Table Of ContentOmslag Rhinoplasty 21-07-2005 09:59 Pagina 3
G . J . N O L S T T R E N I T É
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. R H I N O P L A S T Y
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This third edition expands The editor and his associate authors add another L
and enlarges the canons of valuable link to the puzzle of aesthetic and functional S
A practical guide to
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nasal surgery elegantly rhinoplasty.Emphasizing throughoutthe cardinal
functional and aesthetic
demonstrated in the former principles which apply in the overwhelming majority of T
editions.Six new chapters rhinoplasty procedures,they presentherein directand R surgery of the nose
have been developed, compelling information for the neophyte and E
N
including expanded and experienced surgeon alike.The clear language of the
I
detailed discussions of textis complemented by valuable illustrations
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septoplasty,ethnic designed to allow the reader the understanding to É
rhinoplasty,refinements of apply rhinoplasty principles to a variety of anatomic
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the open approach,alar variants encountered.
batten grafting and an Throughout,the authors uniformly emphasize H
enlarged section on nasal coordinated procedures to repair both functional as I
reconstructive techniques. well as aesthetic deformities and disorders. N
Furthermore,a mostvaluable Strong emphasis is placed on the significant O
addition to the traditionally advantages of cartilage autografts in the treatmentof
P
nicely illustrated chapters both primary and revision surgery,a philosofhy thatis
L
incorporates an interactive generally shared by knowledgeable surgeons world-
A
DVD containing elements of wide.Techniques which occasion less risk of sequelae
S
live surgery,as well as or significantcomplication predominate throughout
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instructive and vivid video the volume.
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clips of surgical techniques. Surgeons who share a deep interestand passion for
the complex operation of rhinoplasty will enjoy the
clear,precise and pragmatic approach incorporated in
this book.Dr.Trinité and associates have produced
whatthey soughtto author - a vital and practical
contemporary guide to rhinoplasty.
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3 nd e n l a r g e d e d i t i o n w i t h i n t e r a c t i v e D V D
Kugler Publications The Hague / The Netherlands
RHINOPLASTY
RHINOPLASTY
A practical guide to functional and aesthetic surgery of the nose
Third enlarged edition
edited by G.J. Nolst Trenité
Kugler Publications / The Hague / The Netherlands
ISBN Book: 90 6299 206 4
ISBN DVD: 90 6299 207 2
ISBN Book and DVD: 90 6299 208 0
Distributors for USA and Canada:
Library Research Associates, Inc.
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For all other countries:
Kugler Publications
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Phototypeset by Palm Produkties, Nieuwerkerk aan den IJssel, The Netherlands
Printed by Koninklijke Drukkerij C.C. Callenbach b.v., Nijkerk, The Netherlands
Bound by Bindery Callenbach, Nijkerk The Netherlands
©Copyright 1993, 1998, 2005 illustrations chapters 2, 3, 4, 5, 7, 8, 9A, 9B, 10, 11, 12, 13, 14, 18 and 29 Bas Blankevoort,
Haarlem, The Netherlands
©Copyright 1993, 1998, 2005 photo's chapters 3, 4, 5, 7, 8, 10, 11, 13 and 14 Jan Keet, The Hague, The Netherlands
©Copyright 1993, 1998, 2005 G.J. Nolst Trenité
All rights reserved. No part of this book may be translated or reproduced in any form by print, photoprint,
microfilm, or any other means without the prior written permission of the copyrightholder, Professor G.J. Nolst Trenité, M.D.,
Academic Medical Center, Department of Otorhinolaryngology, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
Kugler Publications is an imprint of SPB Academic Publishing bv, P.O. Box 97747, 2509 CG The Hague, The Netherlands
CONTENTS
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Foreword, M. Eugene Tardy Jr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Part I: Basics
1. Anatomy, R.M.L. Poublon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2. Aesthetics, G.J. Nolst Trenité . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3. Preoperative management, G.J. Nolst Trenité . . . . . . . . . . . . . . . . . . . . . . . 19
4. Anesthesia and preoperative medication, G.J. Nolst Trenité . . . . . . . . . . . 27
5. Postoperative care and complications, G.J. Nolst Trenité . . . . . . . . . . . . . 31
Part II: Operative techniques
6. Septoplasty and turbinate surgery, M.J. Middelweerd . . . . . . . . . . . . . . . . 41
7. Grafts in nasal surgery, G.J. Nolst Trenité . . . . . . . . . . . . . . . . . . . . . . . . . 49
8. Alar insufficiency surgery, G.J. Nolst Trenité . . . . . . . . . . . . . . . . . . . . . . . 67
9A. Nasal valve surgery - a modified Z-plasty, G.J. Nolst Trenité . . . . . . . . . 75
9B. Nasal valve surgery - spreader grafts, T.D. Zijlker and H.D. Vuyk . . . . 79
10. Basic approaches and techniques in nasal tip surgery, G.J. Nolst Trenité 87
11. Surgery of the osseocartilaginous vault, G.J. Nolst Trenité . . . . . . . . . . . . 97
12. Open tip-rhinoplasty, H.D. Vuyk and T.D. Zijlker . . . . . . . . . . . . . . . . . . . 115
13. External rhinoplasty - the benefits and pitfalls, G.J. Nolst Trenité and
B.C. Vinayak . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
14. Wedge resection in alar base surgery, G.J. Nolst Trenité . . . . . . . . . . . . . 143
Part III: Capita selecta
15. Secondary surgery of the cleft-lip nose, G.J. Nolst Trenité . . . . . . . . . . . . 149
16. The over-projected nasal tip, T.R. Bull . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
17. Augmentation rhinoplasty, I.S. Mackay . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
18. Surgical management of large septal perforations, R. Meyer . . . . . . . . . . 181
19. Three-step reconstruction of saddle nose deformities, G. Rettinger . . . . . 191
20. Rhinosurgery in children. Developmental and surgical aspects,
C.D.A. Verwoerd and H.L. Verwoerd-Verhoef . . . . . . . . . . . . . . . . . . . . . . 201
21. Revision surgery, C. Walter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
22. Nasal vestibular stenosis, G.J. Nolst Trenité . . . . . . . . . . . . . . . . . . . . . . . . 223
23. Guidelines for cadaver dissection, G.J. Nolst Trenité . . . . . . . . . . . . . . . . 235
24. Septoplasty – Basic techniques. The nasal septum in rhinoplasty,
F.W.A. Otten . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
25. New concepts in reconstructive septoplasty, M. Boenisch and
G.J. Nolst Trenité . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
26. Developments in the open rhinoplasty approach, R. Cobo . . . . . . . . . . . 297
27. Ethnic rhinoplasty, R. Cobo and G.J. Nolst Trenité . . . . . . . . . . . . . . . . 309
28. Batten grafts for nasal valve collapse, W.J. Fokkens and
G.J. Nolst Trenité . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
vi
29. Reconstruction of skin cancer defects of the nose, P.J.F.M. Lohuis,
A.J.M. Balm and G.J. Nolst Trenité . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
30. Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
About the editor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Subject index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
CONTRIBUTORS
A.J.M. Balm, M.D., Ph.D.
Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Insti-
tute – Anthonie van Leeuwenhoek Hospital, Plesmanlaan 121, 1060 CX Amsterdam,
The Netherlands
M. Bönisch, M.D.
Department of Otorhinolaryngology, Diakonessen Krankenhaus Linz, Linz, Austria
T.R. Bull, F.R.C.S.
Consultant Surgeon, Royal National Throat, Nose and Ear Hospital & Charing Cross
Hospital, and 107 Harley Street, London W1N 1DG, U.K.
R. Cobo, M.D.
Department of Otorhinolaryngology, Centro Medico Imbanaco, Carrera 38A# 5A-100
Cons 231 Rorre A, Cali, Colombia
W.J. Fokkens, M.D., Ph.D.
Department of Otorhinolaryngology, Academic Medical Centre of the University of
Amsterdam, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
P.J.F.M. Lohuis, M.D., Ph.D.
Department of Otorhinolaryngology/Head and Neck Surgery, Academic Medical Centre
of the University of Amsterdam, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
I.S. Mackay, F.R.C.S.
Consultant E.N.T. Surgeon, Royal Brompton Hospital and Charing Cross Hospital,
London, U.K.
R. Meyer, M.D., Ph.D.
Centre de Chirurgie Plastique, 4 Avenue Marc-Dufour, CH 1007 Lausanne, Switzerland
M.J. Middelweerd, M.D., Ph.D.
Department of Otorhinolaryngology, Head and Neck Surgery, Free University Hospital
Amsterdam, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands
G.J. Nolst Trenité, M.D., Ph.D.
Department of Otorhinolaryngology/Head and Neck Surgery, Academic Medical Center,
University Hospital of the University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam
Z.O., The Netherlands
F.W.A. Otten, M.D., Ph.D.
Department of Otorhinolaryngology, Diaconessenhuis, Houtlaan 55, 2334 CK Leiden,
The Netherlands
R.M.L. Poublon, M.D., Ph.D.
Department of Otorhinolaryngology, Erasmus University Rotterdam, Dr. Molewaterplein
40, 3015 GD Rotterdam, The Netherlands
G. Rettinger, M.D., Ph.D.
Department of Otorhinolaryngology, Head and Neck Surgery, University of Ulm,
Prittwitzstrasse 43, D-89075 Ulm/Donau, Germany
C.D.A. Verwoerd, M.D., Ph.D.
Department of Otorhinolaryngology, Erasmus University Rotterdam, Dr. Molewaterplein
40, 3015 GD Rotterdam, The Netherlands
viii
H.L. Verwoerd-Verhoef, M.D., Ph.D.
Department of Otorhinolargyngology, Erasmus University Rotterdam, Dr. Molewaterplein
40, 3015 GD Rotterdam, The Netherlands
B.C. Vinayak F.R.C.S.
Department of Otorhinolaryngology, Radcliffe Infirmary, University of Oxford,
Woodstock Road, Oxford, OX2 6HE, U.K.
H.D. Vuyk, M.D., Ph.D.
Department of Otorhinolaryngology, Ziekenhuis Gooi Noord, Rijksstraatweg 1, 1261
AN Blaricum, The Netherlands
C. Walter, M.D., Ph.D.
Department of Otorhinolaryngology and Facial Surgery, Klinik am Rosenberg, CH 9140
Heiden AR, Switzerland
T.D. Zijlker, M.D., Ph.D.
Department of Otorhinolaryngology, Ziekenhuis De Wever en Gregorius, Henri
Dunantstraat 5, 6419 PC Heerlen, The Netherlands
FOREWORD
M. Eugene Tardy, Jr.
The pioneers of early rhinoplasty in the late nineteenth and early twentieth century would
take pleasure in the fact that this complex operation still incorporates the fundamental prin-
ciples identified by these visionary men. It is doubtful, however, that any among them could
have foreseen the remarkable refinements rather routinely employed in the past decade.
Important developments have transformed aesthetic and reconstructive rhinoplasty
from a procedure incorporating primarily tissue reduction and sacrifice to one of tissue
reorientation and reconstruction. Time and experience combine to teach that the finest
and most natural long-term outcomes are those in which less removal of nasal structures
is effected, preserving natural form and function. Clearly the best rhinoplasty surgeons
are those who think and plan long-term, tailoring the operation to the exact anatomy
encountered, carrying out maneuvers designed to maintain control of the healing process.
Cartilage grafting procedures, much more common now than in the past, lend unlimited
possibilities to nasal contour sculpturing. Conservative preservation of the various
components of the nasal framework and skin-subcutaneous tissue layer now reigns as
a fundamental cardinal principle of modern rhinoplasty.
For the majority of our predecessors and teachers, the learning process for sophisticated
rhinoplasty procedures was a long and arduous process, rooted in trial and error. The
past two decades, stimulated by educators skilled in teaching techniques and aided by
knowledge gained through anatomical studies and long-term follow-up of patients
operated on by various techniques, have borne witness to a significant shortening of
the otherwise steep and arduous learning curve to rhinoplasty excellence. Operative
television brings the experience and techniques of experts from around the world to the
eager learner at the flick of a video control button. The emergence of the open approach
to certain difficult rhinoplasty anatomical problems allows the neophyte surgeon an
unparalleled opportunity to witness exact relationships and variations in nasal anatomic
components. Fresh cadaver dissection experience has clarified surgical concepts of value
and disqualified those with questionable outcomes. A plethora of detailed textbooks on
rhinoplasty has emerged in the past decade, providing surgical guidance based upon
wide experience and careful patient follow-up.
To this veritable explosion of scholarly information, Nolst Trenité and his associate
authors have added another valuable link to the puzzle of aesthetic and functional
rhinoplasty.
In the expanded second edition of this successful text/atlas new chapters by surgeons
of long experience and vision augment fundamental information from the first edition.
A companion interactive CD-ROM vividly portrayed operative techniques discussed in
the text. Emphasizing throughout the cardinal principles which apply in the overwhelming
majority of rhinoplasty procedures, the authors present herein direct and compelling
information for the neophyte and experienced surgeon alike. The clear language of the
text is complemented by valuable illustrations designed to give the reader the under-
standing to apply rhinoplasty principles to a variety of anatomical variants encountered.
Throughout, the authors uniformly emphasize coordinated procedures to repair both
functional as well as aesthetic deformities and disorders. Strong emphasis is placed on
the significant advantages of cartilage autografts in the treatment of both primary and
