Esthetic Surgery

L
Figs 49J to L
1040 Facial Plastics, Cosmetics and Reconstructive Surgery

Before Esthetic Surgery After Esthetic Surgery

O
Figs 49M to O
 Esthetic Rhinoplasty—Ailed and Ailing Noses 1041

Before Esthetic Surgery After Esthetic Surgery

R
Figs 49P to R
1042 Facial Plastics, Cosmetics and Reconstructive Surgery

Before Esthetic Surgery After Esthetic Surgery

S
Figs 49A to S: Some of the samples of ailed and ailing noses before and after esthetic surgery

So, the acute and subacute afflictions are to be treated 5. Sood VP. Corrective Rhinoplasty. CBS Publishers New Delhi
first and primarily. Decision of precision to address the (India), 2008.
conspicuous or subtle and expressed or unexpressed 6. Browning GG. Burton MJ, Clarke R, Hibbert J, et al. 2008.
features is necessary. One has to keep in mind the innate Scott-Brown's otolaryngology (7th ed., Hodder Arnold
international ed.). London.
idiosyncrasy of the healing tissues. It is comforting to
7. Belaldavar B.P. Lipoid Proteinosis—Aspect of Otorhino­
confirm that the rules are not cut and dried and still there
laryngo­logist: A rare case report. Journal of Scientific
is plenty of room for individual differences of opinion. Society. 2008;35(1):73-6.
Whatever it may be the result should produce reliable 8. Fuchs HA, Tanner SB. Granulomatous disorders of the nose
stable reconstitution of deformity with minimum compli­ and paranasal sinuses. Curr Opin Otolaryngol Head Neck Surg.
cations. With more control and predictability it should 2009;17(1):23-7. doi: 10.1097/MOO.0b013e32831b9e58.
reduce reoperation rate and improve esthetic and func­ 9. Shah AR, Zeitler D, Wise JB. Nasal reconstruction of the
tional problems. The soft tissue envelope of the nose get leprosy nose using costal cartilage. Otolaryngol Clin North
relaxed over time. Maintaining an open attitude, proper Am. 2009;42(3):547-55. doi: 10.1016/j.otc.2009.03.009.
evaluation and listening to the patient help the surgeon to 10. Pribitkin EA, Ezzat WH. Classification and treatment of the
have fair judgment in the management of ailed and ailing saddle nose deformity. Otolaryngol Clin North Am. 2009;
42(3):437-61. doi: 10.1016/j.otc.2009.03.004.
noses appropriately in esthetic rhinoplasty.
11. Rainsbury JW. The place of rhinoplasty in the ageing
face. J Laryngol Otol. 2010;124(2):115-8. doi: 10.1017
REFERENCES S0022215109990892. Epub 2009 Sep 18.
12. Bremke M, Gedeon H, Windfuhr JP, Werner JA, Sesterhenn
1. Tardy Jr. ME, Denneny 3rd. J, Fritsch MH. The versatile AM. Nasal bone fracture: etiology, diagnostics, treatment
cartilage autograft in reconstruction of the nose and face. and complications. Laryngorhinootologie. 2009;88(11):
Laryngoscope. 1985; 95: 523-33. 711-6. doi: 10.1055/s-0029-1224106. Epub 2009 Jun 26.
2. Congdon D, Sherris D, Specks U, McDonald T. Long-term 13. Sachse F, Stoll W. Nasal surgery in patients with systemic
follow up of repair of external nasal deformities in patients disorders. Laryngorhinootologie. 2010;89 Suppl 1:S103-15.
with Wegener's granulomatosis. Laryngoscope. 2002;112: doi: 10.1055/s-0029-1246127. Epub 2010 Mar 29.
731-7. 14. Wright RJ, Murakami CS, Ambro BT. Pediatric nasal injuries
3. Trenite GN. Rhinoplasty: A practical guide to functional and and management. Facial Plast Surg. 2011;27(5):483-90. doi:
aesthetic surgery of nose. Kugler Publications Hague. 2005. 10.1055/s-0031-1288931. Epub 2011 Oct 25.
4. Disant F, Bessède JP. [Guidelines for the clinical practice: 15. Larson K, Gosain AK. Cosmetic surgery in the adolescent
aesthetic and functional rhinoplasty].; Societe Francaise patient. Plast Reconstr Surg. 2012;129(1):135e-141e. doi:
d'Oto-Rhino-Laryngologie et de Chirurgie de la Face et 10.1097/PRS.0b013e3182362bb8.
Cou; Societe Francaise de Stomatologie et Chirurgie Maxillo 16. Ghosh SK. Rhinoplasty in atrophic rhinitis. J Indian Med
Faciale. Rev Laryngol Otol Rhinol (Bord). 2007;128(4):203-30. Assoc. 2012;110(4):246-7.
 Esthetic Rhinoplasty—Ailed and Ailing Noses 1043

17. Anghel I, Anghel AG. Reconstructive rhinoplasty in cases 19. Lawrence R. Pediatric septoplasy: A review of the literature.
with basal cell carcinoma of the nose. Chirurgia (Bucur). Int J Pediatr Otorhinolaryngol. 2012;76(8):1078-81. doi:
2012;107(3):373-8. 10.1016/j.ijporl.2012.04.020. Epub 2012 May 15.
18. Pisera P, Antoszewski B, Fijałkowska M, Kasielska A, Iljin A. 20. Picavet VA, Grietens J, Jorissen M, Hellings PW. Rhinoplasty
Long-term aesthetic results of rhinoplasty in congenital nose from a rhinologist's perspective: Need for recognition of
deformities—comparison of surgeon's and patient's evalua­ associated sinonasal conditions. Am J Rhinol Allergy. 2012;
tion. Otolaryngol Pol. 2012;66(4):280-4. Epub 2012 May 4. 26(6):493-6. doi: 10.2500/ajra.2012.26.3816.
1044 Facial Plastics, Cosmetics and Reconstructive Surgery The Surgical Technique of Otoplasty 1044
CHAPTER

107 Cleft Lip and Palate

G Spinelli, G Carnevali, D Lazzeri, L Autelitano

According to the hypothesis that the condition

OVERVIEW occurs through the interaction of multiple factors,
Cleft lip and palate (CLP) are congenital facial malforma- the malformation depends on genetic predisposition
tions related to abnormal development of the cephalic and various teratogenic agents. The importance of the
structures (upper lip, hard and soft palate) during gesta- genetic contribution in orofacial clefts is evidenced
tion. Because of the rarity of these conditions and the lack by the concordance in monozygotic twins (40% for
of standardization of methods of storage, the exact inci- CLP, 35% for isolated cleft palate). Using “linkage”
dence of this pathology is still unknown, and estimates analysis and allelic association, several potentially
vary widely. The frequency at birth is approximately 1–700, involved genes and cytokines, such as MSX1 and
with greater variability in different ethnic groups:1 transforming growth factor ß3 (TGFß3), have been
• Caucasian: 0.69–2.35/1,000 identified.
• Chinese: 1.31–3.18/1,000 Many human teratogens are associated with an
• Japanese: 1.65–2.71/1,000 increased risk of sporadic clefts, including ethanol,
• Native Americans: 0.55–2.50/1,000 diphenylhydantoin, trimethadione, aminopterin, metho-
• Africans: 0.32–0.82/1,000 trexate, retinoids and hyperthermia. Cigarette smoking
European Collaboration on Cranial Facial Anomalies during pregnancy, especially in combination with TGFa
(EUROCRAN) estimated that there are about 876 new and folic acid deficiency appears to be related to an
cases per year in Italy. Two-thirds of the cases involve increased probability of facial deformities and abnor-
the lip with or without palate deformities (more frequent malities in neural tube closure. Five percent of all cleft
in males), and the remaining one-third occur as isolated cases are syndromic; syndromes occur more frequently
deformities of the palate (especially in females). In unilat- with isolated cleft palate. From 1990 to the present, about
eral forms, left side is the most affected. In most cases, the 340 syndromes that present with an orofacial cleft have
cleft is sporadic and has a multifactorial etiology. The inci- been identified. Most of these syndromes are genetically
dence increases with the age of parents and in multiparae. based (Tables 1 and 2).2

Table 1: Syndromic clefts with relative mutated genes

Cleft lip, cleft lip and palate
Autosomal-dominant developmental ACTB Gorlin PTCH1
malfor­mations, deafness and dystonia
Familiar gastric cancer and CLP CDH1 CLP, ectodermal dysplasia PVRL1
Craniofrontonasal EFNB Holoprosencephaly SHH
Roberts ESCO2 Holoprosencephaly SIX3
Holoprosencephaly GLI2 Branchio-oculo-facial TFAP2A
“Oro-facial-digital” GLI3 Holoprosencephaly TGIF1
Hydrolethalus HYLS1 Ectrodactyly-ectodermal dysplasia-clefting TP63
Van der Woude/popliteal pterygium IRF6 Ankyloblepharon-ectodermal dysplasia-clefting TP63
X-linked mental retardation and CLP PHF8 Tetra-amelia with CLP WNT3

Contd...
 Cleft Lip and Palate 1045

Contd...

Cleft palate
Oculofaciocardiodental BCOR “Oro-facial-digital” GLI3
CHARGE CHD7 Van der Woude/popliteal pterygium IRF6
Lethal and Escobar multiple pterygium CHRNG Andersen KCNJ2
Stickler type 1 COL2A1 Kabuki MLL2
Stickler type 2 COL11A1 Cornelia de Lange NIPBL
Stickler type 3 COL11A2 X-linked mental retardation PQBP1
Desmosterolosis DHCR24 Isolated cleft palate SATB2
Smith-Lemli-Opitz DHCR7 Diastrophic dysplasia SLC26A2
Miller DHODH Campomelic dysplasia SOX9
Craniofrontonasal EFNB1 Pierre Robin SOX9
Kallmann FGFR1 DiGeorge TBX1
Crouzon FGFR2 X-linked cleft palate and ankyloglossia TBX22
Apert FGFR2 Treacher-Collins TCOF1
Otopalatodigital types 1 and 2 FLNA Loeys-Dietz TGFBR1
Larsen syndrome; atelosteogenesis FLNB Loeys-Dietz TGFBR2
Hereditary lymphedema-distichiasis FOXC2 Saethre-Chotzen TWIST1
Bamforth-Lazarus FOXE1

Source: Modified from Dixon MJ, Marazita ML, Beaty TH et al. Cleft lip and palate: understanding genetic and environmental
influences. Nat Rev Genet. 2011;12(3):167-78.

phases in which the fusion of various processes creates

Table 2: Nonsyndromic cleft associated genes the continuity and shape of the lip, nose and palate. Any
Confirmed Likely Intensively studied alteration at these points may cause a facial cleft.
IRF6 ABCA4 locus CRISPLD2 Each process consists of ectodermal tissue, derived
from the hindbrain and midbrain neural crest, and meso-
VAX1 BMP4 FGF8
dermal tissue.
8q24 locus FGFR2 GSTT1 The fate of these cells and tissues is determined by
FOXE1 MTHFR several genes and cytokines that control migration, devel-
MAFB PDGFC opment, apoptosis and therefore, the formation of the face
MSX1 PVRL1 (Fig. 1).3
During the sixth week of embryonic life, the medial
MYH9 SUMO1
and lateral nasal processes fuse with the maxillary
17q22 locus TGFA processes, generating the base of the nose, nostrils, upper
TGFB lip and primary palate (Fig. 2).3 During the eighth week,
the palatal processes become horizontal and fuse with the
Source: Modified from Dixon MJ, Marazita ML, Beaty TH,
septum to form the secondary palate (Figs 3 and 4).3 The
Murray JC. Cleft lip and palate: understanding genetic and
environmental influences. Nat Rev Genet. 2011;12(3):167-78.
marginal ectodermal components undergo apoptosis and
the mesenchyme unifies the structure.
The anterior primary palate fuses with the secondary
EMBRYOLOGY one and then ossifies. Facial clefts occur in case of failure of
fusion of processes in one or more of these different stages
The heterogeneity of facial deformities is attributable to of development. The cleft may be complete or incomplete,
the extreme embryogenetic and anatomical complexity depending on the nature of the fusion failure. When the
of this region. During embryogenesis, there are several defect concerns the fusion of the medial nasal processes
1046 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 1: Facial scanning by electronic microscope of a Fig. 2: A 6-week old embryo by electronic microscopy. During
5-week old embryo the sixth and seventh week of gestation, the maxillary and
Source: Cohen MM. Malformations of the craniofacial region: the nasal processes fuse. The upper lip is still incomplete
evolutionary, embryonic, genetic, and clinical perspectives. Am J Source: Cohen MM. Malformations of the craniofacial region:
Med Genet. 2002;115(4):245-68. evolutionary, embryonic, genetic, and clinical perspectives. Am J
Med Genet. 2002;115(4):245-68.

Fig. 3: Secondary palate in a 53-day old embryo, after the Fig. 4: After 59 days of gestation, the fusion of the secondary
fusion with the primary palate palate is complete
Source: Cohen MM. Malformations of the craniofacial region: Source: Cohen MM. Malformations of the craniofacial region:
evolutionary, embryonic, genetic, and clinical perspectives. Am J evolutionary, embryonic, genetic, and clinical perspectives. Am J
Med Genet. 2002;115(4):245-68. Med Genet. 2002;115(4):245-68.

with the maxillary and the lateral nasal processes, there FUNCTIONAL ANATOMY
is the development of a cleft lip and/or a maxillary cleft.
If the defect concerns the rotation/fusion of one or both To understand the functional defect and the classifica-
palatal processes, a mono- or bilateral cleft of the second- tion and grading of surgical treatment of a cleft of the lip
ary palate will be developed, respectively. and palate, the muscular and neurovascular anatomical
 Cleft Lip and Palate 1047

A B
Figs 5A and B: Musculature of the normal lip and in cleft lip: note the insertion on both sides of the cleft to the wing of
the nose and the columella

characteristics must be understood. The cleft-related

anatomical abnormalities correspond to an equal number
of defects developed during the embryonic formation of
the muscular structures, particularly when the fusion of
each process with its counterpart fails. The non-union of
the orofacial muscles during gestation results in abnor-
mal and non-functional insertions, with subsequent
hypoplasia.
• Muscles of the lip: The orbicularis oris. This is a single
and median muscle that surrounds the oral rim. It is
composed of:
–– A superficial (external) portion composed of
bundles from other mimic muscles of the face
(such as the canine, buccinators, triangular, inci-
sors). It is divided into two semicircles that meet
in the midline. It inserts in the deep skin of the lip,
nose and membranous septum.
–– A deep (internal) portion that is located close to the A B
free edge of the lips. This is composed of an upper
Figs 6A and B: (A) Normal palatal muscles and (B) Cleft
and lower ring that cross at the labial commis- palate muscles
sures and insert on the deep surface of the skin and (HP: Hard palate; PNS: Posterior nasal spine; GPF: Greater palatine
mucosa. It works exclusively as a constrictor of the foramen; H: Hamulus; TVP: The tensor veli palatini; PM: Pharyngo-
mouth. palatine muscle; LVP: Levator veli palatini; U: Uvula; →: Aponeurosis
The labial muscular fibers (compressor labii, musculus of the veil)
cutaneomucosus, rectus labii) are obliquely interspersed Source: Modified from Maue-Dickson W, Dickson DR. Anatomy
between the skin and the mucous membrane, and they and physiology related to cleft palate: current research and clinical
contribute to the act of sucking. These fibers typically implications. Plast Reconstr Surg. 1980;65(1):83-90.
disappear after breast-feeding.
In the complete CLP, the fibers of the orbicularis
muscle rotate upward from the lateral zone to the medial • Muscles of the palate: Tensor veli palatini (TVP) and
zone, along the edge of the cleft. These fibers then stop levator veli palatini (Figs 6A and B).4
on the base of the nasal wing and the columella (Figs 5A –– The TVP originates from the pterygoid process,
and B), where they fit one over the other, or fade in subcu- the sphenoidal angular horn and the anterolateral
taneous tissues. portion of the Eustachian tube.
1048 Facial Plastics, Cosmetics and Reconstructive Surgery

–– It runs in an anteriorinferior direction by inserting Classification of Kernahan and Stark

along the anterior third of the soft palate. In 1958, Kernahan and Stark proposed a graphic scheme
–– Its contraction lengthens and elevates the soft that divides the region of the potential malformation in
palate near the hamulus and enlarges the orifice of nine areas, according to the anatomical and embryologi-
the Eustachian tube. cal characteristics of the incisive foramen (Figs 7 to 9).5,6
–– Depending on the circumstances, it may act syner- • Areas 1 and 4: Lip
gistically or antagonistically with the levator veli • Areas 2 and 5: Alveolus
palatini. • Areas 3 and 6: Palate between alveolus and incisive
–– In children with CLP, this muscle appears t­ hinner foramen
than normal, and its insertion is located at the • Areas 7 and 8: Hard palate
edge of the cleft palate as a single beam or tendon • Area 9: Soft palate.
inserting in the thickness of the levator veli
palatini.
–– A smaller part of the muscle inserts into the poste-
PRENATAL DIAGNOSIS
rior nasal spine (PNS) or the posterior edge of the Prenatal diagnosis is essential to minimize the impact
palatine bone. on parents. Ultrasonography in pregnancy has become a
–– The levator veli palatini is an equal cylindri- routine, noninvasive, inexpensive and well-accepted tech-
cal muscle which originates from the apex of the nique of investigation. In most cases, the diagnosis is made
petrous process of the temporal bone and from the incidentally during routine ultrasonography or during
carotid canal. ultrasonographic investigation of concerns unrelated to
–– It runs in a groove below the Eustachian tube, and the cleft. The sensitivity of this instrumental examina-
its insertion is located at the raphe. tion (the so-called detection rate) varies widely in differ-
–– Its action consists of moving back and elevating the ent centers. The detection rate has increased recently, as
soft palate. ultrasound techniques and the therapeutic protocols have
–– In children with CLP, this muscle is markedly improved. Every effort is made to define the nature and
hypoplastic. Its posterolateral portion inserts at the the etiology of the defect and to exclude any syndromic
palatal arch and the basis of uvula, and its medial deformities. A geneticist consult may be critical, especially
portion is located at the edge of the cleft and inserts in the cases of inherited syndromes.
at the nasal spine, the edge of the palatal bone and There is no consensus in the scientific community
the tendon of the TVP. about the probability that a prenatally diagnosed cleft is
part of unrecognized syndromic spectrum. Based on the
reliable studies, the risk is around 10–12%. It is impor-
CLASSIFICATION tant to educate the parents about the nature of defects,
Over the past 70 years, various classification schemes for the functional consequences, prospectives and expecta-
CLP have been proposed, but few have been universally tion of treatment efficacy. This information includes the
accepted. psychological consequences of decision making regard-
ing the defect, including the possible voluntary termina-
Classification of the International tion of pregnancy after communication of the diagnosis.
Confederation of Plastic and It is essential that the mother receive care in a dedicated
Reconstructive Surgery center, where several specialists including the surgeon can
Based on embryology, three different groups are recog- discuss the primary and secondary problems associated
nized. The groups are further subdivided if the defect is with the available surgical strategies (Fig. 10).
unilateral or bilateral.
• Group 1: Defects involving lip and alveolus
• Group 2: Cleft of secondary palate [hard palate (HP),
PRESURGICAL ORTHOPEDICS
soft palate or both] Unilateral Cleft Lip and Palate
• Group 3: Any cleft involving the primary or/and
secondary palate. Since the 1970s, a passive plate made with hard and soft
Spina reviewed this classification and proposed by resin7 is used to:
adding a fourth group to include all of the rare and atypical • Separate the oral and nasal cavity (allowing adequate
facial clefts. force for sucking and swallowing)
 Cleft Lip and Palate 1049

Fig. 7: Embryology and anatomy of the incisive foramen Fig. 8: The nine areas of Kernahan and Stark Classification
Source: Modified from Kirschner RE, LaRossa D. Cleft lip and palate.
Otolaryngol Clin North Am. 2000;33(6):1191-215, v–vi.

A B C D
Figs 9A to D: Classification chart of some cleft, according to the classification of Kernahan and Stark
Source: Modified from Kernahan DA, Stark RB. A new classification for cleft lip and cleft palate.
Plast Reconstr Surg Transplant Bull. 1958;22(5):435-41

• Facilitate breathing through the correct positioning of is universally accepted. Several methods have been
the tongue proposed, but the most simple and widely used method
• Direct growth vectors provides for the use of a passive plate in association
• Guide the development of the two maxillary abutments with a tape to push back the premaxilla. Since 19969
(using progressive selective attachments applied on an orthopedic plaque has been used to remodel the
the plate itself ) (Figs 11 and 12).8 nasal and alveolar processes. This procedure allows the
gradual reversal of the premaxilla and the simultaneous
Bilateral Cleft Lip and Palate elongation of the columella, which otherwise remains
The need for presurgical orthopedics in bilateral clefts short and flattened (a typical stigmata of a BCLP)
to retract the premaxilla (which is typically protruded) (Figs 13A and B).
1050 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 10: Ultrasound scan with three-dimensional (3-D)

reconstructions of cleft palate; the malformation is visible
as a deep and central recess below the nose

A B
Figs 11A and B: Complete unilateral cleft lip and palate (UCLP), Hotz passive plate and selective grinding
Source: Meazzini MC, Brusati R, Bozzetti A, et al. Malformazioni craniofacciali: coordinamento ortodontico-chirurgico. Bologna: edizioni
Martina; 2011.

A B
Figs 12A and B: Plaster models of complete unilateral cleft lip and palate (UCLP), note the distance of the stumps after
the use of the plate of Hotz
Source: Meazzini MC, Brusati R, Bozzetti A, et al. Malformazioni craniofacciali: coordinamento ortodontico-chirurgico. Bologna: edizioni
Martina; 2011.
 Cleft Lip and Palate 1051

A B
Figs 13A and B: Bilateral cleft lip and palate (BCLP), orthopedic nasoalveolar remodeling plate

SURGICAL TREATMENT With the aid of a microscope, the surgeon isolates and
prepares the palatine muscles, which are rotated from
Surgery remains the mainstay of treatment for the CLP. the nasal plane toward the midline (Figs 15A and B).
The principles underlying the repair proposed in After superimposition, this site is carefully sutured. After
the 1930s by the anatomical studies of Veau remain the release of the mucoperio­steal flaps, with or without
fundamental: lateral incisions, the oral plane is sutured to cover the
• All tissues are present, retracted or displaced. previously repaired nasal floor (Figs 16A and B).
• The correct remodeling of the displaced structures is • Cheilorhinoplasty: The landmarks for reconstruc-
essential for proper repair. tion, including the top of the Cupid’s bow of the
• The defect in facial growth or facial function is primar- healthy side, the top of the Cupid’s bow of the patho-
ily a consequence of a poor anatomic reconstruction. logical side, the base of columella and the base of
Although the essence of treatment has remained the nasal ala on the pathological side, are identified
unchanged, several protocols and surgical techniques are (Fig. 17). Skin marks and incisions are made according
currently followed (EUROCLEFT found 194 different ther- to Millard’s approach (Figs 18 and 19).10 The region of
apeutic protocols in 201 European Centers). the nasal spine is exposed through a mucosal incision.
The basics of the surgical treatment is influenced by A subperichondrial dissection with a dislocation of the
both surgical indications and surgeon’s experience, are foot of the septum is performed to reposition it along
shown below. the median plane (Figs 20A and B). Then, the buccal
mucosa, transverse nasal muscle, external orbicula-
Cheilorhinoplasty of a Unilateral Cleft in ris, anterior nasal floor and finally, the skin undergo
Two Steps reconstruction (Figs 21 and 22). If it is necessary to
First Step obtain a better symmetry of the Cupid’s bow, a small
At 4–6 months of age; often after an orthopedic treatment Z-plasty (Figs 23A and B) in the lower part of the lip is
with passive plate to guide the maxillary growth. performed to obtain vertical elongation of the patho-
• Palatoplasty: An incision is made along the margins logical side.
of the soft palate cleft from the uvula to the posterior • At the end of surgery, nasal conformers, if necessary,
third of the HP. The dissection highlights the palatine are applied.
aponeurosis and the tendon of TVP, and a tenotomy is Second Step
performed (Figs 14A and B). A nasal mucoperiosteal At 18–24 months of age, the residual alveolar and HP cleft
flap from the pterygoid process and the palatine lamina is corrected. The action of the labial and palatal muscu-
on both sides is prepared, and a suture of the nasal lature generally significantly reduces the gap between the
plane from the HP to the tip of the uvula is performed. two stumps (Figs 24 to 26).
1052 Facial Plastics, Cosmetics and Reconstructive Surgery

A B
Figs 14A and B: Palatoplasty, retrieval and tenotomy of the tensor veli palatini (TVP)

A B
Figs 15A and B: Palatoplasty, preparation and rotation on the midline of the palatine musculature

• Gingivoalveoloplasty and repair of the hard palate: the oral and nasal sides is performed. Then the nasal,
The repair begins with an intrasulcular incision on oral, palatine and buccal planes are sutured, restor-
the smaller stump, and then lifting of a vestibular ing the continuity of the fibromucosal flaps in the cleft
mucoperiosteal flap following distal vertical release area. This alveolar space is covered on all sides by
incision. The same procedure is then repeated on the mucoperiosteal tissues, which allows the formation of
larger stump. After a palatine incision is made along new bone tissue without any need for secondary bone
the margins of the cleft, a mucoperiosteal dissection of grafting.
 Cleft Lip and Palate 1053

A B
Figs 16A and B: Palatoplasty, reconstruction of the oral side without releasing incisions

Fig. 17: Cheilorhinoplasty, identification and Fig. 18: “All in one” cheilorhinoplasty, preparation of the
preparation of nasolabial muscles Pichler flap
Source: Modified from Furlow LT. Cleft palate repair by double
opposing Z-plasty. Plast Reconstr Surg. 1986;78(6):724-38.

A B
Figs 19A and B: Cheilorhinoplasty, skin incision and reconstruction of the lip with the Millard’s technique
1054 Facial Plastics, Cosmetics and Reconstructive Surgery

A B
Figs 20A and B: Cheilorhinoplasty, dissection of intercrural cartilage and dislocation of the nasal septum

A B
Figs 21A and B: Cheilorhinoplasty, skin incision and reconstruction with the Mohler’s technique

A B
Figs 22A and B: Cheilorhinoplasty, skin incision and lip reconstruction with the Wave technique
 Cleft Lip and Palate 1055

A B
Figs 23A and B: Cheilorhinoplasty, reconstruction of the lip with the Millard’s technique and small elongating Z-plasty

A B
Figs 24A and B: Unilateral cleft lip and palate (UCLP), before and after primary reconstruction

A B
Figs 25A and B: Bilateral cleft lip and palate (BCLP), Delaire cheiloplasty and Delaire modified cheiloplasty
1056 Facial Plastics, Cosmetics and Reconstructive Surgery

Cheilorhinoplasty of a Unilateral Cleft with First Step

an “All in One” Technique The operation starts with the reconstruction of the
soft palate according to the surgical steps described
This technique can be applied if the palate cleft does not above. The lip correction is performed in a manner
exceed 10–12 mm. similar to that described above, after a careful ortho-
When the alveolar processes of the cleft are near pedic preparation to obtain sufficient elongation of the
each other or in contact, the repair of the defect can be ­columella and an adequate approximation of the stumps
performed following the same two-step surgical proto- (Figs 27A to D).
col, but in a single operation. Otherwise, it is necessary to If the protrusion of the premaxilla is extreme, it is pref-
perform an alveolar bone graft at about 6 years of age. erable to carry out the so-called lip adhesion intervention,
which consists of the suture of the skin and mucosa of the
Cheilorhinoplasty of a Bilateral Cleft in upper two-thirds of the cleft lip. This technique creates
Two Steps a partial cleft in order to retract the premaxilla in a few
The basic principles are those that regulate the two-step months, creating a favorable situation for the repair.
treatment of the unilateral cleft. The role of the preopera- Incisions according to Mulliken approach are
tive orthopedics is extremely important in these cases. performed (Figs 28A and B).11 The alar cartilages are

A B
Figs 26A and B: Bilateral cleft lip and palate (BCLP), before and after primary reconstruction

A B
Figs 27A and B
 Cleft Lip and Palate 1057

C D
Figs 27A to D: Bilateral cleft lip and palate (BCLP), cheilorhinoplasty with primary columellar elongation

undermined from skin through marginal endonasal inci-

sions and are brought towards the midline and sutured
together.
The surgeon then sutures the transverse nasal and
orbicularis oris muscles to rebuild the muscular plane
of the lip. The labial skin is reconstructed and the nasal
conformers are applied.

Second Step
At 18–24 months of age, the residual alveolar/HP cleft
undergo repair following the same surgical procedures
described for the unilateral cleft. It is important to pay
particular attention to the preparation of the premaxil-
lary flaps to avoid compromising the blood supply. This
depends exclusively on the vestibular side, and therefore,
the dissection should be minimal.

A B
SURGICAL OUTCOMES
Figs 28A and B: Bilateral cleft lip and palate (BCLP),
cheilorhinoplasty with primary columellar elongation Nasal Fistulae
Source: Modified from Mulliken JB. Bilateral complete cleft lip and
nasal deformity: an anthropometric analysis of staged to synchronous This complication occurs with frequency ranging from
repair. Plast Reconstr Surg. 1995;96(1):9-23; discussion 24-6. 2% to 30%, depending on the number of cases and the
1058 Facial Plastics, Cosmetics and Reconstructive Surgery

surgical techniques. These occur at the transition point potential side effects, including closed rhinolalia, sleep
between the hard plate and soft palate or more rarely, apnea and difficulty in blowing the nose (Figs 29 to 31).
behind the premaxilla in bilateral clefts. The defect is
repaired using local pedicle flaps, dissected and posi- Maxillary Hypoplasia
tioned without tension. In severe cases, due to the large Depending on the series, the incidence in CLP patients is
size of the fistula or the poor quality of tissues resulting 15–45% and varies in relation to the surgical techniques
from past failures, the surgeon may use pedicle flaps used (Figs 32A and B), the timing of the operation and the
obtained from the tongue or cheeks. operator’s skill. As for the other jaw deformities, the opti-
mal time for the osteotomy is after skeletal maturation.
Velopharyngeal Insufficiency The intervention consists of a high Le Fort I osteotomy
In the case of failure in rehabilitative speech therapy, with mobilization of the bone segment and stabilization
secondary surgery may be considered. Several techniques with plates and screws. The bony gaps are filled with autol-
can be applied, including microscope-aided muscular ogous or bank bone grafts and stem cells (Figs 33 and 34).
repair, the Furlow technique of rotational Z-flaps, and If large advancements are required due to the opposition
sphincterial pharyngoplasty with rotation and suture offered by the existing scars, osteodistraction (Figs 35A
of the posterior wall of pharynx and posterior palatine to D) should be combined with the osteotomy using inter-
pillars. In extreme cases the superior pedicle velophar- nal or external distractors. In selected cases, this tech-
yngoplasty may be used, although this technique has nique can be performed before skeletal maturity occurs.

A B
Figs 29A and B: Surgical outcomes, Sanvenero-Rosselli velopharyngoplasty

A B
Figs 30A and B: Surgical outcomes, Hynes velopharyngoplasty
 Cleft Lip and Palate 1059

A B
Figs 31A and B: Surgical outcomes, Furlow velopharyngoplasty

A B
Figs 32A and B: Cleft lip and palate (CLP) outcomes, maxillary hypoplasia

A B
Figs 33A and B: Surgical outcomes, bone graft
1060 Facial Plastics, Cosmetics and Reconstructive Surgery

A B
Figs 34A and B: Surgical outcomes, bone graft using homologous bone chips and stem cells

A B

C D
Figs 35A to D: Surgical outcomes, maxillary osteodistraction
 Cleft Lip and Palate 1061

Fig. 36: Surgical outcomes, open rhinoseptoplasty

A B
Figs 37A and B: Surgical outcomes, before and after open rhinoseptoplasty

• Asymmetry of the free edge of the lip and/or insufficient

Nasolabial Outcomes thickness: V-Y plasty, vestibular mucosal advancement
These deformities and asymmetries are frequent and and/or lipofilling
widely variable depending on the type of the cleft and the • Nasal asymmetries associated with dystopia of the
skill of the surgeon. alar cartilage: Open rhinoplasty (Figs 36 and 37)
The most common nasolabial deformities and with reduction of the triangular cartilages, removal
asymmetries, along with related treatment options of the Gibbus and basal osteotomies. It is important
include: to remember that a good rhinoplasty is not possible
• Cupid’s bow asymmetry: Lengthening with a Z-plasty without a proper reconstruction of the nasolabial
or shortening through excision muscles
• Uneven mucocutaneous border: Excision and • Shortness of the columella and alar cartilages diastasis:
realignment Columellar lengthening is performed through prepara-
• Insufficient/inadequate muscle reconstruction: Reop­ tion of two skin flaps carved along the previous scars. The
ening of the scar, muscle-periosteal release, realign- alar cartilages are approximated. Bone grafts from the
ment and closure septal cartilage may be performed to support the tip.
1062 Facial Plastics, Cosmetics and Reconstructive Surgery

REFERENCES 9 De Mey A, Swennen G, Malevez C, et al. Long-term follow-

up of UCLP at the Reine Fabiola Children’s Hospital. B-ENT.
1. Gundlach KKH, Maus C. Epidemiological studies on 2006;2(Suppl 4):44-50.
the frequency of clefts in Europe and world-wide. 10 Delaire J, Talmant JC, Billet J. [Evolution of techniques in
J Craniomaxillofac Surg. 2006;34(2):1-2. cheiloplasty for cleft-lip (and study of a few complementary
2. Dixon MJ, Marazita ML, Beaty TH, et al. Cleft lip and palate: measures)]. Rev Stomatol Chir Maxillofac.
understanding genetic and environmental influences. Nat 11 Dion K, Berscheid E, Walster E. What is beautiful is good. J Pers
Soc Psychol. 1972;24(3):285-90.
Rev Genet. 2011;12(3):167-78.
12 Elahi MM, Jackson IT, Elahi O, et al. Epidemiology of
3. Cohen MM. Malformations of the craniofacial region: evolu-
cleft lip and cleft palate in Pakistan. Plast Reconstr Surg.
tionary, embryonic, genetic, and clinical perspectives. Am J
2004;113(6):1548-55.
Med Genet. 2002;115(4):245-68. 13 Fara M. The musculature of cleft lip and palate. In: McCarthy
4. Maue-Dickson W, Dickson DR. Anatomy and physiology JG (Ed). Plastic Surgery, 2nd edition. Philadelphia, PA: WB
related to cleft palate: current research and clinical implica- Saunders; 1990. pp. 2598-626.
tions. Plast Reconstr Surg. 1980;65(1):83-90. 14 Farina R. [Total unilateral harelip: correction of severe deform-
5. Kirschner RE, LaRossa D. Cleft lip and palate. Otolaryngol ity of the palate & lips in a single operation; Le Mesurier’s
Clin North Am. 2000;33(6):1191-215, v–vi. cheiloplasty & Veau-Ernst’s gnatho-urano-staphyloplasty].
6. Kernahan DA, Stark RB. A new classification for cleft lip Ann Chir Plast. 1958;3(3):199-205.
and cleft palate. Plast Reconstr Surg Transplant Bull. 15 Forrester MB, Merz RD. Descriptive epidemiology of oral clefts
1958;22(5):435-41 in a multiethnic population, Hawaii, 1986–2000. Cleft Palate
7. Hotz M, Gnoinski W. Comprehensive care of cleft lip and Craniofac J. 2004;41(6):622-8.
palate children at Zürich university: a preliminary report. 16 Fudalej PS. One-stage repair of complete unilateral cleft lip
Am J Orthod. 1976;70(5):481-504. and palate dentofacial treatment outcome. Wijchen: Benda
8. Meazzini MC, Brusati R, Bozzetti A, et al. Craiofacial anama- Drukkers; 2011.
lies: Surgical-orthodontic management. Bologna: edizioni 17 Grollemund B, Guedeney A, Vazquez MP, et al. Relational
Martina; 2011. development in children with cleft lip and palate: influence of
9. Cutting C, Grayson B, Brecht L, et al. Presurgical columellar the waiting period prior to the first surgical intervention and
elongation and primary retrograde nasal reconstruction in parental psychological perceptions of the abnormality. BMC
one-stage bilateral cleft lip and nose repair. Plast Reconstr Pediatr. 2012;12:65. Doi: 10.1186/1471-2431-12-65.
Surg. 1998;101(3):630-9. 18 Honigmann K. One-stage closure of uni- and bilateral cleft lip
10. Furlow LT. Cleft palate repair by double opposing Z-plasty. and palate. Br J Oral Maxillofac Surg. 1996;34(3):214-9.
Plast Reconstr Surg. 1986;78(6):724-38. 19 Hunt O, Burden D, Hepper P, et al. The psychosocial effects
11. Mulliken JB. Bilateral complete cleft lip and nasal deformity: of cleft lip and palate: a systematic review. Eur J Orthod.
an anthropometric analysis of staged to synchronous repair. 2005;27(3):274-85.
Plast Reconstr Surg. 1995;96(1):9-23; discussion 24-6. 20 Jones MC. The risk than an apparently isolated cleft lip
with or without cleft palate will be associated with anoma-
lies that impact outcome: follow-up of 32 cases ascertained
BIBLIOGRAPHY through prenatal diagnosis. Proc Greenwood Genetic Center.
2000;19:122-3.
1 Al-Omari F, Al-Omari IK. Cleft lip and palate in Jordan: birth
21 Kaplan I, Ben-Bassat M, Taube E, et al. Ten-year follow-up of
prevalence rate. Cleft Palate Craniofac J. 2004;41(6):609-12.
simultaneous repair of cleft lip and palate in infancy. Ann Plast
2 Balboni GC. Anatomia umana. (terza edizione). Milano:
Surg. 1982;8(3):227-8.
edi-ermes; 1990.
22 Kaplan I, Dresner J, Gorodischer C, et al. The simultaneous
3 Burd RS, Mellender SJ, Tobias JD. Neonatal and childhood repair of cleft lip and palate in early infancy. Br J Plast Surg.
perioperative considerations. Surg Clin North Am. 2006;86(2): 1974;27(2):134-8.
227-47, vii. 23 Kaplan I, Taube E, Ben-Bassat M, et al. Further experience in
4 Campbell A, Costello BJ, Ruiz RL. Cleft lip and palate surgery: an the early simultaneous repair of cleft lip and palate. Br J Plast
update of clinical outcomes for primary repair. Oral Maxillofac Surg. 1980;33(2):299-300.
Surg Clin North Am. 2010;22(1):43-58. 24 Kim S, Kim WJ, Oh C, et al. Cleft lip and palate incidence
5 Cheng LR. Asian-American cultural perspectives on birth among the live births in the Republic of Korea. J Korean Med
defects: focus on cleft palate. Cleft Palate J. 1990;27(3): 294-300. Sci. 2002;17(1):49-52.
6 Croen LA, Shaw GM, Wasserman CR, et al. Racial and ethnic 25 Kirby R, Petrini J, Alter C. Collecting and interpreting birth
variations in the prevalence of orofacial clefts in California, defects surveillance data by hispanic ethnicity: a compara-
1983–1992. Am J Med Genet. 1998;79(1):42-7. tive study. The Hispanic Ethnicity Birth Defects Workgroup.
7 Cutting C, Grayson B. The prolabial unwinding flap method for Teratology. 2000;61(1-2):21-7.
one-stage repair of bilateral cleft lip, nose, and alveolus. Plast 26 Landheer JA, Breugem CC, van der Molen AB. Fistula inci-
Reconstr Surg. 1993;91(1):37-47. dence and predictors of fistula occurrence after cleft palate
8 Davies D. The one-stage repair of unilateral cleft lip and palate: repair: two-stage closure versus one-stage closure. Cleft Palate
a preliminary report. Plast Reconstr Surg. 1966;38(2):129-36. Craniofac J. 2010;47(6):623-30.
 Cleft Lip and Palate 1063

27 McLeod NM, Urioste ML, Saeed NR. Birth prevalence of 34 Peterson-Falzone SJ, Hardin-Jones MA, Karnell MP. Cleft Palate
cleft lip and palate in Sucre, Bolivia. Cleft Palate Craniofac J. Speech, 3rd edition. St Louis: Mosby; 2000.
2004;41(2):195-8. 35 Pfeiffer P. [Adhesive bridges for care of patients with cleft lip
28 Meyerson MD. Cultural considerations in the treatment of and palate after maxillofacial surgery and orthodontic treat-
Latinos with craniofacial malformations. Cleft Palate Craniofac ment]. Quintessenz. 1987;38(6):1015-24.
J. 1990;27(3):279-88. 36 Sanvenero-Rosselli G. [Cleft palate plastic surgery using a
29 Millard DR. Nasal and labial flaps for alveolar and hard palate pharyngeal flap]. Langenbecks Arch Klin Chir Ver Dtsch Z Chir.
closure. In: Millard DR (Ed). Cleft Craft: The Evolution of Its 1960;295:895-900.
Surgery. Alveolar and Palatal Deformities, Volume 3. Boston, 37 Shaw WC, Semb G, Nelson P, et al. The Eurocleft project 1996-
USA: Little Brown and Company; 1980. pp. 249-62. 2000: overview. J Craniomaxillofac Surg. 2001;29(3):131-40;
30 Millard DR Jr. Rotation-advancement principle in cleft lip discussion 141-2.
closure. Cleft Palate J. 1964;12:246-52. 38 Strauss RP. Culture, health care, and birth defects in the
31 Mohler LR. Unilateral cleft lip repair. Plast Reconstr Surg. United States: an introduction. Cleft Palate J. 1990;27(3):
1987;80(4):511-7. 275-8.
32 Msamati BC, Igbigbi PS, Chisi JE. The incidence of cleft 39 Suleiman AM, Hamzah ST, Abusalab MA, et al. Prevalence of
lip. cleft palate, hydrocephalus, and spina bifida at Queen cleft lip and palate in a hospital-based population in the Sudan.
Elizabeth Central Hospital, Blantyre, Malawi. Cent Afr J Med. Int J Paediatr Dentist. 2005;15(3):185-9.
2000;46(11):292-6. 40 United States Census Bureau. Population by Age, Sex, Race,
33 Mulliken JB. Correction of the bilateral cleft lip nasal deform- and Hispanic or Latino Origin for the United States: 2000 (PHC-
ity: evolution of a surgical concept. Cleft Palate Craniofac J. T-9). [online]. Available from: www.census.gov/population/
1992;29(6):540-5. cen2000/phc-t9/tab01.pdf. [Accessed November 2012].
1064 Facial Plastics, Cosmetics and Reconstructive Surgery The Surgical Technique of Otoplasty
CHAPTER

108 Lip Reconstruction

Jagadish Tubachi, Karthikeyan Balasubramanian, Sumeet Pahwa, Sultan Pradhan

have minimum of 13–15 mm of tissue preserved near the

INTRODUCTION oral commissure.2
The lips are important in both an esthetic and functional Inferior labial artery branches from facial artery near
sense. Tumor ablative surgery of lip results in considerable the commissure. It traverses deep to depressor angularis
cosmetic and functional morbidity. So, optimal oris to enter orbicularis oris and runs along lower lip to
reconstruction of the lip is important to minimize the anastomose with opposite side.
esthetic and functional morbidity.1 Choice of surgical Inferior labial artery is located at an depth ranging
reconstruction of lip defects depends on the location from 5 mm to 10 mm from the free border of lip.3 Thus,
and extent of the defect. A number of methods have it can be said that during harvesting of Abbe-Estlander
been described, but only few are a practically simple flap, a 10 mm pedicle thickness is enough to preserve the
and reliable. The ultimate goal of lip reconstruction is to arterial integrity.
achieve oral competence and good aesthesis, which is Motor supply to the lip muscles is from the facial nerve,
socially acceptable. primarily the buccal and marginal mandibular branches.
The vermilion is dry due to a lack of mucous glands
and has exposed position outside the oral cavity, whereas
ANATOMY the “wet” portion of the lip is well supplied with mucous
The lips comprise of two mobile structures that represent by minor salivary glands. The red color is due to the rich
the anterior boundaries of the oral cavity. The lips function blood supply to the region. A thin pale junctional zone
dynamically in deglutition, speech and facial expression. of skin (known as the “white line”) demarcates the junc-
The normal lip is at about 5–6 cm long. The orbicularis oris tion between vermilion and skin. This white line should
muscle forms the main bulk of the lip and maintenance be aligned correctly during lip repair for optimal esthetic
of it’s continuity is important for oral competence. This outcome (Fig. 1).
muscle has no bony attachments. A second group of dilator
muscles are attached in radial manner around the orbicu-
laris oris, consisting of the mentalis, depressor anguli oris,
depressor labii inferioris, risorius, zygomaticus major and
minor, levator anguli oris and levator labii superioris. In
opening and closing of the mouth, the orbicularis works
synergistically with a group of dilator muscles arranged in
a radial fashion around the mouth.
Blood supply is from the paired superior and inferior
labial branches of the facial artery. The labial arteries run
submucosally on the intraoral side of the lips, meeting in
the midline (Fig. 1).
Superior labial artery branches from facial artery deep
to zygomaticus major. It gives off angular artery and then
enters orbicularis oris. It runs along the upper lip and
anastomoses with opposite side (see Figs 2A to D).
The average distance of the superior labial artery from
the labial commissure is about 12.1 mm. This is important
in planning of axial flaps. To preserve the arterial integrity Fig. 1: Schematic representation of cross-section of lip: The
during raising of axial flap, the point of rotation should labial arteries run submucosal on the intraoral side of the lips
 Lip Reconstruction 1065

RECONSTRUCTION OF LIP DEFECTS advancement. After resection, assistant stretches the lip with
skin hooks and only the mucosa is lifted from the underlying
Reconstruction of Vermilion Defect: orbicularis oris. As the elevation is continued toward the
Vermilion Advancement labial sulcus, a layer of minor salivary glands is encountered
Very superficial carcinoma of the lip is treated by lip (Fig. 1). Flap elevation is continued between orbicularis oris
shave. Primary closure of wound is ideal for small defects4 and the layer of minor salivary glands into gingivolabial sulcus
(Figs 2A to D). A large defect is reconstructed by the vermilion and above the periosteum of lower alveolus (Fig. 2E). During

A B

C D
Figs 2A to D: Very superficial carcinoma of lip is treated by lip shave.
A resultant small defect was primarily closed

Fig. 2E: Plane of dissection for vermillion advancement

1066 Facial Plastics, Cosmetics and Reconstructive Surgery

the flap elevation, “button holing” is avoided. Adequacy of RECONSTRUCTION OF

flap is assessed. If the flap is short, release incision is made
in the gingival sulcus.4 The flap is draped over the defect in
LIP DEFECTS: ONE-HALF TO
a tension less manner and sutured with non-absorbable TWO-THIRDS OF LOWER LIP
material of surgeon’s choice. Primary closure of defects larger than one-half of
the lip is difficult. So, the defect is reconstructed by
borrowing “like” tissue from the opposite lip.
RECONSTRUCTION OF LIP
DEFECTS: LESS THAN
ABBE CROSS-LIP FLAP
ONE-THIRD OF LIP DEFECT
Abbe cross-lip flap is based on the principle of creat-
Small lesion involving full thickness of lip can be ing a labial artery based full thickness lip flap, which
excised in V-shaped manner. The resultant defect is includes skin, muscle and mucosa. This flap is switched
primarily closed. Larger lesion can be excised in a from donor lip to defect in the opposite lip. This flap is
rectangular fashion. The defect is closed by advancing based on the labial artery—either superior or inferior.
the lip through release incision in the lip-chin crease This is an ideal for lesions involving from one-third to
(Figs 3A and B).5 two-thirds of the lip (Figs 4 and 5).5,6

A B
Figs 3A and B: Direct excision and repair of lower lip lesions. Defect less than one-half can be repaired primarily. Small
lesions can be excised using the “V” excision and the defect is closed in three layers. The larger lesions can be excised
as a rectangle and incisions made in the lip-chin crease to allow advancement of lateral lip tissue for closure

A B C
Figs 4A to C: Abbe cross-lip flap: (A) V-shaped excision is planned around the lower lip lesion and proposed flap from
upper lip; (B) Lesion is excised. Flap is designed with same height as defect, but only 50% of width; (C) Flap is transposed
and sutured into defect
 Lip Reconstruction 1067

A B

C D
Figs 5A to D: Schematic representation of vascular pedicle of Abbe cross lip flap

Flap Design Postoperative Care

The flap width should be approximately one-half of There is a risk of damage to the vascular pedicle either by
the width of the defect so that width of both the upper dental trauma or by opening mouth widely. So patient
and the lower lips is reduced by the same amount. Two is advised liquid and pureed diet till the vascularity is
centimeter is the maximum recommended width of the established.
flap.
Advantage
Surgical Steps • Technically easy to raise the flap.
The surgical steps of Abbe cross lip flap are as follows:
• Measure the lip defect. Disadvantages
• Design the flap on the opposite lip to be half the width • This is a two-staged procedure.
and same height as that of the defect. • There is risk of damage to the pedicle by dental trauma
• Incise skin with knife. Incision is deepened through or by opening mouth is wide.
subcutaneous tissue, orbicularis oris and mucosa. • Relative microstomia, which depends on the size of defect.
Incision stops just short of white line to protect
underlying vascular pedicle.
• Rotate the flap into the defect.
THE ESTLANDER FLAP
• Flap is sutured in three layers. The Estlander flap is quite similar to the Abbe flap. It is ideal
• The pedicle is divided after 3 weeks and necessary for reconstruction of defect involving the oral commissure.
esthetic adjustments are made. The flap is raised similar to Abbe flap. The key difference
1068 Facial Plastics, Cosmetics and Reconstructive Surgery

is that the rotation occurs around the commissure. It Advantages

provides a good esthetic outcome(Figs 6A to F).5 The advantages of this flap are as follows:
• It preserves perioral sensation and function of the
Karapandzic Flap orbicularis oris.
This flap involves reconstruction of central lip defect (30 • It provides good cosmoses.
to 80%) with intact commissure by medial mobilization of
skin, muscle and mucosa of nasolabial region. While doing Disadvantage
so, blood and nerve supply of orbicularis is preserved.9 • Microstomia, which is directly proportional to the
size of defect.
Flap Design (Figs 7A to C)
The key surgical steps begin with drawing the incision Reconstruction of Total Lip Defect
around the defect and continuing the incisions into the After total resection of lip, there is no lip tissue avail-
nasolabial fold superiorly. Only skin and subcutaneous able for reconstruction. In such case, it is not possible
tissue is incised down till orbicularis muscle is reached. to give functional lip. The aim of surgery is to import
Mucosal incision is placed in gingivobuccal sulcus and tissue from other parts of the body to give near normal
sufficient mucosa is advanced. Then skin and mucosal flaps appearance of lip, which is socially acceptable. Various
are advanced into the defect along with intact orbicu­laris options are available ranging from nasolabial flap (NLF)
oris. Mucosa and orbicularis oris are sutured with absorb- to microvascular free tissue transfer.7 Here, authors
able suture material. Vermilion edges of both the cut end describe few reliable local flaps, which are technically
are approximated to achieve optimal esthetic appearance. less demanding.

A B C

D E F
Figs 6A to F: Abbe-Estlander flap: A 45-year-old patient with second primary over left one-third of the lower lip and angle
of mouth. Full thickness excision of lateral third of lower lip with angle of mouth was done. The proposed Estlander flap is
outlined. Flap is raised, rotated and sutured into defect. Postoperative view 6 months later
 Lip Reconstruction 1069

A B C
Figs 7A to C: Karapandzic flap reconstruction: Carcinoma of middle third lower lip (Figs A to C) is represented. Full thickness
resection was done. Incision for Karapandzic flap is outlined. Flap is raised and sutured in place. Meticulous approximation
of vermilion border is done for good esthetic appearance. Postoperative appearance after 2 years

A B

C D
Figs 8A to D: Elderly female presenting with carcinoma of lower lip. Full thickness total lower lip resection was done.
The defect was reconstructed with bilateral NLF. Postoperative appearance after 3 years
1070 Facial Plastics, Cosmetics and Reconstructive Surgery

Bilateral Nasolabial Flap Advantages

A total lower lip resection is a difficult situation for recon- • Technically less demanding.
struction. Author prefers bilateral NLF for reconstruction • Flap has excellent vascularity, so chances of flap
of total lower lip defects (Figs 8A to D). necrosis are minimal.

Flap Design Disadvantages

The length of NLF should be approximately same as • The donor site needs skin grafting and the resultant
the length of the excised lower lip. The height of defect cosmosis is poor. The donor site morbidity is minimized
corresponds to the width of NLF. This flap is based on by the use of a tissue expander.
subcutaneous and dermal plexus.7 In case of thin skin • This is a two-staged procedure, which requires flap
of patient, flap can be harvested to include underlying division.
musculature to increase the bulk of flap.
RECONSTRUCTION OF LIP
Surgical Steps
COMPOSITE DEFECT
The surgical steps of this flap are as follows:
• Full thickness excision of lower lip defect is carried out. Advanced carcinoma of lower lip involves paramandibu-
• Marking for the flap: The flap is outlined such that the lar soft tissues. Curative surgery involves full thickness lip
length of NLF should be approximately same as the resection with segmental mandibulectomy. Reconstru­
width of the excised lower lip. The height of defect ction mandible and surrounding soft tissue is essential
corresponds to the width of NLF. The suture line of to provide adequate oral competence and appearance.4
flap donor site should follow natural nasolabial fold to
minimize esthetic morbidity. Reconstruction of Lip Composite Defect with
• Incise the skin and subcutaneous tissue. Depending on Pectoralis Major Myocutaneous Flap11
the situation, thickness of the flap can be modified by It has an axial blood supply. It is based on the pectoral
including sufficient subcutaneous tissue. Nasolabial branch of the acromiothoracic artery.
flap is elevated on both sides.
• Both the flaps are mobilized. One of the flaps is sutured Positioning, Prepping and Draping
to remaining labial alveolar mucosa, and other flap is The patient is placed in a supine position with the chest
sutured to skin at outer resection margin. Then, both exposed. Entire chest and ipsilateral axilla are scrubbed
flaps are sutured together. and chest is draped as shown in Figure 10.

Reconstruction of Upper Lip Surface Markings of the Vascular Pedicle

Forehead Visor Flap The surface markings of the vascular pedicle are
Visor flap is very useful in reconstruction of entire determined by drawing a line from the shoulder to
upper lip (Figs 9A to D).10 the xiphisternum and another line, vertically from the
midpoint of the sternoclavicular notch to intersect the
Flap Design first line. The point, 2–3 cm medial to corocoid process,
The forehead visor flap is based on bilateral superficial approximately represents surface marking of vascular
temporal (ST) vessels. So, this is a bipedicled flap. hilum. From this point the pedicle runs in a curved
Superficial temporal artery divides approximately 2 cm direction towards the point of bisection which is already
above the zygomatic arch into anterior and posterior described (Fig. 10).
branches, which then sends perforators to the overlying
subdermal layer.8 Flap Design (Fig. 10)
The flap is employed as musculocutaneous island flap. It
Procedure is based on the pectoral branch of the acromiothoracic
• Bilateral ST vessels are traced using doppler ultra­ artery. The skin paddle is designed at the level of nipple so
sonography. Flap is designed around the ST vessels. The that the flap reachs till the site of defect. In order to ensure
height of flap should be twice the height of defect, so that the flap is of adequate length, the distance between the
when folded, it forms both mucosal and skin lining superior edge of the skin paddle and the clavicle should be
• Skin is incised with scalpel till the level of pericranium. equal to the distance between the inferior margin recipi-
Flap is raised above the pericranium. One should be ent site and the clavicle. Size of the flap should be slightly
careful not to violate pericranium, which forms the bigger than the size of defect to compensate for the shrink-
bed for skin grafting. age of skin paddle.
 Lip Reconstruction 1071

A B

C D
Figs 9A to D: Recurrent carcinoma upper lip involving entire lip (Figs A to D). Full thickness excision with premaxillectomy
was done. Superficial temporal vessels are traced by using doppler ultrasonography. Flap is designed on bilateral ST
vessels. Bipedicled forehead flap is raised and sutured to the margins of defect. Rest of the flap is tubed. Donor site is
covered with split thickness skin graft
1072 Facial Plastics, Cosmetics and Reconstructive Surgery

Procedure
• Skin incision is made with scalpel. Incision is further
deepened with electrocautery to minimize blood loss.
An incision is extended laterally from the peripheral
margin of the skin paddle along the anterior axillary
fold, which corresponds with the lateral margin of the
pectoralis major muscle. Incision is carried through
subcutaneous tissue to the level of pectoralis muscle.
Superior flap is developed till the level of clavicle. At
this stage, lateral edge of pectoralis major muscle
is identified. A plane is created through the loose
areolar tissue present between pectoralis major and
minor muscle, until the vascular pedicle is identified.
The pectoralis major muscle is divided lateral to the
pedicle. While doing so, the pedicle is always kept
in view. At this stage, muscle is rotated medially and
attachment of muscle from the rib is released with
electrocautery. Medial end of the muscle is divided
such that perforators of internal mammary vessels are
preserved. Pectoral nerves are encountered during
mobilization of flap are divided.
• Skin tunnel over clavicle: The flap is generally passed
into the neck, superficial to the clavicle through a wide
subcutaneous tunnel, which is created at the level of
Fig. 10: Surface markings of pectoral branch of clavicle (Fig. 10). The tunnel should be large enough to
acromiothoracic artery permit easy delivery of the flap into the neck without

A B
Figs 11A and B
 Lip Reconstruction 1073

C D
Figs 11A to D: Reconstruction of lip composite defect with pectoralis major myocutaneous flap. Carcinoma of right
lower gingivolabial sulcus with involvement of lateral third of lower lip is represented (Figs 11A to D). Full thickness lip
composite resection was done. Defect was reconstructed with bipaddled pectoralis myocutaneous (PMMC) flap. Postoperative
appearance after 6 months

shearing the musculocutaneous perforators supplying gov/pubmed/12794457”\o“Plastic and reconstructive

surgery.” Plast Reconstr Surg. 2003;111(7):2176-81.
the skin paddle and to avoid strangulating the vascular
4. Ramon M, Micheal A. Lip Cancer. Head & Neck Surgery:
pedicle. The flap is passed through the subcutaneous
Otolaryngology, p. 1541.
tunnel and fed into the recipient area. 5. Alzacko SM. Surgical treatment of squamous cell carci-
noma (SCC) of the lip in northern Iraq. The Iraqui
Closure of Donor Site Defect Postgraduate Medical Journal. 2010; 9(2).
The donor site is closed primarily by mobilization of the 6. Papel I, et al. Facial plastic and reconstructive surgery.
surrounding skin. Chapter 51: Lip Reconstruction. Thieme Publishing, New
York, NY; 2002; 634-45.
REFERENCES 7. Eckardt, et al. Reconstruction of oral mucosal defects using
the nasolabial flap: clinical experience with 22 patients.
1. Moretti M, Vitullo, et al. Surgical management of lip Head & Neck Oncology. 2011, 3:28.
cancer. ACTA otorhinolaryngologica italica. 2011;3:5-10 8. Kleintjes WG. The vascular anatomy the forehead and
2. Schutle DL, David A, et al. The anatomical basis of the related forehead flaps and it’s application in plastic and
Abbé flap. The Laryngoscope. HYPERLINK “http:// reconstructive surgery. Dissertation for the degree of PhD
onlinelibrary.wiley.com/doi/10.1002/lary.v111:3/issue- at the University of Stellenbosch; 2007. p. 37.
toc.” 2001;111(3): 382-6. 9. Karapandzic M. Reconstruction of lip defects by local arte-
3. HYPERLINK “http://www.ncbi.nlm.nih.gov pubmed? rial flaps. Br J Plast Surg. 1974;27:93-7.
term=Edizer%20M%5BAuthor%5D&cauthor=tre&caut 10. Nthumba P, Carter L. Visor flap for total upper and lower
hor_uid=12794457” Edizer M, HYPERLINK “http:/www. lip reconstruction: a case report. Journal of Medical Case
ncbinlm.nih.gov/pubmed?term=Ma%C4%9Fden%2O% Reports. 2009;3:7312.
5BAuthor%5D&cauthor=true&cauthor_uid=12794457” 11. Gregor RT. The use of the myocutaneous reconstruc-
Maden O etal.Arterial anatomy of the lower lip: a cada tion after major head and neck surgery SAMEDIESE
eric study. HYPERLINK “http://www.ncbi.nlm.nih TYDSKRIF. 1982; pp. 788-92.
1074 Facial Plastics, Cosmetics and Reconstructive Surgery The Surgical Technique of Otoplasty 1074
CHAPTER

109 Operative Techniques in

Mandible Fractures
Rajesh R Yadav, PV Dhond

INTRODUCTION • Cases in which closed reduction is contraindicated

• All complex and comminuted fractures
In the modern era of rapid life, vehicular accidents and • Cases of severely atrophic edentulous mandible with
violence are a common occurrence. Fractures of the displacement.
mandible are gaining attention due to the upward trend
of accidents of two wheelers and other motor vehicles. The
fracture treatment consists of reduction and immobiliza-
SPECIFIC PREOPERATIVE
tion. Type of reduction depends upon type of fracture. EVALUATION
Before taking patient on table, the following things should
be evaluated:
REDUCTION • Head injuries should be ruled out.
Reduction of fracture means bringing two fractured • Spine injuries should be ruled out.
segments in original anatomical position. In the dentate • Patient should be hemodynamically stable.
mandible, reduction must be anatomically precise. • A brief history should be taken. Previous convulsion
and psychiatric disorder should be ruled out as these
may be contraindications for intermaxillary fixation.
IMMOBILIZATION • Thorough examination should be done. Associated
Following accurate reduction of fragments, the fracture fracture of face and mandible should be ruled out,
site needs to be immobilized to allow the bone-healing to trauma to temporomandibular joint (TMJ) should be
occur. ruled out
• Occlusion of patient should be evaluated. In case of
malocclusion, previous occlusion should be judged by
TYPES OF REDUCTION looking at wear facet, previous dental treatment papers
• Closed reduction or patient’s photograph.
• Open reduction. • X-ray of left and right mandible, in oblique lateral view,
is a must.
• Panoramic film is desirable, as it gives single overall
INDICATIONS FOR THE SURGERY view of the mandible.
• CT scan should be done, in case of:
Closed Reduction
– Multiple facial injuries
• Fractures which are favorable (undisplaced) with – Comminuted fractures
minimal disturbance of occlusion – Missile injuries
• Fractures in children involving developing dentition – Infected malunion, nonunion fractures
• Simple coronoid fractures – Vertical splint fractures.
• Most of the condylar fractures.

Open Reduction ANESTHETIC CONSIDERATIONS

• All unfavorable fractures with change in occlusion Preoperative
• Displaced bilateral condylar fractures
• Malunited fractures • Explain the patient about postoperative events, like
• Nonunion of fractures brief mouth closure.
• If associated with complex facial fractures • Assess nostril patency
 Operative Techniques in Mandible Fractures 1075

• Check for evidence of basal skull fracture and cerebro- trimmed and the posterior edge of the bar needs to be
spinal fluid (CSF) leak, which makes nasal intubation bent to prevent soft tissue injury (Fig. 1B).
contraindicated • After giving local block (using 2% lidocaine and adren-
• In a case of severe trismus, where postoperative aline with one and half inch needle—26 #), wire is
edema may be anticipated, tracheostomy should be passed above and below the arch bar and tightened so
considered that it does not obstruct the lug. It is important to make
• Submental intubation should be considered in case of sure that these wires have been tightly applied. This
a panfacial trauma. is done by checking whether any vertical movement
of arch bar is possible. The wires used are normally of
Perioperative 26 gauge (Figs 1C and D).
• Trismus make intubation look potentially difficult • Intermaxillary fixation can be established by either
preoperatively as the mouth opening is markedly wires or by elastic (Fig. 1E).
limited due to the muscle spasm, hematoma, pain, but
these tend to relax following induction. General Considerations
• Nose should be packed with 4% lidocaine with adrena- There are important points to consider before starting.
line or Otrivin nasal drop should be used. • The occlusion must be checked. In the case of jaw
• A rapid sequence induction with suxamethonium is malformations, like a deep bite deformity, it may be
appropriate. impossible to use arch bars.
• A marked swelling may make intubation difficult and • One pitfall, while using arch bars, is the risk of acquisi-
awake fiberoptic intubation may be required. tion of blood-borne infection from patients.
• Gas induction, while applying the face mask, is often • Passing the wires to secure the arch bar can result in
difficult due to pain. a puncture or tear in the surgeon’s glove and thereby,
• Make sure that the patient, when comes out from anes- possibility of infection.
thesia, should not be sedated and should be completely
awake from the anesthesia. Open Reduction and Immobilization
• If throat pack is placed around, the tube should be Generally, open reduction is done under general anes-
removed before the application of wires. thesia. Depending on the site and type of fracture, three
approaches are used:
Postoperative 1. Extraoral approach
• Observe the patient for some time in recovery before 2. Intraoral approach
sending it to the ward. 3. Use of existing wound.
• Start humidified oxygen.
• Always keep a wire cutter and a suction machine Extraoral Approach
beside the patient’s bed (to cut the wires in case of Submandibular approach: In 1934, Risdon described this
emergency). technique. This is the same incision used for excision of
• Shift the patient with nasopharyngeal airway to the the submandibular gland.
ward. • Indications: This approach is used for fractures of the
mandibular body and angle regions. Generally, this
is used in complex and comminuted fractures, where
SURGICAL STEPS intraoral reduction, exposure and reconstruction plate
• Closed reduction and immobilization placement would be difficult.
• Open reduction and immobilization. • Incision: The incision can either be parallel to the infe-
rior border of the mandible, at least 2 cm below the
Closed Reduction and Immobilization angle of the mandible or be placed in an existing skin
This means fracture segment is reduced manually with- crease for maximum cosmetic benefit (Fig. 2). Incision
out any incision, followed by immobilization. There are is performed after infiltrating the area with 2% lido-
many methods of immobilization. Most commonly used caine with adrenaline.
method is arch bar fixation. • Elevation of flap: Subplatysmal flap elevated up to the
Steps in arch bar fixation: mandible with help of cautery.
• Selection of appropriate length and contouring of • Preservation of marginal mandibular nerve: The main
Erich arch bar according to arch of teeth (Fig. 1A). neural structure is the marginal mandibular branch
• Arch bar to be placed around the teeth for a proper of the facial nerve (cranial nerve VII). The facial artery
measurement. Extra length of the arch bar needs to be and vein are also encountered during this dissection.
1076 Facial Plastics, Cosmetics and Reconstructive Surgery

D
Figs 1A to E: (A) Selection of appropriate length and
contouring of Erich arch bar; (B) Arch bar to be placed on
a teeth for a proper measurement. Extra length of the arch
bar need to be trimmed and the posterior edge of the bar
need to be bend to prevent soft tissue injury. (C and D) Wire
is passed above and below the arch bar and tightened so
as not to obstruct the lug. It is important to make sure that
this wires have been tightly applied by checking whether any
vertical movement of arch bar is possible. The wire used are
of normally of 26 gauge; (E) Intermaxillary fixation can be
E established by either wires or by elastic
 Operative Techniques in Mandible Fractures 1077

Fig. 2: Various submandibular incision

Fig. 3: Face lift incision(preauricle incision)

They are commonly located 1 cm below the angle of
the mandible. This neurovascular structure is identi-
fied by Holder Martin’s method in which facial vessels
are identified and they are retracted, so that they are – The superficial temporal vessels may be retracted
safe in the flap. The dissection is carried out through anteriorly with the skin flap, or left in place.
the deep cervical fascia. – Then, palpate for zygomatic arch. Ask the assistant
• Muscle dissection: The muscle and periosteum are to move the jaw so that you can palpate mandibu-
cut with the help of cautery, and retracted upward. lar condyle.
Mucoperiosteum is incised and elevated to expose the • Incising temporal fascia parallel to frontal branch of
fracture segment. facial nerve
• Wound closure: Wound is sutured in layers; first the – An oblique incision through the superficial layer
muscle layer, then platysma layer and then the skin of the temporal fascia above the zygomatic arch
layer is sutured keeping the drain in the wound. is performed, ensuring that it is parallel to frontal
Preauricular approach: The preauricular approach can branch of the facial nerve.
be used to access and treat fractures in the mandibular – Strip the periosteum off the lateral zygomatic arch
condylar head and neck region. by inserting the periosteal elevator beneath the
• Preservation of important neurovascular structure: superficial layer of the temporal fascia.
Branches of the facial nerve may be involved in this – Dissection will be carried inferiorly to expose the
incision and dissection. The superficial temporal capsule of the TMJ.
artery and vein are commonly encountered in this – The frontal branch of the facial nerve is protected
surgical approach. The vessels should be conserved if within the superficial layer of the deep temporal
possible. fascia.
• Incision: Dingman described this incision. The inci- – Dissection can be carried out inferiorly—dissec-
sion is made in a preauricular skin crease. This inci- tion is proceeded furthur in a subperiosteal plane
sion is called face lift incision. Incision is not extended to reach the neck of the mandibular condyle.
below the lower end of tragus (Fig. 3). A disadvantage of this approach is that the
• Identification of temporal fascia surgeon can reach only a limited portion of the condy-
– Carry the incision through the skin and subcuta- lar neck region.
neous tissues to the depth of the temporal fascia. • Wound closure: If the TMJ capsule has been incised to
The temporal fascia is a glistening white tissue layer access the condylar head, it must be closed as the first
that is best appreciated in the superior portion of step. The temporal fascia is closed as the next step. Skin
the incision. and subcutaneous sutures are placed.
1078 Facial Plastics, Cosmetics and Reconstructive Surgery

Intraoral Approach • Protection of mental nerve: The mental nerve is an

This approach is used for: important structure which needs to be preserved; if it
• Fracture of symphysis and body is severed, there will be paresthesia, numbness at the
• Fracture of condylar process and ramus. lips, chin and vestibule.
In practice, intraoral approach is more commonly • Precautions: When the incision is extended posterior
used. to the canine teeth, the mental nerve can be damaged;
• Advantages this should be kept in mind and then dissect. Keep
– Intraoral approach is more rapid than extraoral the incision superior to the mental nerve in the body
approach region that can be done by making incision 5 mm away
– No external scar from attached gingiva posterior to canine.
– More exposure for horizontal mandible anteriorly. • Dissection: Below the mucosa, lies the mentalis
• Disadvantage muscle. Saving the mental nerve, incision on mentalis
– Only labial cortex is visualized. Thus, there is a muscle is performed with the help of cautery. Keep
possibility of significant gap remaining in the adequate stump attached to mandible so that mentalis
lingual cortex. muscle can be resutured back.
Intraoral approach to the symphysis and body • Exposure of fracture site: Mucoperiosteal flap is incised
• Vestibular incisions: The intraoral approach is the usual and elevated to expose the fracture.
access for simple fractures of the body, symphysis, and • Wound closure: After thoroughly irrigating the wound
angular regions. The approach can be extended poste- and checking for hemostasis, the incision is closed.
riorly (Fig. 4) for better access to the body, angle and Anteriorly, the mentalis muscle is reapproximated to
ramus regions. In complex fractures, including commi- prevent drooping of the chin tissues. The mucosa is
nuted, edentulous and infected fractures requiring the closed with interrupted or running resorbable sutures.
placement of load-bearing reconstruction plates, an A crep bandage is applied on the chin region to prevent
extraoral approach may provide better access. hematoma formation and to support soft tissue.
• Incision: Infiltrate the area with a local anesthetic Intraoral approach to the angle
(2% lidocaine with adrenaline) and wait for a while. • Vestibular incisions: The intraoral approach is used for
Make an incision through the mucosa in the vestibule. the majority of simple angle fractures.
Between the canines, the incision is made 10–15 mm • Mark the incision: Where there is no third molar
away from the attached gingiva in a curvilinear fash- present, or where one is present but has to be left in
ion. Posterior to the canine, the incision is only 5 mm place, a purely vestibular incision approximately 5 mm
away from the attached gingiva, staying superior to the away from the attached gingiva is made (Fig. 5A).
mental nerve. When an erupted third molar is to be removed, the
incision must incorporate the attached gingiva around
the buccal side of the tooth (combination of vestibular
and envelope incision) (Fig. 5B).
• Infiltration: Inject 2% lidocaine with adrenaline at the
marked site.
• Preservation of sensory buccal nerve: The sensory
buccal nerve crosses the upper anterior rim of the
mandibular, ascending ramus in the region of the
coronoid notch. It is usually below the mucosa running
above the temporalis muscle fibers. When the poste-
rior vestibular incision is taken sharply along the bony
rim, the buccal nerve is at risk of transsection, followed
by numbness in the buccal mucosal region. Therefore,
to protect the nerve, the posterior dissection is to be
extended bluntly as soon as the lower coronoid notch
is reached.
• Buccinator muscle: On performing the incision, lower
attachment of buccinator muscle is transected—After
incision taken, buccinator muscle is transected. With
Fig. 4: Intraoral incision for symphysis and body fracture
the help of cautery, mucoperiosteum is elevated and
fracture segment is identified.
 Operative Techniques in Mandible Fractures 1079

A B
Figs 5A and B: (A) Mucosal incision for angle fracture; (B) Mucosal incision for angle fracture
when erupted third molar have to be removed

• Wound closure of the vestibular incision: To reattach prior to closure. The laceration is closed in layers with
the muscle, the sutures in the lateral vestibular region resorbable interrupted sutures, realigning the anatomic
should not only be superficial. The suture should catch structures and eliminating dead space.
all layers (mucosa and muscle) to ensure muscle reat-
tachment. After thoroughly irrigating the wound and Steps After Exposure of Fracture Fragment
checking for hemostasis, the surgeon can close the
Reduction of Fracture Fragment
incision.
An elastic pressure dressing covering the angle region After exposure, fracture fragment is reduced to normal
helps support the soft tissues, and prevent hematoma alignment. Teeth occlusion alignment is more important
formation. Wound closure is done using envelope flap. than bone alignment. The occlusion of patient is brought
The envelope portion of the flap is undermined with to pre-existing alignment with manipulation, and an inter-
scissors to facilitate tension-free advancement over maxillary fixation is put.
extraction site. Generally, resorbable sutures are used
for this closure. The flap is advanced and closed over the Fixation
extraction site. Although many methods of osteosynthesis have been
described, but most practiced, easy and reliable method
The Use of Existing Lacerations of osteosynthesis is miniplate osteosynthesis.
Frequently, patients with facial fractures also have lacera-
tions. Very often, these existing soft-tissue injuries can be Champy’s Lines of Osteosynthesis
used to directly access the facial bones for management of Champy and coworkers, after careful consideration of
the fractures. the biomechanics of mandible, have described osteo-
The surgeon may elect to extend the laceration to synthesis line for placing the miniplate in the mandible
provide adequate access to the fractured area, following (Figs 6A and B).
the relaxed natural skin creases. • A line drawn at the base of the alveolar process corre-
Wound closure: Wound closure for this incision is the sponds to the line of tension. A miniplate and a screw
primary closure of the laceration. Proper cleansing, can be fixed along this line. In the parasymphysis region,
debridement, and hemostasis should be accomplished another line is drawn to neutralize the tension force.
1080 Facial Plastics, Cosmetics and Reconstructive Surgery

A B
Figs 6A and B: (A) Champy’s line; (B) Mini hole plate fixation along the Champy’s line

• Behind the mental foramen, only one plate should be • Soft tissue in-between the fracture line should be
applied, immediately below the dental root and above removed as it does not allow proper alignment. Also,
the inferior alveolar nerve. there is a risk of nonhealing of fracture, if soft tissue is
• Between the two canines and in front of mental fora- placed between fractured fragments.
men, another plate near the lower border of mandible • Use of drill sleeve, while drilling, provides protection to
is applied in addition to the upper plate. soft tissue.
• Drill bit used should be 0.5 mm less than the screw
Technique size. For example, if screw or plate of 2 mm is used,
These miniplates are around 0.9 mm thick and 6 mm wide. then 1.5 mm drill bit should be used to make hole.
The difference between holes is standardized. The screws • Damage to mental nerve, tooth root, inferior alveolar
available are 5–15 mm in length. The diameter of the canal should be avoided.
screws is 2 mm; screws usually used in mandible are 6 mm • A space of about 5 mm should be kept between two
or 8 mm. The screws are of self-tapping type. plates.
• The plate is bent first so as to be adapted to bone. • Then, screw is inserted near the fracture site and grad-
• Plate is placed on mandible, keeping in mind that there ually tightened.
are two holes on either side of fracture line. • This same procedure is carried out for insertion of
• In case of simple fractures, miniplate is used. screw in all the holes of plates.
• In case of complex, comminuted fractures and infected The inferior alveolar nerve region is considered as
fractures, reconstruction plate is used. the neutral zone of the mandible. Avoid plate and screw
• 1.5 mm drill bit is used to create a hole almost perpen- fixation in this area since it can cause damage to the
dicular to the plate. nerve.
• Eccentric drilling or repeated insertion of drill
produces unfavorable hole, thus diminishing the grip Principle
of the screw. The authors follow Champy’s principle of osteosynthesis.
• During drilling, continuous liquid cooling is necessary For example, in simple symphysis and parasymphysis
to avoid thermal necrosis and the early loosening of fracture, they use two mini-hole plate (four holes)—one
screws at upper border and the other on lower border to combat
• A give away indicates penetration of drill in a cortical torsional and rotational force with one hole on either side
bone of fracture (Figs 7A to D).
 Operative Techniques in Mandible Fractures 1081

A B

C D
Figs 7A to D: (A) Parasymphysis fracture; (B) Symphysis fracture; (C) Four-hole plate, one at superior border and one
at inferior border; (D) Four-hole plate one at superior border and one at inferior border

Fracture of Angle and Ramus Complex Angle and Body Fracture

• A single monocortical miniplate applied on the exter- Figures 10A to D show angle and body fractures.
nal oblique line is enough for simple angle fracture
• Fracture between canine and angle (body) can be stabi- Condylar Fracture
lized by superior border plating along the Champy’s These can be treated either by conservative approach
line as shown in (Figs 8A and B). or surgically, depending upon the amount of displace-
ment. Conservative approach is advocated in condylar
Complex Symphysis and Parasymphysis fractures which are without any displacement, condylar
Fracture fractures with little displacement, and slight overriding in
Figures 9A to D show fractures in the parasymphysis young children or subcondylar fractures which are slightly
area. displaced.
1082 Facial Plastics, Cosmetics and Reconstructive Surgery

A B
Figs 8A and B: (A) Fracture of angle; (B) Single mini-hole plate fixation at external ridge

Open Reduction This coronoid fragment is fixed by interosseous wiring or

by miniplate. If reduction is not possible and function is
In grossly displaced condylar fracture, where reduction impaired, coronoid process is removed.
cannot be achieved by conventional method and there is
a fear of future derangement or ankylosis, an open reduc- Alternative Surgical Approaches
tion is indicated.
Transparotid Approach
The indications are
• Cases of condylar fracture with vertical overriding A vertical incision through skin and subcutaneous tissue
• Cases in which normal occlusion cannot be achieved is made, extending from just below the ear lobe to the
by manipulation or traction mandibular angle. It should be parallel to the posterior
• Cases of gross displacement, especially bilateral border of the mandible (Fig. 11).
condylar fracture • Dissection: The subcutaneous tissue is undermined,
• Cases in which condylar fractures interfere with jaw exposing the superficial musculoaponeurotic system
movement (SMAS). A vertical incision is made through the SMAS
• Cases in which condyles are partially fused in a wrong into the parotid gland.
position. • Blunt dissection of the parotid gland: The parotid
The condyle is surgically approached by preauricular, gland is bluntly dissected parallel to the direction of
submandibular or retromandibular approach. The frac- the facial nerve branches and till the posterior border
ture is reduced and fixed by either interosseous wiring or of the mandible. The dissection should be anterior to
by monocortical miniplates. the retromandibular vein. Branches of the facial nerve
may be found during the dissection. A nerve stimula-
Fracture of Coronoid Process tor may be helpful to identify them. They should be
This account for 1% of fractures; most of the coronoid frac- mobilized and protected. Once the posterior border of
tures do not require any treatment. Cases in which coro- the mandible is reached, an incision is made through
noid hinders the opening of mouth, treatment is advised. the pterygomasseteric sling.
 Operative Techniques in Mandible Fractures 1083

A B

C D
Figs 9A to D: (A) Comminuted fracture of parasymphysis; (B) Reconstruction plate (load-bearing osteosynthesis) at the
inferior border to neutralize the tension and the compression force; (C) Basal triangle fracture of parasymphysis area and;
(D) Reconstruction plate (load-bearing osteosynthesis) at an inferior border plus miniplate (load-sharing osteosynthesis) at
the superior border
1084 Facial Plastics, Cosmetics and Reconstructive Surgery

A B

C D
Figs 10A to D: (A) Basal triangle fracture of angle; (B) Miniplate (load-sharing osteosynthesis) at external oblique line plus
reconstruction plate (load-bearing osteosynthesis) at inferior border; (C) Comminuted body fracture; (D) Reconstruction plate
at lower border plus mini-hole plate at upper border
 Operative Techniques in Mandible Fractures 1085

Fig. 11: Transparotid approach skin incision Fig. 12: Retroparotid approach

• Subperiosteal dissection of the mandibular ramus: A from the ramus. Further dissection, superiorly along
periosteal elevator is used to strip the masseter muscle the posterior border, exposes the condylar process.
from the ramus. Further dissection, superiorly along • Wound closure: The wound is reapproximated in
the posterior border, exposes the condylar process. layers for anatomic realignment and avoidance of
• Wound closure: The wound is closed in layers. Any dead space.
dead space formation is avoided. The parotid gland The SMAS is resuspended. A suction drain may be
capsule must be closed tightly to prevent salivary placed.
fistula. The SMAS is resuspended.
The Various Modification of
Retroparotid Approach Preauricular Incision
A frequently used alternative to the transparotid approach Rowe modification
is one in which the parotid gland is lifted rather than • Preauricular incision with temporal extension.
dissected through. This requires the incision to be placed • An incision is angled from the point of the attachment
more posteriorly which means that exposure of the of helix upwards and forward at 45°, lying within the
mandible is limited. Rather than approaching the mandi- hair-bearing area over the temporal region.
ble directly over the ramus, it is approached more posteri- • This incision allows an extensive flap to be raised
orly (Fig. 12). and avoid traction injury to upper branches of facial
• Skin incision: An oblique incision through skin and nerve.
subcutaneous tissue is made, extending from the • Reverse sigmoid-shaped incision gives the most satis-
mastoid process to a point just below the angle of the factory result by helping to disguise the final scars.
mandible. The subcutaneous tissue is undermined, Blair and Ivy
exposing the SMAS. An oblique incision is made • Preauricular incision with an inverted hockey stick
through the SMAS. The posterior aspect of the parotid incision over the zygomatic arch.
gland is identified and dissection continues behind the • It gives easy access and better stability along with facil-
gland. The gland is lifted off the masseter muscle and itated exposure of arch along with the condylar arc.
retracted anteriorly. Alkayat-Bramley preauricular incision
• Dissection: Once the posterior border of the mandi- • Alkayat-Bramley preauricular incision along with a
ble has been reached, an incision is made through the curved temporal extension (question mark shape)
pterygomasseteric sling. is advocated mainly for TMJ ankylosis, as it gives a
• Subperiosteal dissection of the mandibular ramus: A wide area of exposure and also facilitates elevation of
periosteal elevator is used to strip the masseter muscle temporal flap for reconstructive purpose.
1086 Facial Plastics, Cosmetics and Reconstructive Surgery

Endaural Approach in this region. Dissection is carried out to the inferior

• This approach gives good scar but poor access, so border of the mandible. The periosteum is incised
rarely used. sharply and the flap is elevated to expose the anterior
surface of the symphysis.
Submental Approach • Wound closure: The wound is closed in layers to realign
The submental approach is used to treat fractures of the the anatomic structures and to eliminate dead space.
anterior mandibular body and symphysis. These frac- The periosteum and platysma muscle should be closed
tures can usually be approached and treated intraorally. in different layers.
However, depending on the difficulty or severity of the • Option—bilateral extension/submental extension:
fracture, and/or the presence of a laceration, suitable The submental incision can be extended laterally to
an extraoral approach via the submental route may be encompass both the right and left mandible by deglov-
indicated. ing the entire lateral surface of the mandible in the
• Advantages same way as in the submandibular approach. This may
– Lingual surface of the mandible can be easily be necessary in complex fractures, such as commi-
inspected to ensure optimum reduction of fracture nuted, atrophic, and severe bilateral fractures. To
in this segment. approach complex mandibular fractures, the surgeon
– No major structures encountered in this area essentially combines a right and left submandibular
– Scar is not that visible. incision with a submental one.
• Variations in incision (Fig. 13)
– Following curvature of anterior mandible Retromandibular Approaches
– Hidden in submental skin crease. In 1967, Hinds and Girotti first described this approach
• Dissection: The incision is carried through the skin (Fig. 14).
and subcutaneous tissues to the platysma muscle. • Skin incision: Incision is made 3 cm above the subman-
The platysma muscle must be divided. There may be a dibular incision. The incision is carried curving behind
natural separation of the muscle in the midline region. the angle of mandible;
Additionally, the platysma muscle becomes very thin 2% lidocaine with adrenaline can be used for vasocon-
striction effect.
• Subplatysmal flap elevation: Superior subplatysmal
dissection would expose the underlying marginal
mandibular branch of the facial nerve (cranial nerve
VII). By ligating and dividing the facial artery and vein
and then retracting the vessels superiorly, the marginal
mandibular branch of the facial nerve remains
included in the superior flap and is thus protected.
Divide the pterygomasseteric sling and incise the peri-
osteum at the inferior border to expose the fracture
site. This exposes the body and angle region.
• Wound closure: For wound closure, the pterygomas-
seteric sling is closed. The wound is closed in layers.
A drain may be used if necessary.

Alternative Method of Intermaxillary Fixation

Alternative Way of Fixing Arch Bar
Wiring technique
• Gilmer method: This is the simplest way to estab-
lish intermaxillary fixation. This technique is simple
and effective but has a disadvantage that mouth
Fig. 13: Variations in incision. (A) Following curvature of cannot be opened for inspection of the fracture side
anterior mandible; (B) Hidden in submental skin crease without removal of wire fixation. The method consists
 Operative Techniques in Mandible Fractures 1087

A B

C D

Figs 15A to D: (A) Passage of wire; (B) An extra loop is

passed; (C) The wire is passed above and below the arch
bar and; (D) The wire is tightened

Fig. 14: Retromandibular approach

of passing wire ligatures around neck of available

teeth and twisting them in a clockwise direction until
the wire is tightened around its tooth. After adequate
number of wires have been placed, upper and lower
teeth are brought into the occlusion and the wires are
twisted one upper to one lower wire. A stainless steel
(24-gauge or 26-gauge) gauge wires are usually applied
(Figs 15 and 16).
• Eyelet method: This method of fixation has the
advantage that jaws may be opened for inspection
by removal of only the intermaxillary ligatures. This
method consists of twisting a 20 cm length of 24-gauge
or 26-gauge wire around an instrument to establish
a loop. Both ends of the wire are passed through the
interproximal space from the outer surface. One end
of the wire is passed around the anterior tooth and
the other one around the posterior tooth. One end of Fig. 16: Gilmers method of fixation
1088 Facial Plastics, Cosmetics and Reconstructive Surgery

the wire may pass through the loop. The eyelet should Intermaxillary fixation screw technique
project in upper jaw above and in lower jaw below the • Intermaxillary fixation screws were introduced as
horizontal twist to prevent ends from impinging on labour saving device. Intermaxillary fixation screws
each other. After establishment of sufficient number of provide a rapid method of immobilization of teeth
eyelets, the teeth are brought into occlusion and liga- in a good dentition, in uncomplicated fractures. The
tures are passed in loop fashion between one upper number and position of these screws is based on type
and one lower eyelet. The inter-jaw wires are twisted of fracture, the location of fracture, and the surgeon’s
tightly to provide intermaxillary fixation (Fig. 17). preference. Screw must be positioned superior to the
maxillary tooth roots and inferior to the mandible
tooth root (Fig. 18).
• Disadvantage is minimal, and a focused point of force
application to maintain good intermaxillary fixation.
The focus point of force applied may result in maloc-
clusion by leaving the posterior dentition in an open
bite.

SPECIAL INSTRUMENTS USED FOR

THE SURGERY
Instruments for Gaining Surgical Access
• Scalpel
• Blade handle
• Blade.

Instruments for Reflection of

Mucoperiosteum Flap
• Periosteal elevator
Fig. 17: Eyelet method of fixation • Freys elevator or mastoid elevator can be used.

Fig. 18: Intermaxillary fixation screw technique

 Operative Techniques in Mandible Fractures 1089

Instruments for Retraction Instrument Used for Intermaxillary Fixation

• C-shape retractor • Erich arch bar—its standard arch bar is used
• Cat paw retractors • No. 26 reel wire
• Langerbeck right angle retractor • Cutter
• Chin retractors • Long arteries
• Tongue depressor. • Twister.
These instruments are usually available in the authors’
operation theaters.
COMPLICATIONS
Instrument for Drilling Holes Serious complications, arising as a result of mandible
• Drill bits; use 1.5 mm drill bit to drill a hole for 2-mm fracture, are rare as fractures are treated competently
screws; drill bit size should be 0.5 mm less than the nowadays. Minor complications are more common
diameter of screw to be used than the major ones. The complications are divided into
• Drill machine with hand piece. early complications and late complications. The authors
encounter more of late complications than early ones.
Implants for Mandible and Instruments that
Need to Fix Them
Mini Hole Plates
Miniplates are available in various shapes and lengths, but
can only be used with non-locking screws. For mandible,
2.5 mm or 2 mm plates are usually used (Fig. 19).

Reconstruction Plates
These are available in various sizes: 8 holes, 10 holes,
12 holes and 16 holes plates. Usually 2 mm reconstruction
plates are used (Fig. 20).

Screw Driver and Screws

Screw driver is usually used depending on screw. For
example, 2 mm screw driver is used for 2 mm screws. They
are available in 1.5 mm, 2 mm, and 2.5 mm sizes (Fig. 21). Fig. 20: Reconstruction plate

Fig. 19: Mini-hole plates Fig. 21: Screw driver with screw of different sizes
1090 Facial Plastics, Cosmetics and Reconstructive Surgery

Early Complications for this fracture. In such a case, the patient needs to be
operated upon again to fix a correct plate.
Infection Malunion/malocclusion
Most common early complication is infection. Infected • Etiology: Malunions occur due to one of several
fractures usually demonstrate one or more of the follow- reasons:
ing signs/symptoms: – Inadequate occlusal reduction during surgery
• Swelling – Inadequate osseous reduction during surgery
• Erythema – No osseous reduction (e.g. condyle fractures)
• Trismus – Imprecise application of internal fixation devices
• Pain – Inadequate stability (lack of rigidity).
• Purulent discharge. • Treatment: The treatment of a malunion must
Infection occurring in fractures usually results from involve:
one or more of the following etiology: – Identification of the cause and treatment
• Microorganisms – Orthodontic reference
• Fracture instability – Osteotomies as necessary (refracture, standard
• Devital tissues (teeth, bone, etc.). osteotomies, combinations).
The treatment of infected fractures involves:
• Incision and drainage of abscesses, Limitation of Opening of Mouth
• Irrigations of the wounds as necessary Prolong immobilization of mandible and intermaxillary
• Systemic antibiotics fixation can result in weakening of muscles of mastication.
• Removal of devital teeth/bone Substantial hemorrhage within muscle leads to organized
• Removal of any loose internal fixation devices hematoma with early scar tissue formation. All this leads
• Restabilization of fracture to decreased mouth opening.
• Stronger and longer plates need to be applied • Treatment
• Function should be permitted after the infection is – Physiotherapy may accelerate the recovery
cleared period
• Bone grafting should be considered in a case of big gap – Simple jaw exercises should be employed
in a fracture. – Occasionally, manipulation of mandible under
anesthesia may assist the breakdown of scar tissue
Late Complications within muscle.
Fixation Failure Scar
This is the commonest late complication. Implant failure • Etiology
includes plate fracture and screw head fracture and extru- – Contamination of wound with dirt, especially tar
sion, kenacort and hylinese—kenacort and hyaluronic products
acid of screws. Fixation failure results in fracture mobility – Improper technique of suturing
that can subsequently lead to infection, nonunion and/or – Associated infection
malunion. – Tendency of patient.
Fixation fails by a number of mechanisms which • Treatment
include: – Wait and watch for first year as they may soften and
1. Insufficient amount of fixation fed away
2. Fracture of the plate – Massage of the scar
3. Loosening of the screws – Pressure bandage
4. Devitalization of bone around screws. – Application of lanoline
Insufficient amount of fixation: Left mandibular angle – Infiltration of injection of kenacort and hylaronic
fracture was treated using a malleable miniplate 2.0 at the acid
inferior border of the mandible. This is insufficient fixation – Surgical revision if possible.
 The Surgical Technique of Otoplasty 1091
CHAPTER

110 Faciomaxillary Fractures

Arunesh Gupta, Akshay P Deshpande, Dipesh J Malviya

INTRODUCTION PREOPERATIVE EVALUATION

Faciomaxillary fractures are of two types: (1) mandible Clinical Examination (Figs 1 and 2)
fractures and (2) maxilla fractures, of which three predom-
inant types are mentioned. • Oral cavity
1. Le Fort I – Mouth opening
2. Le Fort II • Occlusion
3. Le Fort III – Segmental mobility of mandibular arch
– Dentoalveolar fracture
– Teeth loss
MANDIBLE FRACTURES
– Loose teeth
INDICATIONS – Associated maxillary fracture

The indications for open reduction and internal fixation External Examination (Fig. 3)
are as follows. • Swelling
• Malocclusion • Bruises
• Displaced fracture • Wounds
• Unfavorable fracture • Exposed bone
• Submental nerve compression • Sensation in the region of mental nerve

Fig. 1: Patient of fracture mandible showing malocclusion Fig. 2: Fracture mandible, right maxilla and dentoalveolar
with anterior open bite fracture with teeth loss
1092 Facial Plastics, Cosmetics and Reconstructive Surgery

SPECIFIC ANESTHETIC
CONSIDERATIONS
• Mouth opening
• Loose teeth
• Nasomaxillary fractures
• Active intraoral and intranasal bleed
• Nasal intubation (Fig. 5)

SURGICAL STEPS
Arch Bar Insertion (Figs 6A and B)
This method is a gold standard for achieving maxillary
mandibular fixation (MMF).
Fig. 3: Deformity over chin and scar of injury Maxillary Mandibular Fixation (Figs 7A to D)
It is done when normal occlusion is achieved.

Specific Investigations Other Methods of the Maxillary

1. Orthopantogram Mandibular Fixation
2. CT scan of face with three-dimensional reconstruction • Gilmer method
(Figs 4A to C). • Eyelet method
• Suspension wiring
CLASSIFICATION OF MANDIBLE • Circummandibular wiring.
FRACTURES Approach
Mandibular fractures can be classified as; • Intraoral approach: Incision is taken at lower
gingivobuccal sulcus at the site of fracture with preserv-
Simple ing strip of mucosa on gingival side to facilitate closure
• Linear fracture at the end of procedure (Figs 8A to C).
  This method is used for (i) symphysis and parasym­
Complex physis, (ii) body, and (iii) angle and ramus.
• Comminuted fracture • Extraoral approach: This approach is used, when
• Compound fracture there is (i) existing laceration over the site of fracture,
(ii) comminuted fracture requiring the application of
Classification on the Basis of Region reconstruction plate, (iii) angle and ramus fracture,
• Symphysis and parasymphysis and (iv) condylar process and head fracture.
• Body Different types of incisions used are:
• Angle and ramus • Submental incision: It is used for symphyseal and para-
• Condylar process and head symphyseal fractures.
• Submandibular or Risdon’s incision: It is used for body,
Classification on the Basis of Other angle, ramus and low subcondylar fractures.
Associated Injuries to • Retromandibular incision: It is used for ramus and
• Face condylar fractures.
• Head and neck • Preauricular incision: It is used for condylar and head
• Other areas of the body fractures.
 Faciomaxillary Fractures 1093

B C
Figs 4A to C: (A) CT scan axial sections showing displaced fracture in symphyseal region and dentoalveolar fracture;
(B) 3-D CT-Fracture of symphyseal region of mandible and right maxilla involving zygomaticomaxillary (1) and nasomaxillary
(2) buttresses; (C) 3-D CT-Fracture of left parasymphyseal region of mandible
1094 Facial Plastics, Cosmetics and Reconstructive Surgery

Fig. 5: Patient position—Head in extension

with nasal intubation

A B
Figs 6A and B: Arch bar insertion. (A) Insertion of No. 24 stainless steel (S.S.) wire around tooth and arch bar;
(B) SS wire is twisted clockwise to tighten and its cut edges are inverted to avoid injury to buccal mucosa

A B
Figs 7A and B
 Faciomaxillary Fractures 1095

C D
Figs 7A to D: Maxillary Mandibular fixation. (A) Loop of SS wire placed over 3 lugs each on upper and lower arch bar;
(B) Wire loop tightened to achieve occlusion of teeth; (C) Occlusion on right side; (D) Occlusion on left side

A B

Figs 8A to C: Incision for fracture exploration. (A) Marking of

incision in lower gingivobuccal sulcus; (B) Saline adrenaline
infiltration (1:100000); (C) Incision preserving 4–5 mm of
C mucosal margin on gingival side to facilitate closure
1096 Facial Plastics, Cosmetics and Reconstructive Surgery

Exposure (Figs 9A to D) Body

After taking incision, fracture fragments are exposed taking
care to avoid injury to the surrounding vital structures, i.e. • Two miniplates
submental nerve, facial vessels. Periosteum over fracture • Titanium screws
fragments is stripped. Any granulation tissue/loose bony
piece between the fracture fragments is removed. Angle and Ramus
• One miniplate
Reduction (Fig. 10)
Fracture fragments are reduced manually with the bone Condylar Process and Head
holding forceps or stainless steel wire passed through frag- • One miniplate
ments. After the reduction, occlusion is confirmed.
Comminuted Fractures
Selection of Implants • Reconstruction plate
Symphysis and Parasymphysis (Fig. 11) Plate Contouring and Placement
• Two miniplates Plate is contoured, according to the location of fracture
• Titanium screws fragments.

A B

C D
Figs 9A to D: Exposure of fracture. (A) Periosteum incised and elevated with periosteum elevator; (B) Mental nerve
identified and preserved; (C) Exposed fracture; (D) All callus removed and fracture fragments rocked to achieve reduction
 Faciomaxillary Fractures 1097

Fig. 10: Reduced fracture Fig. 11: Titanium mini plates (2.5 mm diameter ), 4 hole
and 6 hole along with screws (Courtesy of Orthomax)

Drilling of Hole and Screw Placement COMPLICATIONS

(Figs 12A to C)
The complications can be divided into early and late.
Holes are drilled with micromotor drill. Size of drill bit
is 0.5 mm, smaller than that of plate. Screw mounts and Early
screw driver are used to place screws. • Hemorrhage
• Carotid injury
Confirmation of Reduction • Facial nerve injury
and Occlusion (Fig. 12D) • Infection
After the fracture fixation, again reduction of fragments • Avascular necrosis
and occlusion is confirmed. • Osteitis/osteomyelitis

Closure (Fig. 12E) Late

Intraoral closure should be watertight. It is done with • Temporomandibular joints ankylosis
delayed absorbable sutures in horizontal mattress fash- • Nonunion
ion. If external approach is used then wound is closed in • Malunion
two layers i.e. dermis with absorbable sutures and skin • Malocclusion
with non absorbable sutures. • Increased facial width
• Implant failure
MODIFICATIONS
SPECIAL INSTRUMENTS
Transbuccal Approach (FIGS 13A TO D)
It is used for angle, posterior part of the body and ramus, Following special instruments are used.
and lower subcondylar fractures combined with an • Cheek retractor
intraoral approach. • Howarth periosteal elevator
• Bone holding forceps
Endoscopic Approach • Micromotor drill machine
It is used for condylar and head fractures combined with • Transbuccal trocar with cannula set
transbuccal incision. • Screw mounts and screw driver
1098 Facial Plastics, Cosmetics and Reconstructive Surgery

A B

C D

Figs 12A to E: Fracture fixation. (A) Mini plate is placed at

lower border of mandible first and holes are drilled with drill
bit (2 mm diameter); (B) Screw (2.5 mm diameter) is inserted
using Sheath in holes near to fracture fragment; (C) Screws
tightened with screw driver; (D) Similarly mini plate is applied
near upper border and fixed. And simultaneously occlusion is
confirmed; (E) Lower gingivobuccal incision closed in water
E tight fashion with absorbable horizontal mattress sutures
 Faciomaxillary Fractures 1099

OTHER FIXATION TECHNIQUES Lag Screw Technique

Maxillary Mandibular Fixation Only • Used for symphyseal fractures

• In simple, favorable and minimally displaced External Fixator

fractures • For infected, multiple fractures
• Intracapsular condylar head fractures with minimal
displacement

A
B

C D
Figs 13A to D: Instruments required for open reduction and internal fixation of faciomaxillary fractures
(A) Instruments for Maxillary Mandibular fixation (Courtesy of Orthomax)
1. Stainless steel (SS) wire; 2. Arch bar; 3. Wire twister; 4. Long wire twister; 5. SS wire cutter; 6. Cheek retractor
(plastic); 7. Arch bar cutter; 8. Tongue Depressor; 9. Metallic cheek retractor;
(B) Instruments for plate contouring and transbuccal approach (Courtesy of Orthomax)
1. Howarth periosteum elevator; 2. Plate holder; 3. Reconstruction plate; 4. Plate bender; 5. Plate cutter;
6. Transbuccal set with trochar; 7. Plate plier 8. Jaw stretcher; 9. Drill bit sheath
(C) Instruments for wire and plate cutting screw driver (Courtesy of AO foundation)
1. Plate cutter; 2. Bone holding forceps; 3. Plate plier; 4. SS Wire cutter; 5. Arch bar cutter 6. Thick scissor for
cutting SS wire; 7. Plate holding forceps; 8. Drill bit sheath 9. Screw driver 10. Screw gauze
(D) Set of plates and screws with different shape and dimensions (Courtesy of AO foundation)
1100 Facial Plastics, Cosmetics and Reconstructive Surgery The Surgical Technique of Otoplasty
CHAPTER

111 Orbital Floor Fracture

Rajesh R Yadav, Girish Surlikar, PV Dhond

• Enophthalmos of greater than 2 mm persisting for

INTRODUCTION 10–14 days after trauma is cosmetically significant
Management of orbital floor fracture is usually accom- and therefore an indication for surgery. Orbital edema
plished through transconjunctival and subciliary incision. that is present initially may mask any enophthalmos.
Authors hereby would discuss a new way to approach Therefore, measurements must be rechecked once the
orbital floor fractures by endoscope. orbital edema has subsided.
• Fractures involving one-third or more of the orbit need
to be repaired. If left unattended, these fractures tend
ENDOSCOPIC REPAIR OF ORBITAL to result in significant enophthalmos.
FLOOR FRACTURE When surgery is indicated, it is usually best performed
as close to 2 weeks from the trauma date as possible. This
Advantages allows the swelling to subside and a more accurate exami-
• This approach provides adequate visualization and nation of the orbit to be performed.
magnification
• The endoscopic approach obviates the need for an Indications for Endoscopic Repair of Orbital
eyelid incision and thereby avoids potential lid compli- Floor Fracture
cation like lid malposition such as ectropion and entro- • Patient with trap door fracture and medial blowout
pion, which occur with conventional incision fracture are excellent candidates for endoscopic repair
• Posterior orbit cannot be visualized properly due to (Figs 1A and B).
angle of attack and prolapsed orbital fat and thereby,
there is possibility of improper implant placement
resulting into inadequate restoration of orbital volume
and enophthalmos. Using endoscopic approach, the
angle of inclination offers a more direct view of poste-
rior orbit, thereby reduces a risk of poorly positioned
implant.

INDICATIONS FOR ORBITAL FLOOR

REPAIR
• Persistent diplopia after 10–14 days of trauma with a
positive forced duction test and radiologic confirma-
tion of an orbital floor fracture with entrapment of the
inferior rectus or the perimuscular tissues surrounding
the inferior rectus.
Diplopia may be present initially after trauma but A B
may resolve as the neuropraxia and/or orbital edema Figs 1A and B: (A) This figure is showing trap door fracture
subsides. where fracture segment is hinged at one end; (B) This
A subclass of orbital fracture with entrapment is called figure is showing medial blowout fracture where fracture is
white-eye fracture in children. These patients need to extending to medial wall but not extending beyond inferior
be treated early. orbital nerve
 Orbital Floor Fracture 1101

Limitations exposing the anterior wall of maxilla up to the level of

Fractures extending lateral to infraorbital nerve or involv- infraorbital nerve (Fig. 3).
ing lamina papyracea are more difficult to repair endo- Care is taken to avoid excessive traction or trauma to
scopically and these require open approach. nerve. With the help of osteotome and Kerrison punch,
appropriate sized window is created in thin wall of maxilla
(Fig. 4).
PREOPERATIVE EVALUATION Lip is retracted and a cottonoid/patty soaked in 4%
• Short history of mode of injury should be taken lignocaine and adrenaline is placed in maxillary sinus for
• Ophthalmic evaluation should be undertaken to avoid decongestion of mucosa. Then the endoscope is intro-
any visual loss from optic neuropathy, retinal detach- duced to inspect the orbital floor. Any defect in orbital
ment or hyphema floor is analyzed for size, location, soft tissue prolapse
• Computed tomography (CT) scan orbit needs to be and entrapment. Any entrapped tissue is made free and is
done to see the extent of floor injury and accompany- reduced back to orbit with the help of freer elevator.
ing injuries. A cut of 1 mm is required. Prolapsed fat
and entrapment of muscle should be seen
• Head injury and spine injury should be ruled out.
Patient needs to be hemodynamically stable prior to
surgery.

SURGICAL STEPS
Repair is normally done in general anesthesia. Patient
is placed in supine position (head high position of
around 30°).
The forced duction test should be performed to deter-
mine ocular motility immediately after general anesthesia
is induced.
Two percent lignocaine with adrenaline is infiltrated
sublabially.
A 4 cm incision is made in gingivobuccal sulcus (Fig. 2),
Fig. 2: Gingivobuccal sulcus incision
ensuring adequate mucosal stump at the alveolar end, so
that suturing is convenient.
Incision is deepened through the periosteum to reach
the anterior wall of maxilla. The periosteum is elevated

Fig. 3: Periosteum elevated and anterior wall of maxilla Fig. 4: This figure is showing creation of window on
expose till the level of inferior orbital nerve anterior wall of maxilla
1102 Facial Plastics, Cosmetics and Reconstructive Surgery

Hinge Fracture Bone chip of anterior wall can be fixed again or kept
open. Wound is closed in layers by 3.0 vicryl.
Any hinge fracture after replacement of soft tissues to orbit Failure to repair the fracture endoscopically will neces-
is then allowed to snap back into a place maintaining the sitate an alternative approach—subciliary and transcon-
reduction. Excessive medial dissection is avoided as this juctival approach.
may destabilize the hinge and may require placement of
implant. Subciliary Approach

Medial Blowout Fracture Skin Incision

• Elevate the mucosa around defect and expose the edge. Two percent lignocaine with adrenaline is injected in
• Orbital content is reduced and all comminuted frag- lower lid. Few millimeters below the eye lashes, parallel
ments of bone are removed. to lid margin incision is made by No. 15 blade. The inci-
• Size of defect is assessed and suitable implant is trim­ sion is carried through the skin layer only. The underlying
med to size, which is 1 mm bigger than size of defect. orbicular muscle should become apparent immediately
Implant is inserted over the stable posterior edge and is below skin incision.
directed toward anterior edge with the help of freer eleva-
tor and suction implant (Fig. 5). During the manipulation, Dissection
constant check needs to be kept that implant at poste- Initial dissection is superficial to orbicularis for few
rior end is not shifted and remains at the same position. millimeters. The dissection is then deepened by dividing
Anterior edge and the posterior edge form the primary orbicularis oculi muscle. Raising skin-muscle flap and
area of support. the dissection plane is made between the muscle and the
Pulse test (gentle external pressure is applied at globe septum orbitale (Figs 6A to D).
and the pulsations are observed through the endoscope) Precaution must be taken that septum is not breached
is performed to see whether implant is stable. Forced so that prolapse of fat is prevented.
duction test is performed again to check any restriction of The suborbicular flap is extended downward till the ante-
movement. rior edge of the infraorbital rim is reached.

Precautions Periosteal Incision over the Infraorbital Rim

• Injuries to maxillary mucosa should be avoided The skin-muscle flap is retracted inferiorly over the ante-
• Injuries to infraorbital nerve should be avoided rior edge of the infraorbital rim along its whole horizontal
• No bony fragment is pushed into orbital cavity extent (Fig. 7).
• Any bone fragment or mucosa overhanging at area of A periosteum incision is made from anterior to infe-
maxillary ostium should be removed to prevent infection. rior orbital rim to avoid orbital septum damage which is
inserted on superior margin of inferior orbital rim.
Incision on septum can cause scarring, leading to
vertical shortening of the lid. Periosteal edge is marked
with silk on each side to identify the edge for suturing.
Identifying these structures otherwise would be difficult.

Subperiosteal Dissection of Orbit

Periosteal elevators are then used to strip the periosteum
from the underlying floor of orbit, and fracture site is iden-
tified. Fat, muscle is freed from defect and forced traction
test is done to check for any entrapment. Suitable size
implant of appropriate material (that can prevent muscle
adherence and give proper contour to floor) should be
used and placed on the posterior edge of defect. The other
Fig. 5: This figure is showing elevation of periosteum end of implant is placed on anterior orbital ridge. Implant
3–4 mm beyond the defect and placement of implant on is secured by inserting the screw on anterior orbital rim or
posterior edge and orbital rim by glue.
 Orbital Floor Fracture 1103

A B

C D
Figs 6A to D: (A) Subciliary incision extending from punctum to lateral canthus; (B) Skin and orbicularis oculi flap elevated
without injuring septum orbitale; (C) Skin and orbicularis oculi flap elevated till infraorbital rim; (D) Incision on periosteum
is taken to expose orbital floor

Closure
Closure is performed in two or three layers: (1) perios-
teum—the periosteum is redraped over the bony surfaces
and closed with resorbable interrupted sutures, (2) muscle
(optional) and (3) skin—the skin wound is closed with a
6.0 nonresorbable or fast-resorbing suture. Either running
or interrupted sutures can be used.
Care should be taken not to damage the:
• Palpebral anatomical structures
• Lacrimal drainage systems
• Ocular muscles
• Neural structures.
Fig. 7: Globe is retracted with malleable retractor applying Care should be given following the open treatment of
minimal pressure on globe to expose orbital floor orbital fractures.
1104 Facial Plastics, Cosmetics and Reconstructive Surgery

Evaluation of the patient’s vision is performed as Disadvantages

soon as they are out of anesthesia and then undertaken
at regular intervals until they are discharged from the • Restricted access
hospital. • Limited extension
• Greater degree of operative dexterity is required, if
Transconjunctival Approach complications have to be avoided.
Advantages Surgical Steps
• No scar seen Cornea protector is placed over the eye to protect cornea,
• Lower incidence of ectropion globe from instrument, retractor or drill. Traction sutures
• Less changes of lid shortening. are taken in lower lid and inferior conjunctival fornices for
retraction and eversion of lower lid.

Infiltration and Incision

Two percent lignocaine with adrenaline is infiltrated.
Needle is inserted between the conjunctiva and the tarsal
plate and subsequently inserted again through the skin
deep to the palpebral portion of the orbicularis oculi but
superficial to septum. Conjunctival incision below the
lower border of tarsus is taken on the medial aspect and in
line of punctum (Fig. 8).
For the incision, scissors, scalpels or electrocautery
can be used. Lower eyelid retractors are undermined
toward the inner angle of the lids (Fig. 9).
Fat compartment and septum are identified, and
Fig. 8: Conjunctival incision below the lower border dissection is carried out anterior to septum and posterior
of the tarsus to orbicularis oculi muscle (Fig. 10).

Fig. 9: Lower eyelid retractor is transacted and a dis- Fig. 10: This figure shows two incisions—first incision,
section plane is established in front of the orbital septum few millimeters below tarsal plate and second incision on
periosteum few millimeters anterior to rim
 Orbital Floor Fracture 1105

MODIFICATIONS / SUGGESTIONS
Surgeons use titanium implant as it is safe, with less chances
of infection and displacement of implant (when it is handled,
contoured and secured accurately). Surgeons secure the
implant either by placing a screw or by applying glue.

Titanium Meshes/Implant
Advantages
• Easy availability
• Good stability
• Can be well contoured
• Radio-opacity
• Spaces within the mesh to allow dissipation of fluids
• No donor site needed
Fig. 11: Orbital content is elevated with malleable copper • Tissue incorporation may occur.
retractor to expose orbital floor
Disadvantages
The dissection is carried out till infraorbital rim is • Expensive
reached (Fig. 11). Further steps are same as subciliary • Possibility of injury by sharp edges if not properly
incision. trimmed.

Wound Closure
Wound is closed in layers. First the periosteum over the
COMPLICATIONS
periorbital rim is closed and then conjunctival layers • Infraorbital paresthesia: This occurs due to stretching
are closed with 6.0 vicryl. The conjunctival flaps must be of nerve during retraction. It normally improves in
aligned accurately. 2–3 weeks
• Maxillary sinusitis: These complications may occur
Postoperative Positioning due to endoscopic repair
Keeping the patient’s head in an upright position, both • Eyelid malposition like entropion
preoperatively and postoperatively may significantly • Eye lid laxity
improve periorbital edema and pain. • Scleral show: These complications occur due to
subciliary approach. These conditions improve in
Nose-blowing 3–4 weeks
To prevent orbital emphysema, nose-blowing should be • Lagophthalmos: This occurs due to conjunctival
avoided for at least 10 days following orbital fracture repair. approach. It resolves eventually.

Wound Care
Remove sutures from skin after approximately 5 days, if
SPECIAL INSTRUMENTS (FIG. 12)
nonresorbable sutures have been used. Apply ice packs • Corneal shield: This is to protect cornea, globe from
(may be effective in a short-term to minimize edema). instrument, retractor or drill
Avoid sun exposure and tanning to skin incisions for • Copper malleable retractors of various sizes and shapes:
several months. These are used to retract the orbital globe away from
floor without exerting too much pressure on the globe
Clinical Follow-Up • Suitable implant
The patient needs to be examined and reassessed regularly. • Fine scissors for dissection
1106 Facial Plastics, Cosmetics and Reconstructive Surgery

• Fine tipped forceps

• Glue
• 1.5 mm × 6 mm screw and 1 mm drill bit to secure
implant at anterior orbital rim.

OTHER TREATMENTS AVAILABLE

• Antral packing: Antrum is packed with 3–6 meter of
ribbon gauge which is soaked in antibiotic and a lubri-
cant. It is kept in place for 3 weeks.
• Antral balloons: A special antral balloon is used prefer-
ably; if it’s not available then 30 mL Foley’s catheter can
be used.
Fig. 12: Copper malleable retractor on either side, titanium These procedures are blind procedures so do not
mesh of various shape and size and drill bit assure desired results.
 The Surgical Technique of Otoplasty i

Index
Page numbers followed by f refer to figure and t refer to table

A Aponeurosis of veil 1047 Bone

Appearance of grafting of alveolar clefts 981
Abbe-cross-lip flap 1066, 1066f blunt tip and alar retraction 923f holding forceps 1097
Abbe-Estlander flap 1068f nostrils 970f Broad nose 1022f
Ablative lanoline 1090 with saddle 1023f
fractional photothermolysis 829 Arch bar 1099 Brody’s classification 798
laser resurfacing 826 cutter 1099f Burn scars 807
Acanthoma 1031f insertion 1092, 1094f Burnt out rhinoscleroma 1027f
Acanthosis nigricans 799 Assessment of skin 888
Acne Atelosteogenesis 1045
pitting 805 Atrophic rhinitis 1027 C
rosacea 1026f Aufricht’s Calcium hydroxylapatite 878
scarring 805 elevator 900
scars 802f, 821f, 823f Campomelic dysplasia 1045
retractor 890
vulgaris and rosacea 799 Candida organisms 806
Augmentation
Acnetic skin 1032f Cantilever bone grafts for nose 981
of maxilla 981
Acquired shortness deformity 997 Carbon dioxide 827
rhinoplasty 886, 916, 997, 1007f
Actinic keratosis 799 laser 826
Autologous
Alar Carcinoma of
cartilage 938
base reduction 1009, 1011 fascia 928 lower lip 1069f
cartilage 966 tissue 917 middle third lower lip 1069f
flare reduction 1012 Avascular necrosis 1097 Cardiac arrhythmias 806
hooding reduction 1017 Azelaic acid 801 Carotid injury 1097
retractors 890 Cartilage crusher 940f
rim graft 995f Cartilaginous structures 882f
struts in rhinoplasty 993 B Cat paw retractors 1089
Alkayat-Bramley preauricular incision Caudal
Bandage strips 859f
1085 dislocated septum in child 1024f
Basal triangle fracture of
Allergic reactions 961 septum 888
Allograft 999 angle 1084f
parasymphysis 1083f deficiency 992
Alpha-hydroxy acid 797, 802 replacement graft 988f, 989
Altering tip rotation 906 Beta-hydroxy acid 803
Big amorphous nose 1023f Cavernous sinus thrombophlebitis 1028f
Alternative
Bilateral Cerebrospinal fluid 1075
method of intermaxillary fixation
cleft lip 966 Champy’s
1086
and palate 1049, 1051f, 1055f, line 1080f
way of fixing arch bar 1086
Androgen pathway 836f 1056f, 1057f of osteosynthesis 1079
Androgenetic alopecia 835 nasal deformity 966 principle of osteosynthesis 1080
Anesthesia 837, 845, 860 complete cleft lip 972, 978 Cheek retractor 1097, 1099f
toxicity 830 nasolabial flap 1070 Cheilorhinoplasty 1051, 1053, 1053f-1055f,
Anterior Binder’s syndrome 997, 1008f 1057f
facelift incision 870f Biweekly peel schedule for acne scars Chemical peels 797, 877
neck scar contracture 815f 803t Childhood trauma 997
wall of maxilla 1101f Blepharochalasis 853 Chin retractor 1089
 I-ii Atlas of Operative Otorhinolaryngology and Head & Neck Surgery (Vol. 3)

Chronic D Estlander flap 1067

diseases 1027 European collaboration on cranial facial
folliculitis 847 Dacryocystitis 1031f anomalies 1044
sinus disease 1032f Deep peel 799, 802 Excessive
Classification of Deformity over chin and scar of injury alar
hair loss 844 1092f flaring 1011
International confederation of plastic Degeneration of elastic network 797 hooding 1011
and reconstructive surgery 1048 Degree of donor scarring 842
Kernahan and Stark 1048, 1049f nasal obstruction 998 Exophthalmometry 855f
mandible fractures 1092 photoaging 801 Expanded
Cleft Delayed
hair bearing flaps 851
lip healing 961
scalp flaps 844
and palate 1044 purpura 830
Expander deflation 814
nose 997 Dentoalveolar fracture 1091, 1093f
Exposure of
palate muscles 1047f Dermatitis 832
fracture 1096f
Columella 966 Dermatochalasis 853
fragment 1079
flap elevation 897 Dermofat 928
Design of triple advancement scars 849
incision 897 External
Comminuted transposition flap 851f
Developmental deformities 1021 alar base reduction 1011
body fracture 1084f fixator 1099
fracture 1074, 1096 Diastrophic dysplasia 1045
Dislocation of nasal septum 1054f Eyelet method of fixation 1088f
of parasymphysis 1083f
Complete dissection of skin-muscle flap Disorderly arrangement of epidermis 797
Displaced fracture 1091
861f
Dissection of intercrural cartilage 1054f
F
Complex
angle and body fracture 1081 Donor Face lift incision 1077f
symphysis 1081 recipient tumescent 838f Facial
Complications of strip nerve injury 876, 1097
laser skin resurfacing 830 dissection 837, 838, 840f reconstruction 882f
harvest 837, 838, 839f scanning 1046f
peels 805
Dorsal scarring 806
septorhinoplasty 997
augmentation 909 Faciomaxillary fractures 1091
Computed tomography scan 1101
irregularities 1007 Fascia lata 1005f
Conchal cartilage 921
onlay graft 1004f Female alopecia 852
and skin 923f
Dysharmonic esthetic face 1027f Final upper blepharoplasty closure 859f
Condition of
nasal skin 998 Fitzpatrick classification 800, 800t
septal cartilage 998 E Fixation 1079
Condylar fracture 1081 failure 1090
Congenital Ectropion 806 techniques 1099
deformities 997, 1019, 1020 formation 830 Flap design 1067, 1068, 1070
melanocytic nevus 809f-812f Effluvium 842 Flat facial warts and milia 799
pigmented nevi 807 Elevation of Flattening of dermal-epidermal junction
poly deformity 1020f dorsal skin flap 1001 797
syphilis 997 mucoperichondrium 918f Follicular unit 834f, 848f
Contact dermatitis 830 Endoscopic repair of orbital floor fracture hair transplantation 836
Copper malleable retractor 1105, 1106f 1100 Fractional
Correction of Entire nasal pyramid 966 laser resurfacing 830t
deformity of lower alar cartilages 972f Ephedrine nasal drops 914 photothermolysis 828
malocclusion 981 Epidermal cell atypia 797 resurfacing 828
Costal cartilage 921 Erbium:yttrium-aluminum-garnet lasers Fracture of
Crushed cartilage-TPFL grafting 933 818, 827 angle 1082f
C-shape retractor 1089 Erich arch bar 1089 and ramus 1081
Cupid’s bow asymmetry 1061 Eruptive keratoacanthomas 830, 832 coronoid process 1082
Curvature of anterior mandible 1086f Erysipelas 1028f nasal complex 1027
Curved microforceps 850f Esthetic plate 1090
Cutis aplasia 807 rhinoplasty 1019 Freys elevator 1088f
Cyst formation 847 surgery 1042f Frontonasal dysplasia 997
 Index I-iii

Frontotemporal angle 845f Howarth L

Fungal diseases 1030f periosteal elevator 1097
Furlow velopharyngoplasty 1059f periosteum elevator 1099 Lacrimal drainage systems 1103
Hump reduction 899 Lactic acid 798
Hyaluronic acid 878 Lag screw technique 1099
G Hydroquinone 801 Lagophthalmos 1105
Gilmers method of fixation 1087f Hynes velopharyngoplasty 1058f Lambert-Eaton syndrome 864f
Gingivoalveoloplasty 1052 Hypertrophic Langerbeck right angle retractor 1089
Gingivobuccal sulcus incision 1101f scar and keloid 847 Larsen syndrome 1045
Glogau classification 800, 801 Laser resurfacing 877
scarring 800, 830
of photoaging 801t Lateral osteotomy 903
subepidermal healing 806
Glycolic acid 798, 799, 805f Laxity of skin 801
Hypertrophied masseter muscle 1027f
formulations 803 Left occipitoparietal scalp 809f
Hypertrophy of orbicularis muscle 853
Goldman tip 905 Length of nose 916
Hypoplastic maxilla 966
Graft Leprosy 997
harvest 989 Levator veli palatine 1047
material 1007 I Limitation of opening of mouth 1090
migration 890 Lip reconstruction 1064
Iatrogenic deformities 1024 Lipoid proteinosis 1026f
placement 1001
Inadequate muscle reconstruction 1061 Liposuction of neck 870f
and fixation 990
visibility 1007 Indications for Liquid nitrogen 798
Granulomatous disorders 997 endoscopic repair of orbital floor Local anesthesia 838f
Great auricular nerve injury 876 fracture 1100 Long
Greater palatine foramen 1047 hair transplant 844 deformed nose 1022f
laser resurfacing 818 wire twister 1099
orbital floor repair 1100 Loosening of screws 1090
H Inferior Low dose oral steroids 914
fat pads 863f Lower
Hair
orbital nerve 1101f eyelid
cycle 835f
blepharoplasty 859
follicle 834f Infraorbital paresthesia 1105
fat repositioning 863
texture 847 Insertion of tissue expanders 808
retractor 1104f
transplantation 834 Inspect internal nose 889
gingivobuccal
Hairline design 837 Intermaxillary fixation 1089
Hard palate 1047 incision 1098f
screw technique 1088, 1088f
Head and neck sulcus 1095f
Internal
reconstruction 808 lateral cartilages 888
alar base Ludwig classification 836f
tissue expansion 807 excision 1015f
Hemangiomas and vascular Lymphocytic infiltration 797
reduction 1012
malformations 807
fixation of faciomaxillary fractures
Hematoma 847, 875
Hemorrhage 1097 1099f M
Hemorrhagic diathesis 949t Isolated cleft palate 1045
Malposition of lower lateral cartilages 993
Hemostasis 858f Malunited fractures 1074
Hereditary lymphedema-distichiasis
1045
J Mandible fractures 1091
Marginal incisions 897
Herpes Jessner’s solution 799 Mark Rubin’s classification 798
simplex 800, 805 Joseph knife 931f Marking for flap 1070
virus 806, 831
zoster 1028f Massage of scar 1090
High blood pressure 960 K Mastoid elevator 1088f
Hinge fracture 1102 Maxillary
Homologous Karapandzic flap 1068 hypoplasia 1058, 1059f
costal cartilage 930, 938 reconstruction 1069f mandibular fixation 1092, 1095f, 1099
fascia 938 Keratoacanthomas 805 osteodistraction 1060f
tissue 930 Kernahan and Stark classification 1049f sinus 883f
Hooding of upper eyelid skin 853 Kojic acid 801f sinusitis 1105
 I-iv Atlas of Operative Otorhinolaryngology and Head & Neck Surgery (Vol. 3)

Medial Nitrogen plasma 827 Porcine collagen 878

blowout fracture 1102 Nonablative resurfacing 828 Posterior nasal spine 1047, 1048
osteotomy 902 Nonsyndromic cleft associated genes Postinflammatory hyperpigmentation
Medium deep depth peel 799 1045t 799
Melasma 799 Nonunion of fractures 1074 Post-septal abscess 1025f
Mental health disorders and elective Normal palatal muscles 1047f Post-submucosal resection
surgery 963 Norwood classification 836f, 845f columellar retraction 1025f
Metallic cheek retractor 1099 Nostril conformers 973 of septum 1024f
Method of Post-treatment erythema and crusting
inserting silicone 931 831f
maxillary mandibular fixation 1092 O Prefabricated flap elevation 815f
Micrognathia 917f Ocular muscles 1103 Premaxillary
Micromotor drill machine 1097 Open augmentation 989
Microthermal zones 830 book deformity 902 deficiency 991
Mild steroid cream 803 reduction 1074, 1082 Preparation of
Milia 806 and immobilization 1075 fascial tube 1005f
Millard’s rhinoseptoplasty 1061f skin 801
approach 1051 roof deformity 997 solution 802
technique 1053f, 1055f Operative techniques in mandible Pressure bandage 1090
Mini hole plates 1089, 1089f fractures 1074 Presurgical orthopedics 1048
Minor augmentation 1007 Orbital floor fracture 1100 Primary
Missile injuries 1074 Orthopedic nasoalveolar remodeling alopecia 834
Modified Killian incision 918f plate 1051f cheilorhinoplasty 967
Mohler’s technique 1054f Osteitis 1097 columellar elongation 1057f
Molluscum contagiosum lesions 1029f Osteocartilaginous structures 885f rhinoplasty 967, 970, 971
Mottled pigmentation 797 Osteomyelitis 1097 Prolonged erythema 806, 830
Multiple facial injuries 1074 Osteotomies 902, 955f Protusion of intraorbital fat 853
Muscles of Outer layer of skin 835f Pseudofolliculitis barbae 799
lip 1047 Over reduction of nasal hump 997 Pseudomonas
palate 1047 aeruginosa 831
organisms 806
P Ptosis 853
N Pulmonary emboli 962
Palatoplasty 1052f, 1053f
Nasal Papillary dermis 798
airway alterations 961
blockage 889
Parasymphysis 1096 R
fracture 1081, 1081f
deformity and vermillion notch 982f Pectoral branch of acromiothoracic artery Racial shortness deformity 997
dorsum 927f, 1001 1072f Radial artery 946f
fistulae 1057 Pectoralis Radiation keratoses 799
septal major myocutaneous flap 1070 Range of osteotomes 891
cartilage 944f myocutaneous flap 1073f Recall phenomenon 830, 833
perforation 961 Pedicled tubed expanded flap 813f Recent
septum 966 Periosteal facial X-ray therapy 800
perforation 885f elevator 1088 isotretinoin 800
tip 966 incision over infraorbital rim 1102 Reconstruction of
right deviation 884f Pharyngopalatine muscle 1047 lip defects 1065, 1066
vestibulitis 1028 Philtral-columellar points 970 of total lip defect 1068
Nasolabial Phytic acid peels 804 of upper lip forehead visor flap 1070
and nasofrontal angles 880f Pigmentary of vermilion defect 1065
flap 1068 alteration 799, 830, 832 plate 1089, 1089f
muscles 1053 disturbances 799 Recurrent carcinoma upper lip involving
outcomes 1061 Pixie ear deformity 876 entire lip 1071f
Nasomaxillary hypoplasia 997, 1008f Placement of bilateral spreader grafts 956f Reduced fracture 1097f
Needle holders 891 Plasma skin resurfacing 828 Reduction
Neural structures 1103 Polyethylene terephthalate 844 of fracture fragment 1079
Neuroma 847 Polymethylmethacrylate 878 rhinoplasty 886
 Index I-v

Reflection of mucoperiosteum flap 1088 Shortness of columella and alar cartilages Superior maxillary bone 882f
Removal of tissue expanders 808 diastasis 1061 Surgery of nose 960
Renal failure 806 Silicon nostril conformers 973f Surgical
Repair of unilateral complete cleft lip 967 Silicone 930, 938 management of crooked nose 941
Requirement technique
Skeletal corrections 981
for synthetic hair 844
Skewed nose 1021f in open rhinoplasty procedures
of follicles 845t
Skin 948
Resorcinol toxicity 805
Reticular dermis 798 cancer 962 of laser skin resurfacing 818
Retromandibular approach 1086, 1087f contour irregularities 962 Suture cutting scissors 891
Retroparotid approach 1085, 1085f discoloration 961 Symphysis 1096
Revision rhinoplasty 966 disorders 962 fracture 1081f
Rhinoplasty 882f, 960, 965, 981 excision 862f Synthetic hair grafting 844
surgery 960, 965 incision 1086, 1102 Syphilis 997
Rhinoscleroma noses 1030f lesions 1029f
infection 806
Rhinosporidiosis 1029
marking 897
Rocker deformity 902
muscle flap 861f T
necrosis 890
S pinch test 857f Temporomandibular joint 1074
sensation 961 Tensor veli palatine 1047
Saddle nose 1023f
sensitivity 961 Thick sebaceous skin 1026f
Salicylic acid 797, 803, 804
Saline nasal drops 914 swelling 961 Thoracoacromial vessels 815f
Sanvenero-Rosselli velopharyngoplasty tunnel over clavicle 1072 Tissue holding forceps 891
1058f Small tension nose 1020f Titanium meshes/implant 1105
Scalp 808 Smasectomy defect closure 873f Tongue depressor 1089, 1099
flaps 844, 849 Soft tissue Transbuccal trocar with cannula set 1097
laxity 838f Transconjunctival
corrections 981
reduction approach 1104
deficiency 1007
scar 1090
Solar incision 863f
surgery 844
contractures 807 elastosis 799 lower eyelid blepharoplasty 862
Scleral show 1105 lentigines 799 Transcutaneous lower eyelid surgery 860
Sebaceous nevus 807 Spreader grafts 908 Transparotid approach skin incision
Secondary SS wire cutter 1099 1085f
rhinoplasty 981 Stainless steel wire 1099 Traumatic
septorhinoplasty in cleft lip and palate Staphylococcus aureus 831 alopecia 834
982 deformities 1023
Status of columella and nasal tip 997
Sensitive skin 1032f
Stretch back phenomenon 849 Tretinoin peels 804
Septal
Subciliary Trichloroacetic acid 799, 802, 802f
cartilage 918
caudal dislocated nose 1022f approach 1102 Trimming
extension graft 923f incision 860f septal cartilage 921f
hematoma 890 Submental nerve compression 1091 silicone 931
perforation 890 Submucous resection 997 Tuberculosis 997
Septoplasty 895 Subperiosteal dissection of orbit 1102 Tutoplast processed fascia lata 930
Septorhinoplasty 887, 982f, 986f Subplatysmal flap elevation 1086 Types of
Septum 998, 1007 Substance abuse disorders 962 implants 807
Seroma 961
Superficial reduction 1074
Set of plates and screws with different
carcinoma of lip 1065f scalp reduction techniques 850f
shape and dimensions 1099
Setup of operating theater 890 erosions 830
fascia 924f
Severe depression 1000f
Sharp dissecting scissors 890 musculoaponeurotic system 1082
U
Shock 962 peel 799, 802 Ulnar nerve 946f
Short columellar deformity 1020f scarring 799 Unfavorable fracture 1091
 I-vi Atlas of Operative Otorhinolaryngology and Head & Neck Surgery (Vol. 3)

Unilateral V Wound
cleft lip 966 care 1105
and palate 1048, 1050f, 1055f closure 1077, 1086, 1105
Various submandibular incision 1077f
nasal deformity 966
Vertical splint fractures 1074 dehiscence 847
complete cleft lip 969, 974
Unnatural appearance of frontal hairline Vestibular web 966
849 Vibrissae trimming 895
Upper
X
and lower lid blepharoplasty 853
eyelid W Xanthelasma 799
X-linked mental retardation 1045
blepharoplasty 855
nevus 811f Wart 1029f
lateral cartilage 888
Use of
Widening of scars 849 Z
existing lacerations 1079 Wire twister 1099
septal cartilage for augmentation Wiring technique 1086 Z-plasty 982f
1003f Wooden sticks 849f Zygomatic arch 871f