Rhinoplasty 27 2 2013

MASTERCLASS RHINOPLASTY

by Thai Facial Plastic Surgeons

FACIAL PLASTIC SURGERY

Edited by Choladhis Sinrachtanant, MD.

Foreword

The spiraling popularity of aesthetic surgery in this century has culminated in an exponential growth in cosmetic surgery industry in Thailand. Rhinoplasty (nasal surgery) is not an exception.

Thailand, as an important surgical hub in Asia, is globally acclaimed for its creditable surgeons and has always been a prime destination for medical tourism.

The ‘Master-class In Rhinoplasty’ was crafted and consolidated based on experience and various techniques shared by more than 20 reputable facial plastic surgeons from Thailand and all around South East Asia. It offers explicit operational instructions on Asian complexions which cannot be found in Western textbooks. It focuses mainly on dealing with Asians’ unique features rather than those of Caucasians.

This book, hopefully, will prove to be handy for the readers and aid Thailand in its aim to be one of the leading nations in aesthetic surgery when the Asian Economic Community (AEC) is opened in 2015.

Vichai Tienthavorn, MD. Vice Minister for Public Health and Former Permanent Secretary for Ministry of Public Health

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Preface

Thailand has become an even more popular destination for beauty surgery. It has observed a surge of patients from around the world seeking for the best talent in plastic surgery at optimal costs. The trend continues as Thai practice is solidly founded at the world’s best medical standards and keeps advancing with the new techniques.

Given this popularity internationally and domestically, many years ago, we began a project to contemplate the practice of the modern practice of aesthetic surgery in Thailand. We organise the Masterclass Rhinoplasty symposium aimed at gathering the best practitioners to share their expertise. We hope that the symposium participants gain true understanding on know-how so they, too, could preserve and pass on their valuable experience to later generations of doctors in this field. This book is part of the symposium to complete our determination.

This Masterclass Rhinoplasty book attempts to include high quality, and practical, up-to-date techniques by leading specialists. Nose surgery is one of the most common beauty enhancements.

Although with limited supports from the Thai Government, Thai doctors have been practicing intensely and leading advancement inthis field for more than 40 years. We selected leading practitioners to contribute to this symposium. Our plan was to equip dermatologists and dermatologic surgeons with knowledge of aesthetic surgery and be less influenced by regular malpractices.

This symposium should be an ever-evolving project in which we will be introducing entirely new topic in relation to aesthetic surgery in the following volume. Our commitment to you is to convey information that is practical, easy to use, and up-to-date. Enjoy continuous learning. Expand your knowledge, build your expertise, and learn from the masters.

Choladhis Sinrachtanant, MD. Editor President of Facial Plastic and Reconstructive Surgery Association of Thailand

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Acknowledgement

‘Handbook of Masterclass Rhinoplasty’ is a compilation of medical theories shared by a group of experts and specialists in Facial Plastic Surgery who have decades of experience under their belts. It introduces special surgical techniques with regard to rhinoplasty and is extremely comprehensive, easy to understand and can be applied readily in actual operations. The primary purpose of this book is to provide a step-by-step guideline with pedagogical approaches for new plastic surgeons who are pursuing this type of aesthetic procedure. This book should prove not only useful to these surgeons, but is also an asset to other medical specialists who are intrigued by this branch of plastic surgery. With this book, they should be able to strategically imbibe and truly understand the various concepts and eventually be able to apply them. The surgical procedures given this book, however, are most suitable for operations on Asian facial structures. The data collected are almost entirely based on the references from years of experimentations and discoveries from procedures done on South East Asian patients. It is noteworthy that Caucasian and Asian facial features (especially nasal structures) are significantly dissimilar and to apply theories of one to the other would not yield an optimal result.

In this regard, The Royal College of Otolaryngologists Head and Neck Surgeons of Thailand wishes to take this opportunity to express its gratitude to the incumbent President of Facial Plastic and Reconstructive Surgery Association of Thailand and his staff who have contributed and added their personal touches to this book as well as for their unwavering commitment to successfully organize this Masterclass Rhinoplasty Symposium. Hopefully, this book will also be an accurate reflection and indication of the promising abilities of Thai surgeons to emerge as internationally recognized medical aestheticians in the imminent future.

Pakdee Sanikorn, MD. President of The Royal College of Otolaryngologists Head and Neck Surgeons of Thailand

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Contents

1 Foreword

2 Preface

3 Acknowledgement

5 Applied Surgical Anatomy of Rhinoplasty

11 Nasal Physiology for Rhinoplasty 17 Anthropometric Analysis of Thai Nose 19 Preoperative Assessment of Rhinoplasty 22 Surgical Equipments in Rhinoplasty 25 Nasal Implants for Rhinoplasty 29 Painless Anesthesia for Rhinoplasty 35 Procedural Sedation for Outpatient Rhinoplasty 38 Surgical Technique of Alloplastic (Silicone) Augmented Rhinoplasty 44 Surgical Technique of Primary Fat Graft in Augmentation Rhinoplasty 54 Concept of Adipose Tissue Engineering and Adult Human Stem Cells 59 Long-Term Safety of Silicone-Implant Rhinoplasty in Asians 64 “Mantis Strut� Ideal for the Asian Nose 69 Augmentation Rhinoplasty with Silicone T- Technique a Sensible Approach for Saddle Nose with Well formed Tip 74 Common Complications of Rhinoplasty 78 Management of Complications of Augmentation Rhinoplasty 92 Rhinoplasty, Thin Tip Management with Autologous Tragal Perichondium 97 Refinement of The Nasal Tip 103 Autologous Fascia Lata Rhinoplasty 108 Alar Plasty 112 Management of Old Fracture Nose 117 Injection Rhinoplasty 120 Adverse Reactions to Injectable Nasal Soft Tissue Fillers 126 Thread Rhinoplasty 129 Cartilaginous Augmentation Rhinoplasty 132 Nasal Reconstruction 138 Revision Rhinoplasty 144 References

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Applied Surgical Anatomy of Rhinoplasty Samut Chongvisal

Nose is an essentially pyramidal structure that is the most projected part of face which in upright human and claimed to be the most recognized part of all face. Thorough and complete anatomical understanding of nose can help the surgeons to make a successful aesthetic rhinoplasty.

Alternation in nasal framework can make significant changes in facial appearance. External nasal surface anatomy and terminology.

Root (Radix)

Alar Groove

Nasolabial Fold

Supratip Tip Columella

Nasolabial Angle

Root (Radix)

Nasolabial Angle

: Nasion - Nasofrontal suture with nasofrontal angle. : Root of nose (radix) - The bone just below to the glabella between the eyes. : Rhinion - The junction between nasal bone and upper lateral cartilage. : Nasal tip - The most projection part of lower nose and supra-tip is just above the tip. : Glabella - The most proximal point between the eyebrows in midline. : Supratip area - Situated above the cephalic borders of the nasal tip. : Septal angle - The angle formed by the dorsal and caudal edge of the septal cartilage. : Alar groove - TThe junction of the alar and the cheek is known as the alar groove. : Nasolabial angle - The junction of the columella and the upper lip forming the nasolabial angle. : Nasofrontal angle - The angle formed at the junction of nose and forehead. : Tip columellar angle - Imaginary lines join the surface of columella with in to the tip. : Piriform aperture - The base of the nasal pyramid is pear-shaped opening in to the nasal fossa, it is bounded above by the lateral borders of the nasal bones and laterally by the frontal process of maxilla : Soft triangle of converse - At the base of the nose, vestibular skin is directly attached to the lower lateral cartilages.

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The nasal external muscles are encountered deep to the skin and consist of 4 principle groups: the elevators, the depressors, the compressors, and the dilators.

1. The elevators include the procerus and levator labii superioris alaeque nasi.

2. The depressors are made up of the alar nasalis and depressor septi nasi.

3. The compressors of the nose is the transverse nasalis

4. The dilators are the dilator naris anterior and posterior.

The muscles are interconnected by an aponeurosis termed the nasal superficial musculoaponeurotic system (SMAS).

Procerus m.

Nasal muscles

1 Transverse : lateral of piriform aperture pass superome dially and merges in aponeurotic area and same muscles. (opposite side) Transverse nasalis m.

2 Alar part : procerus, Levator labii superioris alaeque nasi Dilator naris Anomalous nasi m. anterior m. muscle : The muscle is attached to the upper frontal Levator labii superioris alaeque nasi m. process of the maxilla and inserts into the skin of the Compressor narium minor m. lateral part of the nostril and upper lip. It dilates the Alar nasalis m.

Depressor septi m. nostril and elevates the upper lip.

Orbicularis oris m.

Bony Anatomy

Superiorly, the paired nasal bones are attached to the frontal bone and connected to the lacrimal bones superolaterally. Inferolaterally, they are attached to the ascending processes of the maxilla.

Nasal Bone

Posterosuperiorly, the bony nasal septum is composed

of the perpendicular plate of the ethmoid. Posteroinferiorly

lies the vomer, which in part forms the choanal opening

into the nasopharynx. The floor consists of the premaxilla

and the palatine bones.

The lateral nasal walls contain 3 pairs each of small, thin, shell-like bones: the superior, middle, and inferior conchae, which form the bony framework of the turbinates. Lateral to these curved structures lies the medial wall of the maxillary sinus.

Inferior to the turbinates lies a space called a meatus, with names that correspond to the above turbinates, such as superior turbinate and superior meatus. The roof of the nose internally is formed by the cribriform plate of the ethmoid. Posteroinferior to this structure, sloping down at an angle, is the bony face of the sphenoid sinus.

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Cartilaginous Pyramid Nasal cartilages : hyaline cartilage 1. Lateral nasal cartilage 2. Greater alar cartilage(lower lateral cartilage) : medial and lateral crus 3. Minor alar cartilags 4. Accessory nasal cartilage

Nasal bone Upper lateral cartilage Alar cartilage

Alar margin

Two upper triangular-to-trapezoidal cartilages called the upper lateral cartilages, which are fused to the dorsal septum in the midline and attached to the bony margin of the pyriform aperture laterally by loose ligaments. The inferior ends of the upper lateral cartilages are free.

The internal area or angle formed by the septum and upper lateral cartilage constitutes the internal valve. Adjacent sesamoid cartilages may be found lateral to the upper lateral cartilages in the fibroareolar connective tissue. These are found variably.

Beneath the upper lateral cartilages lie the lower lateral cartilages.The paired lower lateral cartilages swing out from medial attachments to the caudal septum in the midline, called the medial crura, to an intermediate crus area. They finally flare out superolaterally as the lateral crura. These cartilages are frequently mobile.

Blood Supply and Lymphatics The arterial system is divided into (1) The internal carotid branches, namely the anterior and posterior ethmoid arteries from the ophthalmic artery (2) The external carotid branches, namely the sphenopalatine, greater palatine, superior labial and angular arteries.

The external nose is supplied by the facial artery, which becomes the angular artery coursing over the superomedial aspect of the nose. The sellar and dorsal regions of the nose are supplied by branches of the internal maxillary artery (infraorbital a.) and ophthalmic arteries (internal carotid system).

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Medial internal nasal branch of anterior ethmoidal a.

Supratrochlear n.

Septal branch of posterior enthmoidal a.

Dorsal nasal a.

Exiomal nasal branch of amierior ethmoid

Kiesselbach’s plexus

Infraorbital a.

Lateral nasal a.

Angular a.

Columellor branch Scptal branch

Superior labial a.

Posterior septal branch of sphenopalatine a.

Facial a.

Septea branch of superior labial a.

vasc. Nose

Internally, the lateral nasal wall is supplied by the sphenopalatine artery posteroinferiorly and by the anterior and posterior ethmoid arteries superiorly. The nasal septum also derives its blood supply from the sphenopalatine and the anterior and posterior ethmoid arteries with the added contribution of the superior labial artery (anteriorly) and the greater palatine artery (posteriorly).

The Kiesselbach’s plexus, or the Little’s area, represents a region in the anteroinferior one-third of the nasal septum, where all 3 of the chief blood supplies to the internal nose converge.

Veins follow the arterial pattern. They are significant for their direct communication with the cavernous sinus and for their lack of valves; these features potentiate the intracranial spread of infection. Lymphatic drainage from the superficial mucosa drains posteriorly to the retropharyngeal nodes and anteriorly to the upper deep cervical nodes and/or submandibular glands.

Nerves

The sensation of the nose is derived from the first 2 divisions of the trigeminal nerve.

The following outline effectively delineates the respective sensory distribution of the nose and face of the trigeminal nerve.

Ophthalmic division The ophthalmic division includes the following: • Lacrimal - Skin of lateral orbital area except lacrimal gland • Frontal - Skin of forehead and scalp, including the supraorbital (eyelid skin, forehead, scalp) and supratrochlear (medial eyelid, medial forehead) skin • Nasociliary - Skin of the nose and mucous membrane of anterior nasal cavity.

On a more detailed level, the nasociliary portion of the ophthalmic division includes the following: • Anterior ethmoid - Anterior half of nasal cavity: (1) internal - ethmoid and frontal sinuses and (2) external - nasal skin from rhinion to tip • Posterior ethmoid - Superior half of nasal cavity, namely the sphenoid and ethmoids • Intratrochlear - Medial eyelids, palpebral conjunctiva, nasion, and bony dorsum Maxillary division The maxillary division includes the following: • Maxillary • Infraorbital - External nares • Zygomatic 8

• • •

Superior posterior dental Superior anterior dental - Mediates sneeze reflex Sphenopalatine - Divides into lateral and septal branches and conveys sensation from posterior and central regions of the nasal cavity Infratrochiear nerve

Supratrochlear neve

External brach of anterior ethmoidai nerve Infraorbital nerve

nerve

Parasympathetic nerve supply The parasympathetic supply is derived from the greater superficial petrosal (GSP) branch of cranial nerve VII. The GSP joins the deep petrosal nerve (sympathetic supply), which comes from the carotid plexus to form the vidian nerve in the vidian canal. The vidian nerve travels through the pterygopalatine ganglion (which only the parasympathetic nerves synapse here) to the lacrimal gland and glands of the nose and palate via the maxillary division of the trigeminal nerve.

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Nasal Physiology for Rhinoplasty Perapun Jareoncharsri

Introduction Physiologic functions of the nose are respiration, filtration, humidification, heating,

protection and self-cleaning, olfaction, phonation and secondary sexual organ. Rhinoplastic surgeons should concern not only the aesthetic aspect of the nose but also the functional aspect as well. Thus, the in-depth understanding of the various physiological functions of the nose is of paramount important. The most important physiologic function is the regulation of the inhaled airflow and nasal airway resistance. If this function is disturbed by the patients’ anatomical abnormalities or by surgical procedures, the nasal obstructive symptoms will certainly be complained by patients. Other basic physiologic functions of the nose are discussed in greater details in various textbooks.

Nasal Airflow

On inspiration, air is inhaled into the nose by negative pressure (pressure gradient between external nares and nasopharynx), at the point 1.5-2 cm from the nasal ala (external valve) the air flow converges to pass through the nasal valve (internal valve), it then curves in a parabolic fashion (30 to 60 degrees from initial direction). The flow passes mainly through the middle meatus area above the inferior turbinate, lesser flow passes along the floor of nasal cavity and inferior meatus and the narrow superior part. The flow then bends into the nasopharynx, pharynx, larynx into the trachea. On expiration, the air flow entering the choana passing upward through the nasal cavity in similar reverse fashion and exits through the nostrils.

There are 2 types of nasal airflow, laminar and turbulent. The velocity and direction of laminar flow is rather constant and regular in contrast to the turbulent one which is an irregular current flow of varying in speed and direction. The increase turbulent flow may result in decreasing

Normal nasal airflow

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airflow efficiency and increasing nasal airway resistance (NAR), which the end result of the subjective symptom of nasal obstruction. The amount of nasal airflow depends on the minimal cross sectional area (MCA) of the nasal cavity and the pressure gradient between anterior nares and choana.

The nervous control of nasal mucosal vasculature and erectile tissues also plays an important role in regulation of nasal airflow and NAR. Normally, in the normal nose the airflow can be both laminar and turbulent, due to its complex structure.

During normal nasal breathing, the airflow is slow in velocity, laminar and smooth, which allows the inhaled air to pass over the nasal mucosa and that the basic functions of cleansing, humidifying and warming air can take places. Increase in respiratory rate or decrease in MCA of the nasal cavity, either by structural abnormalities or mucosal swelling, may result in increasing of the turbulent flow. The structures which play an important role in the regulation of airflow are the inferior turbinates and septal mucosa. The nasal mucosa contains the capacitance vessels, venous sinusoids, erectile and contractile tissues which can engorge and enlarge or constrict and shrinkage in size, under the control of autonomic nervous system. This mucosal component also determines the MCA and resistance to airflow of the nasal cavity.

Nasal Cycle

The periodic congestion/swelling and decongestion/shrinkage of nasal mucosa called “nasal cycle�, which occurs as an alternate cycles of 3-4 hours. This will result in increase NAR and decrease nasal airflow on swelling side, while on the contralateral side, the NAR decreases and nasal airflow increases. At the peak of nasal cycle, the different in nasal airflow between the two sides may be 20:80 ratio of total nasal airflow. Individual with normal healthy nose are not aware of the nasal cycle. Those who have structural abnormalities, such as deviated nasal septum (DNS) or nasal spur, may feel the sensation of nasal blockage which correspondence with the alternating nasal cycle.

Rhinoplastic surgeon should recognize the nasal cycle as a normal physiology of nose and differentiate it from other etiologies of nasal obstruction.

NAR and Nasal Obstruction

Total NAR is the summation of resistance to airflow at varying cross-sectional (diameters) areas of nasal cavity. The NAR also varies in individual, depending on nasal cycle, posture, exercise, nasal congestion, in both healthy and diseased states. Increase in NAR will result in the subjective sensation of nasal obstruction.

Nasal Structures and Their Effects on Nasal Airflow and NAR

Common sites of nose that may disturb the nasal airflow and NAR and produce nasal obstruction in rhinoplasty are nostrils/nasal ala/vestibule, nasal valve and nasal cavity proper.

Nostrils/Nasal Alar/Vestibule

The boundaries of nostril are alar lobule, soft tissue alar rim, nostril sill, columella, caudal septum and footplate of medial crus. These boundary structures form the shape and position of nostril. The nostril area can be called external valve or nostril valve, which has significant role in directing the nasal airflow and affecting the NAR. The direction of inspired nasal airflow is 12

controlled by the nostril shape and nasolabial angle together with the action of nasalis muscles, which is normally upward to the nasal valve as described above. If the rhinoplastic surgeons create the nose which is too long or dipping tip with an acute nasolabial angle, which can impinge on inspired airflow by directing it relatively high in the nose and induce the turbulent flow.

External nasal valve nostril valve In contrast, if the tip created is too much elevated (retrousse tip) with large nasolabial angle, the inspired airflow is directed too low in the nasal cavity and flatten.

Abnormalities of the boundary area of the nostril which result in disturbance of the nasal airflow should be evaluated in details before doing rhinoplasty for the excellent results of cosmetic and functional nose.

Long nose or dipping tip with an acute nasolabial angle, the inspired airflow is relatively high in the nose and turbulent flow occurs

Excessive elevated nose (retrousse tip) with large nasolabial angle, the inspired airflow is flatten and directed low in the nasal cavity 13

Nasal Valve or Internal Valve The nasal valve is dynamic complex structure, the narrowest part of upper airway, which is the most important in controlling the NAR. Nasal valve boundaries are lower edge of upper lateral cartilage, corresponding nasal septum and nasal floor of its side.

Endoscopic picture show nasal valve boundaries of right nose During normal inspiration the nasal valve become lightly close and will open or widen during quiet expiration, which is the action of controlling the shape, speed, direction and resistance of the inspired nasal airflow. So, nasal valve works as functional unit of flow-limiting segment which accounts for 50-60% of total NAR. Force nasal inspiratory effort does not increase nasal airflow, it may inversely resulted in collapse of the valve area or the flow-limiting segment.

Normal nasal valve angle is 10 -15 degree. The valve angle formed by the upper lateral cartilage and nasal septum. If the nasal valve is too narrow, the nasal obstruction will occur. Nasal obstruction from the valve area abnormality can be caused by deformities of nasal septum, upper lateral cartilage and hypertrophy of inferior turbinate head. Rhinoplastic procedures which involve the shortening of upper lateral cartilage, separating the septum from upper lateral cartilage, excessive removal of alar cartilage may result in postoperative scarring or web formation and ending with patient’s complaint of troubling nasal obstruction. So, it is essential for rhinoplastic surgeons to familiar with this nasal valve area and evaluating it before doing the surgery.

A

B

C

D

Nasal valve pathology Endoscopic pictures of patient with fixed nasal obstruction right nose after septorhinoplasty.

A=Scar and web formation at Rt.nasal valve area, B=Normal Lt.nasal valve area C= Lower edge of upper lateral cartilage is lifted up to open the Rt.nasal valve area D=Close up picture of C 14

A

B

C

D

Nasal valve pathology A, B=Endoscopic pictures of right and left nasal valve area show Lt.nasal valve obstruction C=Postoperative external surgery patient with right nasal obstruction D=Scar and web formation occluded the whole Rt.external and internal nasal valve area

Nasal Cavity Proper

Nasal cavity proper, the area from behind the nasal valve area to choana, is also frequent site of nasal obstruction. Common etiologic factors of nasal obstruction are nasal septal deviation (bony deviation), rhinosinusitis with and without nasal polyps, various type of rhinitis, sinonasal tumors, drug-induced, pregnancy and anxiety, etc.

Diagnosis of nasal obstruction includes history taking with details characteristics of nasal obstruction, examination of the external nose and nasal endoscopy, rhinomanometry, acoustic rhinometry and CT scan, which will not mention in details in this chapter.

Study of NAR and Nasal Airflow in Augmentation Rhinoplasty Augmentation rhinoplasty with silicone implant in low profile or saddle noses has the following effects: decreasing NAR, increasing NAF and improving subjective sensation of nasal breathing. Thus the augmentation rhinoplasty has beneficial effects not only on the aesthetic aspect but also on the function of the nose. Further studies with more number of patients are recommended.

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Anthropometric Analysis of Thai Nose Kritsada Kowitwibool

Rhinoplasty is one of the most popular procedures in facial plastic surgical operations.

Majority of Rhinoplasty in Asian is augmented rhinoplasty. Clearly understand in anatomical structures of Asian nose will create favorable outcomes from rhinoplasty procedure.

Nose is the structure located in central of face. It has relation to all aesthetic facial unit.

Minimal change in nasal profile create more changing in facial profile. Optimum proportion of nasal length is one-third of facial height and one-fifth of facial wide.

Race has more influence in nasal profiles. Caucasian nose has long nasal length, prominent nasal tip projection and narrow alar base.

Oriental and Thai nose profiles are low nasal bridge, low height, low tip projection bulbous nasal tip and broad alar bases. Short columella, narrow nasofacial angle and narrow nasolabial angle when compare with caucasian nose From Basal

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1

2

3

1. Leptorrhine nose : Caucasian nose, long columella and narrow alar base.

2. Mesorrhine nose : Asian nose, between Caucasian nose and African nose.

3. Platyrrhine nose : African nose, wide alar base and decrease nasal tip

Nasal Imagings from basal view classified oriental nose into three subgroups depend on nasal tip, alar shape and angle between tip and alar.

Type A: Bulbous nasal tip, Alar lobule rounding off, broad alar base and wide angle between tip and alar.

Type B: Prominent tip, less prominent alar lobule and narrow angle between tip and alar.

Type C: Less prominent alar, near linear line from tip to alar at basal view.

Clearly understanding in Asian nasal proportion, differentiation in race appearance will create favorable plans and outcomes of rhinoplasty.

Type A

Type B

Type C

South East Asian

Far East Asian

Middle East Asian

Nasal Imagings from basal view

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South Asian

Preoperative Assessment of Rhinoplasty Rak Tananuvat

Asian nose is an appreciation of ethnic beauty and recognition of the underlying need to maintain racial identity. Westernized nose was seemed to be the ideal for cosmetic concepts in the past due to westernized of the Asian country.

Harmony and balance are elements of beauty that are universal. Moreover, all of the surgical techniques that had been described and utilized can be modified in order to retain ethnic characteristics while modifying or softening some of the extreme ethnic differences that may be offsetting for some patients.

Measurement of the face will lead to standardize the rhinoplasty concept of Asian people.

Before rhinoplasty, Surgeons must evaluate aesthetic proportions in order to improve to better balance and harmonize a patient’s overall attractiveness.

Ideal nose The perception of beauty seems to be the most important, which cosmetic Surgeons need to know limitations in each patient. The harmonious and favorable facial features need define what makes an ideal shape for a female or male nose, but the ideal cannot always be boiled down to simple lines and numbers alone.

First evaluation; Assessment of the nasal skin

Topographic measurements are include Nasal length, columella length, nasal base, intercanthal distance which normally is 3.0-3.5 cm.

Some lines, numbers and measurements can be used as a guideline to the aesthetic ideal

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Reference points on the face Specific measurement on the surface of the face

Balancing face

Vertical balance of the face

Horizontal balance of the face

Frankfurt plane

Angles of the face

Nasofrontal angle

Nasal projection Relations of lips

Nasofacial angle

Nasomental angle

Relations of lips to nasomental line 20

Mentocervical angle

Nasolabial angle

Variation of Alar-columellar relation

Nostril shape can be round, elliptical or flat

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Surgical Equipments in Rhinoplasty Pakpoom Supiyaphun Woraya kattipattanapong

Freer Septum Elevator Right and Left Curved Guarded Chisels

Aufricht Nasal Retractor Nasal/Prosthesis Introducer

Metzenbaum Scissors

Clamp Bayonet Forceps

Chisel

Adson Forceps

Grasping Forceps

Mallet Scalpel Nasal Rasp Nasal Speculum Needle Holder Rigid Telescope

Single hook

Cottle Septum Elevator Double Hook

Suction

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There are many tools to use in rhinoplasty. The use of appropriate instruments is a prerequisite for performing a reliable operation. The surgeons should understand the functions of each tool and learn how to adeptly use each tool according to their functions.

1.Retractor The main advantage of these things are using for better view of surgical field.

2. Blade We usually use blade no. 15 for incision and no. 11 for shaping the silicone or implanted materials.

With blade handle number 3.

3. Forceps There are many kinds of forceps that you can choose depending on the tissue and area you handle including using clamp for grasping implant into the pocket.

4. Scissors To create sub-perichondrial and sub-periosteal plane by using metzenbaum and it easier to use curve point tip to create the pocket at nasal tip area.

5. Elevator Freer elevator for create the pocket by blunt dissection. Aufricht retractor use for elevate the pocket both close and open rhinoplasty and encourage for inserting the implant.

6. Osteotome Using for osteotome nasal bone, straight, left or right guarded for protecting the surrounding tissue. Bone file for bur the hump.

7. Suture set Basically the suture set are needle holder, forceps and suture scissor.

8. Suction Suction elevator is very useful to create the plane on bleeding field.

9. Endoscope When we want to see the field directly and clearly. (Endoscopic dissection plane for Rhinoplasty.)

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Nasal Implants of Rhinoplasty Siripornchai Supanakorn

In the past century all kinds of biological and non-biological materials were used for augmentation of the nasal dorsum and to correct tip deformities. Non-biological implants have a high risk of local infection and extrusion of the implants, compared to biological grafts.

In nasal surgery, there is a frequent need for structural augmentation to improve contour and respiration. Among the more common findings is a deficient osteocartilaginous dorsum; in this situation, augmentation with graft material is required to achieve a desirable result. Establishing a symmetric and smooth nasal dorsum that fulfills the criteria of adequate form and function remains a principle challenge during primary or secondary rhinoplasty.

Many autologous and alloplastic materials are currently available to the rhinoplasty surgeon, each of which carries a characteristic profile of relative advantages and limitations.

Although most rhinoplasty surgeons prefer autologous materials, the choice of material must be individualized to each patient.

The relatively thin skin overlying the nasal dorsum often fails to provide adequate camouflage for poorly contoured replacement tissue. Nasal augmentation has been performed using many different materials. Currently, the most commonly used implants consist of silicone, ePTFE and polyethylene.

Autologous graft augmentation

Many autologous have been used for nasal dorsal reconstruction such as septal cartilage, auricular conchal cartilage, costal cartilage, split calvarial bone, iliac crest bone and costal bone.

Although autologous materials are more resistant to infection than alloplasts, the possibility of resorption and various donor-site morbidities must be considered.

Autologous septal cartilage and auricular conchal cartilage are the most commonly selected graft materials in limited augmentation rhinoplasty. However, in graft depleted patients or patients with severely deficient dorsa, costal cartilage and bone, split calvarial bone, or iliac crest bone can be considered.

Autologous cartilage is contoured with ease while its resilience lends good support to the reconstruction. Infection of autologous cartilage grafts are rare, but resorption, displacement, curling, and sharp edges can develop overtime.

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Table 1 Advantages vs Disadvantages of autograft materials in augmentation rhinoplasty Graft Sources

Advantages

Disadvantages

Septal Cartilage

- Rigid - Easier to precisely shape - Straighter than auricular cartilage

In the posttraumatic or secondary rhinoplasty patient, septal cartilage is frequently defective, insufficient, or missing

Auricular Cartilage

- Easy to harvest - Donor site morbidity is low

More brittle nature, can be more difficult to carve than septal cartilage

Costal grafts

- Abundance of material for augmentation of the severely deficient dorsum - Graft contouring creates a boat-like configuration that blends with the adjacent nasal anatomy

- Associated with the donor site include pain, conspicuous scarring, risk of pneumothorax - Increased operating time if performed by a single surgeon - Need for a short hospitalization

Homograft Rib

- Irradiated homograft costal cartilage(IHCC) exhibits excellent tissue tolerance and good resistance to infection and extrusion - Reduced operative time - Elimination of donor site morbidity

Expensive

Bone

Iliac crest bone: Well tolerated

- Iliac crest bone: perioperative ambulatory morbidity, pain, and a potentially permanent contour deformity, fabrication of a dorsal ‘‘L’’ strut is difficult to achievement - Split calvarial bone: risk of dural tears, cerebral damage, intracranial hemorrhage, difficulty in carving and contouring the grafts and the potential for heterotopic resorption, scar alopecia

Split calvarial bone: Available within the same operative field

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Alloplastic graft augmentation

Alloplastic materials used in rhinoplasty have included Silicone (Silastic), Polyamide mesh (Supramid), Polyethylene tetraphthalate mesh (Mersilene), Expanded polytetrafluoroethylene (Gore-Tex), Polytetrafluoroethylene–aluminum oxide (Proplast), Porous polyethylene (Medpor) and Granular hydroxyapatite.

Table 2 Advantages vs Disadvantages of alloplastic materials in augmentation rhinoplasty Name

Advantages

Disadvantages

Silicone (Silastic)

- Little tissue reaction - Easy sculpting

- Feel like a foreign body - Thick fibrous capsule a nidus for bacterial infiltration, a barrier for antibiotic - Inflammation - Migration/misalignment - Exposure(most common L-shaped silicone implant) - Resorption of underlying bone - Abnormal skin color

Expanded polytetrafluoroethylene (Gore-Tex)

- Outstanding biocompatibility - Hydrophobic composition bacterial barrier - Microporous composition à prevent migration - Easily shaped - No resorption

- Displacement in the early postoperative - Visible externally (think skin)

Polytetrafluoroethylene–aluminum oxide (Proplast)

- Minimal migration (rapid host fibrous tissue ingrowth) - Flexible and easy to shape - Bone compatibility

- Infection - Extrusion - Propensity to fragment and collapse

27

Name Porous polyethylene (Medpor)

Advantages - Rapid ingrowth of vascularized tissue with collagen - Biocompatibility - Resistant to infection, resorption, extrusion, and deformation - Not visible

Disadvantages Stiff

unnatural feeling

Polyamide mesh (Supramid)

High incidence of resorption

Polyethylene tetraphthalate mesh (Mersilene)

- Bacterial colonization of the mesh - Extensive ďŹ broblast (a difficult to remove)

Granular hydroxyapatite

- Low infection - Low resorption and remoldeling

Requires rigid fixation

Conclusion

The reconstructive effort is thus influenced by the complex interplay of numerous variables including anatomy, availability of autologous graft material, prior surgical history, surgeon preference and experience, patient preference, and associated risks. Ultimately, an individualized treatment plan must be devised for each patient that offers an optimal opportunity for success.

The use of autologous tissue avoids the problem of bioincompatibility but sometimes fails to provide necessary volume to provide the size and shape. A more ideal substitute to replace deficient skeletal structure, particularly over the nasal dorsum, would be a neocartilagenous graft reproduced from one’s own cells that closely mimics the original skeletal contour. This cartilage implant has been synthesized through tissue engineering.

Silicone (Silastic)

My design by Chalerm Supakmontri 28

Painless Anesthesia for Rhinoplasty Kowit Pruegsanusak

Painless anesthesia is a feasible procedure for rhinoplasty. Success in anesthesia should be prepared since the very first visit and decide to have surgery. Process, steps of working, techniques of anesthesia and all questions should be simplified and clearly discussion with the patient. For a prolonged and difficult case who needs to have inhalation anesthesia, preoperative anesthetic consult should be done.

Proper local anesthesia infiltration provides painless procedure , correct surgical plane ballooning and reduced bleeding by epinephrine added in the solutions.

Most of rhinoplasty patients are ambulatory cases or walk in the day of surgery. Preoperative evaluation and medications for individual should be done by the surgeon or anestheologist.

Aspirin, vitamin E, garlic, ginseng and ginkgo biloba should be avoided 2 weeks before surgery to prevent prolonged bleeding and bruising.

Anesthesia can be divided to general and local anesthetic. The type of anesthesia depends on type of surgery, preference of patient and doctor. Most patients prefer to know nothing during surgery but local anesthesia with or without conscious sedation is most commonly used in Thailand. General anesthesia with inhalation technique is performed in patient with excessive fear, severe case of nose deformity, nasal reconstruction and necessary for costal cartilage harvesting.

Severe pain usually occurs during local infiltration of local anesthetic agent, due to its property of acidity. Preparing the patient with oral medications 30- 60 minutes and/or intravenous anesthesia 2-3 minutes before local infiltration to prevent unexpected severe pain should be considered. This balanced technique will reduced the dose of each medications, but with synergistic action, then reduced the side effects of each medications.

The medications used in my practice during the recent year with good satisfaction and well co-operation from the patients are as the followings: 1. Oral premedications 30-60 min before surgery: 2tabs of paracetamol 325-500 mg + etoricoxib (Arcoxia ) 1 tab (60-90 mg) or celecoxib (Celebrex) 400mg + midazolam 7.5-15mg + dicloxacillin 500 mg.

The oral premedications are intended to reduce anxiety and pain together with antibiotic prophylaxis.

29

2. Intravenous anesthesia 2-3 mins. before local infiltration: Option A: ketamine 0.2-0.3 mg/kg Patients wt. 50 kg : 10-20 mg = 0.2-0.3 mL of 50 mg/mL (Figure 1A) Option B: fentanyl 0.5-1 microgram/kg Patient wt. 50 kg : 25-50 micrograms N.B. Step 1+2 may be replaced by midazolam 1-2 mg + fentanyl 40-50 mg IV. (Figure 1B)

1A

1B

1A, Ketamine 0.2-0.3 mL is used intravenously 2-3min before local infiltration or 1B, another popular duo: midazolam 1-2 mg + fentanyl 40-50 micrograms

Ketamine is an intravenous sedation with mild pain-killing and amnesia effect that produces minimal cardiovascular and respiratory function instability but emergence of transient delirium, hallucination, excitement, fear, vivid dreaming and euphoria may occur during the first hour with the incidence of 10-30%. The side effect could be reduced by oral premedication or coadministration of benzodiazepines such as midazolam or diazepam and lower ketamine to the subanesthetic dose (0.2-0.3 mg/kg).

The dose of midazolam should be titrated individually with 1-1.5 mg increment because of wide variation in response to midazolam. Patient with oral or IV midazolam must not drive back home himself due to abrupt somnolence could occur anytime, unlike the short acting effect of fentanyl and propofol. Anyway, I never use propofol in my private clinic because of requiring of closed monitoring of vital signs due to its reduction on vascular resistance and marked reduction of blood pressure and respiration may occur. Fentanyl is an effective pain-killing with minimal sedation after it was metabolized. Both propofol and fentanyl are most popular intravenous sedation and induction nowadays, but both of them are allowed to be used in hospital only.

3. Local infiltration 10-15 min before incision: Option A: 1% lidocaine with epinephrine 1:100000 duration 0.5-2 hr (1-4 hr with epinephrine).

Option B: 0.25% bupivacaine with epinephrine 1:200000 for longer duration up to 4 hr Option C: 2% lidocaine with epinephrine 1:200000 Option D: 1% lidocaine with epinephrine 1:100000 + 0.5% bupivacaine with epinephrine 1:200000 Total dose of local anesthetic agent in rhinoplastic surgery is usually far from toxic dose. The maximum volume per 50 kg body weight of the most common use local anesthetic agents is showed in table 1.

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Table 1 Safe dose of lidocaine and bupivacaine

Generic name

Duration (hr)

Maximum dose

Maximum volume with BW 50 kg

1%Lidocaine

rapid, immediate

0.5-2

3.0 mg/kg

15.0 mL

1%Lidocaine with epi.

same

2-3

7.0 mg/kg

35.0 mL

2%Lidocaine

rapid with better diffusion into nerve

0.5-2

3.0 mg/kg

7.5 mL

2%Lidocaine with epi.

same

2-3

7.0 mg/kg

17.5 mL

0.25%Bupivacaine

slow 2-10

2-4

2.0 mg/kg

20.0mL

0.25%Bupivacaine with epi. same

4-6

2.5 mg/kg

25.0mL

0.5%Bupivacaine

same

2-4

2.0 mg/kg

8.5 mL

0.5%Bupivacaine with epi.

same

4-6

2.5 mg/kg

12.5mL

Generic name

Both lidocaine and bupivacaine are amides. They are stable in solution and metabolized in the liver. Local anesthetics act by causing a reversible conduction block in the nerve. By adding vasoconstrictor (epinephrine), the duration of block increases and local anesthetics toxicity decreases. Bupivacaine is four times more potent than lidocaine, then 0.25% bupivacaine is equipotent with 1% lidocaine. It binds tightly to tissues and thus has a long duration of action with up to 24 hours in some cases. With higher concentration, the duration of block will longer.

When the skin and subcutaneous is infiltrated, the action is almost immediate, owning to small unmyelinated nerve fibers being rapidly penetrated by local anesthetics.

Side effects of during local infiltration is usually mild. It may be the effect of lidocaine or epinephrine. Severe side effects such as anaphylaxis, CNS irritability, vagovagal reflex and CVS depression are rare, but it should be concerned and early management of the problems be solved or the patient will turn comatose. The signs and symptoms of lidocaine toxicity will progress from central nervous system, pulmonary depression and cardiopulmonary arrest.

Essential medications and resuscitative instruments such as adrenaline, antihistamine, atropine, benzodiazepine, O2 and endotracheal tube should be ready for this rare complications. Patient selection and thoroughly history taking of anesthetic allergy, blood pressure instability, heart disease, psychological instability are important. Systemic reactions and treatments showing in table2

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table 2 : Systemic reactions and treatments Symptoms and signs

Managements

Vagovagal reflex

Hyperventilation, nausea, hypotension, bradycardia

Reassure, Trenlenlenburg, Atropine 0.4-0.6mg IV for bradycardia Ephedrine 12.5-25 mg IV for hypotension

Epinephrine

Palpitation, hypertension, tremor, angina, fibrillation, cardiac arrest

Reassure, waiting, usually better within minutes, Propranolol or Phentolamine IV

Anaphylactic reaction

Peripheral vasodilation,urticaria, tachycardia, bronchospasm, angioedema

Epinephrine1:1000 0.3 mL SC, antihistamine

CNS toxicity

Circumoral paresthesia, euphoria, restlessness, dizziness, blurred vision, confusion, excitement, seizures

O2 Diazepam 5-10 mg IV

Pulmonary toxicity

Respiratory depression

Respiratory support: intubation, positive pressure ventilation

Cardiopulmonary toxicity

Cardiopulmonary arrest, coma

CPR, ACLS

During waiting for action of IV anesthesia, the patient’s nostril, facial skin should be cleaned with antiseptics and marking is drawed from mid nasal tip up to mid nasal nasion.

Horizontal lines should be drawed between medial canthus at level of nasion.

Marking before local infiltration, the upper most line in at the level of nasion (upper pupillary line)

32

The local infiltration is start 0.5 cm. below nasal tip projection with needle 25 gauge*1 ½ inches and penetrates deep into just between nasal tip subcutaneous layer and cartilage. After 1mL of local anesthetic agent was infiltrated at the tip, the needle is advanced and another 1.5mL was evenly pushed along the mid dorsum closed to the cartilaginous and bony dorsum (figure 3A-B). The needle was drawned back and changed the direction point down to the subnasale keeping between the medial crus using another 0.5mL( figure 3C). The next point is at mid upper dorsum at the level of medial canthus with no more than 0.5mL is needed and then changes to infiltrate through the border of lower lateral cartilage (LLC) into the plane between LLC and subcutaneous layer in both sides, using 0.5mL each sides. Total volume of lidocaine usually does not exceed 5 mL, then is much below the toxic dose of lidocaine. Less volume may be used to avoid distorting of nasal columella, especially infiltration into membranous septum. For patient with lateral nasal bone osteotomy, infiltration at both lateral nasal bone is done through piriform aperture at the plane of closed to nasal bone both mucosal and subcutaneous sides. Patient with combined septoplasty and taking cartilage graft for nasal tip reconstruction, should have preinfiltration packing in the nasal cavity with 4%lidocaine + epinephrine 1:1000 ( 5 mL:1 mmL).

The local infiltration is in the subperichondrial plane bilaterally with multiple points. Pressure should be applied at the nasal dorsum to reduce soft tissue swelling from the anesthetic agent, then more accurate evaluation and intraoperative silicone shaving could be done.

the direction from the nasal tip and B point of entry : 0.5 cm below nasal tip projection.

infiltration of columella and lateral nasal area

33

local pressure is applied to the infiltration area to reduced tissue swelling.

Summary

Proper local anesthetics infiltration combined with premedication and IV sedation is usually adequate and safe for most rhinoplatic surgery. However, essential medications should be prompted in cases with side effect and toxicity.

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Procedural Sedation for Outpatient Rhinoplasty Jaturong Jongsatitpaiboon

Procedural sedation is a technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardio restpiratory function.

Over the last decade, trend of facial cosmetic surgery has increased in all countries. The agents that use for sedation, analgesia, or both may be needed for these procedures. The practitioners have to understand the efficacy and safe administration of these agents. All of sedative and analgesic agents can introduce an independent risk factor for morbidity and mortality. So the American Society of Anesthesiologists (ASA) has developed the practice guidelines for non-anesthesiologists who provide sedation and analgesia. For more information, the practitioners can see from Guidelines for Office-Based Anesthesia, a statement on the Qualifications of Anesthesia Providers in the Office-Based Setting, and Practice Guidelines for Sedation and Analgesia by non-anesthesiologists.

There are available drugs that provide procedural sedation. Midazolam, a short-acting benzodiazepine with or without an opioid analgesic is commonly selected for procedural sedation.

But these combinations will increase the risk of oxygen desaturation and cardiorespiratory complications. So the practitioners should only be used in the presence of oxygen, suction and the ability to airway management and resuscitation. Evidence to support the use of other sedatives (e.g.) etomidate, propofol for procedural sedation is also emerging in the literature.

Etomidate is gaining popularity because it has a very reliable onset of action and has minimal hemodynamic effects. Ketamine may be made patients not be able to speak or respond purposefully to verbal commands. This agent provides a level of sedation but lacks both respiratory depression and major cardiac depression. The pharmacodynamic of mentioned drugs are described below.

35

KETAMINE

Ketamine is a noncompetitive N-Methyl-D-Aspartate receptor (NMDAR) antagonist that has a wide range of effects including analgesia, anesthesia, dysphoric reaction, elevated blood pressure, and bronchodilation. Ketamine primarily use for the induction and maintenance of general anesthesia, usually in combination with other sedative. Ketamine is absorbable via intravenous, intramuscular, oral, and topical routes due to both its water and lipid solubilities.

Bioavailability through the oral, intramuscularly, intranasally, sublingually and rectally are 17-20%, 93%, 25-50%, 30%, and 30% respectively. Peak plasma concentrations are reached within a minute intravenously, 5–15 minutes intramuscularly, and 30 minutes orally. Onset of action for intravenous (IV) administration of ketamine is within 1 minute, and duration of action lasts about 10-15 minutes. The context sensitive half life after administration is roughly 45 minutes.

If administered intramuscularly (IM), the onset of action is observed in 3-5 minutes, and duration of procedural conditions lasts about 20-30 minutes. It does not affect pharyngeal-laryngeal reflexes and, thus, allows a patent airway as well as spontaneous respiration to maintain intact.

It is a unique anesthetic that is fast acting and the least breathing suppression. It may cause of dysphoric reaction, tachycardia and mild increases in blood pressure. So it is not typically used as a primary anesthetic. However, these can be prevented by a benzodiazepine effect.

The proper dose is 0.5-1 mg/kg intravenously or 3-5 mg/kg intramuscularly. Because ketamine is a potent anesthetic so it should only be used in the presence of oxygen, suction and the ability to manage the airway when upper airway obstruction is occurred.

Ketamine may be used in small doses (0.1–0.5 mg/kg) as a local anesthetic, It may also be used as an intravenous co-analgesic with opiates to manage otherwise intractable pain. At these doses, the psychotropic side effects are less apparent and well managed with benzodiazepines.

Ketamine may increase the effects of other sedatives, including benzodiazepines, barbiturates, opiates/opioids, anesthetics, and alcoholic beverages. So the pratitioners should be careful when use a large dose and combine with other sedatives but it maybe good for combination with a small dose.

MIDAZOLAM

Midazolam is a short-acting drug in the benzodiazepine that is most commonly used for procedural sedation, since it produces a faster onset of sedation, more complete amnesia, less pain on injection, and improved awakening. It can be administered intramuscularly, intravenously, intrathecally, intranasally, buccally, or orally. It possesses profoundly potent anxiolytic, amnestic, hypnotic and sedative properties. The drug is also used for treatment of acute seizures, moderate to severe insomnia, and for inducing sedation. The amnesia that occurs from midazolam is an anterograde amnesia that is useful for premedication before surgery to inhibit unpleasant memories and amnesia before medical procedures. Intravenous midazolam is indicated for procedural sedation (often in combination with an opioid, such as fentanyl), for preoperative sedation, for the induction of general anesthesia, and for sedation of ventilated patients in critical care units.

Midazolam require special precaution if used in the elderly. They are more sensitive to the pharmacological effects of benzodiazepines, metabolize them more slowly, and are more prone to adverse effects, including drowsiness, amnesia (especially anterograde amnesia), ataxia, hangover effects, confusion and falls.

36

PROPOFOL

Propofol is an ultra short-acting, intravenously administered hypnotic agent. It uses for procedural sedation and induction and maintenance of general anesthesia. It has largely replaced sodium thiopental for induction of anesthesia because recovery from propofol is more rapid and no any sequelaes. Propofol is not considered an analgesic, so opioids such as fentanyl may be combined with propofol to alleviate pain. Furthermore propofol also induces a euphoric state, which maybe a benefit to use for the surgical team.

Propofol is very poorly soluble in water and is solubilized in milky while suspension of soybean oil, glycerol and egg lecithin. It maybe cause of pain when injected into a more distal smaller caliber vein. The pain can be relieved by administration 20-30 mg of intravenous lidocaine before injection it. Onset of action is very rapid with peak affect seen at 90 - 100 seconds. Duration of action is dose dependant and ranges from 5-10 minutes after bolus administration.

Serious clinical effects of propofol include apnea, loss of airway reflexs and hypotension.

When use with other sedatives or narcotics, cardiac output can be significantly reduced and apnea can be presented so the practitioners should only be used in the presence of oxygen, suction and the ability to airway management and resuscitation.

ETOMIDATE

Etomidate is an immidazole derivative that has an ultra–short-acting sedative hypnotic used for anesthesia. It produces rapid induction without histamine release and with minimal cardiovascular and respiratory effects. It has no analgesic properties. Onset of action is 5-30 seconds with peak action at 1 minute and duration is about 2-10 minutes depending on the dose. Like propofol, etomidate is insoluble in water and is therefore solubilized in propylene glycol. So there is also a high incidence of pain on injection and nausea and vomiting associated with bolus administration.

37

Surgical Technique of Alloplastic (Silicone) Augmented Rhinoplasty Pakpoom Supiyaphun

Implant Style

Silicon implant augmentation is generally considered to provide the best aesthetic results in Asians1 There are several debates concerning which shape of implant can achieve the best aesthetic results. There are two general shapes of nasal implants: I-shaped2 and L-shaped3.

Classic I-shaped implants augment mostly the dorsum4. Surgeons who currently use them usually perform a concomitant tip-plasty to increase tip projection. Some I-shaped implants also have a tip extension4. These implants are placed subperiosteally on the nasal dorsum and act as cantilever grafts to augment the dorsum2 and support tip projection. However, these implants are relatively soft and are generally thought to provide less support for the tip than do L-shaped implants as a columellar extension is absent. Cartilage grafting over the implant tip can also be used to provide more tip projection. Because I-shaped implants are thought to have a propensity to slide inferiorly, cartilage grafting of the tip might also provide more tissue padding and prevent extrusion through the nasal tip.

L - shape silicone

I - shape silicone

38

The L-shaped implant provides both dorsum and tip augmentation3. The columellar extension provides support for tip projection and can also provide volume when there is little columellar show. Critics find that the tip projection is excessive because of this columellar extension, provides an unnatural look, and favors implant extrusion4. It is therefore critical to shorten the columellar part of the implant before insetting. Other surgeons prefer to place an ear cartilage graft over the implant tip to better control the tip shape and infralobule fullness. L-shaped implants appear to be the most commonly used implant shape5,6,7.

L- shape silicone

The L-shaped implant should be placed subperiosteally.

Surgical steps 1. fastidious intranasal aseptic preparation 2. measure and estimate the size of the silicone prosthesis 3. field block local anesthesia 4. carve the prosthesis in to short-leg “L� shape 5. perform rim incision 6. identify and elevate lower lateral cartilage from the vestibular skin.

7. partial skeletonize the lower lateral cartilage beginning lateral to the dome lateralward to as far as 1/2 - 2/3 of lateral crural length, preserving the medial subcutaneous attachment and remove alar subcutaneous fat whenever the nasal tip is round and bulbous 8. divide the medial crus at the junction of the middle and medial crus 9. divide the dome in cases where the nasal tip is broad, a piece of cartilage may be removed if it is extremely broad and hard 10. repeat step 4-8 in another side of the nose 11. develop midline subperiosteal pocket at the nasal bone in continuity with subcutaneous pocket anterior to upper lateral cartilage and subcartilaginous pocket beneath middle crura 12. develop intermedial-crural pocket for L-shaped prosthesis 13. division of depressor septi muscle 14. remove supratip fat lobule whenever a supratip doming appearance exists, particularly when compensatory carving of the prosthesis does not correct the problem 15. insert the carved prosthesis into the developed pocket with its tip beneath divided middle crura 16. close wound with non- absorbable sutures.

17. do compressive taping externally without intranasal packing.

39

Follow-up is scheduled 5 days after surgery for stitches removal and every 1-3 months in the first year and every 1-2 year thereafter, either by office visit or phone call. The results were evaluated by level of patients satisfaction, pre-and postoperative photos, short and long-term complications. Level of satisfaction are graded into 3 groups, i.e., not- satisfied, moderatelysatisfied and highly-satisfied.

Incision line

Dissection

Soft tissues of the nose are then separated from the underlying structure to create the appropriate space for nose implant projecting the nasal tip and increase the height of the nose.

Dissection plane is under subcutaneous and muscles, above cartilage from nasal tip to osteocartilaginous junction (Rhinion) then plane downward deep to subperiosteal plane.

dissection to create space for implant at infratip area.

dissection to create space for implant, dissection subcutaneous above cartilage.

dissection plane turn downward at Rhinion. (Osteocartilaginous junction), dissection subperiosteal plane

(Courtesy of Dr.Choladhis S.)

40

(Courtesy of Dr.Choladhis S.)

Implant insertion

After appropriate created space for nose implant. Insertion of implant was done and adjust for projecting the nasal tip and increase the dorsum height of the nose.

Prepare for Prosthesis insertion

Prosthesis insertion

Skin closure Skin is closed with a 5-0 vicryl suture.

Then hypoallergenic paper tape is applied to the nose.

Skin closure with vicryl 5-0

Paper tape is applied to the nose.

41

Pre & post-operative picture of silicone 42

43

Surgical Technique of Primary Fat Graft in Augmentation Rhinoplasty Choladhis Sinrachtanant

Augmentation rhinoplasty has been one of the most popular procedures in the oriental people, especially in South East Asia and Far East Asia where many people need to augment small and saddle noses. Augmentation rhinoplasty has a long history and has been of interest in South East and Far East Asia. Three dimensional procedure is fully appreciated. One of the major points is mostly opposite of the needs of Western rhinoplasty. Rhinoplasty for Caucasians is mostly used to reduce the size of a large nose. For Asian, it is mostly used to augment a small nose.

Indications and Preoperative Evaluation

When considering what type of implant one will be used for a particular patient and situation, several considerations must be made. Biological implants or Alloplastic prosthesis in augmentation rhinoplasty must be specifically selected for each individual patient. The following criteria need to be considered for the patient’s evaluation.

(1) Skin and subcutaneous tissue thickening of dorsum and tip (2) History of previous nasal operation and complication of previous rhinoplasty (3) Scar & fibrosis formation in postoperative rhinoplasty (4) History of granulomatous lesion (Silicone, Paraffin injection) (5) Contour of nose, and face reading (6) Aesthetic purposes

44

Operative Technique (Lobular Fat Graft) (1) Inject 2% Xylocaine (Lidocaine) with Adrenalin 1: 80,000, 3 ml at the columella, nasal vestibule, tip, bridge, and root of nose.

(2) Make a 1 cm incision at the right nasal vestibule, 2-3 mm posterior to the rim of the anterior nare.

Create a pocket by dissection of the columella, tip, bridge, and root to elevate of the subcutaneous space (Supra SMAS technique)

Insert lobular fat lobule in the pocket; each fat lobule measuring 0.5 cm x 0.5 cm x 0.5 cm

Close the surgical wound with suture 4-0 or 5-0 catgut suture, using 1-3 stitches

45

Before

After

primary lobular fat graft

Before

After

primary lobular fat graft 46

Fat Injection Technique (Micro Lobular Fat Graft)

With this technique, the fat graft can be transferred by utilization of the Fat Injection Technique where an 18G needle or specially blunted cannula (Goldman Cannula) is used. The most important and critical aspect of this method lies in the preparation of the micro fat lobule.

The standard method is to utilize liposuction and centrifugation to obtain a micro lobule of fat.

With this method, the harvested fat stem cell (MSC) CD 105 averages 5% concentration.

In our preparation the fat is harvested in lumps from the belly or thigh. The lumps of mass fat tissue are then cut multiple times until they reach a small lobular size and can be passed through a18G needle or 18G blunt cannula. The advantage of this preparation is the increase in the percentage of the fat stem cell CD105 of more than 10%, with the fat survival rate significantly better than the liposuction method.

The steps in preparation of the micro lobular fat injection are demonstrated as follows:

Â

1. Fat harvested from the belly or thigh

2. Fat lumps cut into multiple small pieces

Â

micro lobular fat

47

Micro lobular fat filled in a syringe

18 G blunt cannula

SMAS

SMAS

Method of injection – A syringe with 18G needle or cannula is inserted at the base of the nose and micro fat lobules deposited

Before

After

Microlobular fat lnjection 48

Before

After

Microlobular fat lnjection

Before

After

Microlobular fat lnjection 49

Histopathology of fat graft

Adipose tissue implant has been found to be suitable for the thin skin at the dorsum of the nose. Tissue samples of the fat graft were taken 2 months and 6 months following the transplant and the study shows living cell fibrosis, infiltration of lymphocytes and larged lipid histiocytes:

Adipose tissue graft taken 2 months after transplant show living fat cell with some fibrous tissue formation.

Sample taken 6 Months following Adipose tissue transplant shows various sizes of fat cells and more fibrosis.

50

Stepwise Augmentation Rhinoplasty (Double or Two Steps Rhinoplasty) In cases where the patient has “thin� skin and soft tissue of nasal dorsum and nasal tip the Stepwise Augmentation rhinoplasty (Double or two step Rhinoplasty) has been found to be a useful operation to increase the skin thickness; after which insertion of a thin piece of silicone under the fat tissue can be undertaken.

The procedure is as follows: Step I Perform augmentation rhinoplasty using abdominal fat graft Step II After 3 months, the remaining fat will have stabilized and the second step of augmentation rhinoplasty can be performed with thin silicone prosthesis, inserted under the fat graft.

Before step 1 fat graft

After step 1 fat graft

After step 2 insert thin silicone prosthesis under fat graft

51

Before step 1 fat graft

After step 2 insert thin silicone prosthesis under fat graft

Before step 1 fat graft

After step 1 fat graft

After step 2 Stepwise byfat graft and ear cartilage graft at nasal tip

52

Before

After

Septal perforation corrected by stepwise with fat graft and ear cartilage graft for tip support

Summary Augmentation Rhinoplasty is a minor operation and has been most popular in South East Asia & Far East Asia. Indications for augmentation rhinoplasty are for cosmetics purposes as well as for correction of congenital defects, trauma, postoperative tumor removal, granuloma.

The materials for implantation and grafts are (1) autologous graft (2) homologous graft (3) xenograft and (4) alloplastic graft of which the autologous graft is the most ideal.

53

Concept of Adipose Tissue Engineering and Adult Human Stem Cells Somyos Kunachak Palapong Chayangsu

Autologous fat transplantation/grafting is a common procedure for soft tissue reconstruction with less donor site morbidity. The main significant disadvantage is an unpredictable degree of resorption. Thanks for the advantage of technology and knowledge in tissue engineering and regenerative medicine, adipose tissue engineering using stem cells is more reliable and predictable.

Although embryonic stem cells can be differentiated into all cell lineages but it is not ideal because 1. increased chance of teratoma 2. difficulty in controlling the differentiation pathways.

Hence, adult human stem cell application and tissue engineering become more popular in generating functional fatty tissue, as stem cells can self-renew and become the source of regenerating adipocytes.

Recent studies have shown that tissue-specific stem cells can generate cells of different types, depending on the stimulus—this process called “stem cell plasticity� that comprise of re-differentiation, dedifferentiation, trans-differentiation, and possibly cell fusion

Mesenehymal stem cell

tion entia differ ion ntiat iffere de-d diff eren tiati on de-d iffer enti atio n

tiation Adipocyte differen progennitor cell de-differentiation

Mature adipocytes

re-differentiation differentiation

de-differentiation

Other mesenehymal progennitor cell

54

Other mature adipocytes, chondrocytes, myocytes, etc

Tissue engineering techniques can be divided into two categories: 1. Cell transplantation approach (ex vivo stem cell manipulation) a) In situ adipogenesis: for smaller-volume defects b) De novo adipogenesis: better for larger-volume defects (with 3D scaffolds) 2. Cell homing approach (uses endogenous stem cells)

The advantages of this approach (employs only endogenous host cells, without cell

manipulation) are reduces the probability of infection and eliminates the possibility of rejection

Cell Transplantation Technique In situ adipogenesis Treatment of smaller soft tissue defects

Exposure to adipogenic differentiation medium

Mesenchymal stem cells

Progenitor cells encapsulated in injectablematrices Adipogenic progenitor cells

In vivo implantation for the restoration of larger soft tissue defects

Growth factors in microspheres

Adipogenic progenitor cells seeded in preformed scaffolds (micro channeled) with growth factor microspheres

MSCs can be exposed to the adipogenic medium to differentiate into adipose progenitor cells.

These adipose progenitor cells can be either encapsulated in injectable matrices for the treatment of smaller soft tissue defects or added to performed scaffolds for the restoration of lager defects.

Cell Homing Technique Encapsulated growth factors in microspheres

In vivo implantation

Growth factors microspheres incorporated in scaffold

Proliferation and differentiation of progenitor cells into mature adipocyte

Neovascularization of the construct

Migration of endogenous (host) progenitor cells into the construct

Three essential steps in de novo adipogenesis using the cell homing technique 1. Neovascularization 2. Migration and concentration of preadipocytes 3. Differentiation of these cells into mature adipocytes 55

Basic requirement for successful adipose tissue engineering 1. Stem cells source 2. Scaffolds and matrix 3. Growth factor 1. Stem cells source: Mesenchymal Stem Cells (MSCs) MSCs can be isolated from fat, bone, bone marrow, pancreas, placenta, and umbilical cord.

The two most widely studied MSCs for the production of adipose tissue are bone marrow–derived stem cells (BMSCs) and adipose-derived stem cells (ADSCs).

Stem cells are characterized by ability to self-renew and differentiate along multiple lineage pathways.

Ideal stem cells for regenerative medicine applications should meet the following criteria 1. Can be found abundant quantities (millions to billions of cells) 2. Can be harvested with a minimally invasive procedure 3. Can be differentiated along multiple cell lineage pathways in a regulatable and reproducible manner 4. Can be safely and effectively transplanted to either an autologous and allogenic host 5. Can be manufactured in accordance with current Good Manufacturing Practice guideline Perfect stem cells source that fulfill all these criteria is “adipose tissue”.

2. Scaffolds and matrix Tissue-specific scaffolds and signaling systems are essential to differentiate stem cells into the required cells and use them effectively to construct three-dimensional (3D) tissues.

Ideal scaffolds or matrix 1. Attachment site for the stem cells 2. Signal to initiate the regeneration process 3. Space for the appropriate extracellular matrix 4. Capacity to integrate newly engineered tissue with the host tissue In addition, suitable scaffolds should be biocompatible, biodegradable, and porous to provide space for tissue growth and nutrient exchange.

The current biomaterials used for adipose tissue engineering: - Type I collagen scaffolds (best for adipose-tissue-like construct) - Collagenous microbeads - Hyaluronic acid based spongy scaffolds - Placental decellular matrix (PDM) and cross-linked hyaluronan (XLHA) scaffolds - Injectable poly lactic-co-glycolic acid (PLGA) spheres - Silk fibroin-chitosan scaffold 3. Growth factor The growth factors played role in adipose tissue engineering by - Induction of angiogenesis (stabilized long-term 3D construct) - Induction of differentiation (ADSCs can differentiate into a variety of lineages, depending on the inducing stimuli and specific growth factors) The current possible biomolecules used for adipose tissue engineering

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Type of Biomolecules

Properties

Fibroblast growth factor-2 (FGF-2)

Promotes chondrogenic and inhibits ostcogenic differentiation

Platelet-derived growth factor (PDGF)-AB

Proliferation potential on human ADSCs and human dermal fibroblasts

Transforming growth factor (TGF)-beta 1

Proliferation potential on human ADSCs and human dermal fibroblasts

Vascular endothelial growth factor (VEGF)

Improves implant biocompatibility Promotes capillary formation in adipose stem cells containing tubular scaffolds

Granulocyte/macrophage colony stimulating factor (GCSF)

Angiogenesis-related cytokine secreted by ADSCs

Stromal-derived factorl alpha

Angiogenesis-related cytokine secreted by ADSCs

Hepatocyte growth factor

Angiogenesis-related cytokine secreted by ADSCs

liposuction (cell havest)

implantation of construct

growth factors hormones

stem cell isolation differentiation

scaffold seeding

expansion cell banking

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The free fat injection with adipose-derived stem cells termed cell-assisted lipotransfer (CAL) play an important role in maintaining the volume of the injected fat tissue. This could become an alternative to soft tissue augmentation surgery, including soft tissue augmentation rhinoplasty.

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Long–Term Safety of Silicone-Implant Rhinoplasty in Asians Somyos Kunachak

Introduction

Phenotypic variations among various ethnic groups in different parts of the world are well recognized, the nose is no exception. On the face, the nose is the most prominent structure, and is among the organs of most concern from an esthetic point of view.

Southeast Asians have typical global low-profile noses, with short, broad and flat nasal bone, a broad round or bulbous tip with inadequate projection, short columella, round or horizontal nostril, acute nasolabial angle, and thick covering skin. All these characteristics unfortunately are limiting factors which may preclude an optimal result in rhinoplasty. The majority of cases require global augmentation, in which the easiest and less invasive way is to use biocompatible implant. The purpose of this study is to present some surgical tips which believed to effect the long-term safety in augmentation rhinoplasty using silicone implant.

Materials and methods

The operation is an ambulatory procedure performed under local anesthesia using 1% lidocaine with 1:200,000 adrenaline.

Results Ninety nine percent of the patients were satisfied with the results, 2215 cases (96.7%) were in the highly-satisfied group, 55 cases (2.4%) in the moderately-satisfied group and 20 cases (0.9%) in the unsatisfied group. All cases in the unsatisfied group were undergone revision.

The complaints in the latter group were 10 (0.4%) due to too high nasal root, 6 (0.3%) deviation of nasal tip, and 4 (0.2%) intranasal exposure of the part of the prosthesis associated with recurrent infection. Most of these cases were encountered in the early years, reflecting the learning curve.

After revision, all the patients did well, except for 2 cases in which permanent removal of the prostheses were requested by the patients for peace of mind not related to complication.

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Discussion

As reported in the literature, various implant materials have been employed for nasal augmentation, i.e., bone graft1, cartilage2, dermis3, fat4, Avatine5, silicone fluid, Teflon6, Supramid7, Proplast8, and silicone rubber9,10,11,12, expanded polytetrafluoroethylene (Gore-Tex), high-density polyethylene(Medpor), polyethylene terephthalate(Dracon)13. Bone and costal cartilage are subjected to some degree of resorption and require additional incision for donor site.

Autogenous cartilage albeit save, no report of extrusion but not without complications. These included infection (1.5-5%), graft migration (1-12.5%), resorption(0.5-5%), warping (2.5-5%)13.

Homologous irradiated cartilage is also useful though deem to have slightly more complications than the autologous counterpart. These included infection (0.87-7.4%), displacement (0.3-5.9%), warping (1-14.8%), exposure (3.6%)13. Tutoplast-processed homologous cartilage reported to have even a higher resorption rates of 7.4-17% and warping of 9%13. Septal cartilage, though very useful and less likely to resorb, may be insufficient to augment a severely flat nose.

Auricular cartilage (concha) is not enough for large volume augmentation and not appropriate for tip support but may be useful for cushioning the tip from pressure effect of other hard implants. Costal cartilage is useful in situations in which massive augmentation is necessary.

Bone was commonly used for moderate or greater dorsal defects. Although most authors reported good results, the use of demineralized bone was found to possess an unacceptable resorption rate of 82.5 percent13. Freeze-dried allograft and calcium hydroxyapatite were associated with good results. Complications included extrusion (3.4-6.3%), infection (1.9-5%), resorption (4-49%), displacement (1.9-3.6%). Dermis, fat, collagen, hyaluronic acid, Avatine, and Supramid are all susceptible to resorption and are unable to project the nasal tip. The use of cadaveric dermis, autologous fat and fibrofatty tissue grafts were reported to have acceptable results in mild to moderate dorsal depression or contour defects. There were no reports of extrusion, infection or displacement13. Silicone liquid, regardless of legitimacy and foreign body reaction issues is useful for augmenting the nasal dorsum, but is not suitable for tip projection and could cause bulbous tip deformity if being injected into the nasal tip. Proplast II is a porous material which is firm enough to augment the entire nose, however it triggers a prolonged granulomatous inflammatory response.

Gore-Tex was found to have acceptable results. Complications included extrusion (1%), infection (1-3.2%). These rates are higher in those patients undergoing revision surgery.

Medpor and Dracon were also reported to give acceptable results. Complications included extrusion (3.1-10.7%), infection (1-6.2%). Several authors noted that the patients complains of local firmness and numbness13.

Silicone rubber has been in use since 1950, and is the most inert material currently used for tissue augmentation. Many Western literatures, and textbooks advise against its use in augmentation rhinoplasty due to the high incidence of extrusion, infection, and displacement.

However upon systematic reviews, complications are comparable to other materials and mostly are preventable or can be minimized by some surgical tips. Complications included extrusion (2.1-3.7%), infection 3.7%, displacement (3%)13. In our series, the complication rate was rather low, and this may be attributable to the following precautions: 1. Preoperatively, the intranasal lining was meticulously cleaned with antiseptic, the vibrissae were trimmed, and postop antibiotic was prescribed to all patients. These measures are likely reduced early postoperative infections.

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2. Suitable sizes of silicone rubber prostheses were used. The implant was carved into a short-leg L-shape and any sharp or pointed part were totally eliminated. The purpose of the “L� (collumellar part) is not to project the nose but to stabilize prosthesis in midline and to minimize downward pushing pressure exerted at the infra-tip by a no-leg type, hence it should not longer than 1 cm or never touch the nasal spine.

This measure is critical in reducing the pressure on the nasal tip and prevent extrusion. We found that late infection was caused by a small dehiscent area at the region of septal angle which results from an unsuitable size of implant which may cause an internal pressure point leading to mucosal perforation. Moreover, too long columellar part of the prosthesis often lead to apparent tip deviation.

3. The implant is placed under the periosteal pocket of nasal bone, while its tip is under the middle crura of the lower lateral cartilage. This can reduce thinning of the covering skin and thus prevent extrusion and displacement at the nasal tip.

4. Division of the medial crura and depressor septi muscle. This facilitates tip projection while reducing pressure of the prosthesis on the skin of the nasal tip.

Conclusion

Silicone rubber implant is a safe and appropriate material for augmentation rhinoplasty in Asian. The use of a suitable size and shape of prosthesis, and proper surgical technique, are critical in reducing the complication rate.

Fig 1. Elevate lower lateral cartilage

Fig 4. Remove a part of lateral crus

Fig 2. Remove alar subcutaneous fat

Fig 3. Division of medial crus

Fig 5. Division of depressor septi muscle Fig 6. Demonstrate position of the caudal

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Fig 7. Samples of pre and postoperative pictures

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Fig 8. Samples of pre and postoperative pictures 62

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Fig 9. Samples of pre and postoperative pictures

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After

Fig 10. Samples of pre and postoperative pictures

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“Mantis Strut” Ideal for the Asian Nose Sampandh Komrit

Silicone has been the material of choice in the past and currently is used extensively in medical rhinoplasty augmentation. It is an inert substance that is easy to manipulate, does not elicit much tissue reaction, and is easily removed without complications. Silicone has since been used by doctors who have shaped and designed the prosthesis on their own with mixed results.

Lately many multinational companies produced several preformed prosthesis which has made rhinoplasty more convenient. However, there has not yet been a prosthesis that has provided a very satisfactory result as problems still exist with instability, extrusion, stiffness, asymmetry, poor angulation, unnatural appearance and proportions.

From my experiences as well as from other doctors’ more than 20 years of experience to design the “Mantis Strut” Preformed Prosthesis which achieves the 4 Goals of the Art: Beautiful, Natural, Safe and Comfortable. The use of this prosthesis has been found to reduce surgical time, increase the chance of a perfect outcome with less than 2% crooked nose and less than 0.5% perforation in a 5,000 case-based design study.

Mantis Strut Given the fact that the nose of each individual is unique and different, the following anatomical structures and their relationship with the Mantis Strut prosthesis should be properly assessed prior to Augmentation Rhinoplasty: 1. Infrastructure of nose – Nasal Bone, Frontal Bone, Septal Cartilage, and Lower Lateral Cartilage are the structures that support the Silicone Strut 2. Superstructure of nose – Skin, Soft Tissue, SMAS, Periostium are structures that cover the Silicone Strut.

Both anatomical groups have to be evaluated in order for the Silicone Strut to be designed correctly and achieve the Goals of the Art. The Mantis Strut was designed with the above noted anatomical structures and requirements in mind and therefore its unique design comprises of the following four important parts as follows:

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1. Head – the head is comprised of a tripod with two wings and one leg, and has a width of 12-15 mm which is wider than preformed prosthesis that are currently available on the market and also thinner. The lower part of the wings rests on the lower lateral cartilage while the leg rests on the edge or bottom edge of the medial crus 2. Neck – the neck dips slightly from the head and is narrower than both the head and body and mimics the suprastructure at the supratip 3. Body – the body augments the nasal bone.

The Mantis Strut body rises from the neck to the level of the head and is about as wide as the head while the rest of the prosthesis is narrower. If upon assessment the infrastructure needs to be augmented more, a wide body should be selected and if lesser augmentation is needed, a narrower body can be selected.

4. Tail – the tail is the portion that rests and is anchored at the root of the nose.

As the suprastructure in this area is thicker, therefore, the height and width of the Mantis needs to be tapered down and curved up to enable its lower part to rest on the frontonasal suture.

The Mantis Strut has 2 standard Asian sizes which come in 2 different widths, 12 mm and 15 mm.

The edges of the Mantis Strut are designed to be as thin as possible to enable it to rest on the infrastructure seamlessly. The ventral groove is deep and adjustable to enable a perfect fit on the nasal bone to duplicate the natural firmness and prevent instability and displacement.

The Mantis Strut has been designed to be easily customised by shortening the head and tail, tapering of all parts. Its unique design also enables it to be used as a complete prosthesis or the different parts can be utilized separately to suit the requirements.

Surgical Technique 1. Preparation: Paint the nostrils with Hibitane in water and follow with Betadine to prep the area.

2. Local Anesthesia: Xylocaine 2% with Adrenaline 3.5 – 4 ml. start infiltrating the Nasal tip and slowly spread outwards over a period of 10 minutes 3. Incision: Unilateral rim Incision is usually used starting with a 2 mm deep skin incision anterior to the anterior part of medial crus. Bilateral or open incision may be used if needed especially when using interdome or intercrura suture technique to achieve the maximum perfect Suture Point.

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Before

After

Before

After

Undermining Technique Proper Layer: The pocket should be made as close to the infrastructure as much as possible and in subperiostium layer o At the tip, separate skin from lower lateral cartilage o Nasal Bone must be in subperiostium layer or Sub SMAS. Proper size: the pocket must be wide and loose enough to prevent stress to prosthesis and should be higher than the Nasion (Frontal – Nasal suture). Especially at the nose tip, the space must be wide enough to enable the skin’s stretching for tip projection.

Symmetry Pocket: Lateral sides of the pocket should be equal.

One Pocket: There must be no connective tissue left to separate or obstruct between the pockets because it might cause stress to the prosthesis.

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Prosthesis Placement

Use the guide to insert the prosthesis, then move left, right up, and down to make it perfectly fit.

Stop bleeding and clearly identify the position of the prosthesis.

Check the position of the prosthesis with special attention to the wings of head Check the midline, nostrils, and nose height.

Finally,check tension at the nose tip using the index finger to assess the tension.

Adjunctive Procedure to Enhance tip Projection Use interdome or intercrura suture technique.

Undermine the pocket to be wide at the tip and supratip.

Remove soft tissue at supratip Multiple incision soft tissue at supratip Medialize alar

Mantis Strut for short nose

Benefits for the Surgeon

Use of the Mantis Strut reduces intraoperative time and is less stressful for the surgeon.

Since the Mantis Strut is already predesigned, there are lesser problems with the midline and symmetry and only the simple use of a blade or scissors is needed for adjustments. In cases where the Mantis Strut has to be removed, the structure remains intact. The Mantis Strut addresses the problems of thin tip, post extrusion, displacement of silicone that are common with other types of silicone prosthesis and if correct surgical technique is utilized, an excellent outcome is easily attainable.

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Augmentation Rhinoplasty with Silicone T Technique a Sensible Approach for Saddle Nose with Well Formed Tip Teerawat Srinakarin

With current technique, a common complication of the silicone augmentation rhinoplasty when aiming to increase nasal tip projection is long-term skin atrophy of the nasal tip.

The complication presents in varying degree, especially in patients who have minimal skin at nasal tip especially those with well form nasal tip cartilage (The dome). Using silicone in these cases have high risk of skin atrophy at nasal tip in varying degree, or result in silicone extrusion when skin was over stretched. A safe way to use silicone to create the nasal tip more projection for these cases can be achieved by T technique, by placing silicone under the interdomal ligament on nasal tip.

T technique is base on the fundamental concept of basal skeletal framework reconstruction by carving silicone. Silicone is used to create a new compatible basal skeletal framework (nasal bone, upper lateral cartilage,cartilaginous septum, and nasal process of frontal bone in some cases) follow by re-draping the undisturbed cover, especially undisturbed skin at nasal tip.

The part of silicone which create a new cartilaginous septum place under the interdomal ligament of nasal tip. Effecting the change in nasal tip projection and more vertical nostril shape in varying degree with longterm safety. The crucial key point to success is how to stabilize this new extended septum. The precise design of the compatible implant is the crucial factor to achieve stability of the extended septum. Compatible implant means compatibility of both anatomical basal skeletal framework and mechanical tension which comes from the thickness, elasticity, and mobility of the cover, especially at the nasal tip, columella, columella base, alar.

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Complete preoperative assessment is important step to achieve precise design of the compatible implant.

1. Careful palpation and inspection is still the fundamental basic in preoperative assessment. Palpation for T technique concentrates the mobility of nasal tip, elasticity of collumela, thickness and elasticity of membranous septum; shortness,durability, shape and alignment of caudal septum.

2. Plain X-ray of nasal bone in lateral view is very beneficial to orientate the position, shape and length of implant to have anatomical compatibility with basal framework. The x-ray give an accurate 4 landmark points on the basal bony framework including its length, this facilitates the design to accurately fit along with 6 point theory.

Complication of T technique is the same as current technique if the improper implant design and placement, this may result in silicone extrusion through skin of membranous septum.

Less skin at nasal tip in cases with well-form cartilage (Dome)

In cases of less skin at nasal tip. In my opinion, the subdermal space of the nasal tip is a no man’s land for silicone because it not only gives an unnaturally projected tip but also risks skin atrophy in long-term.

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Point number 1 is the expected cephalic end point of the implant which is created at the end of the periostial elevation. Point number 2 is the lowest point at nasal bone. Point number 3 is the rhinion. Point number 4 is the angle of the septal cartilage. Point number 5 is anterior nasal spine. point number 6 is the caudal end of the implant that expect to place under the interangular portion of the medial crus, it projects the nasal tip into the desirable position.

Now, we have many measurement for precise implant design.

Preoperative assessment of aesthetic defects must be correlated with the corresponding basal framework defects, which defects will be corrected by the compatible implant. To achieve accurate shape and size of the basal framework, we must use careful palpation and the radiologic study to determine the 5 important points and on its surface where the implant will contact with.

Compatible implant means compatibility of both anatomical basal framework and mechanical tension which comes from the thickness, elasticity, and mobility of the cover, especially at the nasal tip where point number 6 is located under.

Access dissection plane, the incision starts behind the columella base and goes up along inner side of the columella (about 2-3 mm. from columella fold) and cuts into the intermediate portion of medial crus and ends at the interangular portion between both medial crus. After that, making a vertical sharp dissection from AN spine to split the membranous septum, to expose the border of septal cartilage. Then we make a blunt dissection close to the upper surface of the ULC and dissect symmetrically as far laterally as we can to free overlying cover and nasal tip. Now going to important step, the subperiosteal plane. End at the cephalic end point.

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After(2 week)

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After(2 week)

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After(2 week)

Before

After(1 month)

After(1 month)

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After(3 month)

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Common Complications of Rhinoplasty Natamon Charakorn Chanchai Charakorn

Common Asian Rhinoplasty goal is to improve nasal tip contour, definition as a bulbous or tear drop with increase projection. The second goal is to build up the nasal bridge by using silicone implant, and the last goal is to narrow the flaring nostrils by bilateral alar base reduction.

However, augmentation rhinoplasty with silicone implant yields only 16% complication rate and 8 % revision surgical rate. Although asian rhinoplasty is considered to be a safe and effective procedure, few possible complications may be divided into 3 basic categories as follow:

1. Immediate intraoperative compilications.

1.1 Excessive bleeding may be from coagulopathy in case patient who take aspirin should be stopped at least 2 weeks before going to the operating room. Some cases the hematoma can be seen.

1.2 Airway obstruction 1.3 Anaphylaxis 1.4 Visual impairment from local anaesthesia

2. Early postoperative compilications.

2.1 Wound infection (less than 2%) including cellulitis, abscess and toxic shock syndrome (0.016%, mortality rate is 11% )

Cellulitis at nasal bridge (Courtesy of Dr.Choladhis S.)

2.2 Other complications such as subacute bacterial endocarditis, sinusitis and

intracranial complication.

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3. Late postoperative complications.

3.1 Scars, synechia formation, nasal stenosis and fibrous capsular contracture.

Scar formation (Courtesy of Dr.Choladhis S.)

Deviation of silicone strut (Courtesy of Dr.Choladhis S.) Nose may heal in an abnormal shape due to unexpected post surgical trauma. The visible scar that formed on the bridge across the nasal cavity may end as irregularity on the skin.

3.2 Septal perforation, saddle nose formation and nasal valve collapse which may cause deviation of the nasal septum and other deformities which occur in 5% of cases.

Septal perforation (Courtesy of Dr.Choladhis S.)

3.3 Difficulty breathing through the nose and less of sensation with Polly beak nasal deformity.

Polly beak nasal deformity (Courtesy of Dr.Choladhis S.) 75

3.4 Foreign body rejection and implant extrusion. These manyoccur in 2.8% of case.

However, there are some cases either eroding through the nasal tip (if the prosthesis is too long) or eroding through the posterolateral aspect of the columella.

Ulceration with pus Extrusion through the posterola lateral aspect of thecolumellar (Courtesy of Dr.Choladhis

If the pocket is too small, the prosthesis has unenough tissue coverage. In contrast, if the pocket is too large, it may displace. If the prosthesis is inserted too far beyond the proximal end, it may drift up with a high root and snub tip. Finally, if the prosthesis is too short, it may cause “saddle bridge.�

Saddle bridge (Courtesy of Dr.Choladhis S.)

Too long prosthesis (Courtesy of Dr.Choladhis S.) In conclusion, the most difficulty in Asian rhinoplasty is getting the silicone implant on the bridge that sits on the centre rather than off to the side.

3.5 Resorption of the underlying bone or thinning out of the skin. Late infection or rejection (extrusion) is an going concern.

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3.6 Too much tension that breaks down soft tissue may cause tissue necrosis at the alar and the nasal tip.

Perforation (Courtesy of Dr.Choladhis S.)

The other problems unique to Asian rhinoplasty are inadequate strengthening of the tip area, leading to a droopy appearing tip. This is following the inherent weakness of the tip and alar cartilages. Significant reinforcement of the grafting materials, such as ear cartilage, septum cartilage, subdermal fat or fascia lata are required (much preferred) to maintain adequate strength in the tip area.

Silicone injection Liquid silicone injection may cause siliconoma.

Silicone injected in nose 5 years ago

Siliconoma (Injected liquid silicone)

(Courtesy of Dr.Choladhis S.)

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Management of Complications of Augmentation Rhinoplasty Choladhis Sinrachtanant

Augmentation Rhinoplasty involves insertion of prosthetic material not normally anatomically present in the nose. Therefore complications from prosthetic material can arise and can range from mild complications such as a minor deviation with little or no repercussions to major complications such as perforation with scarring and subsequent permanent distortion. Complications occur in Augmentation Rhinoplasty when Alloplastic material is utilized, such as solid silicone prosthesis - currently the most popular material being used. Complication cannot be altogether totally eliminated in every case, but it can be mitigated and corrected if detected, identified and promptly managed. Complications that can arise are as follows: 1. Deviation of Silicone Axis from Central line – the axis of the silicone prosthesis deviates to the left or right and can be classified in 3 groups.

1.1 Tail Deviation -The tail of Silicone prosthesis deviates to one side. Early detection and immediate revision within 1 month are required for easier management. If left uncorrected for months or years, it would become a late case deviation and revision would be very difficult.

Before

After

Tail Deviation - Revision by silicone removal and lobular fat graft replacement 78

Before

After

Tail Deviation - Revision by silicone removal and lobular fat graft replacement 1.2 Tip Deviation - The Silicone Tip deviates to one side. Early Detection and immediate revision are recommended. If left uncorrected for months, fibrous capsule formation may occur around the silicone prosthesis and further progress to mature fibrous tissue formation which is very difficult to correct.

Before Tip (and root) Deviation – Revision by silicone

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After

1.3 All Axis Deviation – Deviation of the whole axis of the silicone prosthesis; Tip – Body – Root to one side. Early Detection and immediate revision should be done. If left uncorrected for months, fibrous capsule formation may occur and would be very difficult to revise. In case of late detection, the revision procedure is to make a new pocket or tunnel under the fibrous capsule and align the axis at the center.

Before

After All axis deviation- Revision by silicone removal and lobular fat graft replacement

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2. Impending Perforation – Skin at the tip of nose is tight with obvious signs of pointed nose tip, stretched skin or redness in some areas. Revision would involve removing the silicone prosthesis and carving a rounder or shorter tip. In cases of near perforation, significant signs to watch out for are inflammation or infection. Immediate administration of antibiotics is necessary.

Before

After

Thin skin of tip - Revision by silicone removal with lobular fat graft replacement

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Thin skin of tip - Revision by silicone removal with lobular fat graft replacement 81

Before

After

Thin skin of Dorsum-Revision by silicone removal and lobular fat graft replacement

Before

After

Too long Silicone Prosthesis-Revision by silicone removal with lobular fat graft replacement 82

Before After Impending tip perforation- Revision by silicone removal with lobular fat graft replacement

Before

After Impending tip perforation- Revision by silicone removal with lobular fat graft replacement

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Before

After

Impending dorsal skin to perforation - Revision by silicone removal and lobular fat graft replacement

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Impending to perforation Correction by increasing skin thickness with micro lobular fat injection over silicone strut

Before

After fat injection

Before

After fat injection

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3. Perforation of Silicone prosthesis 3.1 Pin point perforation – A tiny portion of the silicone prosthesis breaks through the skin.

At the early stage, it usually starts with an acne-like infection that can worsen and form an abscess followed by pin point perforation with fluid/pus at the later stage.

Before

After

Before

After

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3.2 Large perforation - In cases of uncorrected small perforation for a long time of period, The lesion would be worse and further more enlarge continuously until the silicone prosthesis is obvious. The conventional treatment was silicone removal and waiting 4-6 months for complete wound healing. Then the revision rhinoplasty was performed. The method of managing this complication could further cause late serious problems of scar formation at the nasal tip and subsequent permanent distortion and was no longer recommended.

The new technique of treatment is to give full dose of antibiotics until the infection subsides.

Then both the silicone and capsule are removed and replaced with immediate fat graft. The wound will heal within 7 days. In some cases of large perforation, a free flap skin graft might be required to close the perforation at the same time of fat grafting.

Before After Silicone perforation - Revision by silicone removal with lobular fat graft and free flap skin graft.

Before

After

Silicone perforation - Revision by silicone removal with lobular fat graft and free flap skin graft.

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4. Autologous Graft Complications – Using the patient’s own body tissues e.g. fat, cartilage or fascia for augmentation usually does not incur any severe complications. Mild complications are as follows: 4.1 Cartilage (Costal Cartilage) – There may be twist or curling after augmentation for months or years. Treatment is to remove and carve again. There are no problems of dissolving found in costal cartilage.

4.2 Fat Graft - The most serious complication is infection (as in the figure below). This can be prevented by antibiotic converage. Another major problem is unpredictable lysis of fat cells, depending on varying amount of stromal vascular factors, mesenchymal stem cells and viable fat cells of each patient’s fat graft. This may result in the patient’s unsatisfied nasal contours.

However new fat cells can be regenerated from mesenchymal stem cells (fat stem cells) to increase amount or fat cells adequate for new designed nasal shape. From my experiences almost 20 years (1996-2012) approximately 600 cases, fat graft survival rate is increased up to 50 - 80% In cases of unsatisfied nasal contour, one can utilize stepwise revision with fat graft for higher dorsum, or an alternative solution would be to utilize a very thin silicone plate which could be inserted under the remaining fat to create higher nasal contour. The cartilage could also be used for nasal tip elongation.

Fat Graft Infection

After antibiotic treatment

Fat Graft Infection

After antibiotic treatment

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4.3 Fascia – The Fascia Lata is most commonly used to cover the Silicone Prosthesis with very few resulting problems. The only problem that might be unacceptable is that of the resulting scar on the donor site of the patient’s leg.

Most of the other complications will not be discussed as they are only minor complications that are easily resolved or resolve on their own through the body’s own healing process.

5. Management of Siliconoma (Scleosing lipogranuloma) Old fashion of filler injection to nasal dorsum was liquid silicone. The granulomatous formation after injection was foreign bodies reaction or sclerosing lipogranuloma.

Clinical appearances were redness, telangiectasia, tumor like mass or ulceration.

Removal under local anaesthesia and replace with lobular fat graft with high successful result

Histopathological findings of siliconoma (sclerosing Lipogranuloma)

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Before

After

Siliconoma nose, removal and fat graft replacement

Before After Siliconoma nose, removal and fat graft replacement

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Rhinoplasty, Thin Tip Management with Autologous Tragal Perichondium Thongchai Bhongmakapat

Rhinoplasty is one of the most common cosmetic surgery As the nose is in the center of the face, when it changed , the other parts of face seem to be changed too. The natural looking rhinoplasty is also important concept of rhinoplasty technique. For example, when the patient was done rhinoplasty, her friends think that she is looking better but she can not figure out where is the exact changed. They may guess that her eye are looking better from blephaloplasty or any injection of filler on her face.

The ideal rhinoplastic shape of nose should be natural looking. The dorsum part should be fix as sub-periostium plane insertion and also match contour of concave ventral site of prosthesis and convex site of nasal bone. The nasal tip should be naturally mobile similar to un-augmented nose. When the people push the nasal tip to side way the nasal shape should be bend as L shape. It should not be straight as a pencil sit on the nose rotated. More better if we can raise the nasal tip that could be pressed and recoiled as soft nasal tip as natural nasal tip. The estimation of skin tension is important issue to prevent tip perforation and thinning.

The wide exposure for pocket and entrance assess of prosthesis implant is the surgical trick and pearl. The important technique in membranous septum surgery is essential for lengthening nasal shape and tip to improve perfect beauty in saddle and short nose in Asians. Rim of the prosthesis that attach to facial bone should be thin, and slope down to bend, and harmony with surrounding tissue and seemless on palpation. On side view the ventral part of prosthesis should be augmented the nasal bone and cartilage as jigsaw with low pressure and tension on both cartilage and skin or soft tissue. Curvature and smoothness of whole nasal contour are important for 3-D beauty.

So it is very important to carve the prosthesis in complex 3-D shape, for reaching all goals that provided good matching with the patient’s face. In my opinion custom made fine hand craft by skillful rhinoplastic surgeon is better than commercial prosthesis as L–stut, its ventral part is not match nasal dorsum as jigsaw and dorsal part of prosthesis is nearly the same for every patient, making a factory nose looking that may not harmonized with the patient ‘s face.

Tailor made craft is a jigsaw augmentation. Minimally change in any fine art craft of minimally provides a dramatic change that facilitate individual personal characteristic. The exact result of success is not only comparative picture pre and post-operative at 1-4 weeks but also long term 92

follow up more than 3-12 months will show the good and accurate estimation of surgeon in defining the prosthesis. As the skin and soft tissue become thinner, the result will show the real expertise and good vision of surgeon because the patient will have nasal shape like that for all her life or it need to be remove from some reason.The final goal of rhinoplasty is natural beuty, safe and without complication. Anyway some people may have special need for obvious, prominent or project and dramatic changed nasal shape or similar shape of nose as their cracy superstars.

These should be discussed with the patients about result and risk, pre-operatively. The Chinese facial characteristic fortune teller also have influence for decision making to do rhinoplastic surgery in some patients. The cosmetic surgeon should know how to prevent and repair the complication of rhinoplastic procedure, such as thinning tip or perforation. The important issues on the technique of rhinoplasty, correction and also prevention of thining tip will be mentioned.

pre-operative

post-operative

Â

Â

pre-operative 93

immediate post-operative after changing the dressing

pre-operative, immediate post-operative

after autologous tragal perichondium repair at nasal tip, note mild telangiectasia surrounded

The commonly used material for augmentation rhinoplasty in Thailand is a medical grade silicone (allograft). It has been use for a long time from our ancestors in medical profession and many generation of surgeon. We have no doubt in it’s safety, no adding donor defect and convenience, It‘s also suitable to perform a fine handcraft in complex 3-D shape that match and correct and also improve the natural looking or many advantages property as mentioned above by signature design. However many surgeons abandon and ignore to use silicon from bad experience and limited own knowledge.

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One of the disadvantage of the silicone augmentation is thinning and perforation of nasal tip.

This should be prevented by a good estimation of skin tension, elasticity and balance between nasal tip projection for cosmetic reason and safety in long term complication. The wide exposure for pocket and entrance assessment of prosthesis implant is also one factor that reduce this problem as bigger flap coverage with less tension. By the technique divids the membranous septum in vertical shape connected with the slightly wider prosthesis pocket as T-shape. However the problem still exist and this issue should be reduced, corrected and prevented. When the thinning skin of nasal tip becomes a patient’s complaint as long term sequelae, it is a hard situation for surgeon to make a decision to observe or do surgery either from your own patient or from other surgeons that may use different surgical prosthesis. Some kind of prosthesis are very difficult to remove.

Some surgeons do a special deligate sculpture decide at silicone tip resulting in very thin elastic silicone structure mimic the lower lateral cartilage for soft nasal tip and natural recoil of tip after tip pressing. When these patients kiss their friend or baby the natural feeling occur, not a Pinochio kiss. Unnotice or unexperience surgeons, sometime break the prosthesis and can not romove these kind of prosthesis, or even worst situation they tear the thinning, weak nasal tip skin resulting in nasal tip perforation and finally a noticeable nasal tip scar or dimpling occur as a sequelae. Surgeons need to judge to reduce some projection of silicone at nasal tip or not, for balancing the cosmetic reason and complication. There are many techniques that surgeons try to solve the problem such as fat graft that work well. The use of autologous tragal perichondium graft is suitable for repairing the thinning part of nasal tip for the following advantages.

1. thin and tuft make no steping deformity or seemless contour, minimal repair of satisfactory shape of nose except small area of thinning skin 2. the thinning problem resolve quickly, postoperative contour not change much, fast recovery 3. easily harvested as it site is near the nose, no need to turn the head too many angle resist for reperforation and infection 4. can be done through the small standard incision and correct only tip thought need to remove out all prostheses. This suitable for the patients that appreciated with overall contour but not only thinning tip 5. can be calcified in long term to increase the strength 6. can easily fix behind the thinning skin at nasal tip or use absorbable suture to fix at the head part of prosthesis that confront to the thinning part.

7. can be use as perichondium only, perichondium with cartilage and double layer perichondium with cartilage or add up subcutaneous fat in front of perichondium for special purpose 8. there are two sides of material to use as reserve 9. there is less deformity of donor defect

dimping after infected prosthesis from other private clinic

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One of this technique disadvantage is the slightly white color especially when the skin is very thin. However this can be help by undermining the subcutaneous fat in conjunction with the perichondrium and facing the fat side to patient’s skin or using make up powder in sometimes.

As the concept using tragal perichondium work well, we can apply similar techniques by using other kind of materials, for example, autologous fascia from many regions, homologous fascia that available for tympanoplasty if patients do not want donor side defect or incisional scar, fat graft, conchal cartilage and perichondium, and dural patch, a synthetic dural substitute are also interesting materials for nasal tip thinning.

This material are also interesting for nasal tip thinning prophylaxis or prevention. But this should be scienctific proven or shown evidence base result in the future.

The combination of silicone and these kind of material as chimeric graft have potential in rhinoplastic surgery. Future reseach in silicone coated with natural biologic material may be an answer for fine deligate rhinoplasty for individual patient as custom-made.

The incision is made at the rim of tragus, the surgeon should decide preoperatively how many layer or which kind of tissue needed in this patient. The surgical plane of tragal perichondium is easily harvested by using a scalpel blade no.15 and periostium elevator as well as small scissors at the end. The nasal incision can be done as the surgeon choice, the author usually use incision.

The tragal perichondium can be fix by using absorbable suture to tied at the head part of prosthesis that confront to thinning part or put and spread the graft between thinning skin and causative part of prosthesis that confront.

Tragal perichondium harvest and repair

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Refinement of the Nasal Tip Jumroon Tungkeeratichai Techniques in surgery of the nasal tip are numerous, and use of individual techniques.

Many consider rhinoplasty to be the most difficult facial plastic operation. It requires a precise assessment of the deformity, nasal support mechanisms ,soft tissue skin envelope and airway function. Postoperative scar contracture and healing may later modify the nasal structure over the lifetime of the patient. Surgeons should understand the anatomy, surgical approaches, and patient desires which are crucial to be an adequate surgery of the nasal tip.

The quality of the skin should be assessed. Thick skin has a tendency to case postoperative edema and scar and is the least ideal skin type for achieving refinement and definition. Thin skin is preferred because it heals more predictably and allows for critical definition; however, even minor deformities will be easily visible and palpable.

The nasal tip must also be considered as a dynamic structure, influenced by the facial mimetic muscles. These muscles influence the appearance of the nose and may exaggerate or create nasal deformity.

The mimetic muscles of the nose are encased and interconnected throughout by the nasal superficial musculoaponeurotic system (SMAS). This layer serves as a guide to the appropriate dissection plane in nasal surgery. Elevation should occur just deep to the SMAS and immediately superficial to nasal skeleton; this results in ease of dissection, minimal bleeding, minimal damage to the neurovascular structures supplying the nasal tip skin, avoidance of damage to the intact SMAS layer, and reduced scarring.

The minor tip support mechanisms include (1) the dorsal cartilaginous septum, (2) the interdomal ligaments, (3) the nasal spine, (4) the membranous septum, and (5) the alar attachments to the skin. Alterations in the size, shape, and integrity of the limbs of the tripod, together with the disruption of the major and minor tip support mechanisms, result in profound alteration in tip rotation.

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Surgical Approaches to the Nasal Tip

Incision of Rhinoplasty

Nasal tip surgery usually involves modification of the lower lateral cartilages. Access to these cartilages can be made via a delivery or non-delivery approach. When minimal or conservative tip refinement is desired, nondelivery approaches can be used. This approach allows the surgeon to assess the effects of fine alterations during surgery and allows minimal disruption of the normal anatomy of the tip. However, more extensive modification of the nasal tip demands more exposure of the tip structures and this is used when a delivery or open approach may be employed.

Nondelivery approach:

Trans ( intra) cartilaginous incision

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Intercartilaginous incision

Nondelivery approaches to the alar cartilages include the intercartilaginous incision and the transcartilaginous incision. The intercartilaginous incision is performed at or just cephalic to the upper boundary of the lateral crus to the level of the dome. The vestibular skin is then elevated in a retrograde fashion in the supraperichondrial plane deep to the SMAS. The desired amount of lower lateral cartilage is then resected. This incision violates the attachment of the lower lateral cartilage to the upper lateral cartilage which is a major tip support mechanism; the usual result is cephalic rotation of the tip due to scarring and loss of the scroll attachment. With variable resection of a strip of the lateral crus, this rotation can be accentuated if desired. The transcartilaginous incision is performed through the cephalic to the caudal margin of the lower lateral cartilage. The vestibular skin is undermined in a cephalic direction over the portion of alar cartilage to be removed. The desired amount of alar cartilage is then resected.

Delivery approach:

Delivery of the lower lateral cartilages as bipedicled chondrocutaneous flaps may be required for more complex modifications of the nasal tip. A intercartilaginous incision combined with a marginal incision to “deliver� these cartilages for direct inspection and modification.

Modifications of the nasal tip in these patients may require more volume reduction of the medial portion of the lateral crus, weakening of the complete strip with crosshatching, morselization or interrupted strip technique.

Open rhinoplasty:

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This approach is used when more radical alterations of nasal tip anatomy are executed.

Exposure of the nasal skeleton in this way facilitates detection and correction of both major and minor asymmetries. Disadvantages include the columellar scar, prolonged tip edema and disruption of tip structures that are in no need of change. To expose the nasal tip structures, a marginal incision is carried out to the midcolumella bilaterally. Dissection over the lateral crura proceeds in the immediate supraperichondrial plane. The dome and interdomal area is liberated. An irregular incision is made across the columella connecting the marginal incisions and the columellar skin flap is elevated to expose the nasal tip structures.

Septal Incisions:

Killian incision

Modified Killian incision

Transfixion incision

In order to access the septum and columella, transfixion or hemi-transfixion incisions may be required in non-open rhinoplasty approaches. The complete transfixion incision is made from the anterior septal angle along the anterior border of the cartilaginous septum and sweeping posteriorly to the nasal spine. This incision violates a major tip support mechanism: the attachment of the medial crural footplate to the nasal septum. To avoid post-operative loss of tip projection, the medial crural footplates should be resutured to the nasal septum at the end of the surgery.

This incision can, however, be used when tip retro displacement is actually desired. The partial transfixion incision avoids separation of the nasal spine from the medial crural footplates by stopping short of the nasal spine. The high transfixion incision leaves a 5mm strip of caudal septum to preserve the attachments, and the Killian incision (about 1 cm deep to the columella) does not violate the septal cartilage at all.

Tip Projection

Tip Projection

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Procedure for incresed tip projection after nasal surgery is to resuture the medial crural footplates to the caudal septum. Caudal strut may be fashioned from autogenous cartilage.

The caudal strut should be fashioned with a curve that matches the collumella and should be positioned and sutured between the medial crura. A pocket is dissected between the medial crura and the graft is placed here. The graft should not project beyond the domes of the lower lateral cartilages in order to avoid a tented up appearance of the nasal skin. The graft should not rest on the nasal spine, as displacement from the spine will cause the patient to experience nasal clicking and discomfort.

Before

After (Courtesy of Dr.Choladhis S.)

Transdomal suture and tip definition

Tip Definition

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One of the most common problems encounter when addressing tip definition is the bulbous tip. In order to correct this deformity it is important to recognize the underlying problem. The most common causes of bulbous tip are the wide interdomal distance, widening of the domes, weak lower lateral cartilage and thick skin with lack of definition. Transdomal suture is an important role in definition by narrowing the domal structure. Interdomal suture and medial crura suture will also improve definition by decreasing the interdomal distance.

Before tip refinement

Domal Suture

Incision

Split

Ear Cartilage

Cartilage Suture

(Courtesy of Dr.Choladhis S.) Pre and Post operation

pre operation

post operation

Conclusion

Understanding the importance of proper preoperative evaluation, intraoperative assessment and the individual and additive effects of tip-modification maneuvers are paramount to a successful outcome. Improved long-term results occur when the supporting structures of the tip are preserved or restore. A predictable result will be obtained if harmony between the major components of the nasal tip refinement which are nasal tip rotation, definition and projection.

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Autologous Fascia Lata Rhinoplasty Ian Loh

Introduction Autologous Fascia Lata is an ideal material for dorsal augmentation in Asian rhinoplasty.

Compared to alloplastics, it has a lower infection and extrusion rate, and virtually no risk of extrusion.

It can be quickly harvested in larger amounts and contours more easily to the dorsum when compared to conchal and septal cartilage, and has a much lower donor site morbidity and harvest time compared to autologous rib.

It may also have a lower absorption than homologous material, such as irradiated cadaveric fascia lata and rib.

When compared to autologous deep temporalis fascia, Fascia Lata is much thicker and when compared to temporoparietal fascia, a much larger volume of graft material can be harvested.

The Asian dorsum has a softer, more rounded cross section compared to the Caucasian dorsum. Rigid augmentation material (alloplastic or autologous) can result in the appearance of a surgically operated nose with loss of the normal dorsal aesthetic line. Autologous Fascia Lata drapes over the dorsum of the Asian nose, giving a softer, more rounded augmentation that is suited for the Oriental nose.

Advantages of Autologous Fascia Lata Rhinoplasty

Simple, fast harvest, Large volume, Minimal donor site morbidity, Good harvest site cosmesis, Good dorsal contouring, Natural appearing dorsal augmentation, Limited resorption Disadvantages of Autologous Fascia Lata Grafting

Autologous Fascia Lata requires harvest from a separate harvest site, cannot be used for structural grafting, should not be used for large augmentations and requires over-augmentation on table.

The soft nature of Fascia Lata gives it a natural appearance in the nose, but also means it cannot be used for structural grafting.

Augmentation requires the fascia to be folded over itself, and when this is repeated excessively, the lack of rigidity results in the graft being unable to maintain its position and shape over the dorsum of the nose. Wrapping the fascia around a thinner cartilage core can overcome this problem, while maximizing the use of harvested autologous cartilage.

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Immediately following grafting; this stabilizes in 6 weeks and does not result in more than 30% loss in augmentation.

Disadvantages of Autologous Fascia Lata Rhinoplasty

nd

2 separate harvest site, Not suitable for structural grafting, Not for large (more than 4 mm) dorsal augmentation*, Initial limited resorption following grafting *unless used in conjunction with cartilage

Possible Indications for Autologous Fascia Lata Grafting

The soft nature of Fascia Lata make it appropriate for radix and dorsal augmentation, as a onlay camouflage graft and as a soft tissue augmentation graft where there has been injury to the dermal or subcutaneous layer. It can also be used as a fascial envelope for holding diced

Indications for Using Autologous Fascia Lata Grafts

Radix augmentation, Dorsal augmentation, Onlay camouflage graft, Softening contours of cartilage grafts, Soft tissue replacement/augmentation, Fascial envelope for diced cartilage graft

Relevant Anatomy for Harvest of Fascia Lata

The Fascia Lata lies deep to the subcutaneous layer and encloses the entire musculature of the thigh.

It is thickest over the lateral portion of the thigh where it condenses to form the iliotibial band (ITB). The ITB contributes to leg extension and maintaining hyper-extension of the knee when standing. The Fascia Lata is of a good thickness over the anterior thigh but thins over the medial thigh.

The posterior border of the ITB is connected deeply to the lateral intermuscular septum.

The Fascia Lata splits to ensheath the Tensor Fascia Lata superior-laterally. This muscle is continuous inferiorly with the ITB.

The intermediate cutaneous nerve of the thigh pierces the Fascia Lata on its anterior surface approximately 7.5cm below the level of the inguinal ligament to supply the skin of the anterior thigh.

The anterior branch of the lateral cutaneous nerve of the thigh travels in the Fascia Lata and pierces the Fascia Lata approximately 10cm below the level of the ASIS to supply the skin over the anterior and lateral thigh. The superior medial Fascia Lata is pierced by the great saphenous vein.

The Fascia Lata also forms a condensation just above the knee which contributes to knee stability.

Harvest Method

Traditional methods of harvest have involved the use of tendon strippers or large incisions.

Tendon strippers can be used to harvest a thin strip of Fascia Lata with a small incision but the volume harvested is small and of a limited width.

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Large open incision methods are cosmetically unacceptable as they leave a large scar over the lateral thigh.

The author introduces a new minimally invasive harvest method to obtain a good volume of Fascia Lata using no specialized instruments.

Surface marking The knee and hips are flexed and the hip is internally rotated.

This accentuates the lateral intermuscular septum which is marked out.

A 4 cm width of ITB anterior to the intermuscular septum is marked out to be preserved.

The superior limit of the harvest is 17cm distal to the ASIS. This avoids harvesting over the Tensor Fascia Lata muscle. Harvesting at this level also avoids injuring the cutaneous nerves supplying the thigh.

The Fascia Lata 10 cm proximal to the femoral condye marks the inferior limit of harvest.

This preserves the distal Fascia Lata around the knee which contributes to its stability.

Using these landmarks, the area to be harvested is marked out. Harvest is avoided over the medial thigh as the fascia in this area is thin and there is increased risk of injury to the Great Saphenous Vein and its tributaries.

Figure 1 : Legend Green circle : Lateral femoral condyle Red bracket : Fascia Lata 10cm proximal to knee not to be harvested Purple Line : Horizontal line 17cm distal to ASIS Yellow Oval : Harvest site for fascia lata Blue bracket (lined on sides with yellow lines) : ITB

Operative details

Subcutaneous infiltration using Tumescent solution is used 30 mins prior to harvest.

A superior 2cm incision is made and deepened till the glistening white fascial layer is encountered.

The subcutaneous tissue superficial to the fascial layer are separated from the Fascia Lata; a 5-10 cm horizontal incision is made through the Fascia Lata exposing the underlying muscles; next, the underlying muscles deep to the fascial layer are separated from the Fascia Lata. Dissection planes above and below the fascia are extended as distally as possible using blunt dissection once the correct planes are identified. The author uses a long blunt tipped Boies elevator for this purpose.

The free edge of the cut fascia is grasped with an artery forceps and long parallel cuts are made perpendicular to the horizontal incision in the Fascia Lata. These are performed using a shearing action with long Metzenbaum scissors slightly opened at the tip. The artery is now pushed forward in the subcutaneous plane until no further distal excursion is possible.

The tip of the artery is tented against the skin and a small stab incision is made over the site of tenting. A fine artery forcep is used to dissect down onto the tented artery forcep tip.

A second artery is used to grasp the Fascia Lata, delivering the graft out of the stab incision like a piece of tissue from a tissue box.

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When no further delivery of the graft is possible, it is transected at its root, flush against the skin.

A large graft can be harvested using these small incisions.

The wound is flushed and closed in layers. The subcutaneous and deep dermal layer is closed using multiple PDS sutures and the epithelium carefully opposed using 5/0 nylon sutures.

A pressure dressing is applied and compression stockings are issued to the patient after surgery.

Figure 2 : A 2cm proximal incision is used to free the Fascia Lata from the overlying subcutaneous tissue and underlying musculature. Parallel long cuts have been made along the fascia.

The cut free end has been grasped and passed under the skin distally, where a smaller stab incision has been made to deliver the fascia externally.

Figure 4 : Harvested fascia. This is a modestly sized harvest measuring 12 x 4cm, much larger harvest is possible using small incisions as outlined earlier.

Graft preparation

The graft is folded on itself and till the correct amount of augmentation is achieved. The free edge of the stacked graft is stitched using PDS 5/0 sutures. IT is important to over augment by about 30% when designing this graft.

The correct level for the cephalic end of the graft is marked out over the skin.

The graft is grasped using Bayonet forceps and introduced under the soft tissue pocket till the right level. The tip of the Bayonet forceps is tented out against the skin and the graft is pinned into place transcutaneously using a 24G needle. The Bayonet is withdrawn and the position checked.

A 4/0 Prolene suture can be placed through the skin to fix the graft in place at this point in time if felt necessary. However the soft and contourable nature of the graft prevents migration once the skin envelope is placed over the graft, making this unnecessary in most cases.

A separate radix graft can be placed above or below the dorsal graft if more radix augmentation is required.

The caudal end of the graft is anchored against the lower lateral cartilages using loose 5/0 PDS.

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Post-operative care

Some shrinkage and resorption of the graft is expected in the first 6 weeks. Thereafter, further resorption tends to be minimal.

Complications

Harvest complications tend to be few , and minor when they occur.

Complications

Muscle herniation,Scar related complications, Neuralgia, Weakness of knee extension, Hemorrhage and seroma formation, Infection, Delayed ambulation

Post-operative pain tends to be minimal with immediate ambulation possible in most patients.

A small number of patients may develop cutaneous nerve neuralgia especially if the harvest is made too high.

With compression dressing, hematomas and seromas are seldom seen. The need for deep tension sutures must be emphasized when closing the superior incision. The skin over the thigh moves readily on ambulation and broad scars can form if this is not done. With good wound closure, the superior incision heals well and remains well hidden, even when wearing shorts.

The lower stab incision heals inconspicuously and becomes undetectable.

Muscle herniation is to be expected immediately after operation. This is mild and invariable resolves with 3 months after the operation. The use of compression stockings may shorten this process.

Summary

Autologous Fascia Lata offers a large volume of graft material suitable for augmentation of the Asian dorsum. Harvesting fascia lata is a simple procedure with few complications.

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Alar plasty Saranchai Kiatsurayanon

The most frequently performed facial plastic surgery is rhinoplasty which can correct a

wide variety of nose problems such as a bump on the nasal bridge, broard nostrils and much more. This article will explain how alar plasty, one of the rhinoplasty procedures,can correct the nostrils size

Alar base is important for the elegance of the nose. Even if most parts of the nose are well augmented or reconstructed, the wide alar base could make the nose look imperfect. Also, one of the complaints that most of the rhinoplastic patients have after the procedures is their alar bases are too wide.

The alar base is composed of complex three dimension components, which is the area that nostrils are connected to the face (figure 1): 1. Alar insertion 2. Nasal sill 3. Columella

Fig.1The nasal base has three components that may cause a broad nasal base: • Alar base (A), • Nostril sill (S), • Columellar base (CB).

There are two surgical procedures that can reduce the width of the base 1. Wedge excision (figure 2) which is the removal of the tissue of the alar base. this will reduce the width of the alar base without changing the size of the nostrils

Fig.2 : Wedge excision

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2. Weir excision (figure 3) is the procedure that consists of the removal of the alar base (Wedge excision) and the nasal sill. The alar base excision can narrow the nostrils while the nasal sill resection itself may not reduce enough the overall nasal base width.

Fig. 3 : Weir excision (wedge and sill resection)

The reduction of broad nasal base can be performed in single operation or in combination with augmented rhinoplasty .In combination with the other procedures of nose, this must be done after finishing in augmenting the nose due to the shape of nose may be effected by the postaugmented tip. The more the tip is projected, the more the nasal base is narrow. On the other hands, the more the tip is ptosis, the more the nasal base is widen.

Not only the thorough understanding of the facial plastic surgical options is essential to provide the impressive results of the procedures, but also the experiences of surgeons. The alar plasty is not the a complex procedure but not too easy operation. Because in case of extensive resection of alar base in am attempt to reduce the nasal base width may cause the nostrils stenosis by the scar contracture, asymmetry nostrils.

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pre-operative

post-operative

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Management of Old Fracture Nose Virachai Kerekhanjanarong

The nose is an organ on the face that protrudes the most and therefore it is prone to

injury. Statistics reveal that nose injuries are found in 39% of maxillofacial trauma cases which include injury from fights or sports, falls and car accidents. These types of injuries are found more than twice as often in men than in women with majority of the cases in the age group 15-30 years.

The nose comprises of superficial skin and soft tissue with the structure beneath comprised of nasal bone, upper and lowers lateral cartilages, and the nasal septum. The structures are closely integrated and therefore any impact on one structure will affect the other structures.

The types and severity of Facial trauma depend on the strength of the impact. Facial injury will result with side impact of 16-66 newtons and frontal impact of 114-312 newtons.

Facial bones have various impact fracture strength.

When the nose is traumatized and fractured, the physical examination findings can include pain, swelling or bleeding, possible nose deformity, nasal mucosa tear, septal deviation, hematoma, and palpable bone fracture. In the first 6 hours following trauma, there may be only mild edematous mucosa; however after 4-6 hours, the mucosa and soft tissue will become more swollen making it difficult to fully assess and evaluate the nasal structures by palpation. Plain x-ray or CT-scan might be required for diagnosis (details are not discussed in this writing). 4-5 days following trauma, swelling will gradually subside and fibrosis along with bone healing starts after day 8-10. Hence, osteotomy or osteotomy with revision septorhinoplasty is advised to be undertaken after day 10 post-trauma.

In cases where no revision has been provided within 10 days or if revision was already carried out in the acute phase and there is still deformity, further revision has to be carried out.

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The type of anesthesia has to be considered depending on the type of surgery needed.

Either local or general anesthesia can be considered. Statistics show that patients who have received general anesthesia during surgery obtain a satisfactory long term outcome of more than 80%. This is especially true in the cases that require revision of multiple areas.

Osteotomy Comprehensive knowledge and understanding of the structures of the bony nasal vault is necessary when performing a successful osteotomy.

Osteotomies are classified as follows:

1.

2.

3.

4.

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Medial osteotomy Lateral osteotomy Intermediate osteotomy Transverse osteotomy

Pre-surgical Markings for Osteotomy. Straight Medial Osteotomy (Line 1), Fading Medial Osteotomy (Line 2), Intermediate Osteotomy (Dotted Red Line), Lateral Osteotomy (Solid Red Line),

Medial Osteotomy

This procedure is usually performed along with lateral osteotomy to align the lateral nasal vault in cases of hump reduction or for narrowing the width of the nasal bone to correct bony septal deviation. Medial osteotomy can be performed alone as a single procedure to widen the nasal dorsum and nasal cavity.

There are several techniques for medial osteotomy 1. Straight medial osteotomy is performed by cutting straight and parallel to the perpendicular plate of Ethmoid bone (bony septum). (Red line number 1) 2. Fading osteotomy is performed by cutting in a curved manner superolaterally to meet the lateral osteotomy in nasal cavity. (Red line number 2) 3. Perforation osteotomy is performed by cutting the bone through a small skin incision and using chisel to shape the bone in the needed line.

 

Straight Medial Osteotomy

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Lateral Osteotomy

Lateral osteotomy is usually performed along with medial osteotomy to resolve problems of open roof. It is also useful in cases of revision for hump reduction, narrowing the width of nasal bone to correct bony septal deviation, and widening of a narrow nasal vault from trauma.

Technique The point of lateral osteotomy starts from Pyriform vault (aperture) above the inferior turbinate toward the ascending process of the maxilla and curved medially to avoid the frontal process of the maxilla into nasal bone to meet the medial osteotomy or transverse osteotomy line at the edge of the nasal bone.

Alternately, the perforating osteotomy technique can be utilized by opening a small 2 – 3 mm skin incision beside the nose and use 2 mm chisel to cut along the mentioned line.

intranasal lateral osteotomy

Intermediate osteotomy

This is an osteotomy technique to correct severe convexity or concavity, or obvious incongruous nasal bone.

The osteotomy line is between the medial and lateral osteotomy lines as well as behind the medial osteotomy line and parallel with the curved line of lateral osteotomy.

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Summary - Healing of the nasal bone fragments and fusion starts to take place 10 days following fracture - When performing revision septorhinoplasty, osteotomy is the important procedure for structural repair - Before osteotomy, one needs to consider what structures need to be repaired and plan how to conduct the repair - Steps of osteotomy 1. Medial osteotomy – side of the nose that is deviated (medially side) 2. Intermediate osteotomy 3. Lateral osteotomy 4. Revision of septum (if there is a problem with deviated nasal septum) 5. Medial osteotomy 6. Intermediate osteotomy if necessary 7. Lateral osteotomy - Internal and external splint are of importance

Osteotome (Left), Chisel

The minor tip support mechanisms include (1) the dorsal cartilaginous septum, (2) the interdomal ligaments, (3) the nasal spine, (4) the membranous septum, and (5) the alar attachments to the skin. Alterations in the size, shape, and integrity of the limbs of the tripod, together with the disruption of the major and minor tip support mechanisms, result in profound alteration in tip rotation.

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Injection Rhinoplasty Chalermchai Chintrakarn Injection rhinoplasty is a medical procedure in which hyaluronic acid such as Restylane and

Juvederm or calcium hydroxyapatite (Radiesse) are used to shape a person’s nose with noninvasive surgery1,2. The substance fills in depressed areas, lifting the angle of the tip or smoothing the bumps of the bridge3. Injection rhinoplasty is an augmentation procedure. It cannot used to correct functional problems such as breathing difficulties.

Early attempts using paraffin wax and silicone were abandoned when late complications started appearing4. Modern fillers are now in use and gain more popular.

Procedure overview

BEFORE AND AFTER: Low bridge and under-projected nasal tip (left photo) corrected with hyaluronic acid (Juvederm) injection into the tip and dorsum.

BEFORE AND AFTER: Saddle nose with supratip depression corrected with hyaluronic acid (Restylane) injection.

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BEFORE AND AFTER: Saddle nose with low bridge corrected with hyarulonic acid (Juvederm) injection.

BEFORE AND AFTER: Low bridge corrected with hyaluronic acid (Restylane) injection.

Injection rhinoplasty is considered for patients who had aesthetic defect or a defect from a surgical rhinoplasty. It can also be used to correct some birth defects. Because the procedure is not invasive, bruising and swelling are minimal. The procedure can make the nose smaller by making it straighter. It is frequently used to increase the height of the nasal bridge as well as augmenting other defined areas of the nose. The procedure is not used to correct functional defects. Injection rhinoplasty can be used in all ethnic patients.

The filler-injection technique can be used in: • Augmentation of a flat nasal bridge (depressed dorsum) • Added projection of the nasal tip • Correction of retracted columella • Small reduction of nostril size • Perceptual diminution of a nasal hump • Filling a nasal sidewall depression • Enhancing a retracted anterior nasal spine • Enhancing a retracted maxilla lateral to the pyriform aperture

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• Elevation of a saddle nose deformity caused by a failed primary rhinoplasty • Traumatic injury 9

Complications of the procedure are infection, hematoma, anatomic asymmetry, discomfort and foreign body reaction (called granulomas).The surgeon should not inject filler directly in to the blood vessel, so that it can cause blindness. Granulomas are extremely rare, and are most seen with impure silicone and some of the early non-modern versions of methyl-methacrylate.3 Modern fillers Modern injectable fillers include: • Hyaluronic acid (Juvederm, Restylane, Perlane or Voluma) – a safe and non-allergenic

temporary filler that lasts for 6 to 10 months. Some fillers such as Perlane and Voluma can

last long to 12-18 months. This filler can be dissolved with injections of an enzyme called hyaluronidase10.

• Calcium hydroxyapatite (Radiesse) – A calcium based, non allergenic filler that is sturdier than hyaluronic acid and lasts for 10 to 14 months. It is not reversible with injections of hyaluronidase.

• Polymethylmethacrylate (Artefill) – A permanent filler made from inert, microscopic surgical plastic beads. This filler used bovine collagen as a carrier, so a skin test is necessary prior to injection. This filler should be injected over several sessions11,12.

• Liquid silicone – Medical grade silicone is sometimes used in a microdroplet technique for permanent versions of the procedure.

• Polyacrylamide gel (PAAG or Aquamid) – A permanent filler used most frequently in Asia and Australia.

Techniques

The preferred anesthesia for injection rhinoplasty is topical anesthesia. Some physicians use local anaesthesia (i.e. lidocaine injections), but this can cause swelling and obscure the area being injected.

The physician uses a hypodermic needle (e.g. 27-G, 25 mm) to inject under the nasal skin, most commonly in the deep subcutaneous tissues immediately above the periosteum.

The procedure typically take 10 to 20 minutes to perform in the surgeon’s consultation room, after an initial 30 minutes of numbing using topical anesthetic cream. Gently compressed by ice, to prevent bruising or hematoma, until bleeding from injected point was stopped. After the procedure, the patient can resume normal activities immediately.

In the present time, new filler add lidocaine in the gel. This decrease the postoperative pain and the surgeon can shape the filler after injection without pain. By the way, filler with lidocaine should be avoid in patients who had allergy to lidocaine.

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Adverse Recations to Injectable Nasal Soft Tissue Fillers Tanom Bunnapasert

The ideal injectable material for soft tissue augmentation should offer good aesthetic

results and have a long-lasting effect. It should also be safe, biocompatible, and stable at the implantation site, with minimal complications and no risk of migration1,2.

There are many types of dermal fillers currently used for cosmetic and medical indications in routine clinical practice. Fillers can be classified as temporary, semi-permanent, or permanent depending on the length of time the substance remains in tissue. They can also be classified by the composition of the product. Materials can be based on collagen (bovine, porcine, and human), hyaluronic acid, poly-L-lactic acid, calcium hydroxylapatite, polymethal methacrylates, and polyacrylamide gels, among others3.

The most common fillers that are currently used hyaluronic acid and autologous fat.

The complications can be categorized according to different criteria. This chapter discusses the side effects as per minor versus major complications.

Minor complications4 - Swelling and bruising o Avoidance of visible superficial vessels o Avoid medications with anticoagulant effect o Firm pressure and ice packs post injection - Infection o Prevention of infection by sterile technique o +/- Prophylactic antibiotic - Asymmetry, surface irregularities, undercorrection, and overcorrection o Correct by technique and experience

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Major complications - Allergic reactions - Vascular complication o Iatrogenic Retinal Artery Occlusion • Recently heightened awareness of the possibility of iatrogenic blindness • The anastomosis of the dorsal nasal artery from the ophthalmic artery, angular artery, and lateral nasal artery from the facial artery5.

Schematic drawing that shows the anatomy, distribution, and connections between the ophthalmic and the facial arterial systems6 .

Tips and Techniques to Diminish the Risk of Intravascular Injection6.

1. Aspiration before injection.

2. Injections should be performed slowly and with the least amount of pressure possible.

3. The tip of the needle should be moved slightly to deliver the filler at different points along a line rather than as a single deposit.

4. Incremental injections should be fractionated so that any filler injected into the artery can be flushed peripherally before the next incremental injection is performed. The surgeon should limit therefore to 0.1 ml of filler regardless of the filler type.

5. Small syringes should be preferred to larger ones. The use of a high volume syringe (10 ml) may increase the probability of this complication because the surgeon cannot easily control the volume of the filler delivered.

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6. Smaller needles slow injection speed and are less likely to occlude the vessel or block peripheral flow.

7. Repeated treatments with smaller volumes may be preferred to single-stage high-volume injections.

8. Microcannula and the blunt tip needle are inserted into the skin through a hole previously made with a sharp tip needle having the same diameter. These techniques allow facial injection with a limited number of insertion points for the whole face, thus reducing the risk of arterial entry.

9. Application of a topical vasoconstrictor prior to filler delivery decrease risk perforation of an arterial wall.

10. When performing autologous fat tissue transfer, sharp cannulas and small cannulas are much more likely to perforate the wall of an artery and cannulate the artery lumen than are larger, blunt cannulas. (figure3.)

11. Low-pressure microdroplet injection technique with blunt cannulas to avoid a dramatically high injection pressure for a highly viscous substance such as fat tissue. The injection should be accomplished by delivering very small, noncontinuous amounts of 0.1 ml per pass.

12. When surgical procedures of the head and neck, such as face lifts and liposuction, are combined with local autologous fat grafting, the risk of ocular arterial system embolism increases, because intravascular delivery of fat tissue is easier in pretraumatized soft tissue.

This condition should be prevented.

A useful algorithm approach is presented to minimize the occurrence of ophthalmic rterial system embolization during facial cosmetic injections6.

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Treatment To optimize the possibility of fully or partially regaining normal vision, early recognition and treatment are essential for treating ocular circulation emboli. The goal of treatment is rapid restoration of perfusion to the retina and optic nerve before 90 minutes.

Nonsurgical Management - Downstream location to improve retinal perfusion - Globe massage (repeated increased pressure was applied to the globe for 10 to 15 seconds, followed by a sudden release with an in-and-out movement using a three-mirror contact lens for 3 to 5 minutes) - Hyaluronidase a mucolytic enzyme that facilitates the spread of fluids through tissues by lowering the viscosity of hyaluronic acid - Anterior chamber decompression with a needle or sharp cutting blade paracentesis results in an instantaneous decrease of intraocular pressure - Intravenous administration of diuretics such as acetazolamide (intravenous injection of 500 mg of acetazolamide) - Encouraged by carbogen (5 percent carbon dioxide and 95 percent oxygen) inhalation.

- Hyperbaric oxygen therapy may theoretically be beneficial - Systemic and topical corticosteroids - Systemic and local intraarterial fibrinolyses - Anticoagulation with heparin - Intravenous antibiotics, were initiated 8 hours after the occlusive event - Isovolemic hemodilution in patients with a hematocrit greater than 40 percent (500 ml of blood was withdrawn and 500 ml of 10% hydroxyethyl starch was simultaneously infused within 15 to 30 minutes)

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Surgical Management - Surgical embolectomy ( No data support the assumption that surgical embolectomy of the iatrogenically injected materials within the retinal circulation is a safe method for restoring ophthalmic system circulation ) o Skin necrosis : Vascular embarrassment occurs by external compression of the blood supply by the product or occlusion of the vessel via direct injection of the product into the blood vessel The risk of skin necrosis can be reduced by7 1. Aspirating prior to injection 2. Utilizing lower volumes and serial injections 3. Injecting in a more superficial plane 4. Pinching/tenting the skin to provide more space superficial to the branches of the main arteries 5. Manual occlusion of the origin of the supratrochlear vessels with the nondominant finger

Case 1 Skin necrosis

Case 1 Skin necrosis after treatment

Case 2 Skin necrosis

Case 3 Skin necrosis

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Case 3 Skin necrosis

Case 4

Case 5

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Thread Rhinoplasty Wiwat Tatirat

Introduction (History)

Thread Rhinoplasty uses PDS thread an implant or filler in areas of nose. The techniques are described to lift or to form volume of nasal tissue without traditional incisions.

The technique is to pass threads, by needle perforations, to lift or fix them into deep nasal dermis.

Thread Rhinoplasty tips: Dorsum and columella augmentation, nasal root and tip refinement; and nasal alar base narrowing.

Materials

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The thread is a synthetic polydioxanone monofilament absorbable suture (PDS). Traditionally, it is indicated for the use in soft tissue approximation, such as pediatric cardiovascular tissue and ophthalmic surgery. It is absorbed about 182 - 238 days, degraded byhydrolysis. End products are mainly excreted in urine and digestive tract.

Because of its biochemical harmless, PDS thread is applied for a nasal implant or filler and a simple procedure without any surgical incision.

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Methods: Steps in Nasal Augmentation

PDS Thread preparation

Nasal root refinement

Before - After

Thread insertion with needle guidance

Dorsal augmentation

Columella lengthening

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Steps in Alar base narrowing

Mini puncture

Before – After

Indications

PDS Thread insertion

1. Nasal augmentation and root to tip refinement 2. Alar base narrowing Contraindiactions Nasal skin infections, previous implantation Complications The result is non – permanent, not more than one year

Conclusion:

In normal augmented rhinoplasty, the silicone is used to shape the nasal profile. As in thread rhinoplasty, what it did was to invent some techniques to shape the nasal profile externally without making any skin incision. Just need to make injections to allow the threads in to transform the nose and base. The concept is actually rather simple.

However, in the past year, I have done several cases and found that the results are not as lasting as a proper rhinoplasty. This is an only alternative procedure.

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Fixation

Cartilaginous Augmentation Rhinoplasty Neil Solomons

Cosmetic surgery among Asians has become more common & socially acceptable. After surgery to create the ‘double eyelid’, rhinoplasty is probably the commonest requested procedure.

Raising the height of the nose and projecting the tip are the desired outcomes. Reduction rhinoplasty techniques are seldom applicable in the Asian nose.

Cartilaginous augmentation rhinoplasty has its main role in the Asian nose. Augmentation rhinoplasty in the non-Asian or Caucasian nose is mainly performed after trauma to the nose resulting in the classic ‘saddle’ nose. Most Asian patients wanting a rhinoplasty are doing so because of the typical Asian nose characteristics. These are typified by a flat, low dorsum that is often wide as well as poor nasal tip projection. In addition the Asian nose tends to have weak and soft lower lateral cartilages with relatively thick sebaceous skin.

As cosmetic surgery of the Asian nose has evolved, surgeons have sought improvement using alloplastic implants. Although the majority of patients do well with these implants, a number develop complications. These include thinning of the skin over the implant, extrusion, infection, displacement, translucency and chronic pain. A later problem is shortening of the nose due to absorption and atrophy of the tip structures. Other alloplasts used include Gore-tex (PTFE) and Med-Pore.

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Autologous implants that have been used include cavarial bone grafts, iliac bone, costal bone and costal cartilage. Septal and auricular cartilage seldom provide adequate or suitable material for augmentation of the Asian nose.

This talk will focus on the use of costal cartilage as the primary source of material for augmentation rhinoplasty. The advantages and disadvantages will be discussed and salient points of the surgical technique highlighted.

Before After (Courtesy by Dr. Choladhis S.) (Courtesy by Dr. Choladhis S.)

Microscopic Appearance (Courtesy by Dr. Choladhis S.)

Multiplication of Nuclei in Lacuna (Courtesy by Dr. Choladhis S.)

Costal Cartilage After Carving (Courtesy by Dr. Choladhis S.) (Courtesy by Dr. Choladhis S.) 130

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Nasal Reconstruction Pakdee Sanikorn

Nasal defects mostly result from excision of skin tumors as basal cell carcinoma,squamous cell carcinoms,melanoma,etc. Other acquire nasal defects are usually cause by trauma, burn or sepsis.

Principle of Surgical treatment of Nasal malignancy.

1. Complete tumor removal with adequate margin.

2. Maintain function.

3. Proper cosmetic outcome.

Principle of Nasal Reconstruction after tumor removal.

Step ladder in reconstructive surgery is the most important basic principles for planning in nasal reconstruction after tumor removal.

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Primary wound closure is possible for small skin defects of the nose, especially in the elderly patient where nasal skin tends to be redundant, the defect that are 1.0 cm. or smaller in size and located on the dorsum or sidewall are required most easily. When primary wound closure is not possible,cutaneous flaps harvested from the nasal skin may be an alternative for repair of centrally located nasal skin defects that measure up to 2.5.cm. in greatest dimension.Flaps harvested from nasal skin have the advantage of color,texture,and thickness similar to those of the missing skin of the defect.

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1. Full-thickness skin grafts may be used in cases of very superficial cutaneous defects anywhere on the nose without the consequence of significant contour or textural discrepancies between graft and nasal skin.

2. Small lesion can be close by local flaps 2.1 Bilobe flap

2.2 Naso-labial flap

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2.3 Transposition

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2.4 Advancement

2.5 Melolabial flap.

This flap has multiple variations depend on location and size of the defects.

2.5.1 Defect at tip of nose

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2.5.2 Defect of nasal alar

3. In large lesion ( Advance Nasal Cancer) Forehead flap remains the workhorse for major nasal reconstruction today. Paramedian forehead flaps are the preferred local flap for resurfacing most large nasal defects.

Vascularization of the forehead is supplied by the supraorbital,supratrochlear, superficial temporal, postauricular and occipital vessels. All these vessels are lined vertically and permit safe and effective transfer of the forehead flap on multiple individual vascular pedicles. Perfusion of paramedial forehead flap comes from three sourses: randomly, through the frontalis muscle and through the supratrochlear artery. Forehead flap is an axial flap with a pedicle containing its dominant vessel,the pedicle can safely be narrowed to 1-1.2 cm 3.1 Single stage mid-line forehead flap

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3.2 Large defect of nasal alar and lateral wall of nose

3.3 Total Nasal Reconstruction.

In advance malignancy of nose,the most important step is complete excision of tumor with adequate free margin

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after second stage of reconstruction

Conclusion Defects of the nose may be classified according to location,depth,and size. Skin only defect may be replaced with full thickness skin grafts, local flaps, or skin transferred from the cheek or forehead. Defects involving loss of bony structure require replacement of skeletal support and soft tissue coverage.

Application of aesthetic unit princilpes provides a logical cognitive approach to reconstruction.

Missing tissue must be replaced with like tissue in a quantity and quality that exactly replicates the pattern, surface area, and contour of the absent unit.

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Revision Rhinoplasty Levi John Lansangan

Using as a liquid elastomer for a lot of plastic mouldings. Unfortunately, despite numerous reports of its side effects and irreversible destruction of the skin soft tissue envelope a lot of patients still undergo this form of treatment from underground salons and spas for a quick beauty enhancement procedure. The most commonly observed complications are granuloma formation and migration 1. 1st documented use in the late 60’s to augment the nose, it was used primarily to correct deformity caused by trauma to the nose 2. Available at 1000 and 5000 centistrokes which differs upon their viscosity 3. Until the early 70’s there was prevalent use of this product together will injectable paraffin (used for making candles and waxes) and injectable petroleum jelly 4. However during the late 70’s complications of this product started to show such as migration, irregularity, infection, contracture formation and virtual facial deformation that this injection material was banned from the market 5. Unfortunately in our country it is still being used by other aestheticians and unqualified doctors in search for quick source of income irregardless of the patients health 6. When this material is injected into the body, it stimulates a highly reactive process consisting of multi-nucleated giant cells and eventual granuloma formation as an attempt by the body to prevent the spread of this injurious agent thereby creating irregular bumps and humps in the nose

In this patient there is loss of the nasoorbitofrontal line which is an imaginary line from the eyebrows tapering into the nasal tip to. Loss of the line gives an impression of a wide nose.

There is no other solution for this problem but to do a revision rhinoplasty and completely remove the injected material using sharp dissection

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in this patient several cc of the liquid silicone was injected that completely defomed the nose. There was loss of skin elasticity and migration of the material to the nasal tip giving a drooping appearance. There was so much material injected that the skin is on a diseased state, - which on this case is as hard as a stone.

Even with meticulous dissection the material cannot be removed without avulsing the external skin. Therefore in this case I do en bloc skin excision together with the disease tissue and material and re-approximate two normal edges of the skin

B. SILICONE RUBBER IMPLANTS Dimethylsiloxane [S1O(CH3)2], silicone rubber implants with or without polymer fabric have been used in the augmentation for facial plastic surgery since 1950s. The silicone facial implants are solid, yet flexible, and come in several sizes and shapes and can even be custom made from a solid block of silicone. Silicone easily can be modified intraoperatively with a scalpel or scissors. This material has “memory,” which demands adaptation to bone contour in the “relaxed” state, since bending may lead to extrusion or bone resorption.

These implants easily are sterilized using steam autoclave or irradiation without damaging the material. Surrounding tissues do not react adversely to silicone, and only a thin fibrous apsule forms without ingrowth of tissue. Porous silicone implants and silicone bonded to Dacron have been used to enhance stability.

Silicon implants have numerous advantages. They are readily available with an unlimited supply, they are easy to fashion into the desired shape, they resist warping and resorption, and they have no donor-site morbidity. For these reasons, Silicon implants have many proponents.

However, Silicon implants have been noted to have higher rates of infection and extrusion. Infection of the implant may leave the patient with permanent damage to the overlying skin.

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Silicone Implant

• During the 80’s this was regarded as a miracle implant that can correct any desired height for the nasal bridge • It is available as L-type, I-type and the bird type which differs from each other by the presence of a neck • It is a silastic implant that heals by encapsulation.

It is being treated as a foreign body thereby there is very loose attachment between the implant and the nasal tissues • The material is a cheap plastic like material and widely available in prosthetics shops and other body fitting medical devices shops • Other doctor use preformed silicone implants while others carve this to bring a more custom fit implant for the nose

Contracture Formation caused by a failed silicone implant

Extrusion of the silicone implant on the surgeon’s side or area of weakness

Another case of silicone implant extrusion on the surgeon’s side

Cause of deviation following the surgeon’s side of incision

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c. EPTFE

The history of Gore-Tex started in 1958 when Wilbert Gore identified expanded polytetrafluoroethylene (EPTFE) better known to us as DuPont Teflon as a good augmentation material. After more than 700,000 clinical uses, they found out that these soft tissue patches provide the strength and thickness required for demanding repairs . In addition, it was found out that the size of the pores which ranges from 0.5 to 30 microns allow cells such as macrophages to penetrate with the material and incorporate with the surrounding tissue which may be the reason why there is a low incidence of infection after these implants.

However, one of the problems encountered by surgeons when using this implant for facial augmentation is its relative suppleness that makes carving difficult. One of the main difference between EPTFE and silicone is that the former follows the patients nasal anatomy and doesn’t have a body of its own, thereby each implant should be carved individually basing on the patients nose contours and aesthetic desires. A familiarity with our ethnic facial measurements would help us decide on the ideal nasal height and avoid too much or too little of an augmentation common during the initial patients of gore-tex rhinoplasty.

The nasoorbital groove is an ideal landmark in order to guide us on the width of the implant. A natural nose should neither be too straight and too bulky but rather should have a graceful transition from its origin at the medial point of the brow becoming narrower at nasion level wherein the skin is thinnest and, gradually becoming wider again as it approaches the tip defining point. The width of this groove is around 8-12mm, therefore our most superior EPTFE implant should be within this range as well.

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Each implant should be carved tangentially (45o) making sure that the edges will be trimmed well in order to avoid any squared implant appearance.

Nowadays, the standards of beauty have become so high that the profile view of the person is equally as important as the frontal view. The former is the measure of the desired height and its starting projection should be the most anterior projection of the chin. One good measure of nasal beauty is its harmony and symmetry with the rest of the facial features.

The height of Asian noses usually begins just below the imaginary line drawn between the intercanthal distance or at the area of the nasion. It should be elevated by around 4-6 mm in order to reach to desired height at the level of the superior palpebral fissure line. 2 layers of 3mm EPTFE or 3 layers of 2mm can be used for this purpose making sure that each layer should be a little bit wider as compared to the superior layer. For example if the most superior layer is 12mm, the succeeding layer should be 14 mm and so on and so forth.

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The e-PTFE implant can also be infected. The presentation of patients with infection caused by the e-PTFE implant is more severe since there is no point of weakness. Patients usually complain of a fluctuant mass in the ethmoid area with or without draining pus in the vestibular  area.

Infection caused by the e-PTFE implant

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Another infection caused by the e-PTFE implant

Conclusion: Liquid silicone should not be used for augmentation rhinoplasty as this causes dermal thickening and destruction of the skin soft tissue envelope. When choosing an implant material porous implants such as the e-PTFE have lower infection rate because of the mircopore effect that allows tissues and macrophages to pass through the implant. Infection caused by e-PTFE implant are more severe in presentation. The safest materials used for augmentation rhinoplasty are still the autologous implants.

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Edited by Choladhis Sinrachtanant Associate – Editors Jaturong Jongsatitpaiboon

Kritsada Kowitwibool

Natamon Charakorn

Palapong Chayasu

Sacarin Bunbanjerdsuk

Valop Supavanich

Jiratta Ngamsiridesh

Khanti Wiwatwisawakorn

Pataraporn Ouirungroj

Sarinya Urathamakul

Thadchai Suwanwarangkool

Permpoon piyaman

Woraya kattipattanapong

Panyaluk chuchuen

Suwisa tadsawaswong

Thanapan Poomchaivej

Contributors Chalerm Supakmontri

Chanchai Chalakorn

Chalermchai Chintrakarn

Jumroon Tungkeeratichai

Kowit Pruegsanusak

Pakdee Sanikorn

Pakpoom Supiyaphum

Perapun Jareonchasri

Rak Tananuvat

Samphan Khomrit

Saranchai Kiatsurayanon

Siripornchai Supanakorn

Somyos Kunachak

Samut Chongvisal

Tanom Bunaprasert

Thongchai Bhongmakapat

Teerawat Srinakarin

Virachai Kerekhanjanarong

Wiwat Tatrirat

Ian Loh

Lansangan

Neil Solomon

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