Topic Rhinoplasty

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Rhinoplasty

สรพล ซ อตรง, พบ.,วว.โสต ศอ นาสกภาควชาโสต ศอ นาสก

คณะแพทยศาสตร มหาวทยาลัยขอนแก น

Rhinoplasty

• Bone,cartilage,soft tissue of nose

• Osteotomy,tip plasty,alar plasty

• grafting

Rhinoplasty

in ASIAN nose

• Augmentation > Reduction

Asian Nose

• Asian Nose

• Broad low dorsum

• Decreased tip projection

• Thick lobular skin

• Wide lobule

• Abundant subcutaneous fatty tissue

• Alar flaring

• Retracted columella

• Small osteocartilagenous framework

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Augmentation rhinoplasty

• Augmentation of nasal bone,upper-lower cartilage using various grafting materials

Implant materials

nonimmunogenic

Durable

Capable of being scalpted

Resistant to infection

Long lasting

Ideal characteristics

Options

• Biological graft

• Synthetic graft

Biological graft

• Autograft

bone: calvarium/hip/legcartilage: septum,ear,rib

Autologous cartilage

– Short supply

– Donor site morbidity

– Quality of available graft may preclude use

Homograft

Alloderm

Irradiated Rib Cartilage




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Alloderm

• Acellular human dermisobtained from donated humanskin

• Provides soft tissueaugmentation that is stableafter an early period of resorption (6 months); mustovercorrect

• Can be used to camouflagecontour irregularities createdby alloplastic or autoimplantsin nasal reconstruction

Irradiated Homograft Rib Cartilage

• Appears to be stableover time

• Risk of warping

decreased if carved

from core

• Easy to carve and

stabilize with sutures

Alloplasts

• liquid :

liquid silicone (polydimethylsiloxane)

• semisolid : polyacrylamide (aquamid)

• solid

– Silicone rubber

– Porous High Density Polyethylene (Medpor)

– Extended PTFE (Gore-Tex)

Liquid silicone injection

Solid Silicone Rubber [Silastic]• Solid, non-porous implant

which is not incorporated intosurrounding tissues

• Fibrous capsule-forming

• Elicits minimal inflammation

• ?Tendency to extrude/migrate

• Cannot be used in thin-skinnedareas

• Used as L or I-shaped implantor the “bird”

• Easily be carved,removed

• Popular in Asian countries

Silicone Implants

• Solid Silicone has been used as a

material for facial implants since about

1956. The silicone facial implants are

solid, yet flexible. They are manufactured

in different durometers (strengths) to be

soft or quite hard




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Silicone Implants

• Bad thing about silicone implants. or implants in general, is that in some thin-

skinned patients or after aging, the implant

itself can become palpable (easily seen

and felt) - especially if they are not placed

or sized correctly. There is also an

possibility of infection even years after

implantation.

Tissue Engineered Human

Chondrocytes

• Methods of culturinghuman chondrocytesis active area of research

• Recently theengineering of humannasal septalneocartilagedescribed without useof biodegradablescaffold

In car t il age t issue engineer l ab Biological graft

• Advantages

No rejection

Long lasting

Less complications

Biological graft• Disadvantages

Donor site morbidity

Limited quality of graft (cosmetics) Expensive

Synthetic graft• Advantages

No donor site morbidity

Higt quality of graft (cosmetics)

Less expensive




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Synthetic graft

• Disadvantages

More rejection

Long lasting?

More complications

Conclusion

• Silicone elastomer and new inert biomaterials stillhave place in asian rhinoplasty.

• Autogenous cartilage fabrication in the form of nasalprosthesis will replace and use more and moreespecially in complicated,secondary rhinoplasty

• Cartilage tissue engineering in the form of nasal

prostheses will be used in the future.

Rhinoplasty

in Asian nose

• Silicone augmentation – most popular

• Affordable

• Readily available

• Easily fashioned

• No donor site morbidity• Easy,short time operation

หลากหลายรปทรงของ Silicone Prosthesis

รปทรงหลักๆของ Silicone

“I” shape

“L”-shape

Bird shape




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Approaches

• Closed technique

(endonasal)

• Open technique




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Open technique

การเซาะ pocket เพ อวาง Prosthesis• Superficial

• Submucular

• Supra-periostium

• Sub-periostium

• Mixed plane




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Closed technique

Mostly usedtechnique

Patient evaluation

• Motivations

• Expectations

• Concerns

• Explannation/communication

• Pre-op. evaluation

• Photography

History

• nasal trauma

• nasal obstruction

• nasal obstruction

• allergic disorders

• comorbid conditions• medications – aspirin, anticoagulants, and herbal

supplements

Examination

• External nasal deformity

• Internal nasal anatomy

• Tip ptosis

• Septal deviation

• Existence of any purulence in the middlemeatus

Preoperative photographs• frontal view

• lateral view

– Frankfort horizontal plane

• basal view

• oblique view




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• Informed consent

• questions

• concerns

INDICATIONS

• Functional and/or aesthetic

• Nasal obstruction secondary to anatomicdeformities

Indications

• Contours the nose and makes it proportionatewith the rest of the face

• Augments flat nose (Low nasal profiles)

• Narrows nostrils that flares

• Corrects droopy nasal tips, bumps or irregularities

• Defines and sharpens the nasal tip

• Corrects a deviated or crooked nose Makes longand wide noses smaller and thinner

• Corrects nasal length (if too long or too short)

• Improves breathing

Contraindications

• Augmentation rhinoplasty has relatively

few contraindications. Any medical

condition that inhibits patient safety during

the procedure is a contraindication.

• Patients should not be taking any

anticoagulants (eg, enoxaparin [Lovenox],

warfarin [Coumadin], heparin [Hep-Lock]),

aspirin, or nonsteroidal anti-inflammatory

drugs before the surgical procedure

Photography




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Instrumentations




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COMPLICATIONS

• As is true in other surgical procedures,

occasional postoperative complications

should be expected in rhinoplasty.

Fortunately, most complications are minor.

In general, approximately 5-15% of

patients require a revision rhinoplasty

Serious complications

• less than 3% of patients and consist of

– Infection

– rejection

– extrusion

– unfavorable scarring

– anesthesia-related problems

การบางตัวของผวหนัง




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การบางตัวของผวหนังปลายจมก

การทะลของ Prosthesis




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การทะลของ Prosthesis

Deviationการเคล อนตัวลงของ Prosthesis และบางตัวของ

ผวหนังปลายจมก

Depressed scar

การเคล อนตัวลงของ Prosthesis และบางตัวของ

ผวหนังปลายจมก




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สาเหตการบางตัวของผวหนัง และการทะลออก

ของ Prosthesis

• Prosthesis ยาวเกนไป หรอหนามากไป

• มการเคล อนตัวลงภายหลัง

การแก ไขการเคล อนตัวลง

• กดดบรเวณ Dorsal Root , dorsum ระหว างการผ าตัด เพ อ

ด Stability ของ Prosthesis ว ามการเคล อนตัวลงหรอไม • ถ ายาวไป กจะได ตัดให สั นลง ก อนเยบแผลผ าตัด

• หรอเหลา Silicone ให เข า Curve ของสันจมก ในกรณสันจมก

ไม ตรง

ประเมนตาแหน งกระดก, กระดกอ อน,ความยดหย น

เหลา prosthesis ให เข

ารปร

างโครงสร

างจมก




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กดด stability ของ prosthesis ภาพยนตร ตัวอย าง




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Factors for success in rhinoplasty

• Anatomy• Structure-tissue evaluations

• Sterile technique

• Graft charactor-tissue response,selection

• Skills - experiences

• Art

• Patient doctor-relationship

• patience

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