Appendix: Surgical Techniques in Rhinoplasty

Appendix: Surgical Techniques in Rhinoplasty

Techniques in surgery can be seen as tools to help achieve a specific task. A tennis player's tools may be seen as his forehand and backhand, his net game and serve, and so on. These tools on their own are not necessarily enough, but rather the right combination of strokes or tools must be achieved in a particular situation.

While a surgeon must master a number of individual techniques for rhinoplasty, he must also have the judgment, skill and natural ability to choose the right techniques for each individual situation.
The different techniques and approaches used in rhinoplasty are detailed below with diagrams and photographs for demonstration purposes.

Taking down the hump:
Cartilage and bone make up the nasal hump. One approach for taking down the hump is described here, but there are several methods that can be used.

To create a guide to visualize the exact amount of hump to be removed, the surgeon may mark the skin of the nasal bridge when the patient is asleep but before local anesthesia is given. Though the amount of reduction is typically determined well before surgery, this provides another helpful guide for the reduction. The surgeon may also have in the operating room the photos of the imaging goal derived from computer imaging to use as another guide.

Dr. Becker's preferred approach is the en bloc ('in once piece') resection of the nasal hump. A scalpel is used for this method to incise the cartilage of the hump in order to create, as shown below, a 'joint' at the junction of the cartilage and bone.
As illustrated in the diagrams, the osteotome (bone knife) is situated at the bone-cartilage junction. The osteotome can easily cut through bone because it is extremely sharp. The osteotome advances through the bone in the desired path with a gentle tap-tap technique, then the bone-cartilage hump is removed en bloc, or in one piece.

The bone-cartilage hump that has been removed and the patient's nose are carefully examined by the surgeon in order to guide the next step which involves additional excision of small amounts of cartilage in order to fine tune the profile and filling or rasping of the bone in order to smooth it. More on rasping is shown below.

Rasping:
A surgical file or rasp is commonly used to reduce or smooth the bony hump. A powered rasp may be used by some surgeons, including Dr. Becker, in order to achieve more precise results. As awareness grows, we hope that more surgeons use the powered rasp. In fact, Dr. Becker has been credited with popularizing the use of powered instrumentation for rasping in rhinoplasty throughout the world.

Osteotomies:
Though not necessary in all rhinoplasties, osteotomies involve 'cutting' or 'breaking' the nasal bones. Osteotomies are usually required when reducing the nasal hump and are also often used to improve a twisted nose or narrow an overly wide nose.
Though osteotomies may involve several approaches, we have detailed one below:

For minimally traumatic osteotomies, Dr. Becker has designed small specialty osteotomies which are also available to other surgeons through MicroFrance Corporation, a subsidiary of Medtronic-Xomed. There are many advantages to these "Becker" osteotomies as research has shown that they are less traumatic than the larger, bulkier osteotomies and that less bruising and faster healing times typically result.

Spreader grafts:
Rectangular strips of cartilage known as spreader grafts are placed between the septum and the upper lateral cartilages.
Though fairly uncommon, cases requiring widening of the middle third can benefit from spreader grafts, as shows in this example.

In certain patients, spreader grafts can also provide additional support of the middle third of the nose. An example of that type of patient would be one with short nasal bones, long weak upper lateral cartilages, thin skin and a narrow nose. Another type of patient would be one who requires a large hump reduction and thus needs the additional support of the spreader grafts. An example is shown below:

Tip work:
Suture techniques:
Suture techniques: One reliable yet conservative way to make changes to the nasal tip is through the use of suture techniques. These can be used when refining a bulbous nasal tip or doing a tip elevation (projection and rotation).

Suture techniques are reliable and thus have become increasingly popular. It is believed that these techniques are relatively safe when performed by a competent surgeon because there is no resection of tissue.

Shown below is a patient who required suture techniques to address a bulbous tip:

This patient's nose had a droopy appearance so the tip was lifted (projected and rotated) using suture techniques:

As illustrated in the diagrams below, the nasal tip can be elevated and projected by applying sutures to the tip cartilages in a specific way. The sutures borrow or 'steal' cartilage from the side part of the cartilage (lateral crura) and redirect the cartilage so that it becomes part of the medial part of the cartilage (medial crura). As such, this technique is known by surgeons as the 'lateral crural steal'. The suture placement differs from the tip-refining sutures shown above.

Cephalic resection:
A resection of a portion of the tip cartilage can be undertaken to help achieve refinement or 'narrowing' of the nasal tip. This technique is known as 'cephalic resection' and it is another useful method for refining the bulbous tip.

Shown below is an example of a bulbous tip corrected with a cephalic resection:

It's important that surgeons are careful about the amount to take when performing a cephalic resection. More important is that surgeons take care with the amount to leave behind because it is crucial that too much not be taken. Each patient and the strength of their cartilages is different, though there are general guidelines regarding how much is too much. Very little if any cephalic resection should be undertaken in patients with thin, soft, weak cartilages.

Tip grafts:
Tip grafts: According to how the surgeon shapes and places a tip graft, these can be used to achieve several different effects. The patient's own cartilage, preferably taken from the nasal septum during septoplasty, typically comprise the tip graft. Tip grafts can be helpful in creating additional nasal tip refinement and in projecting the nose, lengthening the nose, or both. Revision rhinoplasty often incorporates tip grafts as well. The Rhinoplasty Photo Album contains a number of patients in which Dr. Becker used tip grafts.

Strut:
Surgeons often use a 'strut', which is a rectangular piece of cartilage placed between the medial crura of the tip cartilages, if additional support or strength is needed in the nasal tip. Additional strength to the tip and sometimes some amount of tip elevation (projection and rotation) can be achieved with a strut.

Plumping grafts:
'Plumping' grafts can be placed beneath the skin if the junction of the nose to the upper lip is 'acute' or retracted. Bits of the patient's own cartilage (taken from the nasal septum) are placed through an incision inside of the nose at the base of the naso-labial angle. An overly sharp angle there, often seen as an 'aging' nose, can be improved upon with this technique.

An example is shown below:

Base resection:
An alar base resection may be used to narrow a nose that is too wide at the bottom. This involves the removal of a portion of the nostril at the base of the nose. There are many ways in which this can be done, but we tend to believe that a conservative approach is best.

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