Rhinoplasty

-Intranasal and External approach-Rib cartilage, Conchal cartilage harvest

R4 이홍경

Classification of Surgical Terms

IncisionsTranscartilaginousIntercartilaginousMarginal

Approaches

DeliveryNondeliveryCartilage splittingRetrogradeExternal (open)

Techniques

Volume reduction with:Complete stripWeakened complete stripInterrupted strip

Approach• Endonasal app - delivery, nondelivery• External rhinoplasty app

Surgical approachIncision Endonasal app

Intercartilagenous IntracartilagenousMarginalRim incision

External nasal appSercer’s Goodman’s(inverted V-shaped)Stair stepJugo’sPadovan’s incision

Nondelivery Approaches When the anatomic situation requires conservative or

minimal tip refinement and rotation, a nondelivery (cartilage-splitting or retrograde-eversion) approach is preferred.

The majority of the lateral crus is left intact as a complete strip, with resection of only a few millimeters of the medial-cephalic portion of the lateral crus to effect refinement.

This operation is useful in many patients because it tends to mimic nature; it disturbs very little of the normal anatomy of the tip, and therefore consistently heals predictably, with symmetry and minimal scarring.

Endonasal app Nondelivery technique

Intracartilagenous incision

Simple Less scar formation, postoperative deformity Symmetry Op field problem 가벼운 정도의 비첨성형술에 유용 .

Intracartilaginous Incision-Surgical Technique This incision, called the transcartilaginous incision,

involves transecting the lateral crus of the lower lateral cartilage .

It entails making a curved incision shaped like a wing of a seagull at the cephalic location 4~6mm from the caudal border of the lateral crus of the lower lateral cartilage .

It is performed in full thickness, transecting all the layers of the cartilage.

The resection itself is usually made after a subcutaneous dissection and the cartilage is analyzed by raising the vestibular mucosa.

Intracartilaginous Incision- Application This incision is performed during the cartilage-splitting

approach. During this procedure, direct incision is made on the

cartilage only to the extent where the cephalic resection is possible.

Cartilage-splitting (transcartilaginous) nondelivery approach with preservation of a generous, complete strip used on patients demonstrating satisfactory preoperative projection and minimal interdomal distance who require only minimal tip-cartilage modeling. A, Single incision through vestibular skin only, made several millimeters cephalic to caudal margin of lower lateral cartilage. B, With scissors, vestibular skin is dissected free from a portion of the lower lateral cartilage to be removed. C, Mobilization of the cartilage to be excised for volume reduction of lateral crus; a portion of the dome and medial crus are included when indicated. D, Medial detachment of the lateral cartilage from the dome area. E, Volume reduction of the lower lateral cartilage completed with lateral detachment; a complete strip of intact residual alar cartilage remains. F, Final intended result: symmetric volume reduction and refinement of alar cartilages. A generous intact complete strip remains. G, Transcartilaginous incision repair with 5-0 chromic catgut.

Delivery Approaches As the tip anatomy becomes more abnormal or

asymmetric, more complex surgical techniques are gradually used.

In these patients, a delivery approach is recommended, allowing visual presentation of the alar cartilages as bipedicle chondrocutaneous flaps for further analysis and reconstruction.

Alternatively, an open or external approach may be used. Under direct vision, surgical modifications of varying

designs can then be executed symmetrically. Delivery approaches are indicated almost exclusively

when significant defatting or scar resection is required.

Delivery technique Marginal incision + intercartilagenous incision

• 시야가 좋아 좀더 복잡한 교정가능

• 변형 올 수 있고 , 제자리로 돌아갔을 때의 상태를 정확히 알 수 없다 .

Intercartilginous Incision-Surgical Technique Intercartilaginous incision is an incision made at the

limen vestibuli or the linkage between the upper lateral cartilage and the lower lateral cartilage.

Because there is a risk of damaging the nasal valve in performing this incision, the incision must be made at least 1~2mm away from the limen vestibule and towards the caudal.

During this procedure, usually the cartilage beneath the incision can be partially incised. In applying the incision, the alar rim should be retracted with a double hook and softly pulled upward as the incision is made laterally starting from the medial using a #15 blade.

Intercartilginous Incision-Surgical Technique During this process, the incision from the mucosa to the

cartilage should be performed in one motion. If the unilateral complete transfixion incision is planned,

the skin hook should be located at the medial crural footplate and pulled downward to prevent the formation of a visible scar.

Intercartilginous Incision-Application This incision technique is generally appropriate for

carrying out a retrograde approach by inducing eversion of the lateral crura during a tip surgery or performing surgery using the delivery approach by adding the marginal incision.

In addition, this incision is useful for accessing the osseocartilaginous vault when the incision is extended towards the medial direction to the anterior septal angle and connected to the upper part of the transfixion

incision.

Marginal Incision (Infracartilaginous Incision)-Surgical Technique

Marginal incision, also known as the infracartilaginous incision, is placed at the caudal border of the lower lateral cartilage.

This incision is quite unlike the rim incision, which is situated close to the nostril rim, and is rarely being used today.

It can be made from the lateral to the medial direction all at once.

However, if this incision is selected for the delivery approach, it is recommended that the incision be made in two stages.

Marginal Incision (Infracartilaginous Incision)-Surgical Technique

First, begin the procedure from the dome area to create a lateral limb of the incision.

Since the lateral crus is located further apart from the nostril rim the more it approaches the lateral border, make a lateral component along the caudal border of lateral crus, which is about 15mm apart from the nostril rim margin.

Because, however, in some patients the lateral crus is extremely close to the alar rim, this procedure needs to be performed with great circumspection with accompanying efforts to verify the caudal margin of the lateral crus.

Marginal Incision (Infracartilaginous Incision)-Surgical Technique

The next step involves creating a medial limb. This medial limb must envelop the caudal border of the

lower lateral cartilage (especially in the soft triangle area), spiraling downwards to reach all the way to the mid 1/3 point of the columella.

Marginal Incision (Infracartilaginous Incision)-Application

In delivery approach, this technique is used simultaneously with an intercartilaginous incision.

More than anything else, marginal incision is most commonly used in an open approach rhinoplasty.

In addition, during closed rhinoplasty, using a limited marginal incision to place the onlay graft or shield graft on the tip is also a commonly used technique.

Delivery approach to surgery of alar cartilages using intercartilaginous and marginal incisions. Alar cartilages are delivered as individual bipedicle chondrocutaneous flaps for inspection and sculpturing. A, Intercartilaginous incision created along and above the projecting rim of the upper lateral cartilage. B, Knife elevates skin and soft tissue from the cartilaginous pyramid and septal angle, dissecting in the immediate supraperichondrial plane. C, Curved incision created in the vestibular skin precisely at the caudal margin of lower lateral cartilage. D, Lateral crus and dome dissected free in preparation of delivery through the nostril for sculpturing refinement. E, Cartilage remodeling, conservative excision of a portion of the cephalic margin lateral crus. F, Maximal extent of cartilage excision necessary to preserve a strong, intact, complete strip (4-8 mm). 

Rim Incision This is an incision that is performed around the Alar rim. In Korea, this form of incision is frequently used during a

dorsal augmentation surgery using silicone. The inherent problem of this incision technique is that it

can cause damage to the soft triangle on the medial side while laterally the exposure of the lateral crus is limited.

비첩융기술 . Sheen 법 . A. 상부 비주연절개 (upper colymellar rim incision) 를 통해서 비익연골돔의 직선방과 직상방에 피하포케트를 마련한다 .B. 연골이식편을 방패 모양으로 만든다 .C. 연골이식편을 피하포케트에 넣어 이식한다 .

Open Approach In patients with cleft lip and nose deformities, severely

asymmetric tips, and some markedly overprojecting tips with eccentric anatomy, an open (external) approach to the tip may be helpful, particularly when the variant anatomy is not clear preoperatively.

Although more operative edema and scarring result from this approach, the advantages of precise direct-vision diagnosis, bimanual surgery, and extraordinary exposure render this approach useful in selected patients.

In the open approach, the soft tissues of the nose are elevated off the underlying cartilaginous and bony skeleton to reveal the exact anatomy responsible for the nasal shape.

Open Approach When markedly variant tip anatomy exists, or when

extensive middle vault reconstruction is necessary, the open approach facilitates favorable reconstruction.

Possible Indications for Open Approach Severely twisted nose

   Asymmetrical alar cartilages   Transdomal suturing   Tip graft suturing   Augmentation rhinoplasty   Cleft lip or nose complex deformities   Large septal perforation repair   Excision of nasal tumors   Severe tip overprojection/underprojection   Difficult revision rhinoplasty   Infantile nostrils   Teaching

Goodman’s incision, stair step incision 선호

비주 외측에서는 1.5~2mm 두께로 연장 , marginal incision 과 연결

Transcolumellar Incision and Marginal Incision Applicable to Open Rhinoplasty Approach

Transcolumellar Incision - Surgical Technique Transcolumellar incision, together with bilateral marginal

incision, is used in open rhinoplasty approach. Transcolumellar incision can be made in various shapes

but generally the inverted V shaped incision is popular. In addition, the stair-step shaped incision is also widely used.

However, for patients with a short columellar, there is a risk that one end of the stair-step incision will come too close to the soft triangle thereby resulting in an unsightly scar.

In such a case, it is desirable that the inverted V incision be used.

Transcolumellar Incision - Surgical Technique Both wings of the incision line of the inverted V shaped

transcolumellar incision are located just below the narrowest region of the columella and the inverted V is extended above it for up to 2mm.

In making a transcolumellar incision, first draw on the skin the desired shape of the transcolumellar incision.

The biggest problem in performing the transcolumellar incision is that the skin in this region is too thin and close to the cartilage.

Thus, during the incision, there are many instances where the medial crural cartilage is cut.

Transcolumellar Incision - Surgical Technique To avoid this from happening, what this author

recommends is that the medial limb of the marginal incision be first made on both sides and a space be created between the skin and the cartilage using an iris

scissors. This procedure is repeated in the same manner from

both sides using a #15 blade after verifying the approximate boundary of the caudal margin of the cartilage from around 2mm on the inside of the nostril rim.

Transcolumellar Incision - Surgical Technique The next step is locating a scissors in the space

obtained between the skin and the caudal margin of the cartilage and performing a transcolumellar incision using a #11 blade.

While performing this incision, care must be exercised to make sure that the skin is incised at a right angle instead of tilting if the trapdoor deformity is to be prevented.

If the above method is followed, damage to the cartilage, a common phenomenon during the transcolumellar incision, rarely if ever takes place.

Transcolumellar Incision - Surgical Technique Then, using a double hook to raise the skin flap, verify

the caudal margin of both sides of the alar cartilage while extending the incision laterally.

After the columellar skin flap is elevated, the columellar branch of the two superior labial arteries in front of the cartilage can become visible or, in case they are severed, bleeding frequently takes place.

In this case, a bipolar cautery with a fine tip should be used to control the bleeding.

비내접근 외비성형술 개방성 외비성형술

incision

dissection

exposure

analysis

hemostasis

technique

goal

operation time

edema

scar

revision rate

2ndary rhinoplasty

숨겨짐 , 유동적

제한적 분석

적다

제한적

어려움

일정함

표면미용

잛다

국소적

숨겨짐

> 5%

쉬움

눈에 보임 , 표준화

광범위

많다

완전한 분석

쉬움

유동적

이상적 해부학적 구조

길다

광범위

드러남

< 5%

어려움

Conchal cartilage Auricular cartilage is an excellent alternative to septal

cartilage in that it is easy to harvest with a relatively low morbidity.

Its curved and pliable nature can make this a more attractive option than septal cartilage in situations that require a curved contour.

Conchal cartilage harvest The chosen ear is usually opposite to the side that the

patient uses to talk on the telephone. After standard sterile procedures, subcutaneous

injections of lidocaine, 1%, with epinephrine, 1:100 000, were used along the conchal bowl.

A No. 15 scalpel blade or Beaver blade was used to create an incision just inside the helical bowl, leaving a 2- to 3-mm margin of outer rim of the conchal bowl.

This incision was carried down through the perichondrial layer.

The anterior perichondrium was then sharply dissected from the conchal cartilage until an adequate amount of cartilage was exposed.

Conchal cartilage harvest The chosen ear is usually opposite to the side that the

The maximal amount of cartilage was then harvested with the posterior perichondrium intact.

The incision was closed using a running 6-0 fast-absorbing gut suture.

Two dental rolls were secured with polypropylene mesh (2-0 Prolene; Ethicon, Cornelia, Georgia) to ensure reapproximation of the perichondrial flap.

The dental rolls were removed on postoperative days 5 to 7.

The patients were instructed to avoid sleeping on the operated ear.

Figure 1. Seagull wing technique.

Pedroza, F. et al. Arch Facial Plast Surg 2006;8:396-403

Copyright restrictions may apply.

Figure 1. Creation of the modified back-to-back autogenous conchal cartilage graft.

Koch, C. A. et al. Arch Facial Plast Surg 2011;13:20-25

Copyright restrictions may apply.

Rib cartilage Costal cartilage provides the advantages of a large

volume of graft material with excellent structural support. The disadvantages are warping and the potential donor

site morbidities, including pneumothorax, scar visibility, and chest wall deformity.

Rib grafts can be harvested as a composite osseocartilaginous segment.

Because of warping, the graft would be placed under the thicker supratip skin instead of the thinner soft tissue overlying the nasal dorsum.

If warping could be completely controlled, rib cartilage would be an ideal nasal graft.

Rib cartilage There are surgeons who do not use costal cartilage

because it is dissimilar in consistency to nasal tissue, it is difficult to contour, it is unpredictable in degree of absorption, and it tends to buckle.

In addition, there is the possibility of transplantation of a growth zone in younger patients that can lead to unpredictable overgrowth.

Rib cartilage harvest The incision is performed at the infra-mammary crease

in women to maximally camouflage the incision scar. With increasing experience the length of the incision has

been shortened up to 1.5 cm (2–2.5 cm on the average), making scars more inconspicuous.

Retracting, not incising the external oblique muscle and tightly approximating the muscles after harvesting the cartilage helps to relieve the pain after surgery.

A survey performed in our patients where the rib cartilage was harvested has shown minimal donor site pain and scar.