451.04.76_Daniel Advanced Rhinoplasty

… is constantly changing and evolving. The classic example is the impact that the open approach has had on all aspects of rhinoplasty surgery, from suturing the tip to total septoplasty. Currently we are seeing a new evolutionary wave made up of multiple changes in how we do important surgical maneuvers. After a decade of emphasis on tip surgery, we are starting to see major changes in how we elevate the soft tissue envelope, reduce the dorsal hump, create spreader flaps and do controlled osteotomies to achieve the desired dorsal lines while overcoming the inherent asymmetry of the bony vault. To reach these goals, it was necessary to develop an advanced rhinoplasty instrument set. First, the soft tissue envelope is being elevated beneath the sub-SMAS layer; specifically below the perichondrium and periosteum. The advantage of this dissection plane is that it reduces the common morbidity of swelling and numbness which leads to a faster recovery and final appearence.To achieve this deeper plane of elevation, we have developed the following specialized instruments: sharper pointed scissors, narrower tapered elevators, a special- ized subperichondrial elevator, and a sharper subperiosteal elevator. Second, many surgeons have found spreader flaps advantageous as compar- ed to spreader grafts, as it reduces the amount of cartilage graft material required and may give a more natural appearance. Yet, many of the originators of this procedure have used an osteotome to remove the bony hump over the underlying cartilaginous vault. Yet, we have found delicate rasps to be effec- tive in removing the bony cap over the cartilage vault which in turn minimizes the need for crushed cartilage grafts. The upper lateral cartilages are left intact which allows the cartilage vault to be opened and the spreader flaps created in a controlled fashion. Third, osteotomies have long been considered a fairly standard maneuver designed to narrow the bony vault. However, recent advances have dramati- cally changed the sequence and method of doing osteotomies which in turn requires new osteotomes. The initial change is to consider the width and asymmetry of the dorsal lines which leads to the more frequent use of lateraliz- ed medial oblique osteotomies. Next, the asymmetry and convexity of the lateral wall is controlled using a variety of intermediate osteotomies (high, middle, low) employing a straight delicate V-shape osteotome. Due to the significant asymmetry which occurs in every patient’s nasal walls, the lateral osteotomies are individualized. In most cases, a percutaneous osteotomy will be done using an ultra sharp 2 mm or 3 mm chisel which are sharpened on a wet stone prior to using. This approach allows one to narrow the base bony width (x-point) while preserving Webster’s triangle. When the entire bony vault is quite wide, then a straight 3 mm guided osteotome is employed. It is my sincere hope that all surgeons will find these instruments to be of value in obtaining superior results in their own rhinoplasty surgery. Rollin K. Daniel, MD Board Certified Plastic Surgeon Newport Beach USA Rhinoplasty Surgery