A Practical Approach to Asian Rhinoplasty: How to Design A Fine Nasal Shape

209 Pages·2020·29.937 MB·English

by  Yasushi Sugawara

Yasushi Sugawara
A Practical Approach
to Asian Rhinoplasty
How to Design A Fine Nasal Shape
123
A Practical Approach to Asian Rhinoplasty
Yasushi Sugawara
A Practical Approach to Asian
Rhinoplasty
How to Design A Fine Nasal Shape
Yasushi Sugawara
Lilla Craniofacial Clinic
Ginza, Tokyo, Japan
ISBN 978-4-431-56883-4 ISBN 978-4-431-56885-8 (eBook)
https://doi.org/10.1007/978-4-431-56885-8
© Springer Japan KK, part of Springer Nature 2020
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
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The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and
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The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed
to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty,
expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been
made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Japan KK part of Springer Nature.
The registered company address is: Shiroyama Trust Tower, 4-3-1 Toranomon, Minato-ku, Tokyo 105-6005, Japan
To my parents, Yukiko and Koichiro, and my wife, Noriko, for their support.
Yasushi Sugawara
Preface
Rhinoplasty is like building a home, for two reasons:
The first is a way of being. A home is a very personal and comfortable place for its owner.
Its style might be individual or conventional, but it must also be a safe, functional space that
keeps out the cold and heat, the wind and rain.
The nose should achieve a shape each patient personally considers lovely. There is no com-
mon shape, each nose is very individual, but healthy functions such as breathing and smelling
must be secured.
The other reason that rhinoplasty is like building a home is the process.
The building process includes:
1. Surveying land
2. Researching the surrounding environment
3. Listening to client wishes
4. Drawing a blueprint
5. Procuring material
6. Building work
How about the process of rhinoplasty?
1. Clinical assessment
2. Evaluation of facial balance
3. Listening to patient wishes
4. Creating a simulation
5. Presurgical preparation
6. Surgical work
As you can see, the rhinoplasty process is quite similar to that of building a home.
From this perspective, this atlas explains the process of rhinoplasty along a clinical work-
flow, showing how to create a surgical plan by using digital technology, as well as how to fulfill
this plan by using surgical guides to meet patient expectations (rhinoplasty patients are very
interested in the final outcome in the same way that, when building “home sweet home,” you
are interested in the blueprint).
I hope that surgeons benefit from this atlas and make their patients happy.
Tokyo, Japan Yasushi Sugawara
vii
Acknowledgment
I thank all my mentors, colleagues, hospital staff, and patients for giving me a chance, as well
as sharing their imagination, courage, joy, and happiness with me. Also, I would like to thank
the entire staff at Springer, particularly Lee Klein for his patient support.
ix
Contents
1 Clinical Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 General Concept . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Basic Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2.1 Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2.2 Lines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2.3 Subunits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.2.4 Measurements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.3 Topological Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.4 Structural Nasal Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.4.1 Bony Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.4.2 Nasal Septum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.4.3 The Cartilaginous Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.4.4 The Nasal Superficial Musculoaponeurotic System . . . . . . . . . . . . . . . . 13
1.4.5 Nasal Movement and Aesthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.4.6 The Skin and Soft Tissue Envelope (S-STE) . . . . . . . . . . . . . . . . . . . . . . 13
1.4.7 The Relation Between Nasal Framework
and Surface Topology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
1.4.8 Directional Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2 The Presurgical Workflow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.1 Interview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.2 Photographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.2.1 Lighting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
2.2.2 Camera Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
2.2.3 Shooting of a Complete Set of Clinical Facial Photographs . . . . . . . . . . 20
2.3 Analysis of the Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.3.1 Nasion (Radix Break Point) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.3.2 Nasal Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.3.3 Subnasale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.3.4 Rhinion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.3.5 Alar, Pedestal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.3.6 Facial Proportion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.4 Computer Simulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2.4.1 Basic Technique of Simulation Using Photoshop . . . . . . . . . . . . . . . . . . 31
2.4.2 Making a Harmonized Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
2.5 Clinical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
2.6 Determine the Final Goal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
3 Basic Surgical Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
3.1 Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
3.2 Harvesting Autogenous Tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
3.2.1 Auricular Cartilage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
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xii Contents
3.2.2 Septal Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
3.2.3 Rib Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
3.2.4 Dermal Fat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
3.2.5 Temporal Fascia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
3.2.6 Perichondrium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
3.3 Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
3.3.1 Endonasal Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
3.3.2 Open Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
3.3.3 Vestibular Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
4 Dorsal Augmentation or Height Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
4.1 Dorsal Augmentation with Alloplastic Materials . . . . . . . . . . . . . . . . . . . . . . . . . 55
4.1.1 Silastic Implant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
4.1.2 Gore-Tex Implant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
4.1.3 Complications and Solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
4.2 Dorsal Augmentation with Autologous Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
4.2.1 Ear Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
4.2.2 Septal Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
4.2.3 Costal Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
4.2.4 Dermal Fat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
4.2.5 Complications and Solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
4.3 Dorsal Height Reduction (Humpectomy) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
4.3.1 Bony Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
4.3.2 Cartilaginous Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
4.3.3 Open Roof Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
5 Altering the Nasal Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
5.1 Anatomical Features of the Asian Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
5.1.1 Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
5.1.2 Soft Tissue Envelope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
5.1.3 Morphological Relation Between Frame and Soft Tissue . . . . . . . . . . . . 73
5.2 Structural Tip Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
5.3 Frame Structuring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
5.3.1 Tripod Leg Controlling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
5.3.2 Cartilage Suturing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
5.3.3 Cartilage Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
5.4 Soft-Tissue Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .116
5.5 Balanced Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .116
6 Alar and Pedestals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .119
6.1 Principles of Alarplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .119
6.1.1 Alar Width . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .119
6.1.2 Nostril Shape . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .119
6.1.3 Alar Curvature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .119
6.2 Alar Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .119
6.2.1 Alar Resection, Inner Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .119
6.2.2 Alar Resection, Outer Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .125
6.3 Nostril Base Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .129
6.3.1 Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .129
6.4 Alar Rim Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .131
6.4.1 Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .131
6.5 Alar Rim Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .133
6.5.1 Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .133
Contents xiii
7 Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .137
7.1 Case 1: Primary Rhinoplasty: Dorsal Augmentation, Tip Plasty,
and Alarplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .137
7.1.1 Patient Profile (Figs. 7.1, 7.2, 7.3, and 7.4) . . . . . . . . . . . . . . . . . . . . . . .137
7.1.2 Clinical Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .137
7.1.3 Topological Analysis (Figs. 7.6, 7.7, 7.8, 7.9, and 7.10) . . . . . . . . . . . . .137
7.1.4 Preoperative Simulation (Figs. 7.11, 7.12, 7.13, 7.14, 7.15, 7.16,
and 7.17) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138
7.1.5 Surgical Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138
7.1.6 Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138
7.1.7 Result . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .141
7.2 Case 2: Primary Rhinoplasty: Hump Reduction . . . . . . . . . . . . . . . . . . . . . . . . .154
7.2.1 Patient Profile (Figs. 7.51, 7.52, 7.53, and 7.54) . . . . . . . . . . . . . . . . . . .154
7.2.2 Clinical Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .154
7.2.3 Topological Analysis (Figs. 7.55, 7.56, and 7.57) . . . . . . . . . . . . . . . . . .156
7.2.4 Preoperative Simulation (Figs. 7.58, 7.59, and 7.60) . . . . . . . . . . . . . . . .156
7.2.5 Surgical Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .157
7.2.6 Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .158
7.2.7 Result . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .163
7.3 Case 3: Primary Rhinoplasty: Short Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .166
7.3.1 Patient Profile (Figs. 7.86, 7.87, 7.88, and 7.89) . . . . . . . . . . . . . . . . . . .166
7.3.2 Clinical Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .166
7.3.3 Topological Analysis (Figs. 7.90, 7.91, and 7.92) . . . . . . . . . . . . . . . . . .168
7.3.4 Preoperative Simulation (Figs. 7.93, 7.94, and 7.95) . . . . . . . . . . . . . . . .168
7.3.5 Surgical Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .168
7.3.6 Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .168
7.3.7 Result . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .175
7.4 Case 4: Secondary Rhinoplasty: Dorsal Deviation and Tip Drooping. . . . . . . . .180
7.4.1 Patient Profile (Figs. 7.127, 7.128, 7.129, and 7.130) . . . . . . . . . . . . . . .180
7.4.2 Clinical Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180
7.4.3 Topological Analysis (Figs. 7.131, 7.132, and 7.133) . . . . . . . . . . . . . . .182
7.4.4 Preoperative Simulation (Figs. 7.134, 7.135, and 7.136) . . . . . . . . . . . . .183
7.4.5 Surgical Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .184
7.4.6 Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .184
7.4.7 Result . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .186
7.5 Case 5: Secondary Rhinoplasty: Dorsal Augmentation, Tip
and Alarplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .192
7.5.1 Patient Profile (Figs. 7.156, 7.157, 7.158, and 7.159) . . . . . . . . . . . . . . .192
7.5.2 Clinical Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .192
7.5.3 Topological Analysis (Figs. 7.160, 7.161, and 7.162) . . . . . . . . . . . . . . .193
7.5.4 Preoperative Simulation (Figs. 7.163, 7.164, and 7.165) . . . . . . . . . . . . .193
7.5.5 Surgical Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .194
7.5.6 Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .194
7.5.7 Result . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .197