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RHINOPLASTY TECHNIQUES STEP BY STEP

 INTRODUCTION

History of rhinoplasty originates from many centuries in the past, most probably from historic cultures in Egypt. One of the most important steps in modern open-tip rhinoplasty historical past was taken in 1921 by Rethi, from Budapest, which described an outside approach to expose alar cartilages and nasal dorsum only through a unique high columellar skin sillon, connected with bilateral endonasal skin incisions along the caudal border of the alar cartilages.Typically the Rethi incision became the dictum for transcolumellar method.

Goodman after getting to know Padovan`s work, begun to apply the external method in is rhinoplasty in a systematic manner. This individual formulated the potential ideals of the external method and refined the sillon, also known as “Butterfly” or “Gull-wing”. Goodman described an interrupted, broken line mid columellar skin sillon. He also introduced some innovations to the complete open rhinoplasty procedure, including the use of electro cautery to reduce blood loss and the use of a rotating burr to develop the nasal dorsum.

The concept of “open structure rhinoplasty” was presented by Johnson, an associated of Anderson and Toriumi. This author combined the external approach with the concept of autologous the fibrous connective tissue cartilage grafts to the nasal tip, based on the previous work of Sheen(7), and he gave the most emphasis to a solid structural support of the nose.

Open-tip rhinoplasty, also called external approach or available structure rhinoplasty, has gained much popularity in the past 30 years among rhinoplasty surgeons due to some main features of this system, such as direct visual images of the anatomy and precise diagnosis of the deformities, bimanual control of the structures and chance of electro cautery hemostasis. Another important characteristic of the open approach is the ability to show and teach this method to younger trainees or fellows. Exposure is a simple principle in any surgery, but gains an extra emphasis in aesthetic and reconstructive surgery.


SURGICAL TECHNIQUE

Infiltration

A single very important step in open rhinoplasty is the first one: infiltration. That should be done before disinfecting and dressing the patient, in order to take effect for at the very least quarter-hour and so improve the vasoconstrictive effect of epinephrine.. Infiltration is performed using 8 to 10ml of lidocaine at 1% with epinephrine at 1: one hundred 000, and is applied in six key details: 1) vertically from the nasal tip to the anterior nasal spine; 2) in the columella, through the nasal vestibulum, verticle with respect and anterior to the caudal septum; 3) in the infra tip point parallel to the sinus dorsum; 4) vestibulum, in the intercartilaginous region; 5) through the pyriform béance, lateral and parallel to the ascending process of the maxilla; 6) alongside the nasal septum, in the sub mucosal area. After this, cottonwoods pledges soaked in phenylephrine or cocaine ointment at 10%, are put in both nasal cavities to reduce nasal mucosa, improve direct exposure and minimize loss of blood.


Incision/Surgical Technique

Exposure of the nose osteocartilaginous structure is obtained by by using a transcolumellar incision that is performed at the narrowest area of the middle portion of the columella. In this location there is the support of the lower lateral cartilage (LLC) medial crura, that is very important to minimize scar contraction and is one of the reasons why is so important to preserve intact medial crura. The incision is made parallel to the relaxed skin tension outlines, in an interrupted manner so that the wound`s contractile forces are redistributed. The creators usually use a amount 11 blade to do the inverted “V” sillon with a sawing action (figure 2). Is essential that the blade stays perpendicular to the skin, in order that the wound edges are even and the scar development can be perfect. Inside the horizontal portions of the columellar incision we use the 15 knife because at this stage there aren`t acute angles.

This midcolumellar incision continues laterally with the marginal incisions made on the vestibular pores and skin caudal to the lower border of the medial and intermediated crura, just 2mm behind the primary border of the columellar.

The particular next step is to use the Converse scissor to dissect under the muscle-aponeurotic plane. To accomplish this one as to introduce de Converse scissor by one of the columellar percentage of the marginal incisions and dissect superficial to the caudal margin of the LLCs and tunneling through until reaching the contralateral marginal incision.

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