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Dichotomy of Rhinoplasty Practice: From the Conference Floor to the Operating Room Pietro Palma, MD1,2
Iman Khodaei, MD3
1 The Face Clinic, Milan, Italy 2 Department of ORL/HNS, University of Insubria, Varese, Italy 3 Department of ORL/HNS, Mehregan Clinic, Karaj, Iran
Address for correspondence Pietro Palma, MD, Department of ORL/ HNS, University of Insubria, Varese, Italy (e-mail: [email protected]).
Abstract
Keywords
► rhinoplasty education ► evidence-based rhinoplasty ► rhinoplasty techniques
Advancements in surgical techniques and improvements in clinical practice inevitably lag behind scientific progress and peer-led opinion. The rapid rise and fall in the popularity of rhinoplasty techniques makes scientific evidence-gathering and education a daunting task. Students of rhinoplasty face a long and steep learning curve, and need to acquire sound analytical tools to critically evaluate both literature contributions and operative reports shown in conferences. Such a complex learning process requires continuous self-examination, and must account for the increasingly sophisticated and intricate wishes of rhinoplasty patients whose desires do not always coincide with what surgeons have been taught and practiced. In contemporary practice, the developing rhinoplasty surgeon must be also familiar with the range of racial features, as the broad variety of nasal anatomies and beauty canons are truly staggering, and one formula does not fit all cases. The complex set of circumstances that lead to disharmony between scientific progress and clinical practice is addressed, and a utilitarian plan to remedy this awkward dichotomy is suggested.
Rhinoplasty is such a highly individual-based operation that requires predictability, acceptance, endurance, and safety. For this reason, any absolute dogma can be hardly implemented on a large scale. Lack of evidence-based outcomes still remains an unsolved problem in rhinoplasty education. When evaluating the topics of major rhinoplasty meetings the astute observer will clearly realize that rhinoplasty is not immune from fashion trends. Some techniques have witnessed a sudden flowering of popularity, followed by a rapid wilting and demise as they do not overcome the harsh test of time. Similarly, it is evident that rhinoplasty trends are established by rhinoplasty “gurus.” Their contribution is essential in pushing the borders of rhinoplasty surgery forward. However, these audacious techniques should not be undertaken by less experienced surgeons in a reckless attempt to emulate their mentors.
Issue Theme 11th International Symposium of Facial Plastic Surgery; Guest Editors, Jonathan M. Sykes, MD, FACS, and Anthony P. Sclafani, MD, FACS.
Recent rhinoplasty literature reveals a definite trend to utilize the external approach in rhinoplasty. Open reconstruction instead of reshaping has become the common theme of most current rhinoplasty contributions. In the last two decades rhinoplasty surgeons—especially in North America—felt that nasal structures could not be seen, complex cases were not treatable, and teaching juniors is made more cumbersome by the so-called closed approach that had been trivialized as “reduction rhinoplasty.” In reality, none of these arguments are true. The busy rhinoplasty surgeon has witnessed that neither a “closed” reduction rhinoplasty nor an “external” structural rhinoplasty provides all the answers required by the enormous variety of clinical situations. In particular, the vast majority of patients presenting for cosmetic rhinoplasty neither desire nor require major reconstruction of the nose. “Hybrid” rhinoplasty refers to the happy marriage of the
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1371903. ISSN 0736-6825.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Facial Plast Surg 2014;30:103–112.
Dichotomy of Rhinoplasty Practice
Palma, Khodaei
best of both philosophical approaches: the lessons learned from the external approach, mainly grafting procedures and suturing techniques, are combined with the philosophy of minimal tissue plane distortion and preservation of normal structures of endonasal surgery to create an alternative third pathway for rhinoplasty. So, good reasons exist for believing that the demise of endonasal rhinoplasty cannot be justified, and requires serious reconsideration by surgical educators. Students of rhinoplasty face a long and steep learning curve, and need to acquire sound analytical tools to critically evaluate both literature contributions and operative reports shown on the conference floor. Continuing surgical education beyond final examinations, dissection courses, international conferences, and peer-led evaluation can set the background for bridging the gap between scientific progress and clinical practice. The complex set of circumstances that lead to this disharmony need to be addressed if the highest levels of care for our rhinoplasty patients are to be maintained.
Clinical Situations Four clinical situations frequently encountered in daily rhinoplasty practice have been chosen as paradigmatically controversial in terms of both aesthetic analysis and surgical options. All the four situations were managed by the senior surgeon (P.P.) through an endonasal “extended” transcartilagenous approach. The intracartilagenous incision not only provides direct access to the desired point of exposure and sculpting of the lateral crura, but also allows modelling of the scroll areas as planned in the preoperative game plan. Grafts and sutures can also be used through the transcartilagenous approach and concurrent endonasal incisions (hemitransfixion, partial infracartilaginous or slot “custom-made” incisions). Such an “extended” transcartilagenous approach, allows for greater flexibility in dealing even with intricate tip problems and in recreating more appealing surface aesthetics.
Clinical Situation No. 1 Extracorporeal Septoplasty in Twisted Noses Severe deviations of the septum and external nose represent some of the most challenging situations in rhinoplasty. Many different techniques had been defined for dealing with these cases, but none with a universally excellent and predictable result. In the past, the technique of extracorporeal septoplasty through the open approach has been proposed as the ideal solution for managing the severely deviated nasal septum,1 and the only technique indicated in a severely twisted nose. The technique represents an interesting advance in the surgery of the nasal septum, but cannot be seen as dogma. In the vast majority of cases, more conservative “in situ” septoplasty techniques work successfully when properly planned and correctly executed, without structurally destaFacial Plastic Surgery
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bilizing the dorsal and caudal support of the cartilaginous nose (►Fig. 1).
Clinical Situation No. 2 From the “BI-Tip” to the Smooth Single Tip The evolution of facial analysis over the past few decades shows a marked change in our evaluation of the nasal tip. A simple glance at the pictures of film stars and models 30 years ago displays this difference. In the late 1990s rhinoplasty surgeons had been taught that on the frontal view the tip should have four defining landmarks, the unilateral tip defining points, the supratip break, and the columellar lobular angle. The lines connecting these four landmarks should form two equilateral triangles.2,3 This ideal tip aesthetics led to the development of a plethora of tip-plasty techniques, mainly sutures and grafts.4–6 The concept of the double light reflection from the tip no longer is featured in glossy fashion magazines. At present, the SST makes a firm presence on practically every supermodel’s face, whether male or female. This particular type of tip blends effortlessly with the adjoining aesthetic units, and is inseparable from them. As patients often seek to emulate their icons, requests for the SST are increasing, and require an aesthetic reconsideration on our behalf, a modification of current techniques, and a readjustment in the canons of nasal aesthetic ideals. While emphasizing the importance of creating desirable surface aesthetics, delivering the SST demands alterations in tip surgery, including a reassessment of suturing techniques, structural grafting, and dome-splitting techniques.7 The overall effect of the SST will result in an anatomic rearrangement of all the aesthetic subunits of the nasal tip aimed to restore the subtle interaction of lines, proportions, and create smooth light-shadow interplay (►Fig. 2).
Clinical Situation No. 3 Columellar Strut versus Tongue-in-Groove Suture A common technique in many surgeons’ arsenal, the columellar strut has been used for many reasons, including changing tip position or stability, or increasing tip projection.8 In recent years, clinical experience has shown that columellar strut is not a benign, low-risk surgical procedure and is associated with potential complications (shifting, clicking, tactile perception, and unnatural columellar-lip contour). In contrast, the tongue-in-groove suture9 or modified tongue-in-groove suture coupled with contour grafts10 may result in a stable and more natural contour, despite some rigidity of the caudal septum–middle crura junction. An example of the tongue-in-groove suture used to set the tip in a more aesthetic position can be seen in ►Fig. 3.
Clinical Situation No. 4 Tension Nose A common cosmetic deformity, especially in certain regions of the world, a tension nose consists of an overly large septum
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Dichotomy of Rhinoplasty Practice
Fig. 1 (A–E) Preoperative and (F–J) postoperative views of a young adult male patient with asymmetric nose. The operation highlights “in situ” septoplasty techniques; transcartilagenous approach; asymmetrical sculpting of lateral crura and scroll areas; hump removal; asymmetrical osteotomies to rebuild more asymmetrical brow-dome lines; alar rim contour grafts through “slot” infracartilaginous incisions; and equalization of the alar-cheek junctions.
jutting forward from the facial plane. A tension nose is the result of an overprojection of the middle third of the nose that looks too massive for that particular individual’s nasal and facial proportions.11 The minimal common denominator is represented by an overprojection of the cartilaginous pyramid with the anterior septal angle being the point of maximal dorsal projection. Many tension nose patients require dorsal humpectomy. Several surgeons utilize spreader grafts prophylactically to avoid midvault pinching and the functional sequelae poten-
tially associated with dorsal resection. Placement of cartilaginous spreader grafts complicates surgery and introduces an additional area of possible contour irregularities. The authors tend to minimize the use of spreader grafts in this common clinical situation due to the main implication of such a step: the grafts will broaden the dorsum of the nose which many patients, especially women, do not desire. In addition, these grafts may distort the smooth flow of the brow-dome lines. Moreover, the spreader graft—when aimed to open the internal valve—must be harvested with significant thickness Facial Plastic Surgery
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and may compromise the internal nasal valve area. The internal nasal valve is the main resistive area of the whole airway and a reduction in its cross-sectional area may cause persistent airway obstruction. As an alternative to placing spreader grafts, a fold of mucosa released from the upper lateral cartilages–septum
junction (extramucosal technique proposed by Robin12) may be interposed between the nasal septum and upper lateral cartilages. This latter technique will produce a softer spreading effect and help to prevent a decrease in the vital angle of the internal valve, without causing the above potential problems (►Fig. 4).
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Fig. 2 (A–G) Preoperative and (H–N) postoperative views of a young female patient. The patient asked for straight “aristocratic” dorsum and softening of the tip. The patient specifically requested to diminish the effect of the depressor nasi septi muscle on the upper lip and tip position in the dynamic phase. Operation highlights: septoplasty and depressor septi nasi release via hemitransfixion incision; transcartilagenous approach for tip and scrolls sculpting; hump removal; basal osteotomies and infracture without paramedian osteotomies; and subdomal sutures to improve tip definition/width angles.
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Fig. 2
Palma, Khodaei
(Continued)
A Utilitarian Plan to Remedy the Dichotomies in Rhinoplasty As facial plastic surgery, and rhinoplasty in particular have become more widely acceptable around the world, educating an army of capable, safe, and cautious surgeons has created its own problem. The long years of training required to accumulate enough technical expertise to answer most challenges precludes the ability of short courses, the episodic conference attendance, or reading a review article to produce a competent, experienced surgeon. To be effective, postgraduate education must be systematic, scientific, peer-led, and reflective. This requires both a major investment in time and educational finances, and a long-term commitment by educators to teach, examine, and review results. Continuing the medical education, along with mentoring, travelling to various centers of excellence, and attendance at reputable confer-
ences and dissection courses, form the backbone of contemporary surgical education. Unless we adhere to these guiding principles, the levels of surgical competence will not advance. Scientific research forms the basis of surgical practice. And yet, good quality evidence-based research is scarce due to the time-consuming and costly venture of finding good answers to surgical questions. Furthermore, rhinoplasty has witnessed a very rapid rate of evolution over the past century, so a certain technique may not endure long enough for adequate scientific analysis trials. Certain ideas, such as the widespread use of shield grafts, have witnessed a sudden flowering of popularity, followed by a rapid wilting and demise of the bouquet as routine use of this technique has shown significant drawbacks. Other examples of dichotomy between what is presented in conferences as fashionable, and what is useful in clinical Facial Plastic Surgery
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Fig. 3 (A–H) Preoperative and (I–P) postoperative views of a young male patient with tension nose. The patient requested a strong masculine dorsum and a correction of the animation of tip in the dynamic phase. Operation highlights: septoplasty with caudal infratip shortening; shifting back of the posterior septal angle, reduction of the overprojection of the anteroinferior nasal spine, excision of the depressor septi nasi together with debulking of the soft tissues in-between the feet of the medial crura via hemitransfixion incision; extramucosal approach to the cartilaginous vault; basal osteotomes and infracture without paramedian osteotomies; and tongue-in-groove suture for setting the tip in a more aesthetical position.
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Fig. 3 (Continued)
practice include the progressive restriction of the large scale use of costal cartilage in primary rhinoplasty, relocation of lower lateral cartilages, structural grafting, and extracorporeal septoplasty. While these techniques have been significant in the evolution of rhinoplasty and are still vital in particular cases, an increasing number of surgeons have moved to less complicated and more reproducible techniques. The true secret of a successful rhinoplasty practice is achieving consistently good-to-excellent outcomes in the vast majority of cases rather than the spectacular result in a not too high percentage of cases. This philosophy will also minimize the rate and seriousness of untoward outcomes and complications. Practical facial analysis13 guides the surgeon to create a patient-specific surgical plan. There is a large difference between practical facial analysis that deals with surgically modifiable landmarks important for that particular patient, and the facial analyses that fill power point presentations or major textbooks with several slides and pages of impractical facial angles and proportions.14 Each population has certain ethnic and cultural requirements that need to be considered when applying theories of facial analysis to the relevant operative plan. Therefore, facial analysis needs to be patient-specific and culturally relevant. Many patients, especially primary rhinoplasty patients, do not consider the width
of the cartilaginous vault, slight alar collapse, height/depth of the nasion, or position of the nostril rim in their wish list for change. They usually ask for “no hump,” “raised tip,” or a “shorter nose.” This requires patient-specific surgery, rather than the imposition of a “precooked” treatment plan for each case. Nevertheless, the astute surgeon may still recommend changes that may not be immediately obvious to the patient, such as augmentation of the radix area, a chin implant, or injectable options. These complex considerations have a major impact in the way we screen our patients, elaborate the game plan, and perform surgery. Morphing has become a mandatory step in the authors’ preoperative workup. This tool enables the surgeon to better understand patient wishes, to simplify the surgical plan and to effectively communicate this plan to the patient. Patients currently depend on the Internet for visual confirmation of proposed results. “Before and after surgery” photographs and “morphing”15 have now become a compulsory viewing for patients before they decide on having surgery and on their surgeon. Showing pre- and postoperative pictures on a surgeon’s personal Web site is of critical importance, and must be considered as much more than a marketing tool. In fact, patients looking at the “cases gallery” will have the time to “digest” the aesthetic “attitude” of that specific surgeon, and will allow the patient the opportunity to Facial Plastic Surgery
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Palma, Khodaei
Fig. 4 (A–I) Preoperative and (J–R) postoperative views of a young male patient with severe septal deviation, twisted nose, narrow cartilaginous vault, and moderate tip bulbosity. The patient strongly requested an endonasal approach and conservative changes. Operation highlights: septoplasty, septal angles remodeling, and release of the depressor septi through hemitransfixion incision; upper and upper-lateral aspects of lateral crura together with scrolls were sculpted through a transcartilagenous approach; creation of submucosal tunnels under the cartilaginous vault extended to the bony vault to create a “spreader effect.” Radix and tip position were adjusted to aesthetically match the requested profile line.
match the surgeon’s aesthetic philosophy with the patient’s desires and expectations. After almost 100 years of experience in rhinoplasty, the current trend in surgical education consists of less aggressive tissue removal and the use of reversible techniques when possible. No single approach to rhinoplasty has provided all the answers to specific problems.16–18 The ideal choice is adopting an adaptable technique that has provided predictable, safe results in the hands of that specific surgeon. In this manner, the best techniques derived from external and endonasal surgery can be combined in a single operation, the hybrid rhinoplasty.19 For each patient, the surgeon deFacial Plastic Surgery
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fines a risk–benefit curve and aims for the pinnacle of the graph, before stepping into the red zone of rapid descent toward poor results.20 Even in the best of hands, a small number of patients require a minor touch-up operation: this is the hard reality of rhinoplasty. Both the patient and the surgeon need to accept this before embarking on this operative journey.21
Discussion Surgical education in rhinoplasty has traditionally been peerled and scientifically driven. As rhinoplasty has universally
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Fig. 4 (Continued)
accepted as being one of the more challenging facial plastic operations, the steep learning curve of a at least a decade should not surprise anyone. At present, there are a large number of reputable anatomical and technical courses that provide students of rhinoplasty with a bewildering choice of which one to choose for further education. To complicate matters, the current harsh economic climate has reduced patient numbers and opportunities for surgeons to gain experience in a minefield of rising patient’s demands and expectations. Peer-led education from a conference floor does
not readily translate into better surgical practice for several reasons: the more junior surgeons may require years of technical practice before they become fluent at the most basic level. Every training center and fellowship needs to be encouraged to emphasize and rehearse—and re-rehearse— the fundamental importance of anatomic evaluation and diagnosis. Mistakes in the latter arena are responsible for the majority of rhinoplasty complications. Successful rhinoplasty relies heavily on the surgical expertise of the surgeon whose craftsmanship takes time Facial Plastic Surgery
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to mature and develop. This technical capability can be unique to the surgeon and not readily reproducible by another practitioner. Unlike endoscopic endonasal sinus surgery where the development of technology has had a major impact on the evolution of the techniques or in the implementation of original procedures, rhinoplasty has not witnessed substantial technological advances able to produce seismic shifts in practice. In rhinoplasty, matters are complicated by the patient’s psychological state and needs, and the surgeon’s ability to perform surgically relevant facial analysis, and his/her sense of beauty and harmony in formulating a patient-specific game plan. Technically, creating subtle change in such a challenging area is beyond the abilities of many surgeons as they venture into this field. Expecting students of rhinoplasty to copy a technique they have just seen in a conference is neither realistic nor safe. The second major problem of transferring knowledge into practice consists of the gap, or dichotomy between what patient’s want, and scientific revelation. Patients may be influenced by fashion, trends, friends, or unrealistic expectations. Informing them of the latest progress on the science of facial aesthetics or analysis does little to change their mind or revise their priorities.
excessive surgical maneuvers, rather than individualized, patient-centered surgery. The dogmatic approach to rhinoplasty must be abandoned in favor of an evidence-based rhinoplasty philosophy, or surgeons may face the prospect of stagnation and the demise of excellence in practice.
References 1 Gubisch W. Extracorporeal septoplasty for the markedly deviated
septum. Arch Facial Plast Surg 2005;7(4):218–226 2 Gunter JP. Facial analysis for the rhinoplasty patient. In: 12th
3 4 5 6 7
8
Conclusion
9
Continuing medical education forms the backbone of contemporary surgical education. Rhinoplasty poses specific problems that require thorough reflection as what is presented on a conference floor does not per se translate into better surgical practice. The bulk of knowledge coming from books, articles, and conferences should be filtered by each individual rhinoplasty surgeon in the light of his/her educational background, analytical capabilities, surgical skills level, and profile of his/her individual rhinoplasty practice. There are two major dichotomies in rhinoplasty: first, there is a difference between learning theoretical surgical techniques, and their application in the operating room. Second, there is a distinct difference between what patients want, and the results of scientific research in the field of facial/nasal aesthetics and surgery. The authors have pointed out some complex matters that have a major impact in the way rhinoplasty surgeons should screen patients, elaborate their game plan, and choose the most suitable techniques among the many existing operative options. Collective experience has clearly demonstrated that there is no single best way that can correct the wide variety of anatomic disharmonies encountered and answer all the demands of rhinoplasty patients. While some patients require major structural changes, others only need subtle changes in surface aesthetics.22 Applying the same techniques in every case can result in inadequate surgery, or
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10 11
12 13
14 15
16 17 18
19
20 21 22
Annual Dallas Rhinoplasty Symposium. Dallas, TX: Southwestern Medical Center; 1995:17–27 Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg 2006;8(3):156–185 Tardy ME Jr. Rhinoplasty: The Art and the Science. Philadelphia, PA: WB Saunders Company; 1997 Perkins S, Patel A. Endonasal suture techniques in tip rhinoplasty. Facial Plast Surg Clin North Am 2009;17(1):41–54, vi Daniel RK. Mastering Rhinoplasty. Berlin Heidelberg, Germany: Springer-Verlag; 2010 Dayan S, Kanodia R. Has the pendulum swung too far?: trends in the teaching of endonasal rhinoplasty Arch Facial Plast Surg 2009; 11(6):414–416 Pastorek N, Ham J. The underprojecting nasal tip: an endonasal approach. Facial Plast Surg Clin North Am 2004;12(1):93–106 Kridel RW, Scott BA, Foda HM. The tongue-in-groove technique in septorhinoplasty. A 10-year experience. Arch Facial Plast Surg 1999;1(4):246–256, discussion 257–258 Palma P, Khodaei I. Why do I favour the endonasal approach? B-ENT 2010;6(Suppl 15):25–33 Nolst Trenité GJ. Rhinoplasty: A Practical Guide to Functional and Aesthetic Surgery of the Nose. The Hague, The Netherlands: Kugler Publications; 2010 Robin JL. Extramucosal method in rhinoplasty. Aesthetic Plast Surg 1979;3(1):171–178 Palma P, Khodaei I, Tasman A-J. A guide to the assessment and analysis of the rhinoplasty patient. Facial Plast Surg 2011;27(2): 146–159 Powell N, Humphreys B. Proportions of the Aesthetic Face. New York, NY: Thieme Stratton Inc.; 1984 Agarwal A, Gracely E, Silver WE. Realistic expectations: to morph or not to morph? Plast Reconstr Surg 2007;119(4):1343–1351, discussion 1352–1353 Gunter JP. The merits of the open approach in rhinoplasty. Plast Reconstr Surg 1997;99(3):863–867 Simons RL. A personal report: emphasizing the endonasal approach. Facial Plast Surg Clin N Am 2004;12(1):15–34 Perkins SW. The evolution of the combined use of endonasal and external columellar approaches to rhinoplasty. Facial Plast Surg Clin North Am 2004;12(1):35–50 Palma P, Khodaei I. Hybrid rhinoplasty: The 21. st century approach to remodeling the nose. Arch Facial Plast Surg 2010;12(6): 412–414 Sheen JH, Sheen AP. Aesthetic Rhinoplasty. 2nd ed. St. Louis, MO: Quality Medical Publishing; 1998 Rohrich RJ. Streamlining cosmetic surgery patient selection—just say no!. Plast Reconstr Surg 1999;104(1):220–221 Constantian Mark B. Rhinoplasty: Craft & Magic. St. Louis, MO: Quality Medical Publishing; 2009
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Dichotomy of Rhinoplasty Practice: From the Conference Floor to the Operating Room Pietro Palma, MD1,2
Iman Khodaei, MD3
1 The Face Clinic, Milan, Italy 2 Department of ORL/HNS, University of Insubria, Varese, Italy 3 Department of ORL/HNS, Mehregan Clinic, Karaj, Iran
Address for correspondence Pietro Palma, MD, Department of ORL/ HNS, University of Insubria, Varese, Italy (e-mail: [email protected]).
Abstract
Keywords
► rhinoplasty education ► evidence-based rhinoplasty ► rhinoplasty techniques
Advancements in surgical techniques and improvements in clinical practice inevitably lag behind scientific progress and peer-led opinion. The rapid rise and fall in the popularity of rhinoplasty techniques makes scientific evidence-gathering and education a daunting task. Students of rhinoplasty face a long and steep learning curve, and need to acquire sound analytical tools to critically evaluate both literature contributions and operative reports shown in conferences. Such a complex learning process requires continuous self-examination, and must account for the increasingly sophisticated and intricate wishes of rhinoplasty patients whose desires do not always coincide with what surgeons have been taught and practiced. In contemporary practice, the developing rhinoplasty surgeon must be also familiar with the range of racial features, as the broad variety of nasal anatomies and beauty canons are truly staggering, and one formula does not fit all cases. The complex set of circumstances that lead to disharmony between scientific progress and clinical practice is addressed, and a utilitarian plan to remedy this awkward dichotomy is suggested.
Rhinoplasty is such a highly individual-based operation that requires predictability, acceptance, endurance, and safety. For this reason, any absolute dogma can be hardly implemented on a large scale. Lack of evidence-based outcomes still remains an unsolved problem in rhinoplasty education. When evaluating the topics of major rhinoplasty meetings the astute observer will clearly realize that rhinoplasty is not immune from fashion trends. Some techniques have witnessed a sudden flowering of popularity, followed by a rapid wilting and demise as they do not overcome the harsh test of time. Similarly, it is evident that rhinoplasty trends are established by rhinoplasty “gurus.” Their contribution is essential in pushing the borders of rhinoplasty surgery forward. However, these audacious techniques should not be undertaken by less experienced surgeons in a reckless attempt to emulate their mentors.
Issue Theme 11th International Symposium of Facial Plastic Surgery; Guest Editors, Jonathan M. Sykes, MD, FACS, and Anthony P. Sclafani, MD, FACS.
Recent rhinoplasty literature reveals a definite trend to utilize the external approach in rhinoplasty. Open reconstruction instead of reshaping has become the common theme of most current rhinoplasty contributions. In the last two decades rhinoplasty surgeons—especially in North America—felt that nasal structures could not be seen, complex cases were not treatable, and teaching juniors is made more cumbersome by the so-called closed approach that had been trivialized as “reduction rhinoplasty.” In reality, none of these arguments are true. The busy rhinoplasty surgeon has witnessed that neither a “closed” reduction rhinoplasty nor an “external” structural rhinoplasty provides all the answers required by the enormous variety of clinical situations. In particular, the vast majority of patients presenting for cosmetic rhinoplasty neither desire nor require major reconstruction of the nose. “Hybrid” rhinoplasty refers to the happy marriage of the
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1371903. ISSN 0736-6825.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Facial Plast Surg 2014;30:103–112.
Dichotomy of Rhinoplasty Practice
Palma, Khodaei
best of both philosophical approaches: the lessons learned from the external approach, mainly grafting procedures and suturing techniques, are combined with the philosophy of minimal tissue plane distortion and preservation of normal structures of endonasal surgery to create an alternative third pathway for rhinoplasty. So, good reasons exist for believing that the demise of endonasal rhinoplasty cannot be justified, and requires serious reconsideration by surgical educators. Students of rhinoplasty face a long and steep learning curve, and need to acquire sound analytical tools to critically evaluate both literature contributions and operative reports shown on the conference floor. Continuing surgical education beyond final examinations, dissection courses, international conferences, and peer-led evaluation can set the background for bridging the gap between scientific progress and clinical practice. The complex set of circumstances that lead to this disharmony need to be addressed if the highest levels of care for our rhinoplasty patients are to be maintained.
Clinical Situations Four clinical situations frequently encountered in daily rhinoplasty practice have been chosen as paradigmatically controversial in terms of both aesthetic analysis and surgical options. All the four situations were managed by the senior surgeon (P.P.) through an endonasal “extended” transcartilagenous approach. The intracartilagenous incision not only provides direct access to the desired point of exposure and sculpting of the lateral crura, but also allows modelling of the scroll areas as planned in the preoperative game plan. Grafts and sutures can also be used through the transcartilagenous approach and concurrent endonasal incisions (hemitransfixion, partial infracartilaginous or slot “custom-made” incisions). Such an “extended” transcartilagenous approach, allows for greater flexibility in dealing even with intricate tip problems and in recreating more appealing surface aesthetics.
Clinical Situation No. 1 Extracorporeal Septoplasty in Twisted Noses Severe deviations of the septum and external nose represent some of the most challenging situations in rhinoplasty. Many different techniques had been defined for dealing with these cases, but none with a universally excellent and predictable result. In the past, the technique of extracorporeal septoplasty through the open approach has been proposed as the ideal solution for managing the severely deviated nasal septum,1 and the only technique indicated in a severely twisted nose. The technique represents an interesting advance in the surgery of the nasal septum, but cannot be seen as dogma. In the vast majority of cases, more conservative “in situ” septoplasty techniques work successfully when properly planned and correctly executed, without structurally destaFacial Plastic Surgery
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No. 2/2014
bilizing the dorsal and caudal support of the cartilaginous nose (►Fig. 1).
Clinical Situation No. 2 From the “BI-Tip” to the Smooth Single Tip The evolution of facial analysis over the past few decades shows a marked change in our evaluation of the nasal tip. A simple glance at the pictures of film stars and models 30 years ago displays this difference. In the late 1990s rhinoplasty surgeons had been taught that on the frontal view the tip should have four defining landmarks, the unilateral tip defining points, the supratip break, and the columellar lobular angle. The lines connecting these four landmarks should form two equilateral triangles.2,3 This ideal tip aesthetics led to the development of a plethora of tip-plasty techniques, mainly sutures and grafts.4–6 The concept of the double light reflection from the tip no longer is featured in glossy fashion magazines. At present, the SST makes a firm presence on practically every supermodel’s face, whether male or female. This particular type of tip blends effortlessly with the adjoining aesthetic units, and is inseparable from them. As patients often seek to emulate their icons, requests for the SST are increasing, and require an aesthetic reconsideration on our behalf, a modification of current techniques, and a readjustment in the canons of nasal aesthetic ideals. While emphasizing the importance of creating desirable surface aesthetics, delivering the SST demands alterations in tip surgery, including a reassessment of suturing techniques, structural grafting, and dome-splitting techniques.7 The overall effect of the SST will result in an anatomic rearrangement of all the aesthetic subunits of the nasal tip aimed to restore the subtle interaction of lines, proportions, and create smooth light-shadow interplay (►Fig. 2).
Clinical Situation No. 3 Columellar Strut versus Tongue-in-Groove Suture A common technique in many surgeons’ arsenal, the columellar strut has been used for many reasons, including changing tip position or stability, or increasing tip projection.8 In recent years, clinical experience has shown that columellar strut is not a benign, low-risk surgical procedure and is associated with potential complications (shifting, clicking, tactile perception, and unnatural columellar-lip contour). In contrast, the tongue-in-groove suture9 or modified tongue-in-groove suture coupled with contour grafts10 may result in a stable and more natural contour, despite some rigidity of the caudal septum–middle crura junction. An example of the tongue-in-groove suture used to set the tip in a more aesthetic position can be seen in ►Fig. 3.
Clinical Situation No. 4 Tension Nose A common cosmetic deformity, especially in certain regions of the world, a tension nose consists of an overly large septum
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Fig. 1 (A–E) Preoperative and (F–J) postoperative views of a young adult male patient with asymmetric nose. The operation highlights “in situ” septoplasty techniques; transcartilagenous approach; asymmetrical sculpting of lateral crura and scroll areas; hump removal; asymmetrical osteotomies to rebuild more asymmetrical brow-dome lines; alar rim contour grafts through “slot” infracartilaginous incisions; and equalization of the alar-cheek junctions.
jutting forward from the facial plane. A tension nose is the result of an overprojection of the middle third of the nose that looks too massive for that particular individual’s nasal and facial proportions.11 The minimal common denominator is represented by an overprojection of the cartilaginous pyramid with the anterior septal angle being the point of maximal dorsal projection. Many tension nose patients require dorsal humpectomy. Several surgeons utilize spreader grafts prophylactically to avoid midvault pinching and the functional sequelae poten-
tially associated with dorsal resection. Placement of cartilaginous spreader grafts complicates surgery and introduces an additional area of possible contour irregularities. The authors tend to minimize the use of spreader grafts in this common clinical situation due to the main implication of such a step: the grafts will broaden the dorsum of the nose which many patients, especially women, do not desire. In addition, these grafts may distort the smooth flow of the brow-dome lines. Moreover, the spreader graft—when aimed to open the internal valve—must be harvested with significant thickness Facial Plastic Surgery
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and may compromise the internal nasal valve area. The internal nasal valve is the main resistive area of the whole airway and a reduction in its cross-sectional area may cause persistent airway obstruction. As an alternative to placing spreader grafts, a fold of mucosa released from the upper lateral cartilages–septum
junction (extramucosal technique proposed by Robin12) may be interposed between the nasal septum and upper lateral cartilages. This latter technique will produce a softer spreading effect and help to prevent a decrease in the vital angle of the internal valve, without causing the above potential problems (►Fig. 4).
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Fig. 2 (A–G) Preoperative and (H–N) postoperative views of a young female patient. The patient asked for straight “aristocratic” dorsum and softening of the tip. The patient specifically requested to diminish the effect of the depressor nasi septi muscle on the upper lip and tip position in the dynamic phase. Operation highlights: septoplasty and depressor septi nasi release via hemitransfixion incision; transcartilagenous approach for tip and scrolls sculpting; hump removal; basal osteotomies and infracture without paramedian osteotomies; and subdomal sutures to improve tip definition/width angles.
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Fig. 2
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(Continued)
A Utilitarian Plan to Remedy the Dichotomies in Rhinoplasty As facial plastic surgery, and rhinoplasty in particular have become more widely acceptable around the world, educating an army of capable, safe, and cautious surgeons has created its own problem. The long years of training required to accumulate enough technical expertise to answer most challenges precludes the ability of short courses, the episodic conference attendance, or reading a review article to produce a competent, experienced surgeon. To be effective, postgraduate education must be systematic, scientific, peer-led, and reflective. This requires both a major investment in time and educational finances, and a long-term commitment by educators to teach, examine, and review results. Continuing the medical education, along with mentoring, travelling to various centers of excellence, and attendance at reputable confer-
ences and dissection courses, form the backbone of contemporary surgical education. Unless we adhere to these guiding principles, the levels of surgical competence will not advance. Scientific research forms the basis of surgical practice. And yet, good quality evidence-based research is scarce due to the time-consuming and costly venture of finding good answers to surgical questions. Furthermore, rhinoplasty has witnessed a very rapid rate of evolution over the past century, so a certain technique may not endure long enough for adequate scientific analysis trials. Certain ideas, such as the widespread use of shield grafts, have witnessed a sudden flowering of popularity, followed by a rapid wilting and demise of the bouquet as routine use of this technique has shown significant drawbacks. Other examples of dichotomy between what is presented in conferences as fashionable, and what is useful in clinical Facial Plastic Surgery
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Fig. 3 (A–H) Preoperative and (I–P) postoperative views of a young male patient with tension nose. The patient requested a strong masculine dorsum and a correction of the animation of tip in the dynamic phase. Operation highlights: septoplasty with caudal infratip shortening; shifting back of the posterior septal angle, reduction of the overprojection of the anteroinferior nasal spine, excision of the depressor septi nasi together with debulking of the soft tissues in-between the feet of the medial crura via hemitransfixion incision; extramucosal approach to the cartilaginous vault; basal osteotomes and infracture without paramedian osteotomies; and tongue-in-groove suture for setting the tip in a more aesthetical position.
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Fig. 3 (Continued)
practice include the progressive restriction of the large scale use of costal cartilage in primary rhinoplasty, relocation of lower lateral cartilages, structural grafting, and extracorporeal septoplasty. While these techniques have been significant in the evolution of rhinoplasty and are still vital in particular cases, an increasing number of surgeons have moved to less complicated and more reproducible techniques. The true secret of a successful rhinoplasty practice is achieving consistently good-to-excellent outcomes in the vast majority of cases rather than the spectacular result in a not too high percentage of cases. This philosophy will also minimize the rate and seriousness of untoward outcomes and complications. Practical facial analysis13 guides the surgeon to create a patient-specific surgical plan. There is a large difference between practical facial analysis that deals with surgically modifiable landmarks important for that particular patient, and the facial analyses that fill power point presentations or major textbooks with several slides and pages of impractical facial angles and proportions.14 Each population has certain ethnic and cultural requirements that need to be considered when applying theories of facial analysis to the relevant operative plan. Therefore, facial analysis needs to be patient-specific and culturally relevant. Many patients, especially primary rhinoplasty patients, do not consider the width
of the cartilaginous vault, slight alar collapse, height/depth of the nasion, or position of the nostril rim in their wish list for change. They usually ask for “no hump,” “raised tip,” or a “shorter nose.” This requires patient-specific surgery, rather than the imposition of a “precooked” treatment plan for each case. Nevertheless, the astute surgeon may still recommend changes that may not be immediately obvious to the patient, such as augmentation of the radix area, a chin implant, or injectable options. These complex considerations have a major impact in the way we screen our patients, elaborate the game plan, and perform surgery. Morphing has become a mandatory step in the authors’ preoperative workup. This tool enables the surgeon to better understand patient wishes, to simplify the surgical plan and to effectively communicate this plan to the patient. Patients currently depend on the Internet for visual confirmation of proposed results. “Before and after surgery” photographs and “morphing”15 have now become a compulsory viewing for patients before they decide on having surgery and on their surgeon. Showing pre- and postoperative pictures on a surgeon’s personal Web site is of critical importance, and must be considered as much more than a marketing tool. In fact, patients looking at the “cases gallery” will have the time to “digest” the aesthetic “attitude” of that specific surgeon, and will allow the patient the opportunity to Facial Plastic Surgery
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Fig. 4 (A–I) Preoperative and (J–R) postoperative views of a young male patient with severe septal deviation, twisted nose, narrow cartilaginous vault, and moderate tip bulbosity. The patient strongly requested an endonasal approach and conservative changes. Operation highlights: septoplasty, septal angles remodeling, and release of the depressor septi through hemitransfixion incision; upper and upper-lateral aspects of lateral crura together with scrolls were sculpted through a transcartilagenous approach; creation of submucosal tunnels under the cartilaginous vault extended to the bony vault to create a “spreader effect.” Radix and tip position were adjusted to aesthetically match the requested profile line.
match the surgeon’s aesthetic philosophy with the patient’s desires and expectations. After almost 100 years of experience in rhinoplasty, the current trend in surgical education consists of less aggressive tissue removal and the use of reversible techniques when possible. No single approach to rhinoplasty has provided all the answers to specific problems.16–18 The ideal choice is adopting an adaptable technique that has provided predictable, safe results in the hands of that specific surgeon. In this manner, the best techniques derived from external and endonasal surgery can be combined in a single operation, the hybrid rhinoplasty.19 For each patient, the surgeon deFacial Plastic Surgery
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fines a risk–benefit curve and aims for the pinnacle of the graph, before stepping into the red zone of rapid descent toward poor results.20 Even in the best of hands, a small number of patients require a minor touch-up operation: this is the hard reality of rhinoplasty. Both the patient and the surgeon need to accept this before embarking on this operative journey.21
Discussion Surgical education in rhinoplasty has traditionally been peerled and scientifically driven. As rhinoplasty has universally
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Fig. 4 (Continued)
accepted as being one of the more challenging facial plastic operations, the steep learning curve of a at least a decade should not surprise anyone. At present, there are a large number of reputable anatomical and technical courses that provide students of rhinoplasty with a bewildering choice of which one to choose for further education. To complicate matters, the current harsh economic climate has reduced patient numbers and opportunities for surgeons to gain experience in a minefield of rising patient’s demands and expectations. Peer-led education from a conference floor does
not readily translate into better surgical practice for several reasons: the more junior surgeons may require years of technical practice before they become fluent at the most basic level. Every training center and fellowship needs to be encouraged to emphasize and rehearse—and re-rehearse— the fundamental importance of anatomic evaluation and diagnosis. Mistakes in the latter arena are responsible for the majority of rhinoplasty complications. Successful rhinoplasty relies heavily on the surgical expertise of the surgeon whose craftsmanship takes time Facial Plastic Surgery
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to mature and develop. This technical capability can be unique to the surgeon and not readily reproducible by another practitioner. Unlike endoscopic endonasal sinus surgery where the development of technology has had a major impact on the evolution of the techniques or in the implementation of original procedures, rhinoplasty has not witnessed substantial technological advances able to produce seismic shifts in practice. In rhinoplasty, matters are complicated by the patient’s psychological state and needs, and the surgeon’s ability to perform surgically relevant facial analysis, and his/her sense of beauty and harmony in formulating a patient-specific game plan. Technically, creating subtle change in such a challenging area is beyond the abilities of many surgeons as they venture into this field. Expecting students of rhinoplasty to copy a technique they have just seen in a conference is neither realistic nor safe. The second major problem of transferring knowledge into practice consists of the gap, or dichotomy between what patient’s want, and scientific revelation. Patients may be influenced by fashion, trends, friends, or unrealistic expectations. Informing them of the latest progress on the science of facial aesthetics or analysis does little to change their mind or revise their priorities.
excessive surgical maneuvers, rather than individualized, patient-centered surgery. The dogmatic approach to rhinoplasty must be abandoned in favor of an evidence-based rhinoplasty philosophy, or surgeons may face the prospect of stagnation and the demise of excellence in practice.
References 1 Gubisch W. Extracorporeal septoplasty for the markedly deviated
septum. Arch Facial Plast Surg 2005;7(4):218–226 2 Gunter JP. Facial analysis for the rhinoplasty patient. In: 12th
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Continuing medical education forms the backbone of contemporary surgical education. Rhinoplasty poses specific problems that require thorough reflection as what is presented on a conference floor does not per se translate into better surgical practice. The bulk of knowledge coming from books, articles, and conferences should be filtered by each individual rhinoplasty surgeon in the light of his/her educational background, analytical capabilities, surgical skills level, and profile of his/her individual rhinoplasty practice. There are two major dichotomies in rhinoplasty: first, there is a difference between learning theoretical surgical techniques, and their application in the operating room. Second, there is a distinct difference between what patients want, and the results of scientific research in the field of facial/nasal aesthetics and surgery. The authors have pointed out some complex matters that have a major impact in the way rhinoplasty surgeons should screen patients, elaborate their game plan, and choose the most suitable techniques among the many existing operative options. Collective experience has clearly demonstrated that there is no single best way that can correct the wide variety of anatomic disharmonies encountered and answer all the demands of rhinoplasty patients. While some patients require major structural changes, others only need subtle changes in surface aesthetics.22 Applying the same techniques in every case can result in inadequate surgery, or
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Annual Dallas Rhinoplasty Symposium. Dallas, TX: Southwestern Medical Center; 1995:17–27 Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg 2006;8(3):156–185 Tardy ME Jr. Rhinoplasty: The Art and the Science. Philadelphia, PA: WB Saunders Company; 1997 Perkins S, Patel A. Endonasal suture techniques in tip rhinoplasty. Facial Plast Surg Clin North Am 2009;17(1):41–54, vi Daniel RK. Mastering Rhinoplasty. Berlin Heidelberg, Germany: Springer-Verlag; 2010 Dayan S, Kanodia R. Has the pendulum swung too far?: trends in the teaching of endonasal rhinoplasty Arch Facial Plast Surg 2009; 11(6):414–416 Pastorek N, Ham J. The underprojecting nasal tip: an endonasal approach. Facial Plast Surg Clin North Am 2004;12(1):93–106 Kridel RW, Scott BA, Foda HM. The tongue-in-groove technique in septorhinoplasty. A 10-year experience. Arch Facial Plast Surg 1999;1(4):246–256, discussion 257–258 Palma P, Khodaei I. Why do I favour the endonasal approach? B-ENT 2010;6(Suppl 15):25–33 Nolst Trenité GJ. Rhinoplasty: A Practical Guide to Functional and Aesthetic Surgery of the Nose. The Hague, The Netherlands: Kugler Publications; 2010 Robin JL. Extramucosal method in rhinoplasty. Aesthetic Plast Surg 1979;3(1):171–178 Palma P, Khodaei I, Tasman A-J. A guide to the assessment and analysis of the rhinoplasty patient. Facial Plast Surg 2011;27(2): 146–159 Powell N, Humphreys B. Proportions of the Aesthetic Face. New York, NY: Thieme Stratton Inc.; 1984 Agarwal A, Gracely E, Silver WE. Realistic expectations: to morph or not to morph? Plast Reconstr Surg 2007;119(4):1343–1351, discussion 1352–1353 Gunter JP. The merits of the open approach in rhinoplasty. Plast Reconstr Surg 1997;99(3):863–867 Simons RL. A personal report: emphasizing the endonasal approach. Facial Plast Surg Clin N Am 2004;12(1):15–34 Perkins SW. The evolution of the combined use of endonasal and external columellar approaches to rhinoplasty. Facial Plast Surg Clin North Am 2004;12(1):35–50 Palma P, Khodaei I. Hybrid rhinoplasty: The 21. st century approach to remodeling the nose. Arch Facial Plast Surg 2010;12(6): 412–414 Sheen JH, Sheen AP. Aesthetic Rhinoplasty. 2nd ed. St. Louis, MO: Quality Medical Publishing; 1998 Rohrich RJ. Streamlining cosmetic surgery patient selection—just say no!. Plast Reconstr Surg 1999;104(1):220–221 Constantian Mark B. Rhinoplasty: Craft & Magic. St. Louis, MO: Quality Medical Publishing; 2009
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