(1)
Klinik für Plastische Gesichtschirurgie, Marienhospital Stuttgart, Stuttgart, Germany
Keywords
Rhinoplasty documentationRhinoplasty diagramRhinoplasty imagingJack Gunter first introduced schematic illustrations for rhinoplasty in a specific software, “the Gunter Rhinoplasty Diagrams,” which gained worldwide acceptance for clarifying surgical procedures in rhinoplasty. A new approach was then developed by Gilbert Aiach by the creative use of detailed illustrations that he had personally drawn, depicting single and specific steps of the procedure. However, this tool, which explained his complex surgeries in an easy way, was again used almost exclusively by its author, since no correlated software was available.
In the meantime, more sophisticated techniques have been progressively developed. Denis Codazzi, from the team of Enrico Robotti in Bergamo, generated a very detailed new 3D imaging program, the “Bergamo 3D Rhinoplasty software,” which is currently in its first version. The project was partly funded from the revenues of the Bergamo Open Rhinoplasty biannual course and in equal part by the Sanvenero Rosselli Foundation of Professor Riccardo Mazzola in Milano. The objective is to have a software that is commercially available and easy to use and that includes in detail all the maneuvers performed during a rhinoplasty in a graphic format with easy interpretation. The purpose is both documenting what was specifically done in a single case (record keeping) and to simplify teaching and didactics for future cases. For example, two primary and two secondary cases are presented.
15.1 Case 1: Overprojected Dorsum with Bulbous Tip and Thin Skin (See Sect. 12.2.40)
A 39-year-old female patient was seen after previous rhinoplasty and an unsuccessful attempt to close a septal perforation with a severe plunged tip deformity. The anterior septum was largely missing. The dorsum was overprojected, and the nasal pyramid was very wide.
Using an open approach method, the perforation was closed with a four-flap technique. After harvesting the concha from the right side, a sandwich graft was placed and fixed to the overshortened caudal septum border, giving support to the tip. The bony dorsum was lowered by rasping, and then the nasal pyramid was straightened and narrowed by transcutaneous low-to-low lateral and transverse osteotomies.
The overprojected LLCs were corrected with the sliding or overlap technique. The overlay was 6 mm. The medial crura were fixed to the sandwich graft, and the domes were contoured with transdomal sutures. Spanning sutures and tip suspension sutures were placed, and an extended shield graft was fixed to the dome area.
At the end allogenic fascia lata grafts were tried but removed again because free diced cartilage gave a better result.
Later on function could be improved by inserting a Breathe implant (Karl Storz; Tuttlingen, Germany), to which the upper lateral cartilages were sutured (Figs. 15.1, 15.2, 15.3, 15.4, 15.5, 15.6, 15.7, 15.8, 15.9, 15.10, 15.11, 15.12, and 15.13).
Fig. 15.1
Lowering the dorsum
Fig. 15.2
Lowering the dorsum
Fig. 15.3
Osteotomies: paramedian, low to low lateral, and transverse; spreader flaps
Fig. 15.4
Osteotomies: paramedian, low to low lateral, and transverse; spreader flaps
Fig. 15.5
Cephalic trim
Fig. 15.6
Lateral sliding (lateral crural overlay)
Fig. 15.7
Double-layered conchal graft working as columellar strut
Fig. 15.8
Fixing the medial crura to the sandwich graft; transdomal sutures; tip suspension suture; transseptal mattress sutures = kilting sutures
Fig. 15.9
Fixing the medial crura to the sandwich graft; transdomal sutures; tip suspension suture; transseptal mattress sutures = kilting sutures
Fig. 15.10
Contouring the dorsum with free diced cartilage; extended shield graft
Fig. 15.11
Front view: Pre-op/post-op
Fig. 15.12
Lateral view: Pre-op/post-op
Fig. 15.13
Base view: Pre-op/post-op
15.2 Case 2: Overprojected, Hourglass-Shaped Narrow Dorsum
A 26-year-old patient presented with an overprojected hourglass-shaped narrow dorsum. In an open rhinoplasty approach, the dorsum was lowered with a component technique. After dissecting the extended parts of the ULCs from the undersurface of the bony pyramid, the septum was lowered with a straight scissors. The bony dorsum was then reduced with a chisel so that the excess could be removed in one piece. After transcutaneous low-to-low lateral and transverse osteotomies for narrowing the nasal bones, the leftover ULCs were invaginated and fixed as spreader flaps to the new dorsal septum. The weak lateral crura were strengthened by fold-under flap technique (slipping the cephalic portion under the lateral crus). After placing a columellar strut, the tip was contoured by transdomal sutures. For narrowing the tip, spanning sutures were applied, and the tip complex was fixed by tip suspension suture with a posterior sling to the dorsal septum. The depressor muscle was partially resected, a rim graft was placed on the left side for symmetry, and both soft triangles were augmented with allogenic fascia lata after using this kind of graft as a full-length graft for camouflaging the dorsum (Figs. 15.14, 15.15, 15.16, 15.17, 15.18, 15.19, 15.20, and 15.21).
