COMPLEX OPERATING TECHNIQUES IN FACIAL PLASTIC … · nasal dorsum and tip correction, revision...

Author and editor:

Stefan MAASwith contributions from:

Hans Rudolf BRINER Frank RIEDEL, Axel SAUER

COMPLEX OPERATING TECHNIQUES IN FACIAL PLASTIC SURGERY

AND RHINOSURGERYThe RHINO® Workshop Guidelines

Complex Operating Techniques inFacial Plastic Surgery and Rhinosurgery

The RHINO® Workshop Guidelines

Author and editor:Stefan MAAS

With contributions from:Hans Rudolf BRINER

Frank RIEDELAxel SAUER

www.rhino-workshop.de

Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery

The RHINO® Workshop Guidelines

Author and editor:Stefan MAAS

With contributions from:Hans Rudolf BRINER

Frank RIEDELAxel SAUER

www.rhino-workshop.de

Acknowledgments

I express my sincere thanks to Dr. h.c. mult. Sybill Storz and her staff for their kind, generous, and always dependable support.

I thank Prof. Wolfgang Elies for his intensive, forthright, persistent, demanding, and encouraging surgical training.

Thanks to the participants and contributors at the RHINO® Workshop and to the coauthors of these guidelines, who have consistently and constructively advanced the development of the RHINO® Workshop.

On behalf of the entire team at Elisabeth Hospital in Kassel, Germany, I thank our administrator, Mr. Albin Zimmermann, for his pleasant and trusting collaboration and for his solid support.

I thank Dr. Katja Dalkowski for her professional handling of the illustrations and her constant willingness to help.

Above all, I am grateful to my family: my brother Frank, who contributed his advice and talents to the RHINO® Workshop from the beginning, and my wife Nicole, without whose patient, indulgent, and loving support I would not have been able to maintain a busy surgical practice or conduct the RHINO® Workshop.

Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery6

Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery – The RHINO® Workshop GuidelinesAuthor and Editor: Stefan MAAS1

With contributions from: Hans Rudolf BRINER2 Frank RIEDEL3 Axel SAUER11 Plastic Fascial Surgery and Special ORL ORL Surgical Center at the Elisabeth Hospital, Kassel, Germany

2 ORL Center, Hirslanden Hospital, Zürich, Switzerland3 Rhein-Neckar ORL Center, Mannheim, Germany

Address for correspondences:

Illustrations by: Katja Dalkowski, M.D. Grasweg 42, D-91054 Buckenhof, Germany [email protected]

© 2015 Tuttlingen, Germany ISBN 978-3-89756-193-9, Printed in Germany P.O. Box, D-78503 Tuttlingen, Germany Telephone: +49 74 61/1 45 90 Fax: +49 74 61/708-529 E-mail: [email protected]

Editions in languages other than English and German are in preparation. For up-to-date information, please contact Tuttlingen, Germany, at the address indicated above.

Layout and image processing: Tuttlingen, Germany

Printed by: Straub Druck + Medien AG 78713 Schramberg, Germany

01.15-0.25

Important notice:

Medical knowledge is ever changing. As new research and clinical experience broaden our knowledge, changes in treatment and therapy may be required. The authors and editors of the material herein have consulted sources believed to be reliable in their efforts to provide information that is complete and in accord with the standards accepted at the time of publication. However, in view of the possibility of human error by the authors, edi-tors, or publisher of the work herein, or chan-ges in medical knowledge, neither the authors, editors, publisher, nor any other party who has been involved in the preparation of this work, warrants that the information contained her-ein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from use of such information. The information contained within this brochure is intended for use by doctors and other health care professionals. This material is not intended for use as a basis for treatment decisions, and is not a substitute for professional consultation and/or use of peer-reviewed medical literature.

Some of the product names, patents, and registered designs referred to in this booklet are in fact registered trademarks or proprietary nameseven thoughspecific reference to thisfact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain. All rights reserved. No part of this publication may be translated, reprinted or reproduced, transmitted in any form or by any means, electronic or mechanical, now known or hereafter invented, including photocopying and recording, or utilized in any information storage or retrieval system without the prior written permission of the copyright holder.

All rights reserved.No part of this publication may be transla-ted, reprinted or reproduced, transmitted in any form or by any means, electronic or mechanical, now known or hereafter invented, including photo copying and recording, or utili-zed in any information storage or retrieval sys-tem without the prior written permission of the copyright holder.

Dr. med. Stefan Maas Plastische Gesichtschirurgie und Spezielle HNO-Chirurgie Operative Schwerpunktpraxis am Elisabeth-Krankenhaus Kassel Obere Karlsstraße 2a 34117 Kassel, Germany Telephone: +49 (0)561 109 49 55 Fax: +49 (0)561 109 49 56 Internet: www.plastische-

gesichtschirurgie-hessen.de

Co-Authors:

KD Dr. med. Hans Rudolf Briner ORL-Zentrum, Klinik Hirslanden, Witellikerstrasse 40 8032 Zürich, Switzerland Internet: www.orl-zentrum.com

Prof. Dr. med. Frank Riedel HNO-Zentrum Rhein-Neckar Goethestraße 16a, 68161 Mannheim, Germany Internet: www.hno-praxis-rheinneckar.de

Dr. med. Axel Sauer Plastische Gesichtschirurgie und Spezielle HNO-Chirurgie Operative Schwerpunktpraxis am Elisabeth-Krankenhaus Kassel Obere Karlsstraße 2a 34117 Kassel, Germany

7Complex Operating Techniques in Facial Plastic Surgery and Rhinosurgery

Table of Contents 1.0 Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

2.0 Before the Operation . . . . . . . . . . . . . . . . . . . . . . . . . . 8

2.1 Patient Interview . . . . . . . . . . . . . . . . . . . . . . . . . . 8

2.2 History and Physical Examination . . . . . . . . . . . 8

2.3 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

2.4 Informed Consent . . . . . . . . . . . . . . . . . . . . . . . . . 92.4.1 Risk Disclosure . . . . . . . . . . . . . . . . . . . . . . 92.4.2 Postoperative and

Posthospital Instructions. . . . . . . . . . . . . . 92.4.3 Cost Issues . . . . . . . . . . . . . . . . . . . . . . . . . 92.4.4 Postoperative Course. . . . . . . . . . . . . . . . . 11

2.5 Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

3.0 Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

3.1 Positioning, Anesthesia, Medication . . . . . . . . . 11

3.2 Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123.2.1 Closed Approach . . . . . . . . . . . . . . . . . . . . 123.2.2 Open Approach with

Medial Crural Protection (MCP) . . . . . . . . 14

3.3 Individual Septal Reconstruction (ISR) . . . . . . . 163.3.1 Case Report 1 – Crooked Nose . . . . . . . . 203.3.2 Case Report 2 – Crooked Nose

and Alar Deformity . . . . . . . . . . . . . . . . . . . 24

3.4 L-Beam. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263.4.1 Traditional Costal Cartilage Graft . . . . . . . 263.4.2 Costal Cartilage Harvest

and Wound Closure . . . . . . . . . . . . . . . . . . 263.4.3 L-Beam Concept. . . . . . . . . . . . . . . . . . . . . 28

Similarities and Differences between the I-Beam and L-Beam . . . . . . . . . . . . . . . 28

Indication for the L-Beam . . . . . . . . . . . . . 283.4.4 L-Beam Fabrication . . . . . . . . . . . . . . . . . . 293.4.5 L-Beam Implantation and Fixation . . . . . 30

3.5 IndividualSeptalReconstruction(ISR) with the L-Beam . . . . . . . . . . . . . . . . . . . . . . . . . . 303.5.1 Case Report 1 – Saddle Nose . . . . . . . . . . 303.5.2 Case Report 2 – Cleft Lip and Palate . . . . 32

3.6 Rhinoplasty without Osteotomy . . . . . . . . . . . . . 343.6.1 Case Report 1 – Humped Nose . . . . . . . . 343.6.2 Case Report 2 – Humped Nose

and Alar Deformity . . . . . . . . . . . . . . . . . . . 36

3.7 The I-Beam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383.7.1 Surgical Concept – Operating Technique 383.7.2 Case Example – Saddle Nose . . . . . . . . . . 40

3.8 Perforated Septum . . . . . . . . . . . . . . . . . . . . . . . . 41

3.9 Nasal Tip Correction . . . . . . . . . . . . . . . . . . . . . . 44

3.10 Rhinophyma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

4.0 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

5.0 InstrumentsforComplexFacialPlastic Surgery and Rhinosurgery. . . . . . . . . . . . . . . . . . . . . . 515.1 Instruments for Complex Rhinosurgery

Recommended Set acc. to MAAS and SAUER with depicted items. . . . . . . . . . . . . . . . . . . . . . . . . 52

5.2 Instruments for Costal Cartilage Harvest (L-Beam Technique) Recommended Set acc. to MAAS and SAUER without depicted items . . . . . . . . . . . . . . . . . . . . . . 54

5.3 Instruments for Complex Rhinosurgery Recommended Set acc. to MAAS and SAUER with depicted items . . . . . . . . . . . . . . . . . . . . . . . . 55

5.4 Instruments for Costal Cartilage Harvest (L-Beam Technique) Recommended Set acc. to MAAS and SAUER with depicted items . . . . . . . . . . . . . . . . . . . . . . . . 67

5.5 Burrs and Irrigation Systems . . . . . . . . . . . . . . . 69

6.0 Basic Equipment for Videoendoscopic and Micro scopic-assisted Complex Rhinosurgery . . . . . 746.1 HD Video Camera Systems . . . . . . . . . . . . . . . . . 756.2 KARL STORZ Monitors . . . . . . . . . . . . . . . . . . . . 846.3 Cold Light Fountains and Accessories

for Video Documentation. . . . . . . . . . . . . . . . . . . 866.4 Data Management and Documentation . . . . . . 87

7.0 RHINO® Workshop Case Documentation . . . . . . . . . 91


1.0 PrefaceThe RHINO® Workshop is a once-a-year continuing education symposium that is organizedforofficephysiciansandinterestedhospital-basedphysicians.

The workshop consists of two parts.

Part 1: Continuing Education on Wednesday Afternoon. An interdisciplinary team of experts presents reports on topics in facial plastic surgery and rhinology with the goal of fostering a common professional discourse. Part 1 usually ends with a practical exercise that addresses or expands upon the contents of a report.

Part 2 of the RHINO® Workshop, called Rhinosurgery Live, takes place on the Thursday and Friday after the Wednesday program. Part 2 involves the live, HD transmission of complex nasal operations such as open and closed techniques of nasal dorsum and tip correction, revision septorhinoplasties using auricular or costal cartilage, and the repair of septal perforations using auricular cartilage and bridge-flaptechniques.Oneoperationistransmittedliveatanygiventimesothatallaspectsof the procedure can be discussed with the Workshop participants.

The goal of the RHINO® Workshop is dialogue. Performing a surgical procedure with technical precision does not always guarantee success. This particularly applies to complex procedures in functional, aesthetic, and cosmetic rhinosurgery. Issues relevant to practicing rhinosurgeons are addressed and discussed in a collegial atmosphere.

2.0 Before the Operation

2.1 Patient InterviewAs rhinosurgeons gain experience, the level of satisfaction of their patients will usually increase. There are three reasons for this: (1) Years of informed experience in rhinosurgery leads to better outcomes. (2) As surgeons become more familiar with the various personality structures of patients seeking rhinoplasty, they can more readily identify patients who will be unhappy with their surgery regardless of the outcome. (3) Detailed preoperative counseling and disclosure will enhance patient satisfaction by preparing the patient for typical peri- and postoperative sequelae. True to the motto “Honesty is the best policy,” fostering realistic expectations is the foundation for a trusting doctor-patient relationship. The interview is of key importance in the management of rhinoplasty patients. The importance of follow-up visits should also be explained so that surgeons can self-assess the quality of their long-term results. Follow-up visits should be maintained for as long as possible (at least 1 year, or at least 5 years in patients with costal cartilage grafts) and are an integral part of the treatment plan.

2.2 History and Physical ExaminationAll signs and symptoms, even ones that patients deny, should be documented when the history is taken. Otherwise it cannot be determined if the physician forgot to ask about a particular symptom, or the patient denied a symptom, by looking at the patient’s chart.

Besides visual inspection, the physical examination includes palpation of the skin, cartilage, and nasal bones. It is common for examiners to forget the nasal bone. Its size, or rather lack of size, may assume tremendous importance in cases where lateral osteotomies are planned.


2.3 Indications There are various reasons in otorhinolaryngology to select patients for corrective surgery of the internal and external nose.

Functional, aesthetic, and cosmetic indications are integral to our specialty, and an understandingofhowfunction,aesthetics,andcosmeticsaredefinedcanbeveryhelpful for the practice of rhinosurgery and for communicating with patients. In its guidelines on morphologic abnormalities of the internal and external nose, the German Association of Scientific Medical Societies defines these three terms as follows:3

Function: The creation or restoration of a function (e.g., nasal breathing).

Aesthetics: The creation or restoration of a normal form or symmetry (abnormal normal).

Cosmetics: The correction of an inherently normal form (normal optimal = true cosmetic surgery).

A good rule to follow for all indications is to wait until the patient is skeletally mature and longitudinal growth is complete. Exceptions are functional disorders in children that would compromise normal development.

The highest priority in midfacial cosmetic surgery is to create a trusting relationship between doctor and patient. This relationship is almost always established by an attentive, patient, and honest counseling process. If not, the physician should not hesitate in referring the patient to a different rhinosurgeon.

2.4 Informed Consent

2.4.1 Risk DisclosureEvery surgical procedure constitutes a punishable bodily injury under the law, and only informed consent by the patient exempts the surgeon from liability. Informed consent, then, is a key legal concern for physicians. The requirements for informed consent are more rigorous for a medically unnecessary cosmetic procedure than for a medically indicated intervention.

We use a standard information sheet that covers all potential risks and complications. These sheets are given to patients following their initial interview with the surgeon. This gives patients the opportunity to read about the operation and review its poten-tial risks and complications even while at home.

Approximately 1–2 weeks before the operation, the patient is scheduled for a second counseling and disclosure session with the surgeon and is given a customized information sheet (e.g., with a diagram showing where the incisions will be made). The possibility of an unsuccessful outcome should always be disclosed, especially in purely cosmetic operations.

Years of informed experience in rhinosurgery are a key factor in achieving a high degree of patient satisfaction. But even very experienced rhinosurgeons will have patients who, for understandable reasons, are dissatisfied with the postoperativeresult. Even in cases of this kind, it is easier and less complicated to work with a patient who is well informed.

2.4.2 Postoperative and Posthospital InstructionsPatients are routinely furnished with postoperative and posthospital instructions. We routinely give the instructions twice, especially at the time of discharge. Necessary precautions regarding exposure to sunlight, sports activities, nasal hygiene, etc. are reviewed with the patient.

2.4.3 Cost IssuesLately we have also been counseling our patients on possible out-of-pocket costs relating to surgical procedures that are not medically indicated. Patients may have to shareinthefinancialcostsofdiseasesthatdevelopasaresultofcosmeticsurgery.


1 Patient before (a), shortly after (b) and 1 year after open revision rhinoplasty (c).

a

2 Patient before (a), shortly after (b) and 1 year after open primary septorhinoplasty (c).

a

3 Patient before (a), shortly after (b) and 1 year after open septorhinoplasty revision with a costal cartilage graft (c).

a

b

b

b

c

c

c


2.4.4 Postoperative CoursePatients dissatisfiedwith their appearancewill often enter recoverywith a critical attitude. We therefore describe postoperative healing in realistic terms and, when in doubt, may even exaggerate potential discomforts to help our patients cope with the normal healing process.

Healing after rhinoplastic surgery takes 6 to 12 months, and the healing process may varysignificantlyfromonepatienttothenext.Figures 1–3 show patient photographs taken preoperatively, several weeks postoperatively, and at one year.

As the follow-up pictures illustrate, an initially good result may become less favorable over time (Fig. 1a–c). Conversely, a result that is less favorable initially may improve duringthefirstyear (Fig. 2a–c). The third possibility is that the early postoperative result is essentially the same at one year (Fig. 3a–c). A more technically complex procedure does not necessarily lead to delayed wound healing or an unstable result. Patient 3, for example (Fig. 3a–c), underwent a long and demanding septorhinoplasty revision with costal cartilage grafting.

2.5 ImagingIf imaging is indicated, it should consist of low-dose computed tomography with axial scan acquisitions and coronal reconstructions. CT will reliably detect coexisting paranasal sinus pathology, for example, and will provide essential imaging data in case the operation needs to be extended to the sinuses.

Ultimately, further diagnostic studies are directed by the results of the history and physical examination.

3.0 Operation

3.1 Positioning, Anesthesia, MedicationRhinosurgery is often performed in the sitting position, so the patient is positioned with the neck slightly hyperextended and the head turned slightly to the right side. Infiltration anesthesia with articaine plus 1:100,000 epinephrine is administeredwith a cartridge syringe (Fig. 4). This type of syringe makes it possible to use small-gaugeinjectionneedles,andaninjectionvolumeof1.7to3.4mLisoftensufficient.We administer an oral cephalosporin for antibiotic prophylaxis. Intra operative decongestion is aided by giving 100 to 250 mg prednisone approximately 20 minutes before the start of the operation, barring contraindications. Pledgets soaked in decongestant nose drops are packed into the nasal cavity to decongest the turbinates.

4 Cartridgesyringeforinfiltrationanesthesia.


3.2 ApproachAdiscussionofopenandclosedapproachesinrhinosurgeryalonecouldfillanentirebook. Ultimately it is the decision of the operating surgeon.

Our basic rule: If a closed approach can yield an equally good postoperative result, we prefer it over an open approach.

There is no general consensus on this point because the decision is always based on the individual experience of the surgeon. The arguments for or against a closed or open technique are well known and need not be detailed here.

The open approach is used for the great majority of cases presented at the RHINO®

Workshop.

3.2.1 Closed ApproachThe closed or endonasal approach is an option if a reasonably wide septal frame can be left along the nasal dorsum, and the caudal septal border can retain its natural attachment to the nasal spine (Fig. 5). If the caudal septal border must be mobilized, it should at least be possible to reattach it through an endonasal approach. The closedapproachisalsoexcellentfornasaltipmodificationsbythecartilage-deliverymethod, for example.

5 Lateral view of the nasal septum and its support by the anterior nasal spine.

Fortheendonasalapproach,anasalspeculumisplacedtoaididentificationoftheanterior septal border. The incision can then be made from above downward (Fig. 6). The tension exerted by the speculum on the mucosa over the anterior septal border willpreventsignificantbleeding.Thesubperichondrialandsubperiostealtunnelscanthen be developed.

6 Incision along the anterior septal border in the closed approach. The nasal speculum compresses the blood vessels and improves

visualization of the anterior septal border.


7 Patient 4. Nasal skeleton fracture before (a, c, e) and after (b, d, f) treatment by closed septorhinoplasty.

a

c

e

b

d

f


Fornasaltipmodification,anintercartilaginousincision(betweenthealarandlateralcartilages) and an infracartilaginous incision (along the inferior margin of the alar cartilage) is made on each side (Fig. 8). These incisions permit the alar cartilages to be mobilized and exteriorized for further treatment (Fig. 9).

10 Incision of the columella.

8 Infra- and intercartilaginous incisions combined with the hemitransfixionincision.

9 Alar cartilages are mobilized and delivered through the infra- and intercartilaginous incisions.

11 Incision along the inferior margin of the alar cartilage.

3.2.2 Open Approach with Medial Crural Protection (MCP)The open approach can easily become a tedious, time-consuming, and traumatizing procedureunlessadefinitesequenceofstepsisfollowed.Themodificationshownishelpfulandprovidesmaximumsafetyandefficiencyforbothprimaryandrevisionprocedures. First the incision (inverted V) is drawn across the narrowest part of the columella (Fig. 10). Then the skin is incised along the inferior margin of the alar cartilage with a No. 15 blade (Fig. 11). The skin incision is spread open with a scissors (Fig. 12), and the cephalic portion of the alar cartilage is exposed. Next the skin is incised along the anterior margin of the medial crus (Fig. 13). After these skin incisions have been made on both sides, the columellar skin is dissected from the anterior margin of the medial crus with a small, angled nasal scissors (Fig. 14). At this point we place a forceps handle between the columellar skin and medial crura to protect the crura from iatrogenic injury (MCP). The columellar skin can then be incised safely and without loss of time (Fig. 15). The steps are illustrated in Fig. 16 a–f.


12 Skin incision is spread open with a scissors.

14 The skin is mobilized from the medial crura.

13 Skin is incised along the anterior margin of the medial crus.

15 The medial crura are protected with a forceps handle (MCP) while the inverted-V incision is made through the columella.

16 Incision along the inferior margin of the alar cartilage.

a

Skin incision along the anterior margin of the medial crus.

b

Columellar skin is mobilized with a small angled scissors.

c

Medial crura are protected with a forceps handle (MCP).

d

Completed inverted-V incision.

e

Example of the precise dissection allowed by this modifiedapproach.

f


3.3 Individual Septal Reconstruction (ISR)Correction of the external nose is one of the most demanding types of facial plastic surgery.Significantdeformitiesofnasalshapeareoftenassociatedwith functionaldisorders and may necessitate simultaneous corrections of the internal and external nose. Septoplasty is typically viewed as a procedure for junior surgeons. But proficient surgery of the nasal septum requires a detailed diagnosticworkup,meticulous technique, and an experienced surgeon. Considerable effort may be needed to overcome the “memory effect” of the septal cartilage. Many surgeons do not fully appreciate the importance of the nasal septum for nasal form and function, or the complexity of septal corrections, until they have begun to learn rhinoplastic techniques. Our approach to apparently simple problems has become more complex over the years. Conversely, we follow the principle of “less is more” when dealing with seemingly complex problems (see Sect. 3.6, Rhinoplasty without Osteotomy).

Correction and reconstruction of the nasal septum is central to our rhinosurgical work on the internal and external nose. We use proven surgical techniques to correct or reconstruct the nasal septum. We select the method that provides the greatest possiblesafetyandefficiencywiththe least invasiveness.Thegoal isan individualseptal reconstruction (ISR). An individual septal correction or reconstruction may be described as superselective, selective, subtotal, or total. It involves the use of incisions and suture techniques that are performed through a closed approach (with endoscopic assistance if needed) or an open approach, depending on technical complexity and required exposure. Grafts or implants are used as needed.

The goal of the ISR concept is to achieve a complete, physiologic reconstruction of the nasal septum which:

definesthepositionofthecolumella; definesthepositionofthenasal tip; definesthewidth, height, and alignment of the cartilaginous nasal dorsum without additional rhinoplastic measures;

and creates an optimum nasal valve angle whenever possible (Fig. 27a–f).

17 Soft-tissue elevation over the nasal dorsum. 18 Anterior septal border is exposed with the scalpel.


19 Use of the suction dissector. 20 Cartilaginous hump is shaved with the scalpel.

In some cases this may require a technically complex septal reconstruction like the Gubisch extracorporeal septoplasty.11 This technique is illustrated by diagrams (Figs. 17–26) and intraoperative photographs (Fig. 28a–n) in Patient 5 (see also Fig. 27a–f). First the soft tissues over the nasal dorsum are undermined with a scissors and a No. 15 blade through an open approach (Fig. 17). Then the anterior septal border is exposed with the scalpel or scissors (Fig. 18).

Next, subperichondrial and subperiosteal tunnels are developed on both sides of the septum. A suction dissector may be a helpful tool at this stage (Fig. 19). When both tunnels have been developed, the bony and cartilaginous hump can be taken down as needed. The cartilaginous portion is shaved with a No. 11 scalpel blade (Fig. 20). The bony portion of the dorsal hump is removed with a freshly sharpened osteotome (Fig. 21).

21 Bony portion of the dorsal hump is removed with an osteotome.


23 Perpendicular plate is fractured. 24 Nasal septum is removed.

22 Separation of the lateral cartilage from the septal cartilage.

a

Paramedian osteotomy with an osteotome (b) and Lindemann burr (c).

c

b

A slight bony excess may be left because the osteotomy will be smoothed with a coarse diamond burr. Any portions of the lateral cartilage still attached to the septal cartilage are released with a No. 15 blade (Fig. 22a). Paramedian osteotomies are now performed with an osteotome or Lindemann burr (Fig. 22b, c). The nasal septum is completely mobilized from the premaxilla, fractured through the anterior portion of the perpendicular plate (Fig. 23), and removed in one piece (Fig. 24).


Next the anterior nasal spine is grooved in the facial midline with the Lindemann burr (Fig. 25a), and a hole is drilled transversely through the spine (Fig. 25b). At this point the surgical site is packed with pledgets soaked in nasal decongestant drops to ensureabloodlessfieldduringimplantationandfixationofthereconstructedseptum.The next step is to straighten the septum on the operating table. This may be done, for example, by doubling or layering the cartilage, sewing spreader grafts to the septal border, and reusing straight septal remnants. A variety of technical options are available. A good rule to follow: the simpler, the better.

Gross straightening of the septal plate is followed by replantation. The reconstructed septum is fitted into the sagittal groove and secured with nonabsorbable suture material (Fig. 25c, d).Thefixationmaybeginatthenasalspineorlateralcartilages.Inmanycases, initialfixation to the lateralcartilageswillallow forfine trimmingofthe caudal septal border. Fixation to the anterior nasal spine is more technically demanding but is easier if the septal plate has already been fixed to the lateralcartilages. Fine trimming of the dorsal border can be done with a No. 11 blade and coarse diamond burr. If an open roof remains, it is closed by performing a lateral and transverse osteotomy (Fig. 26). The columellar incision is provisionally closed and the resultisassessedtoseeifanyfinecorrectionsarestillneeded.

25 A sagittal groove is cut in the anterior nasal spine with the Lindemann burr (a). A transverse hole is drilled through the anterior nasal spine (b).Theneoseptumisfittedintothesagittal

groove (c) and secured with nonabsorbable suture material (d).

a cb d

26 Osteotomy lines and skin incisions for the transcutaneous lateral and transverse osteotomies.


3.3.1 Case Report 1 – Crooked NoseThis patient (Fig. 27a–f) had a septal deviation to the left, nasal deviation to the right, and asymmetric nostrils. An individual septal reconstruction was performed without a lateral or transverse osteotomy.

The septal reconstruction was able to: definethepositionofthecolumella; definethepositionofthenasal tip; definethewidth, height and alignment of the cartilaginous nasal dorsum without additional rhinoplastic measures;

and create an optimum nasal valve angle.

27 Patient before (a, c, e) and 11 months after the operation (b, d, f).

a

c

e

b

d

f


28

a b c

28 Soft-tissue elevation over the cartilaginous and bony nasal dorsum (a). The caudal septal border is exposed with a small angled scissors (b).

Lateral cartilages are detached from the septal cartilage with the scalpel (c).Paramedian osteotomy (d).Appearance after lateral cartilage detachment and paramedian osteotomy (e). Fracturing the perpendicular plate (f).

d e f

The steps of the operation are illustrated in Figs. 10–16 and Fig. 28a–n. This procedure was performed through an open approach (Figs. 10–16) with soft-tissue elevation over the alar cartilages and the cartilaginous and bony nasal dorsum (Fig. 28a). Bilateral subperichondrial and subperiosteal tunnels were developed with a pointed scissors, suction tip, and standard dissector. The lateral cartilages were released from the septal cartilage (Fig. 28c), and bilateral paramedian osteotomies were performed (Fig. 28d, e). The septum was completely detached from the premaxilla, and the perpendicular plate was fractured with a chisel (Fig. 28f).


Next the cartilaginous septum was completely removed along with the attached piece of perpendicular plate (Fig. 28g). Before any further steps were done, a sagittal groove was cut in the anterior nasal spine in the facial midline, and a transverse hole was drilled through the nasal spine.

While further work was being done on the septum, the surgical site was packed with pledgets soaked in decongestant nose drops. The removed septum is outlined on the operating table (Fig. 28i) to create a template for sizing the reconstructed septum (Fig. 28j). In this case the septum was additionally stabilized with PDS foil.

28 The deviated septum viewed from above.

g

Anterior nasal spine with sagittal groove and transverse drill hole. Suture material has been passed tentatively through the drill hole.

h

28 Template drawn on the operating table.

i

The straightened septum is grossly trimmed to match the template.

j


Spreader grafts were also sewn to the upper border of the septal plate with mattress sutures (Fig. 28k, l). After coarse trimming, the reconstructed septum was replanted andfixedtothelateralcartilagesandanteriornasalspinewithnonabsorbablesuturematerial (Fig. 28m). Fixation to the anterior nasal spine is aided by looping the suture material through the transverse drill hole three times before tying. The last photograph shows the straightened nasal dorsum, which is completely closed by the spreader grafts (Fig. 28n). Final tailoring of the nasal dorsum was done with a coarse diamond burr. Since there was no open roof in this case, it was unnecessary to add lateral and transverse osteotomies. There was also no need to correct the alar cartilages, and the medial crura were simply reapproximated. Comparison of the pre- and postoperative photographs (Fig. 27a–f) shows how the individual septal reconstruction reshaped the external nose without the need for additional rhinoplastic measures.

28 Reconstructedseptumisfixedtotheanteriornasalspine(m). View of the nasal dorsum after straightening and smoothing with a coarse diamond burr (n).

m n

28 Reconstructed septum with spreader grafts and PDS foil.

k l


3.3.2 Case Report 2 – Crooked Nose and Alar Deformity This patient had a crooked (deviated) nose with aesthetic and functional impairment, septal deviation to the left, conspicuous columellar subluxation to the right, asymmetric nostrils, and asymmetry of the nasal tip (Fig. 29a, c, e).

29 Patient before (a, c, e) and 11 months after the operation (b, d, f).

a

c

e

b

d

f


30 Alar cartilage asymmetry corrected with an onlay graft.

e

Emphasis was again placed on achieving an individual septal reconstruction, in this case without PDS foil but with a unilateral spreader graft and unilateral strut to stabilize the caudal edge of the septum (Fig. 30a, b). Again, the reconstructed septumwasfixedtothelateralcartilagesandanteriornasalspinewiththeaidofasagittal groove and transverse drill hole (Fig. 30c, d).

The septal reconstruction was able to:

definethepositionofthecolumella; definethepositionofthenasal tip; definethewidth, height and alignment of the cartilaginous nasal dorsum; and create an optimum nasal valve angle.

An onlay graft was added in this case to restore symmetry of the alar cartilages (Fig. 30e).

30 Individual septal reconstruction with stabilization of the caudal septal border and a unilateral spreader graft.

a b

30 Sagittalgrooveintheanteriornasalspinebeforeandafterfixationofthereconstructed septum with nonabsorbable suture material.

c d


3.4 L-Beam

3.4.1 Traditional Costal Cartilage GraftSignificant deformitiesmay necessitate the use of amajor graft such as a costal cartilage graft. Rhinoplasty with rib cartilage is a “two-cavity procedure,” giving rise to two sets of problems. Whenever possible, then, we try to avoid the use of costal cartilage. An elegant alternative is the I-beam made of auricular cartilage (see Sect. 3.7 I-Beam). A costal cartilage graft is necessary in patientswith significantpathology and is often necessary after previous failed surgery. We will describe a harvesting technique with low donor-site morbidity along with a simple method (L-beam) for preparing and using costal cartilage.

We try to avoid the traditional costal cartilage graft technique whenever possible. A very common technique is to reconstruct the nasal dorsum with an onlay graft supported by a columellar strut (Fig. 31). Another piece of costal cartilage is placed in the septal pocket if necessary. Shaping and positioning the costal cartilage is a demandingtask,andevenexperiencedrhinosurgeonsfinditdifficulttoestimatetheforce vectors that will tend to alter and distort the tissues over time. The procedure may become an ordeal for the patient and the surgeon.

31 Diagrammatic representation of a common traditional technique for costal cartilage use.

a b

3.4.2 Costal Cartilage Harvest and Wound ClosureThe eighth rib is the most frequent source for costal cartilage grafts. The ninth rib is thefirstmobile rib that isnot integrated into thecostalarch (Fig. 32). It can be palpated in slender patients and, with practice, in heavier patients as well (Fig. 33).

32 Diagrammatic representation of the costalarch.Theninthribisthefirstribthat is not integrated into the costal arch.

33 Palpation of the ninth rib permits indirect identificationoftheoverlyingeighthrib.


Whenever possible, the overlying soft tissues and muscle are divided by a single, deep incision with a large blade (Fig. 34a)tocreateonewell-definedcutedge.Theperichondrium is exposed (Fig. 34b) and incised to form two, fully intact perichondrial flaps (Fig. 34c, d). The rib cartilage is incised, and a segment of the eighth rib is elevated with a dissector (Fig. 34e, f). The perichondrium deep to the rib is carefully preserved (Fig. 34g). Finally a suction drain is inserted and the wound is meticulously closedinfivelayers(perichondrium,fascia,twosubcutaneouslayers,andtheskin;Fig. 34i, j).

34 Overlying soft tissues are incised to the eighth-rib perichondrium with a No. 19

blade.

a

34 A single, deep incision produces clean cut edges.

b

The eight rib is elevated and a segment is removed.

e

Saline test to exclude leakage.

h

Twointactperichondrialflapscanbecleanlyreapproximatedlaterwithsutures.

c d

f

Diagram and intraoperative photograph of wound closure.

i j

Perichondrium deep to the rib remains intact.

g


3.4.3 L-Beam ConceptCorrections of the internal and external nose are complex procedures, especially when a major graft is needed. Complex and difficult questions require a simple answer. In the case of rib cartilage, the answer is to combine the ISR concept with the principle of mutually canceling force vectors.

1 Individual septal reconstruction (ISR) + 2 neutralization of deforming forces (with a double-layer construct).

Comment on 1: ISR means that a septum reconstructed with costal cartilage can definethepositionofthecolumella,thepositionofthenasaltip,and the width, height and alignment of the cartilaginous nasal dorsum while also creating an optimum nasal valve angle.

Comment on 2: Neutralization of deforming forces. As with the I-beam, deforming forces are neutralized by layering the graft construct (see also Sect. 3.7, I-Beam). The graft includes the outer segments of the cartilaginous rib, whose deforming force vectors are visible and palpable, especially after smoothing with a diamond burr. The concave sides of these outer pieces (which should have the same tension) are apposed and sewn together with mattress sutures to neutralize the deforming force vectors.

Nomenclature: A serviceable remnant of septal cartilage or another strip of rib cartilage is sandwiched between the two outer pieces of rib cartilage to create an L-shaped neoseptum. Analogous to the I-beam, the symmetrical layered structure of the construct gives it a constant, stable shape. This suggested the name L-beam.

35 Intraoperative photographs of Patient 7.Loss of cartilaginous support has caused a saddle nose deformity with sagging lateral cartilages and lateral crura protruding into the vestibule and nasal cavity (a).Note the collapsed lateral cartilages and inverted crura (b).

a

b

Similarities and Differences between the I-Beam and L-BeamBeam is a term used in structural engineering to describe a highly stable load-bearing member – a property that is shared by the I-beam and L-beam. Other common features are a stable shape achieved with layered cartilage strips and an essentially physiologic septal reconstruction. The I-beam provides a partial (caudal) septal reconstruction, while the L-beam reconstructs all portions of the septum with a supportive function. Hence the I-beam is also called a caudal septal extension graft while the L-beam is described as an individual septal reconstruction. The I-beam obtains its layered structure by apposing and suturing together the convex sides of a conchal cartilage graft. In the L-beam, the concave sides are sutured together. The I-beam is fabricated from a piece of conchal cartilage, while the L-beam consists of three separate pieces of rib cartilage or two pieces of rib cartilage plus one piece of septal cartilage.

Indication for the L-BeamPronounced saddle nose deformity is a classic indication for an L-beam reconstruction. Loss of cartilaginous support leads to collapse of the nasal dorsum withawidenednasalvalveangleandinversionofthelateralcrura.Theconfigurationof thenasal roof resemblesaflat-roofbungalow (“ballooning”phenomenon).A ribcartilage graft placed on the nasal dorsum can improve the outer contour of the nose but will not correct the functional pathology (Fig. 35a, b). The goal, therefore, is to converttheflat-roofbungalowtoapitchedroof.ThisisaccomplishedbymobilizingthelateralcartilagesandfixingthemhigherupontheL-beam.


3.4.4 L-Beam Fabrication In most cases, a scalpel is used to slice curved outer strips from the harvested rib cartilage along with a straight piece from the center. The grafts are immersed in physiologic saline solution to retard warping after implantation (Fig. 36), but this does not guarantee that the construct will maintain its shape in situ. A proven technique for making a straight, stable strut from curved conchal cartilage is to approximate (layer) the two convex sides of the cartilage and suture them together to neutralize the opposing force vectors and create a straight construct (see also Sect. 3.7, I-Beam). This is the principle that underlies the stable shape of the L-beam. A straight piece of rib cartilage is obtained by separating the outer walls of the eighth rib with a scalpel (Fig. 37a–c) and thinning them with a coarse diamond burr (Fig. 38). Then the two concave sides are approximated and sewn together with mattress sutures (Fig. 39a). If a serviceable remnant of septal cartilage is available, it is placed between the two outer strips of rib cartilage (Fig. 39b) so that the construct can be braced against the anterior nasal spine. This produces an L-beam composed of costal and septal cartilage. If a serviceable septal cartilage remnant is not available, the L-beam can be fabricated from three pieces of rib cartilage (Fig. 40a, b).

36 Central piece of rib cartilage and two outer strips are immersed in physiologic saline

solution.

37 Eighth rib cartilage is incised with a scalpel to obtain two outer segments and one central segment.

a b c

38 The rib cartilage is shaped with a coarse diamond burr.

40 L-beam composed of two outer strips of rib cartilage and a piece of central rib cartilage.

a b

39 Principle of mutually canceling force vectors. Apposing the two concave sides of the outer strips of rib cartilage cancels out the force vectors, yielding a construct with a stable shape (a). Provisional L-beam composed of two outer strips of rib cartilage and a serviceable remnant of septal cartilage (b).Theconstructisprovisionallyimplantedbeforefinaltrimming.

a

39 Provisional L-beam assembly composed of two outer strips of rib cartilage and a serviceable septal remnant (Patient 7).

c

b


3.4.5 L-Beam Implantation and Fixation To permit a secure fixation, the L-beam is attached with nonabsorbable suture material to the lateral cartilages (Fig. 42) and anterior nasal spine. Fixation to the nasal spine is done in several steps. First a sagittal groove is drilled into the anterior nasal spine. This groove should lie on the facial midline, so it may be placed off-center on the nasal spine or may even be oblique to the spine axis. Next a hole is drilled transversely through the nasal spine. Before implanting the securing the L-beam, the surgeon should make sure that the needle and suture material can pass easily through the transverse drill hole (Figs. 25, 28h and m). After coarse trimming of the L-beam,itisdefinitivelyfixedtotheanteriornasalspine(Fig. 41) and lateral cartilages (Fig. 42).ThenthenasaldorsumistrimmedtoitsfinalshapewithaNo.11bladeand/or coarse diamond burr.

41 Intraoperative endoscopic view in a patient whounderwentfivepreviousrhinoplasties,two with rib cartilage (autologous and allogeneic). Due to the heavy scarring and decreasedbloodsupply,fixationoftheL-beam was done under endoscopic vision. ThisviewshowstheL-beamfixedtothenasal spine with nonabsorbable suture material. Fine trimming of the L-beam on the columellar side has not yet taken place. This should be done very carefully and may even require multiple steps since the lower edge oftheL-beamdefinesthepositionofthecolumella.

42 L-beamfixedtothelateralcartilages.

43 L-beam positioned at a typical site in Patient 7. The lateral and alar cartilages require additionalmobilization.ThelateralcartilagescanthenbefixedashighontheL-beam

as possible, and the alar cartilages can be reapposed.

a b

3.5 IndividualSeptalReconstruction(ISR) with the L-Beam

3.5.1 Case Report 1 – Saddle NoseThis patient had a posttraumatic saddle nose following multiple severe nasal injuries. The nasal valve angle was abnormally widened. The collapsed cartilaginous nasal dorsum (Fig. 35b) and inverted lateral crura (Fig. 35a) protruded into the nasal cavity.


44 Patient 7 before (a, c, e) and 20 months after the operation (b, d, f).

a

c

e

b

d

f

Individual septal reconstruction was performed with an L-beam composed of two outer cartilage strips from the eighth rib (Figs. 37b, 39a and b) and a remnant of septalcartilage.Atoperation,theL-beamwassecurelyfixedtothelateralcartilages(which were also raised as much as possible to improve the nasal valve angle) and to the sagittal groove in the anterior nasal spine. After removal of the septal splints, the patientreportedasignificantimprovementinnasalbreathingthatwasstillstableat20 months (Fig. 44b, d, f).


3.5.2 Case Report 2 – Cleft Lip and PalateIndividual septal reconstruction with the L-beam is also suitable for patients with cleft lip and palate. The deformities in these patients include septal deviation and subluxation toward the healthy side and deviation of the external nose. Additionally, the columella and alar cartilages are shortened on the cleft side, and this is associated with weak projection and protection of the nasal tip (Fig. 45). Nasal breathing is consistently impaired. Surgical correction is difficult and has its limitations. Asignificantnumberofpatientshavealreadyhadpriorsurgery.

45 Typical features of unilateral cleft lip and palate, with septal deviation and subluxation toward the healthy side, deviation of the external nose, and asymmetric alar cartilages.

46 This photograph of Patient 8 shows three scars. The donor site for rib cartilage used in the previous operation starts just below the nipple. The donor site for the L-beam (3 months

postoperatively) is on the costal arch. The third scar (\) is unrelated to the nasal operations.

\


47 Patient 8 with unilateral cleft lip and palate following two previous nasal operations, which included the use of rib cartilage. Revision consisted of an individual septal reconstruction with an L-beam. The postoperative photographs (b, d, f) were taken at 21 months. The patient has had unrestricted nasal breathing since the operation.

a

c

e

b

d

f


3.6 Rhinoplasty without OsteotomyThe title of this section is short. A more descriptive title might be:

Is closure of the open roof with extended spreader grafts, without transverse and lateral osteotomies, a reasonable alternative in selected cases?

A key requirement in traditional rhinosurgery is closure of the open roof by osteotomies. The open roof is closed by mobilizing and repositioning the lateral nasal walls. But does a good postoperative result require closure of the open roof, or does it require osteotomies? Are lateral and transverse osteotomies just a means to an end, and are they one of several options for closing an open roof? We answer this question in the following two case reports, in which extended spreader grafts were used to close the open roof (Fig. 48).

3.6.1 Case Report 1 – Humped Nose In this patient (Fig. 49a–f) the dorsal hump was removed through an open approach and the open roof was closed with extended spreader grafts (Fig. 48) while omitting lateral and transverse osteotomies. The patient is very pleased with the result. It is an acceptable result from a surgical standpoint. Lateral and transverse osteotomies may have yielded a better result in some circumstances. But performing these osteotomies does not guarantee a better outcome. As the degree of nasal framework mobilization increases, so does the risk of failure.48 Closure of the cartilaginous and bony

open roof with extended spreader grafts. Onlay grafts can be placed on the lateral cartilage to optimize the brow-tip aesthetic line.


49 Patient before (a, c, e) and 14 months after the operation (b, d, f). The open roof was closed with spreader grafts. Transverse and lateral osteotomies were not performed.

a

c

e

b

d

f


3.6.2 Case Report 2 – Humped Nose and Alar Deformity This patient also had an open roof following dorsal hump removal. As in the previous case, it was closed with extended spreader grafts (Fig. 48). The nasal tip was corrected by incising and folding over the alar cartilage on each side. As with the L-beam made of costal cartilage, we cause the opposing force vectors to cancel out and restore a physiologic shape to the lateral crura. Folding the cartilage on itself also reinforces the lateral crura to prevent alar collapse and nasal valve stenosis (Fig. 50). The photographs (Fig. 51a–f) show the patient before and 12 months after the operation.

50 The cephalic portion of each alar cartilage is incised while leaving the deep perichondrium intact. The cartilage is then folded lengthwise, apposing the perichondrial surfaces, and

fixedwithsuturematerial.


51 This patient also had an open roof closure with spreader grafts. Transverse and lateral osteotomies were not performed. The patient is shown before (a, c, e) and 12 months after the operation (b, d, f).

a

c

e

b

d

f


3.7 The I-BeamThe caudal cartilaginous nasal septum is responsible for stabilizing the cartilaginous lower third of the nasal dorsum and also provides crucial tip support. Weakening of the septal cartilage in this area due to external trauma, previous septal surgery, or destructive inflammatory changes in the septal mucosa can compromise this supportive function. This leads to the saddling of the cartilaginous nasal dorsum and drooping of the nasal tip that are characteristic of this pathology. Besides the cosmetic impairment caused by the saddled cartilage, the ptotic nasal tip also leads to impaired nasal breathing. This results from a decrease in both the projection (height of the nasal tip) and protection of the nasal tip (resistance of the tip to external pressure). The loss of projection and protection causes narrowing of the nasal valve and impaired nasal breathing. Thus, reconstruction of the caudal nasal septum is necessary for the correction of cosmetically objectionable saddle nose and for the functional improvement of nasal breathing.

3.7.1 Surgical Concept – Operating TechniqueIdeally, the caudal nasal septum is reconstructed with septal cartilage taken from more dorsal portions of the septum. Very often, however, there is not enough nasal septal cartilage available for this type of reconstruction. In these cases the caudal nasal septum can be reconstructed with a different material such as costal cartilage. But reconstruction with costal cartilage leads to a relatively stiff nose in the reconstructed area due to the higher elastic modulus of rib cartilage. Moreover, harvesting costal cartilage leaves a thoracic scar and may lead to prolonged and troublesome post operative pain.

Auricular cartilage provides an elegant alternative for reconstructing the caudal nasal septum. Cartilage harvested from the auricular concha is elastic and is much like thecartilagenaturallypresentinthenasaltip.Thedifficultyofseptalreconstructionwith conchal cartilage lies in the fact that the cartilage is relatively thin and not very stable. Another problem is its concave curvature. Both disadvantages can be offset by creating a double-layer conchal cartilage graft (Fig. 52). As with the L-beam (see Sect. 3.4.3 L-Beam Concept), suturing the two layers together will cancel out the force vectors that cause bowing of the cartilage. This increases the stability of the graft, and the mirror-image arrangement of the layers eliminates the curve, resulting in a straight implant.

52 I-beam principle with a double-layer conchal cartilage implant in the columella.


This double-layer conchal cartilage graft, also called the I-beam, is implanted between the medial crura of the lower alar cartilages in the columella to restore nasal tip projection and protection. The surgery is performed through an open rhinoplasty approach. The base of the conchal cartilage implant (I-beam) is positioned just in front of the anterior nasal spine and extends into the dome area of the nasal tip. This is possible because the entire choncha is harvested, yielding a I-beam length of up to 35 mm (Fig. 53a, b).TheI-beamisplacedintothecolumellaandfixedwith nonabsorbable sutures to restore original nasal tip projection and protection.

The still-saddled portion of the cartilaginous nasal dorsum is now sutured to the stable, reconstructionnasal tip. If thisfixation isnotadequate, thesunkenareaofthe nasal dorsum can be augmented with a conchal cartilage onlay graft. One ear will supply enough conchal cartilage in most cases; it is rarely necessary to harvest cartilage from both ears. Reconstruction of the caudal nasal septum with the double-layer conchal cartilage implant (I-beam) leads to stable long-term cosmetic and functional results and provides a nasal tip elasticity similar to the original state. If I-beam use is not an option, we use an L-beam instead. The techniques for safely harvesting rib cartilage with minimal pain and for fabricating and implanting the L-beam are described in Sections 3.4 and 3.5.

53 Harvesting conchal cartilage.

a

Two strips of conchal cartilage are apposed to make a straight I-beam.

b


3.7.2 Case Example – Saddle Nose

54 Saddle nose deformity and ptotic nasal tip due to loss of caudal septal support

following two nasal injuries and two septo-rhinoplasties.

a

c

e

Postoperative result 3 years after caudal septal reconstruction with an I-beam (b, d, f).

b

d

f


3.8 Perforated SeptumThe close of a perforated septum was long considered an operation with an uncertain outcome. Conventional advancement flaps or transposition flaps suchastheturbinateflaphavenotproveneffectiveforclosinglargeseptalperforations.ThebridgeflaptechniquedescribedandestablishedbySchultz-Coulon has proven very reliable.17 We have had good results with it in our patients. We will describe the modificationthatweuse.Whenperformingthebridgeflaptechnique,wemakesurethat themucosa ismobilized sufficiently to allow a tension-free closure.We alsoavoid additional mucosal incisions so that once the septal perforation and access incision have been closed, a complete mucosal lining is obtained. This also shortens healingtime.Forthesereasons,themodifiedbridgeflaphasbecomeourstandardtechnique for closing septal perforations (Fig. 55). Septal perforations can be repaired through a closed or open approach. If doubt exits we favor an open approach, especially when dealing with perforations that have a large vertical extent. Following theopenapproach,wefirstexposetheanteriorseptalborderwithaNo.15blade. Subperichondrial and subperiosteal tunnels are then developed with a pointed scissors, suction tip, and dissectors above and below the perforation site. Next the mucosal tunnels above and below the perforation are joined together. We now expose the piriform aperture and extend the lower mucosal tunnel to a point below

55 Modifiedbridgeflaptechniquewithoutmucosalincisions.Themucosaismobilizedfromthenasalfloorandnasalrooftoallowatension-freeclosure.Wegenerallyusetragalorconchalcartilage for the cartilage graft, depending on the size of the defect.

a

b

56 View of the piriform aperture (bottom of image), the anterior nasal spine (left side of image), and the mucosa, which has been mobilized to a point below the inferior turbinate on the left side (right side of image) (a).

The mucosa on the left nasal roof is completely mobilized as far as the anterior nasal artery. (The anterior nasal artery is oftenmistakenforthefirstolfactoryfiber,but the latter is located behind the anterior nasal artery.) Note also the complete separation of the mucosa from the nasal roof medially (septum) and laterally (lateral nasalwall)sothatlargemucosalflapscanbe developed (b).

the attachment of the inferior turbinate (Fig. 56a). The upper tunnel is then extended to the attachment of the middle turbinate. We have found that starting posteriorly will often make the dissection easier. It is important to respect the anterior nasal artery as the posterior limit of the dissection (Fig. 56b). Carrying the dissection farther posteriorlymayleadtoavulsionoftheanteriornasalarteryandtheolfactoryfiberslocated there.

Whentheuppertunnelsanduppermucosalflapsaredevelopedproperly(Fig. 56b), enough mucosa should be available for a tension-free closure of the septal perforation. Thisalsorequiresadequatemobilizationofthemucosaanduppermucosalflapsinthe area of the lateral cartilage – a step that can be technically demanding and may require the aid of a microscope. When the mucosa has been adequately mobilized on all sides of the perforation, tension-free closure of the mucosa is carried out.


The septal perforation is closed with three to six simple interrupted sutures placing the knots internally (Fig. 56c, d). We obtain a physiologic three-layered repair (mucosa-cartilage-mucosa) by implanting autologous tragal cartilage or, for largerdefects,autologousconchalcartilage.Thegraftisfixedwithabsorbablesuturematerialorfibringlue.Generallywedonot transferposteriorseptalcartilage forathree-layered septal perforation repair to minimize the risk of a recurrent perforation or a new perforation at a different site. At the end of the operation, silicone septal splints with breathing tubes are inserted. They are shortened in height to allow for the temporarily decreased vertical dimension of the nasal cavity.

A question often asked at the RHINO® Workshop is whether the size reduction of the nasal cavity caused by mobilizing the mucosa is temporary or permanent. Figure 56e shows the obliterated nasal roof at the end of the operation, and Fig. 56f shows the site 12 months after surgery. We always address abnormalities of the cavernous tissues separately in a second procedure to avoid compromising the blood supply to themucosalflaps.Thepossibleneed fora two-stageprocedureshouldalwaysbe noted during informed consent. We recommend a nasal septal prosthesis for patients with a symptomatic perforation who refuse surgery or are likely to have a poor outcome.

56 The needle is passed from inside to outside so that the knots can be placed internally (c). Tension-free closure of the mucosa (view into the left nasal cavity) (d).

c

fd

56 Temporary reduction of nasal cavity size with obliteration of the nasal roof at the end of the operation.Anormalconfigurationofthenasalroofisseenoneyearaftersurgery.

e

ff


57 Patient with a perforated septum before (a, c, e) and 12 months after the operation (b, d, f) (open approach).

a

c

e

b

d

f


3.9 Nasal Tip Correction Besides an individual septal reconstruction (ISR), control of nasal tip position is a key component of every successful rhinoplasty. The rhinosurgeon is often confronted with an overprojected nasal tip.Nasal tip projection is defined as the distance ofthe tipdefiningpoint (apexof thealarcartilageconvexity) fromthe facialplane. Inprinciple, an overprojected nasal tip may occur as an isolated phenomenon, creating a nasal deformity also known as the “Pinocchio” nose. An overprojected nasal tip is also found in cases where all portions of the nose are enlarged (rhinomegaly).12 Nasal tipprojectionisevaluatedonaprofilephotographofthepatient.Inmostcasesanoverprojected nasal tip is caused by hypertrophy of its anatomic subunits. Thus it is useful to distinguish among alar cartilage hypertrophy, septal cartilage hypertrophy, hypertrophy of the nasal spine, combined hypertrophy of multiple components, and iatrogenic hypertrophy. It may be assumed that an isolated overprojected nasal tip is based on hypertrophy of the alar cartilages alone. With a rhinomegalic nose, all nasal components are too large.12,19Oftenitisnotsufficientinthesecasestocorrectone anatomic component. The fact that many techniques for decreasing nasal tip projection have been described in the literature attests to the difficulties that are associated with this step. A standard method has not yet been devised. Any surgical alteration of the complex relationships of the alar cartilage segments requires careful preoperative planning. Various surgical principles can be applied to decrease nasal tip projection. One way to decrease projection is by the surgical reduction of oversized structures that support the nasal tip (tip support mechanisms).5,12 Especially when dealing with a tension nose in rhinomegaly, it is important to release the supporting ligamentous structures and reduce the overdeveloped septum before correcting the nasal tip to see how much of the overprojection is caused by the septum. A second possibility is to normalize underdeveloped or malformed structures that border the nose and give the tip an overprojected appearance (pseudohypertrophy of the nose), such as saddling of the nasal dorsum, a protruding maxilla, or retrognathia with a retrusive lower jaw. A third way to decrease projection is by the surgical reduction of underdeveloped anatomic component(s), especially the alar cartilages.14 The dynamics of the nasal alae can be understood in terms of the tripod concept described by Anderson in 1969. In this concept the lateral crura each form one leg of the tripod while both medial crura combine to form the third. Changing the length of one leg will cause the nasal tip position to move in various directions. Shortening the outer legs will lower the nasal tip and rotate it upward. Shortening the center leg will move the tip downward and decrease its projection.2 Based on the tripod model, we can identify two ways in which the legs of the tripod can be surgically altered: with or without division of the alar circumference. Suture techniques provide a way to reduce projection without disrupting the anatomic framework. Suturing the medial crura to the caudal septal border can produce at least a small amount of deprojection.14,20SurgicaldivisionofthealarcircumferencewasfirstdescribedbyGoldman in 1957, although this initial description involved a technique for increasing nasal tip projection.9 He achieved this by dividing the alar cartilage just lateral to the dome on both sides and suturing the medial crura together. This created a strong medial unit with increased projection and greater medial support of the nasal tip. But tip projection could also be decreased by shortening the medial crura and trimming the lateral crura in patients with skin that is able to undergo contraction.


One disadvantage of the Goldman technique is that it creates a discontinuity in the alar cartilage. This could lead to postoperative tip irregularities, especially in thin-skinned patients. This is also why many surgeons have avoided dividing the alar cartilages. They tried to avoid these problems by dividing the cartilage in the dome while preserving the vestibular skin.18 Constantinidespublishedamodificationofthevertical dome division in 2001, using the more anatomically correct term “vertical lobule division” since the division may be made anywhere along the alar lobule.4 The alar cartilage can be divided just medial or lateral to the dome, and one end is overlapped over the other to decrease projection while rotating the tip upward or downward. Kridel and Konior described a similar technique in 1990 in which they resected the entire dome region after placing a suture at the level of the new dome. They preserved the vestibular skin by previously elevating it from the cartilage in the nasal tip area.13 In dome resections where the cartilaginous circumference is restored by suturing the cut edges, care should be taken that the caudal margin of the lateral alar cartilage is not lower than the cephalic margin after the reconstruction. In some cases that can be achieved with nonparallel excisions (Fig. 58).21

58 Diagrammatic representation of the vertical lobule division technique.


Otherwise the functionally and aesthetically important curved contour of the free alar margin would be lost. To avoid tip irregularities in thin-skinned patients, coverage with a tip onlay cartilage graft is also recommended.15,16,21 Figure 59a, b shows pre- and postoperative views of a patient in whom this technique was used to decrease nasal tip projection. Figure 60a, b shows the intraoperative appearance before and after deprojection.

59 This patient underwent primary functional-aesthetic septorhinoplasty for a slight dorsal hump and overprojected nasal tip. The hump was resected and the tip deprojected by the dome division technique. The nose was restructured with spreader grafts, a septal extension graft, and a tip onlay graft.

a b

While Adamson also described excision techniques for deprojection initially, he refinedhistechniquelaterbyoverlappingthealarcartilage.1 This corresponds to the lateral crural overlay technique described by Foda and Kridel (1999), which increases tip rotation and decreases projection by dividing the lateral crus relatively close to its foot and overlapping the cut ends (Fig. 61).8

60 Intraoperative photographs of the same patient before (a) and after (b) deprojection.

a

b

61 Diagrammatic representation of the lateral crural overlay.


This technique can be combined with a second division of the alar cartilage circumference in the medial crus either to shorten the columella or to correct a tip region (lobule) that is too long relative to the columella. The cut ends of the lateral crus are overlapped and sutured into place. In the medial crus, cartilage is resected but the ends are not overlapped. Instead, the medial crural segments are splinted to an interposed columellar strut that is sutured into place.7 The lateral and medial shortening deproject the tip without changing its rotation. The same principle is applied in the medial or lateral sliding technique described by Gubisch (Fig. 62).6, 10, 11

Conclusion: Besides an individual septal reconstruction (ISR), the control of nasal tip projection, rotation, and contours is the key component of a successful rhinoplasty. A variety of techniques are available for achieving this. Along with adequate stabilization of the nasal base, these techniques lead to good long-term results that preserve the nasal tip projection achieved by surgery. The successful nasal surgeon adapts his technique to individual patient anatomy in order to achieve reliable and stable long-term results.

62 Diagrammatic representation of the medial sliding technique.


3.10 Rhinophyma Rhinophyma is a lobular hyperplasia of the sebaceous glands that may or may not be associated with rosacea and occurs almost exclusively in males. Since surgical removal leaves islands of epidermal tissue deep within the hypertrophic sebaceous glands that will create a nidus for reepithelialization, this type of tumor can be effectively managed by “cutting it off.” We use three methods for this:

Scalpel and scissors

Dermabrasion

Laser

The firstmethod is themost widely used. Its advantage is that the surgeon can accurately assess the depth of the excision by noting the amount of tissue above the knife or scissor blades. It is also easy to identify the base of the excision, which should never extend below the hypertrophic sebaceous gland. For heavy bleeding, we recommend a CO2 laser coupled to a Sharplan™flashscanneroperatedinSilkTouch™ mode (Lumenis GmbH, Dreieich-Dreieichenhain, Germany). Irregularities can be smoothed with a diamond wheel like that used for dermabrasion. After surgery we make a light pressure dressing with ointment-impregnated gauze, which may contain cortisone and antibiotic if desired. Reepithelialization takes from two to four weeks. Placingafinger in thenose ishelpful formonitoringthedepthof theexcisionandavoiding an overexcision that could cause cartilage damage.

63 Diagrammatic representation of a rhinophyma patient before (a), during (b) and after surgical treatment (c). Some instruments are also shown (b).

a b c


64 Patient before and 11 months after the operation.

a

c

e

b

d

f


4.0 References1. ADAMSONPA.Refinementofthenasaltip.FacialPlastSurg1988;5:115–134

2. ANDERSON JR. The dynamics of rhinoplasty. In: Proceedings of the 9th

International Congress of Otolaryngology. 1969; International Congress Series206. Excerpta medica, Amsterdam

3. AWMF (Arbeitsgemeinschaft der Wissenschaftlichen MedizinischenFach gesellschaften e. V.). Formstörungen der inneren und äußeren Nase(mit funktioneller und/oder ästhetischer Beeinträchtigung). Stand: 01.02.2010,gültigbis28.02.2015,Reg.-Nr.017-070,KlassifikationS2k

4. CONSTANTINIDES M, LIU ES, MILLER PJ, ADAMSON PA. Vertical lobuledivision in rhinoplasty: maintaining an intact strip. Arch Facial Plast Surg 2001;3(4): 258–263

5. DYERWK2nd.Nasaltipsupportanditssurgicalmodification.FacialPlastSurgClin North Am 2004; 12: 1–13

6. EICHHORN-SENS J, GUBISCH W. The sliding technique: a precise method fortreating the overprojected nasal tip. HNO 2009; 57: 1262–1272

7. FODA HM. Alar setback technique: a controlled method of nasal tipdeprojection. Arch Otolaryngol Head Neck Surg 2001; 127(11): 1341–1346

8. FODA HM, KRIDEL RW. Lateral crural steal and lateral crural overlay. Anobjective evaluation. Arch Otolaryngol Head Neck Surg 1999; 125(12):1365–1370

9. GOLDMAN IB. The importance of mesial crura in nasal-tip reconstruction.AMA Arch Otolaryngol 1957; 65(2): 143–147

10. GUBISCH W, EICHHORN-SENS J. The sliding technique: a method to treat theoverprojected nasal tip. Aesthetic Plast Surg 2008; 32: 772–778

11. GUBISCHW.Theextracorporealseptumplasty:atechniquetocorrectdifficultnasal deformities. Plast Reconstr Surg 1995; 95(4): 672–82

12. KREUTZER C. Die Reduktion der überprojizierten Nasenspitze mit der Sliding-Technik:retrospektiveAnalysezurQuantifizierungdesOperationsergebnisses.2006; Dissertation, Ruprecht-Karl-Universität Heidelberg(http://www.ub.uni-heidelberg.de/archiv/6493)

13. KRIDEL RW, KONIOR RJ. Dome truncation for management of theover projected nasal tip. Ann Plast Surg 1990; 24: 385–396

14. PAPANASTASIOU S, LOGAN A. Management of the overprojecting nasal tip:a review. Aesthetic Plast Surg 2000; 24: 353–356

15. PECK GC, PECK GC Jr., ADAMS WP Jr. Long-term follow-up of the onlaytip graft and umbrella graft. In: JP Gunter, RJ Rohrich, WP Adams Jr., DallasRhinoplasty: Nasal Surgery by the Masters, 1st Ed. St. Louis, Mo.: QualityMedical Publishing 2002; P. 292

16. RIEDEL F, BRAN G. Cartilage grafts in functional and aesthetic rhinoplasty.HNO 2008; 56: 185–200

17. SCHULTZ-COULONHJ.Experienceswiththebridge-flaptechniquefortherepair of large nasal septal perforations. Rhinology 1994; 32(1): 25–33

18. SIMONS RL. Vertical dome division in rhinoplasty. Otolaryngol Clin North Am1987; 20: 785–796

19. TARDY ME Jr., WALTER MA, PATT BS. The overprojecting nose: anatomiccomponent analysis and repair. Facial Plast Surg 1993; 9: 306–316

20. TEBBETS JB. Sharing and positioning the nasal tip without structuraldisruption: A new systematic approach. Plast Reconstr Surg 1994; 94: 61–65

21. TORIUMI DM. New concepts in nasal tip contouring. Arch Facial Plast Surg2006; 8: 156–185


5.0 InstrumentsforComplexFacialPlastic Surgery and Rhinosurgery

Otorhinolaryngology is one of the most challenging, diverse, and interesting specialties in surgery. This particularly applies to facial plastic surgery and rhinosurgery. A detailed knowledge of the often complex anatomy is as essential as knowing the overall architecture of the nose and the properties of different tissues and their interactions during wound healing.

Years of intensive training combined with a critical self-assessment of long-term results will enable rhinosurgeons to manage their rhinoplasty patients with a high degreeofconfidenceandreliability.

A high level of patient satisfaction can be achieved only if the surgical concept and preoperative plan can be successfully put into practice on the operating table.

This practical implementation relies critically on the use of high-quality, precise, ergonomic instruments. Quality equipment can avoid irregularities caused by imprecise cutting instruments and unnecessary tissue trauma.

Not infrequently, one millimeter or less may decide the success or failure of a rhinoplastic procedure. An instrument-related failure or less-than-optimum result should be avoided whenever possible.

By and large, it may be true that an experienced surgeon can get by with fewer instruments. But when it comes to a functional, aesthetic, or cosmetic nasal operation, maximum precision is essential and is best achieved with instruments that are optimally designed for the requisite surgical steps. Besides instrument quality, then, an adequate assortment of instruments is crucial for the practical realization of a surgical concept.

Mistakes due to poor instrumentation are easy to avoid and, consequently, should never be a reason for failure.


5.1 Instruments for Complex Facial Plastic Surgery and RhinosurgeryRecommended Set acc. to MAAS and SAUER

1 2

4

5 7 9 bl bm bn

bo bp bq br

bs

bt

bu

cl

cm

cn

co cp cq cr cs ct cu dl dn dp dq dr ds dt du

el

em en eo

ep eq er es et eu fl fm fn fo fp fq

fr

fs

ft

fu

gl

gm gn go gp

dm do

6 8

3


1 7230AA 1 HOPKINS® Straight Forward Telescope 0°, enlarged view, diameter 4 mm, length 18 cm, autoclavable, fiber optic light transmission incorporated, color code: green

2 7230BA 1 HOPKINS® Forward-Oblique Telescope 30°, enlarged view, diameter 4 mm, length 18 cm, autoclavable, fiber optic light transmission incorporated, color code: red

3 403540 1 KILLIAN-STRUYCKEN Nasal Speculum, standard model, blade length 40 mm, length 13.5 cm

4 403555 1 Same, blade length 55 mm5 403575 1 Same, blade length 75 mm6 403655 1 COTTLE Nasal Speculum, blade length 55 mm,

length 13 cm7 403675 1 Same, blade length 75 mm8 400500 1 HARTMANN Nasal Speculum, for adults,

length 13 cm9 488002 1 COTTLE Nasal Speculum, extra slender,

without set screw, special matt finish, blade length 35 mm, length 13 cm

bl 456001 1 BLAKESLEY Nasal Forceps, straight, size 1, working length 11 cm

bm 456003 1 Same, size 3bn 450004 1 HARTMANN Nasal Cutting Forceps, round,

size 4, working length 11 cmbo 488038 1 RUBIN Septum Morcelizer, double action,

straight, special matt finish, length 20 cmbp 467000 1 HEYMANN-KNIGHT Septum Forceps, straight,

working length 11 cmbq 468500 1 BECKER-CAPLAN Septum Scissors,

double action jaws, serrated, working length 9.5 cmbr 449012 1 HEYMANN Nasal Scissors, medium,

serrated blades, working length 9.5 cmbs 511314 1 JOSEPH Scissors, straight, length 14 cmbt 511414 1 Same, curved bu 512614 1 METZENBAUM Scissors, with tungsten carbide

inserts, curved, length 14 cmcl 513200 1 WALTER Scissors, angled, length 10 cmcm 513700 1 FOMON Dorsal Scissors, angular,

serrated blades, slender, working length 6.5 cmcn 791202 1 Scissors, curved, sharp/blunt, length 14.5 cmco 506000 1 WALTER Nasal Retractor, double-ended,

one side with retractor, width of retractor blade 12 mm, length of retractor blade 45 mm, other side with two pronged retractor for nasal wings, length 12.5 cm

cp 498400 1 COTTLE Retractor, narrow (standard model), length 14 cm

cq 499202 2 JOSEPH Double Hook, sharp, width 2 mm, length 15 cm

cr 499205 2 Same, width 5 mmcs 499210 2 Same, width 5 mmct 505200 1 COTTLE Retractor, two prongs, sharp,

with thimble, width 10 mm, length 5.5 cmcu 484202 1 COTTLE Crossbar Osteotome, graduated,

double-edged grinding, straight, width 2 mm, length 18.5 cm

dl 484204 1 Same, width 4 mmdm 484209 1 Same, width 9 mm

dn 486102 1 WALTER Osteotome, flat, double-edged grinding, width 2 mm, length 19 cm

486102SB 1 Osteotome, flat, double-edged grinding, with enlarged distal finger grip plate, width 2 mm, length 19 cm (not illustrated)

do 486103 1 WALTER Osteotome, flat, double-edged grinding, width 3 mm, length 19 cm

486103SB 1 Osteotome, flat, double-edged grinding, with enlarged distal finger grip plate, width 3 mm, length 19 cm (not illustrated)

dp 487010 1 RUBIN Osteotome, flat, straight, double-edged grinding, rounded corners, with finger grip stabilizer, width 10 mm, length 16.5 cm

dq 487012 1 Same, width 12 mmdr 487014 1 Same, width 14 mmds 487016 1 Same, width 16 mmdt 174200 1 COTTLE Metal Mallet, length 18 cmdu 231000 1 Hone, “ARKANSAS” oil stone, wedge-shaped,

size 10 x 4 cmel 523910 1 TOLSDORFF Bone and Cartilage Crusher,

round, to press pieces of bone up to 4 cm evenly extended in all directions

em 474000 1 FREER Elevator, double-ended, semisharp and blunt, length 20 cm

en 479000 1 MASING Elevator, double-ended, graduated, sharp and blunt, length 22.5 cm

eo 479800 1 Suction Elevator, with stylet, length 19.5 cm 479800SB 1 Suction Raspatory, length 19.5 cm (not illustrated)ep 488070 1 JOSEPH Elevator, slightly curved,

special matt finish, width 4 mm, length 17.5 cmeq 525800 1 Elevator, heavy model, for the repositioning of

nasal fractures, length 17 cmer 477703 1 BALLENGER Swivel Knife, bayonet-shaped,

width 3 mm, length 19.5 cmes 496800 1 Nasal Knife, curved, roundly tipped blade,

width 4.5 mm, length 13.5 cmet 521410 1 Rasp, diamond coated, rasp blade 6 x 10 mm,

length 16.5 cmeu 521600 1 AUFRICHT Glabella Rasp, curved,

cuts with pressure and traction, length 20 cmfl 523600 1 Nasal Rasp, double-ended, fine, length 21.5 cmfm 523700 1 Same, double-ended, coarse (rasp)fn 426516 1 JANSEN Nasal Dressing Forceps,

bayonet-shaped, length 16.5 cmfo 533112 1 ADSON Tissue Forceps, 1x 2 teeth, length 12 cmfp 533212 1 ADSON-BROWN Tissue Forceps, atraumatic,

fine side grasping teeth, length 12 cmfq 516013 1 Needle Holder, tungsten carbide inserts,

length 13 cmfr 516117 1 RYDER Needle Holder, tungsten carbide inserts,

extra delicate, length 17 cmfs 498822 1 AIACH Cartilage Graft Forceps, for grasping

and preparation of cartilage and bone grafts, with slotted jaws, length 15 cm

ft 535012 1 HALSTEAD “Mosquito” Artery Forceps, straight, length 12.5 cm

fu 535212 1 HALSTEAD “Mosquito” Artery Forceps, curved, length 12.5 cm

gl 755120 1 HALLE-BIRKETT Forceps, light model, straight, length 20 cm

It is recommended to check the suitability of the product for the intended procedure prior to use.


gm 208000 1 Surgical Handle, Fig. 3, length 12.5 cm, for Blades 208010 – 15, 208210 – 15

208210 1 Blade, Fig. 10, sterile, package of 100 (not illustrated)

208211 1 Same, Fig. 11 (not illustrated)

208215 1 Same, Fig. 15 (not illustrated)

gn 204810 1 FERGUSON Suction Tube, with cut-off hole and stylet, LUER, 10 Fr., working length 11 cm

go 204812 1 Same, 12 Fr. 810810 2 Cup Medicine, 100 ccm, diameter 80 mm,

height 30 mm (not illustrated)

810820 1 Same, 200 ccm, diameter 100 mm, height 50 mm (not illustrated)

gp 844219 1 Bipolar Coagulating Forceps, insulated, bayonet-shaped, blunt, tip 1 mm, length 19 cm

847000E 1 Bipolar High Frequency Cord, to KARL STORZ Coagulator 26021B/C/D, 860021B/C/D, 27810B/C/D, 28810B/C/D, AUTOCON® system (50, 200, 350), AUTOCON® II 400 system SCB (111, 113, 115) and Erbe-Coagulator, T- and ICC-row, length 300 cm

252570 1 INTRA Drill Handpiece, angled, length 12.5 cm, transmission 1:1 (40,000 rpm), for use with KARL STORZ EC micro motor and straight shaft burrs

261114 1 Tungsten Carbide Straight Shaft Burr, with cross cut, stainless, sizes 014, diameter 1.4 mm, length 7 cm, for use with High-Performance EC Micro Motor 20 7110 33 and Connecting Cable 20 7111 73

261123 1 Same, size 023, diameter 2.3 mm


261150 1 Same, size 050, diameter 5 mm


20 7110 33 1 High Performance EC Micro Motor II, for use with KARL STORZ motor systems UNIDRIVE® II/UNIDRIVE® ENT/OMFS/NEURO/ECO and Connecting Cable 20 7110 73, or for use with KARL STORZ motor systems UNIDRIVE® S III ENT/ECO and Connecting Cable 20 7111 73

20 7111 73 1 Connecting Cable, to connect High-Performance EC Micro Motor 20 7110 33 to UNIDRIVE® S III ENT/ECO/NEURO/OMFS control units

262223 1 Rapid Diamond Burr, straight shaft, with coarse grit diamond coating for precise cutting by light hand pressure, length 70 mm, diameter 2.3 mm, for use with KARL STORZ High-Performance EC Micro Motor 20 7110 33 and Connecting Cable 20 7111 73, color code: gold





263518 1 LINDEMANN Burr, conical, stainless, sterilizable, size 018, diameter 1.8 mm, length 7 cm



280030 1 Rack, for 36 straight shaft burrs with a length of 7 cm, can be folded out, sterilizable, size 22 x 11.5 x 2 cm

280080 1 Brush, for cleaning atraumatic jaws, sterilizable, package of 5

39552B 1 Sterilizing and Storage Tray, provides safe storage of accessories for KARL STORZ drilling/grinding systems during cleaning and sterili zation, includes tray for small parts, for use with rack 280030, rack included

5.2 Instruments for Costal Cartilage Harvest (L-Beam Technique)Recommended Set acc. to MAAS and SAUER

511812 1 KILNER Scissors, curved, flat end, length 12.5 cm

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COMPLEX OPERATING TECHNIQUES IN FACIAL PLASTIC … · nasal dorsum and tip correction, revision...

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Transcript of COMPLEX OPERATING TECHNIQUES IN FACIAL PLASTIC … · nasal dorsum and tip correction, revision...