Excellent surgical outcomes in rhinoplasty derive from two interrelated factors: (1) a de-tailed understanding of the multiple nasal anatomic variants encountered, and (2) an ac quired knowledge of the ultimate long-term effects of surgical alterations of these anatomic components—the evolution of healing.
The first skill can be learned by detailed observation, enhanced by cadaver dissection, the second skill only by careful follow-up of operated patients over time.
The general concepts of nasal anatomy have been fundamentally clear for centuries, but only in recent decades have surgeons appreciated the finely detailed nuances of nasal anatomic dynamics that influence the surgical creation of a natural, pleasing rhinoplasty re sult, free of surgical stigmata. A detailed comprehension of nasal anatomy must therefore transcend knowledge of basic anatomic relationships. The surgeon must judge, by inspection and palpation, the character of the skin and subcutaneous tissues as they vary from nasal region to region, the influences of facial mimetic musculature, the relative strength and support of the cartilaginous and bony framework and substructure, and the limitations imposed by the interrelationship of all these structures upon the ultimate favorable result. As important as the evaluation of what can reasonably be accomplished during rhinoplasty is the acquired knowledge and skill to assess what cannot be accomplished.
This judgment is largely predicated on the critical analysis of each patient’s individual anatomy, coupled with technical refinements guided by experience, and generally requires years of personal surgical result evaluation to become keen.
In this dissection manual, Drs. Becker and Toriumi have created a unique study guide and cadaver dissection manual dedicated to guiding the learner in a disciplined manner. They admirably extend the tradition of the University of Illinois Department of Otolaryngology’s leadership in teaching anatomy and surgery in rhinoplasty. Cadaver dissection constitutes a privilege not available to all, and, as such, this precious material must be wisely and conservatively approached. Experience teaches that a disciplined, structured approach to dissection of the nose produces the beat educational outcome.
An important favorable development in contemporary rhinoplasty is the appropriate con cern for conservative and subtle anatomic changes that by definition derives from a preser vative attitude toward nasal tissues. Commonly, rather than excisional sacrifice of large segments of cartilage or bone, a philosophy of preservation and restoration of tissues is de veloping that precludes creation of unnecessary tissue voids which may heal and scar unpredictably. Wise surgeons recognize that even a larger nose, well balanced to the surrounding facial features, is always aesthetically preferable to a nose made over-small by radical surgery. Conservation surgery thereby further extends the surgeon’s control over the final surgical result, as an appropriate equilibrium between the corrected nasal skeleton and soft tissue covering is more reliably achieved. Conservative sculpture and volume reduction of the alar cartilages clearly produce more favorable results, generally avoiding major resections and vertical interruption of the intact residual strip of lateral and medial crus. Notching, pinching, afar cephalic retraction, over-rotation, and asymmetries are all almost entirely eliminated in long-term healing when this conservative philosophy is em braced. A further striking example of conservatism is the preservation of a strong, high pro -file in many patients, a distinct contrast to the dramatic retrousee profiles created in decades past by sacrifice of over-generous segments of nasal bony humps.
Finally, thoughtful nasal surgeons, through accurate anatomic diagnosis, discern which portions of the nasal anatomy are pleasing and satisfactory, striving to avoid disturbing these structures and areas when correcting (or gaining access to) anatomic components in need of correction. This philosophy further extends the surgeon’s favorable control over ul timate healing. Thoughtful cadaver dissection provides the learner with visual pathways to gain access to structures to be modified, while preserving normal tissues and relationships. Important tissue planes, vital in live surgery, can be appreciated best when viewed at leisure in the dissection laboratory.
This well-conceived work, properly employed, contributes substantially to shortening the steep learning curve characteristic of rhinoplasty.
M. Eugene Tard ‘ v, Jr., M.D., F.A.C.S.
Professor of Clinical Otolaryngology Director, Division of Facial Plastic and Reconstructive Surgery University of Illinois Medical Center Chicago , Illinois
Professor of Clinical Otolaryngology Indiana University School of Medicine