Facial Plastics and Rhinoplasty Assessment · FACIAL PLASTICS AND RHINOPLASTY ASSESSMENT ....

Bhaskar Ram

Aberdeen Royal Infirmary

Dundee FRCSENT VIVA course

www.frcsentvivacourse.co.uk

FACIAL PLASTICS AND RHINOPLASTY ASSESSMENT

Aesthetic Principles • Ensure Complete Excision

• Consider Moh’s surgery • Replace tissue with like tissue ▫ Replace all missing components • Restore units and aesthetics • Evaluate tissue surrounding donor and recipient sites

Nasal Reconstruction • What does the patient want?

Expectations REMEMBER KIS • Patient Factors Health of patient, health of skin, smoker • Diagnose the nasal defect Subunits, tissue layer, internal structures • Evaluate donor materials for missing surface and tissue layers

FACIAL REGIONS

NASAL SUBUNITS

Restore units and aesthetics

• If greater than 50%, then best

to excise and recon entire

subunit.

• Match color and texture.

Replace tissue with like tissue • Cutaneous cover

Full thickness skin graft

Local or regional flaps

Structural support

Septal cartilage

Auricular or rib cartilage

Calvarial bone

• Lining flaps

▫ Septal mucoperichondrial flaps

Vestibular or turbinate mucosal flaps

HOW TO RECONSTRUCT

• START from the THE BASE

• BUILD the SUPPORT next

• COMPLETE with COVERING the defect with the skin

NASAL LINING FLAPS

• Bipedicled vestibular flap (Aka bucket handle flap)

(must be defect <1.5cm in

vertical height)

▫ Make intercartilagenous incision between upper and lower lats

Elevate the flap, sufficiently to mobilize

• Auricular cartilage can serve as framework to attach to.

Lining Flaps

• Unilateral Septal

Mucopericondrial hinge flap

(Can measure up to 4-4.5cm

in length and 2.5 – 3 cm in

Width)

▫ Sub-perichondrial dissection

is completed from above

downward towards the floor

and from anteriorly to

Posteriorly

▫ Turn flap laterally as a hinge

Framework

Framework

• Cephalic Dorsum – cranial bone.

▫ These are secured to frontal bone with miniplates.

• Caudal Dorsum – septal or auricular cartilage.

• Lateral Sidewall – may be replaced with bone or

cartilage.

• Alar defects – cartilage (usually contralateral

concha cymba).

Nasal Reconstruction – CUTANEOUS DEFECTS-Ladder • Primary closure

• Healing by secondary intention

• Dermabrasion

• Full thickness skin grafts (FTSG)

• Composite grafts

• Random Flaps

• Pedicled Flaps

Secondary Intention

Typically for medial canthal defects

• Results in contraction

and distortion of nose

• Poor aesthetic

outcomes on most

defects of nose

Primary closure • Little redundant skin on nose ▫ Easier on elderly patients • Defect usually < 1cm ▫ Dorsum or sidewall • May produce alar or tip distortions (rotation of tip).

Full Thickness Skin Graft • Used instead of STSG to avoid contraction

• Need intact framework to support

• Use like tissue

• Best on younger patients with thin skin

• Best for nasal sidewal unit defects

Local Flaps

LOCAL FLAPS Types of Flaps: Defined by direction of

tissue movement

• Advancement flaps: Linear movement

▫ Y-V advancement

• Rotational Flaps: Radial movement

• Transposition Flaps: Raised from donor sites

and rotated over to defect

Interpolated Flaps: Flap passed over or under

bridge of skin separating site : Island flap, Paramedian forehead flap.

from defect:

▫ Important to recognize vectors of pull and force

▫ Especially when pulling from structures with low

tensile strength such as the eyelid.

What flap to use and Where

Nasal Dorsum – Cutaneous cover

Glabellar Flap

Forehead flap

Primary closure

FTSG

Nasal Sidewall- Cutaneous Cover

FTSG

Transposition Flap

Bilobed Flap

Forehead Flap

Nasal Tip Lobule – Cutaneous cover

• Bilobe flap • Forehead flap • FTSG

Tip Lobule – Bilobe Flap

• Original design by Esser (1918)

Total transposition of ‹100°

• Ideal for defects:

1.5 - 2.0cm

▫ Best of ›5mm from margin of

nostril

Preferably laterally based

Most common nasal local flap Double transposition flap Little distortion of alar rim

Paramedian Forehead flap Based off supratrochlear Artery 1.7 – 2.2cm lateral to midline Performed on same side of majority of defect Pedicle can be as narrow as 1.2cm ▫ Allows for greater arch of Rotation ▫ Minimizes standing deformity

Columella – Cutaneous cover FTSG (superficial)

Composite graft (<1.5cm)

Melolabial flap

Forehead flap

Alar rim – Cutaneous cover

• Melolabial flap

• Forehead flap

• Composite graft

Melolabial

•Melolabial Interpolation Flap • Preserves alar-facial sulcus

▫ Pedicle crosses sulcus and is

taken down at 3 weeks

• Three types:

▫ Superiorly Based

Lateral nasal wall, nasal ala

Single stage

▫ Inferiorly Based

Nasal sill and columella

▫ Island Pedicled flap

Indicated for whole subunit

alar surface replacement

TEMPLE AND FOREHEAD DEFECTS

CHEEK DEFECTS

Take home points Mohs Surgery – Principles

Reconstruction of Mohs Defects

Cosmetic Principles

Healing by Secondary Intent

Skin Graft

Primary closure

Flap Reconstruction

Reconstruction of specific locations

FACIAL ANALYSIS OF THE RHINOPLASTY PATIENT

Bhaskar Ram

Consultant Otolaryngologist

The standard attractive face

Symmetry

Proportions

Angles

Relationships

Correction of what is askew determines the surgical plan

Primary points of interest

Trichion

Glabella

Nasion

Supratip

Tip

Subnasale

Stomion

Menton

Zimbler, Marc Ham, Jongwook. Aesthetic Facial Analysis, Cummings: Otolaryngology: Head and Neck Surgery, 4th ed 2010

•Trichion: Anterior hairline in the midline

•Glabella: Most prominent midline point of forehead, well appreciated on lateral view

•Nasion: Most posterior midline point of forehead, typically corresponds to nasofrontal suture

•Rhinion: Soft-tissue correlate of osseocartilaginous junction of nasal dorsum

• Supratip: Point cephalic to the tipTip: Ideally,

• Subnasale: Junction of columella and upper lip

•Menton: Most inferior point on chin

•Pogonion: Most anterior midline soft-tissue

Nasal aesthetic subunits

Zimbler, Marc Ham, Jongwook. Aesthetic Facial Analysis, Cummings: Otolaryngology: Head and Neck Surgery, 4th ed

Tip Support

•Major

•LLC size and shape

•LLC attachment to ULC

•LLC attachment to caudal spine

•Minor

•Interdomal ligament

•Soft tissue envelope

•Cartilagenous dorsum membranous septum

•Nasal spine

Rhinoplasty consultation

• First Consultation

• Understand patients wants

• Are they genuine, realistic

• Understand what you can realistically achieve

•

• Will the pt be happy with the outcome

•

BEWARE • Intranasal substance abuse (eg, cocaine)

• Psychological or psychiatric instability

• SIMON (single, immature, male, overly expectant, narcissistic) personality traits

• Patient refusal of external scar

• Very thick nasal skin

STANDARD FACIAL PHOTOGRAPHS

Facial Analysis

Horizontal 1/3s

Trichion glabella

Glabella subnasale

Subnasalementon

Lower 1/3 may be subdivided

Upper lip 1/3

Lower lip + chin 2/3

Orten, Steven and Hilger, Peter. Facial Analysis of the Rhinoplasty Patient. Papel: Facial and Plastic ReconstructiveSurgery, 2002.

Facial Analysis

• Vertical 1/5s- intercanthal distance


Frontal View •Twisted

•Dorsal width

•Alar base

•Tip defining

points

•Asymmetry of

domes

Rhinoplasty DominicMCastellanoM.D. Castellano&HowardSpecialtyCenter Tampa,Fl , Osler Review Course

Frontal view

• A curved, unbroken line should sweep from the medial brow to the tip defining point


Disruption of brow-tip esthetic line

http://www.drhilinski.com/rhinoplasty-tutorial/spreader-grafting/

Abnormal contour involving the middle vault of the nose

Frontal View- Symmetry

• A line from midglabella to the menton should bisect the nasal bridge and tip symmetrically

Deviated Nose

/

http://www.drlamperti.com/blog/post/how-to-fix-a-crooked-nose-with-rhinoplasty

Frontal View- Nasal Dorsum and Alar base

• The width of the alar base = intercanthal distance

Alar base Reduction

http://www.plasticsurgerypractice.com/issues/articles/2011-01_02.asp

Frontal View

•The width of the bony sidewall of the nose should be 75-80% of the normal alar base.

WIDE BONY SIDEWALL

Surgically corrected with lateral osteotomy

http://www.noses.co.nz/Photo%20Gallery?Service=Show&Image=4

Frontal View- Tip Defining Points

• Represent light reflection from the skin overlying the domes of lower lateral cartilages

Tip- Angle of Divergence •Angle of divergence

•Lateral angulation from midline 50-60°

•Variations

• Narrow

• Elongated tip

• Wide (Bulbous)

• “Box and ball” Rhinoplasty DominicMCastellanoM.D. Castellano&HowardSpecialtyCenter Tampa,Fl , Osler Review Course

Angle of Divergence- Wide vs Narrow

Wide angle of divergence = BOX Narrow angle


Frontal View- Columella Columella should hang

just inferior to alar rims

Infratip lobule should be a gentle “gull in flight”

Too much-reduction

Retracted-augmentation Orten, Steven and Hilger, Peter. Facial Analysis of the Rhinoplasty Patient. Papel: Facial and Plastic

ReconstructiveSurgery, 2002.

Lateral View

•Dorsal hump

•Projection

•Rotation

•Nasofrontal

Angle

•Columella Rhinoplasty DominicMCastellanoM.D. Castellano&HowardSpecialtyCenter Tampa,Fl , Osler Review Course

Profile- Nasofrontal angle

Connects the brow with the nasal dorsum

GlabellaNasion

NasionNasal tip

Nasion (deepest point) should lie at supratarsal crease

Angle is usually 115-130 degrees

No well established parameters, use judgement to determine what is too shallow and too deep.


Tip Projection- 60% Goode method

•Line from alar crease tip

•Nasiontip

•Ratio should be 0.55-0.60 (alar) to 1.0 (nasion)

www.rhinoplastyspecialistsurgeon.com/

Tip Projection- relation to lip

•Nasal tip projection may also be measured in relation to the upper lip

•50-60% of the horizontal projection of the nose lies anterior to upper lip

•>60% is over projected

•<50% is under projected Orten, Steven and Hilger, Peter. Facial Analysis of the Rhinoplasty Patient. Papel: Facial and Plastic

ReconstructiveSurgery, 2002.

Lateral View- Dorsum

Line from Nasion to desired tip projection

Nasal dorsum should lie at or slightly (1-2mm) posterior and parallel to this line

Slight supratip break of dorsum gives definition and helps distinguish dorsum from tip

NasoFacial Angle

•The incline of the nasal dorsum in relation to the facial plane.

•Ideally 36 degrees (varies 30 to 40)

Zimbler, Marc Ham, Jongwook. Aesthetic Facial Analysis, Cummings: Otolaryngology: Head and Neck Surgery, 4th ed

Tip rotation- Nasolabial Angle

•Line anterior to posterior point of nostril

•Vertical line perpendicular to Frankfurt plane, dropped along upper lip

•Men 90-95

•Women 95-115

Tripod theory

• First proposed by Anderson JR (1969)

• Tripod • Lateral cruras= two posterior legs

• Conjoined medial cruras = anterior third leg

• Helps predict the tip rotation • Tilt in the direction of the shorter leg

• Cephalic rotation • Shortening of the lateral cruras

• Lengthening medial cruras

Tripod Theory

Alar -Columellar Relationship

• 2-4 mm columella should be visible below alar margin on profile

• >4 mm is excessive

• Retracted alar lobule

• Hanging caudal septum


Columella- double break

• Columella is seen to have a double break

• 1st-tip of the nose turns posterior-inferior to infratip lobule

• 2nd- mid columella , where takes a horizontal course to subnasale

Base View


Size Shape Orientation Width and length of columella Height of Lobule

http://noserevisionsurgeryandsurgeons.blogspot.com/

Base View

•Isosceles Triangle

•Lobule 1/3

•Columella 2/3

•Nostrils

•Symmetric

•Pear shaped

•Columella flare at base and at infratip lobule

Chin Position

• Gonzales-Uloa

• Line from nasion perpendicular to Frankfort planechin should approximate this line

Orten, Steven and Hilger, Peter. Facial Analysis of the Rhinoplasty Patient. Papel: Facial and

Plastic ReconstructiveSurgery, 2002.

Inadequate Chin

Microgenia

Underdeveloped mental portion of mandible

Micrognathia

Underdeveloped mandible with class II occlusion

Retrognathia

Mandible is normal in size but retruded with class II occlusion

Micrognathia or retrognathia= orthognathic surgery

Microgenia or doesn’t desire orthognathic surgery=augmentation mentoplasty

Nasal –Forehead


A forehead that slopes posteriorly from the brow to the hairline tends to exaggerate the appearance of nasal length and projection. A flat, vertically oriented, or protruding forehead diminishes the appearance of nasal length.

Summary- Frontal View

Frontal View

Divide the face

▪ Horizontal 1/3

▪ Vertical 1/5

Look for asymmetry

Dorsal width

▪ 75% of alar base

Alar width

▪ Intercanthal distance

Shape and asymmetry of tip

Note abnormalities in the dental occlusal relations

Summary-Lateral View

• Nasal length

• Tip projection

• Goode 1: 0.6 ratio

• Crumley 3,4,5

• Tip Rotation

• Nasolabial angle 90-95 men

• 950-115 in women

Nasal Relation

• All analysis of lips should include assessment of forehead, brow, lips, chin, dentition.

• Forehead- Nasofrontal angle

• Chin- Vermillion borders to chin (should be within 2-3 mm)

THE END

Now that I have your attention, let’s practice!

LIP DEFECTS

Lip defects

<1/2 – primary closure, w plasty

1/2-2/3- lip switch (abbe if away from commissure, estlander + commissureplasty if near commissure) flap width ½ defect width, kerapanzic

>2/3- bernard webster bipedicled advancement flap, melolabial transposition, temporal forehead flap, free flap

Abbe

W plasty

Karapanzic

Bernard burrows

Estlander

Estlander Flap

Abbe fLAP

Facial Plastics and Rhinoplasty Assessment · FACIAL PLASTICS AND RHINOPLASTY ASSESSMENT ....

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