Aesthetic Plastic Surgery of the East Asian Face, 1e [PDF]

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Aesthetic Plastic Surgery of the East Asian Face

Hon g Ryu l Jin , MD, Ph D Professor an d Ch air Depar t m en t of Otorh in olar yngology–Head an d Neck Su rger y Boram ae Medical Cen ter Seoul Nat ion al Un iversit y College of Medicin e Seoul, Repu blic of Korea

956 illu st rat ion s

Th iem e New York • St u t tgar t • Delh i • Rio de Jan eiro

Execut ive Editor: Tim othy Y. Hiscock Man aging Editor: J. Ow en Zurh ellen IV Editorial Assist an t: Naam ah Sch w art z Director, Editorial Ser vices: Mar y Jo Casey Product ion Editor: Ken n eth L. Ch u m bley International Production Director: An dreas Schabert Vice President, Editorial and E-Product Developm en t: Vera Spilln er In tern at ion al Market ing Director: Fion a Hen derson In tern at ion al Sales Director: Louisa Turrell Director of Sales, North Am erica: Mike Rosem an Sen ior Vice President and Chief Operating Of cer: Sarah Vanderbilt Presiden t: Brian D. Scan lan Medical Illu st rators: Hyu n -Hang Lee Librar y of Con gress Cat alogin g-in -Pu blicat ion Dat a Nam es: Jin, Hong Ryul, editor. Title: Aesth et ic plast ic surger y of th e East Asian face / [edited by] Hong Ryul Jin . Descript ion : New York : Th iem e, [2016] | In clu d es bibliograp h ical referen ces an d in dex. Iden t ifiers: LCCN 2015048817| ISBN 9781626231436 (h ardcover : alk. pap er) | ISBN 9781626231443 (eISBN) Su bject s: | MESH: Recon st ru ct ive Surgical Procedu res | Cosm et ic Tech n iques | Surger y, Plast ic--m eth ods | Face--surger y | Asian Con t in en t al An cest r y Group Classificat ion : LCC RD119 | NLM WO 600 | DDC 617.9/52—d c23 LC record available at h t t p://lccn .loc.gov/2015048817

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Th is book, in cluding all par t s th ereof, is legally protected by copyrigh t . Any use, exploit at ion , or com m ercializat ion outside th e n arrow lim it s set by copyrigh t legislat ion w ith ou t th e p u blish er’s con sen t is illegal an d liable to prosecut ion . Th is applies in part icular to ph otost at reproduct ion, copying, m im eograph ing or duplicat ion of any kin d, t ran slat ing, preparat ion of m icro lm s, an d elect ron ic dat a processing an d storage.

Dedicated to th ose p hysician s w h o believe th at a p h ilosophy is requ ired to ch ange even a sm all par t of th e face.

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Contents Forew ord ................................................................................................................................................................................................. ix Dean M. Torium i

Forew ord .................................................................................................................................................................................................. x Stephen S. Park

Preface ..................................................................................................................................................................................................... xi Ack n ow ledgm en t s ..............................................................................................................................................................................xii Con t r ib u tor s ........................................................................................................................................................................................xiii

I Intro ductio n 1. Th e Ch an gin g Face of Aest h et ic Facial Plast ic Su r ger y am on g East Asian s ........................................................................... 3 Keng Lu Tan and Hong Ryul Jin

II Rhino plasty 2. Au gm en t at ion Rh in op last y Usin g Silicon e Im p lan t s .................................................................................................................13 In-Sang Kim

3. Th e Use of Cost al Car t ilage for Dor sal Au gm en t at ion an d Tip Graft in g ...............................................................................26 Victor Chung and Dean M. Torium i

4. Nasal Tip Mod if cat ion in Asian s: Au gm en t at ion an d Rot at ion Con t rol ..............................................................................47 Hong Ryul Jin and Jong Sook Yi

5. Hu m p Resect ion ................................................................................................................................................................................... 60 Tae-Bin W on and Hong Ryul Jin

6. Cor rect ion of t h e Deviated , Tw isted Nose .....................................................................................................................................72 Hun-Jong Dhong

7. Cor rect ion of t h e Sad d le Nose .........................................................................................................................................................87 Keng Lu Tan and Chae-Seo Rhee

8. Alar Base Mod if cat ion .......................................................................................................................................................................99 Ian Loh Chi Yuan and Hong Ryul Jin

9. Aest h et ic Rh in op last y for Sou t h east Asian s...............................................................................................................................108 Eduardo C. Yap

10. Cor rect ion of t h e Sh or t , Con t racted Nose...................................................................................................................................122 Hong Ryul Jin

11. Man agem en t of Allop last -Related Com p licat ion s ....................................................................................................................135 Eunsang Dhong

III Blepharo plasty 12. Dou b le-Eyelid Su r ger y: Non in cision al Su t u re Tech n iqu es ....................................................................................................151 Jin Joo Hong and Hae W on Yang

13. Dou b le-Eyelid Su r ger y: In cision al Tech n iqu es ..........................................................................................................................162 Jae W oo Jang

14. Agin g-Related Up p er Blep h arop last y ...........................................................................................................................................173 Hok yung Choung and Nam ju Kim

15. Ep ican t h op last y an d Aest h et ic Lateral Can t h op la st y..............................................................................................................184 Yongho Shin

16. Low er Blep h arop last y ......................................................................................................................................................................196 Yoon-Duck Kim and Kyung In W oo

17. Cor rect ion of Ptosis ..........................................................................................................................................................................210 W oong Chul Choi and Juw an Park

18. Man agem en t of Dou b le-Eyelid Su r ger y Com p licat ion s ..........................................................................................................225 In-chang Cho and Aram Harijan

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Content s IV Facial Bo ne Surge ry 19. Zygom a Red u ct ion ............................................................................................................................................................................243 Sanghoon Park and Jihyuck Lee

20. Man d ible Red u ct ion .........................................................................................................................................................................254 Sanghoon Park and Seungil Chung

21. Aest h et ic Or t h ogn at h ic Su r ger y ....................................................................................................................................................268 Seong Yik Han and Kar Su Tan

22. Gen iop last y .........................................................................................................................................................................................286 Seong Yik Han and Kar Su Tan

V Facial Skin and Hair Rejuvenatio n 23. Man agem en t St rategies for t h e Agin g Asian Face: Ph ilosop h y an d Evolu t ion .................................................................303 Sam uel M. Lam

24. Facial Fat Graft in g ..............................................................................................................................................................................311 Kyoung-Jin (Saf ) Kang

25. En d oscop ic Foreh ead an d Brow Lift .............................................................................................................................................324 Tee Sin Lee and Stephen S. Park

26. Facial Reju ven at ion Usin g En er gy Devices .................................................................................................................................339 Un-Cheol Yeo

27. Hair Tran sp lan t at ion in East Asian s .............................................................................................................................................349 Sungjoo (Tom m y) Hw ang

28. Aest h et ic Laser Hair Rem oval for t h e Asian Face ......................................................................................................................364 W ooseok Koh

VI Minim ally Invasive Facial Plastic Surgery 29. Aest h et ic Facial Use of Bot u lin u m Toxin in East Asian s..........................................................................................................377 Kyle Seo

30. Facial Con tou r in g Usin g Filler s ......................................................................................................................................................392 Jongseo Kim

31. Man agem en t of Facial Filler In ject ion Com p licat ion s .............................................................................................................405 Hyoung Jin Moon and Jong Sook Yi

In d ex .....................................................................................................................................................................................................415

Forew ord Th ere is n o p op u lat ion in th e w orld th at h as a h igh er grow th of in terest in aesth et ic su rger y th an th e East Asian pop u lat ion . It is repor ted th at on e in five w om en in th e Repu blic of Korea h ave u n dergon e aesth et ic facial surger y. Th is dram at ic in crease is m u lt ifactorial an d is in p ar t driven by local p opu lar cu lt u re an d m edia. Th is t ren d h as been n otable over recen t years, w ith th e adven t of Korean pop u lar cu lt u re an d th e associated d esire to look like th e fam ed K-pop st ars. Th e look is quite ch aracterist ic of Korean aesth et ics, w ith m any pat ien ts sh ow ing th eir su rgeon ph otos of th e sam e Asian m edia p erson alit ies. Th is t ren d h as becom e so fash ion able th at it is n o longer a st igm a to un dergo cosm et ic surger y in th e Rep u blic of Korea an d Ch in a. In fact , it m igh t n ow be con sidered a stat u s sym bol an d reflect u pw ard m obilit y in th e eyes of m any. Th is age of th e “selfie” an d Facebook h as m ade “looking good” even m ore im port an t to th is grow ing populat ion . Th ese social ch anges h ave dram at ically in creased th e dem an d for Asian cosm et ic surger y, st im u lat ing a sign ifican t in crease in th e n um ber of su rgeon s perform ing th e su rger y. Th e aesth et ics of th e Asian face are con st an tly ch anging, an d surgical tech n iqu es m u st ch ange to accom m odate such ch anges. Today, th ere is often th e desire for a roun der foreh ead, h igh er n asal dorsum , n arrow er n asal t ip, an d a less roun d, m ore angu lar m an dible an d ch in . Many of th ese ch aracterist ics m ay in dicate a desire for a m ore “Western ” look. How ever, th ere are differen t degrees of ch ange an d th is m ust be recogn ized by th e surgeon . Hong Ryul Jin un derstan ds th e im por t an ce of th is varian ce from p at ien t to p at ien t . Th is requires th e su rgeon p erform ing en ough su rgeries to h ave acquired a n um ber of tech n iques in th eir arm am en tarium . In th is book, Dr. Jin h as com piled an out stan ding collect ion of ch apters w rit ten by an exper t group of surgeon s. Th e book covers th e m ost u pdated tech n iqu es on con touring th e Asian face covering rh in oplast y, Asian eyelid su rger y, facial con tou ring, an d aging-face surger y. Th e book also covers th e rapid ly ch anging field of n on su rgical t reat m en t s, su ch as bot u lin um toxin , fillers, an d lasers. In the section on rhinoplast y, the authors discuss the use of im plants and autologous m aterials for Asian augm entation rhinoplast y. The difference in these techniques is very significant and is reflected in these w ritings. Use of im plants continues to be the m ost com m only used m ethod to augm ent the nose. Nuances in the techniques are discussed in great detail and are covered by several authors. Com bined techniques using alloplastic m aterials for dorsal augm entation and ear cartilage for the nasal tip have becom e popular to avoid som e of the potential com plications of extending

alloplastic im plants into the nasal tip. The use of costal cartilage for augm entation is discussed in detail, describing techniques used to stabilize the nasal tip and augm ent the nasal dorsum . Also covered are the nuances of perform ing dorsal augm entation w ith costal cartilage and how to m inim ize the likelihood of warping. Popular techniques, such as diced cartilage for dorsal augm entation and tip grafting, are covered as well. Th e m any tech n iques available for m an aging th e Asian eyelid are covered, in cluding in cision al an d n on in cision al su t u re tech n iqu es, as w ell as conven t ion al in cision al tech n iques. Precision m easu rem en t an d m arking, an esth et ic inject ion s, in cision placem en t , m an agem en t of th e fixat ion m eth od, postoperat ive care, an d m an aging com plicat ion s are all discussed. Also covered is th e m an agem en t of th e ep ican th al fold. In the sect ion on facial contouring, the chapters cover m anagem ent of the Asian m alar region, m andible, perialar augm entation, chin augm entation, m asseter m uscle contouring, forehead contouring, and com plications. Also covered are the nuances of facial contouring that provide the surgeon w ith m any options for creating a m ore aesthetically pleasing Asian face. Th e sect ion on n on surgical m an agem en t covers th e u se of bot ulin u m toxin for facial m uscle con tou ring, brow con tou ring, an d rhyt id m an agem en t . Th is sect ion also covers fat inject ion s an d con tou ring u sing au tologou s fat . Laser resu rfacing is discu ssed as w ell. Dr. Jin h as been a st rong academ ic figure in Korea for m any years an d h as becom e w ell kn ow n arou n d th e w orld. He h as frequ en tly lect u red in th e Un ited St ates an d all over Asia. He is n ow con sidered an in tern at ion al expert on Asian rh in oplast y an d Asian facial cosm et ic surger y. His in tern at ion al in flu en ce is reflected in th e d iversit y of th e auth ors con t ribu t ing to h is book, an d h e h as don e a m asterful job edit ing th is w ork. Readers w ill fin d th is book com preh en sive in it s con ten t an d det ail of surgical descript ion s an d u se of qu alit y op erat ive ph otography an d illu st rat ion s. Th is book is an essen t ial referen ce for th e su rgeon in terested in p roviding th e best ou tcom es in Asian aesth et ic facial su rger y. Dean M. Torium i, MD Professor Division of Facial Plast ic and Reconst ruct ive Surgery Departm ent of Otolaryngology–Head and Neck Surgery Universit y of Illinois Chicago, Illinois

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Forew ord Hon g Ryu l Jin h as le d t h e w ay in creat in g a u n iqu e book on aest h et ic facial su rge r y for t h e East Asian p at ie n t . Th e re are m any u n iqu e var ian ces w it h p at ie n t s from t h is region of t h e w orld , an d t h ey h ave p u t toget h e r a colle ct ion of ch ap t e r s t h at cove r all asp e ct s of facial aest h et ic su rge r y as it p e r t ain s to t h e Asian face. Th e book h igh ligh t s t h e m any n u an ces in facial aest h et ic su rge r y in t h is grou p , an d any su rge on w h o h as t h e occasion al Asian p at ie n t w ill b e w ell se r ve d to h ave t h is e d it ion in h is or h e r refe re n ce librar y. A solid p or t ion of th is book is dedicated to th e tech n iqu es of Asian rh in oplast y. It is n ot lim ited to st rictly alloplast ic dorsal im plan ts, bu t covers m any subtlet ies th at are often required w ith Asian pat ien t s. Th e th ird sect ion is ded icated to th e p eriorbit al rejuven at ion of th e Asian pat ien t , in clu ding ptosis an d th e dou ble eyelid procedu re. Th ere are in t ricacies to th is p rocedu re th at dist ingu ish

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a good from a great result , an d th is book capt ures th em w ell. Th e rem ain ing sect ion s touch on oth er procedu res perform ed in facial aesth et ic su rger y, in clu ding facial bon e con tou ring, m in im ally invasive an d office based procedu res, an d h air rejuven at ion . Herein is a collect ion of m any au th ors w ith vast exp erien ce in facial aesth et ic su rger y in th e Asian pop u lat ion . It is com p reh en sive, eloqu en tly w rit ten , an d w ill ser ve as an invaluable resource for years to com e. Dr. Jin is to be congrat ulated for a terrific book. Stephen S. Park , MD Professor and Vice-Chairm an Depart m ent of Otolaryngology Director, Division of Facial Plast ic Surgery Universit y of Virginia Charlottesville, Virginia

Preface Aesth et ic facial plast ic surger y h as com e un der th e spotligh t in East Asian coun t ries in th e p ast t w o decades. Korea cam e un der th e spotligh t in th is field recen tly an d in t rigued m any from all corn ers of th e w orld to com e, learn , an d u p date th eir tech n iqu es. It is m y h ope th at th is kn ow ledge can be sh ared far an d w ide w ith th e English speaking crow d, w h o h as been fin ding it difficu lt to access in form at ion th at h as been p assed on in variou s Asian langu ages. Th e ch apters in th is book describe m ost of w h at you n eed to kn ow abou t aesth et ic plast ic surger y on th e face. Th e ch apters w ere w rit ten by m y ren ow n ed colleagu es in th eir resp ect ive sp ecialt ies, det ailing special tech n iqu es an d poten t ial pitfalls. Th ese det ails do n ot com e from overn igh t

en ligh ten m en t , bu t rath er reflect experien ce an d learn ing accum ulated over decades of su rgeries. Th e con ten t in th is book is h igh ly scien t ific an d eviden ce based, w h ich m ean s it h as proven to be safe an d efficien t . Th is book n ot on ly focu ses on in t roducing tech n iqu es th at are n ew, but teach es th e basic con cept s of h ow -to-do-it in a st ru ct u red m an n er to en sure th at readers are able to clearly con cept u alize th e tech n iqu es an d th eories beh in d ever y m an euver. I sincerely hope and expect that this book w ill guide the new surgeons venturing into aesthetic plastic surgery of the Asian face, as well as provide valuable inform ation to the others. Hong Ryul Jin

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Acknow ledgments It w as n ot an easy journ ey for th e publicat ion of th is book, an d I w ould like to express m y m ost h ear tfelt grat it ude to all m y colleagu es w h o h ave con t ribu ted to it . I thank Thiem e Publishers and its people for allow ing m e to publish this. Due to their great work, this book changed from an ugly duckling into a swan. Doctors w ho contributed their valuable expertise to this book need special acknow ledgm ent

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for their patience in allow ing and enduring my continuous requests. I also w ish to thank my fellows, Woo-Seong Na, Hahn Jin Jung, and Som asundran Mutusamy, for helping m e to edit the m anuscript. Our excellent illustrator, Mrs. Hyun-Hang Lee, w ho devoted her tim e and talents to this book, did a wonderful job in expressing the details in every draw ing per the requests of each contributor. I give my sincere thanks to her.

Contributors In-chang Cho, MD Bio Plast ic Surger y Clin ic Seou l, Repu blic of Korea Woo ng Chul Cho i, MD Director of Myou ng Ocu loplast ic Su rger y Clin ical At ten ding Professor Depar t m en t of Op h th alm ology St . Mar yʼs Hospital Cath olic Un iversit y of Korea Seou l, Repu blic of Korea Ho kyung Cho ung, MD, PhD Assistan t Professor Depar t m en t of Op h th alm ology Boram ae Medical Cen ter Seou l Nat ion al Un iversit y College of Medicin e Seou l, Repu blic of Korea Se ungil Chung, MD, PhD Division of Facial Bon e Su rger y Depar t m en t of Plast ic Surger y ID Hospital Seou l, Repu blic of Korea

Aram Harijan, MD Academ ic Con sultan t Well Plast ic Surger y Clin ic Seoul, Repu blic of Korea Jin Jo o Ho ng, MD, PhD Head JJ Medical Group Seoul, Repu blic of Korea Sung jo o (To m m y) Hw ang, MD, PhD Director Dr. Hw angʼs Hair Tran splan tat ion Clin ic Seoul, Repu blic of Korea Jae Wo o Jang, MD, PhD Vice Presiden t Oph th alm ic, Plast ic, an d Recon st r u ct ive Surger y Kim ’s Eye Hospit al Konyang Un iversit y Seoul, Repu blic of Korea

Victo r Chung, MD Director La Jolla Facial Plast ic Surger y San Diego, Californ ia

Ho ng Ryul Jin, MD, PhD Professor an d Ch air Depart m en t of Otorh in olar yngology–Head an d Neck Surger y Boram ae Medical Cen ter Seoul Nat ion al Un iversit y College of Medicin e Seoul, Repu blic of Korea

Eunsang Dho ng, MD, PhD Professor Depar t m en t of Plast ic an d Recon st ru ct ive Su rger y Gu ro Hospit al, Korea Un iversit y Medical Cen ter Seou l, Repu blic of Korea

Kyo ung-Jin (Safi) Kang, MD, PhD Director Educat ion al Cen ter of KCCS Seoul Cosm et ic Surger y Clin ic Bu san , Rep ublic of Korea

Hun-Jo ng Dho ng, MD, PhD Professor Depar t m en t of Otorh in olar yngology–Head an d Neck Su rger y Sam su ng Medical Cen ter Seou l, Repu blic of Korea

In-Sang Kim , MD Ch ief Execut ive Depart m en t of Facial Plast ic Su rger y Doctor Be Aesth et ic Clin ic Seoul, Repu blic of Korea

Se o ng Yik Han, MD, DDS, PhD Director Facial Plast ic Surger y Sim m ian Maxillofacial Plast ic Surger y Un it Seou l, Repu blic of Korea

Jo ngseo Kim , MS Director Depart m en t of Plast ic Surger y Kim -Jongseo Plast ic Su rger y Clin ic Seoul, Repu blic of Korea

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Contributors Nam ju Kim , MD, PhD Associate Professor Dep ar t m en t of Oph th alm ology Seou l Nat ion al Un iversit y Bu n dang Hosp ital Seongn am -Si, Kyeonggi-Do, Repu blic of Korea Yo o n-Duck Kim , MD, PhD Director Oculop last ic an d Orbital Su rger y Division Professor Dep ar t m en t of Oph th alm ology Sam su ng Medical Cen ter Sung Kyu n Kw an Un iversit y Sch ool of Medicin e Seou l, Repu blic of Korea Wo o se o k Ko h, MD Director Dep ar t m en t of Derm atology JMO Hair Rem oval Derm atology Clin ic Seou l, Repu blic of Korea Sam uel M. Lam , MD, FACS Director Willow Ben d Welln ess Cen ter Plan o, Texas Jihyuck Lee, MD Ch ief Division of Facial Bon e Su rger y Dep ar t m en t of Plast ic Surger y ID Hospit al Seou l, Repu blic of Korea Te e Sin Le e, MBBS (S’po re), MRCS (Edin), MMed (ORL), FAMS (ORL) Dep ut y Director an d Con su ltan t Facial Plast ic an d Recon st ru ct ive Su rger y Ser vice Dep ar t m en t of Otorh in olar yngology–Head an d Neck Su rger y Ch angi Gen eral Hosp ital Clin ical Lect u rer Yong Loo Lin Sch ool of Medicin e Nat ion al Un iversit y of Singap ore Singapore Hyo ung Jin Mo o n, MD Presiden t Dr. Moon Aesth et ic Su rger y Clin ic Seou l, Repu blic of Korea

Juw an Park, MD, PhD Associate Professor Depar t m en t of Oph th alm ology Yeou ido St . Mar y’s Hosp ital Th e Cath olic Un iversit y of Korea Seoul, Rep ublic of Korea Sangho o n Park, MD Ch airm an Depar t m en t of Plast ic Su rger y ID Hospit al Seoul, Rep ublic of Korea Ste phe n S. Park, MD Professor an d Vice- Ch air Depar t m en t of Otolar yngology Un iversit y of Virgin ia Ch arlot tesville, Virgin ia Chae-Seo Rhee, MD, PhD Professor Depar t m en t of Otorh in olar yngology–Head an d Neck Su rger y Seoul Nat ion al Un iversit y College of Medicin e Seoul Nat ion al Un iversit y Bu n dang Hospital Seongn am -Si, Kyeonggi-Do, Repu blic of Korea Kyle Seo, MD, PhD Clin ical Associate Professor Depar t m en t of Derm atology Seoul Nat ion al Un iversit y College of Medicin e Seoul, Rep ublic of Korea Yo ngho Shin, MD, PhD Director of Bio Plast ic Surger y Clin ic Clin ical At ten ding Professor Depar t m en t of Plast ic Su rger y Korea Un iversit y Seoul, Rep ublic of Korea Kar Su Tan, MBBS (S’po re ), MRCS (Edin), MMed (ORL), FAMS (ORL) Medical Director Th e Rh in oplast y Clin ic ENT Facial Plast ics Singapore Keng Lu Tan, MD, MRCS, MS (ORLHNS) Ear, Nose, an d Th roat , Head an d Neck Surgeon Facial Plast ic an d Recon st ru ct ive Surgeon Depar t m en t of Otorh in olar yngology Un iversit y of Malaya Ku ala Lum p ur, Malaysia

Contributors Dean M. To rium i, MD Professor Dep ar t m en t of Otolar yngology–Head an d Neck Su rger y Un iversit y of Illin ois at Ch icago Ch icago, Illin ois

Facial Plast ic Su rgeon Belo Medical Grou p Man ila, Ph ilip pin es

Tae-Bin Wo n, MD, PhD Associate Professor Dep ar t m en t of Otorh in olar yngology—Head an d Neck Su rger y Seoul Nat ion al Un iversit y Hospital Seoul, Repu blic of Korea

Un-Cheo l Ye o, MD, PhD Ch airm an S an d U Derm atologic Clin ic Clin ical Professor Depar t m en t of Derm atology Sam su ng Medical Cen ter Su ngkyu n kw an Un iversit y Seou l, Republic of Korea

Kyung In Wo o , MD, PhD Professor Dep ar t m en t of Op h th alm ology Sungkyu n kw an Un iversit y Sch ool of Medicin e Sam su ng Medical Cen ter Seoul, Repu blic of Korea

Jo ng So o k Yi, MD Assist an t Professor Depar t m en t of Otorh in olar yn ology–Head an d Neck Surger y Bu n dang CHA Medical Cen ter Seongn am -si, Repu blic of Korea

Hae Wo n Yang, MD Ch ief Division of Plast ic an d Recon st r u ct ive Su rger y JJ Medical Group Seoul, Repu blic of Korea

Ian Lo h Chi Yuan, MBBS, MRCS, MMED, FAMS Director Facial Plast ic an d Recon st r u ct ive Ser vice Depar t m en t of Otorh in olar yngology–Head an d Neck Surger y Ch angi Gen eral Hosp ital Singap ore

Eduardo C. Yap, MD

xv

I Introduction

1 The Changing Face of Aesthetic Facial Plastic Surgery among East Asians Keng Lu Tan and Hong Ryul Jin

Pearls • Asian s, part icularly th ose in East Asia, h ave seen

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rapid developm ent in th e eld of aesth et ic facial plast ic surger y, especially in th e re n em en t of Asian -speci c tech n iques, over th e past t w o decades. Th e t ypical Asian belief in n ot altering th e physical ap pearan ce of on e’s face, at t ribu ted to resp ect for th e elderly an d on e’s an cestors, h as evolved w ith globalizat ion , resu lt ing in a m ore n eu t ralized Asian cult ure, w h ich is a cross bet w een East an d West . More Asian s realize th at to be at th e leading edge of societ y, an at t ract ive ap pearan ce p lays an im p ort an t role in d eterm in ing success. Th ere h as been a sh ift in social accept an ce of aesth et ic su rger y, an d w e see m ore dem an d for it th an ever before. East Asian feat ures of th e face are discussed in detail in th e follow ing ch apters, w ith par t icular at ten t ion to single-eyelid, sm all palp ebral ap ert u re, at n asal bridge and t ip, m alar prom in en ce, broad m an dible, ret ruded prem axilla, an d m any oth er Asian -speci c aesth et ic su rgeries.

■ Introduction The recent surge in the n um ber of people seeking aesthet ic facial surger y is a testam en t to th e em ph asis placed on on e’s looks as a w ay to gain con siderable leverage in societ y. The n ew m ovem en t also involves the con cept of etern al youth fuln ess; being young is con sidered at tract ive, an d looking younger can im prove th e com pet it iven ess of a w orker.1,2 This t rend, w hich started in Western count ries around the en d of th e t w en t ieth cen t ur y, is fast becom ing w orldw ide. As of th is w rit ing Asia is th e m ost act ively grow ing econ om y in th e w orld. With m ore th an h alf of th e w orld’s popu lat ion residing on th is con t in en t , th e im pact of any m ovem en t in Asia w ill be in u en t ial.3 With th e populat ion get t ing m ore a u en t an d w ith th e in creasing a ordabilit y of a h igh er st an dard of living, th e past 10 years h ave seen m any Asian s seeking aesth et ic p rocedures to en h an ce th eir facial feat u res or to at ten u ate th e aging p rocess. Alth ough th e broad term Asians is gen erally used to den ote people w h o origin ate from Asia, in t ruth various eth n icit ies an d races w ith d i eren t facial m orp h ologies reside in Asia. West an d Sou th Asia st retch es to Tu rkey an d In dia, w h ere Cau casoid p eop le (i.e., Tu rks an d In dian s) are fou n d . In

• Com m on aesth et ic surgeries of East Asian s also

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in clude double-eyelid surger y, ep ican th oplast y, rh in oplast y, facial bon e con touring surger y, fat inject ion , an d m any oth er tech n iques discu ssed in th is book. New er tech n iqu es, in clu ding th e com bin at ion of n on su rgical tech n iques in facial rejuven at ion su ch as llers an d bot u lin u m toxin , an d laser h air rem oval and h air t ran sp lan t at ion sp eci c to East Asian ch aracterist ics, are discu ssed in det ail. Th e pros an d con s of n on surgical tech n iques su ch as laser an d ult rasoun d for facial rejuven at ion are also th orough ly described to keep readers updated w ith th e latest tech n ologies an d th e opt ion s available to ach ieve desired ou tcom es. Most im p or tan t , th is book n ot on ly con t ain s su rgical tech n iqu es an d pearls from surgeon s w h o are exp er ts in th eir resp ect ive elds of aesth et ic facial plast ic surger y, but also in corporates com m en t s on pitfalls an d com plicat ion s, an d h ow to overcom e th em , in detail.

East Asia, w h ere Ch in a, Korea, an d Japan are located, people possess East Asian feat u res. Alth ough East Asian s are grouped in th e Mongoloid st rain along w ith th e Sou th east Asians (In don esian s, Th ai, Polyn esian s, etc.), th e facial feat ures am ong th e Mongoloids are st ill quite dist in ct from each oth er.3 Fig. 1.1 d ep icts th e average of di eren t beau t ifu l Asian faces as d escribed by Rh ee.4 In dian s, Ch in ese, an d Jap an ese are all con sidered Asian s; h ow ever, th eir facial feat u res can be qu ite di eren t . Du e to Asia’s long-st an d ing t rade rou tes con n ect ing East an d West , m odern Asian cit ies are often com prised of m ult iple eth n ic groups, re ect ing th e m odern t ren ds of in terracial m arriages an d globalizat ion . Th ere is a rapidly t ran sform ing e ect of globalizat ion on facial feat ures as w ell, alth ough at th is t im e w e st ill see rath er ch aracterist ic Orien t al feat u res am ong East Asian s. Aesth et ic facial su rger y in East Asia h as exp an ded an d developed at an exp on en t ial rate in th e p ast t w o decades. Su ch rap id p rogress h as en abled u s to develop su rgical tech n iqu es suitable for Asian s an d to accum ulate a con siderable am ou n t of exp erien ce (Fig. 1.2). Th e n ew skill set s an d exp erien ce h ave been t ran slated in to tech n ical advan cem en t an d bet ter su rgical ou tcom es. Th ose exp erien ces an d advan ces in aesth et ic facial su rger y m ore su ited

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I Introduction

Fig. 1.1 At tractive composite faces of di erent races. At tractive famous female entertainers’ faces were morphed by sequentially mixing photographs at the mean values to generate the composite faces. (Used with permission from Rhee et al. At tractive composite faces of di erent races. Aesthetic Plast Surg 2010;34:800–801.)

Hair rem oval or transplantation

Fat injection

Blepharoplast y

Botox and fillers

Rhinoplast y

Facial bone contouring Fig. 1.2 Typical surgeries and nonsurgical procedures to improve facial aesthetic appearance in East Asians. These various techniques will be addressed throughout this textbook, with speci c modi cations for Asians.

1 The Changing Face of Aesthetic Facial Plastic Surgery am ong East Asians for Asian s are becom ing m ore an d m ore p opu lar, especially am ong th e m ore a u en t Asian s living in th e Western cou n t ries. Au th ors of th is book believe th ere is n o bet ter t im e th an now to h ave ou r kn ow ledge an d experien ce gath ered an d sh ared to st im u late m ore develop m en t in th is eld. Many years h ave p assed sin ce th e in t rodu ct ion of speci c tech n iqu es for Asian aesth et ic su rger y. Mu ch h as evolved over th e years, an d th e cu rren t focu s seem s to be on re n ing th e tech n iques to address th e st igm a faced by Asian pat ien t s. Alth ough w e st ill n d a h an dfu l of pat ien t s com ing to th e surgeon w an t ing to look like a part icular pub lic gu re, m any are steering aw ay from th at t ren d. Pat ien t s th ese days often request a n at ural-looking face an d w ish to en h an ce th eir curren t appearan ce w h ile ret ain ing th eir facial ch aracterist ics, an d th ey especially w an t to preven t th eir plast ic su rgeries from being n ot iced by oth ers. W h ile em bracing th eir exist ing facial ch aracterist ics, p at ien t s p refer n ot to look th e sam e as oth ers w h o desire th e ideal com p osit ion of a beau t ifu l face, albeit all sim ilar looking. Th is h as resu lted in su rgeon s reinven t ing th em selves an d m oving in to th e n ext level of aesth et ic facial su rger y, com bin ing less invasive p rocedures w ith su rger y w h en ever possible. Th e art of com bin ing n on surgical an d surgical tech n iqu es to create a beaut iful face w ill n o longer be based on a gu t feeling bu t w ill be object ively described in th is book.

■ The Change in Cultural

Beliefs and the Modernization of Asian Thinking

Th e Asian desire for a pleasan t face is h eavily in u en ced by facial physiogn om y in th e past . Th e com bin at ion s of pleasan t-looking feat u res described in th e an cien t books w ere illu st rated w ith pict ures of faces th at dict ated th e fut ure of a p erson , dow n to th e p osit ion of m oles on th e face an d body.5 Th ere w as a realizat ion of th e n eed for an aesth et ically pleasing face, bu t few oth er th an Sh usrat a ven t ured in to th e aesth et ic su rgical eld. In dividuals w ith pleasan tlooking faces w ere m ore likely to be ju dged to h ave a good life an d a good job, an d th ose w ith u np leasan t-looking feat u res w ere often associated w ith socially less resp ectable jobs or even crim in alit y. Th e lat ter t yp es of faces w ere d eem ed in au sp iciou s an d st ill ver y m uch in uen ce h ow a p erson is ju dged in m odern societ y. Desp ite th is, th ere w as lit tle develop m en t in th is eld. Few w an ted to ch ange th eir looks surgically, par tly due to the un re n ed state of su rgical skills at th at t im e an d th e st rong in u en ce of Con fu cian ism all over Asia, w h ich em ph asized th e san ct it y of th e physical body as a sacred gift from our paren t s. Altering on e’s physical appearan ce w as con sidered disrespectful to on e’s an cestors.1 As globalizat ion an d Western izat ion exerted m ore in uen ce in Asian societ y via Western m edia, th e de n it ion of beaut y becam e associated w ith w h ite Caucasian fea-

t ures, such as double eyelids an d t all, w ell-de n ed n oses. Fair skin is seen as th e m arker of class. On e an cien t saying in Jap an ese, Korean , an d Ch in ese societ ies goes, “A w h ite com plexion overrides th ree appearan ce aw s,”6 em ph asizing th e long-st an ding im port an ce of ligh t-colored skin in m u lt iple cou n t ries across Asia. Th is w as rein forced d u ring th e Western colon izat ion period, w h en th e European s w ere presen t in Asia an d enjoyed h igh social st at u s. In “Th e Histor y of W h ite People,” Neil Pain ter even argued th at Caucasian s produce “th e m ost beau t ifu l race of m en” an d th at Ch in ese eyes are an “o en ce to beau t y.”7 Th e ideal beau t y of Cau casian s w as on ce th e w ell-accepted de n it ion of beaut y in Asia. Recen tly, Asian coun t ries h ave becom e st ronger an d m ore in u en t ial econ om ically. Sch olars h ave started to debate about “Eurocen t ric” beaut y an d th e ph en om en on in Asia w h ere it h as becom e th e n orm to alter on e’s facial ap pearan ce u sing p last ic su rger y to be m ore Western ized. With grow ing con den ce w ith in Asian societ y, h ow ever, Asian s h ave started to em brace th eir ethn ic feat ures. Th e fu sion of cert ain desirable Western feat u res w ith Asian feat u res is n ow seen as th e id eal form of beau t y in Asia. Th e key con cept n ow is to blen d at t ract ive feat ures rath er th an h aving a cert ain de n ed tem plate, a con cept th at h as been h eavily crit icized an d is rapidly falling out of favor. Th e good-looking feat u res are, of cou rse, th ose th at suit a person’s facial st ru ct u re, person alit y, an d th e person as a w h ole. En h an cem en t rath er th an alteration of th e facial feat u res h as becom e th e n ew t ren d . Stat ist ics sh ow th at up to 58% of w om en in Korea h ave plast ic surger y by th e age of 50.1,8 Th e percen tage is grow ing in th eir m ale coun terpar t s too. Th e desire to obtain aesth et ic p last ic su rger y is often driven by th e psych osocial aspirat ion of th e pat ien t . Rapid developm en t in th is eld is largely driven by th e n eed to app ear m ore at t ract ive in order to be bet ter accepted in a societ y th at places a lot of em p h asis on beau t y an d pleasan t app earan ce. Looking m ore beau t ifu l becom es an invest m en t to ach ieve h igh er socioecon om ic st at u s an d to en su re on e w ill n d a w ealthy rom an t ic p ar t n er. Th u s a n ew cu lt u re or t ren d h as em erged, u n stop p able by past cu lt u ral beliefs an d t aboos, an d st rongly d riven by n ovel con cept of beau t y, w ealth , an d a good life. As th is con cept h as grow n , th e su bject s seeking cosm et ic en h an cem en t h ave becom e younger an d younger. As Korean dram as an d m ovies h ave becom e m ore popular th rough ou t Asia, so h as th e in u en ce of th e Korean de n it ion of beaut y spread all across Asia. Th is ph en om en on of “Han Ryu ” (th e Korean t ren d) w as p op u lar am ong view ers of all ages. With at t ract ive actors an d act resses port rayed as h eroes an d h eroin es, m any fan t asized becom ing like on e of th em , w h ich could be ach ieved by altering th eir looks. Th is t ren d becam e a st rong driving force in th e developm en t of aesth et ic surger y in Asia, en abling surgeon s to grow an d ach ieve a n ew level of u n d erst an ding of aesth et ic su rgeries. How ever, it is u p to th e con scien ce of in dividu al pract it ion ers to guard th e san ct it y of th is eld, preven t ing

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I Introduction th e dou ble-edged sw ord of h arm to our pat ien t s an d to th e p ract ice of aesth et ic surger y, by prescribing on ly approp riate an d scien t i cally soun d procedu res to pat ien t s an d p roviding th e best su rgical pract ices tested by t im e an d exp erien ce.

■ Anatomic Di erences and Their Implications

Most East Asians share the phenot ypic features represented by the Mongoloid pro le. It is currently the m ost w idely distributed physical t ype, constituting over a third of the hum an species. Therefore, it is not surprising to nd that m any living throughout Asia share the sam e facial features. Mongoloid features are t ypically represented by epicanthal folds and neoteny. While som e of the features, such as the single eyelid and m axillary retrusion, are not com m on am ong Westerners, they are w idely encountered in Asians, w ith doubleeyelid surgery being the m ost popular plastic surgery sought (Fig. 1.3). High cheekbones, a broad m andibular angle, and a low nasal pro le are features in Asians that are not highly favored, and are often associated w ith aggression or m anliness. Generally, a well-projected nose is preferred. A low n asal bridge is n ot lim ited to Mongoloids. Th e Malay people fou n d in m ost of Sou th east Asia across th e Ph ilippin es, Malaysia, Th ailan d, an d In don esia often requ est ch anges to address a low n asal bridge an d w ide aring ala (Fig. 1.4). Becau se th e an atom y of th e eyelids, n ose, an d facial bon es in Asian s di ers sign i can tly from th at of Caucasian s, a u n iqu e m an agem en t st rategy is requ ired to su ccessfu lly im p rove th e aesth et ic ou tcom e. Th e m an agem en t st rategy sh ou ld be aim ed at h an dling an atom ic issu es speci c to th e Asian face such as th e follow ing: 1. Th e pret arsal skin of the upper eyelid is n ot at tach ed to th e levator palpebrae m uscle, leading to a poorly d e n ed superior p alp ebral fold. Th e con st ruct ion of a d ou ble eyelid th at su it s th e m orph ology of an Asian face is di eren t from p ract ice involving Cau casian s. 2. Excessive fat is dist ributed bet w een th e orbicularis oculi m uscle an d th e levator m uscle w ith relat ively th ick palpebral skin an d orbicularis oculi m uscles. 3. Orbits are sm aller w ith a m ore prot ruding orbital m argin com p ared w ith Western ers. Th erefore, recreat ing th e feat u res of Caucasian eyelids h as p roven u n su it able. Aesth et ic eye surger y sh ou ld be re n ed an d subtle rath er th an dram at ic, or it can give rise to a th ick, deep u pp er eyelid, w h ich is n ot su itable for sm aller orbit s. 4. Th e n asal sclera t riangle is rou n ded due to th e p rom in en t m edial epican thal fold. A variet y of tech n iqu es (an d th eir pros an d con s) to elim in ate th e obt un ded angle w ill be described in detail in th e ch apter on epican th oplast y.

5. Th e n arrow an d relat ively sm all palpebral aper t ure result s in sm all eyes. Th is h as resulted in m any tech n iqu es inven ted an d m odi ed over th e past decade to in crease th e palpebral apert ure by lateral can th oplast y. Proper con siderat ion of th e an atom y involved in lateral an d m edial epican th oplast y sh ou ld be given before th e su rger y is don e to preven t later com plicat ion s su ch as low er eyelid ect ropion . 6. A at n asal bridge and a poorly de n ed cart ilagin ous st ru ct u re of th e n ose resu lts in poor p roject ion of th e n ose. 7. Th ere is a sm aller n asal pyram id w ith sh orter n asal bon e length in Asian s com p ared w ith oth er eth n icit ies. A st u dy don e by Naser an d Boroujen i con clu ded th at th e n asal bon e length st udied in th e skulls of Korean s w as sm aller th an in Am erican In dian s, An atolian s, Iran ian s, an d African Am erican s.9 Th e soft an d sm all n asal sept um en coun tered som et im es p oses di cu lt y to th e su rgeon n eed ing a cart ilage graft from th e n asal sept u m . Du e to th is, th e use of h om ologous an d autologous rib cart ilage graft s h as becom e popular w h en syn th et ic im plan t s are n ot su it able or n ot preferred by p at ien t s. Pat ien t s sh ou ld be adequ ately cou n seled , as th e likelih ood of n eeding a rib graft is h igh er in Asian pat ien t s. 8. Th e n asal skin is th ick w ith abun dan t sebaceous glan ds. Th is m akes m an euvering th e n asal t ip su bst an t ially m ore tech n ically dem an ding. 9. Asian s possess di eren t skin proper t ies com pared w ith oth er racial groups. Asian s are kn ow n to h ave a th in n er st rat u m corn eu m , th e sm allest in term s of p ore size an d pore n u m bers, an d th e h igh est w ater an d lip id con ten t in th e st rat u m corn eu m com p ared w ith oth er peoples. Th eir skin is also kn ow n to h ave th e w eakest ch em ical barrier. All th ese ch aracterist ics sign ify th at topical drug pen et rat ion is th e best in Asian skin an d th at th e form at ion of w rin kles is less in Asian s. Such an atom ical d i eren ces in th e epiderm al layer of th e Asian skin m ake m an agem en t of scars an d skin lesion s di eren t in th e Asian popu lat ion . 10. Asian s h ave a h igh m alar prom in en ce due to a p rom in en t zygom at ic body or arch . 11. Th e broad m an dibular angle is associated w ith m asseter hyp ert rop hy. 12. Asians’ hair is th ick and coarse, is round in shape, and grow s faster. Asian s also h ave a h igh er prevalen ce of curly hair, but th ick and st raight hair is predom inan t am ong East Asian s. Th ese an atom ic di eren ces in Asian h air com pared w ith Caucasian hair require h air t ran splan t equipm en t an d procedu res th at are di erent from those that are convent ionally used. To successfully address th e above issu es, on e sh ould un derst an d th e u n ique an atom ic presen t at ion of th e Asian face to p rop erly m odify an d m ake re n ed adju st m en t s to th e gen eric tech n iques presen ted in earlier textbooks.

1 The Changing Face of Aesthetic Facial Plastic Surgery am ong East Asians

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b

c

d

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Fig. 1.3 Typical East Asian wom an who had rhinoplast y with blepharoplast y. (a–c) Typical East Asian face, illustrating the wide mandibular angle, high cheekbones, poorly de ned upper eyelid crease, broad and low nasal dorsum, and poorly de ned nasal tip. (d–f) The same individual after rhinoplast y and blepharoplast y. Her appearance greatly enhanced, the individual seems more approachable and attractive, with softening of the unfavorable wide angle of the mandible.

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I Introduction

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Fig. 1.4 (a–c) The face of a t ypical Southeast Asian woman, with natural double eyelid crease, wide nasal alar, broad nasal bridge and bulbous nose with a voluminous lip. These are some of the features associated with the Southeast Asian t ype of face.

■ Modi cation and Re nement of Surgical Techniques

To enhance existing Asian facial characteristics, re nem ent of the techniques is often required. Such re nem ent is well illustrated by the various techniques of epicanthoplast y to address a slightly di erent curve of the m edial epicanthus, suturing techniques to m ake eyes w ith ptotic or pu y upper eyelids appear larger and m ore relaxed, and lateral canthopexy to achieve a m ore attractive and lively appearance of the eyes. Th e conven t ion al m eth ods of epican th oplast y, such as Y-V, V-W, an d W plast y, w ere n oted to give rise to u n sigh tly scars. As su rgeon s in Asia accu m u lated m ore exp erien ce, m any n ew tech n iqu es w ere develop ed, su ch as th e palpebral m argin in cision m eth od (Ch en , m edial epican th oplast y), w ith oth ers com m on ly com bin ing bleph aroplast y w ith m edial epican th oplast y by exten ding th e in cision , result ing in an obscured scar. With th e in creasing n um ber of lateral can th oplast ies don e to w iden th e palpebral apert ure of th e Asian eye, com plicat ion s such as hyper t roph ic scars an d scar con t ract u re cau sing th e p alpebral ssu re to becom e n arrow again are possible. Th e procedu re m ay also result in asym m et rical resu lt s du e to unpredict able scar form at ion . In cases w h ere th e lateral can th al ligam en t is cut to ach ieve m axim al open ing of th e palpebral apert ure, low er eyelid ect rop ion an d sagging m ay occu r in th e fu t ure as th e soft t issu e an d m u scu lar su p p or t is w eaken ed. Th erefore, su ch surgeries are n ever to be t aken ligh tly an d sh ould be don e on ly after su cien t risk an d ben e t assessm en t .

Su ch re n em en t in su rgical tech n iqu es is also seen in rh inoplast y su rgeries, w ith m ore versat ile use of alloplast ic m aterials such as Gore-Tex (W.L. Gore & Associates In c., Flagsta , Arizon a) an d h om ologou s cart ilage in recon st ru ct ion of th e n ose. Nasal augm en tat ion is rarely a n eed for th e Western pat ien t . In con t rast , alm ost ever y East Asian pat ien t requests n asal dorsal augm en tat ion . In th e past t w o decades, w e h ave seen th e popularit y of silicon e im plan t s fall an d th e su bsequ en t in creased accept an ce of Gore-Tex as a m ore versat ile im p lan t m aterial. Alth ough th e u se of silicon e im p lan ts is declin ing d u e to th e h igh er com plicat ion rate an d rigid appearan ce of th e n asal dorsum , w e see a cu rren t t ren d of su rgeon s car ving silicon e im p lan t s m ore ju diciou sly, get t ing rid of th e L-st ru t an d com bin ing use of th e im plan t w ith oth er soft t issu e to produce a softer an d n at u ral look an d red u cing th e rate of im plan t ext ru sion . Th is allow s th e su rgeon to con t in u e u sing th e silicon e im plan t , w h ich does h ave som e advan t ages com pared w ith oth er ch oices of im plan t s. On th e oth er h an d , con t in u ou s t rials using au tologous costal cart ilage for dorsal augm en tat ion h ave sh ow n m u ch im provem en t over th e years w ith im proved reliabilit y an d con sisten cy. We h ave seen a sh ift recen tly tow ard th e in creased popularit y of autologous graft s com pared w ith syn th et ic graft s du e to th e su periorit y of th e au tologou s graft in resist ing in fect ion an d preven t ing long-term com p licat ion s.10,11 Re ce n t ly, t ip su rger y in ad d it ion to d orsal augm en t at ion h as becom e a st an dard p roce d u re u n d er t aken d u rin g rh in op last y. Th e t ip h as to be p rop erly su p p or te d an d rot ate d after d orsal augm e n t at ion to p rod u ce a n at u ral, p leasan t -lookin g n ose. Th is is largely ach ieved by u sin g

1 The Changing Face of Aesthetic Facial Plastic Surgery am ong East Asians t h e op e n ap p roach . Tip rot at ion ach ieved w it h a sept al exten sion graft an d t h e u se of m u lt ip le laye rs of au tolo gou s m ater ial su ch as m u scle fascia an d car t ilage cou p le d w it h som e su t u re tech n iqu es are t h e m ost p op u lar opt ion s em p loye d n ow . Bot h p at ien t s an d su rge on s h ave sh ied aw ay from syn t h et ic m ater ial for t ip w ork d u e to t h e h igh ext r u sion rate an d t h e su bsequ e n t d isast rou s sequ elae of an in fect ion . Au tologou s m ate r ial is t im e tested an d sh ow n to h ave t h e least com p licat ion s an d b est resu lt s so far. Th e ove raggressive t ip w ork associated w it h ove ram bit iou s m an eu vers is h igh ly advised again st , as too m u ch of a good t h in g in any circu m st an ces w ill on ly resu lt in t h e op p osite of t h e d esired e ect . Over p roject ion an d rot at ion of t h e t ip is associated w it h a d efor m ed t ip in t h e lon g r u n as a cer t ain d egree of resor pt ion of t h e car t ilage graft u sed an d scar r in g of soft t issu e w ill cau se in st abilit y of t h e t ip con st r u cted . Th erefore, from ou r exp er ien ce, ju d iciou s adju st m en t of t h e d orsu m w it h a m atch in g t ip sh ou ld be t h e lim it to su ch augm en t at ion p roced u res, alt h ough it m ay be ver y invit in g in t raop erat ively to ach ieve a m a xim u m e ect . Un d e rst an d in g t h e sp eci c an atom ic d i eren ces in Asian s h as e n abled u s to com bin e t h e u se of var iou s adju n ct ive su rger ies an d p roced u res w it h rh in op last y to p rod u ce a m ore favorable ou tcom e t h an is p ossible w it h ju st rh in op last y alon e. Som e of t h ese p roce d u res in clu d e p aran asal im p lan t , ch in im p lan t , n asal alar resect ion , an d colu m ella-len gt h en in g ap s to ad d ress issu es like m a xillar y ret r u sion , ret rogn at h ia, w id e n asal ala, an d sh or t colu m ella, resp ect ively, w h ich are com m on p roble m s fou n d in Asian s. Asian su rge on s h ave also p er fe cted t h eir skills in m alar red u ct ion , w h ich is a m ore com m on p roced u re in t h e East com p ared w it h t h e West . Previou s exp er ien ce h as resu lted in som e cases of facial saggin g, facial asym m et r y, an d d ow nw ard m ovem e n t of t h e m alar p oin t . Th e red u ct ion of t h e an gle of t h e m an d ible is also a com m on aest h et ic su rger y in Asia as op p osed to t h e West , as a softe r look an d a “V-sh ap e d ” face are st ron gly favored in Asia. Asian su rgeon s h ave su bst an t ially m ore exp er ie n ce w h en it com es to t h is kin d of skelet al re d u ct ion w ork. Ot h er skelet al alterat ion su rger ies t h at are p op u lar in Asia in clu d e or t h ogn at h ic su rger y su ch as bim a xillar y advan ce m en t /red u ct ion or m an d ibu lar red u ct ion / ad van cem en t , w h ich can be solely for cosm et ic p u r p oses. Th ese su rge r ies w ere or igin ally in ten d ed to cor rect con gen it al d efor m it ies relate d to fu n ct ion al p roblem s su ch as m alocclu sion . As t h e ap p earan ce of a p rot r u d in g m an d ible or ret r u d in g m a xilla is u n at t ract ive, p at ien t s t h ese d ays are w illin g to u n d e rgo su rger ies even w it h ou t fu n ct ion al p roblem s, an d even w h e n t h e r isk of associated com p licat ion s ou t w eigh s t h e ben e t . The grow ing popularit y of fat graft ing h as im proved p at ien t sat isfact ion t rem en dously. Fat graft ing produces a long-last ing e ect in facial rejuven at ion . Th is is esp ecially t rue in th e you nger pat ien t s in w h om a su rgical face lift

w ou ld p rove too drast ic an d dest ru ct ive. It also plays an im port an t role as an adjun ct to m any cosm et ic procedu res. Fat graft ing tech n iques h ave progressed from th e use of cru de fat lobules to m icrofat grafts, giving rise to im proved longevit y in th e recipien t site. Th e use of fat graft s is also ver y p op u lar to im p rove th e con tou r of facial top ograp hy, proving to be ver y versat ile in creat ing w h atever topography is desired. With th eir expert ise in th is eld, th e auth ors of th is book are able to sh are m any of th eir valuable experien ces in re n ing an d perfect ing th e u se of th is tech n iqu e to im prove surgical outcom es. Hair restorat ion h as also becom e a p opu lar procedu re don e for aesth et ic purposes in Asia in recen t years. It is not on ly popu lar for m ales experien cing an drogen ic h air loss but also for fem ales w h o w ish to resh ape th e face an d to soften th e ou tlin e of th e face by altering th e h airlin e. More fem ales are seeking h air t ran splan t procedures to exten d th e h airlin e at th e tem p oral region , th u s redu cing th e m uscularit y of th e face, or to ch ange th e face to a m ore favorable “oval” sh ape. Hair t ran splan t at ion is qu ite di eren t in Asian s. Th is is due to th eir th icker an d coarser hair st ruct ure, a broad er base for th e follicles, an d a h igh er in ciden ce of keloid-form ing scars com pared w ith Cau casian s. Th erefore, follicular un it ext ract ion an d use of a m icropu n ch d esign ed to m in im ize scarring an d m axim ize hair follicle ext ract ion h ave becom e m ore popular th an th e conven t ion al single-st rip h ar vest ing tech n ique. Due to th e th icker an d coarser h air foun d in Asian s, during follicular un it ext ract ion th e direct ion an d depth of th e scorings m u st be precise an d th e base h as to be broad en ough so th at th e germ in al un it of th e h air w ill n ot be dam aged. As curly hair is m ore com m on in Asian s th an in Caucasian s, th e direct ion of th e im plan tat ion h as to be con sidered so as not to h ave un n at u ral h air grow ing in di eren t d irect ion s. Th ese an d m any oth er pearls related to h air restorat ion in th e Asian populat ion w ill be presen ted in th e corresponding ch apters. We w ill also d eal w it h facial h air re m oval u sin g laser for aest h et ic p u r p oses. Th e w id t h of t h e foreh ead for m s t h e sh ap e of t h e face in t h e su p e r ior t h ird . Th e foreh ead is also t h e locat ion of t h e “ch akra” w h ere t h e t h ird eye or sixt h sen se resid es as p e r San skr it scr ipt u res. A n arrow foreh ead p u t s too m u ch em p h asis on t h e m id d le an d low er p ar t s of t h e face an d is often associated w it h lack of rad ian ce. A balan ced foreh ead can be created w it h p erm an e n t rem oval of t h e ap p rop r iate am ou n t of h air w it h least p roblem of d ysp igm en t at ion in Asian s, w h o ge n erally h ave d arker skin ton e. Nd :YAG lase r h as p roven to be a good ch oice for h air re d u ct ion in Asian s, com p ared w it h conven t ion al d iod e laser, an d w as fou n d to be su p er ior in h air re d u ct ion .12 Many st u d ies are st ill bein g con d u cte d on laser h air rem oval regard in g t h e p arad oxical e ect of n e h air grow t h p ost rem oval. An excit in g jou r n ey lies ah ead , w it h m ore d et ails revealed in t h e ch ap ter on lase r h air re m oval.

9

10

I Introduction

■ Procedural Techniques

■ Conclusion

Facial cosm et ic procedures can n o longer rely on surger y alon e. Many pract it ion ers can n o longer a ord to sh u n th e u se of laser, in ten se p ulsed ligh t (IPL), an d m any oth er n on su rgical tech n iqu es to ach ieve bet ter ou tcom es. Alth ough m any of th ese tech n iqu es do n ot p rovide long-term e ect s as good as su rgical in ter ven t ion , th ey often com plem en t th e surgical ou tcom e or delay surgical in ter ven t ion appropriately. Exam ples are th e use of th read lift ing for younger pat ien t s w h ere a surgical face lift is too drast ic an d un n at ural, laser or h igh -frequ en cy focu sed u lt rasoun d (HIFU) in face lift ing for m ild soft t issu e sagging, laser an d /or IPL in resurfacing various t ypes of scars an d recon st ructed aps, an d ller inject ion for sp eci c facial con tou r augm en t at ion in lim ited areas. Various t ypes of ller inject ion , ranging from collagen , hyalu ron ic acid, an d calcium hydroxyl ap at ite to p oly-L-lact ic acid an d platelet-rich plasm a, are becom ing m ore an d m ore accessible to pat ien t s as th ey are n on invasive, are tech n ically easier to ap ply, an d provide a reason able ou tcom e for a n on su rgical p rocedu re. At th e t im e th is book is being prepared, hyaluron ic acid rem ain s th e m ost w idely used ller due to it s longevit y an d it s safet y pro le com pared w ith th e oth er t ypes of llers. It is im portan t , h ow ever, th at th e reader be able to discern th e ben e t of th e ller inject ion an d verify th at it ou t w eigh s th e risks of its u sage, w h ich in clu de, in th e w orst-case scen ario, blin dn ess due to em bolism of th e ret in al vessels.13 Alth ough n ot as severe as blin dn ess, oth er com p licat ion s, such as skin n ecrosis of th e injected area, sh ou ld n ot be overlooked as recon st ru ct ion of th e a ected area can be ver y t roublesom e if it involves a large area requ iring com plex reconst ru ct ive tech n iqu es. Th e rst sign of th e grievous com plicat ion s ju st m en t ion ed (p ain in th e pat ien t post inject ion ) sh ou ld n ot be sim ply disregarded, an d prom pt usage of hyaluron idase w ith or w ith out hyperbaric oxygen is called for. Non surgical facial rejuven at ion is often overlooked by m any su rgeon s du e to its relat ively brief h istor y. How ever, w ith th e grow ing num ber of clients preferring non surgical in ter ven t ion to surgical in ter ven tion and its de nite role in com plem ent ing surgical outcom es, nonsurgical in ter vent ion has sur vived and is rapidly being reinvented and diversi ed in providing solu tion s to facial rejuven ation . Alth ough these techn iques need to be further proven w ith m ore st udies an d research , surgeons shou ld be aw are of the n on su rgical tech n iqu es available in th e m arket because ultim ately patients w ho need surger y m ay be those w ho h ave experien ced com plicat ion s from th ese n on surgical tech n iqu es. In certain circum stan ces, th ese n on su rgical tech niqu es can also be e ect ively com bin ed w ith th e u se of su rgical tech n iques to ach ieve bet ter results.

New t ren ds, con cept s, an d tech n iqu es are rap idly ap pearing in Asia for aesth et ic facial plast ic surger y. Th is t ren d can n ot be ign ored an d w ill becom e our st rength as experien ce grow s. Many of th e n ew tech n iqu es sh ou ld be review ed judiciously an d m et iculously an d u sed carefully. Th erefore, th is n ew book is open ing up a w h ole n ew ch apter in aesth et ic facial surger y for East Asian s.

References 1. Holliday R, Joan n a EH. Gen der, globalizat ion an d aesth et ic surger y in South Korea. Body Soc 2012;18(2):58–81 2. Weeks DM, Th om as JR. Beaut y in a m ult icult ural w orld. Facial Plast Surg Clin North Am 2014;22(3):337–341 3. Raw lings AV. Eth n ic skin t ypes: are there di eren ces in skin st ruct ure an d fu nct ion ? In t J Cosm et Sci 2006;28(2): 79–93 4. Rh ee SC, Lee SH. At t ract ive com posite faces of di eren t races. Aesth et ic Plast Su rg 2010;34(6):800–801 5. Tem park T, Shwayder T. Chinese fortune-telling based on face and body m ole positions: a hidden agenda regarding m ole rem oval. Arch Derm atol 2012;148(6):772–773 6. Wagat sum a H. Color an d race: th e social percept ion of skin color in Japan . Daedalu s 96(2);1967:407–443 7. Zh ang L. Eurocen t ric Beaut y Ideals as a Form of St ru ct ural Violen ce: Origin s an d E ects on East Asian Wom en , in Violen ce an d Su ering in th e Con tem p orar y World (Sp ring 2013). 4–11 8. 90% of Korean w om en w ould h ave plast ic su rger y, poll show s. Ch osun Ilbo 2009 (October 26): 11 9. Asieh ZN, Mariyya PB. CBCT evaluat ion of bony n asal pyram ic dim en sion s in Iran ian p opulat ion : a com parat ive st udy w ith eth n ic groups. Intern at ion al Sch olarly Research Not ices 2014:1–5 10. Jin HR, Won TB. Nasal t ip augm en tat ion in Asian s u sing au togen ou s cart ilage. Otolar yngol Head Neck Su rg 2009;140(4):526–530 11. Park JH, Jin HR. Use of au tologou s cost al cart ilage in Asian rh in oplast y. Plast Recon st r Surg 2012;130(6):1338–1348 12. Wan it p h akd eedech a R, Th an om kit t i K, Seth abu t ra P, Eim pun th S, Man uskiat t i W. A split axilla com parison st udy of axillar y h air rem oval w ith low u en ce h igh repet it ion rate 810 n m diode laser vs. h igh u en ce low repet it ion rate 1064 n m Nd:YAG laser. J Eu r Acad Derm atol Ven ereol 2012;26(9):1133–1136 13. Carru th ers JD, Fagien S, Roh rich RJ, Wein kle S, Carru th ers A. Blin dn ess caused by cosm et ic ller inject ion : a review of cause an d th erapy. Plast Recon st r Surg 2014;134(6): 1197–1201

II Rhinoplasty

2

Augmentation Rhinoplasty Using Silicone Implants

In-Sang Kim

Pearls • For East Asian noses, m ajor augm entation is •

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frequen tly required for th e n asal dorsu m an d th e t ip. Th e silicon e im plan t is w idely used in Asian coun t ries becau se it is easy to use, lim itless in volu m e, cost-e ect ive, an d su p erior to th e au to- or h om ograft from th e aesth et ic view poin t . Th ere are t w o sources of problem s related to th e allop last ic im p lan t . On e is th e problem s in h eren t in th e m aterial itself, w h ich can be m in im ized. Th e oth er is p roblem s from tech n ical or ju dgm en t al errors, w h ich are m ore com m on an d m u st be avoided. In fect ion is a seriou s p roblem th ough u n com m on . Th orough san it izat ion of th e operat ion eld, in clu ding th e n asal vest ibule an d an terior n asal cavit y, is im por tan t . Care sh ould be t aken n ot to tear th e m ucosal barrier using at raum at ic tech n iques. Operat ion t im e sh ou ld be redu ced to decrease th e ch an ce of in fect ion . Th e im plan t m ust be im m ersed in an t isept ic solu t ion before an d after any m an ip u lat ion . Design ing an im p lan t m u st be in d ivid u alized . Th e su rgeon sh ou ld h ave in m in d th e desired sh ape of th e n ose. In dividu al an atom ic ch aracterist ics m ust be con sidered such as th e n asofron t al angle, dorsal con tour, an d t ip project ion .

■ Introduction Th e n oses of East Asian people are di eren t in m any asp ects from Cau casian n oses. Augm en t at ion rh in op last y is on e of th e m ost com m on aesth et ic p rocedures in Asian coun t ries because of th e relat ively at an d w ide Asian n ose. How ever, augm en t at ion rh in op last y sh ou ld be con ser vat ive, preser ving th e eth n icit y to m ake th e n ose appear ver y n at u ral an d h arm onious w ith oth er facial un it s. In Asian coun t ries, augm en t at ion rh in oplast y is n ot a m ajor recon st ru ct ive op erat ion . It is regard ed as on e of th e u n com plicated com m on cosm et ic procedures. It is often regarded as a t ren dy op erat ion , an d th e aesth et ic st an dard of p at ien t s is gen erally h igh . People w an t sh ort recover y t im es an d a quick ret urn to th e job, alth ough m ajor augm en tat ion is frequ en tly requ ired. In th is sit u at ion , a pract ical an d cost-e ect ive opt ion for a surgeon is rh in oplast y u sing an alloplast ic im plan t .

• Proper select ion of a t ip tech n ique is im port an t .

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• •

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Accord ing to th e t ip tech n iqu e, th e design of an im plan t varies. Th e im plan t sh ould be con n ected to th e augm en ted t ip sm ooth ly an d seam lessly. Do n ot t r y to augm en t th e t ip w ith th e im plan t . Un like th e relat ively im m obile dorsum , th e t ip is h igh ly m obile. Th erefore, on ly au tologou s cart ilage m ust be used for th e t ip, w ith appropriate tech n iqu es to preven t ext rusion an d skin problem s. An im plan t p laced on th e t ip is aesth et ically u npleasing because it alw ays leads to a rot ated t ip w ith an u n n at urally th ick in frat ip lobule. With th e u se of on ly au tologou s cart ilage for th e t ip, skin problem s are preven ted and m ore n at ural outcom es are en sured. Stacking of m ult iple layers of on lay graft s is com m on ly required for su cien t t ip project ion in Asian s. Th e w ing graft sh ou ld be used in com bin at ion w ith th e st acked on lay graft to preven t n ot iceabilit y of th e on lay graft an d pin ch ing deform it y. Com plicat ion rates of alloplast ic im plan t s are m edically accept able. Com p licat ion s are m ore frequ en tly th e resu lt of th e su rgeon’s tech n ical an d judgm en t al errors, rath er th an th e fault of in h eren t ch aracterist ics of th e m aterial it self.

Am oun t s of autologou s m aterials except for costal car t ilage are lim ited for th e u su al large-volu m e augm en t at ion . How ever, w ith th e u se of costal car t ilage, econ om ic an d p sych ological burden s are h eavy for pat ien ts. Oth er disadvan t ages in clude postoperat ive scarring on th e ch est , rigidit y of th e t ip, prolonged operat ion t im e, an d a long recover y period. In addit ion , th e u se of cost al car t ilage is n ot free of com plicat ion s. Problem s of w arping an d resorpt ion are w ell kn ow n . In fect ion is rare but is possible. Th erefore, cost al cart ilage is reser ved as a last resor t by m any surgeon s. On th e oth er h an d , allop last ic im p lan t s are ready to u se, easy to car ve, varied in size, an d su p erior to au tologou s m aterials from an aesth et ic view p oin t . Also, th ey are n ot su bject to resorpt ion or w arping. Am ong th e m ost com m on ly u sed allop last ic m aterials are silicon e, exp an ded polytet ra u oroethylen e (Gore-Tex), an d porous h igh -den sit y polyethylen e (Medp or, St r yker, Kalam azoo, Mich igan ). Silicon e is th e m ost frequen tly used m aterial in Asian count ries. It is n onporous, in con t rast to th e oth er t w o

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II Rhinoplast y m aterials, w ith n o t issu e ingrow th or vascu larizat ion seen after im p lan t at ion . Becau se of it s n onp orou s n at u re, it is n on ad h esive to su rroun ding t issue an d en closed in a brou s cap su le. Also, it is free from deform at ion , easy to sterilize, an d easy to rem ove w h en n ecessar y. It is relat ively ch eap an d available in a range of soft n ess values. Expan ded polytet ra uoroethylen e (ePTFE) is com p osed of n od ules of Te on in tercon n ected by brils of p olytet ra u oroethylen e an d h as a m icrop orous arch itect ure, w ith pore sizes ranging from 10 to 30 m m . It s porosit y m akes it easily m alleable an d su scept ible to long-term com pression , result ing in volum e decrease or deform at ion of th e im plan t . Its hydroph obic an d porou s n at ure m akes th e sterilizat ion process using an an t isept ic or an t ibiot ic solu t ion di cu lt . Relat ively h igh cost is an oth er disadvan t age. For th e revision cases, som et im es it is ver y di cult to rem ove th e previou s ePTFE im plan t , especially w h en th e im plan t is th in , an d th e durat ion of im p lan t at ion is long. W h en th e surroun ding soft t issue is rem oved togeth er w ith th e im plan t , th e result ing soft t issue irregularit y is ext rem ely d i cu lt to repair. Porous polyethylen e (Medpor) con sists of a con t in uous system of in tercon n ect ing p ores of size 125 to 250 m m . Th e vascu lar an d brou s ingrow th leads to in tegrat ion an d st abilizat ion of th e im plan t . Th e ten sile st rength of th e m aterial is ver y h igh , con t rar y to th e case for ePTFE. Becau se of it s st i n at u re, it sh ou ld be used w ith ut m ost caut ion in m obile areas su ch as th e m em bran ou s sept u m or t ip. Syn th et ic im plan ts in rh in oplast y h ave been a topic of great con t roversy. In part icular, silicon e, w h ich is th e single m ost com m on ly u sed im p lan t m aterial in Asian cou n t ries, is a poin t of w orldw ide con ten t ion .1 Asian n oses are con sidered m ore recept ive to allop last ic im p lan ts becau se of th eir th ick skin .2 Th is is t rue to som e exten t , but even th icker skin can n ot resist long-term th in n ing, ext ru sion , in am m at ion , an d in fect ion . Th erefore, p roper tech n iqu es u sing an adequ ately design ed im plan t m u st be execu ted . W h en an experien ced surgeon uses proper tech n iques, th e com plicat ion rate for alloplast ic im plan t s is su rprisingly low and in a m edically accept able range. Recen t st udies about th e com plicat ion rates of alloplast ic im plan t s for augm en tat ion rh in op last y sh ow th at th ey are m u ch low er th an th ose in st udies from th e 1960s an d 1970s.3 Th ese ch anges are due to im provem en t s in im plan t design, con ser vat ive su rgical tech n iqu es, su rgeon s h aving m ore exp erien ce, an d th e u se of softer silicon e.

Profession al recom m en dat ion s sh ould be given to th e pat ien t after a th orough an alysis of th e face. Th e relat ion sh ip of th e n asal dorsu m , t ip , p h ilt ru m , lips, an d m en t u m w ith th e ver t ical facial axis sh ou ld be invest igated. In an alyzing the face, any facial asym m et r y m ust be n oted an d revealed to th e pat ien t before th e surger y, because th e augm en tat ion rh in op last y m ay w orsen or accen t u ate a pre-exist ing facial asym m et r y. W h en th e vert ical facial axis is skew ed or de ected, th e augm en ted n ose can n ot be absolutely ver t ical an d st raigh t . In pat ien t s w ith sign i can t facial asym m et r y, it is bet ter to augm en t th e n ose in a di eren t ver t ical axis from th e an atom ic dorsum . In th ese pat ien t s, n asal bon es on th e t w o sides are frequen tly asym m etric in term s of th e w id th an d th e slope. W h en th e bony asym m et r y is sign i can t , th e bot tom of th e im p lan t is better car ved asym m et rically accordingly. Facial asym m et r y com m on ly accom pan ies asym m etric n asal alae. Pre-exist ing alar asym m et r y m akes th e n ose look deviated even after augm en tat ion to th e correct axis. Asym m et ric alar resect ion in th ese pat ien t s m ay n ot correct th e problem sat isfactorily. Alar asym m et r y relat ing to facial asym m et r y is d i cu lt to correct becau se of it s m u lt idim en sion al n at ure. A system ic exam in at ion of th e n ose is p erform ed from top to bot tom (Fig. 2.1). Th e relat ion sh ip of th e foreh ead w ith th e n asal root is im port an t for a su ccessful dorsal augm en t at ion . Th e Asian foreh ead is relat ively at an d less p rot ruding. Gen erally, Cau casian s are m ore dolich oceph alic

■ Patient Evaluation Th e sh ape an d pro le of th e n ose requ ested by th e pat ient , an d th eir feasibilit y or desirabilit y are discu ssed in th is sect ion . Advan t ages an d disadvan t ages of u sing allop last ic im p lan t s an d p ossible altern at ives to alloplast ic m aterials are also discu ssed .

Fig. 2.1 Key areas that should be considered for successful augmentation rhinoplast y: forehead slope, nasofrontal transition, projections of the nasal tip, prem axilla, and chin.

2 an d Asian s are m ore brach iocep h alic. Brow ridges in Asian s are also n ot as prom in en t as in Cau casian s. As a resu lt , th e n asofron tal angle in Asian s is like a gen tle an d gracefu l cu r ve rath er th an an angle. Augm en t at ion rh in op last y in Asian s m u st preser ve th is gen tle cur vaceous t ran sit ion from th e foreh ead to th e n asal dorsu m . An d th e augm en ted n ose m u st h arm on ize w ith th e relat ively at foreh ead . Th erefore, excessive augm ent at ion of th e radix area sh ould be avoided in pat ien t s w ith a at foreh ead. Th e proxim al en d of th e im p lan t sh ou ld be carefu lly tap ered to accom m odate to th is area an d n ot be visible or p alpable. Desp ite th e ret ruded foreh ead, if th e pat ien t w an t s a subst an t ial am ou n t of dorsal augm en tat ion , com bin ed foreh ead augm en t at ion sh ou ld be con sid ered. Foreh ead augm en t at ion surger y is rarely perform ed in th e West; h ow ever, it is a com m on su rger y in Asian cou n t ries, u sing alloplast ic im p lan t s or m icrofat inject ion . In p at ien ts w ith excessive skin an d soft t issu e crow ding in th e glabellar an d n asal root area, th e brow lift sh ou ld be con sidered. Th at is because augm en t at ion rh in oplast y m ay m ake th is area look h eavier an d th icker an d m ay w orsen th e m ascu lin e look in th ese pat ien ts, leading to u n sat isfactor y outcom es. Aged pat ien t s ten d to h ave brow ptosis an d a th ick soft t issu e load in th e glabellar area. Th erefore, a com bin ed brow lift surger y sh ould be con sidered in aged p at ien t s an d augm en t at ion of th e radix area sh ou ld be m in im ized, focu sing m ore on t ip augm en tat ion . How ever, even in you ng p at ien ts h aving a sh ort dist an ce from glabellar area to n asion , dorsal augm en t at ion m ay fu rth er sh orten th e dist an ce, m aking th e n asal root area u n n at u ral an d at ten ed. Th erefore, a com bin ed brow lift su rger y m ay be con sidered in th ese young pat ien ts also. Th e en doscopic brow lift is th e best opt ion for young pat ien ts con sidering th e e ect on th e m edial brow an d m in im izing postoperat ive scarring. Th e glabellar an d n asal root region sh ow s a w ide range of variat ion even in Asians. Th erefore, th e proxim al im plan t sh ou ld be car ved carefu lly according to in dividu al an atom y to t in th is area. Preoperat ive X-ray m ay be h elpful for visualizat ion of th e bon e an d soft t issue an atom y of th is area (Fig. 2.2). Exam in at ion by m an u al palp at ion of th is area before or d u ring th e operat ion is also ver y im p ort an t . Carefu l dorsal exam in at ion p reced es th e design of an im plan t . Th e n asal bon e is exam in ed for it s length , w idth , an d asym m et r y. Man u al p alpat ion along th e dorsu m is h elpfu l in revealing soft t issu e th ickn ess, presen ce of h u m p , or dorsal irregu larit y. Skin th ickn ess of n asal t ips is qu ite variable in Asian s. For th e th in -skin n ed pat ien ts, visibilit y of graft s or th e im plan t m igh t be problem at ic. On th e oth er h an d, for th e th ick-skin n ed pat ien t s w ith bulbou s t ips, it is ver y di cult to obt ain a n e de n it ion of th e t ip. Wide alae are com m on in Asian s. For th e en h an ced outcom e of dorsal augm en t at ion , alar resect ion m ay be requ ired in som e p at ien ts. If alar asym m et r y an d asym m etric m axillar y develop m en t are p resen t , th ey are d iscu ssed

Augm ent ation Rhinoplast y Using Silicone Im plant s

Fig. 2.2 A preoperative X-ray helps in planning by visualizing the bone and soft tissue anatomy of the nose.

w ith th e pat ien t , becau se it is u n realist ic to t r y to m ake th e sides of th e alae com pletely sym m et ric. In p at ien ts w ith un derdevelopm en t of th e m axilla or prem axilla, paran asal or prem axillar y augm en tat ion m ay be con sidered as an cillar y p rocedures of th e augm en tat ion rh in oplast y. How ever, it sh ou ld be taken in to con siderat ion th at acu te n asolabial angle is n ot u n com m on in Asian s. Som e Asian n oses are beaut ifu l en ough even w ith th e acute n asolabial angle, an d in som e p at ien t s acute n asolabial angle is not a con cern at all. Pat ien t s w ith prot ruding lips can ben e t from th e com bin at ion of rh in oplast y, m axillar y augm en tat ion , an d ch in augm en tat ion . Th is com bin at ion of su rgeries w ill dram at ically en h an ce th e facial pro le in selected pat ien ts.

■ Surgical Techniques Skin Marking Skin m arking for th e augm en tat ion m u st be don e in th e sit t ing p osit ion . Marking a vert ical lin e for th e dorsal augm en t at ion is im p or t an t , becau se frequ en tly th e glabella, nasal dorsu m , an d n asal t ip are o th e sam e vert ical axis,

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II Rhinoplast y an d augm en t at ion rh in op last y m ay accen t u ate th e deviated look of th e n ose. Th erefore, th e surgeon m ust set a ver t ical lin e for th e augm en tat ion . Th e lin e th at looks th e st raigh test is carefu lly ch osen for th e lin e of augm en tat ion (Fig. 2.3). W h en th e dorsu m an d t ip are ver t ically m isalign ed, u sually a vert ical lin e exten ded upw ard from th e t ip is m ore appropriate for th e lin e of augm en tat ion , rath er th an th e lin e along th e d orsu m , alth ough th is is n ot alw ays th e case. Th e n asal start ing poin t is set an d a h orizon t al lin e is m arked, u su ally at th e h eigh t of th e ciliar y m argin s. In gen eral, w h en th e p at ien t w an t s a h igh er dorsu m , th e lin e m ay be draw n at th e h eigh t of th e su prat arsal crease. W h en th e p at ien t w an t s a m ore n at ural look, th en th e lin e is draw n bet w een th e ciliar y m argin an d th e pupil. How ever, it is in dividualized according to th e pat ien t’s facial ch aracterist ics. Th is h orizon t al lin e also provides a lan dm ark for th e ceph alic exten t of th e subperiosteal dissect ion .

Anesthesia and Positioning Th e pat ien t is put un der an esth esia in a supin e posit ion an d drap ing is don e. Augm en tat ion rh in oplast y u sing alloplast ic im plan ts is don e un der gen eral an esth esia or in t raven ou s an esth esia w ith sedat ion . W h en it is don e u n der in t raven ou s an esth esia, close m on itoring of th e respirat ion is cru cial. Main t ain ing th e oral air w ay du ring th e surger y

Fig. 2.3 Skin marking is done in a sit ting position using a straight wooden stick. A vertical line is drawn. The nasal starting point, rhinion, and nasal tip are marked.

is required. Any blood or secret ion in th e oral an d ph ar yn geal cavit y is su cked ou t rep eatedly u sing a su ct ion cath eter th rough th e oral air w ay during th e operat ion . To redu ce th e secret ion , in t raven ou s inject ion of glycopyrrolate before th e surger y is recom m en ded. Oxygen supplem en t at ion th rough th e oral air w ay also can be h elpful.

Preparation of the Implant Before local an esth et ic inject ion , an im plan t is prep ared an d t ried on th e d orsu m (Fig. 2.4). Th e su rgeon m u st ch eck w h eth er it is suit able for th e desired h eigh t an d desired n asal pro le, w h eth er it is w ell t ted for th e n asofron t al angle, an d th e d orsal con gu rat ion . Th en in it ial car ving is perform ed using a n o. 15 surgical blade before th e surger y. A correctly design ed im plan t is crucial for a su ccessful outcom e. Any single im plan t m ust be custom ized according to in dividu al an atom y. Th e th ickn ess of th e im plan t is decided rst . Im plan t s w ith 4 to 5 m m of th ickn ess are m ost frequ en tly ch osen am ong th e 2 to 10 m m th ickn ess range. How ever th e th ickn ess is n ot u n iform an d varies along th e dorsu m after car ving according to th e in dividual’s an atom ic ch aracterist ics. In gen eral, w h en th e n ose is low in radix an d th e t ip is w ell projected, the im plan t is car ved proxim ally th ick an d dist ally th in . On th e con t rar y, w h en th e n ose is adequ ately h igh in radix an d th e t ip is low, th e im plan t is car ved proxim ally th in an d dist ally th ick. W h en a h u m p is p resen t , th e im plan t is often car ved th in n er in th e rh in ion area (Fig. 2.5). Th e im plan t’s sh ape, especially th e distal por t ion , is also variable according to th e preferred t ip augm en t at ion tech n iqu e. Th e in it ially car ved im plan t is im m ersed in an t isept ic solu t ion su ch as hyp och lorou s acid u n t il it s later u se. Th e

Fig. 2.4

The implant is tried on the dorsum for the initial carving.

2

Augm ent ation Rhinoplast y Using Silicone Im plant s for later closu re an d th ere is n o risk of n otch ing deform it y. Th e colum ellar ap is elevated in th e conven t ion al m an ner. Elevat ion of th e skin ap from th e t ip is on th e supraperich on drial plan e for th e th in -skin n ed pat ien t s as u sual. How ever, for th e th ick-skin n ed Asian p at ien t , th e defat t ing procedure is frequen tly requ ired for debulking th e th ick soft t issu e an d for bet ter de n it ion of th e t ip . For th e defatt ing procedure, a layer of soft t issue is deliberately left on th e cart ilage surfaces elevat ing th e skin ap (Fig. 2.6). Becau se th e t ip soft t issu e is arranged in a layered fash ion , it is n ot qu ite as di cu lt to raise th e ap w ith an even th ickn ess. Th is tech n ique is bet ter for sm ooth an d even rem oval of th e soft t issu e along th e cart ilage su rfaces th an defat t ing from th e un dersurface of th e skin ap after su p rap erich on drial elevat ion . Th ere is th ick soft t issu e on th e suprat ip area also, an d it can be rem oved or preser ved depen ding on th e sit uat ion . On th e car t ilagin ou s dorsum , th e plan e is ch anged to th e su praperich on drial plan e.

Fig. 2.5 The initial carving is done using a no. 15 surgical blade. The three most common shapes of implant s are shown (top, proximally thin and distally thick; middle, proximally thick and distally thin; bottom, anatomically carved). Implants are further custom ized during the surgery.

hypoch lorous acid is suit able for th is purpose because it is clear in n at ure an d relat ively less toxic, n on irritat ing, an d p oten t .

Harvest of Ear Cartilage After local an esth et ic inject ion s at th e n ose an d th e ear, con ch al car t ilage is h ar vested rst w h en it is expected to be n ecessar y. Con ch al car t ilage is h ar vested com m on ly th rough a postauricular in cision . An d it is h ar vested from th e cavum con ch a an d cym ba con ch a separately, leaving th e cru s of h elix as a bridge. Th is valuable an atom ic landm ark of th e au ricle is best preser ved for aesth et ic p u rposes an d st ru ct u ral su p p or t , an d to m ain t ain th e abu n dan t n eu rovascular su pp ly of th is area. Th e h ar vested con ch al cart ilages are p reser ved in th e an t ibiot ic solut ion .

Creation of the Periosteal Pocket As dissect ion proceeds on th e n asal bon e, th e plan e is ch anged again to th e subperiosteal plan e (Fig. 2.7). It is ver y im p or t an t to accu rately raise th e periosteal ap from th e n asal bon e. W h en th e im plan t is n ot correctly placed in th e subperiosteal space, th e im plan t ten ds to be m ore m ovable an d m ore visible. To elevate th e periosteu m p recisely, it is bet ter to u se a sh arp an d n arrow t ip elevator, su ch as th e Joseph elevator, at rst . W h en th e subperiosteal space is correctly raised par t ially, th en a w ider elevator is in serted an d th e sp ace is w id en ed . If a w ide an d blu n t in st ru m en t is used from th e st art , th e periosteum is easily torn . Close to th e n asofron t al su t u re lin e, bleeding is likely to en su e becau se of p roxim it y of vessels to th e su t u re lin e.

Incision and Elevation of the Skin Flap For an open rh in oplast y, t ran scolum ellar an d m argin al in cision s are m arked rst . In Asian p at ien t s, occasion ally th e caudal m argin s of th e alar car t ilages are n ot prom in en t th rough th e vest ibular skin . Th erefore, m arking for m argin al in cision is h elp fu l for a p recise an d sym m et ric in cision . Th e m argin al in cision is p laced 1 m m an terior to th e caudal m argin of th e alar cart ilages, because th is is bet ter

Fig. 2.6 Elevating the skin ap. A thin layer of soft tissue on the alar cartilage is deliberately left for the defat ting procedure.

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II Rhinoplast y Th e soft t issue on th e su rface of th e alar car t ilages an d in the su prat ip area th at w as left deliberately du ring ap elevat ion for th e defat t ing procedure is n ow rem oved. Clear ident i cat ion an d delin eat ion of th e cart ilage m argin s are im port an t at th is st age for later procedu res (Fig. 2.8). Margin al in cision s are exten ded laterally as n eeded, esp ecially w h en th e ten sion on th e augm en ted t ip is expected to be h igh . Th e p iriform ligam en t s m ay also be fu rth er released as n ecessar y. For m ore release of ten sion , th e scroll area m ay be dissected. How ever, th e dissect ion sh ould be as con servat ive as p ossible, becau se m ore dissect ion w ill cau se m ore distort ion , scar form at ion , an d u npredictabilit y.

Harvest of Septal Cartilage

Fig. 2.7 The dissection plane is supraperichondrial on the cartilaginous dorsum and subperiosteal on the nasal bone.

If th is bleeding is n ot con t rolled correctly, h em atom a can arise postop erat ively on th e n asal root . Hem atom a is a serious com plicat ion , because if n ot adequately t reated, it w ill be accom pan ied by bacterial in fect ion . Th e posit ion of th e im plan t m ay also be ch anged by a h em atom a. Th erefore, it is bet ter n ot to dissect overly exten sively in th e ceph alic direct ion if it is n ot n ecessar y. Excessive ceph alic dissect ion m ay also lead to ceph alic m igrat ion of th e im plan t . Th e subperiosteal pocket is w iden ed laterally as n eeded. Th e space sh ould be close to sym m et ric an d adequately w ide for th e im plan t to be sn ugly placed in side. W h en th e su bp eriosteal pocket is too sm all, th e im p lan t m ay n ot be placed properly an d m ay later be displaced or deviated. On th e oth er h an d, an overly w ide pocket is also a com m on cause of early postoperat ive displacem en t of th e im plan t .

Next th e m em bran ou s sept u m is dissected an d th e cau dal m argin of th e sept u m is iden t i ed. Th e septal cart ilage is h ar vested, leaving th e L-st ru t . In Asian s, th e sept al car t ilage is frequ en tly w eak an d sm all. In th ose pat ien t s w ith a w eak sept u m , m ore of th e septal cart ilage sh ou ld be preser ved th an th e conven t ion al 1 cm w idth for th e dorsal an d caudal st rut to m ain tain th e st ru ct ural st abilit y. Th erefore, th e am ou n t of h ar vested sept u m is frequ en tly ver y sm all. Even w h en th e h ar vested am oun t of sept al car t ilage is en ough , th e caudal sept u m is too w eak an d frail to provide longterm stable suppor t for th e sept al exten sion graft . In th is regard, t ip surger y using sept al cart ilage on ly h as clear lim itat ion s in m any Asian pat ien t s. How ever, despite th ese draw backs, th e sept al exten sion graft is st ill on e of th e m ost reliable t ip tech n iques for Asian s. It provides t ip project ion an d rotat ion /derot at ion it self, as w ell as p roviding st rong m edial su p port for com bin ed on lay graft s (Fig. 2.9). How -

Defatting and Release of Ligamentous Attachments After th e dissect ion along th e d orsu m is n ish ed, th e t ip su rger y is in it iated . A su ccessfu l dorsal augm en tat ion can n ot be accom p lish ed w ith ou t a su ccessfu l t ip augm en tat ion .

Fig. 2.8 Cartilage m argins are clearly delineated after the defatting procedure.

2

Fig. 2.9 Septal extension grafting is done on the caudal septum as an overlapping pat tern.

ever, excessive ten sion from overzealou s t ip augm en t at ion relying on ly on th e sept al exten sion graft w ill be a cause of sept al bu ckling, long-term resorpt ion or w eaken ing of th e caudal sept um , an d t ip drooping. Th erefore, a m in im al to m oderate am ou n t of ten sion sh ou ld be app lied, con sidering th e st rength of th e in dividual sept al car t ilage. After h ar vest ing th e sept al cart ilage, osteotom ies are p erform ed if required. Alth ough th e osteotom y is n ot a con t rain dicat ion for alloplast ic dorsal augm en t at ion , th e osteotom y sh ould be as at raum at ic as possible an d m u cosal tearing sh ou ld be m in im ized to exclu de th e ch an ce of ascen ding bacterial in fect ion .

Insertion of the Implant Th e prefabricated im plan t is n ow in ser ted in th e dorsal pocket (Fig. 2.10). Th e excessive length ou t side th e pocket is t rim m ed. Th e p ro le of th e n ose is closely exam in ed an d com pared w ith th e plan n ed sh ape. Th e con form it y of th e im p lan t on th e n asal dorsum is closely ch ecked. Th e proxim al en d sh ou ld n ot be visible, read ily p alp able, or m ovable. Th e dorsu m sh ou ld be sm ooth an d st raigh t , or m ildly con cave in w om en . To obt ain th e desired sh ape an d dorsal sm ooth n ess, repeated car ving an d t rials of th e im p lan t m ay be n ecessar y. Th e p roject ion an d rot at ion of t h e t ip , w h ich is tem p orar ily for m ed by t h e d ist al t ip of t h e im p lan t , is carefu lly exam in ed . Th e im p lan t m ay be u sed as a d u m m y for t h e t ip su rger y. Th e su rgeon can est im ate t h e requ ired am ou n t of p roject ion by t h e t h ickn ess of t h e im p lan t t ip . An d also t h e su rgeon can est im ate t h e d esired am ou n t of rot at ion /d erot at ion by m ovin g t h e t ip of t h e im p lan t back an d for t h .

Augm ent ation Rhinoplast y Using Silicone Im plant s

Fig. 2.10 pocket.

The prefabricated implant is inserted into the dorsal

Preparation of the Stacked Onlay Graft Accord ing to th e est im ated am ou n t of t ip p roject ion , on lay graft s using sept al or auricular car t ilage are prepared. Because th e am oun t of sept al car t ilage is lim ited in Asian s usually, auricular car t ilage is gen erally used for th is purpose. Stacking of m u lt iple on lay graft s is frequen tly n ecessar y becau se th e requ ired am ou n t of t ip augm en t at ion is com m on ly substan t ial in Asian s.4 Stacking of t w o or th ree layers of auricu lar cart ilage is u sually requ ired, alth ough th e n um ber is variable. Th e layered cart ilages m ay be su t u red togeth er. Th ree layers of au ricu lar car t ilage w ill be arou n d 5 m m in th ickn ess. Th e graft sh ould be ceph alo-caudally long en ough to be placed over th e dom es of th e alar cart ilages. Th e m argin s of th e graft are m et iculously t rim m ed to be devoid of any sh arp edges. W h en th e stacked on lay grafts are prepared, th e sam e ceph alo-cau dal length as used for th e graft is resected from th e distal im plan t (Fig. 2.11). Th e rem oved part of th e im plan t is replaced by th e on lay graft , w h ich is sut ured to th e cut en d of th e im plan t . By su t uring th e graft to th e im plan t , an u nbroken , seam less t ran sit ion from th e dorsum to th e t ip is en su red. Tip m obilit y is m ildly decreased but n ot rest ricted by su t u ring th e graft to th e im p lan t . How ever, w h en th e septal exten sion graft is u sed, decreased t ip m obilit y is an in evitable t rade-o . Th e th ickn ess of th e dist al en d of th e im plan t is adjusted to m atch th e th ickn ess of th e on lay graft . Th e distal part of th e im plan t m ay be beveled according to th e in clin at ion of th e lateral crura of th e alar cart ilages. Th e st acked on lay graft is suppor ted m edially by th e sept al exten sion graft . With ou t strong m ed ial su p port , th e

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II Rhinoplast y

Fig. 2.11 The same length of the silicone implant as the stacked onlay cartilage tip graft is cut out from the caudal end. Fig. 2.12 graft.

The wing graft s are applied on both sides of the onlay

e ect of th e graft w ill abate w ith th e collap se of colu m ella an d m em bran ou s sept u m , requ iring m ore am ou n t s of cart ilage, an d th e colum ellar-lobular rat io w ill deteriorate.

Insertion of the Uni ed Graft and Implant Hybrid The uni ed graft an d im plant hybrid is inserted into th e dorsal pocket , and the pro le is closely exam ined again. The surgeon has to exam ine the nose carefully, tem porarily closing the incision by pulling dow n the colum ellar ap, because the pro le can be changed due to the tension on the skin . Repeated car ving m ay be required at th is stage also. W h en th e desired sh ape of th e n ose is n ally obt ain ed, th e on lay graft is xed to th e alar cart ilages w ith sut ures. Th e n al n e m odi cat ion of th e t ip an d t ip lobules is don e by car ving an d addit ion al graft ing. A sh ield graft in fron t of th e graft or addit ion al on lay grafts can be added as n ecessar y.

Placement of the Wing Grafts After obt ain ing a n al t ip sh ap e, so-called w ing graft s are ap plied bilaterally on th e lateral sides of th e on lay graft (Fig. 2.12). Th e w ing graft is sh ap ed to assim ilate th e lateral cru ra of th e alar cart ilages, to corresp on d w ith th e dom e n ew ly created by th e stacked on lay graft . Auricu lar cart ilage is best suited to th is purpose because of it s n at ural cu r vat ure. Th e pu rpose of th e w ing graft is to preven t th e collapse or pin ch ing deform it y on th e lateral sides of th e on lay graft . With out th e w ing grafts, th e t ip is cen t rally prom in en t on ly n ear th e on lay graft , an d laterally t ip lob u les are collapsed an d pin ch ed. Th e w ing graft p rovides a sm ooth t ran sit ion from th e t ip to th e lobu les, soften s th e m argin s of th e on lay graft , an d act s as a st ru ct u ral su pp or t again st soft t issu e collapse. Th e w ing graft is also h elp ful in

cases of alar rim ret ract ion , because it is secu rely xed to th e on lay graft to provide st rong suppor t again st ret ract ion , com pared w ith the alar rim graft . In a w idely u sed tech n iqu e for alloplast ic augm en t at ion in Asia, th e t ip of th e im plan t (st raigh t or L-sh aped) is placed on top of th e alar car t ilages, an d th en a piece of autologous cart ilage is laid on top of (on lay-like) or in fron t of (sh ieldlike) th e dist al im plan t in an at tem pt to decrease th e risk of skin p roblem s su ch as ext ru sion . Th ese tech n iqu es p rovide t ip project ion an d rot at ion w ith relat ive ease, an d produce fair ou tcom es in selected cases, esp ecially in th ose w ith u n der-p rojected an d un der-rot ated n asal t ips. How ever, th ese tech n iqu es h ave apparen t disadvan t ages. Th e resultan t t ip ten ds to be over-rotated an d u n n at ural, because th e project ion an d rotat ion in crease w ith out proport ion al elongat ion of th e t ip. Th e in frat ip lobule becom es un n at urally th ick w ith a decreased colum ellar-lobular rat io. Fin e t ip m odi cat ion is also di cult using th ese tech n iques, an d th e t ip often looks sh arp an d poin ted. In addit ion , th e piece of cart ilage on th e dist al im plan t is likely to becom e con spicu ou s w ith t im e. In con t rast , for th e previou sly described tech n iqu e u sing th e st acked on lay graft , it is easy to elongate th e t ip . Fin e t ip sh aping is possible w ith addit ion al car ving an d graft ing. Com bin ing th e w ing graft s, it is m ore n at u rally sm ooth in sh ape, an d th ere are n o visibilit y or con sp icu it y problem s of on lay graft s over t im e.

Variant Techniques Th e aforem en t ion ed procedures can be don e using th e en don asal app roach . How ever, gen erally th is m akes it m ore di cult to m an ipulate th e graft s an d to con t rol th e ten sion on th e t ip skin . For m ore visualizat ion an d m ore release

2 of ten sion , a m argin al in cision is exten ded m edially over th e foot plate to th e n asal sill, an d laterally to th e piriform ligam en ts. W h en th e h eight di eren ce bet w een th e t ip an d th e an terior septal angle is sign i can t an d th e in clin at ion of lateral cru ra is con siderable, a varian t tech n ique can be u sed (Fig. 2.13). Th e su bst an t ial t ip -to-sept u m h eigh t d ifferen ce an d lateral cru ral in clin at ion are com m on ly created by th e st rong t ip project ion w ith th e sept al exten sion graft; h ow ever, a con siderable t ip -to-sept u m h eigh t d i eren ce is presen t even prior to surger y in som e pat ien ts. In th is sit u at ion , th e dist al im plan t is car ved in a w edge sh ape w ith ap prop riate th ickn ess to t in th e cep h alic divergen ce of alar car t ilages. Th e im p lan t m ay be su t u red to th e cep h alic m argin s of th e alar cart ilages. For som e pat ien t s, on ly th e low n asal bridge, n ot th e t ip, is th e problem an d th eir con cern . Th en on ly a correctly car ved im plan t according to th e in dividual dorsal an atom y w ill su ce. Th e im plan t is in serted th rough th e m argin al or in tercar t ilagin ous in cision . In adequ ately n arrow, sm all, or asym m et ric dorsal pockets w ill predispose to ext rusion . For th e sym m et r y of th e dorsal pocket , bilateral in cision an d dissect ion are recom m en ded. Th e dist al en d of th e im plan t is t apered to be p aper th in to sm ooth ly cont in u e to th e ceph alic port ion of th e alar cart ilages. An im plan t of excessive length , in a sm all or asym m et ric pocket , m ay ext ru de, esp ecially w h en th e dist al im p lan t is in direct con tact w ith th e in cision site. In th is regard, m argin al in cision is m ore app ropriate for th e alloplast ic im p lan tat ion . With th e m argin al in cision , addit ion al t ip graft ing or oth er t ip m an ipu lat ion s are also p ossible.

a

Augm ent ation Rhinoplast y Using Silicone Im plant s

Closure and Splinting For th e n al procedure, m et iculous sut ure closure is don e. Th en irrigat ion w ith an t ibiot ic an d an t isept ic solut ion s is perform ed using a syringe after th e closure. Taping is don e to decrease th e edem a an d to decrease th e m obilit y of th e im plan t an d grafts. Th en a th erm oplast ic splin t is applied on th e dorsum . Th e splin t ing is im port an t to im m obilize th e im plan t an d to preven t edem a an d h em atom a on th e rad ix area in th e im m ed iate p ostoperat ive period. Th e splin t sh ould be applied along th e pre-m arked ver t ical lin e of th e augm en t at ion . Th e splin t is m ain t ain ed for at least 7 days.

■ Key Technical Points 1. Design ing an im p lan t is th e rst an d m ost crit ical step. Based on th e d esired sh ape an d in dividu al an atom y, th e im p lan t sh ou ld be car ved correctly. 2. Th e subperiosteal pocket is created. Th e pocket sh ou ld be sym m et ric an d ap prop riately w ide for th e im plant to be sn ugly placed in side an d n ot be excessively m obile. 3. For th e sept al exten sion graft , excessive ten sion on th e graft is un desirable, especially w h en th e sept al cart ilage is frail. It provides a st able platform for th e on lay t ip graft , w h ich is u sed for furth er t ip project ion an d de n it ion , com m on ly required in Asian pat ien t s.

b

Fig. 2.13 (a,b) When the gap is signi cant bet ween the tip and the anterior septal angle, the implant m ay be carved in a wedge shape and suture xed to the cephalic margins of the alar cartilages.

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II Rhinoplast y 4. The pre-car ved im plan t is in serted in th e pocket an d th e dorsal pro le is carefu lly ch ecked . Rep eated car ving m ay be n ecessar y. Using th e distal im plan t as a d u m m y for th e t ip augm en tat ion allow s th e am oun t of t ip project ion an d rotat ion to be est im ated . 5 . Th e on lay gra ft is p re p a re d . It is com m on ly st acke d in m u lt ip le laye rs for su fficie n t t ip p roje ct ion . Th e sam e le n gt h a s t h e on lay gra ft is excise d from t h e d ist a l im p la n t . Th e on lay graft is su t u re d t o t h e cu t e n d of t h e im p la n t . 6. The w ing graft is prepared m im icking th e lateral cru s. It is placed on both sides of th e on lay graft to p reven t th e p in ch ing deform it y of t ip lobu les, to d ecrease th e con sp icuit y of th e on lay graft . 7. Fur th er n e t ip sh aping is ach ieved by delicate car ving an d th e use of addit ion al on lay or sh ield graft s. 8. Met iculous closure an d irrigat ion using an t ibiot ic an d an t isept ic solu t ion s are don e. Use of a com pressive dressing w ith a th erm oplast ic splin t is im port an t to im m obilize th e im p lan t an d to preven t edem a an d h em atom a.

■ Complications and

Problems Caused by Inherent Physical Characteristics of Alloplastic Implants Capsule Formation In cases w h ere com plicat ion s su ch as con t ract ion do n ot occur, th e brous capsu le preven t s th e im plan t from bon d ing w ith skin , preven t s skin dam age, an d m ain tain s th e th ickn ess of th e skin an d soft t issue to som e degree. On th e oth er h an d, th e brou s cap su le h as a side e ect of m aking th e area suscept ible to in fect ion by preven t ing an t ibiot ics from e ect ively p en et rat ing th e area arou n d th e im p lan t an d by let t ing th e silicon e im p lan t create dead sp ace w ith in th e capsule as it m oves in side. In cert ain sit u at ion s, th e cap su le cau ses severe com p licat ion s, m ost n ot ably th e con t racted n ose.6 Creat ion of an excessively th ick an d w ide capsu le an d con tract ion is u su ally cau sed by add it ion al factors su ch as bacterial in fect ion an d excessive t issu e dam age. Th erefore, to avoid overproduct ion of capsules an d it s en su ing com p licat ion s, th e su rgeon m u st take care to p reven t in am m at ion or in fect ion from occu rring du ring or after su rger y, w h ile m in im izing t issu e dam age an d bleed ing by surger y.

Their Management

Skin and Mucosal Damage

Negat ive react ion s tow ard allop last ic im p lan t s for rh in oplast y w ere com m on in th e Western part of th e w orld. Th is m ay stem from exp erien ce w ith injectable m aterials su ch as p ara n oil, liqu id silicon e, an d early im p lan ts of excessive size.5 In terest ingly, recen t research sh ow s m uch low er com plication rates from silicon e im plan ts com pared w ith rep or t s publish ed in th e 1960s an d 1970s. Th ese ch anges are th ough t to be du e to im provem en ts in im p lan t d esign , con ser vative su rgical tech n iqu es, physician s h aving m ore exp erien ce, an d u se of softer silicon e. Many p hysician s in Asia perceive th e com plicat ion rates of silicon e im plan t s as acceptable, in part d u e to m ore exp erien ce w ith rh in op last y using silicon e im plan t s com pared w ith Western p hysician s. Com plicat ion s from silicon e im plan ts can be largely grouped into t w o categories, th ose caused by in h eren t t rait s of silicon e it self an d th ose result ing from th e su rgeon’s tech n ical or judgm en t al errors. For a successful su rgical resu lt , it is essen t ial to m in im ize th e in evit able problem s from in h eren t p hysical ch aracterist ics of th e m aterial an d to m ake e ort s to reduce tech n ical an d judgm en t errors.5 Com m on com plicat ion s, such as deviat ion , t ip skin problem s, an d infect ion , are m ore frequen tly related to techn ical errors th at are avoidable, an d less frequen tly to th e physical ch aracterist ics of th e m aterial it self.

St im u lat ion of th e skin , dam age to skin an d appen dages, skin th in n ing, skin con t ract ion , an d telangiect asis are longterm com plicat ion s. Th e sligh t yet repet it ive dam age cau sed by th e solid im plan t can h arm th e m ucous m em bran e an d create recurring ch ron ic in am m at ion , possibly by ascen ding bacterial in fect ion th rough sm all m u cosal defects. To m in im ize su ch p hysical dam age from silicon e im p lan ts, th e im plan t sh ould be of appropriate length an d w idth , an d it m u st be w ell t ted an d im m obile. Addit ion ally, u sing a softer m aterial for th e im plan t can h elp redu ce p hysical st im ulat ion . Sut uring a layer of derm is or derm ofat on th e ou ter surface of th e im plan t is h elpful in th in -skin n ed pat ien t s or revision cases to decrease m ech an ical st im u lat ion , an d m obilit y an d visibilit y of th e im plan t (Fig. 2.14).

Calci cation W h en rem oving a long-seated im plan t , the surgeon m ay com e across calci cat ion of th e im plan t . A calci ed im plan t form s a h arder an d rough er su rface, in creasing st im ulat ion to th e overlying skin an d let t ing th e irregu lar su rface sh ow th rough th e skin . Calci cat ion m ay w orsen w ith t im e.7 Calci cat ion also relates to m ech an ical st im ulat ion an d dam age to surroun d ing t issue.

2

Augm ent ation Rhinoplast y Using Silicone Im plant s im plan t for im m obilizat ion by t issue ingrow th . It is h elpful to im m obilize th e im p lan t; h ow ever, it is di cu lt to correct w h en th e im plan t is xed bu t deviated. An d it is said to be th e cau se of su dden h em atom a or bleed ing in th e late postoperat ive period, because a su dden t raum a or m ovem en t of th e im p lan t w ill disru pt th e blood vessels of th e ingrow n t issu e. Constant m ovem ent by the m alpositioned im plant can be a cause of chronic skin irritation and ch ron ic in am m ation.

Infection

Fig. 2.14 The outer and lateral surfaces of the silicone implant are covered with a dermal graft.

Problems Caused by Technical or Judgmental Errors of the Surgeon Extrusion and Thinning of Tip Skin Ext r u sion rates of silicon e im p lan t s rep or ted ly var y from 0.48% to 50%, p robably d u e to t h e d i e ren ces in su rgical tech n iqu e, im p lan t sh ap e, an d t h e su rgeon ’s level of exp er ien ce.3 W h en excessive ten sion is ap p lied to t h e n asal t ip ’s skin w it h t h e in ten t ion of givin g a ten t -p ole e ect u sin g t h e im p lan t , esp ecially t h e L-sh ap ed silicon e im p lan t w it h a lon g colu m ellar segm en t , t h e r isks of skin d am age an d im p lan t ext r u sion in crease. An im p lan t of excessive le n gt h m ay t h in t h e n asal t ip skin over t im e, an d m ay even t u ally ext r u d e. Th e im p lan t can also ext r u d e in to t h e n asal cavit y t h rough t h e m u cou s m em bran e. Ch ron ic in am m at ion an d in fect ion are also com m on cau ses of ext r u sion . Ext r u sion is a com p licat ion t h at can be avoid e d by u sin g an ap p rop r iately size d im p lan t , t ip graft in g w it h au tologou s car t ilages, an d in fect ion an d in am m at ion p rotect ion .

Implant Displacement and Movement Im p lan t deviat ion is a frequ en t side e ect . To preven t displacem en t , th e im plan t sh ou ld be placed in th e sub periosteal pocket . Silicon e im plan t s h ave a h igh er risk of m ovem en t com pared w ith m aterials w ith pores, su ch as Gore-Tex. Th erefore, it is im port an t to im m obilize th e silicon e im plan t for th e period of t im e using a splin t after surger y. Som e su rgeon s m ake w edge excision s or h oles on th e

Alloplast ic im plan t s are su scept ible to in fect ion an d , w h en in fected, exh ibit t ypical sym ptom s such as er yth em a, sw elling, an d puru len t secret ion . How ever, tem p orar y er yth em a an d sw elling in th e form of su bclin ical in fect ion can occu r rep eatedly. Subclin ical in fect ion is th ough t to occur w h en th e n u m ber of bacteria is sm all, or if bacteria are presen t in th e form of bio lm on th e su rface of silicon e. Th orough sterilizat ion of th e surgical eld is n ecessar y for redu cing in fect ion , especially in th e n asal vest ibule an d th e en t ran ce part of th e n asal cavit y. Du ring surger y, it is im port an t to preven t disru pt ion of n at ural barriers su ch as th e m ucou s m em bran e. A lengthy surgical t im e m ay reduce blood ow to th e t issue an d increase th e risk of in fect ion . Im p lan ts m u st be im m ersed in sterilizing solu t ion du ring procedures.8

■ Case Studies Case 1 A 22-year-old fem ale visited th e clin ic for a rh in oplast y (Fig. 2.15). Sh e sh ow ed t ypical Asian facial feat u res su ch as a at foreh ead, sh allow n asofron t al angle, at n asal bridge w ith w eak t ip project ion , an d m axillar y ret rusion . Con sidering th e sh allow n asofron tal angle an d u n derprojected t ip, a silicon e im plan t w as car ved to be proxim ally th in an d dist ally th ick. Bilateral m edial an d lateral osteotom ies w ere perform ed. For su cien t project ion , a th ree-layer st acked on lay graft w ith w ing graft s u sing con ch al cart ilage, an d a sept al exten sion graft w ere used in com bin at ion for th e t ip. For m ore de n it ion of th e t ip, defat t ing of th e soft t issue on th e t ip w as don e. On e-year p ostop erat ive p ict u res sh ow adequ ate t ip project ion , a m ore de n ed n asal t ip, an d an augm en ted, narrow ed n asal bridge. Th e st igm a of rh in oplast y, in cluding th e un n at urally at n asofron tal t ran sit ion , visible im plan t con tour in th e radix, an d sh arp poin ted t ip, are barely not iceable.

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II Rhinoplast y Fig. 2.15 Case 1: Primary dorsal augmentation with tip-plast y. (a,c) Preoperative frontal and lateral views show at forehead, shallow nasofrontal angle, at nasal bridge with weak tip projection, and maxillary retrusion. (b,d) One-year postoperative pictures show adequate tip projection, a more de ned nasal tip, and an augmented, narrowed nasal bridge.

a

b

c

d

Case 2 A 25-year-old fem ale visited th e clin ic for revision rh in op last y (Fig. 2.16). Sh e h ad developed an in fect ion after silicon e im p lan tat ion in th e previou s su rger y. Sh e sh ow ed severe con t ract ion , a at dorsu m w ith low radix, an over-rotated t ip , an d irregu lar d eform ed t ip skin w ith a depressed scar. Septal car t ilage w as u sed for th e t ip -plast y in th e previou s su rger y.

Bilateral extended spreader grafts using rib cart ilage an d stacked on lay tip grafts w ith w ing grafts u sing auricular cart ilage w ere em ployed. Auricular cart ilage has advan tages over rib cartilage for th e on lay or sh ield graft an d th e w ing graft, becau se of its n at ural cu r vat ure an d less st i n at ure. The dorsum w as augm en ted w ith a silicone im plant , w hich w as covered w ith a derm al graft from th e postauricu lar skin . Use of th e silicon e im plan t is usually safe even in secon dar y cases. In con trast to case 1, the im plan t w as designed to be proxim ally th ick and distally thin. One year after the revision operat ion , th e resu lt rem ain ed stable.

2

Augm ent ation Rhinoplast y Using Silicone Im plant s Fig. 2.16 Case 2: Correction of the postoperative contracted nose. (a,c) Preoperative photos show severe contraction, at dorsum with low radix, over-rotated tip, and irregular deformed tip skin with a depressed scar. (b,d) One-year postoperative photos show elevated dorsum, decreased tip rotation, and improved tip skin dimpling.

a

b

c

d

References 1. Lee MR, Unger JG, Rohrich RJ. Man agem en t of th e n asal d orsum in rh in oplast y: a system ic review of th e literat u re regard ing tech n iqu e, ou tcom es, an d com p licat ion s. Plast Recon st r Su rg 2011;128:538e–550e 2. Lam SM, Kim YK. Augm en t at ion rh in oplast y of th e Asian n ose w ith th e “bird” silicon e im plan t . An n Plast Su rg 2003;51(3):249–256 3. Peled ZM, Warren AG, Joh n ston P, Yarem ch uk MJ. Th e use of alloplast ic m aterials in rh in oplast y surger y: a m et aan alysis. Plast Recon st r Surg 2008;121(3):85e–92e 4. Ah n J, Hon rado C, Horn C. Com bin ed silicon e an d car t ilage im p lan t s: augm en t at ion rh in op last y in Asian pat ien t s. Arch Facial Plast Su rg 2004;6(2):120–123

5. McCurdy JA, Lam SM, eds. Cosm et ic Surger y of th e Asian Face. Lon don , UK: Th iem e Medical Pu blish ers; 2005 6. Jung DH, Moon HJ, Ch oi SH, Lam SM. Secon dar y rh in oplast y of th e Asian n ose: correct ion of th e con t racted n ose. Aesth et ic Plast Su rg 2004;28(1):1–7 7. Jung DH, Kim BR, Ch oi JY, Rh o YS, Park HJ, Han W W. Gross an d pathologic an alysis of long-term silicon e im plan t s in serted in to th e h um an body for augm en tat ion rh in oplast y: 221 revision cases. Plast Recon st r Surg 2007;120(7): 1997–2003 8. Jang YJ, ed. Rh in oplast y an d Septoplast y. Seou l, South Korea: Koonja Pu blish ing; 2014

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3

The Use of Costal Cartilage for Dorsal Augmentation and Tip Grafting

Victor Chung and Dean M. Toriumi

Pearls • Rhinoplast y in an East Asian patient requires

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at tention to a di erent set of aesthetic goals than for a Caucasian patient. Digital im age m orphing soft w are is very im portant to be able to com m un icate proposed changes to the patient population. Th e East Asian n ose is de cien t in st ruct u ral su p p or t . Augm en tat ion is n ecessar y to ach ieve th e desired re n em en t . A st ruct ural approach to East Asian rh in oplast y allow s th e surgeon to accom plish th e est ablish ed goals. Alth ough allop last ic im plan t s h ave been w id ely u sed in East Asian rh in op last y, autologou s costal cart ilage is being used m ore frequen tly in th e East Asian n ose as a desirable altern at ive. A th orough h istor y, in clu ding previou s su rger y, in fect ion , im plan ts, or injectable llers, is n ecessar y to elu cidate factors th at w ill in crease th e com plexit y of th e surger y. For safe an d successfu l costal cart ilage h ar vest , th e su rgeon m u st be fam iliar w ith th e an atom y of th e rib cage to select th e rib w ith th e best con tou r for th e n ecessar y graft s. Th e barrier to m astering cost al car t ilage graft ing is learn ing to ju dge w h ere to u se each poten t ial graft an d h ow to p rop erly p rep are th e grafts.

• Age is th e m ost im port an t factor to con sider w h en •

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car ving cost al car t ilage. On e of th e m ost im portan t con cepts in su ccessful costal cart ilage grafting is to car ve th e m aterial sequ en tially w ith repeated cycles of car ving, soaking, an d dr ying th e graft to iden tify its n at ural ben d. Alth ough cross-h atch ing an d sp lin t ing are u sefu l, it is im por tan t to u n derst an d th at th ese tech n iqu es can n ot overcom e th e select ion of an in appropriate piece of costal cart ilage. In th e set t ing of East Asian dorsal augm en tat ion , osteotom ies are u sually un n ecessar y. Serial car ving, perich on driu m cam ou age, an d rigid xat ion are key st rategies in p erform ing dorsal augm en tat ion . Tip augm en tat ion , accom p lish ed w ith sh ield or h orizon tal on lay grafts, creates project ion an d re n em en t; h ow ever, a st able fou n dat ion is required to con t rol length an d rot at ion . In th e East Asian n ose, w ith it s w ide air w ay an d th icker lateral sidew alls, alar bat ten an d alar rim graft s are in frequ en tly in dicated. After st ru ct u red rh in op last y w ith au tologou s cost al cart ilage augm en t at ion , tech n ically di cult base redu ct ion s m ay be required to balan ce th e n ose.

■ Introduction

■ Patient Evaluation

Aesth et ic rh in op last y of th e East Asian face requ ires a differen t app roach th an th at u sed for th e Cau casian face. Th is altern at ive ap proach is du e to di eren ces in n asal an atom y, pat ien t expectat ion s, an d surgical tech n iques. Regardless of th e approach , th e prin ciples of st ruct ure rh in oplast y rem ain th e sam e: surgical m an ipulat ion of th e n asal con st ru ct cau ses w eakn esses su scept ible to scar con t ract u re. For a long-term aesth et ic an d fun ct ion al outcom e, augm en t at ion m u st w ith st an d th e distort ing forces of t issu e h ealing.1 Su p port ing th e n ose by augm en t at ion requ ires a sign i can t am ou n t of graft ing m aterial. Au tologou s cost al cart ilage provides a boun t iful source of m aterial th at can be used to produ ce a last ing aesth et ic an d fun ct ion al result in th e East Asian face.

Th e in it ial pat ien t con sultat ion start s w ith a com plete h istor y an d physical exam in at ion to d iagn ose th e st ru ct u ral problem s th at cau se th e un desirable aesth et ic feat ures of th e pat ien t’s n ose. In addit ion , th e con sult at ion sh ou ld elucidate any h istor y of n asal obst ruct ion or com plicating h istor y: p revious su rger y, in fect ion , or foreign bodies, in cluding im plan ts an d inject able llers. Th e physical exam w ill con rm ch aracterist ic an atom ic feat u res of th e East Asian n ose, in cluding: at glabella; low n asal dorsum w ith cau dally placed n asal st ar t ing poin t; th ick, sebaceous skin overlying th e n asal t ip an d su p rat ip; w eak low er lateral car t ilages; sm all cart ilagin ou s sept u m ; foresh or ten ed n ose; ret racted colum ella; an d th icken ed, h anging alar lob u les (Fig. 3.1).2

3

a

The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting

b

c

Fig. 3.1 Native East Asian characteristics: thick skin, wide and low dorsum, retracted colum ella, underprojected and amorphous tip. (a) Frontal view; (b) lateral with midpupillary horizontal line; (c) base view.

Preoperative Evaluation Th e preoperat ive evalu at ion con t in ues w ith th e ph otodocum en tat ion of th ese an atom ic feat ures in st an dardized view s (fron tal, lateral, th ree-qu ar ter, an d base view s). Th ree-dim en sion al stereoph otogram m et r y can be perform ed at th is p oin t to p rovide a baselin e for postoperat ive com parison an d m easu rem en t s.3 Digit al im age m or p h in g soft w are p rovid es an op p ort u n it y for a fran k d iscu ssion b et w e e n t h e p at ie n t an d su rge on . Ph otograp h ic m an ip u lat ion is a t ran sp are n t m e d iu m for t h e com m u n icat ion of exp e ct at ion s, p r ior it izat ion of goals, an d id e n t i cat ion of p ote n t ial p it falls. Typ ical goals for t h e East Asian n ose in clu d e elevat ion of t h e n asal d orsu m , re n e m e n t of t h e n asal t ip , n ar row in g of t h e n asal base, an d cor re ct ion of colu m ellar ret ract ion . Fu r t h e r m ore, t h e soft w are can p rom p t su bje ct ive p refe re n ces (Weste r n ize d ve rsu s n at u ral) an d obje ct ive p aram et e rs: n asal le n gt h , d orsal h e igh t , p roje ct ion , rot at ion , w id t h , an d t ip re n e m e n t . Th rough ou t t h is exch an ge, t h e su rge on n e e d s to cou n sel t h e p at ie n t t h at t h e fron t al view is t h e rst p r ior it y. Im p rove m e n t s w ill be m ad e regard in g t h e p ro le an d b ase view s; h ow eve r, t h e fron t al view w ill n ot b e sacr i ce d for su ch im p rove m e n t s. Agree m e n t on t h e p lan n e d ou t com e is n e cessar y p r ior t o t h e op e rat ive d at e.

Preoperative Discussion and Counseling Fu rther preoperat ive coun seling sh ould in clude in cision p lacem en t (colu m ellar an d alar for base redu ct ion ), in creased st i n ess of th e n ose, ext ra operat ive t im e for cost al car t ilage h ar vest , com plicat ion s (pn eum oth orax an d w arp ing), an d postoperat ive cou rse (sw elling, follow -u p sch edu le). Th is is th e t im e to tell th e p at ien t th at to ach ieve th e goals of dorsal augm en t at ion an d t ip re n em en t in th e set t ing of th ick skin , a large am ou n t of graft ing m aterial w ill be used, essen t ially m aking th e n ose bigger. Th is is n ecessar y in East Asian rh in op last y, as th e prim ar y cases w ill often be lacking in septal car t ilage. Sim ilar to th e qualit y of th e upper an d low er lateral car t ilages, th e sept um is th in an d w eak. Accord ing to th e prin ciples of st ru ct u re rh in oplast y, destabilizing th e already w eak car t ilage by reducing th e st ru ct ural com pon en t s w ill allow scar con t ract ure to have an even m ore dram at ic an d often u n desirable e ect . Th is em ph asizes th e n eed for augm en tat ion . To address th e lack of m aterial, it is th e auth ors’ opin ion th at au tologous cost al car t ilage can provide th e best aesth et ic an d fun ct ion al result s in th e East Asian pat ien t’s n ose. Cost al cart ilage is in h eren tly st ronger an d, th erefore, can be car ved th in n er, avoiding bulk in th e n ose. Th e vascu lar dem an d is less th an for auricular cart ilage, decreasing rates of resorp -

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II Rhinoplast y t ion . Cost al car t ilage is available in greater volum e, providing all of th e n ecessar y graft s from a single don or site. As th ere is less cauter y required for h em ost asis at th e rib com p ared w ith th e ear, don or site pain is also less.4 Postoperat ive com plicat ion s seen w ith syn thet ic im plants—w oun d in fect ion , graft ext rusion , inju red skin envelop e—are rare; h ow ever, th e risk of com p licat ion s rem ain s for a lifet im e (Fig. 3.2). For th ese reason s, au tologou s costal car t ilage is ideal for th e East Asian n ose an d is th e focus of th is ch apter.

■ Surgical Techniques Th e sen ior auth or (DMT) perform s augm ent at ion rh in oplast y th rough a st an dard extern al rh in oplast y approach u n der gen eral an esth esia w ith en dot rach eal in t u bat ion in an ou t p at ien t su rgicen ter. Th e su rgeon injects th e ch est an d n ose w ith 1% lid ocain e w ith 1:100,000 ep in ep h rin e prior to prepping an d draping to allow for opt im al vasocon st rict ion . W h ile inject ing th e sept um , th e surgeon can in it iate th e elevat ion of m ucoperich on drial aps via hydrostat ic d issect ion . At th e sam e t im e, n eed le palp at ion can di eren t iate cart ilagin ous versus bony n asal sept um , for an est im at ion of available m aterial for graft ing. Th e n ose is p acked w ith cot ton pledget s soaked in 0.05%oxym et azolin e, for fu rth er vasocon st rict ion .

Opening the Nose By op en ing th e n ose rst , th e su rgeon can m ake a clear assessm en t of th e am ou n t of car t ilage graft ing m aterial requ ired to com plete th e case. A m idcolum ellar inver ted-V in cision is d em arcated w ith an t icipat ion of th e t ip project ion outcom es. If th ere is a plan n ed in crease of project ion , th e in cision is draw n sligh tly (1 m m ) posterior to th e m idcolum ella. Th e colum ellar in cision is m ade w ith a n o. 11 blade scalpel. Margin al in cision s an d colum ellar in cision exten sion s are m ade bilaterally w ith a n o. 15 blade scalpel. Using Converse scissors, th e in cision s are con n ected sh arp ly. Part icu lar at ten t ion is d irected to preser ving th e soft t issu e t riangles as w ell as m ain t ain ing an adequ ate cu of t issue separat ing th e m argin al in cision from th e alar rim , ~ 3 m m . Carelessn ess h ere can resu lt in n otch ing of th e alar m argin . Using th ree-p oin t ret ract ion , th e skin envelop e is raised sh arply. Preser ving th e subderm al plexus by m in im izing blu n t sp reading im p roves h em ostasis an d m in im izes p ostop erat ive edem a. Sh arp d issect ion con t in u es from th e low er lateral cart ilages su p eriorly to th e car t ilagin ou s dorsu m an d bony-cart ilagin ous ju n ct ion . A key poin t is to u se th e Josep h periosteal elevator in a lim ited fash ion , preser ving a t igh t pocket in an t icipat ion of a dorsal graft . A t igh t pocket w ill rest rict graft m ovem en t an d aid in rapid xat ion to p reven t w arping.5 Ad dit ion ally, as m ost Asian pat ien t s do n ot require a h um p redu ct ion , w ide subperiosteal dissect ion is n ot w arran ted.

Fig. 3.2

L-shaped silicone implant rem oved in revision surgery.

Th e n asal sept um is exposed by lateral ret ract ion of th e low er lateral car t ilages an d sh arp dissect ion to th e an terior septal angle. Bilateral m u cop erich on drial ap s are raised in the appropriate subperich on drial plan e to decrease th e risk of septal perforat ion . Again , as m ost Asian pat ien t s do n ot requ ire a h u m p redu ct ion , a su bm u cou s resect ion m ay be perform ed at th is t im e, w h ile preser ving 15-m m caudal an d dorsal st ru t s. Th e septal cart ilage h ar vest w ill p rovide a sm all volu m e of graft ing stock th at is n ot p ar t icu larly st rong bu t is at low risk for w arp ing. After decon st ru ct ing th e n asal fram ew ork, th e su rgeon su r veys th e n ose an d review s th e graft s an t icip ated to be n ecessar y to resu pp or t th e n ose, augm en t th e dorsu m , an d re ne th e n asal t ip before ch anging gloves an d t u rn ing to th e chest .

Costal Cartilage Harvest Prior to th e costal cart ilage h ar vest , th e surgeon m ust con sider several pat ien t factors, in clu ding age, breast an atom y, an d excessive scarring. Despite variabilit y in n asal an atom y, cost al car t ilage an atom y is relat ively con sisten t across differen t eth n ic backgrou n ds. Th e m ost im port an t factor is th e age of th e pat ien t .6,7,8 You nger pat ien t s are at h igh er risk for graft w arp ing. Older p at ien t s are at h igh er risk for fract u ring du ring h ar vest or graft m an ipu lat ion . Pat ien t s bet w een th e ages of 30 and 50 are gen erally at low er risk of w arping, an d fract uring can usu ally be preven ted w ith careful h an dling of th e graft s. In th e East Asian pat ien t popu lat ion , th e average volum e of breast t issu e obligates th e su rgeon to m in im ize the in cision length for th e sake of a sm aller scar th at can n ot be h idden in an in fram am m ar y crease (Fig. 3.3). With th e in creased p revalen ce of breast augm en tat ion , in cision s h idden in th e in fram am m ar y crease m ay risk pun ct ure or t raum a to the breast im plan t . Fur th erm ore, ribs directly u n der an im p lan t (t ypically rib 6) p rovide

3 a

The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting b

Fig. 3.3 Scar comparison. (a) Harvested costal cartilage and chest incision intraoperatively. (b) Right scar marked with t wo dots is the costal cartilage harvest site after 5 years. Left scar is a breast augmentation scar (arrow).

im p ort an t st ru ct ural su pp ort to th e breast im plan t . Har vest of a support ing rib m ay resu lt in u n desired asym m et ries of th e breast posit ion or discom for t from th e w eigh t of th e im p lan t lying on th e m an ipu lated rib. Hyper t roph ic scarring an d keloid form at ion sh ou ld be elu cidated from th e p at ien t’s h istor y for appropriate coun seling preoperat ively. Abn orm al ch est w all an atom y an d elevated body m ass in dex m ay also in crease th e com plexit y of th e h ar vest . W h en select ing a rib to h ar vest , on e m ust be fam iliar w ith th e relat ion sh ips of th e in dividual ribs to on e an oth er. Th e fth rib h as a free superior an d in ferior m argin ; h ow ever, it can lie u n d ern eath breast t issu e or p ectoralis m u scle. It is also relat ively sh or t an d cur ved an d m ay n ot be of adequ ate size for dorsal augm en tat ion . Th e sixth rib t yp ically h as a free su perior m argin , but th e in ferior m argin is con n ected to th e seven th rib m edially. Th e sixth rib is usually at an ideal depth , bu t it h as a sligh t gen u th at m ay n ot be ideal if a long st raigh t segm en t is n eeded (Fig. 3.4). Th e seventh rib is st raighter and w ill usually h ave con n ection s w ith th e surrounding ribs on both the superior and in ferior borders. The eighth an d greater n on oating ribs w ill h ave signi cant connect ions to surroun ding ribs an d are th in n er an d m ay n ot be of adequate w idth for a dorsal graft. Th e seven th an d eigh t ribs are located sligh tly deeper u n dern eath the skin com pared w ith th e sixth rib. As the ribs are follow ed m edially, th ey course deeper un der th e subcutaneous t issue. Ult im ately, the rib w ith the best contour for the necessar y grafts should be selected, but generally the cartilage com ponent of the seventh rib has the best contour. After th ese con siderat ion s, th e surgeon sh ould m an ually p alpate th e ch est w all arou n d th e poten t ial ribs for h ar vest . On ce orien ted, carefu l n eedle p alp at ion w ith a

3.75-cm (1.5-in ), 27-gauge n eedle localizes th e osseocart ilagin ou s jun ct ion an d determ in es the degree of ossi cat ion . Be forew arn ed: Blin d n eedle pokes m ay pu n ct ure th e pleura an d lung paren chym a, result ing in a closed ten sion pn eum oth orax. On ce th e id eal rib h as been selected an d ch aracterized, th e overlying skin is m arked an d th e surroun ding area is injected w ith 1% lidocain e w ith 1:100,000 epin eph rin e. Cost al cart ilage from th e righ t side is preferred to avoid inju r y to th e pericardium an d con fusion of postoperat ive

1 2 3 4 5 6

Incision Infram am m ary fold

Fig. 3.4

Harvest incision placement.

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II Rhinoplast y discom fort w ith angin a. Th e don or site is a separate sterile eld, an d cross-con t am in at ion w ith n asal ora sh ou ld be avoided by ch anging gloves an d using a separate set of surgical in st ru m en t s. Du e to th e sen ior au th or’s experien ce, h e is able to start w ith a 10-m m in cision th at m ay st retch to a n al length of 12 or 13 m m . Th e ch est in cision is m ade sm all to m inim ize th e visible scar an d m orbidit y to th e pat ien t . For pat ien t safet y, surgeon s sh ould con t inu e to use a larger in cision u n t il th ey are fam iliar w ith th e dissect ion .5 After a skin in cision is m ade, sh arp dissect ion con t in u es th rough th e subcu tan eous fat to th e fascia overlying th e m uscle. For h em ostasis, bip olar cau ter y is u sed to m in im ize postop erat ive p ain . A n o. 15c scalpel is u sed in th e sm all w in d ow to sh arply in cise th e m uscle fascia. Th e m u scle is blun tly spread to decrease bleeding an d postop erat ive p ain . Th e keyh ole p ersp ect ive is m ain tain ed w ith ret ractors to view th e perichon drium overlying th e rib. Th is w in dow can be t ran slated m edially an d laterally along th e course of th e rib. Recall th at th e rib’s cou rse is n ot a st raigh t lin e, bu t an obliqu e an d th ree-d im en sion al arc th at ch anges depth as it cu r ves from lateral to m ed ial. Th rough th e process of exp osing th e rib, th e bou n daries of th e rib sh ou ld be con rm ed by carefu l n eed le p alp at ion . On ce exp osed , th e an terior p erich on d riu m is in cised w ith a n o. 15c scalpel along th e lateral lim it , superior bord er, an d in ferior border of th e rib. Th e perich on drium is m obilized w ith a Freer elevator an d h ar vested sh arply. Th e rest of th e perich on driu m w ill rem ain in t act to en sure th e in tegrit y of th e h ar vest site.

Having op en ed th e n ose, th e su rgeon sh ou ld h ave in m in d th e graft s th at w ill be u sed to st ru ct u re th e n ose. Th e h ar vested costal cart ilage sh ou ld be taken in dim en sion s ap prop riate for th e plan n ed graft s. Usu ally 3 to 4 cm of costal car t ilage is h ar vested. To en su re an in t act h ar vest site an d avoid violat ion of th e pleu ra, th e rst in cision sh ou ld start by u sing th e sh arp en d of th e Freer elevator to cu t 0.5 m m from th e su perior an d in ferior m argin s of th e rib. After 50% pen et rat ion th rough th e depth of th e car t ilage, th e in cision is com pleted w ith th e blun t en d of th e Freer elevator. Th e goal is to m ain tain a p rotect ive cu of car t ilage th at gu ides th e dissect ion in to a safe p lan e above th e p osterior/ deep perich on drium an d pleura. Medial an d lateral boun daries of th e car t ilage are rst sh arply in cised w ith a n o. 15c blade th rough 10% of th e th ickn ess, follow ed by a sh arp Freer elevator th rough 70%; th e blun t Freer elevator com pletes th e n al 30%. On ce m obilized on in ferior, superior, lateral, an d m edial borders, th e un dersu rface of th e rib is freed w ith a Freer elevator u sing a lift ing m ot ion (Fig. 3.5). Follow ing th e h ar vest , th e m edial an d lateral edges of th e rem ain ing cart ilage are sm ooth ed w ith Takah ash i forceps. Th e w oun d bed sh ould be in spected for violat ion s of th e perich on drium or pleura, w ith poten t ial inju r y to th e lung paren chym a an d a result ing pn eu m oth orax. Th e w oun d bed is lled w ith salin e. A Valsalva m an euver con rm s an in t act h ar vest site, if th e salin e volu m e is con st an t an d th ere are n o bu bbles. Any defect s sh ou ld be repaired im m ediately. To repair su ch defects, th e lung is de ated an d a cath eter is placed in th e defect . A p u rse-st ring st itch sh ould be p laced arou n d th e defect an d t ied after th e cath -

b

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Fig. 3.5 Costal cartilage harvest technique. (a) Blunt dissection through muscle to the perichondrium on the anterior surface of the rib. (b) Liftingtechnique with Freer elevator to preserve the posterior perichondrium. (c) Removal of costal cartilage en bloc. (Used with permission from Toriumi DM, Pero CD. Asian rhinoplast y. Clin Plast Surg 2010;37:335–352.)

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3

The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting

eter is p laced on su ct ion , an d rem oved w h en th e lu ng h as been m axim ally reexpan ded. A repeat in spect ion an d Valsalva m an euver are w arran ted . Inju r y to th e lu ng p aren chym a m ay require a ch est t ube in sert ion . The chest harvest site rem ains open for the duration of the operation as a contingency for m ore graft m aterial or perichondrium . The site is protected w ith an antibiotic-soaked gauze sponge and blue towel. After com pleting the rhinoplast y, the surgeon again changes gloves. The rib harvest site is irrigated and inspected. Closure begins w ith 3–0 PDS suture to reapproxim ate the m uscle and its fascia. Careful attention is paid to this layer of closure to ensure the separation of m uscle and fascia from the overlying subcutaneous tissue. A suture spanning the t wo layers w ill result in tethering of the overlying tissue to the deeper fascia, inhibiting independent m otion. The subcutaneous fat is reapproxim ated w ith 4–0 PDS suture. The deep derm al layer is closed w ith 5–0 PDS suture. The subcuticular layer is closed w ith 6–0 Monocryl suture. The cutaneous layer is reapproxim ated and everted w ith 5–0 fast-absorbing gut suture. Finally, cyano acrylate adhesive is applied super cially to seal the wound. Th e sen ior auth or recom m en ds rout in e postoperat ive ch est X-ray an d a period of obser vat ion after cost al cart ilage h ar vest u n t il th e su rgeon is fam iliar w ith th e p rocedu re. For pat ien ts w ith a p ropen sit y for keloids or hyper t rop h ic scars, Ken alog (10 m g/m L) m ay be injected at th e cost al cart ilage h ar vest site. After th e skin glue falls o , silast ic sh eet ing m ay be u t ilized to h elp m in im ize th e visibilit y of an u n sigh tly scar.

Costal Cartilage Carving At th is p oin t of th e p roced u re, th e su rgeon n eeds to focu s on th e crit ical step of cart ilage car ving. Regardless of th e am ou n t of en ergy exp en ded on th e h ar vest or com p licat ion s en coun tered during th e h ar vest , th e surgeon can n ot lose con cen t rat ion . Th e barrier to m astering costal car t ilage graft ing is learn ing to ju dge w h ere to u se each p oten t ial graft an d h ow to properly prepare th e graft . Prior to any car ving, th e surgeon sh ou ld repeat th e sur vey of th e n ose an d p lan all of th e n ecessar y graft s; on e sh ou ld n ot car ve th e graft s as th ey are n eeded in th e procedure. If a large dorsal augm en tat ion is plan n ed, an appropriately th ick piece of cost al car t ilage stock n eeds to be preser ved for th e dorsal graft , start ing w ith th e rst cut in to th e cost al cart ilage. Im proper car ving, select ion , or xat ion of th e cost al cart ilage graft s could poten t ially create m ore deform it y th an th e de cien cy on e is t r ying to repair. Again , age is th e m ost im por tan t factor to con sider w h en car ving th e cost al cart ilage. Th e cart ilage w ill h ave a w h iter-ap pearing ou ter p ort ion , w h ich con t ain s a brou s com pon en t . In th e younger pat ien t , th e outer por t ion of th e rib h as an in creased ten den cy to ben d. In th e older p at ien t , th e ou ter brou s com pon en t is less pron e to fract ure, in w h ich case it is preser ved.9,10 Th e cen t ral piece m ay ben d

less th an th e periph eral slices; h ow ever, it m ay be brit tle an d pron e to fract u re in older p at ien t s. With th e prop er t ies of th e cen t ral an d outer/ brou s com pon en t in m in d, th e su rgeon m ay begin to car ve th e cost al car t ilage. On e of th e m ost im port an t con cept s in su ccessfu l costal car t ilage graft ing is to car ve th e m aterial sequen t ially. Repeat ing soaking an d dr ying cycles bet w een car vings en cou rages th e car t ilage to reveal any ten den cy to ben d in 30 to 60 m in utes. First th e h ar vested segm en t is cut in to th ree pieces along th e longest axis, creat ing an terior, cen t ral, an d posterior slices. Th ese pieces are allow ed to soak an d th en th ey are car ved in to th in n er p ieces. After allow ing th e fresh ly car ved car t ilage to sh ow it s n at ural ben d , th e key is to ut ilize th at ben d w h en select ing in dividual pieces for speci c grafts. Most graft s require som e degree of cu r vat ure for opt im al fun ct ion . Th e in h eren t st rength of cost al car t ilage allow s it to be car ved ver y th in to decrease th e bulk in th e n ose; h ow ever, a th ickn ess less th an 1 m m in creases th e risk of torqu ing. At tem pt ing to car ve th e cart ilage in to a st raigh t piece is n ot advised, as it m ay result in unpredict able w arping after xat ion . Lim ited m an ipu lat ion of th e cost al car t ilage is possible an d is part icu larly u sefu l if w arping is a con cern . Th e t w o tech n iques available to th e surgeon are cross-h atch ing an d sp lin t ing, w h ich m ay be u sed sep arately or in com bin at ion . Cross-h atch ing con sist s of part ial-th ickn ess cu ts in to th e con cave side of a cur ved piece of cart ilage to release th e bow ing forces on th e graft . Th e degree of release is di cult to predict , an d overzealous cross-h atch ing m ay result in overcorrect ion an d cur vat u re in th e opposite direct ion . Part ial-th ickn ess cu t s on th e convex side in crease th e existing cur vat ure. Splin t ing involves th e sum m at ion of cur ves. Tw o cur ved pieces are sut ured togeth er w ith opposing con cavit ies to create a single st raigh t graft (Fig. 3.6). Alth ough cross-h atch ing an d splin t ing are useful, it is im port an t to un derst an d th at th ese tech n iques can n ot overcom e th e select ion of an in ap prop riate p iece of costal cart ilage.

Management of the Bony Vault Th e im port an ce of addressing th e bony vault in th e East Asian n ose lies in set t ing th e foun dat ion for dorsal augm en t at ion . Mism an agem en t of th e bony vau lt w ill resu lt in failure to create a n at u ral-appearing dorsu m . Start ing w ith a low, w ide n asal dorsum , it seem s coun terin t uit ive to forgo n arrow ing osteotom ies. In fact , th e exist ing w ide bony dorsum w ill create a desirable pyram idal sh ape w h en a dorsal augm en t at ion graft is st acked on top of it . A bony vau lt n arrow ed by aggressive osteotom ies w ill p rovide vert ically orien ted sidew alls an d create an un n at ural t ubular sh ape w h en com bin ed w ith a dorsal augm en tat ion graft (Fig. 3.7). Addit ion ally, excessive n arrow ing of th e bony upp er th ird m ay prove to be too m uch for th e an atom ic lim it at ion s of th e n asal base, creat ing an im balan ce bet w een th e w idth s of th e ceph alic an d caudal port ion s of th e n ose.

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II Rhinoplast y Con ser vat ion of a low, w ide n asal dorsal fou n dat ion sh ould n ot preclu de th e su rgeon from m an ip u lat ing th e n asal bon es. Osteotom ies to address bony deviat ion m ay be necessar y. Excessive w idth m ay require judicious n arrow ing osteotom ies. Depressed bony segm en t s m ay n eed outfract ure. Avoiding m edial osteotom ies w ill h elp preven t excessive n arrow ing. If th ick cort ical bon e is p reven t ing back fract ure from th e lateral osteotom y sites, laterally fading m edial osteotom ies m ay be n ecessar y. Lateral osteotom ies are p erform ed in a h igh -low -h igh fash ion . Th e sen ior au th or p refers to u se a st raigh t 3-m m osteotom e to lim it soft t issu e t rau m a. An d th e su rgeon sh ou ld lim it th e force ap plied by th e dom in an t h an d w h en m an u ally adju st ing th e nasal bon e to avoid a tellt ale “th um bprin t” sign .

Management of the Middle Third

a

b

Fig. 3.6 Graft splinting technique. (a) A curved graft is matched with a sliver of cartilage with opposing curvature.The graft and sliver are sutured together with 6–0 Monocryl. (b) Final graft with multiple splints.

After set t ing th e bony vau lt at an ap prop riate w id th , th e su rgeon p roceeds cau dally to address th e m idd le th ird of th e n ose, con t in u ing a rm st ruct ural foun dat ion for dorsal graft ing. Th e m ost com m on ly u sed tech n iqu e is spreader graft ing. In th e East Asian n ose, sp reader graft s op en th e in tern al n asal valve an d aid in set t ing an d preser ving n asal length an d p roject ion . By resist ing th e ceph alic pu ll on th e t ip com plex, st rong spreader grafts preven t over-rot at ion an d n asal sh or ten ing. Th ey st rength en th e dorsu m , p reven t ing sadd ling. Th ey can be t u cked u n d er an ou tfract u red n asal bon e to p reven t postoperat ive recollap se. Sp reader graft s m ay be p laced t radit ion ally or in su b m u cosal pocket s (Fig. 3.8). By keep ing th e u p p er lateral cart ilages at t ached to th e sept um , th e surgeon does n ot n eed addit ion al t im e to recon st ruct th e m id dle n asal vault ,

Plane of illustration

a

b

Osteotomy

Fig. 3.7 Dorsal augmentation graft without osteotomies. (a) Plane of Illustration. (b) When the dorsal augmentation graft is placed on a wide base the outcome is a favorable contour with a smooth transition from graft to maxilla. Osteotomies that inappropriately narrow the base disrupt this transition, creating a vertical drop-o from the graft to the cheek. (Used with permission from Toriumi DM, Pero CD. Asian rhinoplast y. Clin Plast Surg 2010;37:335–352.)

3

a

d

The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting

b

e

w h ich requires close at ten t ion to avoid palpable an d visible d eform it ies of th e brow –t ip aesth et ic lin e. Unless addressing a saddle or weak L-strut, the spreader grafts m ay be fashioned or carved from less desirable cartilage stock. It is m ore com m on to use the central portion of the costal cartilage harvest for the spreader grafts unless the surgery is for a younger patient, w here the central com ponent m ay be better for the dorsal graft. The nasal anatom y m ay be m easured from the bony-cartilaginous junction on the dorsum to the tip -de ning point to extrapolate the appropriate graft length. Dim ensions of spreader grafts vary from patient to patient, but t ypically are 15 to 20 m m in length.. The spreader grafts are tapered at each end. The inferior edge is trim m ed to avoid obstruction of the valve. One should note any deviations requiring for sm all adjustm ents of the tip. The spreader grafts are t ypically oriented w ith opposing convexities.11 Multiple or asym m etric grafts m ay be placed to account for m iddle vault w idth or collapse. To assess, digital

c

Fig. 3.8 Submucosal spreader graft technique. (a,b) Frontal views. The Cottle elevator creates a submucosal tunnel without dissection of the middle vault. (c,d) Spreader grafts are placed in the tunnel. (e) Bilateral submucosal spreader grafts in position.

palpation is m ore im portant than visual inspection, as soft tissue swelling can be deceptive. Slight overcorrection is recom m ended on the side of the depression. Spreader grafts are secured w ith 5–0 PDS sut ure to th e dorsal septal strut. Extended spreader grafts are sut ured to the caudal septal extension graft or caudal septal replacem en t graft . Th e relat ion sh ip bet w een th e exten ded spreader grafts an d caudal septal exten sion /replacem en t graft can be adjusted to alter tip project ion , n asal length , dorsal h eigh t, an d tip rotation . Th is is carefu lly set to avoid overprojection , excess length, and a sh ort or over-rotated tip. Th e upper lateral cart ilages are sut ured to th e spreader graft s to avoid an inverted-V deform it y. Care is t aken to avoid en t rapping n asal m ucosa th at m ay blun t th e in tern al nasal valve, an d clocking sut ures m ay be placed to adjust for t ilt .12 On ce th e spreader grafts are secured to a st able m idlin e n asal base, th e dorsal augm en tat ion graft can be reliably set on top of th at st rong foun dat ion .

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II Rhinoplast y

Management of the Nasal Base At th e cau dal asp ect of th e n ose, th e n asal base is th e last com pon en t to create a stable foun dat ion for all fut ure t ip w ork an d dorsal augm en tat ion . Weakn ess at th e n asal base m ay m an ifest as collap se over t im e resu lt ing in t ip ptosis, loss of p roject ion , an d p olly-beak deform it y. Un addressed deviat ion of th e n asal base w ill result in persisten t deviat ion of th e en t ire n ose. Prior to addressing th e n asal base, it is im port an t to reexam in e th e preoperat ive p h otograph s an d assess relevan t lan dm arks: cau dal sept u m , n asal spin e, den t it ia, an d lip con tour. Th e best van tage poin t is th e h ead of th e bed, w h ere th e deviat ion s or asym m et ries w ill reveal th em selves.2 Pat ien t con siderat ion s to t ake in to accou n t in clu de th e sm ile. Ch anges in th e n asal base m ay result in upper lip st i n ess, ch ange in lip p osit ion , an d u pper lip crease form at ion . In th e East Asian n ose it is com m on to blu n t or m ove th e n asolabial angle. If th e n ose is m oved dow n , sm iles th at go u p at th e corn ers of th e m ou th w ill likely get tethered m edially an d a h orizon tal crease w ill form . Th ese poten t ial outcom es sh ould be discussed w ith th e pat ien t preoperat ively. Gen erally th e n asal base w ill be eith er m idlin e or deviated. If it is m idlin e, th e n asal base m ay on ly n eed augm en tat ion , lengthen ing, or st rength en ing. If th ere is a caudal septal de ect ion , a sw inging d oor m an euver or cau dal sep t um resect ion and a su btot al sept al recon st ruct ion m ay be requ ired. Min or caudal septal de ect ion can be add ressed w ith th e sw inging door m an euver, w h ich requires dissec-

a

b

t ion of th e sept um o of th e m axillar y spin e. On ce posit ion ed at m idlin e, th e n asal base is secured w ith t w o 4–0 PDS su t u res an ch oring th e sept u m to th e p eriosteu m . If th ere is in adequate periosteum , on e can use 16-gauge n eedles to bore in to th e n asal spin e to h old th e sut ure. Th in slivers of costal cart ilage can be u sed as sp lin t ing graft s to fu rth er st abilize th e n ew ly m idlin e st ru ct u re. If th e n asal spin e is deviated , a 5-m m osteotom e p laced at m idlin e is u sed to create a n otch in th e n asal spin e before securing th e caudal sept um w ith t w o 4–0 PDS sut ures. To su pp or t th e n asal base, t h e sen ior au th or p refers cau dal sept al exten sion graft s or cau dal sept al replacem en t graft s to p rovid e th e st rength to su p p or t a large d orsal graft w it h ou t collap sing. Th ese cau dal sept al graft s are secu red to th e n asal sept u m an d w ith exten d ed sp read er graft s, an d st abilized w ith sp lin t ing slivers of cost al cart ilage or 0.25-m m PDS plates (Fig. 3.9). In th e au t h or’s exp erien ce u se of a cau dal sept al rep lacem en t graft , an advan ced tech n iqu e, is u sed to rep lace a severely d eviated or dam aged n at ive cau dal sept u m , as less car t ilage is requ ired for a m ore p redict able resu lt . It is im p or t an t to kn ow th at th ese cau dal sept al graft s are th e on ly graft s th at n eed to be st raigh t . Sept al car t ilage h as a low likelih ood of w arp ing; h ow ever, it is t yp ically w eak in th e East Asian n ose, m aking it a p oten t ially poor ch oice of sou rce m aterial. In stead , cost al car t ilage m ay be u sed after it h as gon e th rough m u lt ip le cycles of soaking an d d r ying to determ in e it s ten den cy to w arp . Cross-h atch ing an d sp lin t ing w ith slivers of cost al car t ilage m ay be u sed to cou n teract a m in or deviat ion in th e graft .

c

Fig. 3.9 Caudal septal extension graft splinted and secured with slivers. (a) Frontal view. Caudal septal extension graft external to nose. (b) Frontal view. Caudal septal extension graft with supporting slivers. (c) Surgeon’s view. Caudal septal extension graft is secured to native caudal septum with supporting slivers.

3

The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting

Dorsal Augmentation After laying dow n a st rong fou n dat ion at th e n asal base, m iddle vau lt , an d n asal bon es, th e su rgeon is ready to in crease dorsal h eigh t w ith a dorsal graft . Th e sen ior au th or does n ot u se allop last ic m aterials an d ackn ow ledges th e ch allenges involved w ith u sing autologous cost al cart ilage. Th e com p lexit y of th is graft lies in its in abilit y to tolerate visible edges or w arping. Serial car ving, p erich on drium cam ou age, an d rigid xat ion are key st rategies to address th ose ch allenges.5 In th e sen ior au th or’s opin ion , a single p iece of costal car t ilage w orks best . Th e cen t ral core of th e h ar vested costal cart ilage is less pron e to w arping; h ow ever, as previously st ated , th e p at ien t’s age st rongly in u en ces th e ten den cy for w arping an d fract ure. It is im por tan t to serially car ve th e car t ilage w ith soaking-dr ying cycles to allow th e piece to dem on st rate it s cur vat ure. As th e cur vat ure can n ot be t ruly con t rolled, th e surgeon sh ould u t ilize th e n at ural cur ve by direct ing th e con cave side dow n an d in con t act w ith th e n at ive dorsum . With rigid xat ion , th is orien tat ion w ill lim it postoperat ive w arping. Th e convex side of th e cart ilage is car ved in to a can oe sh ape to allow sm ooth t ransit ion s from graft to n asal dorsum (Fig. 3.10). In th e East Asian face, th is can oe-sh aped graft is ideally posit ioned to m atch th e graft’s ceph alic m argin at th e pat ien t’s m idp u p il.13 Perich on driu m h ar vested w ith cost al cart ilage h as m any fu n ct ion s in th e dorsal augm en t at ion graft . Alon e it can provide 1 m m of reliable augm en tat ion . It sh ould be orien ted w ith th e previously car t ilage-exposed surface facing th e osteo-cart ilagin ou s st ru ct u res an d th e m u scleexp osed su rface facing th e skin envelop e. As soft t issu e coverage, cost al perich on drium provides a sm ooth t ran si-

t ion from th e graft to th e n asal dorsu m (Fig. 3.11). On th e un dersu rface of th e dorsal augm en tat ion graft , th e cost al perich on drium supplem en t s rigid xat ion , preven t ing graft m obilit y an d m igrat ion . From th e begin n ing of th e operat ion , th e surgeon sh ou ld be th in king abou t rigid xat ion . Lim ited dissect ion of th e dorsal skin envelope w ith th e Joseph periosteal elevator w ill yield a t igh t pocket , w h ich is a key com ponen t for rigid xat ion of th e dorsal graft . Th rough out th e process of serially car ving th e graft , it is n ecessar y to place th e graft in to th e pocket to evaluate dorsal h eigh t . Th e surgeon sh ou ld avoid excess m an ip u lat ion of th e pocket w h en t ran sferring th e graft in to an d out of th e pocket . In addit ion to a t igh t pocket , th e dorsal graft requ ires xat ion cau dally. Th ree-poin t xat ion w ith 5–0 PDS sut ure on each side of th e low er aspect of th e graft h olds th e car t ilage in place un t il scar con t ract ure t akes over.14 To en sure a rigid xat ion , th e bony dorsal surface is rough en ed by violat ing th e cort ical bon e w ith a n o. 3 osteotom e or n arrow low -pro le bon e rasp. Th e perich on driu m on th e un dersurface of th e dorsal graft can in tegrate in to th e cor t ical defect s in th e n at ive bon e, w ith form at ion of an ossi ed bon d bet w een th e dorsal graft an d th e bony dorsum . If th ere is n o t igh t pocket , d u e to excessive elevat ion , previous im plan t , or in fect ion , th e ceph alic aspect of th e graft m ay be secured w ith a tem porar y 0.45-m m th readed Kirsch n er w ire, rem oved on postoperat ive day 7.15 Th e Kirsch n er w ire is advan ced th rough a sm all stab in cision over th e u pp er asp ect of th e dorsal graft an d is engaged 3 to 4 m m in to th e bony dorsum (Fig. 3.12). If th e graft is n ot th ick en ough to engage m u lt ip le th reads of th e w ire, a t ran sn asal sut ure tech n ique ut ilizing 16-gauge n eedles to create a t u n nel th rough th e n asal bon e is em ployed. Sut u res looped th rough th e t un n el an d over th e dorsal augm en ta-

a

c

b

Fig. 3.10 Serial carving of dorsal augmentation graft. (a) Dorsal augmentation graft is carved with a no. 10 blade. (b) Canoe-shaped dorsal augmentation graft in frontal view. (c) Dorsal augmentation graft oriented with concave surface facing down in lateral view.

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II Rhinoplast y a

Perichondrium

Perichondrium

b

Rasped or perforated bone

c Fig. 3.11 Perichondrium on undersurface of dorsal augmentation graft for xation. (a) Lateral view with concave surface facing down. (b) Lateral view with superior undersurface of the graft covered in perichondrium. (c) Drawing showing the appropriate placement of perichondrium on the undersurface of the dorsal augmentation graft in contact with the nasal bone for strong graft xation. (Used with permission from Toriumi DM, Pero CD. Asian rhinoplast y. Clin Plast Surg 2010;37:335–352.)

a

d

b

c

Fig. 3.12 Kirschner wire placement. (a) Vertical incision with a no. 11 blade. (b) Placement of Kirschner wire. (c) Clipping Kirschner wire with cut ter. (d) Lateral view of Kirschner wire cut to length.

3

The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting

t ion graft en sure rm con t act for in tegrat ion an d bony xat ion (Fig. 3.13). Fin al xat ion occu rs after t ip m an ip u lat ion is com pleted to p erm an en tly set th e dorsal h eigh t in prop ort ion to th e n asal t ip posit ion .

Tip Contouring Typically, th e East Asian n ose w ill require t ip augm en t at ion an d n arrow ing to add ress th e n at ive ch aracterist ics: sm all an d w eak lateral cru ra, th ick sebaceou s skin , t ip bu lbosit y, ret racted colum ella, an d h anging alar lobules.2 Favorable t ip con tour can be ach ieved w ith au tologous costal cart ilage in th e East Asian n ose. Using 4–0 plain gut sut ure on a Keith n eedle, the m edial crura are reapproxim ated to the caudal septal extension

a

d

b

or replacem ent graft. Desirable tip projection and rotation are con rm ed before securing the m edial and interm ediate crura w ith 5–0 PDS sut ure. Tip bulbosit y due to convex lateral crura is addressed w ith lateral crural strut grafts.16 The strut grafts at ten the crura. It is rare that repositioning is needed in the Asian patient unless they have alar retraction. Due to cam ou aging thick skin , th e East Asian n ose rarely requires repositioning of the lateral crura, regardless of tip cartilage orientation. The Asian sit uation is the opposite of the hanging colum ella-tip lobule and retracted ala fam iliar in the Caucasian nose. More often East Asian noses have retracted colum ella and hanging alar lobules. Repositioning of the low er lateral cartilages is a powerful m aneuver that could exacerbate the patient’s inherent problem . How ever, if the ala is retracted or notched, lateral crural strut grafts w ith repositioning can bring it dow n.

c

Fig. 3.13 Transnasal suture placement. (a) 16-gauge needle passed through nasal bones. (b) Suture needle placed in lumen of 16-gauge needle. (c) Suture passed transnasally from left to right. (d) Suture crosses back to the left side under the skin envelope and over the dorsal augmentation graft.

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II Rhinoplast y To prepare the site for lateral crural strut grafts, the tightly adherent vestibular skin is dissected o of the undersurface of the native lateral crura. Hydrodissection w ith 1% lidocaine w ith 1:100,000 epinephrine m akes this task easier. The plane of dissection is continued laterally tow ard the piriform apert ure to create a pocket for the grafts. The carved costal cartilage sh ould be evaluated for ideal pieces 25–30 m m × 4–5 m m × 1–2 m m w ith a sligh t curve. Wom en w ill have shorter grafts than m en. After selecting ideal pieces of costal cartilage w ith the concave side facing the vestibular skin, the m edial edge is cut at 45 degrees and placed directly under the apex of the dom e. It is secured w ith 5–0 PDS sut ure, keeping all kn ots aw ay from th e vestibular skin to prevent extrusion (Fig. 3.14). Oblique dom e sutures are placed to at ten the dom es and orient the lateral crura w ith the caudal edge higher than the cephalic edge. Reposit ion ing of th e low er lateral cart ilages involves fu lly m obilizing th e lateral asp ect s of th e lateral cru ra. If th ese cart ilages are large, th e lateral-m ost aspect m ay be h ar vested for soft t issu e cam ou age. Th e lateral cru ral st ru t graft s are p erform ed as described p reviou sly, except for th e lateral pockets design ed to correct asym m et r y of th e ala: a n eu t ral or h orizon t al p ocket for th e low er alar lobu le an d a d ow nw ard-orien ted p ocket for th e ret racted alar lobu le. In rep osit ion ing, any p lan n ed cep h alic t rim is redu ced, an d

th in -sliver alar bat ten grafts m ay be n eeded to support th e valve area previou sly h eld open by ceph alically orien ted low er lateral cart ilages. Tip augm en t at ion w ith autologous cost al car t ilage creates addit ion al project ion an d re n em en t . St retch ing th e skin creates t ip d e n it ion . Th is can be accom p lish ed w ith sh ield, lateral cru ral, an d bu t t ress graft s. Th e sh ield graft provides th e project ion , but th e lateral crural an d but t ress graft s st abilize th e t ip graft , p reven t ing rot at ion cau sed by th e ceph alic pulling force of a th ick skin envelope. Adjusting th e posit ion of th e sh ield graft varies th e am ou n t of in creased project ion an d in frat ip augm en tat ion . In ad dit ion to st abilizat ion , lateral crural an d but t ress graft s beveled to m eet th e sh ield graft sm ooth th e t ran sit ion s from th e graft’s edges an d preven t graft visibilit y. Most pat ien t s th at un dergo placem en t of a sh ield graft w ith lateral crural graft s do n ot n eed any oth er w ork don e on th e lateral cru ra, as th ey are deep to th e in uen ce of th e sh ield graft . A less aggressive altern at ive is a rect angu lar, h orizon t ally orien ted t ip on lay graft secured w ith 6–0 Mon ocr yl sut ure (Fig. 3.15). Variat ion in th e size an d p lacem en t of th e graft can set th e project ion , t ip w idth , suprat ip break, an d overall re n em en t of th e t ip . With in creasing am ou n ts of t ip augm en tat ion , th e n ost ril-to-colu m ellar rat io w ill m ove from 2:1 to 1:1.

a

a

b

b

Fig. 3.14 Lateral crural strut graft technique. (a) Lateral crura dissected free. (b) Lateral crural strut grafts suture in position underneath lateral crura.

Fig. 3.15 Shield graft versus horizontal onlay graft. (a) Shield graft seen in surgeon’s view. (b) Horizontal onlay graft seen in surgeon’s view.

3

The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting

After at ten ing the lateral crura, in creasing projection, an d re n ing the tip, the surgeon replaces the dorsal graft and redrapes the skin to assess the relationship bet w een projection and the dorsal height. Once it is considered satisfactory, the dorsal graft can be secured into place for rigid xation.

Alar Batten and Alar Rim Grafts In th e East Asian n ose, w ith it s w ide air w ay an d th icker lateral sidew alls, alar bat ten an d alar rim graft s are in frequen tly in dicated, because th e lobu les rarely pin ch or collap se. Cost al car t ilage is an excellen t source m aterial sin ce it m ain tain s it s st rength even w h en car ved ver y th in . If cost al car t ilage is u sed for th ese grafts, a sm ooth t aper is n ecessar y to preven t graft visibilit y.2 Alar bat ten graft s sh ou ld be placed in p recise p ockets orien ted along th e su pra-alar crease an d sut ured in to place. Th ese bat ten grafts are appropriate for in tern al valve collapse an d if th e lateral crura h ave been reposit ion ed w ith lateral cru ral st rut graft s. Alar bat ten graft s are in dicated for add ressing lateral w all de cien cy an d p in ch ing from aggressive cep h alic t rim or oth er p reviou s surger y. Alar bat ten graft s are rarely n eeded in Asian pat ien t s, as th eir air w ay ten ds to be relat ively large. Alar rim grafts are p laced in precise pocket s along th e m argin al in cision en d ing m edially beh in d th e t ip com p lex. Th ese graft s address extern al n asal valve collapse, pin ch ing of the t ip, an d irregular t ran sit ion s from th e t ip lobule to th e alar lobule.

Closure At this point, the surgeon needs to perform a m eticulous closure of the colum ellar incision to prevent the stigm ata of the open rhinoplast y approach, a visible scar. Closure begins w ith an interrupted 6–0 Monocryl suture in the m idline. This suture aligns the soft tissue envelope and rem oves tension from the skin edge. Using a 7–0 nylon suture, seven interrupted vertical m attress sutures approxim ate and evert the inverted-V colum ellar incision. Between the nylon sutures, 6–0 fast-absorbing gut suture is placed in a sim ple interrupted fashion. The m arginal incision is closed w ith sim ple interrupted 5–0 chrom ic gut sutures, w hile observing the nostril m argin. If there is inadequate vestibular lining. this stitch can lead to notching of the nasal rim , in w hich case a com posite graft m ay be necessary. The m ucoperichondrial aps are reapproxim ated w ith a 4–0 plain gut suture on a Keith needle in a running m attress fashion, closing the septum . Radio-opaque 0.25-m m septal splin ts (Reuter bivalve septal splin ts, Medtron ic, Jacksonville, Florida) are sutured in place if turbinate or septal w ork was perform ed to prevent synechiae form ation. Lateral w all splints are used if lateral crural strut grafts w ere placed w ith reposition ing of the lateral crura. If there is any nostril asym m etry a vestibular splint can be used interm it tently. Th e senior author does not use any nasal packing. The nose is taped and an external cast is applied. Antibiotic ointm ent is applied to all incisions.

Base Reduction After closure of the nose, the nasal base w idth is assessed. As a result of structured rhinoplast y w ith autologous costal cartilage augm entation, particularly w ith lateral crural strut grafts, the East Asian nose m ay require nasal base reduction to balance the nose w ith the w idth of the new ly augm ented dorsum . This can be perform ed w ith techniques involving any com bination of internal or external excision and base-cinching sutures. Caution is warranted, as sm all errors in perform ing base reductions result in glaring deform ities. Unsightly scars at the nasal base are di cult to correct. To im prove outcom es, plan for an incision slightly adjacent to the alar-facial or alar-vestibular junction. Avoid local anesthetics as they can deform the tissue contours. Using a no. 11 blade, create a slight bevel of the incisions to prom ote eversion of the skin edge. Avoid all cautery. Meticulously close the base reduction sites w ith a deep 5–0 PDS suture, 7–0 nylon vertical m attress sutures, and 6–0 fast-absorbing gut sim ple sutures.

Glabellar Augmentation To further balance the nose, it is im portant to evaluate the East Asian face w ith lateral views. From this perspective, a de cient glabella m ay be observed. This observation m ay be m ade preoperatively and discussed w ith the patient through digital im age m orphing software. The senior author perform s glabellar augm entation by an endoscopic technique. Attention is directed at the forehead area, w here two hairline incisions are m ade, and the endoscope is dropped dow n to the glabellar region in a subperiosteal plane. A soft piece of septal cartilage covered w ith perichondrium is sutured on both sides w ith 5–0 PDS, keeping the suture tail long w ith needles attached. The graft is deposited through the scalp incision site. Then using 16-gauge needles, ports are created on the lateral aspects of the de cient glabella. The needles connected to the graft are passed through 16-gauge needles and delivered externally. Sym m etry and positioning should be noted w ith the endoscope before t ying the anchoring sutures at the skin. The scalp incisions are closed w ith 5–0 PDS and 5–0 fast-absorbing gut. The anchoring sutures are cut in 7 days. Another option is to use autologous fat augm entation of the glabella.

■ Postoperative Care All patien ts are seen on postoperative day 1. Vestibular splints m ay be rem oved. The n ose is clean ed and antibiotic oin tm ent is applied. Patients undergoing costal cartilage grafting receive oral uoroquinolone and perform uoroquinolone antibiotic nasal soaks in addition to a second-generation cephalosporin. The external cast, tape, lateral w all splints, Kirschner w ire, and colum ellar sutures are rem oved in 7 days. If base reductions w ere perform ed, these sut ures are rem oved at 10 to 14 days postoperatively. A m ild narcotic pain m edication is provided, but an early transition to acetam in ophen is encouraged. Aspirin and n onsteroidal anti-

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II Rhinoplast y in am m ator y drugs are avoided postoperatively. Despite a low level of discom fort, patients often refrain from taking deep inspirations to protect the costal cartilage donor site. Postoperatively, patien ts are en couraged to perform in cen tive spirom etr y and am bulation to avoid atelectasis.

■ Key Technical Points 1. The chest incision is m ade sm all to m inim ize the visible scar; h ow ever, a surgeon sh ou ld con tin ue to u se a larger in cision u ntil fam iliar w ith th e dissect ion. 2. By m ain t ain ing a p rotect ive cu of p erich on d riu m , th e cost al cart ilage h ar vest tech n ique sh ould en su re an in t act h ar vest site, avoiding violat ion of th e pleura. All n al cut s of th e cost al car t ilage are p erform ed w ith th e blun t en d of th e Freer elevator. A lift ing m ot ion is ut ilized to protect th e un derlying p erich on driu m an d pleura. 3. W h en open ing th e n ose, th e Joseph periosteal elevator sh ould be used in a lim ited fash ion , p reser ving a t igh t dorsal p ocket , in an t icipat ion of a d orsal augm en tat ion graft . 4. In th e set t ing of spreader grafts or splin t ing, by opposing con cavit ies, th e surgeon can ut ilize th e n at u ral cu r vat u re of th e costal cart ilage grafts. 5. By keeping th e upper lateral cart ilages at t ach ed to th e dorsum , th e surgeon can u se subm ucosal spreader grafts an d does n ot n eed addit ion al t im e to recon st ruct th e dorsu m . 6. Th e dorsal graft is secured on ly after all t ip w ork is com plete. 7. Th e dorsal augm en tat ion graft requ ires rigid xat ion to preven t w arping. Th e su perior aspect of th e graft m u st be secu red w ith a t igh t p ocket , t ran sn asal su t u re, or Kirsch n er w ire.

but stressed that she preferred a “natural look.”. In her preoperative com puter im aging we agreed on a m odest degree of dorsal augm entation that would com plem ent a m oderate increase in nasal tip projection (Fig. 3.16). We also discussed chin augm entation to com plem ent her nasal projection and other facial features. We harvested a 3.5-cm segm ent of her sixth rib through a 1.1-cm chest incision. Perichondrium was harvested from the surface of the rib as well. Th e r ib car t ilage w as car ved in to t h ree sep arate segm en t s t h at w ere exam in ed for t h e p rop er ben d in g (Fig. 3.17). Over several h ou rs a p recisely car ved cost al car t ilage d orsal graft w as fash ion ed an d obser ved for a ten d en cy to ben d . An exter n al rh in op last y ap p roach w as u sed (Fig. 3.18) an d sp ecial care w as t aken to d issect a t igh t su bp er iosteal t u n n el along t h e m id lin e of h er n asal d orsu m . Th e base of t h e n ose w as st abilized u sin g a cau dal sept al exten sion graft su t u red to t w o exten d ed sp read er graft s t h at w ere p laced in to bilateral su bm u cosal t u n n els u n d er t h e u p p er lateral car t ilages. Th e d orsal graft w as fash ion ed so t h at it h ad a sligh t con cave cu r vat u re t h at w as or ien ted again st t h e n asal dorsu m . A st r ip of p er ich on d riu m w as su t u red to t h e u n d ersu r face of t h e su p er ior p or t ion of t h e d orsal graft w it h 5–0 PDS su t u re. A n ar row n e rasp w as u sed to rough en t h e n asal d orsu m to create a p orou s bon e su r face t h at cou ld t h en in tegrate w it h t h e p er ich on d r iu m an d x t h e dorsal graft to t h e n asal bon es. Th e d orsal graft t sn uggly in to t h e su bp er iosteal t u n n el, xing t h e d orsal graft in to p osit ion . Th en a sh ield graft w as p rojected ~ 3 m m above t h e exist in g d om es an d su t u red to t h e m ed ial cr u ra. Bilateral lateral cr u ral graft s w ere su t u red to t h e p oster ior su r face of t h e sh ield graft an d t h en su t u red to t h e lateral cr u ra. To p re ven t graft visibilit y p er ich on d r iu m w as su t u red on to t h e lead ing edge of t h e sh ield graft . Th e colu m ellar in cision w as closed u sin g a 6–0 Mon acr yl su bcu t an eou s su t u re an d 7–0 ver t ical m at t ress su t u res.

8. Tip projection m ay be achieved w ith a shield graft or h orizontal onlay graft. The horizontal onlay graft is less aggressive and w ill not change the infratip lobule. 9. W h en in creasing project ion , on e m ust con t rol for rot at ion w ith a st able fou n dat ion . Septal exten sion graft s precisely con t rol th ese variables. 10. Base redu ct ion s are tech n ically di cu lt w ith th e p oten t ial for deform it y. Avoid con tour-altering local an esth et ics an d cau ter y w h ile p erform ing base redu ct ion s.

■ Case Studies Case 1 This Asian patient presented for augm entation rhinoplast y and requested to have her rib cartilage used for the augm entation. She was interested in a m odest degree of augm entation

Fig. 3.16 Preoperative computer im aging showing proposed modest change in nasal dorsal height and tip projection. Chin augmentation was recommended as well.

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The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting

a

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Fig. 3.17 (a) A 3.5-cm segment of the sixth rib was harvested through a 1.1-cm chest incision. (b) Harvested costal cartilage was carved into three separate segment s to allow selection of the best piece for the dorsal graft.

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Fig. 3.18 (a) Bilateral spreader grafts were used to stabilize the caudal septal extension graft. The extension graft was placed to control nasal tip projection and rotation. (b) Dorsal graft with slight bend with the concave side oriented inferiorly against the dorsum of the nose. Perichondrium was sutured to the undersurface of the upper margin of the dorsal graft. (c) Dorsal graft with perichondrium sutured to the undersurface of the superior end of the graft. (d) Shield graft sutured to the medial crura. The graft is projecting 3 mm above the existing domes. (e) Bilateral lateral crural grafts sutured to the posterior surface of the shield graft to prevent over-rotation of the tip graft. (f) Perichondrium sutured to the leading edge of the shield graft to minimize the likelihood of graft visibilit y.

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Fig. 3.19 (a–c,g) Preoperative photographs. Preoperative frontal view shows a lack of de nition of the upper dorsum. Lateral and oblique view show low nasal dorsum and under-projected chin. Wide nasal base is noted on basal view. (d–f,h) Postoperative (2 years) photographs. Frontal view shows a nice improvement in upper dorsal de nition with symmetric aesthetic dorsal lines. Lateral and oblique views show a modest increase in dorsal height and increased tip projection. The chin augmentation helps to balance the increase in tip projection.

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The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting

Th e pat ien t did w ell, w ith a n ice im provem en t in th e ap pearan ce of h er p ostop erat ive view (Fig. 3.19). Th e ch in im plan t balan ced th e ch anges to h er n ose an d com plem en ted h er oth er facial feat u res.

Case 2 Th is pat ien t presen ted for secon dar y rh in oplast y. Th e pat ien t w as un h appy w ith h er dorsal im plan t , w h ich occasion ally becam e in am ed. Sh e u n der w en t t w o p reviou s su rgeries an d w ish ed to h ave h er im p lan t rem oved an d replaced w ith h er ow n cart ilage. Sh e w an ted a low er radix an d im p roved t ip con tou r. We dem on st rated h er p ro le ch anges u sing com pu ter im aging (Fig. 3.20). At th e t im e of su rger y w e n oted a large Gore-Tex dorsal im p lan t . Th e im plan t h ad t w o layers in th e radix area an d w as ver y di cu lt to rem ove (Fig. 3.21). A 4.5-cm segm en t of cost al cart ilage w as h ar vested from h er righ t ch est (Fig. 3.22). Th e p at ien t u n d er w en t revision rh in oplast y (Fig. 3.23). Sh e h ad h ad a colu m ellar st ru t placed in a p revious surger y. We left th e st rut in place an d sut ured a costal cart ilage sh ield graft to th e m edial cru ra. Th e sh ield graft w as st abilized u sing a bu t t ress graft su t u red beh in d th e t ip graft . Soft t issu e an d scar w ere su t u red along th e lateral edges of th e t ip graft . A costal cart ilage dorsal graft w as design ed to set a low er radix. Perich on driu m w as sut u red to th e u n dersu rface of th e d orsal graft to aid in xat ion of th e dorsal graft . Mult iple perforat ion s w ere m ade in th e bony dorsum to allow m ore rapid in tegrat ion w ith th e perich on driu m on th e un dersu rface of th e dorsal graft . A large space w as created w ith th e dissect ion of th e Gore-Tex dorsal im p lan t . To xate th e dorsal graft a th readed Kirsch n er w ire w as placed th rough a sm all dorsal in cision , th rough th e dorsal graft an d in to th e bony dorsum . A com posite skin -cart ilage graft w as h ar vested from th e righ t cym ba con ch a. Th e com posite graft w as sut ured in to th e left m argin al in cision w h ere th ere w as a vest ibu lar skin de cien cy. Th e Kirsch n er w ire aided xat ion of th e dorsal graft to th e bony dorsum . Th e Kirsch n er w ire w as rem oved on th e seven th postoperat ive day. Th e p at ien t did w ell an d sh e w as h ap py w ith h er ou tcom e (Fig. 3.24).

Fig. 3.20

Preoperative computer imaging showing lower radix.

Fig. 3.21 Gore-Tex dorsal graft rem oved. Note the double layer of Gore-Tex over the radix region and its extension into the glabellar.

Fig. 3.22

Costal cartilage harvest from sixth rib.

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Fig. 3.23 (a) Shield graft sutured to medial crura. (b) But tress graft sutured behind leading edge of the shield graft. Soft tissue and scar placed along edges of the shield graft for additional camou age. (c) Costal cartilage dorsal graft carved. (d) Perichondrium sutured to the undersurface of the dorsal graft. (e) Kirschner wire advanced through a small incision over the nasal dorsum . (f) Composite skin-cartilage graft harvested from right cymba concha. (g) Composite graft sutured into the left marginal incision. (h) Kirschner wire in position xing the dorsal graft to the underlying bone.

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Fig. 3.24 (a–c,g) Preoperative photographs. (d–f,h) Postoperative (2 years) photographs.

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■ Conclusion

7. Balaji SM. Cost al cart ilage n asal augm en tat ion rh in oplast y: st u dy on w arping. An n Maxillofac Su rg 2013;3(1): 20–24

In th e East Asian n ose, au tologou s costal cart ilage is th e m aterial of ch oice to address th e rh in op last y su rgeon’s goals: dorsal augm en t at ion an d t ip re n em en t . Th is p referred bu t com plex m aterial is di cu lt to m aster, requiring t im e for th e surgeon to develop th e ju dgm en t to properly select , p repare, an d u t ilize th e graft s.

8. Sunw oo WS, Ch oi HG, Kim DW, Jin HR. Ch aracterist ics of rib cart ilage calci cat ion in Asian pat ien t s. JAMA Facial Plast Su rg 2014;16(2):102–106

References 1. Toriu m i DM. St ruct ure approach in rh in oplast y. Facial Plast Surg Clin North Am 2002;10(1):1–22 2. Toriu m i DM, Pero CD. Asian rhin oplast y. Clin Plast Surg 2010;37(2):335–352 3. Toriu m i DM, Dixon TK. Assessm ent of rh in oplast y tech n iques by overlay of before-an d-after 3D im ages. Facial Plast Su rg Clin North Am 2011;19(4):711–723, ix 4. An an t an arayan an P, Raja DK, Ku m ar JN, et al. Cath eterbased don or site an algesia after rib graft ing: a prosp ect ive, ran dom ized, dou ble-blin ded clin ical t rial com p aring rop ivacain e an d bu pivacain e. J Oral Maxillofac Surg 2013;71(1):29–34 5. Toriu m i DM. Discu ssion: u se of autologous cost al cart ilage in Asian rh inoplast y. Plast Recon st r Su rg 2012;130(6):1349–1350 6. Rejt arová O, Slízová D, Sm oran c P, Rejt ar P, Bukac J. Cost al cart ilages—a clue for determ in at ion of sex. Biom ed Pap Med Fac Un iv Palacky Olom ou c Czech Repu b 2004;148(2): 241–243

9. Lopez MA, Sh ah AR, West in e JG, O’Grady K, Torium i DM. An alysis of th e p hysical prop ert ies of cost al cart ilage in a porcin e m odel. Arch Facial Plast Su rg 2007;9(1): 35–39 10. Kim DW, Sh ah AR, Toriu m i DM. Con cen t ric an d eccen t ric car ved cost al cart ilage: a com parison of w arp ing. Arch Facial Plast Surg 2006;8(1):42–46 11. Ah m ed A, Im an i P, Vuyk HD. Recon st ru ct ion of sign i can t saddle n ose deform it y u sing au togen ou s cost al car t ilage graft w ith in corporated m irror im age spreader graft s. Lar yngoscop e 2010;120(3):491–494 12. Guyu ron B, Uzzo CD, Scu ll H. A pract ical classi cat ion of septon asal deviat ion an d an e ect ive guide to sept al su rger y. Plast Recon st r Surg 1999;104(7):2202–2209, discu ssion 2210–2212 13. Toriu m i DM, Sw artou t B. Asian rh in oplast y. Facial Plast Surg Clin North Am 2007;15(3):293–307, v 14. Gu n ter JP, Clark CP, Friedm an RM. In tern al st abilizat ion of autogen ous rib car t ilage graft s in rhin oplast y: a barrier to cart ilage w arping. Plast Recon st r Surg 1997;100(1): 161–169 15. Sarifakioglu N, Cigsar B, Aslan G. K-w ire: a sim ple an d safe m eth od for in tern al st abilizat ion of cost al car t ilage in Lst rut graft s. An n Plast Surg 2002;49(4):444 16. Gu n ter JP, Friedm an RM. Lateral cru ral st ru t graft: tech n ique an d clin ical applicat ion s in rh in oplast y. Plast Recon st r Su rg 1997;99(4):943–952, discussion 953–955

4

Nasal Tip Modi cation in Asians: Augmentation and Rotation Control

Hong Ryul Jin and Jong Sook Yi

Pearls • For t ip surger y in East Asian s, project ion , rot at ion , •

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an d volu m e are th e th ree m ost im p or tan t factors to con sider. Sin ce in h eren t t ip support is w eak an d th e skin is relat ively th ick in Asian s, t ip augm en t at ion is m ostly ach ieved by car t ilage graft ing rath er th an su t u re m odi cat ion tech n iqu es alon e. Pat ien t p referen ce, th e ch aracter of th e t ip, an d su rgeon exp erien ce an d preferen ce are som e of th e factors to be con sidered in ch oosing th e app rop riate ap proach for t ip su rger y. For th e t ypical Asian pat ien t , th e open approach gives bet ter an d m ore diverse opt ion s for m odifying th e t ip sh ape, w h ile th e closed approach is e ect ive in lim ited cases. A cap graft w ith or w ith ou t a colu m ellar st ru t an d in terdom al sut u re th rough th e en d on asal or open ap proach p rovides an e ect ive in crease in t ip project ion an d rot at ion .

■ Introduction Th e gen eral goal in t ip -plast y is to create a n at ural-looking n asal t ip th at is in h arm ony w ith th e n asal dorsu m an d in balan ce overall w ith th e facial feat u res. Th is basic ph ilosophy applies n ot on ly to Asian s but also to pat ien t s from oth er eth n ic backgrou n ds. Su ch h arm ony can on ly be ach ieved w ith a su cien t u n derst an ding of th e p er vad ing cult ural environ m en t an d w ith con t in uous exposure an d dedicat ion to th e speci c eth n ic pat ien t . It is m an dator y, th erefore, th at each operat ion be h igh ly in dividu alized according to th e eth n ic backgrou n d. For t ip su rger y in Asian s, project ion , rot at ion , an d volu m e are th e t h ree m ost im p or t an t factors to con sid er. A h arm on iou sly m atch ed p roject ion of th e n asal t ip adju sted to th e augm en ted dorsu m , w ith a gen t le rou n d sh ape in stead of a w ell-de n ed, angu lated t ip , along w ith su bt le accen t u at ion are th e id eals th at con tem p orar y Asian n asal t ip su rger y asp ires to ach ieve.1 On e im por t an t poin t th at sh ou ld be kept in m in d is th at m any Asian p at ien t s requ est

• Th e sept al exten sion graft is a w orkh orse u sed to

•

•

• •

m odify th e t ip sh ap e, an d it sh ou ld be su p ported by a st rong cau dal sept u m or rein forced w ith bat ten or exten ded sp reader grafts. W h en design ing th e sept al exten sion graft , project ion an d rot at ion are m odi ed by carefu lly design ing th e sh ape of th e graft con sidering th e posit ion of th e n ew dom e. Ap p lying bon e as a septal exten sion graft or overly aggressive applicat ion of th e sept al exten sion graft sh ou ld be avoid ed to p reven t pain , h ard n ess, an d discom for t at th e t ip. Even for relat ively th ick skin at th e n asal t ip, t ip graft s n eed to be carefu lly beveled an d car ved to keep from sh ow ing u p in th e long term . To com plem en t m odi cat ion of th e t ip sh ape, ceph alic resect ion , th e sh ield graft , th e prem axillar y graft , th e lateral cru ral graft , an d th e alar rim graft are also u sed.

an in crease in t ip p roject ion w it h avoidan ce of excessive in creased t ip rot at ion . Th e am ou n t of p roject ion an d rot at ion n ecessar y for a case d i er according to p erson al preferen ce, age, sex, occu p at ion , an d overall facial feat u res. In gen eral, m ost p at ien t s requ ire an d u n dergo dorsal augm en t at ion , so t h e am ou n t of t ip p roject ion sh ou ld be balan ced accordingly. Nasal t ip w idth sh ou ld alw ays be evalu ated in th e con text of overall facial an atom y an d n ot as an isolated feat u re. If t h e face is relat ively w id e, a n arrow t ip can ap p ear con sp icu ou s an d d em on st rate an operated-on look. To obt ain a m ore aesth et ically pleasing n asal t ip in Asian s, several procedures are em ployed. Com m on ly ap plied p rocedu res are cart ilage graft ing tech n iqu es, in cluding variou s t ip on lay graft s an d sept al exten sion graft s. Th eoret ically, th ey m ay su ce w h en u sed in divid ually, bu t in pract ice a com bin at ion of th e variou s tech n iqu es is n ecessar y to ach ieve th e desired goal. Sin ce in h eren t t ip su p p or t is w eak an d th e skin is relat ively th ick in Asian s, t ip augm en tat ion is rarely ach ieved by su t u re tech n iqu es alon e an d is reser ved for a select grou p of p at ien ts.2

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■ Patient Evaluation Cu rren t t ip sh ap e an d sup por t n eed to be carefully obser ved an d an alyzed w h en p lan n ing for t ip su rger y. A dep en den t , caudally rot ated, less projected t ip w ith good cart ilagin ous su p p or t is relat ively easy to t reat . Th e m ost di cu lt case is a t ip th at is already sligh tly u pt u rn ed, is poorly p rojected , an d h as ver y w eak low er lateral car t ilages an d a de cien t sept u m (Fig. 4.1). Care sh ou ld be t aken in th is case becau se t r ying to in crease th e project ion of th e t ip w ith out proper m an euvers w ill in crease th e cep h alic rotat ion an d create a sh ort-looking n asal t ip . Tip suppor t is evaluated by palpat ing th e t ip, th e cau dal sept um , an d th e skin because th ese st ruct ures are m ost im p ort an t in deciding th e t ip sh ap e. A n asal t ip suppor ted by large low er lateral car t ilages an d a st rong sept um is relat ively easy to con t rol. How ever, m any Asian pat ien t s h ave th e w orst com bin at ion , rudim en t ar y t ip cart ilages an d a ret ruded an d de cien t caudal sept um w ith th ick skin . Th e pat ien t’s w ish es an d expectat ion s are discussed. Con tour of th e t ip sh ape is lim ited by m any factors. Skin an d car t ilage are m ost im port an t . Th e p at ien t’s w ish es sh ou ld be th orough ly ad dressed becau se th ere can be m isu n derst an ding during discussions. A ver y sen sit ive pat ien t m ay com p lain of ver y su btle di eren ces in th e n ost ril sh ap e as seen from below. Preop erat ive ph otos sh ou ld alw ays be taken an d an alyzed before surger y. In creasing th e t ip project ion m ay exaggerate pre-exist ing sligh t discrepan cies of th e rim h eigh t or colum ellar slan t ing. Pat ien t preferen ce, th e ch aracter of th e t ip, an d surgeon exp erien ce an d p referen ce are som e of th e factors th at are to be con sidered in ch oosing th e app rop riate app roach for t ip surger y. Many pat ien ts st rongly dem an d an en don asal ap proach to avoid a colu m ellar scar from an op en app roach .

a

In su ch cases, advan t ages an d lim itat ion s of th e en don asal ap proach sh ou ld be brough t for w ard du ring th e con su ltat ion an d th orough ly discu ssed. Regarding th e ch aracter of th e t ip, t w o factors sh ou ld be con sidered in deciding th e righ t approach . Th e rst is t ip support . W h en th e size an d st rength of th e low er lateral car t ilages are adequ ate, an en don asal app roach can be a good choice. W h en th e car t ilages are w eak an d sup port is m in im al, h ow ever, en don asal t ip -plast y tech n iques becom e in e ect ive.3 Th e secon d factor is th e st at us of t ip project ion an d rotation . In sert ing a colum ellar st rut , con verging th e low er lateral cart ilages, an d p lacing a cap graft w ill project th e t ip togeth er w ith sligh t ceph alic rot at ion . Th is in crease in rot at ion m ay create an excessively overrot ated appearan ce in pat ien t s w h o already h ave a borderlin e sh ort n ose. A sept al exten sion graft via an extern al ap proach is m ore app rop riate for th ese p at ien t s. Th e best in dicat ion , th erefore, for th e en don asal approach is w h en th e t ip is sligh tly droopy w ith low er lateral car t ilages th at are large an d st rong. It is also best u sed in p at ien ts w h o do n ot h ave th ick skin an d severe deform it ies or asym m et r y of th e t ip car t ilage.

■ Surgical Techniques Augmenting Tip Projection via the Endonasal Approach Cap Graft via the Endonasal Approach Th e site w h ere th e graft w ill be placed is m arked on th e t ip skin . After th e h ar vest of cart ilage from th e n asal sept u m or th e cym ba con ch a, t w o to th ree pieces are overlapped an d

b

Fig. 4.1 Evaluation of tip shape and support. (a) In this hump nose patient, the tip is slightly caudally rotated and projection is less than optimal, but the cartilaginous support is strong. This t ype of tip shape is relatively easy to change favorably either by the endonasal or open approach. (b) A slightly cephalic rotated tip with poor tip projection and weak support. This tip tends to rotate m ore cephalically if projection is increased without speci c measures to prevent cephalic rotation.

4 Nasal  Tip  Modi cation  in  Asians:  Augm ent ation  and  Rot ation  Control  49 su t u red, taking in to con siderat ion th e degree of augm en tat ion n eeded an d th e exist ing t ip size. Th e size of th e graft is design ed so th at it does n ot exceed th e usu al in terdom al dist an ce, w h ich is 6 to 8 m m , an d th e m argin s are carefully t rim m ed. On e or t w o kn ot s are m ade, an d th e th readed n eedles are left u n cut . Th e m argin s of th e graft are t rim m ed to m ake a sm ooth er t ran sit ion w ith th e su rrou n ding t issu e or are m orselized using Brow n -Adson forceps. Failu re to do th is m ay lead to graft visu alizat ion . Using an in fradom al m argin al in cision , th e in sert ion p ocket is m ade sligh tly larger th an th e graft (Fig. 4.2). Th e n eedles of a 5–0 PDS su t u re are in t rodu ced th rough th e in cision site, com ing ou t th rough th e previously m arked dot s on th e t ip. By pulling on th e su t ure, th e graft can be placed at th e cen ter of th e pocket (Fig. 4.3). Th e in cision site is closed w h ile gen tle t ract ion is m ain tain ed on th e sut ure. Th e pulled-out sut u re is xed w ith tape to th e skin an d rem oved after a w eek.

Utilizing Columellar Strut, Interdomal Suture, and Onlay Graft via the Endonasal Approach Cartilage h ar vested from th e n asal sept u m or th e ear is designed according to the plann ed procedure (e.g., cap graft , sh ield graft, or colum ellar st rut). Th e in cision can be m odied based on th e size an d th e n at ure of th e in ten ded graft , but bilateral infradom al m arginal incisions extending to the lateral colum ella are usually em ployed to expose and dissect both low er lateral cartilage dom es an d the m edial crura. An int radom al sut ure is done at the low er lateral cart ilage to produce a slight in crease in projection. This sut ure begins from th e upper part of th e m edial crus m edially, passing through th e interm ediate crus to exit at the lateral crus. Th e su t u re is th en don e in reverse, from th e lateral to th e m edial cru s an d th e kn ot th row n m edial to th e m edial cru s. Care sh ou ld be t aken to m ain tain sym m et r y of th e dom es an d to avoid excessive m edializat ion of th e lateral crura or lateral crural steal. If th is h ap pen s, com plicat ion s such as deform it y of th e low er lateral car t ilage or an overly n arrow ed m edial an d lateral cru ral angle can occur. To rein force t ip support , a pocket is m ade bet w een th e m edial crura, follow ed by in sert ion of th e colum ellar st ru t (Fig. 4.4). Th e colu m ellar st ru t , h ar vested from th e n asal sept u m , sh ou ld be st raigh t w ith adequ ate length an d st rength . An in terdom al su t u re, in corp orat ing th e colu m ellar st rut by p assing th e n eedle from side to side, is don e (Fig. 4.5). Altern at ively, both dom es are p u lled ou t to on e side of th e n ost ril an d su t u red as n ecessar y. Th e excess p ort ion of th e colum ellar st rut th at project s over th e dom e is t rim m ed. An on lay cap graft is placed above the dom e as described previously, if n ecessar y. Th e dom e is relocated to it s n at u ral posit ion , th e t ip is p osit ion ed, an d th e d orsal h eigh t is cross-ch ecked from th e lateral an d basal view s.

Fig. 4.2 Cap graft through the endonasal approach. Using an infradomal marginal incision, the graft insertion pocket is made slightly larger than the graft.

Fig. 4.3 A double layer of conchal cartilage is sutured with 5–0 PDS and the needle is introduced through the incision, coming out through the previously marked center of the graft on the skin. The needle is pulled gently until the graft is placed at the center of the pocket.

Tip Projection and Rotation Control Using the Septal Extension Graft Concept Th e septal exten sion graft is th e w orkh orse for t ip -plast y in th e Asian n ose. By providing a rm foun dat ion upon w h ich th e low er lateral cart ilages can be reposit ion ed, t ip project ion an d rot at ion are e ect ively con t rolled. By ch anging it s sh ape an d locat ion , th e graft can be e cien tly u sed to augm en t , rot ate or de-rotate, or length en th e n ose, or to correct th e n asolabial angle.4

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Fig. 4.4 Colum ellar strut and interdomal suture through endonasal approach for tip augmentation. After bilateral infradomal marginal incisions extending to the lateral side of the columella, both domes and medial crura are exposed. A columella strut is inserted after making a pocket bet ween the medial crura. Both domes and the strut are sutured together for stabilit y.

Fig. 4.5 When performing this maneuver, start from the medial crus going to the lateral crus, and then from the lateral crus moving to the medial crus. Care should be taken to maintain symmetry of the domes and to avoid excessive medialization of the lateral crus.

A septal exten sion graft is design ed w ith th e degree of t ip project ion an d rot at ion t aken in to con siderat ion . Low er lateral car t ilages are reposit ion ed an d su t u red to th e n ew ly form ed cau dal sept u m , resu lt ing in im m ediate t ip elevat ion an d rot at ion . Th is tech n iqu e is u sefu l in sh ort n ose cases or to in crease t ip project ion in pat ien t s w h o lack t ip suppor t , sin ce st rong su p port of th e t ip can be ach ieved. How ever, it w ou ld be p ru den t n ot to overu se th e septal exten sion graft w h en oth er m eth ods of in creasing t ip project ion are available (e.g., colu m ellar st ru t or cart ilage t ip graft), becau se th e sept al exten sion graft involves a m ore invasive proced u re requ iring m ore t issu e dissect ion com p ared w ith oth er m eth ods. On e draw back is decreased t ip elast icit y resu lting in a st i n asal t ip, w h ich , h ow ever, ten ds to im prove over t im e. An oth er d raw back is th at th e exten sion graft can ben d w h en excessive ten sion is applied.5 Th is usually h ap p en s w h en th e cau dal sept um is w eak or th e reposit ion ed low er lateral car t ilage an d th e drap ing skin an d soft t issu e exert too m u ch ten sion on th e n ew t ip . Th e su rgeon sh ou ld be con scien t ious in in form ing th e pat ient of all th ese possibilit ies preoperat ively.

xed to a port ion of th e cau dal sept u m . Th is is u sed in cases w h ere on ly a m oderate am oun t of project ion is requ ired an d w h ere th e septal cart ilage is relat ively th ick an d st rong. In any t ype, th e graft can be rein forced u sing septal car t ilage or bon e to preven t possible ben ding or buckling by th e ten sion placed on th e graft . An en d-to-en d septal exten sion graft rein forced by exten ded sp reader graft s h as dist in ct advan t age com p ared w ith th e overlapping t ype: It avoids th icken ing or buckling of th e caudal sept um an d th us rarely causes n asal obst ruct ion .

Types of Septal Extension Grafts Tw o di eren t t ypes of sept al exten sion graft s exist: th e overlap p ing t ype an d th e en d-to-en d t ype. Th e overlapp ing sept al exten sion graft can be divided in to variou s t ypes depen ding on th e car t ilage st rength an d in tegrit y of th e caudal sept um , am oun t of available cart ilage, an d desired t ip sh ape. A com m on t ype is a sept al exten sion graft overlapp ing th e en t ire cau dal sept um an d exten ding to th e an terior n asal sp in e. Du e to its in creased st abilit y it can be used in m ajor t ip augm en tat ion . It can be placed an d

The Septal Extension Graft Technique 1. For e ect ive execut ion , m ost sept al exten sion graft ing is perform ed via th e open approach . A large, at piece of cart ilage is t ypically h ar vested from th e posterior n asal sept um . Th e sept al exten sion graft is design ed con sidering th e n al sh ape an d stabilit y of th e t ip . For exam p le, to correct colu m ellar ret ract ion , th e por t ion of th e sept al exten sion graft correspon ding to th e colum ella is design ed to prot rude past th e sept u m , an d th e m edial crura of th e low er lateral car t ilage are su t u red in a tongue-in groove fash ion to th e n ew cau dal sept um created by th e graft . 2. W h en th e in h eren t septal support is st rong, a sept al exten sion graft can be ap plied as an overlap p ing t yp e to th e cau dal sept u m (Fig. 4.6). Avoiding an overly th ick cau dal sept u m by carefu l car ving is im p ort an t for a w ell-breath ing n ose. A sligh tly cur ved graft can be used in an e ort to place th e en d of th e graft in th e m idlin e.

4 Nasal  Tip  Modi cation  in  Asians:  Augm ent ation  and  Rot ation  Control  51

Fig. 4.6 An overlapping t ype of septal extension graft depending solely on the caudal septum for support.

3. After un ilateral dissect ion , un less in dicated oth er w ise, con t ralateral dissect ion is m in im ized on ly to th e exten t w h ere th e sept al exten sion graft can be secu rely su t u red to th e cau dal sept u m (Fig. 4.7). 4. W h en th e cau dal sept um is w eak, rein forcem en t is ach ieved in t w o w ays: First , th e posterior septal angle of th e cau dal sept u m is su t u re- xed to th e an terior n asal sp in e. Secon d, th e septal exten sion graft is supported using a spreader graft or bat ten graft . Using th in bon e for bat ten ing pu rposes is n e, bu t u sing it as a sept al exten sion graft is n ot advisable. If th e h ar vested car t ilage is big en ough , rein forcem en t an d exten sion can be ach ieved sim u lt an eou sly by design ing th e graft as a bat ten graft prot ruding from th e cau dal sept um . 5. In th e en d-to-en d st yle, th e sept al exten sion graft is st abilized at t w o or th ree poin t s: Th e posterior sept al angle is st abilized to th e an terior n asal spin e, u sing gu re-of-8 sut u res x th e sept al exten sion graft to th e en d of th e caudal sept um , an d th e septal exten sion graft is stabilized w ith a u n ilateral or bilateral exten ded spreader graft (Fig. 4.8).6,7 6. Th e low er lateral cart ilage can be reposit ion ed by su t u ring it to th e sept al exten sion graft u sing 5–0 PDS or 6–0 clear nylon to create th e n ew dom e (Fig. 4.9). Addit ion al su t u res bet w een th e low er lateral car t ilage an d th e sept al exten sion graft are p erform ed to st rength en th e xat ion . Fu r th er

Fig. 4.7 An overlapping graft is xed on the left side of the caudal septum. 5–0 or 4–0 PDS is used to securely x the graft onto the caudal septum. Note that the septal mucosal dissection is done entirely on the left side, but partially on the right side, just enough to secure the extension graft.

rein forcem en t can be obt ain ed by t ran s xion su t u ring of th e m em bran ou s sept u m to th e sept al exten sion graft u sing 4–0 p lain gu t . If in dicated, a cap graft or sh ield graft can be perform ed on th e n ew ly created dom e, to obt ain furth er re n em en t in t ip sh ape (Fig. 4.10).

Other Useful Techniques to Modify Tip Shape Shield Graft A sh ield graft p laced at th e an tero-in ferior part of th e n asal t ip (above th e m edial crus) can in crease t ip project ion as w ell as en h an ce de n it ion of th e su p rat ip an d in frat ip breaks. Sept al car t ilage is com m on ly used, w ith rib cart ilage used on occasion . Th e w idth of th e upper part of th e sh ield graft is d esign ed to be 6 to 8 m m in size, sim u lating th e t ip de n ing poin ts. Th e m argin s of th e graft are t rim m ed. At least four st itch es to th e m edial crus are m ade to m ain t ain stabilit y (Fig. 4.11). In th is case a bu t t ress graft sh ou ld be placed posterior to th e sh ield graft to preven t t ilt ing of th e graft an d un in ten ded ceph alic rotat ion .8

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b

a

Fig. 4.8 (a,b) An end-to-end t ype of septal extension graft is reinforced with a bilateral extended spreader graft. In both t ypes, the graft shape is decided considering the amount of projection and rotation.

Fig. 4.9 Tip modi cation using a septal extension graft. Lower lateral cartilages are moved and xed to a new dome created by the septal extension graft.

Cephalic Resection of Low er Lateral Cartilage Lateral Crus W h en th e t ip looks too roun d or boxy du e to a w iden ed in terdom al dist an ce of large low er lateral car t ilages (boxy n asal t ip , bulbou s t ip), cep h alic resect ion of th e lateral crus an d convergen ce of th e in term ediate cru s can redu ce th e volu m e an d n arrow th e t ip . Th is m an euver also resu lts in sligh t cep h alic rotat ion of th e t ip du e to secon dar y scar con t ract ion . In pat ien t s w h o h ave relat ively th ick skin , th is

Fig. 4.10 An additional onlay graft with conchal cartilage is used for more projection or de nition.

m an euver does n ot cau se a dram at ic decrease in t ip volu m e, w h ile in th in -skin n ed pat ien ts it can be an e ect ive tech n iqu e. Th is procedu re can be don e eith er en don asally or w ith th e open approach . Th e resect ion sh ould leave at least 7 to 8 m m of th e low er lateral car t ilages equally on both sides.9,10 Care m u st be t aken n ot to resect th e in term ediate cru ra that form the t ip de n ing poin t s. Using a n o. 15 blade, a par t ial-th ickn ess in cision is m ade to preven t injur y to th e u n derlying m u cosa of th e low er lateral car t ilage. Th e car t ilage is then dissected from th e m ucosa using iris scis-

4 Nasal  Tip  Modi cation  in  Asians:  Augm ent ation  and  Rot ation  Control  53

Fig. 4.12 Cephalic resection to reduce tip volume. At least 7 to 8 mm of lateral crura should be preserved, maintaining symmetry on both sides.

Fig. 4.11 Shield graft (arrow) via the open approach. The shield graft is placed and secured to at least four sites using 5–0 PDS or 6–0 clear nylon. The edges are beveled and a but tress graft is added for more stabilit y if necessary.

sors (Fig. 4.12). Im m ediately after th e procedu re, th e t ip becom es n arrow er. With t im e, secon dar y scarring takes p lace, m aking th e t ip even n arrow er.

Lateral Crural Graft Lateral cru ral graft s preven t collap se of th e low er lateral cart ilages an d create a sm ooth er alar–t ip con tou r. Th ere are t w o t ypes of lateral crural graft s: lateral crural on lay graft s an d lateral cru ral st ru t grafts. Lat e ral cr u ral on lay graft s are u se d to restore t h e lat e ral cr u s w h e n it h as be e n d am age d or d efor m e d , an d to re in force t h e alar car t ilage w h e n t h e t ip is au gm e n t e d .1 1 W h e n t h e low e r lat e ral car t ilage is seve rely dam age d w it h loss of t ip su p p or t , n asal t ip su p p or t is rst restore d at t h e in t e r m e d iat e an d m e d ial cr u ra t h rou gh t h e u se of a se pt al ext e n sion graft or colu m ellar st r u t . A graft d esign e d to m at ch t h e lat e ral cr u ral sh ap e is t h e n p lace d on t h e late ral cr u s (Fig. 4 .1 3). Usin g 5 – 0 ch rom ic gu t , t h e car t ilage graft an d t h e vest ibu lar skin are su t u re d u sin g t h rough -an d -t h rough su t u res. Sym m et r ical graft s an d su t u r in g are im p or t an t to avoid p ostop e rat ive asym m e t r y of t h e n asal ala . Cap or sh ield graft in g can be p e rfor m e d sim u lt an e ou sly, as n e e d e d .

Fig. 4.13 Lateral crural onlay graft. Septal or rib cartilage is designed to match the shape of the lateral crus and is grafted onto both lateral crura as a lateral crural onlay graft.

Lateral cru ral st ru t graft s are com m on ly u sed to correct th e sh ape of or to reposit ion th e lateral crus (Fig. 4.14).12 W h en th e lateral crura are too con cave or too convex, th e t ip sh ape m ay app ear u n n at u ral. A st raigh t p iece of car t ilage is placed ben eath th e lateral crus to at ten or st raigh ten it ou t an d m ake for a m ore n at u ral t ran sit ion bet w een th e lateral an d in term ediate cru ra.12 After dissect ing th e vest ibular skin ben eath th e lateral cru s, a st raigh t p iece of car t ilage design ed from th e sept al cart ilage is in serted. Th e cart ilage graft an d th e vest ibu lar skin are th en th rough -an d-th rough su t u red u sing 5–0 ch rom ic gu t . More su t u res are add ed to x th e graft if n ecessar y. Th rough th is p rocedu re th e lateral crura can be at ten ed.

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c

a

b

d

Fig. 4.14 Correction of alar-columellar disproportion. (a) Preoperative photo shows de cient nasal dorsum, hanging columella, and slightly retracted alar rim . (b) Six months after surgery, the dorsum is well augmented and the ala and colum ella show a norm al relationship. (c) After degloving, the lower lateral cartilage is round in shape due to lack of angulation bet ween the medial and lateral crura. (d) A at piece designed from the septal cartilage is inserted in the dissected plane bet ween the lateral crus and vestibular skin. The intermediate crura are xed to the septal extension graft. The resulting change in the shape and angle formed by the intermediate and medial crura can be appreciated.

In cases w here th e lateral crura are posit ioned along the longit udinal axis of the nose (“m alposit ion ed”), the t ip can look like a ball, cont ributing to an unnat ural look. The appearan ce of th e t ip can be im proved by ch anging th e lateral crura from a vertically orien ted position to a m ore h orizontally oriented one. After the lateral crura are com pletely dissected o from the vestibular skin, a long st rut graft can be applied, extending past th e lateral crura. The lateral crus is then rotated caudally and xed tow ard the piriform apert ure after dissection of th e soft t issue in th at area. Th is lateral crural repositioning m aneuver is w ell described an d used in Caucasian s, but it is not so e ective in Asians, w ho h ave relatively thick skin an d subcutan eous tissue.

Premaxillary Graft In Asian s th e p rem axillar y area is com m on ly u n derdevelop ed, resu lt ing in ret ru sion of th e su bn asale, an acu te n asolabial angle, an d colum ellar ret ract ion . Autologous (cart ilage, bon e) or art i cial (Gore-Tex, silicon e, Mersilen e) graft s can be in ser ted n ear th e an terior n asal spin e or p rem a xilla, to im prove colu m ella ret ract ion an d to ach ieve a n at u ral elevat ion an d rot at ion of th e n asal base.11,13 Au tologou s or syn th et ic grafts are in serted an terior to th e m axilla an d just in ferior to th e an terior n asal spin e. A fair am ou n t of m aterial is u su ally n eeded, m aking syn th et-

ics th at can be sh aped easily, such as Gore-Tex or Mersilen e m esh , m ore com m on ly em p loyed . Rib car t ilage can p rovide su cien t au tologou s graft ing m aterial. Th e p rem axillar y area can be app roach ed after dissect ing bet w een th e m edial cru ra or th rough sublabial in cision . A pocket sligh tly larger th an th e graft is m ade, follow ed by in ser t ion of th e graft m aterial. Aggregates of sm all cart ilages can be p lu m p ed in th e pocket , or a large piece of cart ilage is in serted an d xed to th e su rrou n d ing t issu e or an terior n asal sp in e to p reven t slip ping d ow n or m igrat ion . It is im p or tan t to design th e graft to t th e cur vat ure an d sh ape of th e prem axilla. Diced car t ilage w rap ped w ith au tologou s fascia is an oth er good opt ion . In case of an u n derdeveloped prem axilla w ith poor t ip project ion , a prem axillar y graft in tegrated in to an exten ded colu m ellar st ru t can be u sed.

Alar Rim Graft Alar rim graft ing is a p rocedu re in w h ich a th in p iece of cart ilage graft is placed along th e alar rim st ar t ing from th e n asal facet (soft t issue t riangle), to obtain a sm ooth t ran sit ion from th e t ip lobu le to th e alar lobu le. It rein forces th e alar m argin an d low ers th e alar rim sligh tly w h en alar ret ract ion is presen t .14,15,16 In an open approach , soft t issue d issect ion along th e alar rim is started, begin n ing from th e n asal facet u sing sh arp iris scissors. Dissect ion is p erform ed

4 Nasal  Tip  Modi cation  in  Asians:  Augm ent ation  and  Rot ation  Control  55 close to th e alar rim m argin , t aking care n ot to m ake th e p ocket too big. A th in , at p iece 2 to 3 m m in w idth an d 12 to 15 m m in length is design ed from th e h ar vested sept al cart ilage.16 Th e graft is in ser ted in to th e pocket an d th e in let is su t u red after bru ising th e t ip w ith Brow n -Adson forceps.

■ Key Technical Points 1. An on lay cap graft th rough th e en don asal approach is best ach ieved by adequate pocket dissect ion , careful graft car ving, an d exact posit ion ing th rough gu idan ce su t u re. 2. A com bin at ion of in terdom al sut ure, colum ellar st ru t , an d on lay t ip graft s th rough th e en don asal ap proach gives a m in or to m oderate t ip augm en t at ion w ith gen tle cep h alic rotat ion . 3. A sept al exten sion graft is design ed w ith con siderat ion of th e vector n eeded to augm en t or rot ate th e t ip . 4. Th e overlapping t ype of sept al exten sion graft is cen tered in th e m idlin e by carefu l car ving an d p osit ion ing of th e graft to avoid t ip deviat ion . 5. Th e en d-to-en d t ype of sept al exten sion graft is p u t bet w een th e m edial crura an d align ed w ith th e caudal sept um in en d-to-en d fash ion w ith gu re-of-8 su t u res. It is fu r th er rein forced w ith exten ded sp reader graft s or th in bat ten graft s. 6.

Various tip m odifying techniques including shield grafts, cephalic resection, lateral crural grafts, prem axillary grafts, and alar rim grafts, are properly m ixed w ith septal extension grafts to further m odify the tip.

■ Complications and Their Management

Loss of Projection Th e in creased project ion ach ieved w ith a colum ellar st rut w ith on lay t ip grafts m ay lessen as t im e goes by. Decreased sw elling w ith t im e an d graft absorpt ion m ay p lay a role in p roject ion loss. To preven t th is, a sept al exten sion graft su p p or ted at th e an terior n asal sp in e is u sed.

Over-rotation Over-rotat ion is a com m on com p licat ion in w h ich th e p roject ion is overly in creased w ith ou t con sidering th e vector of t ip rotat ion . With ou t appropriate preven t ive m easures, in creased project ion using variou s t ip graft s an d st rut s w ill even t ually rot ate th e t ip in th e ceph alic direct ion . Th is com plicat ion can be preven ted by appropriately design ing

th e septal exten sion graft con sidering th e rot at ion an d project ion of th e t ip.

Tip Asymmetry or Deviation Tip asym m et r y or deviat ion is com m on w h en th e n at u ral sh ape of th e t ip is m odi ed. Exact p osit ion ing of th e caudal sept um or septal exten sion graft in th e m idlin e is a key elem en t to preven t th is com plicat ion . In addit ion , t ip on lay graft s n eed exact an d sym m et ric p osit ion ing an d su t u ring. In m any cases, a ver y m ild asym m et r y of th in , sm all low er lateral cart ilage is easily cam ou aged by th ick n asal skin . How ever, ever y e ort n eeds to be exerted in graft car ving an d p osit ion ing to avoid asym m et r y or t ilt ing.

Graft Show ing Graft sh ow ing is n ot in frequ en tly seen in th in -skin n ed pat ien t s. Carefu l car ving an d avoiding overly aggressive elevat ion w ill preven t th is in m ost cases in m edium - to th ick-skin n ed pat ien ts. How ever, in th e ver y th in -skin n ed pat ien t , even th is kin d of m easu re w ill even t ually en d up w ith th e graft ing sh ow ing. Perich on drium , fascia, or soft t issue covering w ith ext rem e care on th e beveling of th e graft s h elp s to p reven t graft sh ow -u p .

Pain or Discomfort Pain or d iscom for t of th e t ip u su ally disap pears as t im e goes by, bu t occasion ally th is rem ain s con t in u ou sly long after su rger y. Too m u ch st retch ing of th e t ip by overzealous project ion using a sept al exten sion graft , using a h ard m aterial su ch as sept al bon e or Med por for a sept al exten sion graft or colu m ellar st ru t , or overly aggressive/in adverten t t issue w ork on th e t ip are th e proposed et iologies. It w ou ld be p ru den t n ot to p u sh th e lim it s in project ing or rot at ing th e t ip using a sept al exten sion graft an d to use addit ion al on lay grafts on th e n ew dom e for m a xim al m odi cat ion of th e t ip. Often , p ain or discom fort disapp ears after graft rem oval.

Nasal Obstruction Nasal obst ru ct ion can occu r w h en an ap p lied septal exten sion graft/colu m ellar st ru t or th e exten ded spreader graft used to h old th e sept al exten sion graft is too th ick, resulting in n arrow ing of th e n ost ril. Buckling or d islocat ion of th e sept al exten sion graft or cau dal sept um is an oth er sou rce of n asal obst ru ct ion . Carefu l d esign of th e graft to avoid a th ick colum ella or caudal sept um an d a st rongly secu red , w ell-cen tered sept u m on th e an terior n asal sp in e are key elem en t s to p reven t bu ckling or dislocat ion of th e caudal sept um .

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■ Case Studies Case 1: Tip Augmentation w ith an Endonasal Onlay Graft A 40-year-old fem ale visited ou r clin ic an d w an ted to im p rove h er n asal sh ap e. Physical exam in at ion sh ow ed a low an d w ide dorsum w ith a sligh tly u n der-projected t ip

a

Fig. 4.15

b

(Fig. 4.15). After con su lt at ion , sh e decid ed to u se a silicon e im plan t for dorsum augm en t at ion an d con ch al car t ilage for th e t ip (Fig. 4.16). A 3-m m -th ick, I-sh ap ed silicon e im p lan t w as car ved an d in serted via in fracar t ilagin ou s in cision w ith in fradom al exten sion . Th e t ip w as augm en ted using a t w o-layer con ch al cart ilage on lay graft in serted th rough th e sam e in cision . Ph otograph s taken 6 m on th s after surger y sh ow im p roved t ip project ion w ith a n at u rally augm en ted dorsu m (Fig. 4.17).

c

(a–c) Case 1. A slightly low dorsum and less than ideal tip projection are observed from the preoperative photos.

Fig. 4.16 Case 1. Intraoperative photo shows a carved I-shaped silicone implant with a t wo-layer conchal cartilage cap graft before insertion.

4 Nasal  Tip  Modi cation  in  Asians:  Augm ent ation  and  Rot ation  Control  57 a

Fig. 4.17

b

(a–c) Case 1. Six months after surgery, the well-augmented dorsum and the tip are in balance.

Case 2: Tip Modi cation through an Open Approach A 39-year-old fem ale d esir in g to im p rove t h e ap p earan ce of h er n asal t ip an d d orsu m visite d ou r clin ic. Her n asal d orsu m w as low w h ile t h e t ip w as w id e, am or p h ou s, an d u n d e r-p roje cted , an d t h e alar-colu m ellar relat ion sh ip w as n ot in h ar m ony (Fig. 4.18). Her d orsu m w as

a

Fig. 4.18

c

b

au gm en te d w it h r ib car t ilage. Th e t ip sh ap e w as m od ied u sin g an en d -to -en d sep t al exte n sion graft re in force d w it h a bilateral exte n d ed sp read e r graft , cap graft , lateral cr u ral on lay graft , an d alar r im graft (Fig. 4.19). Ph otograp h s t aken 1 year after su rger y sh ow im p roved p roject ion , rot at ion , an d volu m e of t h e t ip w it h a h ar m o n iou s alar-colu m ellar relat ion sh ip . He r d orsu m w as ad equ ately augm e n ted , givin g a m ore n at u ral-lookin g n ose (Fig. 4.20).

c

(a–c) Case 2. Preoperative photographs. Before surgery, a low dorsum with a poorly projected tip is evident.

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a

b

c

d

e

f

Fig. 4.19 Case 2. Intraoperative photographs. (a) Rib cartilage harvest. (b) Septal extension graft using septal cartilage and reinforcement with rib cartilage. (c) Repositioning of lower lateral cartilage. (d) Alar rim graft. After making an incision lateral to the nasal facet and tunneling along the alar rim, a pre-designed piece of cartilage is inserted into the pocket. (e) Cap graft, lateral crural onlay graft, and coverage with perichondrium. (f) Dorsal onlay graft with carved rib cartilage.

a

b

c

Fig. 4.20 (a–c) Case 2. Photos taken 1 year after surgery show a naturally augmented dorsum and the tip with good alar-columellar relationship.

4 Nasal  Tip  Modi cation  in  Asians:  Augm ent ation  and  Rot ation  Control  59

References 1. Park SS, Jin HR. Non -Caucasian rh in oplast y. In : Flin t PW, ed. Cum m ings Otorh in olar yngology—Head an d Neck Surger y. Vol. 1, 5th ed . Ph iladelph ia, PA: Sau n ders Elsevier; 2010:568–579 2. Won TB, Jin HR. Nuan ces w ith th e Asian t ip. Facial Plast Surg 2012;28(2):187–193 3. Sh een JH. Closed versus open rh inoplast y—an d th e debate goes on . Plast Recon st r Su rg 1997;99(3):859–862 4. Ha RY, Byrd HS. Sept al exten sion graft s revisited: 6-year exp erien ce in con t rolling n asal t ip p roject ion an d sh ape. Plast Recon st r Su rg 2003;112(7):1929–1935 5. Kim MH, Ch oi JH, Kim MS, Kim SK, Lee KC. An in t rod uct ion to th e sept al exten sion graft . Arch Plast Su rg 2014;41(1):29–34 6. Guyuron B, Vargh ai A. Length en ing th e n ose w ith a tongu e-an d-groove tech n iqu e. Plast Recon st r Su rg 2003;111(4):1533–1539, discussion 1540–1541 7. Han K, Jin HS, Ch oi TH, Kim JH, Son D. A biom ech an ical com parison of vert ical gu re-of-eigh t locking su t u re for sept al exten sion graft s. J Plast Recon st r Aesth et Surg 2010;63(2):265–269

8. W h it aker EG, Joh n son CM Jr. Th e evolut ion of open st ruct ure rh in oplast y. Arch Facial Plast Su rg 2003;5(4): 291–300 9. Zijlker TD, Vuyk H. Cart ilage graft s for th e n asal t ip. Clin Otolar yngol Allied Sci 1993;18(6):446–458 10. Dan iel RK. Th e n asal t ip: an atom y an d aesth et ics. Plast Recon st r Su rg 1992;89(2):216–224 11. Bren n er MJ, Hilger PA. Graft ing in rh in oplast y. Facial Plast Surg Clin North Am 2009;17(1):91–113, vii 12. Gu n ter JP, Friedm an RM. Lateral cru ral st ru t graft: tech n ique an d clin ical applicat ion s in rh in oplast y. Plast Recon st r Su rg 1997;99(4):943–952, discussion 953–955 13. Gu n ter JP, Lan decker A, Coch ran CS. Frequ en tly u sed graft s in rh in oplast y: n om en clat u re an d an alysis. Plast Recon st r Surg 2006;118(1):14e–29e 14. Roh rich RJ, Ran iere J Jr, Ha RY. Th e alar con tou r graft: correct ion an d p reven t ion of alar rim deform it ies in rh in oplast y. Plast Recon st r Surg 2002;109(7):2495–2505, discu ssion 2506–2508 15. Boah en e KD, Hilger PA. Alar rim graft ing in rh in op last y: in dicat ion s, tech n ique, an d ou tcom es. Arch Facial Plast Su rg 2009;11(5):285–289 16. Toriu m i DM. New con cept s in n asal t ip con tou ring. Arch Facial Plast Su rg 2006;8(3):156–185

5

Hump Resection

Tae-Bin Won and Hong Ryul Jin

Pearls • Th ree com m on feat u res of th e Asian h um p n ose • • • •

are sm all size, low radix/low dorsu m , an d u n derprojected t ip. Managem ent strategy should be focused on achieving an ideal n asal pro le and not on hum p rem oval. Obt ain ing a n at u ral brow t ip aesth et ic lin e in th e fron t al view is as im p ort an t as obt ain ing an ideal pro le in th e lateral view. Th e am oun t of h um p resect ion sh ould be tailored based on th e predicted am oun t of dorsal augm en tat ion an d t ip p roject ion . Radix an d t ip augm en t at ion often m in im izes or obviates th e n eed for h um p rem oval.

■ Introduction Rh in oplast y is on e of th e m ost com m on facial plast ic su rgeries p erform ed in Asia. Alth ough th e p rin cip les an d goals m ay be sim ilar, th e act u al execu t ion is qu ite di eren t from th e Western version . An atom ic ch aracterist ics of th e Asian n ose coupled w ith di eren ces in aesth et ic stan dards dem an d th at it be approach ed in a un ique w ay. Num erou s art icles h ave been pu blish ed h igh ligh t ing th ese di eren t ap proach es an d tech n iqu es.1,2,3,4 Rh in oplast y am ong Asian s involves p ecu liarit ies th at dist ingu ish th e procedu re from it s Cau casian cou n terpart . Nasal h u m p su rger y is com m on ly regarded as a “redu ct ion ” surger y in m ost Western rh in oplast y textbooks an d is also referred as “redu ct ion rh in op last y.” Th e com m on goal of a h u m p n ose su rger y is to obt ain a n at u ral con tou r of th e n asal dorsum th rough adequate dorsal reduct ion w h ile dealing w ith th e issues of an open roof. Alth ough th ere are Asian pat ien t s w h o h ave large h um ps, m ost Asian h u m p n oses di er from Western on es in th at th e size of th e n asal h u m p is n ot big, an d th e n ose is frequ en tly associated w ith a relat ively low n asal dorsu m an d un der-project ion or un der-rot at ion of th e n asal t ip. Nat urally, correct ing a h u m p n ose in Asian s en t ails dist in ct d i eren ces both in con cept an d tech n ique. A sm all hu m p an d th e addit ion al n eed for augm en t at ion of th e dorsum an d th e t ip often m in im ize th e am oun t of h um p rem oval an d som et im es obviate th e n eed for resect ion itself. Prof loplast y in stead of reduct ion rhinoplast y m igh t be a m ore suit able w ord w h en dealing w ith

60

• Am ong variou s tech n iqu es for addressing h u m p

• •

n ose, con ser vat ive h um pectom y of th e bony an d/or cart ilagin ous h um p, follow ed by radix an d/or dorsal augm en tat ion is th e m ost com m on ly u sed m eth od. In case of a large h u m p , com pon en t h u m p resect ion w ith recon st ruct ion of th e rh in ion using spreader graft s is recom m en ded. Com plicat ion s of h um p reduct ion in clude inverted-V deform it y, dorsal irregularit y, an d n asal obst ruct ion . Th ese can be preven ted by con ser vat ive h um p rem oval and u se of spreader grafts or cam ou age graft s.

Asian h u m p n oses. In th is ch apter, ch aracterist ics of th e Asian h um p n ose w ill be addressed w ith em ph asis on surgical tech n iqu es com m on ly u sed to obt ain reliable resu lt s.

■ Patient Evaluation The key in preoperative planning is determ ining the ideal pro le, w hich is som ew hat sim ilar to perform ing dorsal augm entation. There are t wo im portant points. The rst is determ ining the level and height of the nasion. The level of the nasion, in other words, is the starting point of the nose. Di erences in the starting point am ong di erent races have been em phasized consistently.5 Traditionally, the supratarsal crease has been considered the ideal starting point for Caucasians and the m idpupillary line for Asians. However, there is a trend in w hich contem porary Asian patients are asking for a higher starting point. The authors consider the starting point in Asians to be som ew here in bet ween the supratarsal crease and m idpupillary line accounting for individual preferences (Fig. 5.1). The height of the nasion is usually determ ined by the nasofrontal angle. The ideal nasofrontal angle in Asians is around 135 degrees for m ales and 140 for fem ales. The next step is determ ining the desired nasal tip post ure, w hich is done by considering nasal projection and rotation (nasolabial angle). The ideal pro le can be achieved w hen a line is draw n from the nasion to the tip and the hum p can be resected and/or the dorsum augm ented as needed. Oth er practical issu es to consider in clu de skin th ickn ess, character of the hum p, presence of deviation, and length of

5

Hum p Resection

Supratarsal crease level Ideal nasion level Midpupillary level

Fig. 5.1 Starting point of the nose in Asians. The ideal starting point of the nose or the level of the nasion in Asians is considered to be in bet ween the supratarsal crease and the midpupillary line.

the nasal bones. The ch aracteristics of the nasal hum p are evalu ated th rough careful visualization and palpat ion. The hum p m ay be generalized or localized. The generalized hum p usually has a bony and cartilaginous com ponent w hile a localized hum p can be the result of a prom inence of the nasal bone and/or upper lateral cartilage. A pseudo hum p refers to the visual phenom enon of an accentuated height of the rhinion (resem bling a hum p nose), w hich can be caused by a deep radix and/or a depressed lower vault near the supratip (Fig. 5.2). Strategies in this situation should be focused on restoring support and augm entation instead of resection. We u su ally st ress th e pro le or oblique view w h en evalu at ing th e h u m p n ose pat ien t . How ever, th ere are also salien t feat u res in th e fron t al view th at w e h ave to con sider an d correct to ach ieve a good resu lt in h u m p n ose pat ien t s. Th e fron t al view is th e m ost im port an t view after all. Hum p st igm as in th e fron t al view in clu de u n n at u ral brow t ip aesth et ic lin es (n arrow ing, w iden ing, break, etc.), ligh t re ex in th e area of th e h u m p, an d skin th in n ing w ith frequen t hyperem ia or discolorat ion . Obt ain ing a n at ural brow t ip aesth et ic lin e in th e fron t al view is as im p or tan t as obtain ing an ideal pro le in th e lateral view.

■ Surgical Techniques It is im port an t to em p h asize again th at su rgical tech n iqu es of h u m p reduct ion are n ot th at di eren t from th e Western procedures. How ever, th e decision of un dergoing reduct ion versu s augm en tat ion or redist ribu t ion is th e key in m an aging h um p n oses in Asian s.

Fig. 5.2 Pseudo hump. A dorsal convexit y can be seen in a patient who has a depressed lower vault near the supratip, resembling a hump nose.

Anatomic Consideration and Clinical Implication Th e dorsal skin is th ickest in th e n asion an d th in n est in th e rh in ion (Fig. 5.3), resu lt ing in a sligh t n at u ral convexit y in th e rh in ion area. Th ere are t w o clin ical im plicat ion s related to th is an atom ic feat u re of th e dorsum . First , w h en dissecting n ear th e area of th e rh in ion or h um p, a cur ved periosteal elevator com es in h an dy; an d secon d, w h en reducing a h u m p , a at dorsu m is in dicat ive of over-resect ion . An atom y of th e rh in ion area of th e osseocart ilagin ous vau lt is an oth er im port an t p oin t to u n derstan d w h en p erform ing a h u m p red u ct ion . Th ere is a broad overlap of th e n asal bon es above an d th e sept u m an d u pp er lateral cart ilage (ULC) below (Fig. 5.4a). Many t im es it is su cien t to rem ove th is bony h um p u nt il it reveals th e un derlying cart ilage. Th ere is a ch ange in th e sh ape of th e dorsal sept um an d in it s relat ion w ith th e ULC as it p rogresses cau dally from th e bony ju n ct ion —n am ely, from a broad “T” sh ap e to a “Y” sh ap e to an “I” sh ape (Fig. 5.4b). Resect ion of th e dorsal sept u m w h ile p erform ing h u m p redu ct ion w ill dest roy th is n at ural an atom y. Recon st ru ct ion w ith regard to th e

61

62

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a

Fig. 5.3 Thickness of the dorsal nasal skin. The dorsal nasal skin is thickest in the nasion and thinnest in the rhinion, resulting in a slight natural convexit y in the rhinion area.

n at u ral th ickn ess of th e dorsal sept u m w ill preven t aesth et ic an d fun ct ion al com plicat ion s such as th e inverted-V d eform it y an d n asal obst ruct ion .

The Approach: Open versus Closed Hu m p redu ct ion it self can be perform ed w ith equ al su ccess via an en don asal or an open approach . Th erefore, th e ch oice of approach is usu ally dict ated by th e n eed for con com it an t procedu res to th e dorsum an d t ip. Th e auth ors use th e en don asal approach for a localized h um p th at does n ot n eed ad dit ion al dorsal w ork oth er th an augm en t at ion (i.e., spreader graft) an d n eeds on ly m in or t ip m an ipu lat ion . A u n ilateral or bilateral in tercart ilagin ous in cision com bin ed w ith a part ial t ran s xion or h em it ran s xion in cision is preferred for accessing th e dorsum , an d a sep arate m argin al in cision is used for th e t ip. An open approach is preferred in th e m ajorit y of pat ien t s w h o h ave a gen eralized h um p n eeding rem oval of th e dorsal sept al car t ilage, h ave con com it an t n asal deform it ies su ch as asym m et r y or deviat ion , an d n eed m ajor t ip ch anges. Alth ough th ese m an euvers can be perform ed en don asally, th e au th ors p refer th e open ap p roach becau se it p rovides bet ter visu alizat ion an d pat ien t com fort in ap plying an d secu ring graft s, th u s en su ring a m ore st able an d reliable resu lt . Th e draw back of th e op en ap p roach (i.e., a n ot iceable colu m ellar scar) can be m in im ized by adh ering to basic w ou n d closu re tech n iqu es.

b Fig. 5.4 Relationship of the bony and cartilaginous dorsum. (a) In the region of the rhinion area there is a broad overlap of the nasal bones above and the septum and upper lateral cartilage below. (b) The shape of the dorsal septum changes as it progresses caudally from the bony junction from a broad “T” shape to a “Y” shape to an “I” shape.

W h en th ere is sign i can t septal deviat ion or a n eed for cart ilage h ar vest , septoplast y is perform ed rst . Usually th e sept al car t ilage is har vested leaving 10 m m of car t ilage dorsally an d caudally, but w h en a con siderable h u m p resect ion is plan n ed w e leave m ore car t ilage or h ar vest th e septal cart ilage after h u m p ectom y.

Dissection and Septal Cartilage Harvest

Sequence of Surgery and Tip-Plasty

Regardless of th e approach , th e soft t issue is elevated in a su p rap erich on d rial an d su bp eriosteal p lan e. Th e an terior sept al angle is exposed an d th e en t ire n asal dorsu m visu alized .

Prior to dorsal w ork, w e usually perform tip surger y. Rough ly 90% of the desired tip shape w ork (including project ion , rotat ion, and de nit ion ) is accom plished. The n al tou ch es are m ade after com plet ion of th e dorsal w ork. Th e

5 auth ors use th is sequen ce becau se it often m in im izes or obviates the n eed for dorsal reduction . It is n ot in frequen t to n d yourself in th e odd sit uation w h ere you n eed to augm en t th e dorsum again after dorsal reduction to m atch th e desired height of th e dorsum . Techniques of t ip surger y are beyond the scope of th is chapter and w ill be dealt w ith in an oth er on e. Brie y, for th e t ypical Asian pat ien t w ith w eak tip support, project ion and rotat ion are usually perform ed in t w o steps. The rst step is stabilizat ion of the nasal t ip. This is th e key step in Asian t ip -plast y. The object ive is to establish a rm foundat ion on w hich furth er grafting can be don e. Stabilizat ion of the nasal tip can be achieved by m eans of either a colum ellar strut or a septal extension graft. Of the t w o, th e septal extension graft is by far the m ore pow erfu l tool an d can be u sed reliably in pat ien ts w h o h ave ver y w eak t ip support or n eed a substan tial in crease in tip project ion . It can alter projection and con trol rotat ion sim u ltaneously. The second step is ne sculpting of th e nasal tip. This is done by com bining sut ures and a variet y of grafts to obtain the desired outcom e (Fig. 5.5). Th e on lay graft su ch as a cap graft or sh ield graft is th e m ain w orkh orse.

Hum p Resection

a

Hump Reduction in Large -Hump Asian Noses Many tech n iqu es for n asal h u m p resect ion h ave been suggested , in clu d ing en bloc resect ion , com p on en t resect ion , an d Skoog d orsal resect ion .6,7,8,9 In th e classic “com p osite en bloc h u m p ectom y” th e com p on en t s of th e h u m p (bon e, dorsal sept u m , an d both upper lateral cart ilages) are all rem oved togeth er (en bloc), leaving an open roof. Th is tech n ique is usually applied to th e gen eralized osseocar t ilagin ou s h um p com m on in Western n oses. Brie y, a n o. 15 blade is h eld at th e bony-cart ilagin ous jun ct ion of th e dorsu m in th e h orizon t al p lan e an d advan ced cau dally in th e plan e of reduct ion to excise th e car t ilagin ou s port ion of th e h u m p , t ran sect ing th e u pp er laterals an d th e car t ilagin ou s sept u m , leaving it at tach ed to th e n asal bon es. A 10-m m Ru bin osteotom e is th en in serted u n der th e car t ilagin ous segm en t an d th e bony dorsu m redu ced in th e d esired plan e, rem oving th e en t ire osseocart ilagin ous h um p en bloc. Judicious rasping an d cart ilage t rim m ing is follow ed w ith careful palpat ion of th e dorsum . In “com pon en t h u m p ectom y” th e com p on en t s of th e h u m p are redu ced on e by on e, allow ing precise m an ipu lat ion an d preser vat ion of th e n asal m ucosa. Th e upper lateral car t ilages are separated from th e n asal sept u m p rior to h u m p redu ct ion . Th e dorsal sept u m is red u ced, follow ed by bony h u m p rem oval (Fig. 5.6). Fin ally, th e u p p er lateral cart ilage can be t rim m ed, placed above th e sept um , or used as au tospreader graft s or spreader ap s (Fig. 5.7). Th e au th ors prefer to use th is tech n ique in large-h um p Asian n oses. Lateral osteotom y is perform ed eith er en don asally or percut an eously in pat ien t s w h o h ave an open roof deform it y, a w ide dorsu m , or an associated n asal d eviat ion .

b Fig. 5.5 Nasal tip surgery. Comm on steps in Asian tip-plast y with poor tip support. Tip support is restored by (a) applying a septal extension graft followed by (b) ne sculpting with additional onlay tip grafts.

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b a

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Fig. 5.6 Component hump reduction 1. (a) Visualization of the hump. (b) Upper lateral cartilages separated from the septum. (c) Reduction of the cartilaginous hump with a no. 15 blade. (d) Reduction of the bony hump with a Rubin osteotome.

a Fig. 5.7

b

c

Component hump reduction 2. The upper lateral cartilages can be (a) trimmed with scissors or (b,c) used as autospreader aps.

5

Hum p Resection

Spreader Grafts Sp reader graft s are p referably p osit ion ed bilaterally in pat ien t s in w h om w e h ave resected substan t ial am oun ts of dorsal sept u m in th e rh in ion area (Fig. 5.8). Th e reason s for in corp orat ing spreader grafts after a h u m pectom y are as follow s: 1. To support and reinforce the rhinion (keyston e), preventing th e inverted-V deform it y. This is especially im portan t in patien ts w h o h ave sh ort n asal bones. A short nasal bone m eans a short connection bet w een the upper lateral cart ilage an d the nasal bone, and often this connect ion is disrupted after h um p rem oval, cau sing m iddle vau lt collapse.10 2. To con t rol m idvault w idth an d ach ieve a sm ooth brow t ip aesth et ic lin e. Th e th ickn ess of th e sept um in creases dorsally, an d excision of th e th ick d orsal sept u m w ill n arrow th e m idvau lt . 3. To preven t n asal obst ruct ion . Th is is th e fun ct ion al coun terpart of a n arrow m idvault , w h ich can cau se n asal obst ru ct ion du e to in tern al valve n arrow ing. 4. To correct deviat ion or asym m et r y of th e m idvault , if p resen t . 5. Th ere is n o st u dy on th e am ou n t of cart ilagin ous resect ion an d th e use of spreader graft s; h ow ever, th e auth ors en courage th eir use w h en th ere is any d ou bt .

Conservative Humpectomy in Asian Small-Hump Noses Becau se th e h u m p is relat ively sm all in m ost Asian h um p n oses, com posite resect ion m ay n ot be a su it able tech n iqu e for h u m p rem oval. Often sim ple bony rasp ing w ith m in or t rim m ing of th e dorsal sept al cart ilage is su cien t to ach ieve th e d esired dorsal h eigh t or obt ain th e p latform for fu rth er dorsal augm en t at ion . Using a sm all st raigh t osteotom e in stead of a big Rubin osteotom e follow ed by in crem en tal rasp ing w ith sm all rasps or a drill un der direct visu alizat ion is h elp fu l. Bony h u m p ectom y w ill reveal th e overlap p ing cart ilagin ou s vau lt u n dern eath , an d p recise redu ct ion of th e cart ilagin ous vault can follow (Fig. 5.9). Th e auth ors use th e term conservat ive h um pectom y, an d it is th e p rocedu re u sed in th e m ajorit y of sm all or isolated h u m p n ose Asian p at ien ts. Subsequen t dorsal augm en tat ion w ith on lay graft s above an d/or below th e h um p in com bin at ion w ith t ip surger y con t ribu tes to th e frequen t u se of con ser vat ive h um p rem oval. Alth ough th e overlapping upper lateral cart ilage can be visible un dern eath th e n asal bon es in th e rh in ion , th ere is rarely an open roof, obviat ing th e n eed for lateral osteotom ies. An oth er reason th at lateral osteotom y is n ot frequen tly perform ed is because fu rth er dorsal augm en t at ion

Fig. 5.8 Spreader grafts placed bilaterally in the dorsal septum after humpectomy.

w ill cam ou age for th e w ide n asal base. Min or resect ion of th e cart ilagin ous h um p w ill decrease th e n eed for spreader graft s an d rarely violates th e n asal m u cosa, w h ich can redu ce th e risk of in fect ion w h en using alloplast ic im plan t s for dorsal augm en t at ion . W h en th e desired dorsal h eigh t exceeds th e h eigh t of th e h um p, th ere is a ch oice bet w een leaving it alon e an d perform ing augm en t at ion on top of it . Th e auth ors prefer to perform h u m p red u ct ion to sm ooth th e dorsu m p rior to augm en t at ion . Th e am ou n t of resect ion in th is sit u at ion depen ds on th e m aterial used for dorsal augm en t at ion . W h en silicon e is u sed, th e u n dersurface of th e rh in ion area can be car ved aw ay, cam ou aging for sm all resid u al convexit y. For oth er graft ing m aterials, such as car t ilage, exp an ded p olytet ra u oroethylen e (ePTFE), an d h om ologou s fascia, a com plete h u m pectom y is p erform ed becau se it is bet ter to perform a u n iform augm en t at ion th at leaves less ch an ce of an irregular dorsum or residual convexit y.

Final Touch: Dorsal Augmentation and Tip Re nement Dorsal augm en tat ion is p erform ed to obt ain th e desired heigh t of th e dorsu m an d cam ou age any rem ain ing irregularit ies. Th is can t ake th e form of radix augm en tat ion or radix an d dorsal augm en t at ion (Fig. 5.10). Th e lat ter h as th e

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a

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d

Fig. 5.9 Conservative humpectomy in a small Asian hump nose. (a) Visualization of the hump. (b,c) Bony humpectomy using osteotome and rasp. Bony humpectomy reveals overlapping cartilaginous vault in the rhinion. (d) Reduction of the cartilaginous hump (dorsal septum and upper lateral cartilage).

a

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d

Fig. 5.10 Radix and dorsal augmentation. (a) Radix augmentation with crushed cartilage, (b) Radix and dorsal augmentation with ePTFE. (c) Radix augmentation with periosteum. (d) Radix and dorsal augmentation with perichondrium.

5 advan t age of a sm ooth an d gapless t ran sit ion in th e th in skin n ed rh in ion area. Carefu l palp at ion w ith w et gloves is im p ort an t for detect ing irregularit ies after h u m pectom y. Re n em en t of th e t ip is p erform ed at th e en d to produce a h arm on iou s n ose. To obt ain a favorable facial balan ce togeth er w ith a h arm on ious n ose, it is advisable to con sider gen iop last y in th e p at ien t w h o h as a ret ru d ed ch in .

■ Key Technical Points 1. A com pon en t h um pectom y is used for large, gen eralized h u m p n oses. Th e com p on en t s of th e h u m p are red u ced on e by on e, allow ing p recise m an ip u lat ion an d p reser vat ion of th e n asal m u cosa an d u pp er lateral car t ilage. 2. A con ser vat ive h um pectom y is u sed in th e m ajorit y of sm all or isolated Asian h um p n oses. Th is is usu ally follow ed by dorsal augm en tat ion above an d/or below th e h um p in com bin at ion w ith t ip surger y. 3. W h en perform ing dorsal augm en tat ion after h u m p ectom y, a com bin ed radix an d d orsal augm en tat ion h as th e advan t age of a sm ooth an d gapless t ran sit ion in th e th in -skin n ed rh in ion . 4. Use soft t issue or crush ed cart ilage w h en perform ing radix augm en t at ion sin ce solid cart ilage is p ron e to sh ow in th is area. 5. Sp reader graft s or ap s are p erform ed w h en ever th ere is any doubt to m in im ize th e ch an ces of an inverted -V deform it y.

■ Complications and

Hum p Resection

Functional Problems (Internal Valve Collapse) Preser vat ion of th e in tern al n asal valve after dorsal hu m p redu ct ion is frequ en tly em ph asized in th e Western literat ure. Dorsal reduct ion it self w ill n arrow th e n asal valve. In ad dit ion , lateral osteotom y an d in fract u re of th e lateral nasal w alls to close th e open -roof deform it y can subsequen tly m edialize th e upper lateral cart ilages, result ing in in tern al valve collapse an d leading to sign i can t n asal obst ruct ion . Tech n iques to preser ve or recon st ruct th e m iddle vau lt an d in tern al valve in th e set t ing of h u m p redu ct ion in clude u sing th e classic spreader graft s, th e “p u sh dow n ” tech n iqu e,9 an d spreader or auto-spreader ap s.11 How ever, obst ruct ion due to in tern al valve collapse is rare in Asian s, even after m edializat ion of th e lateral w alls, du e to th eir th ick skin an d soft t issu e envelope w ith w ide intern al valve angle.12 A p reviou s st u dy in Asian h u m p n ose pat ien t s sh ow ed n o in ciden ce of postop erat ive n asal obst ruct ion after lateral osteotom ies regardless of th e use of spreader graft s.2

Residual Convexity Cau ses of residu al convexit y in clu de overly con ser vat ive hu m pectom y, in adequate augm en t at ion or resorpt ion of radix im plan t , an d t ip drooping. Failure in th e est im at ion of th e appropriate am oun t of h u m p rem oval togeth er w ith failu re to execu te on e or m ore step s of h u m p rem oval can be th e cause of a residual t rue h um p. Th e th ough t th at th e am ou n t of h u m p resect ion sh ou ld be m in im ized to adju st th e am oun t of dorsum th at w ill be augm en ted m ay h ave led to in su cien t h um p rem oval.

Their Management

Irregularity of the Dorsum

Inverted-V Deformity

Th e dorsum , especially th e rh in ion , w h ere th e skin is th in nest , is pron e to sh ow irregularit ies on long-term follow up. Visible dorsal irregularit ies are a com m on cause of secon dar y rh in op last y.13 Th e relat ively th ick dorsal skin of th e Asian n ose an d sim ult an eous dorsal augm en tat ion w ith h um p rem oval can redu ce th e ch an ces of dorsal irregularit ies. Veri cat ion of a sm ooth dorsu m by careful palpat ion after redraping of th e skin is essen t ial. Con t in u ous augm en t at ion of th e dorsum (from radix to th e suprat ip) can also reduce th is problem . W h en perform ing radix augm en tat ion , t r y to avoid u sing solid cart ilage graft s sin ce th ey are pron e to sh ow. Th e auth ors prefer soft t issue grafting m aterial such as fascia (au tologous or h om ologous) or ePTFE. W h en m ore augm en t at ion is n eeded, cru sh ed car t ilage is in ser ted below th e soft t issue graft .

Cau ses of an inverted-V deform it y are m id dle vau lt collap se, failure to close th e bony open roof, an d detach m en t of th e u p p er lateral car t ilage from th e n asal bon es. Alth ough th is deform it y is n ot com m on in sm all-h u m p Asian n oses, pat ien ts w h o h ave sh ort n asal bon es are relat ively predisposed. Sh ort n asal bon es m ean a sm all overlap bet w een th e car t ilagin ous vault an d th e n asal bon es, an d th is con n ect ion can be disrupted during h um p rem oval. To preven t m iddle vau lt collapse an d subsequen t inver ted-V deform it y, spreader graft s, bin ding sut ures, an d cam ouage on lay graft s can be u sed.

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■ Case Studies

1. Th e open approach

Case 1

3. Tip -plast y w ith colum ellar st rut an d cap graft

2. Septoplast y an d septal cart ilage h ar vest

A 35-year-old fem ale p at ien t com p lain ed of a bu m p on h er n ose (Fig. 5.11). Ch aracterist ics of h er n ose in clu ded a m oderate h u m p w ith a low radix, a sligh tly u n der-p ro jected t ip , an d m oderately th ick skin . Operat ive tech n iqu es w ere as follow s:

4. Con ser vat ive en bloc resect ion of th e bonycart ilagin ous h um p w ith bony rasping 5. Radix augm en tat ion w ith bruised septal cart ilage The 1-year postoperat ive ph otos sh ow im proved brow t ip aesth et ic lin es in th e fron t al view. Lateral an d oblique view s sh ow a w ell-balan ced p ro le w ith sm ooth dorsu m an d in creased t ip p roject ion an d rot at ion .

a

b

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Fig. 5.11 Case 1. (a–c) Preoperative facial photographs of a 35-year-old female patient show a m oderate hump, low radix, and a slightly under-projected nasal tip with moderate skin thickness. (d–f) Postoperative 1-year facial photographs show a balanced pro le with augmentation of the radix and the tip.

5

g Fig. 5.11 (Continued) (g) Graphic drawing of operative procedures.

Hum p Resection

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Case 2 A 23-year-old fem ale p at ien t p resen ted w ith cosm et ic issu es con cern ing h er n ose (Fig. 5.12). Sh e w an ted to get rid of h er h u m p . An alysis of h er n ose revealed a gen eralized h u m p , low radix, sligh tly ptot ic an d bu lbous t ip, an d m oderately th in skin . Op erat ive tech n iqu es w ere as follow s: 1. Sept al car t ilage h ar vest th rough a m od i ed Killian in cision 2. Th e open approach an d degloving of th e n ose w ith d etach m en t of th e u pp er lateral cart ilage from th e sept u m

3. Com pon en t h um pectom y: resect ion of th e dorsal cart ilagin ous h um p w ith a n o. 15 blade, in crem en tal redu ct ion of th e bony h um p w ith a Rubin osteotom e an d rasp, an d t rim m ing of th e u p per lateral cart ilage w ith scissors 4. Bilateral spreader graft to correct deviat ion an d con t rol th e w idth of th e dorsum 5. Ceph alic resect ion , colum ellar st rut , an d cap graft to re n e th e t ip 6. Bilateral lateral osteotom y to close th e open roof an d n arrow th e bony pyram id The 1-year postoperative photos show a balanced pro le on lateral view, w ith tip re nem ent. The nose is straight on the frontal view, w ith sm ooth brow tip aesthetic lines of adequate w idth.

a

b

c

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Fig. 5.12 Case 2. (a–c) Preoperative facial photographs of a 23-year-old female patient show a generalized hump and slightly bulbous, under-projected nasal tip with moderately thin skin. (d–f) Postoperative 1-year facial photographs show a balanced pro le with reduction of the hump and the tip re ned. A straight nose with sm ooth brow tip aesthetic lines of adequate width is also noted in the frontal view.

5

Hum p Resection

g Fig. 5.12 (Continued) (g) Graphic drawing of operative procedures.

References 1. Toriu m i DM, Sw artout B. Asian rhin oplast y. Facial Plast Surg Clin s North Am 2007;15(3):293–307, v

8. Skoog T. A m ethod of h um p reduct ion in rh in oplast y. A tech n iqu e for p reser vat ion of th e n asal roof. Arch Otolaryngol 1966;83(3):283–287

2. Jin HR, Won TB. Nasal h um p rem oval in Asian s. Acta Otolar yngol Su pp l 2007;558:95–101

9. Hall JA, Peters MD, Hilger PA. Modi cat ion of th e Skoog dorsal reduct ion for preser vat ion of th e m iddle n asal vau lt . Arch Facial Plast Su rg 2004;6(2):105–110

3. Jin HR, Won TB. Nasal t ip augm en tat ion in Asian s using au togen ou s cart ilage. Otolar yngol Head Neck Su rg 2009;140(4):526–530

10. Sh een JH. Spreader graft: a m eth od of recon st ru ct ing th e roof of th e m iddle n asal vau lt follow ing rh in oplast y. Plast Recon st r Su rg 1984;73(2):230–239

4. Won TB, Jin HR. Nuan ces w ith th e Asian t ip. Facial Plast Surg 2012;28(2): 187–193

11. Gru ber RP, Park E, New m an J, Berkow it z L, On eal R. Th e sp reader ap in p rim ar y rh in op last y. Plast Recon st r Su rg 2007;119(6):1903–1910

5. Jin HR, Won TB. Recen t advan ces in Asian rhin oplast y. Au ris Nasus Lar yn x 2011;38(2):157–164 6. Ish ida J, Ish ida LC, Ish ida LH, Vieira JC, Ferreira MC. Treat m en t of the n asal h um p w ith preser vat ion of th e cart ilagin ous fram ew ork. Plast Recon st r Su rg 1999;103(6):1729–1733, d iscussion 1734–1735 7. Roh rich RJ, Mu za ar AR, Jan is JE. Com pon en t dorsal h um p redu ct ion : th e im p ort an ce of m ain t ain ing dorsal aesth etic lin es in rh in oplast y. Plast Recon st r Su rg 2004;114(5): 1298–1308, discu ssion 1309–1312

12. Su h MW, Jin HR, Kim JH. Com p u ted tom ograp hy versu s n asal en doscopy for the m easurem en t of th e in tern al nasal valve angle in Asian s. Act a Otolar yngol 2008;128(6): 675–679 13. Won TB, Jin HR. Revision rh in op last y in Asian s. An n Plast Surg 2010;65(4):379

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6

Correction of the Deviated, Tw isted Nose

Hun-Jong Dhong

Pearls • Precise preoperat ive clin ical an alysis of extern al • • • •

•

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an d in tern al n asal st ru ct u res is th e corn erston e of a su ccessfu l correct ive rh in op last y. It is essential to have a su cient preoperative discussion bet ween the patient and the surgeon about the surgical options and w hat can be corrected. Facial asym m et r y sh ould be th orough ly evaluated preoperat ively, an d th e pat ien t sh ould be in form ed of th e result s of th e evaluat ion . Th e surgeon sh ou ld con sider cosm et ic im provem en t of th e deviated n ose as w ell as its fun ct ion al restorat ion . Dorsal deform it ies frequ en tly accom pany a deviated sept u m , an d th e m ost im port an t step in correct ive rh in oplast y is to create a st raigh t sept um along th e m idlin e. Th e stabilit y of a recon st ructed n ose is determ in ed by th e st rength of th e st raigh ten ed sept um , w h ich

•

• • • •

origin ates from th e in tegrit y of th e keyston e area, rein forcem en t of th e L-st rut , an d a xat ion to th e an terior n asal sp in e. All ext rin sic an d in t rin sic deform ing forces sh ou ld be evaluated an d relieved in t raoperat ively w ith m et icu lou s m an ip u lat ion of each osteocart ilagin ou s fram ew ork. Bony deviat ion is corrected w ith accurate osteotom ies based on detailed evaluat ion of each bony pyram id. Th e preferred tech n iqu es for correct ion of th e low er t w o-th irds of a deviated n ose are use of a spreader graft an d septal exten sion graft . Deform ed osteocart ilagin ou s fram ew orks sh ou ld be m an aged in a con ser vat ive m an n er to th e exten t possible. Postop erat ive care an d follow -u p are as im p ort an t as th e surger y.

■ Introduction

■ Patient Evaluation

In rh in op last y, correct ion of a crooked or t w isted n ose rem ain s on e of th e m ost ch allenging surgeries. Nasal asym m et r y is related to facial at t ract iven ess, pat ien t satisfact ion , an d qu alit y of life.1,2 Deform it ies in clude n ot on ly aesth et ic problem s bu t also fun ct ion al con sequen ces, an d th u s correct ion of th ese coexist ing p roblem s sh ou ld be accom plish ed sim ult an eously. Th e n asal an atom y of a pat ien t w ith a t w isted n ose m ay be related to a bony pyram id deform it y, sept al d eviat ion , asym m et r y of th e u p per an d low er lateral car t ilages, or variou s com bin at ion s of th ese. Th e problem can be congen it al, or acquired secon dar y to t rau m a or p reviou s su rger y. Fu r th erm ore, p at ien t s often h ave baselin e facial asym m et r y, an d th is a ects th e outcom es of correct ive rh in oplast y. Because an an atom ic recon st ru ct ion carries th e risk of w eaken ing th e suppor t ing bony an d cart ilagin ous skeleton , a th orough un derstan ding of n asal an atom y an d physiology, precise preoperat ive an d in t raop erat ive an alysis, th e surgical kn ow ledge an d skill to p erform a t ailored su rgical procedu re, an d m et icu lou s postoperat ive m an agem en t are all essen t ial for correct ion of a t w isted n ose. In addit ion , the surgeon sh ould be skillfu l an d com p eten t to p erform a revision su rger y if n eeded.

A th orough social an d m edical h istor y sh ou ld be obt ain ed from th e p at ien t an d en tered in to th e m edical record. In p ar t icu lar, th e obt ain ed in form at ion sh ou ld in clu de sm oking st at u s, occu pat ion , degree of con cern w ith facial app earan ce, n asal t rau m a, p reviou s n asal su rger y, an d co-m orbidit ies su ch as allergic rh in it is an d ch ron ic rh in osin u sit is.

Physical Examination Examination of the External Nose Th e in it ial ste p for su ccessfu l cor re ct ion of a d eviate d n ose is a syst e m at ic p h ysical exam in at ion t h at an alyzes exist in g aest h et ic p rob le m s an d u n d e rlyin g an at om ic d efor m it ies. W h e n d raw in g a st raigh t lin e from t h e m idglabellar area to t h e m e n t on , t h e n asal br idge an d t ip sh ou ld be bise ct e d sym m et r ically in an id eal n ose. Ad d it ion ally, t h e n asal d orsu m sh ou ld be ou t lin e d by t w o sym m et r ic b row t ip aest h et ic lin es ext e n d in g from t h e m e d ial su p raciliar y r idges t o t h e t ip - d e n in g p oin t s

6

Correction of the Deviated, Twisted Nose

(Fig. 6 .1). Usin g t h is m et h od , t h e d egre e an d t yp e of n asal d eviat ion can b e evalu ate d . If th e deviat ion is am bigu ou s, a bird’s-eye view or lateral illu m in at ion is h elp fu l to iden t ify any su btle deform it y m ore clearly (Fig. 6.2 an d Fig. 6.3). Th en m et icu lou s palpat ion of each an atom ic elem en t , in cluding th e bony pyram id, upper an d low er lateral car t ilages, car t ilagin ous dorsu m , an d colum ella, sh ould be perform ed to evaluate size, sh ape, sym m et r y, an d resilien ce. Facial asym m et r y is not rare in pat ien t s w ith a deviated n ose, an d m ost pat ien t s becom e ext rem ely con scious of th eir facial appearan ce after su rger y.3 Th erefore, any m in or asym m et ries sh ou ld be described preoperat ively to preven t pat ien t s from at t ributing th em to su rger y. Th e com m on causes of facial asym m et r y are listed below.

Fig. 6.1 Facial midline and brow tip aesthetic line. The brow tip aesthetic line begins at the medial brow, curving inferiorly along the dorsal border, and gently blending with the tip-de ning point. It should be parallel, uninterrupted, and symmetric.

Common causes of facial asymmetry include : • • • • • • • •

a

Di eren ce in facial w idth Asym m et ric eyebrow s Orbit al level di eren ce O -cen ter an terior n asal spin e Lateral p lacem en t of th e p iriform apert u re Non h orizon tal alar base Maxillar y or m an d ibu lar hyp er-/hyp op lasia Malar prom in en ce or recession

Examination of the Internal Nose A p at ien t w ith a deviated n ose sh ou ld be assessed for th e presen ce of n asal obst ruct ion . Th rough en doscopic exam inat ion of th e n asal cavit y an d n asop h ar yn x, p aten cy of th e extern al an d in tern al valves, sept al deviat ion , an in ferior t urbin ate con dit ion , aden oid hypert rophy, an d any abn orm al n dings m u st be evalu ated preoperat ively.4 Th ese

b

Fig. 6.2 (a,b) A bird’s-eye view: Dorsal irregularities are more obvious because the distance bet ween the nasal tip and lips and the distance bet ween the lips and chin become less.

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b

alterat ion s sh ou ld be som ew h at pred ict able p reop erat ively by several test s, such as acoust ic rh in om et r y an d paran asal com puted tom ography. If th ere is anyth ing th at could cause n asal obst ru ct ion , it sh ou ld be m an aged d u ring correct ive rh in op last y.

Examination of the Nasal Skin and Soft Tissue Envelope Th e clin ical an alysis of extern al n asal deform it ies sh ould in clu de an evalu at ion of th e skin –soft t issue envelope (SSTE). If th e pat ien t h as a th ick SSTE, it w ill t ake longer for th e ed em a to su bside an d w ill disru pt th e postoperat ive aesth et ic outcom e.5 In con t rast , a th in SSTE is likely to reveal sm all rem n an t deform it ies u n dern eath th e skin .

Medical Photography Stan dardized ph otograp h s are essen t ial in th e preop erat ive facial evalu at ion to con rm th e clin ical an alysis of th e n ose an d th e face. Fron tal, lateral, obliqu e, basal, an d bird ’s-eye view s are th e basic p h otograp h s th at sh ou ld be obt ain ed. Med ical p h otograp h s en able th e iden t i cat ion of im portan t facial n dings th at m ay h ave been m issed during in it ial in spect ion an d allow for com parison of th e p ostop erat ive ou tcom e an d p reop erat ive st at u s.6 Fu n dam en t al facial an alysis in clu des m easurem en t s an d evalu at ion of p roport ion s of th e eyebrow s, m edial can th us, n asion , rh in ion , alar sidew all, alar facial ju n ct ion , colu m ella, colu m ellar-labial ju n ct ion , ph ilt ru m , m outh angle, an d gn ath ion (Fig. 6.4).

Fig. 6.3 (a,b) E ect of oblique lighting. A light and darkness contrast can exaggerate the deformit y of the brow tip aesthetic lines.

Surgical Planning Th e n ext step is plan n ing th e surgical procedure based on clin ical an alysis. Th e surgical plan m ay con sist of correct ion of th e deform it y an d rein forcem en t of th e fram ew ork. Th e ap prop riate ap p roach an d su rgical tech n iqu es sh ou ld be determ in ed according to th e deform it ies of each an atom ic elem en t . If use of a graft tech n ique is an t icipated, th e surgeon sh ou ld kn ow th e m aterials p referred by th e pat ien t before th e surger y.7 Pat ien t s m ust be in form ed abou t th e pros an d con s of each graft m aterial, in cluding autologou s (sept al, con ch al, or costal cart ilage), allograft (fascia lat a, alloderm ), an d ar t i cial m aterials (Gore-Tex, silicon e).8

Patient Interview and Selection On ce th e su rgeon h as develop ed a p lan , th ere sh ou ld be a discu ssion w ith th e pat ien t about th e det ails of th e procedure an d expected surgical ou tcom e. Becau se th ere can be discrepan cy in th e de n it ion of an opt im al outcom e bet w een th e perspect ives of th e surgeon an d th e pat ien t , th e surgeon sh ould explain th e result s of th e an alysis an d th e expected outcom e of surger y based on th e ph otograph s. Addit ion ally, th e su rgeon sh ou ld exp lain th e p oten t ial differen ces bet w een surgical goals an d ult im ate outcom es. Th e n al step of th e preoperat ive evalu at ion is pat ien t select ion , an d th is is as im p ort an t as th e clin ical assessm en t . Pat ien ts w h o h ave a realist ic exp ectat ion for th e su rger y an d an u n derst an ding of th e su rgical lim itat ion s are good su rgical can didates. Su rgeon s sh ou ld p ay part icu lar at ten t ion to detect poor surgical can didates w h o sh ow

6

Correction of the Deviated, Twisted Nose

Fig. 6.4 Facial analysis. The nasion, nasal tip, and philtrum should all be along the midline. The distance from each landmark on both sides to midline should also be the same. Evaluation of facial asymmetry is very important in consultation of deviated nose.

Facial analysis • Eyebrows • Medial canthus • Nasion/rhinion • Alar side wall • Alar facial junction • Columella

• Columellar–labial junction • Philtrum • Mouth angle • Gnathion

excessive con cern abou t m in or deform it ies or h ave u n realist ic expect at ion s.

■ Surgical Techniques Choice of Approach Th e ch oice bet w een en don asal an d extern al approach es depen ds on th e surgical plan an d th e surgeon’s preferen ce.6 Alth ough p reop erat ive clin ical an alysis m ay en able select ion of a part icular approach , pat ien t s w h o un dergo th e en don asal ap proach m u st be in form ed of th e p ossibilit y of conversion to an extern al approach for m ore com plete correct ion . In gen eral, th e en don asal approach can be app lied for cases w ith subtle deform it ies of th e u pp er or m iddle vau lt , an d for p at ien ts w ith keloid, w h o requ ire avoidan ce of unpredict able con t ract ures associated w ith an open ap proach .9 Meanw h ile, an extern al ap p roach is p referred for th e m an agem en t of deviat ion of th e low er t w o-th ird s an d severe asym m et ries of th e n asal bon e, an d som e cases requ ire m axim al exp osu re, m obilizat ion , an d resh aping. Th rough bilateral m argin al in cision s con n ected to a t ran scolum ellar inverted-V in cision , com plete exposure of th e n asal t ip an d m idvau lt in th e su praperich on drial plan e can be ach ieved. To approach a bony pyram idal deform it y, an exten ded dissect ion in th e su bp eriosteal plan e is essen t ial.

Correction of Deviation Alth ough th ere h ave been variou s classi cat ion s for th e deviated nose,3,4,10,11 th ey all originated from th e n eed for stat ist ical an alysis of ou tcom es rath er th an a clin ical gu id e-

lin e for surger y. Th e deviated n ose n eeds to be an alyzed according to each an atom ic dom ain (u p p er, m iddle, an d low er th ird) an d reciprocal relat ion sh ips from a perspect ive of align ing to th e m idlin e.

Upper-Third Deviations Deviat ion of th e u p per on e-th ird of th e n ose is cau sed by asym m et r y an d h um p of th e bony pyram ids. Th rough m et icu lou s p alp at ion an d com pu ted tom ography, th e size, sh ape, an d sym m et r y of each bony pyram id sh ou ld be evaluated. In cases of m in or deform it ies, th e bony dorsu m can be corrected by a cam ou age or rasping tech n ique. A pat ien t w h o h as on ly a deviated bony dorsum is likely to have a h istor y of n asal t raum a or a h um ped bony pyram id.12 Gen erally, m ost bony pyram idal deviat ion s en tail a de ected m iddle th ird of th e n asal d orsu m .

Cam ou age Th is tech n ique can be applied to a pat ien t w h o h as a localized depression or asym m et r y of th e bony pyram id. Crush ed sept al cart ilage is th e preferred graft m aterial. Th e m aterial is p laced u n der a periosteal ap to redu ce m obilit y an d visibilit y. Th e skin over th e bony dorsu m is relat ively th in ; th erefore, the surgeon m ust be cer tain to con ceal th e con tour of th e graft on th e skin .13

Rasping In som e cases w ith bony pyram idal deform it ies, rasp ing can be a conven ien t surgical m odalit y. If th e bony pyram id h as a sym m et ric arch bu t th e dorsal p ro le is deviated or deform ed, th e rasp can be solely applied to correct

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II Rhinoplast y th e deform it ies. In m any cases, rasping is used to t rim th e dorsal con tou r before bony pyram idal recon st ruct ion of asym m et rical n asal bon es th rough osteotom ies. It sh ou ld be n oted th at rasping m ust be perform ed carefully w ith con siderat ion of h ow th e bony pyram id w ill be posit ion ed after th e recon st ru ct ion .

ten t , an d double lateral (Fig. 6.5). Th ough osteotom ies are u sually perform ed un dern eath th e soft t issue envelop e, a percut an eous extern al approach can be used for lateral an d t ran sverse osteotom ies. Pun ct ure site visibilit y after percutan eous osteotom y is n egligible.16 To produ ce an accurate fract u re lin e despite an atom ic di cu lt ies, th e t ip of th e osteotom e sh ould alw ays be sh arp.

Osteotom y Th e osteotom y is on e of th e m ost essen t ial bu t di cu lt tech n iqu es of correct ive rh in oplast y. It involves cut t ing th e n asal pyram id bon es to correct a deviat ion . With out osteotom ies, th e deviated bony dorsu m can n ot be com p letely corrected. Th e osteotom y is a blin d procedure, w ith n o direct visualizat ion of cut t ing lin es; th erefore, it is ch allenging to learn . Th u s, surgeon s sh ould m ake an e ort to gain reliable an d reprodu cible su rgical skills. To avoid un n ecessar y com plicat ion s, it is essen t ial to h ave sou n d kn ow ledge of th e basic an atom y of th e bony dorsu m before perform ing an osteotom y. Th e bony dorsu m is com p osed of th e fron t al bon e, n asal bon e, an d fron tal process of th e m axilla; an d th ese st ruct ures are join ed togeth er. Th e ch aracterist ics of th e bon e, especially ch anges in th ickn ess, sh ou ld be un d erstood . Gen erally, th e n asal bon e is th icker in m en th an in w om en . It is th ickest at th e n asofron tal su t u re lin e (5 to 6 m m ) an d th en becom es progressively th in n er tow ard th e low er m argin (2 to 3 m m ).14,15 Th e lateral w all of th e bony dorsum con sist s of th e n asal bon e an d th e fron tal process of th e m axilla, an d th e th ickn ess of th e lateral p rocess is less th an 2.5 m m . Th ere are various t ypes of osteotom y, in cluding m edial (m edial obliqu e, param edian ), lateral, t ran sverse, in term it-

3

Lateral Osteotomy Th e purpose of th e lateral osteotom y is to cu t th e n asal dorsu m from th e side w all. It en ables th e su rgeon to obtain com plete m obilit y of th e n asal bon es an d th en reposit ion th em on th e m idlin e. As sh ow n in Fig. 6.6, th e lateral osteotom y m akes a con t in uous cu r ved fract ure lin e on th e lateral asp ect of th e bony pyram id w ith an osteotom e an d h am m er. En don asal osteotom y is frequen tly perform ed u sing th e vest ibular approach . First , a sm all lin ear in cision is m ade w ith a n o. 15 blade on th e lateral en don asal w all at th e an terior m argin of th e in ferior t urbin ate. Th en iris scissors are in serted to dissect th e soft t issu es in th e su bp eriosteal plan e along th e lateral rim of th e piriform aper t ure. Th e dissect ion on ly n eeds to be w ide en ough to in sert a gu ard ed osteotom e (cu r ved or st raigh t). W h en determ in ing th e start poin t of a lateral osteotom y, Webster’s t riangle, w h ich is a sm all t riangular port ion of th e fron t al process of th e m a xilla, sh ould be preser ved because th e in ferior t urbin ate in ser ts in to th is st ruct ure. Oth er w ise, th e in tern al valve m ay be com p rom ised (Fig. 6.6). Th e t riangle can be preser ved by start ing th e osteotom y at th e sligh tly an terosu p erior p oin t of th e p iriform ap ert u re edge.17 Th rough caut ious palpat ion of th e guard t ip, th e lateral osteotom y

Fig. 6.5 Various t ypes of osteotomy. Compared with a medial oblique osteotomy, a paramedian osteotomy is more useful in the patient with short, narrow nasal bones.

4

2 1 5 1 Lateral osteotomy 2 Medial osteotomy (medial oblique) 3 Transverse osteotomy 4 Medial osteotomy (paramedian) 5 Intermediate osteotomy

6

Fig. 6.6 Lateral osteotomy. To avoid over-narrowing of the nasal cavit y, it is recommended that a small triangular area (yellow colored area) of the piriform aperture at the level of the nasal oor be preserved. Lateral osteotomy usually begins at or just above the junction of the inferior turbinate and the lateral nasal wall.

can be con t in ued along th e design ated osteotom y lin e. Th e osteotom y sh ould stop at th e level of th e in tercan th al lin e an d ap proxim ate th e u p p er m argin of m edial osteotom y. In som e pat ien ts w h o h ave a severe asym m etric con tour or excessive convexit y of the lateral bony w all, a single lateral osteotom y is n ot en ough to con st ruct a sym m et ric n ose. In th ese cases, an addition al osteotom y on the deform ed lateral bony w all is usefu l to produ ce a sym m etric an d n at ural con cavit y of th e lateral n asal w all (dou ble osteotom y). Th e fract ure lin e sh ould be parallel to th e lateral osteotom y an d approxim ate th e n asom axillar y sut u re lin e.

Correction of the Deviated, Twisted Nose

m argin , m ed ial m ovem en t of th e n asal bon e can in du ce a green st ick fract u re of th e m edial an d u pp er p or t ion of th e nasal bon e th at is n eeded for sh ift ing of th e n asal bon e. How ever, th ese green st ick fract u res do n ot alw ays take place appropriately, an d can result in an un desirable outcom e. To avoid in com plete con n ect ion bet w een m edial an d lateral osteotom ies, a percu t an eous t ran sverse osteotom y can be perform ed. Asian s in par t icular h ave a relat ively at an d th ick bony dorsu m .18 Becau se of th ese an atom ic feat ures, a p ercut an eous t ran sverse osteotom y for back fract u re is m ore frequ en tly requ ired th an in Cau casian s. A m edial osteotom y m ay also be n eed ed for som e p at ien t s w h o h ave a bony dorsum th at is too n arrow an d requires w iden ing w ith a spreader graft . Th e upper lim it of th e m edial osteotom y sh ou ld be un der th e level of th e in tercan th al lin e, par t icularly in a param edian osteotom y. An osteotom y sh ould be su cien tly com plete to m obilize th e bony pyram id w h ile decreasing t issue t raum a as m uch as possible to ach ieve opt im al consisten cy. Th e au th or’s t ips for perform ing a safe osteotom y are as follow s: 1. Do n ot m ake periosteal elevat ion over th e n asal bon e too far laterally. Periosteal at tach m en t over th e bon es provides st abilit y of bony fragm en ts. 2. Use th e sm allest possible osteotom e. Th is m in im izes t raum a to th e soft t issue adh eren t to th e in tern al su rface. 3. Feel th e sen sat ion of th e break th rough th e bon e d uring tapping. 4. Avoid dam age to th e ju n ct ion bet w een th e u pper lateral car t ilage (ULC) an d n asal bon es. 5. Use a “low -to-h igh ” or “high -low -h igh ” lateral osteotom y to avoid com plicat ion s.

Medial Osteotomy Th e m edial osteotom y is a surgical tech n iqu e th at involves sep arat ing th e m edial aspect of th e n asal bon e from th e bony sept um . Gen erally, m edial oblique an d param edian osteotom ies are preferred am ong th e various m edial osteotom ies. Using a 2- or 4-m m osteotom e, a m edial osteotom y sh ou ld begin at the in ferior m argin of th e jun ct ion of th e n asal bon e w ith th e dorsal bony sept um , tow ard th e u pp er m argin of th e lateral osteotom y. W h en p erform ing a m edial osteotom y, it sh ou ld be n oted th at th e th ickn ess of th e bony dorsum varies con siderably by region ; th erefore, it is im port an t an d ch allenging to m ake a con t rolled aesth et ic fract ure lin e. Because th e n asal bon e gradually th icken s tow ard th e fron t al bon e, an u p p er m argin of a m ed ial osteotom y th at is too h igh can result in th e rest rict ion of m edial sh ift ing of th e n asal bon e or a rocker deform it y. Fin ally, back fract u re of th e m obilized n asal bon e is perform ed at th e level of th e m edial can th al lin e an d can be don e w ith a green st ick fract ure. After lateral osteotom y w ith superior oblique exten sion of th e upper osteotom y

Midvault and Tip Deviations Deviat ion of th e low er t w o-th ird s of th e n ose is th e m ost com plex con dit ion . Many com bin ed path ologies of th e cart ilage fram ew orks m ay coexist an d a ect each oth er. Th e surgeon sh ould evalu ate aberran t an atom y during th e operat ion . Th e m ain surgical procedures in clude th e cam ou age graft , st raigh ten ing of th e sept um along th e m id lin e, recon st ruct ion of th e an terior n asal spin e, xat ion of th e deviated low er lateral car t ilage to th e n ew ly posit ion ed sept u m , form ing a sym m et ric dom e, an d rebu ilding a rm an d st raigh t colu m ella.

Nasal Septum Th e m ost im port an t an d fun dam en tal procedure in correct ion of th e t w isted or crooked n ose is st raigh ten ing of th e n asal car t ilagin ou s sept um w ith or w ith out rein forcem en t .19 Deform ing forces cau sing sept al deviat ion m ay be

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II Rhinoplast y eith er in t rin sic or ext rin sic. Release of ext rin sic forces is essen t ial to correct th e cart ilagin ou s sept al deform it y, an d th ese preven t surgical failure or recu rren ce.20 Ext rin sic forces m ay origin ate from th e u p per lateral cart ilage, bony sept u m , n asal spin e, septal m u cosa, low er lateral car t ilage, an d colu m ellar soft t issu e. Th rough elim in ation of th e e ect s of ext rin sic forces on e by on e, a d eviated sept u m can be st raigh ten ed. If th e freely m obilized sept um sh ow s any d eform it y, in t rin sic deform ing forces m ust be add ressed an d corrected. In t rin sic forces can be released by w eaken ing th e car t ilage or th rough rein forcem en t w ith su t ures an d graft s. Th e sept um sh ould be st raigh ten ed w h ile m axim izing residual dorsal n asal su pp ort . With th ese t w o goals in m in d, th e deviated port ion of th e sept u m sh ou ld be resected w h ile p reser ving at least an 8- to 10-m m dorsal an d cau dal L-st ru t (Fig. 6.7).21 Th e resect ion can in clu de th e m a xillar y crest , th e perpen dicular plate of th e eth m oid, an d th e vom er. In th e keyston e area, th e L-st ru t sh ou ld rem ain at t ach ed to th e perpen dicular plate. In addit ion , th e at t ach m en t bet w een th e n asal spin e an d th e caudal port ion of th e L-st rut sh ould be preser ved if possible. If th e cau dal sept u m is su blu xated from th e m idlin e of th e n asal sp in e, th e sept um n eeds an atom ic correct ion w ith separat ion from th e n asal spin e an d low er lateral car t ilage, follow ed by xat ion using a gure-of-8 su t ure tech n ique (Fig. 6.8). Variou s su rgical tech n iqu es can be ap p lied for st raigh ten ing th e sept u m , in clu d ing th e sw inging door tech n iqu e, w edge resect ion , bat ten graft , sp reader graft , cu t t ing an d su t u re tech n iqu e, an d scoring an d su t u re tech n iqu e.22,23,24,25,26 In com plex cases, ext racorp oreal septop last y m ay be an e ect ive, safe, an d reliable tech n iqu e, especially for m arkedly t w isted n oses u n dergoing su rger y.27,28

Middle Third After th e st raigh ten ed n asal sept u m h as been align ed in th e m idlin e, th e m idvault m u st be recon st ructed to ach ieve an aesth et ic an d fu n ct ion al ou tcom e. Using variou s sept al su p p or t ing grafts an d p recise su t u re tech n iqu e, th e m iddorsu m sh ould be rm ly st raigh ten ed.

Fig. 6.7 L-strut of septal cartilage. It is important to preserve the L-strut with at least an 8- to 10-m m width to prevent saddle nose deformit y. The size of the L-strut depends on the strength and sti ness of the remaining septal cartilage.

Th rough m et iculous dissect ion of th e m idvault in th e su p rap erich on drial p lan e, th e n asal dorsu m is exp osed en ough to be evalu ated . After in t raop erat ive evalu at ion of any dorsal deform it ies an d cau sat ive factors for each an atom ic com pon en t , th e bilateral su bp erich on d rial d issect ion of the sept um is exten ded to th e dorsal sept u m an d across th e upper lateral cart ilage w h ile preser ving m ucoperich on drial in tegrit y. Th e dissect ion sh ould be w ide en ough to align th e sept u m to th e m idlin e. Next , th e dorsal sept u m is released from th e upper lateral cart ilage, an d th is en ables evalu at ion an d assessm en t of any in t rin sic deform it y of th e dorsal sept um . In th e presen ce of dorsal sept al deviat ion , a un ilateral or bilateral spreader graft m ay be th e t reat m en t of choice (Fig. 6.9). Th e spreader graft acts to x th e dorsal sept um in to a st raigh t orien t at ion an d p reven t late ret u rn of th e deform it y. In addit ion , th e graft s can m ain t ain or restore th e in tegrit y of th e in tern al n asal valves. Th e ideal graft m ate-

Fig. 6.8 Repositioning of the dislocated caudal septum . When the caudal septum is subluxated, it is frequently necessary to separate the cartilaginous septum from the underlying bone. Then disarticulated cartilage should be xed to the anterior nasal spine using sutures.

6

Correction of the Deviated, Twisted Nose

Lower Third

Fig. 6.9 Spreader graft. After separation of the upper lateral cartilage from the septal cartilage, a spreader graft is inserted and xed using 4–0 PDS. This procedure is helpful in widening the air passage as well as in cosmetic improvement of m iddle-third deviation.

rial is septal car t ilage, esp ecially th e p osteroin ferior p ort ion , w h ich h as th e m ost con sisten t w idth . Th e grafts are secu red w ith several 5–0 PDS m at t ress su t u res p arallel to th e dorsal sept u m . To decrease th e likelih ood of recurren ce, th e deviated sept al cart ilage can be cross-h atch ed before su t u ring. In th e case of ou t w ard bow ing of th e m idvau lt on th e convex side of th e dorsum , a bat ten graft can be placed below the jun ct ion of th e sept um an d upper lateral car t ilage. As sh ow n in Fig. 6.10, sligh t dorsal d eviat ion can be st raigh ten ed th rough th e di eren t ial su t u re bet w een th e u p p er lateral cart ilage an d septal d orsu m .29 Sim ilarly, th is su t u re tech n iqu e can be u sed to correct rem n an t deviat ion after a sp reader graft .30

a

As in th e m idvault , correct ion of low er-th ird deform it ies is based on h ow to m ake a st raigh t an d st rong caudal sep t um . Deform ing forces from th e cart ilagin ous fram ew ork of th e m idvault frequen tly a ect th e t ip; th erefore, a carefu l dissect ion is som et im es n eeded to det ach th e low er lateral car t ilages from th e up per lateral cart ilage. If th e caudal sept um is n ot in th e m idlin e, it sh ould be carefully released from th e m axillar y crest an d an terior n asal spin e an d a xed to th e m idlin e. Fu rth erm ore, if th ere is congen ital deform it y or post t raum at ic ch ange of th e an terior n asal spin e or m axillar y crest it self, th ese deform it ies sh ou ld be preferen t ially corrected. Caudal deviat ion of th e sept um can be e ect ively corrected w ith an exten ded spreader graft or sept al bat ten graft u sing h ar vested car t ilagin ou s an d bony sept u m .31 Th e n ext step is to create a rm ver t ical st ru t in th e m idlin e. A sept al exten sion graft is u sefu l w h en th e t ip is w eak or d eviated . It is e ect ive for obt ain ing a st raigh t cau dal en d an d p rom in en t project ion . How ever, on e m u st be carefu l to avoid fu n ct ion al n asal obst r u ct ion cau sed by th e th icken ed cau dal sept u m , an d th e p at ien t sh ou ld be in form ed of th e loss of exibilit y of t h e m em bran ou s sept u m . Th e en d of th e sept al exten sion graft sh ou ld be beveled an d is a xed to th e cau dal sept u m w ith m u lt ip le an ch oring su t u res. Th e sept al exten sion graft act s as a reliable st ru t n ot on ly for su p p or t ing th e low er lateral car t ilages, bu t also to con t rol t ip p osit ion an d de n it ion (Fig. 6.11). Th e d egree of t ip p roject ion an d rot at ion , an d t h e colu m ellar pro le an d st rengt h can be deter m in ed by t h e size an d sh ape of t h e design ed graft an d th e p osit ion . A m ore st able colu m ella recon st r u ct ion is obt ain ed th rough t ight xat ion of each of th e m iddle an d m edial cr u ra to th e septal exten sion graft .

b

Fig. 6.10 Oblique suture to correct cartilaginous deviation. Compared with the horizontal suture, the di erentially oblique suture provides force to draw deviated septal cartilage to the midline. This technique can be used to correct the cartilaginous deviation (a) without or (b) with a spreader graft.

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II Rhinoplast y an d skin ad h esive, th e n asal dorsu m is t aped w ith ¼-in ch paper tape. St rips of di eren t length s are carefully applied t ran sversely from th e bony dorsum to th e suprat ip w h ile avoiding excessive pressu re over th e recon st ructed fram ew ork. Sym m et ric long st rip s are ap plied from th e bony dorsu m along th e cau dal asp ect of th e n asal lobu le to su p port th e t ip. An extern al splin t is applied for pat ien t s w h o h ave u n dergon e osteotom ies to su ppor t th e reposit ion ed st ru ct ures an d to con t rol bon e bleeding. Th e splin t is placed over th e u pper t w o-th irds of th e dorsum w h ile com pressing m edially. Th e low er m argin of th e splin t sh ou ld n ot exten d over th e su p rat ip area to avoid dead sp ace bet w een th e su p rat ip skin an d th e u n derlying fram ew ork. After 5 to 7 days, colum ellar sut ures, skin t ape, an d th e extern al splin t are gen tly rem oved. Fig. 6.11 Septal extension graft to correct the caudal deviation. The septal extension graft is a very useful technique to correct caudal deviation when the tip is weak and resilient.

Th e sym m et r y of th e lateral crus an d dom es sh ould be evaluated an d properly corrected. Th e in terdom al ligam en t is su t u red to th e dom al segm en t of th e sept u m or th e exten sion graft . Th e a xat ion sh ou ld be adju sted for ideal sym m et r y of each d om e. Th e cep h alic border of th e lateral cru s can be t rim m ed to be in lin e w ith th e pro le con tou r of th e exten sion graft .

Wound Closure and Dressing If an extern al app roach is ap plied, th e colu m ella in cision sh ou ld be rep aired rst . Su bcu t an eou s ap p roxim at ion w ith 5–0 vicr yl sh ould be follow ed by m et icu lou s skin closure w ith 6–0 nylon . Several quilt ing sut ures are n eeded on th e dissected m ucoperich on drial ap, an d a sm all m ucosal in cision can be m ade on on e side of th e sept u m to p reven t septal h em atom a, if n eeded. In tern al sp lin t s, su ch as a silast ic sh eet , can be ap plied to avoid h em atom a bet w een th e m ucoperich on drial aps an d to st abilize the recon st ru cted st ru ct u res, w h ich p rom otes th e h ealing process an d preven t s m u cosal p roblem s like syn ech iae. A single th rough -an d-th rough sut ure is su cien t to x th e splin t to th e sept u m . Prophylact ic an t ibiot ics are n eeded w h ile th e splin t is in place. Splin t s are gen erally rem oved 1 to 2 w eeks after su rger y in th e ou t pat ien t depart m en t . In cases of exten sive sept al recon st ruct ion , th e splin t s rem ain in place for longer periods (u p to 3 w eeks). Soft n asal packing (e.g., NasoPore, Gelfoam ) is en ough to con t rol bleeding an d to su p p or t a ap or graft . Packing is rem oved w ith in 1 to 2 days. Extern al dressings are com posed of soft t issue t aping an d an extern al sp lin t . After skin prep arat ion w ith alcoh ol

■ Postoperative Management Prophylact ic an t ibiot ics are used w h ile th e n asal splin t is ap plied. Sh ort-term , h igh -dose steroids can be u sed in t raoperat ively an d postoperat ively to m in im ize w ou n d edem a. Gen erally, pat ien t s w h o h ave u sed an t icoagu lan t s are in st ru cted to stop th e m edicat ion for 1 w eek p reop erat ively an d can begin th e m edicat ion 5 to 7 days p ostop erat ively. An algesics for p ostop erat ive p ain are p rescribed as n eed ed . Pat ien ts sh ou ld avoid st rain ing related to con st ip at ion or n au sea, an d prop hylact ic m edicat ion for th e causes of st rain ing sh ould be prescribed as n eeded. An t ibiot ic oin t m en t sh ould be applied to th e in cision site daily. Salin e n asal sp ray is u sed th ree to fou r t im es daily to keep m u cosal su rfaces m oist an d clean . Pat ien t s sh ou ld avoid su n exposu re to facial bru ises to p reven t skin p igm en tat ion . At a m in im u m , pat ien t s sh ou ld be seen in follow -u p at 1 w eek, 1 m on th , 3 m on th s, an d 6 m on th s, an d p ostoperat ive m edical ph otography sh ould be obt ain ed. Th ereafter, pat ien t s sh ould be evaluated ever y 1 to 2 years to assess long-term result s.

■ Key Technical Points 1. Th e deviated n ose con sists of a bony upper th ird an d cart ilagin ou s low er t w o-th irds, an d each com par t m en t sh ould be assessed con sidering di eren t su rgical con cept s an d tech n iqu es. 2. Th e ch oice of approach depen ds on a surgical plan th at is based on an accurate preoperat ive clin ical an alysis. 3. Th e m idvault an d t ip are dissected in th e su p rap erich on drial plan e, an d th e bony dorsu m requires subperiosteal dissect ion . 4. Precise osteotom y is a key procedure for correct ing bony pyram idal deform it ies.

6 5. In correct ion of th e t w isted n ose, st raigh ten ing an d rein forcem en t of th e n asal car t ilagin ou s sept um are th e m ost im port an t p rocedu res. For th is, th e sept u m sh ou ld be released from ext rin sic d eform ing forces, w ith su bsequ en t assessm en t of th e in t rin sic d eform it ies, w h ile preser ving th e L-st rut . 6. The in tegrit y of th e keyston e area m ust be m ain t ain ed an d th e cau dal en d of th e L-st ru t sh ou ld be rm ly a xed to th e an terior n asal spin e using a gu re-of-8 su t u re. If th e an terior n asal sp in e is d isp laced, it sh ou ld be rep osit ion ed. 7. A spreader graft is a usefu l tool for sim ultan eous st raigh ten ing an d rein forcem en t of th e car t ilagin ou s d orsu m . 8. Tip correct ion is based on a st raigh t an d st rong caudal sept u m as a reliable ver t ical st rut in th e m idlin e. 9. The a xat ion of low er lateral car t ilages sh ould be adju sted for ideal sym m et r y of each dom e at th e m idlin e.

Correction of the Deviated, Twisted Nose

year after su rger y; th erefore, th e pat ien t sh ou ld be given reassu ran ce. In som e cases w ith excessive scarring, local steroid (t riam cin olon e acetate) inject ion m ay be h elpfu l. Su p er cial inject ion sh ou ld be avoided to preven t w h it ish pigm en t at ion . Of n ote, steroid inject ion can resu lt in sub derm al at rophy w ith subsequen t u n desirable problem s, in cluding dorsal con tour deform it ies an d t ran slu cen cy of th e epiderm is.

Dorsal Irregularity/ Deviation In som e p at ien ts, dorsal deviat ion or irregu larit y can presen t d u ring th e p ostoperat ive p eriod. Th e cau se an d degree of deform it ies sh ould be evaluated to determ in e w h eth er revision surger y is n eeded. Com m on causes of late bony deviat ion are listed below. Im m ediate postoperat ive deviat ion sh ould be reassessed as soon as possible, an d m in or deform it ies in th e early postoperat ive period can be corrected w ith m an ual pressure. If revision is required, it can be don e 6 to 12 m on th s after th e prim ar y surger y.

10. The colum ellar in cision sh ould be repaired w ith m et icu lou s su t u ring w ith ou t ten sion .

■ Complications and Their Management

Causes of late deviation of the bony pyramid include : • In com p lete osteotom ies: in com p lete con n ect ion

Bleeding/ Hematoma Sligh t postop erat ive oozing is com m on in th e rst 48 h ou rs after rh in op last y. Toilet gau ze d ressing is h elp fu l to redu ce pat ien t discom fort , an d h ead elevat ion can reduce bleeding by decreasing ven ous pressu re. If bleeding persists, th e su rgeon sh ou ld im m ediately evalu ate th e w ou n d. W h en fu rth er n asal p acking is n ot en ough to con t rol bleeding, th e su rgeon sh ou ld con sider tot al rem oval of p acking m aterials an d reevalu at ion of th e n asal cavit y. A pat ien t w h o com plain s of un con t rolled n asal pain sh ould be assessed for sept al h em atom a. Regardless of locat ion , postoperat ive h em atom as requ ire im m ediate drain age. An u n t reated sep tal h em atom a can result in devastat ing com plicat ion s, such as sept al abscess an d p erforat ion . In ser t ion of a silast ic drain in to th e drain age site of th e h em atom a h elps preven t recurren ce.

Persistent Edema Postop erat ive edem a u su ally occu rs w ith in th e rst 4 w eeks. Variou s m odalit ies are available to m in im ize edem a, in clu ding cold com presses, h ead elevat ion , t aping, an d perioperat ive steroids. Late edem a can be obser ved several m on th s postop erat ively, an d it origin ates from ongoing scar rem odeling. Most late edem a is self-lim ited arou n d th e rst

• •

bet w een th e m edial an d lateral osteotom ies. Mem or y of th e overlying soft t issu e can p u ll th e n asal bon e to th e origin al posit ion . In com p lete correct ion of th e p osterior–su p erior de ect ion of th e bony sept um . In su cien t correct ion of deform it ies of th e cart ilagin ous low er t w o-th irds.

■ Case Studies Case 1 A 22-year-old m an presen ted w ith a crooked n ose th at had a C-sh aped deform it y of th e sept u m to th e righ t w ith su bject ive n asal obst ru ct ion on th e righ t side. Th e brow t ip aesth et ic lin es w ere asym m et ric, an d th e bony an d cart ilagin ou s d orsu m w as o th e m idlin e (Fig. 6.12). Th is case required correct ion s of both th e bony dorsum an d th e m idvau lt; th erefore, op en correct ive rh in oplast y w as perform ed. Th e au th or p refers to u se th e extern al ap proach to correct th e low er t w o-th irds deviat ion , w h ich usu ally n eeds a spreader graft or septal exten sion graft . Th rough th e extern al approach th e auth or can con den tly ap ply graft m aterials as w ell as evalu ate th e an atom ic

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II Rhinoplast y abn orm alit ies. In term s of order of procedu res, septoplast y is carried ou t rst after elevat ion of th e skin soft t issu e envelop e. If th ere is a h u m p deform it y, rasp ing or h u m p ectom y is don e. Th e n ext step is to correct th e low er t w oth irds deform it ies using graft ing an d sut ure tech n iques. This is follow ed by t ip surger y, w h ich is m ain ly for cosm et ic p u rposes. Medial an d lateral osteotom ies are usually don e at th e en d of th e operat ion to avoid soft t issu e sw elling du ring su rger y. In cases w ith a w ide alar base, its correct ion w ill be th e n al procedu re.

a

b

c

d

In th is case, su rgical tech n iqu es in clu ded lateral an d m edial osteotom ies, release of th e cart ilagin ou s sept u m from th e u pp er lateral car t ilage, a left-sided sp read er graft , septoplast y, rep osit ion ing an d rein forcem en t of th e cau dal sept al L-st rut w ith a gu re-of-8 su t ure an d colu m ellar st rut , ceph alic t rim of th e low er lateral car t ilage, an d in terdom al su t ure on th e t ip. Th e pat ien t w as sat is ed w ith th e fu n ct ion al an d aesth et ic ou tcom es after su rger y. At 1 year after th e su rger y, th e dorsu m h ad a sym m etric con tou r w ith ou t any p ostop erat ive distor t ion .

Fig. 6.12 Case 1. (a,b) Preoperative frontal and bird’s-eye views show a C-shaped deviated bony and cartilaginous dorsum. (c,d) Postoperative photographs show a straightened nose.

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Correction of the Deviated, Twisted Nose

e Fig. 6.12 (Continued) (e) Surgical diagram showing the techniques used.

Case 2 A 27-year-old w om an presen ted w ith a n asal d eform it y w ith out any h istor y of n asal t raum a or surger y. Her ch ief com plain t w as a deviated n ose w ith sligh t n asal st u n ess on th e righ t side. As sh ow n in preoperat ive m edical ph otography, h er bony dorsu m w as st raigh t bu t h ad a sm all h um p an d th e m idvau lt w as deviated to th e righ t side (Fig. 6.13).

By m ean s of an extern al approach , th e h um p w as rem oved u sing rasping, an d a left-sided exten ded spreader graft an d in terdom al su t u re w ere u sed to st raigh ten th e m idvau lt an d t ip . Th e sept al d eviat ion w as corrected w ith a caudal w edge excision of th e sept um . Ph otograp h s taken 14 m on th s after su rger y sh ow sym m etric brow t ip aesth et ic lin es an d a w ell-p osit ion ed dorsu m in th e m idlin e.

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b

c

d

e

f

Fig. 6.13 Case 2. (a–c) Preoperative photographs show straight bony pyramid but deviated cartilaginous dorsum with mild hump. (d–f) Postoperative photographs show well-aligned dorsum with reduced hump.

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g Fig. 6.13 (Continued) (g ) Surgical diagram showing techniques used.

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References

16. Gr yskiew icz JM. Visible scars from percu t an eou s osteotom ies. Plast Recon st r Su rg 2005;116(6):1771–1775

1. Roxbur y C, Ish ii M, Godoy A, et al. Im pact of crooked n ose rh in oplast y on obser ver p ercept ion s of at t ract iven ess. Lar yngoscop e 2012;122(4):773–778

17. Bloom JD, Im m erm an SB, Con st an t in id es M. Osteotom ies in th e crooked n ose. Facial Plast Su rg 2011;27(5): 456–466

2. Cingi C, Eskiizm ir G. Deviated nose at ten uates th e degree of pat ien t sat isfact ion an d qu alit y of life in rh in op last y: a p rospect ive con t rolled st u dy. Clin Otolar yngol 2013;38(2):136–141

18. Jang YJ, Alfan t a EM. Rh in op last y in th e Asian n ose. Facial Plast Su rg Clin North Am 2014;22(3):357–377

3. Hafezi F, Nagh ibzadeh B, Nouh i A, Yavari P. Asym m et ric facial grow th an d deviated n ose: a n ew con cept . An n Plast Su rg 2010;64(1):47–51 4. Pot ter JK. Correct ion of th e crooked n ose. Oral Maxillofac Su rg Clin North Am 2012;24(1):95–107 5. Ch o GS, Kim JH, Yeo NK, Kim SH, Jang YJ. Nasal skin th ickn ess m easured using com puted tom ography an d it s effect on t ip su rger y outcom es. Otolar yngol Head Neck Surg 2011;144(4):522–527 6. Stepn ick D, Guyu ron B. Surgical t reat m en t of th e crooked n ose. Clin Plast Su rg 2010;37(2):313–325 7. Din i GM, Iurk LK, Ferreira MC, Ferreira LM. Graft s for st raigh ten ing deviated n oses. Plast Recon st r Surg 2011;128(5):529e–537e 8. Sh ipchan dler TZ, Papel ID. Th e crooked n ose. Facial Plast Su rg 2011;27(2):203–212 9. Bagh eri SC, Khan HA, Jah angirn ia A, Rad SS, Mort azavi H. An an alysis of 101 prim ar y cosm et ic rh in op last ies. J Oral Maxillofac Su rg 2012;70(4):902–909 10. Jang YJ, Wang JH, Lee BJ. Classi cat ion of th e deviated n ose an d it s t reat m en t . Arch Otolar yngol Head Neck Surg 2008;134(3):311–315

19. Sykes JM, Kim JE, Sh aye D, Boccieri A. Th e im port an ce of th e n asal sept u m in th e deviated n ose. Facial Plast Su rg 2011;27(5):413–421 20. Roh rich RJ, Adam s W P Jr. Nasal fract u re m an agem en t: m in im izing secon dar y n asal d eform it ies. Plast Recon st r Surg 2000;106(2):266–273 21. Roh rich RJ, Gu n ter JP, Deu ber MA, Adam s W P Jr. Th e deviated n ose: opt im izing results using a sim pli ed classi cat ion an d algorith m ic approach . Plast Recon st r Surg 2002;110(6):1509–1523, discu ssion 1524–1525 22. Jang YJ, Yeo NK, Wang JH. Cu t t ing an d su t u re tech n iqu e of the caudal sept al cart ilage for th e m an agem en t of caudal sept al deviat ion . Arch Otolar yngol Head Neck Su rg 2009;135(12):1256–1260 23. Pastorek NJ, Becker DG. Treat ing th e cau dal sept al de ect ion . Arch Facial Plast Su rg 2000;2(3):217–220 24. Sh een JH. Spreader graft: a m eth od of recon st ru ct ing th e roof of th e m iddle n asal vau lt follow ing rh in oplast y. Plast Recon st r Su rg 1984;73(2):230–239 25. Roh rich RJ, Hollier LH. Use of sp reader graft s in th e extern al approach to rh in oplast y. Clin Plast Surg 1996;23(2): 255–262 26. Byrd HS, Salom on J, Flood J. Correct ion of th e crooked n ose. Plast Recon st r Su rg 1998;102(6):2148–2157

11. Boh lu li B, Moh aram n ejad N, Bayat M. Dorsal h u m p su rger y an d lateral osteotom y. Oral Maxillofac Surg Clin North Am 2012;24(1):75–86

27. Lee SB, Jang YJ. Treat m ent outcom es of ext racorporeal sep toplast y com pared w ith in sit u sept al correct ion in rhinoplast y. JAMA Facial Plast Surg 2014;16(5):328–334

12. Higu era S, Lee EI, Cole P, Hollier LH Jr, St al S. Nasal t rau m a an d th e deviated n ose. Plast Recon st r Surg 2007;120(7, Su p pl 2):64S–75S

28. Gu bisch W. Ext racorp oreal septoplast y for th e m arkedly deviated sept um . Arch Facial Plast Surg 2005;7(4): 218–226

13. Toriu m i DM. St ru ct u re ap proach in rh in op last y. Facial Plast Su rg Clin North Am 2005;13(1):93–113

29. Pon t iu s AT, Leach JL Jr. New tech n iqu es for m an agem en t of th e crooked n ose. Arch Facial Plast Surg 2004;6(4): 263–266

14. Harsh barger RJ, Su llivan PK. Th e opt im al m ed ial osteotom y: a st u dy of n asal bon e th ickn ess an d fract u re p at tern s. Plast Recon st r Su rg 2001;108(7):2114–2119, discu ssion 2120–2121 15. Harsh barger RJ, Su llivan PK. Lateral n asal osteotom ies: im p licat ion s of bony th ickn ess on fract u re pat tern s. An n Plast Su rg 1999;42(4):365–370, discu ssion 370–371

30. Guyu ron B, Beh m an d RA. Cau dal n asal deviat ion . Plast Recon st r Surg 2003;111(7):2449–2457, discussion 2458– 2459 31. Byrd HS, An doch ick S, Copit S, Walton KG. Sept al exten sion graft s: a m eth od of con t rolling t ip project ion shape. Plast Recon st r Su rg 1997;100(4):999–1010

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Correction of the Saddle Nose

Keng Lu Tan and Chae-Seo Rhee

Pearls • Evalu at ion of th e degree of sept al su p p or t is th e

• •

•

m ost im p or tan t step in p reop erat ive p lan n ing in a pat ien t w ith saddle n ose deform it y. Th is is becau se a sadd le n ose is often du e to a dam aged car t ilagin ou s sept u m . Class 1 saddle n ose has good cart ilagin ous sept al su p p or t w ith a m in or su p ra-t ip dep ression . Th is can be easily corrected by cosm et ic dorsal cam ou age. Class 2 saddle n ose has m oderate loss of sept al cart ilagin ous support w ith m oderate dorsal depression , w h ich can be m an aged by rein forcem en t an d recon st it u t ion of th e sept u m an d/or dorsu m . Class 3 saddle n ose has severe loss of septal cart ilagin ous support w ith a m oderate to severe

•

•

dorsal depression . Subtotal sept al recon st ruct ion w ith cost al car t ilage sh ou ld be adm in istered to correct th is saddle deform it y. Class 4 saddle n ose has severe loss of septal cart ilagin ous support w ith both bony an d cart ilagin ous dorsal depression , in w h ich case th e dorsal fram ew ork from th e radix to th e t ip n eeds to be tot ally recon st ructed w ith cost al cart ilage. Correct ion frequen tly requires st raigh ten ing or recon st it u t ing th e L-st ru t . A st able L-sh aped st rut of sept al car t ilage to th e n asal spin e is crucial to su p p or t th e u p per an d low er lateral cart ilages to m a xim ize th e resu lts in creat ing a st raigh t an d fu n ct ion al n ose.

■ Introduction

■ Anatomic Considerations

Nasal deform it ies a ect ing m ain ly th e low er t w o-th ird s of th e n ose due to th e loss of sept al h eigh t an d t ip support are d e n ed as “sadd le n ose” d eform it ies (Fig. 7.1). A sad dle n ose w as rst described by Joh n Orlan do Rose in 1887 as a “p ug n ose.” A p ug is a kin d of can in e w ith an alm ost com plete absen ce of a sn out or n asal dorsum . Th e depression n oted on th e m iddle vau lt of th e n asal dorsal su rface resem bles th e saddle of a h orse—h en ce th e term saddling. Com plex deform it ies of th e n asal sept um can h ave both an aesth et ic an d a fu n ct ion al im p act on a p at ien t’s n ose. If th ere is a severe com prom ise of th e cart ilagin ou s sept al in tegrit y w ith su bsequen t loss of m iddle vault su pp ort by th e sept u m , dorsal depression develops, follow ed by loss of t ip de n it ion an d oth er associated feat u res (Fig. 7.2 an d Fig. 7.3).1,2 Th is kin d of n asal deform it y is often ver y d ist ressing to th e pat ien t as th e deform it y is obvious an d u n at t ract ive. Fun ct ion ally, pat ien t s can com p lain of n asal obst ruct ion due to th e collapse of th e in tern al n asal valve. W h ile saddle n ose deform it y is caused by th e loss of septal su pport an d sh ow s a t ru e loss of dorsal h eigh t , a pseu do sad dle is a relat ive depression of th e su prat ip region cau sed by a h u m p n ose. For correct ion , a saddled n ose requ ires th e recon st ru ct ion of th e sca old of th e dorsu m —for in stan ce, th e sept u m —bu t a pseu do saddle n eed s to h ave th e h um p resected to allow th e suprat ip region to look n orm al again .

Saddling of th e n ose is essen t ially cau sed by th e loss of nasal sept al support for th e dorsum of th e n ose. Support of th e n asal dorsum is provided by th e cart ilagin ous an d bony st ru ct u res involved in n asal project ion . Th e n ose is d ivid ed in to th e upper, m iddle, an d low er th irds, com m on ly know n also as th e u pp er, m iddle, an d low er vau lt s. Th e upper th ird is supported by th e pyram id of th e nasal bon e. Th e in terlocking of th e quadrangular cart ilage w ith th e n asal bon e form s th e keyston e area, w h ich is th e key area th at sh ou ld be p reser ved to p reven t th e collap se of th e saddling of th e dorsum an d creat ion of th e inver tedV dorsal deform it y (Fig. 7.2). Th e qu adrangu lar car t ilage is th e single m ost im por t an t car t ilage th at support s th e low er t w o-th ird of th e nose, in clu ding th e n asal dorsum an d th e paired upper an d low er lateral cart ilages. Most of th e et iologies m en t ion ed above disrupt th e in tegrit y of th is cart ilage to cau se saddle n ose deform it y. Th erefore, correct ion of th e saddle n ose deform it y usually, if n ot alw ays, cen ters on recon st ruct ing an d reest ablish ing th e st rength of th e quadrangular cart ilage. Th e paired upper lateral cart ilages con st it u te th e lateral side of th e m iddle vau lt . Th e angle form ed by th e u p p er lateral car t ilage an d th e n asal sept um is th e in tern al n asal valve. Sin ce th e st rength of th e u p per lateral car t ilages relies h eavily on th e n asal sept um , loss of support in th e nasal sept um w ill resu lt in collapse of th e in tern al n asal

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Fig. 7.1 Saddle nose and pseudo saddle. (a) Saddle nose shows loss of dorsal height and support of the underlying nasal septal structures with upward rotated tip. (b) As opposed to the presence of saddle, the depression is due to an abnormal protrusion over the dorsum rather than a true depression itself.

b

a Fig. 7.2 The keystone area and saddle. (a) Quadrangular cartilage, as seen in the illustration, forms the single most important support structure for the nasal dorsum. The area of overlapping with the nasal bone and upper lateral cartilage, the keystone area, deserves particular attention. (b) When the keystone area is interrupted, it causes instabilit y to the quadrangular cartilage and thus saddling of the nasal dorsum, with a resulting inverted-V deformit y.

valve. Rect ifying a saddle n ose w ith ou t addressing th is area w ill leave fu n ct ion al problem s such as n asal obst ruct ion . Low er lateral cart ilages de n e th e tip an d are also sup ported by the septal cartilage. Loss of heigh t an d w idth of the septal cart ilage w ill cause m isalignm ent of th e low er lateral cartilages, result ing in loss of tip de nit ion, t ip ptosis, cephalic rotat ion, and retrusion of the colum ella (Fig. 7.3).

b

■ Etiology of Saddle Nose In recen t years, m ost sadd le n ose d eform it ies h ave com e from t rau m a, an d from n asal su rgeries, in clu ding septoplast y an d rh in oplast y. In am m ator y diseases w ere com m on cau ses in th e p ast .2,3

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a

Correction of the Saddle Nose

b

c Fig. 7.3 Loss of support of the nasal septum causes distortion of the lateral cartilages. (a,b) Considerable loss of septal support causes the upper and lower lateral cartilage to distort. (c) Saddling of middle vault, tip ptosis with cephalic rotation, and columellar retrusion will develop.

Trauma

Systemic Diseases

Trau m a m ay physically dest roy th e cart ilagin ou s or bony st ru ct u res of th e d orsu m an d th e n asal sept u m . Post t rau m at ic h em atom a in th e n asal sept u m m ay be a cau se of sept al dest ru ct ion or p erforat ion du e to h em atom a organ izat ion an d resorpt ion or in fect ion an d abscess form at ion secon dar y to th e h em atom a. Saddle deform it y after t rau m a is u su ally accom pan ied by a deviated n ose, septal deviat ion , an d n asal valve collapse.

System ic diseases such as gran ulom atous diseases an d au toim m u n e diseases m ay com prom ise th e in tegrit y of th e n asal su pport ing st ruct ures an d cause saddle n ose deform it y. Gran ulom atous diseases such as Wegen er’s gran u lom atosis; in fect ion su ch as lep rosy an d syp h ilis; an d au toim m u n e diseases su ch as relap sing polych on drit is, sarcoidosis, an d Croh n’s disease m ay dest roy th e septal car t ilage along th e disease process du e to ch ron ic in am m at ion .

Iatrogenic Factors

Malignancy

Sa d d le n ose cou ld a lso b e a se con d ar y d efor m it y d u e t o resor p t ion or a p rob le m at ic im p lan t u se d in n a sa l se p t u m or n a sa l d or su m re con st r u ct ion , esp e cia lly if t h e keyst on e a rea is in flict e d d u r in g se p t op la st y or rh in op last y. Ove r - rese ct ion of t h e qu a d ra n gu la r ca r t ilage cau sin g w ea ke n in g of t h e se p t a l ca r t ilage d u r in g su r ge r y cou ld resu lt in sa d d lin g. It is t h e refore im p or t an t t o p re se r ve at le ast 10 m m of t h e d or sal a n d ca u d al p a r t of t h e qu a d ran gu la r ca r t ilage w h e n cu t t in g t h e n a sa l se p t u m . Som et im es sa d d lin g ca u se d by n a sa l su rge r y w ill n ot b e ap p are n t im m e d iat ely a ft e r t h e su r ge r y b u t w ill slow ly m an ifest ove r t im e.

NK-T-cell lym p h om a, squ am ou s cell carcin om a, m align an t m u cosal m elan om a, aden ocarcin om a, m in or salivar y glan d t um ors, an d m etast at ic lesion s are just som e of th e m alignan cies kn ow n to dest roy st ruct ures th at provide dorsal su p p or t to th e n ose, in du cing saddling.

Vascular Ischemia of the Nasal Septum A classical cau se of saddling is sept al p erforat ion du e to cocain e abuse, secon dar y to th e repeated an d sustain ed act ion of su cking in cocain e th rough th e n ose. Isch em ia to

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II Rhinoplast y th e n asal septal vasculat u re w ill even t ually result in a large sept al perforat ion , especially in th e cart ilagin ou s p or t ion , an d collap se of th e dorsu m . Sim ilar assau lt to th e n asal sep t um could be caused by prolonged use of oxym et azolin e n asal sp ray or oth er vasocon st rict ive agen ts.

■ Patient Evaluation Assessment of the Patient Histor y of t rau m a, previou s su rger y, system ic diseases, u se of a top ical vasocon st rictor, an d cocain e abuse sh ould be elicited. Det ails of previous su rger y an d th e surgical m an ip u lat ion cou ld give in sigh t in to th e available rem n an t cart ilage an d st ruct ural de cien cy th at h as resulted in th e sadd ling. Proper con sult at ion w ill st art w ith th orough an atom ic evalu at ion for factors th at could a ect th e n asal deform it ies. Carefu l palpat ion an d in spect ion can reveal th e relat ion am ong th e st ruct ural deform it ies in cluding th e n asal sept u m , car t ilagin ou s an d bony dorsu m , t ip , n asal valve, an d t u rbin ate. Th e resist an ce an d resilien ce of cart ilage sh ou ld be evalu ated in accordan ce w ith th e st rength an d sh ape of th e t ip an d cau dal sept u m . Descript ion of th e n ose sh ou ld be m ad e from all angles. In th e p h otos, th e lateral n asal length , th e degree of depression , th e presen ce of colu m ellar ret ract ion , an d th e degree of t ip rot at ion /derot at ion sh ould be carefully n oted. In gen eral, saddle n ose sh ow s a broad d orsu m , w ide base, an d inver ted-V deform it y in case of keyston e area dam age on fron tal view. Lateral an d oblique view s reveal low er pro le dorsum , saddling, ret racted an d sh ort colu m ella, low p roject ion of th e t ip , an d cep h alic rot at ion in severe cases. Th e basal view reveals a low t ip, rou n d an d ared n ost rils, sh or t colu m ella, an d w id e base (Fig. 7.3). Th e presen ce of a dorsal h um p th at gives rise to a saddled ap pearan ce m u st n ot be con fu sed w ith p seu do saddle. Nasal cavit y evalu at ion sh ou ld be perform ed also. Sept al evalu at ion is crit ical for evalu at ion of t rau m at ic deform ed n ose. Som et im es overlapping fract ured car t ilage an d rep lacem en t of scar t issu e in th e a ected car t ilage or fract u re lin es can m ake sept al m u cosa elevat ion di cu lt . Nasal valve obst ru ct ion sh ou ld be assessed clin ically follow ed by acoust ic rh in om et r y or rh in om an om et r y tests, w h ich could docu m en t an d assess th e level of obst ruct ion prior to th e surger y. Th e availabilit y of sept al cart ilage, sep tal perforat ion , an d any deviat ion sh ould be carefully n oted during en doscopic exam in at ion to facilitate plan n ing of th e su rger y. If en doscopic n dings suggest oth er m edical p roblem s cau sing th e loss of septal cart ilage, be sure th at th e pat ien t is screen ed for autoim m un e or in fect ious diseases, as previou sly discu ssed, before th e rep air is p lan n ed .

After extern al an d in tern al exam in at ion , discu ssion about th e p referred sou rces of graft s is m an dator y. Pat ien t s sh ould be given th e ch oice of au tologou s, h om ologou s, or syn th et ic graft s dep en d ing on th e circu m st an ces after th e pros an d con s of each opt ion h ave been discussed. Rib cage view s cou ld be n ecessar y if rib cart ilage graft ing is p lan n ed . Most p at ien t s w an t to correct th e both cosm et ic an d fu n ct ion al p roblem s. On som e occasion s, a pat ien t m ay request a h igh er project ion an d a bet ter-de n ed t ip com pared w ith th e prem orbid n ose. Th erefore, a realist ic con su ltat ion sh ou ld be carried ou t w ith th e pat ien t .

Classi cation of Saddle Nose Deformity Saddle n ose can be classi ed in to fou r grou ps th at w ill determ in e th e repair of th e n ose.3 Un derst an ding an d h aving a m ap of th e deform it y involved is th e rst step to plan n ing for a su ccessfu l ou tcom e. Class 1: Good cart ilagin ou s septal su p port w ith a m in or su p ra-t ip d ep ression . Th is can be easily corrected by cosm et ic dorsal cam ou age (Fig. 7.4a). Class 2: Moderate loss of sept al cart ilagin ou s su pp ort w ith m oderate dorsal depression , w h ich can be m an aged by sept al rearrangem en t , recon st it u t ion , rein forcem en t of th e sept um , an d recon st ruct ion of th e n asal dorsum (Fig. 7.4b). Class 3: Severe loss of sept al car t ilagin ou s su p port w ith m oderate to severe dorsal depression . Th is deform it y calls for su btot al septal recon st ruct ion (Fig. 7.4c). Class 4: Severe loss of sept al car t ilagin ou s su p port w ith both bony and car t ilagin ous dorsal depression , in w h ich case a dorsal on lay graft an d exten ded colum ellar st ru t m ust be totally recon st ructed w ith cost al car t ilage. Th is can bypass th e septal recon st ruct ion . Th e exten ded colum ellar st rut n eeds to be st abilized to th e an terior n asal sp in e (Fig. 7.4d).

■ Surgical Techniques Plan n ing for th e rep air of a sadd le n ose begin s w ith a m et iculous assessm en t . Treat m en t of th e un derlying causat ive m edical con dit ion sh ou ld be com plete or at least th e bony an d th e car t ilagin ou s st ru ct u re of th e n ose sh ou ld h ave stabilized in it s deform it y before surgical repair is un der t aken . Su rgical in ter ven t ion largely depen ds on th e degree of th e sadd ling according to th e classi cat ion system m en t ion ed previously.

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Correction of the Saddle Nose

Fig. 7.4 Four t ypes of saddle nose deformit y. (a) Class 1: Good cartilaginous septal support with a minor supra-tip depression. (b) Class 2: Moderate loss of septal cartilaginous support with moderate dorsal depression. (c) Class 3: Severe loss of septal cartilaginous support with moderate to severe dorsal depression. (d) Class 4: Severe loss of septal cartilaginous support with both bony and cartilaginous dorsal depression.

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Class 1 Saddling On ly sim p le cam ou age on th e su p ra-t ip area u sing sept al or con ch al car t ilage, soft t issue or fascia is recom m en ded for saddles in th is class. It can be ach ieved by en don asal tech n iqu es. In th in -skin n ed in dividuals, cam ou age graft s u sing cart ilage sh ould be sligh tly bruised or crush ed to preven t graft visibilit y th rough th e skin con tou r. In th ickskin n n ed in d ivid u als, bet ter-de n ed graft s m ay be n ecessar y in get t ing a d esired ou tcom e, or oth er w ise som e su bcu tan eou s t issu e can be t rim m ed from th e overlying soft t issu e cover. Pocket s of su bcu tan eou s t issu e of exact

size sh ou ld be created for in sert ion of th e cam ou age graft s to en su re th e graft st ays at w h ere it sh ou ld be. Displacem en t of th e cam ou age graft an d distor t ion of th e n al sh ap e w ill resu lt if th e size of th e p ocket created is im precise.

Class 2 Saddling In class 2 saddling, there is often loss of cartilaginous sep t um stabilit y. The stabilit y should be reconst it uted by adding struct ural support. Th us, it requires open rhin oplast y an d recon struct ion of th e dorsal fram ew ork. Such st ruct ural

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II Rhinoplast y su pport in cludes th e use of th e spreader graft, septal bat ten graft , or septal exten sion graft w ith or w ith out rein forcem en t of th e caudal sept um . Un ilateral or bilateral spreader grafts can be used as th e exten ded version or n ot , depen ding on the strength of the caudal part of the sept um . Spreader grafts are u sually obtain ed from th e sept um if th ere is su fcien t cartilage to graft. W h en h ar vest ing septal cartilage in Asians, care sh ould be taken since the cartilage is not as strong an d th ick as in Caucasian s, an d aggressive h ar vest ing of the septal cart ilage w ill only further com prom ise septal instabilit y. Thus, it is im portant th at a 1.0-cm strut be left dorsally, anteriorly, and especially at th e keyston e region. Som et im es th e straigh t part of a perpen dicular plate of eth m oid bon e can be used for reinforcem ent instead of th e septal cartilage. After th e h ar vest ing of cart ilage, spreader grafts (approxim ately t w o st rips 3 m m in w idth an d 15 to 25 m m in length each) are fashioned and placed over the dorsal strut bilaterally. They are rst xed w ith a xation n eedle an d subsequen tly anchored w ith 4–0/5–0 PDS at t w o or three posit ions (Fig. 7.5). An exten ded spreader graft can be used w hen th e caudal sept um is oppy and needs ext ra su pport. It can be used in conju n ct ion w ith th e septal exten sion graft an d/or septal bat ten graft for furth er rein forcem en t. Th e exten sion of th e cau dal en d of th e graft beyon d the low er border of th e upper lateral cartilage increases the reinforcem ent caudally, providing struct ural support along the w hole dorsum caudally dow n to the t ip.4 In cases of class 2 sad dling w ith rot ated t ip, m ore often th an n ot th e cau dal sept um is de cien t , sh ort , an d oppy. In such cases, a septal exten sion graft is n eeded to m ake th e nasal t ip st rong an d to get a projected t ip (Fig. 7.6). Th e septal exten sion graft is often fash ion ed from th e septal cart ilage or th e cost al cart ilage. Th e car t ilage sh ould be a at , broad p iece an d sh ou ld be overlap p ed w ith th e existing septal cart ilage. If th e sept al car t ilage h as a previous fract u re lin e or cu r vat u re, th e overlap ped region sh ou ld in clude th is area. If n eeded, th e oth er side of th e septal exten sion graft can be fu r th er st rength en ed w ith an oth er piece of cart ilage. Th e sept al exten sion can be su t ured at th e sides to th e spreader graft s superiorly an d to th e an terior n asal sp in e in feriorly to m ake su re th at th e cau dal en d of th e n ose is su p ported from below in th e m id lin e, is st raigh t , an d w ill n ot collap se or ben d du ring th e h ealing period.

Fig. 7.5 Bilateral spreader graft s are temporarily xed with needle and sutured with horizontal mat tress sutures using 4–0/5–0 PDS.

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Class 3 Saddling Su btot al recon st ru ct ion of th e n asal sept u m is recom m en ded . In th is d egree of sadd ling, on e w ill n d th e sept al cart ilage n ot ju st w eak, bu t w ith part s of it m issing or w ith volu m e, area, an d in tegrit y loss. Su btot al recon st ru ct ion of th e sept um involves recon st it ut ing th e dorsal h eigh t of th e n ose an d th e project ion an d rot at ion of th e t ip, by recon st ru ct ing th e L-st ru t . Th is m an euver often requ ires abu n dan t cost al car t ilage. The process begin s w ith fabricat ion of

b Fig. 7.6 (a,b) The septal extension graft is the workhorse for supporting the caudal end of the septum. It can function to strengthen and straighten the caudal septum , lift the medial crura of the lower lateral cartilage, increase tip projection, and derotate the tip downward in the case of a rotated tip in a saddled nose.

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Correction of the Saddle Nose

Class 4 Saddling

Fig. 7.7 Fabrication of the L-strut. The caudal septum is replaced with a at costal cartilage piece and supported with an extended spreader graft. The L-strut should sit rmly on the anterior nasal spine and not oat on top of it. Support should be provided by it to the lower lateral cartilages and not the other way around.

th e L-st rut using on e or t w o at an d st rong pieces of costal cart ilage or sept al cart ilage. Th is cart ilage sh ould sit rm ly on top of th e an terior n asal spin e, superiorly h eld rm ly by th e bilateral spreader graft s (Fig. 7.7). Oth er tech n iqu es th at can p rodu ce th e sam e st abilit y are to car ve a th ick, st rong p iece of dorsal st ru t to in terlock w ith a sh or ter but sim ilar sect ion of cart ilage at th e L-st rut . Th e L-st rut can be an ch ored to th e an terior n asal spin e w ith 4–0 PDS by drilling a h ole th rough the n asal spin e w ith a 1-m m drill bit or a 16-gauge n eedle; or sut ured to th e periosteum sn ugly using gure-of-8 sut uring at t w o p oin t s, on e an terior an d on e posterior. The an terior n asal spin e sh ou ld be ren dered st raigh t before th e an ch oring is don e. Th e L-st ru t sh ou ld be p laced rm ly before th e exten ded sp reader graft s are placed. Th e n ew dorsum th at th e spreader graft form s sh ould be st rong an d st raigh t , an d an overlap in to th e n asal bon e is som et im es desirable to in crease graft st abilit y w h en th e n asal bon e is stable en ough to en du re osteotom y. Th e t w o sides of th e u p p er lateral car t ilage sh ou ld be rm ly su t u red to th e spreader grafts using 5–0 PDS at t w o or th ree poin t s. Sp ecial at ten t ion is to be p aid w ith regards to th e sym m et r y of th e upper lateral car t ilage w h en sut uring so as n ot to cause any iat rogenic deviat ion . On ce th e graft s are rm ly in p lace, th e m edial cru ra of th e low er lateral cart ilages sh ould be sut ured to th e n ew L-st rut . Re n em en t can be ach ieved by adju st ing th e angles of sut uring or by n al applicat ion of cam ou age grafts.

A tot al dorsal recon st r u ct ion from t h e radix to t h e t ip is n ecessar y w h en th ere is m ajor loss in t h e sept al st r u ct u re an d p ossible loss of th e n asal pyram id bon es. Tot al recon st ru ct ion of t h e n asal bon e m ay requ ire a rep lacem en t graft u sing cost al car t ilage. How ever, in cases of severe sad d lin g w it h loss of n asal bon e, or if sept al recon st r u ct ion is im p ossible or n ot n eeded, a on e-piece dorsal on lay graft an d exten d ed colu m ellar st r u t cou ld be u sed alter n at ively. Th e exten ded colu m ellar st r u t sh ou ld be st abilized rm ly to th e an terior n asal sp in e. Th e on e-p iece block of dorsal on lay graft cou ld be design ed u sing cost al car t ilage. It is form ed in to a boat sh ap e. Th e can t ilever on lay graft sh ou ld id eally sp an t h e rad ix to th e low er lateral cart ilages. A groove is m ade in th e cau dal en d of th e on lay graft , w h ich is u n ited w ith t h e exten d ed colu m ellar st ru t over th e an ter ior n asal sp in e (Fig. 7.8). Th is can su p p or t th e n ose w ith ou t recon st ru ct ion of t h e sept u m . Up per an d low er lateral car t ilages restore to th e st able colu m ellar st ru t– d orsal graft . Last bu t n ot least , after th e restorat ion of th e dorsal h eigh t an d t ip p roject ion , t h e n asal t ip n eeds to be addressed m et icu lou sly, w h ich is described in a sep arate ch apter.5

■ Key Technical Points 1. Tech n iques for a saddle n ose correct ion var y depen ding on th e degree of saddling. Proper assessm en t of th e et iology an d d egree of sad dling form s th e basis for th e su rgical tech n iqu e u sed. 2. Th e cam ou age graft is th e m ain tech n iqu e used for class 1 saddling. Careful design of th e skin pocket is th e key to a su ccessful surger y in cam ou age graft s. 3. Class 2 saddling requires par t ial recon st it ut ion an d recon st ruct ion of th e sept um an d dorsum . 4. Subtot al septal recon st ruct ion is required to address a class 3 sad dling. More often th an n ot cost al cart ilage is n eeded to recon st ru ct th e dorsal su ppor t an d th e L-st ru t . Th ese t w o st ru ct u res w ill form th e pillars of n asal dorsal recon st ruct ion . 5. Th e recon st ructed caudal L-st ru t n eeds to be an ch ored rm ly to th e an terior n asal sp in e to preven t long-term sequaelae an d recurren ce of sadd ling. 6. In th e class 4 saddling deform it y, tot al recon st ruct ion is n eeded to restore n asal dorsal h eigh t from th e radix to th e t ip. Com bin ed bony an d cart ilagin ous dorsal recon st ru ct ion n eeds h inging w ith th e colum ellar st rut cau dally, bypassing th e sept al su pp ort .

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Fig. 7.8 Total dorsal reconstruction bypassing septal support. The costal cartilage graft is carved to recreate the dorsum from the radix to the tip and for bypassing the nasal septum support. (a) An extended colum ellar strut should be stabilized rm ly to the anterior nasal spine. (b,c) Boat-shaped dorsal onlay graft carved from one piece of costal cartilage. An extended columellar strut is combined with the onlay graft in tongue-in-groove fashion. The septum was partially replaced using carved costal cartilage. (d) The upper and lower lateral cartilages are xed to the dorsal onlay graft.

■ Case Studies Case 1 A 31-year-old fem ale pat ien t visited th e clin ic com p lain ing of saddle n ose deform it y after previous septoplast y (Fig. 7.9). Sh e h ad a septop last y 2 years p reviou sly an d slow ly develop ed sadd le n ose deform it y after th e su rger y. On p hysical exam in at ion , h er dorsu m sh ow ed depression from th e rh in ion to th e t ip . Palp at ion of th e t ip an d dorsu m sh ow ed n o u n d erlying sept al su p p or t . An in t ran asal exam sh ow ed p osterior sept al d eviat ion to th e left side bu t n o cart ilagin ous support on palpat ion .

Th e extern al approach w as u sed, follow ed by sept al m u cosa elevat ion (Fig. 7.10). Costal cart ilage an d p erich on drium w ere h ar vested. A boat-sh aped dorsal on lay graft w as car ved from th e cost al cart ilage. Th e can t ilever dorsal on lay graft exten ded from th e rh in ion to th e t ip. A groove w as m ade at th e cau dal en d of th e dorsal on lay graft , w h ich w as h inged to th e exten ded colum ellar st ru t rm ly an ch ored to th e an terior n asal sp in e. Up per an d low er lateral cart ilages w ere restored to th eir p osit ion s an d su t u red to th e d orsal on lay graft . Perich on d riu m w as u sed to drap e th e dorsum from th e radix to th e on lay graft . Six-m on th postoperat ive ph otos sh ow greatly im proved n asal sh ap e (Fig. 7.11).

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Correction of the Saddle Nose

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Fig. 7.9 (a–c) Case 1. The patient had developed saddle nose after septoplast y. A middorsal depression is observed and the septum is too weak to support an onlay cartilage graft. A dorsal onlay graft was carved from costal cartilage. An extended columellar strut was anchored rmly onto the anterior nasal spine inferiorly and superiorly and extends into the groove created at the caudal end of the dorsal graft.

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Fig. 7.10 Case 1. Intraoperative photos. (a) Dorsal graft carved from the rib cartilage is hinged to the extended columellar strut. (b) Lower lateral cartilages are reat tached to the new dome created by the grafts.

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(a–c) Case 1. Six-month postoperative photos show improvement of saddle from three di erent views.

Case 2 A 22-year-old m ale visited th e clin ic du e to a deform ed n ose an d n asal obst ruct ion (Fig. 7.12). He h ad a n asal t raum a h istor y in early ch ildh ood. On physical exam in at ion , h e w as foun d to h ave saddling of th e low er t w o-th irds of h is n ose; an un der-projected, sligh tly upt urn ed n asal t ip; an d hypert rophy of both t u rbin ates. Using au togen ous

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rib cart ilage, an exten ded colu m ellar st ru t rein forced w ith m in i bilateral exten d ed sp reader graft w as u sed for t ip an d caudal support (Fig. 7.13). Lateral cru ral on lay graft s an d t ip onlay graft s w ere added for t ip con touring. A dorsal on lay graft u sing car ved rib cart ilage w as u sed for dorsal augm en tat ion . Th ree years after surger y, a n orm al-looking n ose can be obser ved in all view s (Fig. 7.14).

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Fig. 7.12 (a–c) Case 2. Preoperative photos show a t ypical severe saddle nose deform it y with middle vault collapse and tip ptosis with slight cephalic rotation.

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Correction of the Saddle Nose

Fig. 7.13 Case 2. Surgical ndings. (a) Intraoperative photograph shows dorsal onlay graft, bilateral lateral crural graft s, and tip onlay grafts using rib cartilage with overlying perichondrium. (b) Surgical diagram showing operative techniques.

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Fig. 7.14 (a–c) Case 2. Three-year postoperative photos show well-augmented but smooth dorsum and more desirable tip projection and rotation compared to preoperative status.

References

■ Conclusion Saddle n ose d eform it y correct ion can range from a p rocedure as sim ple as applying a cam ou age graft to a tot al n asal recon st ruct ion . Saddle n ose is a com m on problem presen ted by Asian pat ien t s due to th e in h eren t low -pro le n ose w ith a soft an d u n d er-developed n asal sept u m su scept ible to in sult . As a result , th e volum e an d exten t of saddle n ose repairs in th e auth ors’ cen ters h ave provided th e oppor t un it y to gain m u ch experien ce an d re n e tech n iques in h an dling saddle n ose. It sh ould be assessed m et icu lou sly an d su rger y plan n ed w ith all even t u alit ies an t icipated to en su re th e best ou tcom e. Th e best ou tcom e is w h en th e procedure is don e righ t th e rst t im e. Th at being said, m any of th e recon st ruct ion s for saddle n ose m ay n eed revision s in variou s stages.

1. Young K, Row e-Jon es J. Current approach es to sept al saddle n ose recon st ruct ion using autograft s. Curr Opin Otolar yn gol Head Neck Su rg 2011;19(4):276–282 2. Kevin Bren n er JC. Saddle nose deform it y. In : Mu rphy M, Azizzadeh B, Joh n son CM Jr, Nu m a W, eds. Master Tech n iques in Rh in oplast y. 1st ed. Saun ders; 2011:293–298 3. Durbec M, Disan t F. Saddle n ose: classi cat ion an d th erapeut ic m an agem en t . Eu r An n Otorh in olar yngol Head Neck Dis 2014;131(2):99–106 4. Tardy ME Jr, Schw art z M, Parras G. Saddle n ose deform it y: autogen ous graft repair. Facial Plast Su rg 1989;6(2): 121–134 5. Dan iel RK. Rhin oplast y: sept al saddle n ose deform it y an d com posite recon st ruct ion . Plast Recon st r Surg 2007; 119(3):1029–1043

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Alar Base Modi cation

Ian Loh Chi Yuan and Hong Ryul Jin

Pearls • Modi cat ion s to th e d orsu m an d n asal t ip w ill • • •

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• It is param ou n t th at a cu r ved port ion of th e n ost ril

a ect th e alar base w id th , as w ell as th e deliberate creat ion of illu sion s, as a resu lt of object ive ch anges. Alar base su rger y sh ou ld be p erform ed as th e n al procedure in th e rh in oplast y sequen ce. Ap p ropriate design , sym m et r y, an d m et icu lou s soft t issu e h an dling are p aram ou n t in creat ing th e desired outcom e in alar base surger y. Th e m odi ed Weir excision is th e m ost com m on ly em ployed d esign for East Asian s, w h o t ypically n eed redu ct ion of alar aring, n ost ril size, an d alar base w idth . Th e use of a cin ch ing sut ure to m ain tain a ten sion free skin closu re is an im p ort an t p ar t of alar base su rger y.

■ Introduction Th e alar base describes th e port ion of th e n ose w h ere th e alar side w all at t ach es to th e m idface. Modi cat ion to th is area ch anges th e alar base w idth , th e degree of alar aring, an d n ost ril sh ap e an d size. Eth n ic variat ion s in th e alar base h ave been w ell described. Th e m ajorit y of East Asian n oses (especially th ose of South east Asian origin ) can n ot con form to th e ideal an atom ic relat ion sh ip described in Cau casian s. Th e alar base of th e East Asian n ose is w ider com pared w ith th e European n ose, w ith a m arked ten den cy to are but n ot to as severe a d egree as th ose fou n d in African s or Sou th east Asian s, in clu ding th ose of Filip in o, Malaysian , In d on esian , an d Viet n am ese eth n icit y.1 The shape and extent of alar aring w ill depend on the sh ape and elasticit y of th e un derlying n asal cartilage, the connection bet w een the lateral crura and th e face, an d the prom inence of the nasal tip. In addition to the aring and w ide alar base, other abnorm alities such as alar rim hanging,2 retrusion of colum ella, w ide colum ellar base, and excessively th ick alar rim should also be con sidered. Tech niques to change th e alar sh ape are ch osen after assessing all these param eters individually and judging com prehensively, con sidering harm ony of the ala w ith the rest of the face. Given th ese eth n ic variat ion s, it sh ou ld n ot be su rprising th at alar base su rger y is on e of th e m ost com m on ly requested p rocedu res du ring con su ltat ion for East Asian rh in op last y.

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be preser ved to avoid creat ing a teardrop n ost ril during th e excision design . Con ser vat ism sh ould be obser ved during resect ion s, as correct ion of over-excision is ver y d i cu lt . Com plicat ion s of alar base surger y in clude th e creat ion of a teardrop n ost ril, asym m et r y of th e nost rils, an d various scar-related com plicat ion s, in cluding vest ibular sten osis w ith accom panying nasal obst ruct ion . Most com p licat ion s are iat rogen ic an d can be avoided w ith good design an d t issue h an dling. Th e ben e ts of alar base surger y m ust be w eigh ed again st th e poten t ial for com plicat ion s; th is is esp ecially t ru e for East Asian p eop les, w h ose skin is m ore p ron e to scar-related com p licat ion s.

Th e poten t ial in dicat ion s for alar base surger y are (1) in creased alar base w idth , (2) excessive aring of th e alar side w alls, (3) large n ost rils, (4) th ick alar side w alls, (5) h ooded or h anging alar side w alls, an d (6) cleft n ose or n ost ril asym m et r y.

■ Patient Evaluation A carefu l an d det ailed h istor y sh ou ld be t aken du ring con su ltat ion to id en t ify th e pat ien t’s con cern s. Exam in at ion of th e alar base sh ould focus on th e n ost ril shape, size, an d sym m et r y; th e degree of alar aring; an d th e w idth of th e n asal base. Any pre-exist ing asym m et r y of th e n ost rils sh ould be n oted an d poin ted ou t to th e pat ien t , an d corrected w h en ever possible during surger y; th is is also im port an t to avoid any con cern s th at m ay h ave arisen iatrogen ically after surger y.

Physical Examination On fron t al view, th e alar rim sh ou ld arc an d en d h igh er th an th e colum ella, giving a gull’s-w ing-in - igh t appearan ce. Exaggerat ion of th e gull-in - igh t cur ve im plies ret ract ion of th e ala or depen den cy of th e in frat ip lobule. On lateral view, th e alar rim u su ally sit u ates 2 to 3 m m above th e nasal colum ella, creat ing a colum ellar sh ow. Th e lateral

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II Rhinoplast y view is also th e best view for evaluat ing th e alar-colum ellar relat ion sh ip . W h en th e colu m ella is n ot seen , th is m ay in dicate a ret racted colu m ella or h anging ala. Norm ally, th e w idth of th e alar base is equal to the dist an ce bet w een th e m edial can th i. Th e th ickn ess an d aring of th e ala an d th e d egree of recu r vat ure of th e alar base in sert ion s sh ou ld also be n oted. Ideally, th e n ose as seen from basal view sh ou ld be an isosceles t riangle w ith a rou n d apex, sligh tly bulging alar side w alls, an d n ost rils t ilted 30 to 45 degrees from th e m idlin e, w ith th e ap p earan ce of a p ear. Th e rat io of th e colu m ella an d in frat ip lobule is 2:1, an d th e begin n ing of th e are of th e m edial cru ral foot p lates divides th e alar base in to h alves (Fig. 8.1).

The E ect of Illusions on the Nasal Base Alth ough alar base su rger y is frequ en tly requ ested as an isolated procedu re, th e pat ien t m ust be in form ed th at th e ap pearan ce of th e alar base is a ected by m odi cat ion of th e n asal t ip an d dorsu m , an d th at surger y to th is area can n ot be con sidered in isolat ion . In creased n asal t ip project ion and dorsal augm en tat ion w ill both create an illusion of decreased alar base w idth . Conversely, n arrow ing th e alar base w ill create th e illusion of a broader n asal t ip. If su rgeries in th ese areas are also requ ired, th e pat ien t sh ould be advised accordingly. In cert ain cases, m odi cat ion of th e dorsu m an d t ip alon e m ay su ce to create th e illu sion of decreased alar base w idth an d aring, m aking alar base surger y un n ecessar y. It is im p erat ive th at th e pat ien t be in form ed th at m odicat ion s to th ese oth er areas in u en ce th e ch aracterist ics

a Fig. 8.1

of th e alar base, an d m ay m ake alar base surger y un n ecessar y. In case of d ou bt , alar base excision s sh ou ld also be perform ed as a staged procedure, after th e pat ien t h as a ch an ce to evaluate th e e ect th at th ese oth er m odi cat ion s m ay h ave on th e alar base.

Quality of Skin Alar base su rger y is essen t ially a skin excision of th e alar base region . Th e qualit y of th e pat ien t’s skin is an im portan t determ in an t of th e surger y’s outcom e. Th e skin of th e alar base region is n at u rally th ick an d sebaceou s. In addit ion , East Asian skin is th icker an d m ore pigm en ted th an Cau casian skin . Th ese factors p redisp ose th e East Asian pat ien t to hyper t roph ic scarring, keloid form at ion , an d post-in am m ator y hyperpigm en t at ion w h en un dergoing alar base su rger y.3 A p at ien t w ith th ick sebaceou s skin w h o gives a h istor y of scar-related com p licat ion s sh ou ld be w arn ed of th e possibilit y of th ese com plicat ion s w h en plan n ing alar base su rger y. An d m et icu lou s p ostop erat ive care sh ou ld be pract iced to m in im ize such com plicat ion s.

Function Any st at ic an d dyn am ic collap se of th e extern al n asal valve m u st be n oted. Alar base su rger y th at redu ces th e size of th e vest ibular aper t ure can cau se extern al valve sten osis. Th e pat ien t sh ould be asked to in spire th rough th e n ose rapidly, an d any collapse of th e alar side w all sh ould be noted. Pat ient s w ith sm all n ost rils sh ould h ave excision design s th at do n ot furth er reduce th e n ost ril apert ure;

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Ideal alar shape of East Asians. (a) Frontal view. (b) Lateral view. (c) Basal view.

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8 Alar  Base  Modi cation p at ien t s w ith dyn am ic collapse sh ould con sider fun ct ion al su rger y to st rength en th e low er lateral car t ilages con com it an tly, such as th e use of bat ten grafts, togeth er w ith alar base surger y if required.

Photographs Proper ph oto docu m en t at ion u sing a prim e port rait len s an d di u se ligh t ing is a clin ical an d m edico-legal requ irem en t for rh in op last y. A fron t al view, p ro le view, an d basal view are u sed in evalu at ing for alar base su rger y. Com p u ter sim u lat ion can be p art icu larly u sefu l to illu st rate th e com plex relat ion sh ips bet w een dorsal length , t ip project ion , t ip bulbosit y, an d alar base w idth , w ith th e pat ien t’s decision s carefully docum en ted. From th e fron tal view ph otograph , th e w idth of th e n asal base can be evaluated; th is sh ould ideally lie just outside of th e m iddle h orizon t al fth of th e face in Orien tals. Th e base can appear w ide from excessive aring or from a large in ter-alar distan ce. Excision t arget ing th e righ t areas m u st be design ed to add ress th ese problem s. From th e basal view th e size of th e n ost rils an d degree of aring can be object ively assessed. Ver t ical lin es passing th rough th e alar facial groove can be draw n in th e basal view. Excess alar side w all lateral to th is lin e gives an object ive m easu rem en t of th e degree of alar aring an d aids in plan n ing th e excision design (Fig. 8.2). From th e lateral view, a lin e draw n th rough th e long axis of th e n ost ril allow s th e su rgeon to evalu ate th e exten t of h anging alar deform it y an d th e am oun t of “lift” required to correct alar h ooding.2

■ Surgical Techniques Surgical Anatomy Alar base su rger y is perform ed as th e n al procedu re in th e rh in oplast y sequen ce. Th is allow s th e su rgeon to fully evalu ate th e e ect s from any m odi cat ion s to th e dorsu m an d t ip on th e alar base (Fig. 8.3). If an op en rh in op last y

Fig. 8.2 De nition of alar aring. The aring is determined according to the degree of alar projection based on a vertical line drawn at the alar-facial groove as seen from the basal view.

ap proach h as been perform ed, th e colu m ella in cision is closed w ith a few m on o lam ent sut ures to restore ten sion to th e skin pocket . Th e n eed for alar base su rger y is th en assessed from th e basal view, fron tal view, an d pro le view as ou tlin ed earlier in th e ch apter. Th e alar base region con sist s of th ick sebaceous skin extern ally, h air-bearing vest ibu lar skin in tern ally, an d bro-fat t y t issu e in bet w een . Th ere are n o car t ilagin ou s st ru ct u res fou n d h ere. Th e ju n ct ion of th e alar side w all an d lateral n asal sill form a n at ural cu r vat ure at th e in ferior lateral asp ect of th e n ost ril, w h ich m u st be preser ved d u ring any alar base su rger y to avoid creat ing a teardrop n ost ril. Th e jun ct ion bet w een th e alar side w all an d m idface form s th e alar facial groove, an d w h en ever possible, th is sh ou ld be p reser ved. Leaving beh in d a 1-m m cu of soft t issue above th e alar facial groove w h en plan n ing th e in ferior in cision greatly facilitates closu re an d faster w ou n d healing.

Fig. 8.3 Increased nasal tip projection leads to decreased alar are. (a) Alar aring is noticeable in the preoperative basal view. (b) As the nasal tip is augmented, the are of ala is decreased without any alar base procedure being done.

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Excision Design Th e con ce p t of n ar row in g t h e alar base w as in t rod u ce d by Robe r t W ie r in 1892, an d h e d escr ibe d t h e u se of ext e r n al alar w e dge excision s to cor re ct t h e u n at t ract ive alar are. Di e re n t m od i cat ion s of t h e We ir alar base excision are p ossib le, an d t h e excision d esign is d e p e n d e n t on t h e su rgical obje ct ives (Fig. 8.4). Th e alar arin g is im p rove d by p e r for m in g a cresce n t -sh ap e d w e dge rese ct ion of t h e ala alon g t h e alar-facial groove. Th e w id e alar base can b e re d u ce d by a slid in g alar ap or n ost r il sill excision . On t h e ot h e r h an d , a w id e alar base com bin e d w it h alar ar in g can be im p rove d by com bin in g alar w e dge an d n ost r il sill excision .

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d Fig. 8.4 Types of alar base surgery. (a) Wedge resection of the ala to decrease the alar aring. (b) Resection of the nostril sill to decrease the width of the alar base. (c) Sliding alar ap to reduce the width of the alar base. (d) Combined sill and wedge resection to correct the alar aring and wide alar base.

Combined Alar Wedge Resection and Sill Excision The use of a m odi ed Weir excision for reduct ion of alar aring, n asal base w idth , an d n ost ril size is dem on strated in Fig. 8.5. Th is is th e m ost com m on ly em ployed design in East Asian pat ients. The excision design is draw n using a n e-t ipped felt m arker or tooth pick stain ed w ith m ethylen e blue prior to inject ion. The incision for the alar w edge excision is m arked at 1 to 2 m m above th e alar-facial ju n ct ion . This preser ves the nat ural sulcus and m akes eversion of the sut ure easy, th u s m axim ally cam ou aging th e in cision scar. Excision inside the nost ril m ust preser ve the cur ved portion of the nost rils and be checked m eticulously for sym m etr y. In alar w edge resect ion , th e in cision sh ou ld n ot exten d to th e m edial side of ala, an d in n ost ril sill excision , th e n ost ril base adjacen t to th e colum ella sh ould be preser ved to preser ve th e n at ural alar sulcus an d to preven t a ten t pole app earan ce. In lt rat ion is th en adm in istered. A sm all am ou n t of in lt rate con t ain ing adren alin e an d lidocain e is preferred by th e auth ors. Th e volum e of in lt rate sh ould be kept sm all to avoid distor t ion to th e su rrou n ding t issu e. Ten m in u tes is allow ed to lap se before th e in cision s are m ad e for con st rict ion of th e blood vessels. A fresh n o. 15 blade is used to m ake th e in cision s st arting w ith th e superior lim b of th e w edge excision follow ed by th e in ferior lim b. Th e in cision s are beveled sm ooth ly tow ard each oth er to en su re sym m et rical w edges of soft t issu e are rem oved from each side. On ly skin an d subcutaneous t issue are resected, an d care sh ou ld be t aken to n ot violate th e m u scle in th e deep plan e. Bleeding is u su ally con t rolled by su t u ring an d rarely needs cauterizat ion . If n ecessar y, h em ost asis is ach ieved using bipolar cauter y. A gure-of-8 sut ure is th en passed th rough th e prem axillar y soft t issue. A PDS 3–0 sut ure is m ou n ted on a large free n eedle an d p assed th rough th e m edial in cision on th e righ t side, t raversing deeply th rough th e prem axillar y soft t issu e to em erge th rough th e m edial in cision on th e con t ralateral side. Th e n eedle th en catch es th e brofat t y t issue in th e free cut edge of th e alar side w all before being passed back in a sim ilar m an n er to catch th e brofat t y t issue of th e righ t alar side w all. Th e sut ure is th en t ied ju st t igh tly en ough to relieve ten sion on th e excision sites, bu t n ot so t igh tly as to cau se bu n ch ing of th e prem axillar y soft t issu e. Th e kn ot s are th en buried in th e soft t issu e. Met icu lou s closu re u sing n e m on o lam en t (6–0 nylon ) sut ures is th en perform ed. Th e au th ors use absorbable su t u res to close th e in cision on th e in side of th e n ost ril. Su t u re rem oval is p erform ed on th e fth p ostoperat ive day. Sim ilar m eth ods are u sed for isolated sill (Fig. 8.4b) an d alar side w all excision s (Fig. 8.4a). Th e ap ex of th e w edge excision sh ou ld n ot exten d in to th e vest ibu lar skin if redu ct ion of th e n ost ril size is deem ed un desirable.

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8 Alar  Base  Modi cation

a

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Fig. 8.5 A combined sill excision and wedge resection of ala. (a) Preoperative picture of a patient with under-projected tip and dorsum, bulbous tip, and wide alar base. (b) The tip has been projected with the use of a columellar strut and cap grafts, and the dorsum has also been augmented. An illusion of inter-alar distance narrowing has already been created through tip projection. The design for alar base excision has been marked out. Note how a portion of the curved area of the nostril has been preserved to avoid the creation of a teardrop nostril. Also note how a small strip of vertical skin has been preserved on the right to facilitate closure later. (c) The right wedge excision has been performed. (d) The gure-of-8 suture has been passed from right to left through the deep premaxillary tissue. Note how the needle has engaged the brofat t y tissue of the cut free edge of the alar side wall. (e) The direction of the needle is reversed and the needle is passed back in a similar manner to catch the alar brofat t y tissue on the other side. (f) The suture is tied and the knot buried. The incisions are closed with ne m ono lament sutures.

V-Y Advancement for Large Alar Wedge Resection

Correction of Too -Wide Columellar Base

W h en a con siderable am oun t of alar w edge resect ion is don e, a diam eter di eren ce bet w een th e upper an d low er alar in cision s w ill n ot create a n at u ral alar-facial su lcu s. A V-Y sh ap ed su t u ring can solve th is problem ; h ow ever, it can create a n ew scar, w h ich is best cam ou aged by placing it along th e n asolabial su lcu s.

W h en th e m edial crura are too divergen t or prom in en t , th e colum ellar base is too w ide an d som et im es causes n asal obst ruct ion by obst ruct ing th e n ost ril. To correct th is, a lateral colu m ellar in cision is don e bilaterally an d th e m edial cru ra are dissected an d exposed (Fig. 8.7). Often su t u re ligat ion of th e t w o dissected m edial crura is n ot en ough to narrow th e colum ellar base. Rem oval of sm all am ou n t of soft t issu e bet w een th e t w o cru ra or part ial cru ral resect ion h elps to redu ce th e base e ect ively.

Correction of Hanging Alar For correct ion of h anging ala, refer to Ch apter 9 of th is book.

■ Key Technical Points

Alar Base Surgery for the Cleft Nose Com plete correct ion of th e cleft n ose deform it y requires reposit ion ing an d recon st ruct ion of th e low er lateral cart ilage, reposit ion ing of th e colum ella, an d augm en tat ion of th e prem axillar y region in addit ion to alar base m odi cat ion (Fig. 8.6). Det ailed descript ion of th ese com plicated tech n iqu es is n ot w ith in th e scope of th is ch apter.

1. Th e resect ion am ou n t sh ou ld be kept con ser vat ive. Revision excision s are sim ple to perform but restorat ion of excised t issue is ext rem ely di cult . 2. Preser vat ion of th e cur ved por t ion in side of th e n ost ril du ring excision is n ecessar y to p reven t a teardrop deform it y. 3. Th e in cision for th e alar w edge excision is m arked at 1 to 2 m m above th e alar-facial jun ct ion .

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II Rhinoplast y Fig. 8.6 Unilateral cleft nose deformit y. (a) Preoperative photo shows t ypical asym metric alar base of unilateral cleft nose deformit y. (b) Three-month postoperative photo shows improved symmetry with elevated left alar base.

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4. The superior extent of wedge sections should be kept as inferior as possible in the alar facial groove. The skin in this area is thick and sebaceous, and scar-related com plications here are conspicuous and unforgiving. The lateral nasal artery also runs 4 m m superior to the level of the nasal sill and should be preserved.4 5. Ten sion sut ures ( gure-of-8) passed u n der th e p rem axillar y soft t issue aid in ten sion -free closure an d h ealing of th e in cision s.

■ Complications and Their Management

Scarring Ach ieving an aesth et ically accept able scar is p ossible w ith proper excision design , m et iculous soft t issue h an dling an d closu re during su rger y, an d good postoperat ive care. Th e

a

excision design sh ou ld be p laced as m u ch as p ossible in th e alar-facial groove to ach ieve good cam ou age; a sm all ver t ical cu of skin from th e ala can be preser ved to facilitate closure. With expected scar con t ract ure, th is in cision sh ou ld even t u ally lie w ell cam ou aged in th e groove it self. In in st an ces w h ere th e in cision is m ade in th e groove directly, closure of th e n ear ver t ical alar side w all skin to th e h orizon t al m idface skin w ill be di cult . Th e ten uous ep ith elializat ion of skin over th is righ t-angled closu re site is often delayed an d w ill break dow n frequen tly w ith m in or displacem en t , resu lt ing in poor w oun d h ealing, gran u lat ion , an d scarring (Fig. 8.8). Th e excision design sh ou ld also be kept as in ferior as possible in th e alar-facial groove. High excision design s are con spicuou s, especially in th is sebaceous area of th e face, w h ich scars poorly, an d can be seen from th e fron t al, pro le, an d basal view s, often resu lt ing in p at ien t dissat isfact ion . Occlu sive an t ibiot ic oin t m en t sh ou ld be ap p lied to th e excision sites t ill ep ith elizat ion occu rs an d st itch rem oval is com p leted . Th ereafter, silicon e gel sh ou ld be ap plied for th e follow ing 3 m on th s. Th e pat ien t sh ou ld also be advised

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Fig. 8.7 Narrowing of columellar base. (a) Too-wide columellar base by divergent medial crura causes nasal obstruction. (b) After lateral columellar incision and dissection, the divergent medial crura are exposed, excised, and cinched together. (c) Im mediately after surgery, the columellar base looks narrower than before the surgery.

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8 Alar  Base  Modi cation

Fig. 8.8 Complications of alar base surgery. This patient demonstrates several complications of alar base surgery including obvious scarring in the alar-facial groove, asymmetric nostrils, and the creation of a right teardrop nostril.

looking n ose after alar base surger y. Isolated an d excessive redu ct ion of alar aring an d inter-alar dist an ce can create th e illusion of a bulbou s t ip or accen t uate th e appearan ce of a long n ose; th e n ose can also app ear p in ch ed or boxy from th e basal view if th e colum ella project ion is in adequate. Th is occurs because th e appearan ce of th e t ip w idth an d nasal length is referen ced again st th e in ter-alar dist an ce from th e fron t al view, w h ile th e adequ acy of colu m ella project ion is referen ced again st th e in ter-alar dist an ce in th e basal view. Reduct ion of th e in ter-alar w idth th erefore creates an illusion of in creased t ip w idth , n asal dorsum length en ing, an d decreased t ip project ion . Con siderat ion of th e in terplay bet w een these factors is im por tan t w h en plan n ing rh in oplast y.

Nasal Obstruction again st excessive u lt raviolet exp osu re to th e op erat ive site. In t ralesion al steroid s can be ad m in istered if hyp er t rop h ic scarring d evelop s.

Teardrop Nostril A teardrop nostril occurs w hen the curved portion of the nostril is not preserved during alar base resection. This results in the alar side wall and nasal sill m eeting at an acute angle after closure of the wedge excision. When seen from the basal view, there is a loss of the norm al kidney bean shape of the nostril, w ith the nostril resem bling a teardrop (Fig. 8.8). The creat ion of a teardrop deform it y is best avoided w ith correct excision design , preser ving th e cur ved por t ion of th e n ost ril.

Aggressive reduct ion of th e alar base an d redu ct ion in th e n ost ril size can resu lt in nasal obst ruct ion . Th e n ost ril form s th e an terior boun dar y of th e extern al n asal valve. W h en th is aper t ure is excessively reduced in absolu te term s, a st at ic extern al n asal valve obst ruct ion can result . A dyn am ic collap se can also resu lt if th e p at ien t h as p reexist ing w eak low er lateral car t ilages. Excision design s that spare the vest ibular skin should be used in patients w ho have sm all nostrils. Any pre-exist ing w eakn ess of th e low er lateral cart ilages sh ould also be iden ti ed preoperat ively and the patient inform ed of th e poten tial risk for nasal obst ruct ion after alar base surger y, w ith the option of rein forcing the low er lateral cart ilages w ith bat ten grafts during the rh inoplast y o ered to the pat ient .5

■ Case Studies Asymmetry Any p re-exist ing asym m et r y of th e n ost rils m u st be iden t ied an d docu m en ted (Fig. 8.8). Correct ion of n ost ril asym m et r y is a tech n ically di cu lt p art of rh in op last ic su rger y. It is im p or tan t to poin t th is out to th e pat ien t before surger y. Asym m et r y in th e alar base can be corrected w ith n on -sym m et ric excision s. How ever, asym m et ries occurring h igh er in th e alar side w all, su ch as alar ret ract ion asym m et ries secon dar y to con tou r, n eed to be corrected th rough m an ipu lat ion of th e low er lateral car t ilages, rim , an d/or com posite graft s. Th ese sh ou ld be d iscu ssed w ith th e pat ien t beforeh an d.

Poor Harmony of Alar Base w ith Nasal Dorsum and Tip Th e in t im ate relat ion sh ips bet w een th ese th ree areas h ave been elaborated earlier, an d a careful preoperat ive assessm en t is n ecessar y to avoid creat ing a dish arm on iou s-

Case 1: Combined Nostril Sill and Alar Wedge Resection A 25-year-old w om an visited th e clin ic desiring rem oval of her n asal h um p an d re n em en t of h er nasal t ip (Fig. 8.9). Physical exam in at ion revealed a m ild reverse C-sh ap ed dorsu m w ith a sm all h um p. Her n asal t ip w as bulbou s w ith insu cien t project ion an d h er n asal base w as w ide. Th ere w as n o sept al deviat ion , an d h er skin w as fair an d of m ediu m th ickn ess. An open septorhinoplasty approach was taken and her septal cartilage harvested. Osteotom ies were perform ed to straighten her deviated dorsum w hile a caudal septal extension graft was used to elevate her nasal tip. Soft tissue reduction of the nasal tip was perform ed, w ith the excised m aterial used as a radix graft. Septal cartilage was used for dorsal augm entation. Th ereafter, as par t of th e n al rh in oplast y sequen ce, a m odi ed Weir resect ion w as u sed to resect both th e alar side w all an d th e n asal sill to e ect redu ct ion in alar aring, nost ril size, an d n asal base w idth .

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II Rhinoplast y Fig. 8.9 Case 1. Patient with combined nostril sill and alar wedge resection. (a,b) Preoperative photos show a mild reverse C-shaped dorsum with a small hump. Her nasal tip is bulbous with insu cient projection and her nasal base is wide.

a

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Fig. 8.10 (a,b) Case 1. Two years after surgery, the tip shows signi cant narrowing with reduced alar base width and alar aring.

a

b

Postop erat ive p ict u res t aken 2 years later sh ow sign i can tly n arrow ed n asal t ip, alar base w idth , an d alar aring (Fig. 8.10). In creased radix, dorsu m , an d t ip p roject ion is eviden t . Th e d orsal h um p h as been cam ou aged.

Case 2: Combined Nostril Sill and Alar Wedge Resection An 18-year-old m an w as seen in t h e clin ic d esir ing re n em en t of t h e n asal t ip , cor rect ion of t h e d eviated n ose, an d augm en t at ion of t h e n asal d orsu m (Fig. 8.11). Physical exam in at ion revealed an u n d er-p rojected n asal d orsu m d eviated to t h e left . Th e n asal t ip w as boxy an d bu lbou s w it h p oor p roject ion . Th e alar base ap p eared w id e an d

n ost r il asym m et r y w as n oted . En d oscopy revealed a r igh t deviated n asal sept u m . Th e p at ien t ’s skin w as t h ick an d sebaceou s. An open septorh in oplast y approach w as un der taken an d th e sept al car t ilage w as h ar vested . Osteotom ies w ere used to st raigh ten th e bony dorsum . A colum ellar st ru t w as used to in crease t ip project ion togeth er w ith t w o st acked cap graft s to th e t ip. Stacked sept al cart ilage w as used to augm en t th e dorsu m . Fin ally, a m odi ed Weir excision w as used to excise th e sill an d alar side w alls to reduce aring, alar base w idth , an d n ost ril size. The 1-year postoperative photographs dem onstrate straightening and augm entation of the dorsum w ith increased tip projection and tip re nem ent (Fig. 8.12). The alar base w idth, nostril size, and alar aring have all been reduced.

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8 Alar  Base  Modi cation Fig. 8.11 Case 2. Patient with combined nostril sill and alar wedge resection. (a,b) Preoperative photos show an under-projected and deviated dorsum and boxy, bulbous nasal tip with poor projection. The alar base appears wide and the nostrils asymmetric.

a

b Fig. 8.12 (a,b) Case 2. After 1 year, his nose is straight and the dorsum is well augmented. The bulbous tip has been re ned and the tip projection increased. The alar base width, nostril size, and alar aring have all been reduced.

a

b

References

3. Raw lings AV. Eth n ic skin t ypes: are there di eren ces in skin st ruct ure an d fu nct ion ? In t J Cosm et Sci 2006;28(2): 79–93

1. Farkas LG, Hreczko TA, Deut sch CK. Object ive assessm en t of st an dard n ost ril t ypes—a m orph om et ric st udy. An n Plast Su rg 1983;11(5):381–389

4. Jung DH, Kim HJ, Koh KS, et al. Arterial supply of the nasal tip in Asians. Laryngoscope 2000;110(2 Pt 1):308–311

2. Yap E. Im proving th e h anging ala. Facial Plast Surg 2012;28(2):213–217

5. Ballert JA, Park SS. Fun ct ion al con siderat ion s in revision rh in oplast y. Facial Plast Surg 2008;24(3):348–357

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Aesthetic Rhinoplasty for Southeast Asians

Eduardo C. Yap

Pearls • Th e bony-car t ilagin ous st ruct u re of South east Asian

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n oses is gen erally sm all in all dim en sion s, result ing in a relat ive abun dan ce of skin an d soft t issu e. To ach ieve a long-last ing e ect , a st rong fram ew ork is n eeded to cou n teract th e forces of w oun d h ealing an d th e h eavy skin an d soft t issu e com p lex. Hanging ala of variou s d egrees is often n oted an d can be easily corrected via “sail” excision . Th is procedure also im proves colum ellar sh ow. Th e sept al exten sion graft (SEG) is th e w orkh orse in providing st urdy su pport to th e t ip. Th e SEG m ay be in adequate as su ppor t in som e cases. Addit ion al graft s can be used to support th e SEG (e.g., exten ded spreader an d cau dal m argin exten sion graft s). Becau se of th e pau cit y of sept u m th at can be h ar vested, folded con ch al cart ilage at t ach ed ben eath th e SEG is often u sed. Tip -p last y is don e before dorsal augm en tat ion . After m odifying th e t ip as desired , th e dorsal graft is m ade to blen d th e n ew t ip an d th e radix. Am ong syn th et ic produ cts for d orsal augm en tat ion m aterial, exp an ded p olytet ra u oroethylen e (ePTFE,

■ Introduction Noses of Sou th east Asian p eop les are gen erally sm all an d sh ort w ith a bu lbou s t ip , th ick skin an d soft t issu e envelop e (SSTE) an d a low n asal dorsum . Nasal bon es m ay be w ide at th e at t ach m en t to th e u pp er lateral car t ilage. The t ip is u su ally u pt u rn ed. Th ere is a cer tain degree of h anging ala, an d colu m ellar sh ow is often de cien t . Th e n asal fram ew ork is u su ally sm all, w ith a sm all n asal sept u m . Th e low er lateral car t ilages are also sm all an d w eak, an d th e dom e is ill de n ed w ith sh or t m edial crura. Th e an terior n asal spin e an d p rem axilla are often u n d erdevelop ed. Becau se of t h e feat u res ju st m en t ion ed , t h e su rger y p lan n ed sh ou ld in clu d e elon gat ion an d p roject ion of t h e t ip , augm en t at ion of t h e d orsu m , alar lift ing an d rest r u ct u r in g of t h e colu m ella for a bet ter colu m ellar sh ow an d alar-colu m ellar relat ion sh ip , an d augm en t at ion of t h e p rem a xilla to im p rove t h e n asolabial angle. Th e m ost cr it ical p roced u re is p rop er rot at ion an d p roject ion of t h e

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popu larly kn ow n as Gore-Tex) is preferred because it h eals by t issu e adh esion w ith n o capsu lar form at ion . It p rovides a m ore n at u ral look albeit w ith som e un desirable poten t ial com plicat ion s such as deviat ion , visibilit y, an d in fect ion . ePTFE in sh eet form or preform ed sh ou ld be lim ited to a single piece if p ossible. St acking of sh eet s m ay t rap con t am in an t s. Th e im plan t sh ould be rem oved from it s p ackage on ly w h en it is t im e for dorsal augm en tat ion to avoid prolonged air exp osu re. ePTFE in sh eet form is p referred for a sh allow radix w h ereas th e preform ed t ype is preferred for correct ing a deep radix. Th e im plan t sh ould be car ved to follow th e con tou r of th e n ose. Th e caudal en d of th e im plan t sh ould be sut ured to th e dom e to ach ieve a con t in uous st ru ct u re of th e dorsu m an d th e t ip . A gap of space u su ally is left at th e ju n ct ion of th e upper cart ilage an d low er cart ilage after placem en t of th e im plan t . Th is space sh ould be lled w ith car t ilage to preven t postoperat ive su prat ip depression .

t ip to a n ew p osit ion . As t h e sept u m is t h e m ost st able st r u ct u re, t h e cen t ral p ar t of t h e sept u m is h ar vested an d is u sed for an exten d ed sept al su p p or t graft for xat ion of t h e low er lateral car t ilage to for m a w h ole n ew t ip . Th is m an eu ver also exten d s t h e colu m ella for a bet ter colu m ellar sh ow . Th e op en ap p roach is often u sed . Th e SSTE dissect ion is w id ely exten d ed u p to t h e p ir ifor m ap er t u re laterally, n asal sp in e in fer iorly, an d glabella su p er iorly. Th e d issect ion p lan e sh ou ld be below t h e su p er cial m u scu lo-ap on eu rot ic layer system (SMAS) on t h e u p p er an d low er lateral car t ilages, an d below t h e p er iosteu m on t h e n asal bon e.

■ Patient Evaluation “Th an k you Dr. Yap for [th e] n ice w ork you d id on m y nose; h ow ever, I don’t like to look at m yself in th e m irror because I see a di eren t person ” (a fem ale pat ien t , 1 m on th postoperat ive).

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Aesthetic Rhinoplast y for Southeast Asians

Rh in oplast y rem ain s th e m ost com m on facial aesth et ic procedure don e in th e South east Asian region . Pat ien ts sh ou ld determ in e th e righ t su rgeon for th em selves th rough th orough con sultat ion w ith prospect ive su rgeon s. Prior to discu ssing th e surgical plan , th e pat ien t sh ould alw ays be asked abou t th e im p rovem en t sough t for h is or h er n ose. Com puter sim ulat ion can be a dangerous tool because it m ay lead to fu t u re dissat isfact ion resu lt ing in argu m en ts w ith th e surgeon . It sh ould be explain ed to th e pat ien t th at im provem en ts from th e su rger y largely depen d on th e exist ing st ruct ures. Th e aim of aesth et ic rh in oplast ic surger y is to im prove th e curren t appearan ce, not to ach ieve p erfect ion . Th e m ajorit y of ou tcom es are good an d fall w ith in p at ien ts’ an d su rgeon s’ exp ect at ion s. How ever, th ere m ay be som e cases w h ere th e outcom e falls drast ically sh ort of expectat ion s. Th is is often seen in n oses w ith m u lt iple aesth et ic de cien cies (e.g., sm all n ose, low bridge, bulbous upt urn ed t ip, ret racted colu m ella, ret ru ded prem a xilla, h anging ala, an d w ide alar base). Th e pat ien t sh ould be aw are th at after th e rh in oplast y su rger y, th ere are a few p ossible react ion s to th e n ew n ose. Peop le w h o h ave frequ en t en cou n ter w ith th e p at ien t (e.g., fam ily m em bers, o ce m ates, an d th e pat ien t h erself) m ay n d th e ch ange ver y obviou s. Th ose w h o see th e p at ien t occasion ally (e.g., h igh sch ool an d college alum n i frien ds) m ay n ot be able to n ot ice th e di eren ce; th ese p eop le w ill gen erally com m en t th at th e p at ien t looks m ore beau t ifu l th an before. People w h o h ad n ever m et th e pat ien t prior to th e surger y m ay n ot even n ot ice th at th e pat ien t h as h ad su rger y don e on th e n ose. Pat ien t s sh ould be in form ed of th e surger y in det ail beforeh an d: exten t of th e surger y, durat ion of th e surger y, t yp e of an esth esia given , don or site, possible m orbidit y after h ar vest , an d oth er per t in en t poin t s. Risks of th e operat ion sh ould be discussed th orough ly as w ell. Set t ing a realist ic su rgical goal is im port an t . Pat ien t s are advised to keep an old pict u re of th em selves close at h an d for t w o p u rposes: for iden t i cat ion an d to rem in d th em selves of th eir previous appearan ce. Th eir n ew n oses sh ould be com pared w ith th eir previous on es, n ot w ith oth er people’s n oses.1

nique, th e face an d th e auricles are draped as a w h ole. Lidocain e 2% w ith 1:100,000 adren alin e is used as local an esth et ic. Cau t ion is advised tow ard th e safe dose of lidocain e w ith adren alin e, w h ich is 7.0 m g per kilogram of body w eigh t . Th e con ch al car t ilage is h ar vested eith er an teriorly, if on ly a sm all am oun t of cym ba an d cavum con ch a is needed, or posteriorly, if a bigger am oun t is n eeded. Th e an terior in cision is d on e at th e p osterolateral p or t ion of th e cavum con ch a. Th e skin of th e cavum con ch a is dissected above th e p erich on driu m an d elevated to th e cym ba con ch a. An in cision in th e cart ilage is th en m ade n ear th e skin in cision site, leaving 2 m m of car t ilage ben eath . Dissect ion is th en perform ed at th e posterior side, m aking sure th at th e perich on drium is preser ved an d rem ain s at t ach ed to th e car t ilage. Th e con ch al cart ilage h ar vested sh ould con tain perich on drium on both sides to preser ve th e st rength . It sh ou ld be soaked in n orm al salin e solu t ion at all t im es before being fash ion ed as graft s. For th e p osterior ap p roach to con ch al cart ilage h ar vest , an in cision is m ade bet w een th e su lcu s an d th e h elix. Dissect ion is above th e p erich on driu m . Bleeders can be cau terized. To m axim ize th e h ar vest of cym ba an d cavum con ch a, t w o or th ree hypoderm ic n eedles are used to pierce an teriorly at th e edge of th e con ch al car t ilage th rough an d th rough . Th e car t ilage is th en in cised an d dissect ion is carried above th e p erich on driu m an teriorly, p reser ving 5 to 8 m m of con ch al car t ilage n ear th e extern al auricular can al. Closu re of in cision s is a bit di eren t . For in cision s don e an teriorly at th e cavum th e donor defect sh ould h ave 2 m m of con ch al cart ilage below th e site of skin in cision . Th is w ill be h elpful because it w ill ser ve as a platform for skin w ou n d h ealing. Closu re w ith a sim p le in terru pted su t u re is don e u sing nylon 5–0, in clu ding th e car t ilage to avoid a crum pled look at th e in cision site. A bolster sut ure is also applied to avoid h em atom a form at ion . For a posterior in cision , closu re is don e u sing nylon 5–0 vert ical m att ress sut ures. Som et im es th e h ar vest site of th e cym ba an d cavum con ch a con t ract s, especially at th e big auricle; to avoid collapse an d con t ract ure, a st rip of cart ilage bet w een th e cym ba an d cavum is preser ved.

■ Surgical Techniques

Alar Lift Surgery via Sail Excision

Conchal Cartilage Harvest

Hanging ala is com m on in Sou th east Asian n oses. Before th e st ar t of surger y th e t ip is m an ually pu lled to its desired posit ion to sim u late coun ter-rot at ion an d project ion . At ten t ion sh ou ld also be given to th e alar-colu m ellar relat ion sh ip. If th ere is a n eed for alar lift ing it sh ould be don e as th e in it ial procedu re sin ce th e w h ole low er p art of th e nose is st ill m obile an d w ill allow m axim al exibilit y in m an euvering th e ala du ring m arking, t ract ion , excision , an d su t u ring. Th e alar rim can be lifted by excision of a t riangular piece of t issue in th e in n er lateral vest ibu lar skin (Fig. 9.1).

Most Sou th east Asian rh in op last ies n eed con ch al car t ilage for graft ing sin ce th e h ar vested car t ilage available from th e sept u m is lim ited. Th is p rocedu re is don e before th e act u al rh in oplast y. Histologically, sept al cart ilage is a hyalin e cart ilage an d is rm er; h en ce it is used as a support graft . Con ch al car t ilage, w h ich is an elast ic cart ilage, is softer an d is u sed m ain ly for con tour, ller, and cam ou age graft s. The surger y can be don e un der gen eral an esthesia or in t raven ou s sedat ion . Follow ing th e usual asept ic tech -

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II Rhinoplast y Fig. 9.1 Designing the “sail” for alar lift. The t wo sides of the triangular sail are the caudal side, which is the inner margin of the alar rim, and the cephalic side, which is determined by a groove in the lateral vestibule. The base is m arked just before the area of the sill. The apex is determined by the highest point of the wing of the “gull in ight” on frontal view.

Apex

Cephalic side (vestibular groove)

Apex (peak of gull wing)

Caudal side Base

Th e irregular t riangular piece of skin t issue is sh aped like th e sail of a sailboat . Th e t w o sides are m arked at th e in n er alar rim m argin , an d a skin groove in th e lateral vest ibu le area is m arked by th e t ran sit ion of th in vibrissae to th ick vibrissae. Th e apex of th e t riangle is located at th e h igh est cur ve in th e “gull w ing” on the fron t al view. Th e alar rim skin is m ade to roll cep h alically as a ap, th u s lift ing th e w h ole alar rim . Th e defect is closed using nylon 6–0 sim ple in terru pted su t u res (Fig. 9.2).2 Th ere are som e in st an ces w h ere th e alar base is low er th an th e colum ellar base. Th e alar lift su rger y sh ould be aggressive to lift th e alar base as w ell. Th is procedure involves a radical “sail” excision by exten ding th e in cision in feriorly an d posteriorly follow ing th e vest ibular groove. Th e design of the exten ded sail excision is act ually a sm all t riangle in ferior to th e sail diagram ; it s apex is poin t ing in ferior-p osterior (Fig. 9.3). Closu re is don e via absorbable su t ure 6–0 sim p le in terru pted at th e sill area an d nylon 6–0 sim ple in terru pted at th e rim (Fig. 9.4).

The Approach Sin ce th e m ajorit y of South east Asian n oses n eed st ruct ural m odi cat ion , an open approach is preferred for bet ter visu alizat ion . A m argin al in cision is rst m ade. Th e colu -

a

m ellar in cision at th e m edial cru ra is m ade beh in d th e skin m ou n d an d an terior to th e h air-bearing area. An oth er in cision is m ade 2 to 3 m m cau dal to th e edge of th e low er lateral car t ilage. Th e m edial in cision an d th e caudal m argin al in cision s are th en con n ected m ain t ain ing 2 to 3 m m of skin . Main t ain ing a 2- to 3-m m vest ibu lar skin allow an ce en su res good coapt at ion du ring closing w ith su t u res. Dissect ion of th e low er lateral cart ilage is ap p roach ed at th ree sites: rst at th e m edial crura, th en at th e low er lateral car t ilage, an d n ally at th e dom e. A soft t issue dissect ion is don e at th e m edial cru ra. Th e dissect ion of th e low er lateral car t ilage is done above th e perich on drium . At th is t im e a t ran scolum m ellar in cision can be m ade an d th e dom es are dissected aw ay from th e overlying skin an d soft t issue envelope. Th e dissect ion of th e low er lateral car t ilage is carried superiorly an d laterally up to th e scroll jun ct ion of th e u pper lateral car t ilage an d th e lateral en ds of th e low er lateral cart ilage. Th e dissect ion of th e dorsu m at th e area of th e upper lateral cart ilage sh ou ld take place ben eath th e SMAS. Th is is ach ieved by carefully applying blun t an d sh arp dissect ion at th e dorsal sept um n ear th e an terior angle. On ce th e plan e is iden t i ed at th e dorsal sept u m , a blun t dissect ion is don e lateral-w ard un t il th e piriform open ing edge of th e m a xillar y bon e is reach ed . At th is t im e th e low er lateral cart ilage sh ould be fully m obile for t ip reposit ion ing.

b

c

Fig. 9.2 Closure of the sail excision. (a) Markings for the triangle shaped “sail” are made. If there is a need for alar base surgery, the markings are made higher. (b) The defect after excision of skin and subcutaneous tissue. (c) Closure using nylon 6–0 starts at both ends. The caudal side act s as a ap that coapts with the cephalic side and the base.

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Fig. 9.3 Extended sail excision for correction of hanging alar rim and alar base. The extended correction is done by designing a small triangle posterior to the sail diagram and following the vestibular groove as a guide infero-posterior to the nasal sill. Removing the vestibular skin with its subcutaneous tissues and suturing the defect will result in maximum lift at the alar base.

Th e upper dorsum com prises th e n asal bon es. Th e plan e of dissect ion is subperiosteal. Use a sh arp periosteal elevator, an d take care to avoid injur y to th e dorsal n asal n er ve th at exit s 5 to 6 m m lateral to m idlin e bet w een th e n asal bon es an d u p per lateral cart ilage (Fig. 9.5).

Membranous Septum Dissection: Two Points in a Plane Determine a Line Th e m em bran ous sept um sh ould be open ed for access to th e caudal edge of th e sept um . Th e dissect ion also frees th e m edial cru ra an d foot p late for ten sion -free t ip reposit ion ing an d colu m ellar sh ow.

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Aesthetic Rhinoplast y for Southeast Asians

b

Fig. 9.4 Extended sail excision. (a) Preoperative and (b) immediately postoperative correction of hanging alar rim and alar base. This maneuver is done as an initial step, with no other procedures having been done yet. Note the instant lift of the alar base and better alar-columellar relationship.

A safe ap proach to sp lit th e m em bran ou s sept u m is follow ing th e geom et ric ru le of “t w o poin ts in a plan e determ in e a lin e.” Poin t A is th e an terior angle of th e sept u m an d p oin t B is th e foot p late. Th e “p lan e” is th e m em bran ou s sept u m . After iden t ifying th e an terior angle of th e sept u m , th e bers of th e opposing m edial crura are dissected via blu nt dissect ion up to th e an terior n asal spine. Th is m an euver exp oses th e foot p lates. A sh arp dissect ion of th e m em branous sept um bet w een th e an terior angle of th e caudal sept u m (p oin t A) an d th e foot p late (p oin t B) is n ow p erform ed u n t il on e reach es th e cau dal m argin of th e sept u m .3

Septum Dissection: It Is Not How Much You Have but How Much You Leave Behind

Fig. 9.5 Dorsal nasal nerve (arrows) as it exits bet ween the nasal bone and upper lateral cartilage. Care should be taken to preserve it. The subperiosteal dissection for the dorsal implant should be medial to the nerves.

After th e cau dal edge of th e sept u m is iden t i ed, th e brou s at t ach m en t s of th e m ucosa are sh arply dissected to expose th e perich on drium . A bilateral subperich on drial dissect ion is m ade un t il th e bony part s of th e sept um are reach ed. Th e cen t ral quadrangu lar sept al cart ilage is h ar vested, leaving at least 10 m m of caudal an d dorsal st rut . Any deviat ion in th e rem ain ing sept u m is st raigh ten ed w ith various tech niques (Fig. 9.6). Any bony spu rs an d deviat ion are rem oved using rongeur forceps.3,4,5 Th e at tach m en t s of th e upper lateral cart ilage w ith th e sept u m m ay be divided an d corrected w ith sp read er graft s in cases w h ere th ere is a gross deviat ion . Min or deviat ion s can be cam ou aged w ith a dorsal graft .

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Fig. 9.6 Dorsal and caudal strut s. At least 10 mm of strut should be preserved. In instances where there is a need for a bigger septum for support, more can be harvested from the caudal side, thus leaving a smaller caudal strut of ~ 8 mm.

Designing the Septal Extension Graft: Achieving Strength and Symmetry Because the septum in Southeast Asian noses is usually sm all, any septal cartilage h ar vested is utilized m ain ly for support grafts (e.g., SEGs and spreader grafts). Th erefore, on e should alm ost alw ays h ar vest con chal cartilage for con tour and cam ou age grafts. The vector of th e tip reposition ing should be kept in m ind before com m encing surgery to achieve th e ideal tip projection. At tention should also be given to the varied thickness of th e SSTE w hen redraping the restructured nose since the fram ew ork w ill be elongated an tero-caudally and the SSTE w ill be stretched. The norm ally thicker radix skin w ill be redraped caudally, an d th e thick bro-fat t y tip skin w ill be relocated cephalically at the

Fig. 9.7 Manual stretching of the SSTE for simulation. In structural rhinoplast y where the nose is elongated, the thicker radix skin is pulled caudally when the SSTE is stretched to redrape the new tip. The supra-tip bro-fat t y skin will appear more cephalic and the low radix will appear higher.

supratip area (Fig. 9.7). In traoperative m an euvering of the SSTE h elps in th e nal design of th e SEG and dorsal grafts. After the quadrangular cartilage is h arvested, the edges of the harvested cartilages, especially the inferior at tachm ents to the palatine crest, are checked for irregularities and shaved for a sm ooth plane. Th e h ar vested cartilage from the dorsal area is usually thicker and is best suited for use as SEG. The inferior portions are used as additional support grafts (e.g., spreader graft, caudal m argin extension graft).5,6,7,8 Placem en t of th e SEG n eeds th ree or fou r su t u res for xation : on e cen t ral, on e an terior, on e in ferior, an d n ally a loop arou n d (Fig. 9.8). Th e loop -arou n d su t u re preven t s th e sw inging door deform it y of th e SEG, w h ich m ay cause in tern al valve obst ruct ion an d t w ist ing of th e t ip. Th e SEG m ay be w eak or d eviated, an d it m ay be st rength en ed u sing oth er su p p or t graft s (e.g., sp reader graft or cau dal m argin exten sion graft). Th e u se of cau dal exten sion graft s also im proves th e colum ellar sh ow an d augm en t s th e prem axilla. Folded con ch al car t ilage is also a good m aterial for sup port of SEGs. It is placed bet w een th e in ferior m argin of th e SEG an d th e cau dal st ru t . (Fig. 9.8 an d Fig. 9.9).9,10

Tip Projection and Counter-Rotation: A Must for the Southeast Asian Tip Becau se th e low er lateral car t ilage is n ot alw ays sym m et ric, th e dom es are rst m arked w ith gen t ian violet an d th en xed to th e an terior angle of th e SEG u sing a 25-gauge hypoderm ic n eedle, m aking su re th ere is n o buckling of th e SEG or deviat ion of th e t ip . Avoid excessive ten sion of th e low er lateral cart ilage. Tw o polydioxan on e (PDS) 5–0 xat ion sut ures are placed on th e dom e. Th e posterior edge of th e m edial cru ra is sut ured to th e SEG via polyglact in (Vicr yl) 5–0 in th e sequ en ce vest ibu le skin –m edial cru ra–SEG– m edial cru ra–vest ibu le skin .11

Fig. 9.8 The four-point suturing of the SEG and the folded conchal cartilage for support of the SEG. The SEG should be xed with three anterior sutures (dorsal, central, and caudal) and a loop-around structure to prevent deviation and tip t wisting. After the conchal cartilage is scored on the concave side and folded, it is anchored bet ween the SEG and the caudal strut.

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Aesthetic Rhinoplast y for Southeast Asians

Osteotomy: For Safety, Guide and Glide

Fig. 9.9 Folded conchal cartilage as support for the SEG. This graft prevents the collapse of the SEG and augments the anterior nasal spine, improving the premaxilla.

A sh ield graft an d a backstop graft are design ed to furth er coun ter-rotate an d project th e t ip. Grafts are sut ured at th e cau dal port ion of th e dom e u sing PDS 5–0 (Fig. 9.10). On ce th e t ip graft s are xed in p lace, th e sept al m u cosa can be sut ured using a Vicr yl 5–0 run n ing quilt closure starting at th e in ferior port ion of caudal st rut an d ru n n ing ran dom ly in a loop fash ion . Make sure th e areas of th e in tern al valve an d th e m em bran ou s sept u m are w ell coapted. At th is poin t th e SSTE can be draped to ch eck th e t ip project ion an d coun ter-rot at ion . On ce th e surgeon is sat is ed w ith th e rest ruct ured t ip, a dorsal graft can used to blen d th e n ew t ip w ith th e radix.9

Fig. 9.10 Contour tip grafts. Once the lower lateral cartilages are at tached to the SEG, multiple backstop, shield, and onlay grafts are put in place for further counter-rotation and projection of the tip.

Osteotom y is d on e on n oses sh ow ing an inverted -V deform it y bu t on ly on ce th e fram ew ork of th e t ip is accom plish ed. Th e inver ted-V deform it y usually disappears on ce a dorsal im plan t is pu t in place, or som et im es ju st a lateral osteotom y m ay be n eeded. A m edial osteotom y com m ences at 5 to 6 m m from the m idline and is directed superolaterally not to extend beyond the im aginary line bet ween the m edial canthi. A w ide platform is needed to accom m odate the dorsal im plant. Osteotom y follow s the “guide and glide” principle, w here the surgeon guides the osteotom e to cut the bones and glides along the desired path, w hich is usually thin. There w ill be a feeling of resistance or a change in pitch from tapping of the m allet w hen one reaches a solid bone. The lateral osteotom y can be approached directly transcutaneously or intranasally. The transcutaneous approach is done using a 3-m m osteotom e. The intranasal approach com m ences at the aperture near the nasal process of the m axillary bone superior to the inferior turbinate. A guarded curve osteotom e is introduced through a sm all stab incision in the nonhair-bearing area of the vestibule just above the attachm ent of the inferior turbinate. The guard should be palpated transcutaneously w ith the nondom inant hand along the tract of the lateral osteotom y. The tract should run through the softer bones at the nasal process of the m axilla. Som e surgeons have approached the lateral osteotom y intraorally at the gingivo-buccal sulcus.12

Designing the Dorsal Implant Th e m ajorit y of South east Asian n oses n eed dorsal augm en t at ion . In gen eral, th e th icker th e im plan t th e m ore visible it m ay becom e. Dorsal im plan t s usually range from 2 to 4 m m in th ickn ess. Depen ding on th e design , th e im plan t sh ou ld be on e w h ole p iece from th e radix to th e u p p er lateral car t ilage or exten d sligh tly caudally over th e low er lateral car t ilage. Th ere are several m aterials used for dorsal im plan t s. Au tologou s m aterials are st ill th e best , an d in clu d e car t ilages, derm is, fascia, an d fat . How ever, because of th e n eed for volum e in dorsal augm en tat ion , syn th et ic m aterials are p referred. Syn th et ic m aterials in clu de silicon e, ePTFE (Gore-Tex), an d porous polyethylen e (Medpor). Th ere are also h om ograft s su ch as p rocessed derm is, fascia, an d rib.10 Of all th e m aterials m en t ion ed, th e th ree m ost com m on ly u sed in dorsal im p lan ts are silicon e, ePTFE, an d cart ilage. Th ese m aterials h ave th eir respect ive ben e t s an d risks. On e ben e t of silicon e is th at it is relat ively ch eap an d easy to rem ove w h en in fected . How ever, w h en h ealed th ere is a capsu lar form at ion th at m ay give a surgical look years later because th e subcu tan eous fat of th e SSTE at roph ies w ith t im e. Silicon e is also m obile despite th e precise design of the subperiosteal pocket . It h as a ten den cy to m igrate su p eriorly to th e rad ix or cau dally to th e t ip, cau sing

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II Rhinoplast y ch ron ic pressure n ecrosis an d su bsequen t ext rusion . Th e im p lan t sh ap es are gen erally classi ed as “I” or “L” sh apes. The “I” sh ape im plan t exten ds from radix to th e t ip, w h ile th e “L” sh ape im plan t h as a st rut th at goes bet w een th e m edial cru ra to th e an terior sp in e. Th e “L” sh ape m ain t ain s th e t ip project ion an d preven t s superior m igrat ion of th e im p lan t; h ow ever, it is frequ en tly associated w ith t ip skin p ressu re n ecrosis. Expan ded PTFE, on th e oth er h an d, h eals w ith adh esion an d d oes n ot form a cap su le. It closely adh eres to th e n asal bon e an d car t ilages, giving a m ore n at ural look. How ever, in cases of long-st an ding react ion an d in fect ion it m ay be d i cu lt to rem ove. Th e in ciden ce of ePTFE in fect ion varies w orldw ide, bu t if st rict sterilit y an d p rop er su rgical tech n iqu e are em p loyed, th e in ciden ce is low. Cartilage as an im plan t is best for correction of sm all dorsal defects. Since the septal cartilage is m ainly used for su pport, con ch al cartilage is u sed for th e dorsal graft. If m ore volu m e is n eeded, bilateral h ar vest of con ch al cart ilage is done. The cartilage is cut into 5- to 8-m m strips. Th e st rips are scored on th e con cave side an d stacked using nylon or PDS sut ures. Stacked con ch al cart ilage is e ective; h ow ever, the st rips resorb and m ay w arp over tim e. There m ay also be irregu larities found w hen palpat ing the dorsum .13 Com paring th e ben e t s an d risks of th e th ree m ost com m on m aterials used for dorsal augm en t at ion , th e use of ePTFE is preferred because of its n at u ral look an d low risk of react ion an d ext ru sion . It com es preform ed an d in sh eet s. Alth ough ePTFE sh eet s can be stacked an d su t u red togeth er, it is recom m en ded th at a single p iece of im p lan t be used as m u ch as possible because of th e risk of con t am in an ts becom ing t rap p ed bet w een sh eet s du ring h an d ling. Noses w ith a low radix n eed m ore augm en t at ion , so a preform im plan t is w ell suited w h ile a n ose w ith a sh allow radix m ay just n eed a th in sh eet . In su t uring of sh eet s, m on o lam en t su t u res sh ou ld be u sed. Avoid u sing absorb able braided su t u res to preven t im p u rit ies being in t roduced an d em bedded in th e ePTFE m aterial.

Designing a Preformed ePTFE Implant Preform ed ePTFE im plan ts sh ould be rem oved from th e sterile p ackaging on ly w h en it is t im e for in sert ion . In serting th e im plan t is a t rial-an d-error procedu re. First th e SSTE sh ou ld be redrap ed an d th e radix dow n to th e t ip sh ou ld be palpated to determ in e th e ven t ral sh ape of th e im plan t . Th e ven t ral side of th e im plan t is th en car ved accordingly. Th e im plan t is rein serted an d th e length of th e im plan t is ch ecked again st th e dom e. If th e im plan t is long, th en it is cut (Fig. 9.11). At ten t ion is th en d irected at th e n ew radix, su p rat ip, w idth , an d rh in ion . Because th e rh in ion’s convexit y w ill be at a di eren t site from th e st retch ed SSTE w h en redraped, care sh ould be t aken to avoid a h um p look of th e im plan t . Th e rh in ion side of th e im plan t can be determ in ed in t w o w ays. On e w ay is to app ly extern al p ressu re to th e dorsu m to p rodu ce a convexit y of th e im plan t; th e oth er w ay is by using a Brow n -Adson forceps (on e jaw ben eath th e im p lan t to p alp ate th e bony-cart ilagin ou s ju n ct ion an d on e jaw above th e im p lan t) an d m ake a p in ch m ark on ce th e bonycart ilagin ous jun ct ion is located (Fig. 9.12). Th e im p lan t is th en rem oved an d car vings are don e accordingly.13 Sin ce m ost t ips in rh in oplast y go dow n on long-term follow -u p, it is recom m en ded th at th e cau dal en d of th e im plan t be sut u red to th e dom e to allow th e w h ole un it of th e dorsum to blen d w ell w ith th e t ip, even w ith long-term resorpt ion of th e t ip. Th e sut u ring also preven t s caudal deviat ion of th e im plan t . Th ere m ay be a space bet w een th e upper cart ilage an d th e ven t ral side of th e im plan t . Th e space sh ou ld be obliterated, p referably w ith car t ilage rath er th an a th in sh eet of ePTFE because th e lat ter m ay cause ch ron ic pressu re at th e m ucosa bet w een th e upper lateral cart ilage an d low er lateral car t ilage, w ith subsequen t in fect ion (Fig. 9.13).

b

a

Fig. 9.11 Preformed ePTFE implant. (a) The dorsal shape is analyzed to match the ventral side of the implant. (b) The ventral side is carved using a no. 10 surgical blade.

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a

b

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d

Aesthetic Rhinoplast y for Southeast Asians

Fig. 9.12 Two ways to determine the rhinion. (a) External pressure on both ends will give a convexit y of the ePTFE. (b) A bet ter way is inserting a Brown-Adson forceps up to the junction of the upper lateral cartilage and the nasal bone; the implant is pinched as a marker for the rhinion. (c) The marks of the forceps teeth are noted and marked. (d) The marked area is carved out.

a

b

Fig. 9.13 Gap bet ween ePTFE and upper lateral cartilage. (a) A space is often noted in the area of the upper lateral cartilage, especially in a tip repositioned for projection. (b) The space can be lled up with cartilage. This is done to prevent collapse of the implant, causing supratip depression.

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Designing a Sheet ePTFE Implant

Alar Base Surgery

Sh eet ePTFE com es in several th ickn esses. Usu ally sh eets of 2 or 3 m m th ickn ess are used for m in im al augm en tat ion w h ile preform ed im plan ts are u sed for bigger augm en t at ion . Depen ding on th e d im en sion s of th e sh eet , it is cut in to in dividual st rips of at least 50 m m length an d 13 m m w idth . Th e st rip s are in dividu ally packed in a dou ble pouch an d sterilized by gas or steam . Dividing a sh eet for m u lt iple-p at ien t u se in t raop erat ively sh ou ld n ot be don e because of th e possibilit y of cross-con t am in at ion . In design ing a sh eet im plan t , th e length is rst est im ated by p lacing th e sh eet on top of th e n ose. Th e sid es are t rim m ed u sing a n o. 10 blade an d m ain t ain ing 5 to 6 m m at th e m ed ial port ion . Th e ceph alic an d cau dal en ds are t rim m ed ben eath an d at th e corn ers. Th e sh eet im p lan t is th en in ser ted, n ot ing speci cally any depression th at is fou n d, w h ich is usually in th e m iddle th ird of th e n ose. A sm all ePTFE sh eet or car t ilage is u sed to elevate th e sh eet for bet ter form . Car t ilage is preferred over ePTFE sh eet as th e m aterial used to elevate th e sh eet im plan t because th e lat ter m ay dislodge th e im plan t in to th e m ucosa bet w een th e upper lateral cart ilage an d low er lateral cart ilage, causing ch ron ic pressu re an d subsequen t erosion an d in fect ion (Fig. 9.13). Th e SSTE is redraped for n al in spect ion . Palpat ion is im p or t an t at th is t im e to iden t ify a sm ooth dorsum from th e radix to th e t ip. After m aking cer tain th at th e n ew dorsu m w ith ePTFE sh eet im p lan t is sm ooth w ith n o depression , th e cau dal en d of th e sh eet im p lan t is th en su t u red at th e dom e using nylon 6–0. If fur th er project ion or coun ter-rot at ion is n eeded, addit ion al on lay or sh ield grafts are u sed . Cam ou age graft s are also u sed at th is p oin t if deem ed n ecessar y.13

Th e alar base m ay appear w ide despite project ion of th e t ip. Alarplast y is don e as th e last p roced u re. An ellip se of skin t issue in th e n asal sill is excised follow ing Weir’s tech n ique. Cin ch ing of th e alar base h elps in coapt ing th e alarplast y defect for ten sion -free closure. Cin ch ing sh ould n ot be t igh t because it can cause discom fort an d a rot at ion look of th e t ip. Closure is by nylon 5–0 sim ple in terru pted sut ures.

Closure of the Incision Closu re of th e t ran s-colum ellar in cision sh ould be don e in t w o layers. Vicr yl 6–0 is rst used to sut ure th e subcut an eous t issue, an d th e skin is closed using nylon 6–0 sim ple in terru pted sut ures. To ach ieve sym m et r y in skin closure, it is advisable to sut ure altern ately left an d righ t to follow th e cut pat tern of th e in cision .

■ Key Technical Points 1. In n oses w ith h anging ala, perform an alar lift su rger y via a “sail” excision as th e rst step becau se th e w h ole t ip an d ala are fully m obile, allow ing accu rate m arking, excision , an d closu re of th e d efect . 2. Th e plan e of dissect ion is above th e perich on drium in th e low er lateral cart ilage an d upper lateral cart ilage, an d is subperiosteal in n asal bon es. Dissect ion sh ou ld be w ide to allow redraping of th e SSTE w ith n o ten sion . 3. Fixat ion of a SEG n eeds four sut ures to ach ieve stabilit y. Add it ion al graft s are u sed to su pp ort th e SEG if d eem ed n ecessar y. 4. Fixat ion of the dom e to th e SEG sh ould be free from ten sion . Ch eck for bu ckling of th e SEG or deviat ion of th e t ip. 5. Im plan ts sh ould be car ved carefully in all dim en sion s to ach ieve a good blen ding of th e im plan t w ith th e un derlying st ruct ures. 6. Th e caudal en d of th e im plan t sh ould be sut ured to th e dom e to ach ieve a un i ed st ruct ure. If th e t ip loses it s project ion over th e long term , th e w h ole t ip—in cluding th e im plan t—w ill go dow n as on e u n it bu t st ill h ave good t ip de n it ion . Th e xat ion also preven t s su blu xat ion of th e im p lan t , cau sing deviat ion . 7. A gap of space m ay occu r bet w een th e im plan t an d u pp er lateral car t ilage an d it sh ou ld be lled u p w ith cart ilage. 8. Th e caudal m argin of th e im plan t sh ou ld be cleared from th e lin e of in cision . 9. Closure of in cision s sh ould be m et iculous. No few er th an seven su t u res sh ou ld be u sed in th e m idcolu m ellar in cision . 10. Alarplast y is don e as th e last procedure.

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■ Complications and Their Management

As m ost rh in oplast y in South east Asian s involves alterat ion of th e n ose’s st ruct ural fram ew ork, com plicat ion s of th e su rger y are also closely related to th e rest ru ct u red fram ew ork. Most of th e t im e, th e am ou n t of n asal sept u m h arvested is on ly su cien t for th e SEG. Th ere is alm ost alw ays a n eed to u se con ch al cart ilage for con tou r graft s (e.g., sh ield graft s, cap grafts). Sou n d ju dgm en t is im p or tan t as to th e am ou n t of dorsal an d cau dal st ru t th at is left beh in d, w h ich sh ou ld be en ough to h old th e st ruct ural grafts an d con tour graft s an d to w ith st an d th e pressure force from th e SSTE du ring closu re. Gen erally, a sm all n ose w ith a sm all, rm sept u m m ay n eed on ly 8 m m of st ru t w h ile a n ose w ith a th in sept um n eeds 10 to 12 m m of st rut .10 Th e surgeon sh ould be able to visualize th e vector for th e new t ip to properly place th e SEG. Th e low er lateral cart ilage sh ould n ot be pu lled too m uch because such forces m ay cau se bu ckling of th e SEG. Th is, in t u rn , w ill cau se t w ist ing of th e t ip an d com pression of th e in tern al n asal valve.4 Th e low er lateral cart ilage sh ould be sym m et rically xed to th e SEG. Any de cien cy in th e d esired t ip p roject ion and coun ter-rotat ion can be corrected by th e u se of con ch al car t ilage for on lay or sh ield graft s, respect ively. Do n ot app ly too m u ch ten sion on th e dom e w h en xing it to th e SEG. If tw isting of the tip is noticed w hile still in surgery, all grafts should be rem oved and all structures should be realigned. In late-onset t w isting of the tip, correction should involve m inim al access and m inim al m anipulation of the w hole structure. Correction is usually accom plished by placem ent of a cam ou age graft (crushed cartilage, tem poralis fascia, or sacroderm al fat) to achieve sym m etry; if there is an accom panying obstruction in the internal valve, subm ucous resection or scoring/suturing of the SEG can be done. Palp at ion is ver y im p ort an t to detect any gap bet w een th e im plan t an d it s u n derlying st ruct ures in th e radix an d su p ratip area. Th e t ip sh ou ld be w ell de n ed visu ally an d con rm ed by palpat ion before n al closure.13 Su rgeon s sh ou ld adh ere to th e st rict m an n er of h an dling dorsal im plan ts to avoid in fect ion . In fect ion occurring in th e rst 2 m on th s m ay be iat rogen ic, w h ile in fect ion

Aesthetic Rhinoplast y for Southeast Asians

beyon d 2 m on th s is usu ally related to im m u n e respon se. Early sign s of in fect ion can be reversed by in t ake of an t ibiot ics. Persisten t edem a of th e dorsu m after augm en t at ion rh in oplast y m ay require rem oval of th e im plan t an d revision u sing an au tologou s graft .13 Tip cart ilage visibilit y is seldom en cou n tered in Sou th east Asian n oses becau se of th e th icker t ip skin ; h ow ever, in exten sive t ip project ion an d coun ter-rotat ion , cart ilage visibilit y m ay be an u n exp ected sequ ela. Th erefore, it is recom m en ded th at crush ed cart ilage or a soft t issue graft be placed over th e n al t ip graft .8 Th e n al appearan ce of th e recon st ructed n ose in t raop erat ively w ill rep resen t th e n al ou tcom e of th e n ew n ose postoperat ively. In t raoperat ive palpat ion is an im port an t step to h elp visu alize th e n al sh ap e of th e recon st ru cted n ose postop erat ively in th e m on th s to com e.

■ Case Studies Case 1 A 25-year-old w om an w an ted a rh in op last y to im p rove th e appearan ce of h er face (Fig. 9.14). Physical exam in at ion sh ow ed a st raigh t dorsu m an d sept um . Th e dorsum , h ow ever, w as low ; n asal bon es ap p eared w ide; th e t ip w as bulbous an d sligh tly upt urn ed; th e colum ella w as sligh tly ret racted w ith a ret ruded prem axilla; th e alar base w as w ide w h ile th e alar rim w as h anging. Alar lift surger y via a sail excision w as don e as th e rst step. Con ch al cart ilage w as h ar vested an teriorly. Th e su rger y w as an open ap proach septorh in oplast y w ith a sept al exten sion graft at th e righ t side of th e cau dal st ru t . Folded con ch al cart ilage w as placed below th e SEG for suppor t an d for p rem axillar y augm en t at ion (Fig. 9.15). After th e d om e of th e low er lateral car t ilages w as xed to th e SEG, con ch al car t ilage w as used for t ip grafts. A 3-m m ePTFE sh eet w as used to augm en t th e dorsum an d w as blen ded in w ith th e n ew t ip an d th e radix. A sm all p iece of con ch al cart ilage w as p laced bet w een th e u n derside of th e im p lan t an d th e upper lateral cart ilage. A plum ping graft using pieces of con ch al cart ilage w as in ser ted in to th e prem axilla. Alar base su rger y w ith a cin ch ing tech n iqu e w as don e as th e last procedure. Results are sh ow n in Fig. 9.16.

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Fig. 9.14 Case 1. A t ypical Southeast Asian nose is shown. (a) Preoperative frontal view shows a low but straight dorsum. The tip is upturned, wide, and bulbous. The nasal bones are wide. The alar base is wide, the rim is hanging, and the columella is retracted. (b) Lateral view shows a low dorsum and retracted premaxilla. The columella is not visible and the alar rim is hanging.

b

Fig. 9.15 Case 1. Schematic drawing of the soft tissue correction and structural grafting. The main support graft is a SEG, which is further supported with an extended spreader and folded conchal cartilage. Tip de nition grafts include shield, backstop, and crushed onlay grafts. Medial and lateral osteotomies were done. A 3-mm ePTFE sheet was used for dorsal augmentation. Soft tissue correction includes sail excision for alar lift and alar base surgery.

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Aesthetic Rhinoplast y for Southeast Asians Fig. 9.16 Case 1. (a) Postoperative frontal view shows a bet ter dorsal nasal aesthetic line. The tip is narrower and counterrotated. The alar width is narrower. There is a bet ter alar-columellar relationship. (b) Lateral view shows good tip counter-rotation and projection. The dorsum is augmented and the premaxilla is fuller. The columella is visible and the alar rim is elevated.

b

Case 2 A 28-year-old m an desired im p rovem en t of h is n ose, esp ecially it s t ip (Fig. 9.17). Physical exam in at ion sh ow ed a st raigh t dorsu m an d sept u m . Th e dorsu m , h ow ever, w as low w ith p rom in en t glabellar fron t al bossing; n asal bon es w ere w id e; th e t ip w as low an d bu lbou s; th e colu m ella w as ret racted w ith a ret ruded prem axilla; th e alar base w as w ide w h ile th e alar rim w as h anging. An alar lift via sail excision w as don e as the rst step. Cavum an d cym ba con ch al cartilage w as h ar vested an teri-

orly. The surger y w as an open approach septorh inoplast y w ith a septal exten sion graft at the right side of the caudal stru t an d a caudal m argin exten sion graft . After th e dom al cart ilages w ere xed to the SEG, conchal cart ilage w as used for t ip grafts (Fig. 9.18). A 4-m m preform ed ePTFE piece w as used to augm ent the dorsum . A sm all piece of conchal cartilage w as used to ll up the space bet w een the underside of the im plan t an d the upper lateral cartilage. Pieces of conch al cartilage w ere used for a plum ping graft . After closure of th e rhinoplast y incision, alar base surger y w ith cinching w as th en carried ou t. Results are sh ow n in Fig. 9.19.

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II Rhinoplast y Fig. 9.17 Case 2. (a) Preoperative frontal view shows a wide ala, a retracted columella, and a de cient middle vault. (b) Lateral view shows a low dorsum, bulbous tip, and retracted premaxilla. The middle vault seems de cient.

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Fig. 9.18 Case 2. Schematic drawing of the soft tissue correction and structural grafting. The m ain support graft is a SEG, which is further supported with a caudal margin extension graft. Tip de nition grafts include shield, backstop, and crushed onlay grafts. Medial and lateral osteotomies were done. A 4-mm preformed ePTFE implant was used. Soft tissue corrections included a 5-mm sail excision for alar lift and a 2-mm alar base resection.

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Aesthetic Rhinoplast y for Southeast Asians Fig. 9.19 Case 2. (a) Postoperative frontal view shows a good dorsal nasal aesthetic line. The alar-columellar relationship is better. The alar base is narrower. (b) Lateral view shows a good augmented dorsum and projected tip. The premaxilla is fuller and there is columellar show. The alar rim is well lifted.

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References 1. Akkus AM, Er yilm az E, Gun eren E. Com parison of th e effect s of colum ellar st rut and sept al extension graft s for t ip support in rh in oplast y. Aesthet ic Plast Surg 2013;37(4): 666–673 2. Baladiang DE, Olveda MB, Yap EC. Th e “sail” excision tech n iqu e: a m odi ed alar lift p rocedu re for Sou th east Asian n oses. Ph ilip p J Otolar yngol Head Neck Su rg. 2010; 25:31–37 3. Byrd HS, An doch ick S, Copit S, Walton KG. Sept al exten sion graft s: a m eth od of con t rolling t ip project ion shape. Plast Recon st r Su rg 1997;100(4):999–1010 4. Ch oi JY, Kang IG, Javidn ia H, Sykes JM. Com plicat ion s of sept al exten sion graft s in Asian pat ien t s. JAMA Facial Plast Su rg 2014;16(3):169–175 5. Jang YJ, ed. Rh in oplast y an d Septoplast y. Seoul, Korea: Koonja; 2014 6. Kim JH, Song JW, Park SW, Oh WS, Lee JH. E ect ive sep t al exten sion graft for Asian rh in oplast y. Arch Plast Surg 2014;41(1):3–11

7. Koch CA, Friedm an O. Modi ed back-to-back autogen ous con ch al cart ilage graft for cau dal sept al recon st ru ct ion : th e m edial cru ral exten sion graft . Arch Facial Plast Su rg 2011;13(1):20–25 8. Lin J, Ch en X, Wang X, et al. A m odi ed sept al exten sion graft for th e Asian nasal t ip. JAMA Facial Plast Surg 2013;15(5):362–368 9. Pern ia NE, Galvez JA, Victoria FA. Th e dim en sion s of th e n asal sept al cart ilage: a prelim in ar y st udy in adu lt Filipin o Malay cadavers. Ph ilipp J Otolar yngol Head Neck Su rg. 2011;26:10–12 10. Toriu m i DM, Bared A. Revision of th e su rgically oversh orten ed n ose. Facial Plast Surg 2012;28(4):407–416 11. Yap E. Im p roving th e h anging ala. Facial Plast Su rg 2012; 28(2):213–217 12. Yap EC. Prin cip les of st ru ct u ral rh in op last y in Sou th East Asian n oses. Ph ilipp J Otolar yngol Head Neck Su rg. 2014; 29:41–44 13. Yap EC, Abu bakar SS, Olveda MB. Exp an ded p olytet ra u oroethylen e as dorsal augm en tat ion m aterial in rh in op last y on Sou th east Asian n oses: th ree-year experien ce. Arch Facial Plast Surg 2011;13(4):234–238

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Correction of the Short, Contracted Nose

Hong Ryul Jin

Pearls • Repeated rh in oplast ies causing t rau m a to th e skin ,

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soft t issu e, an d car t ilages, im p lan t u se over th e low er lateral cart ilage causing pressure n ecrosis, an d over-resect ion of car t ilages w ill en su e scar con t ract u re w ith resultan t sh or t , con t racted n ose. With every e ort m ade to correct the deform ity, often the postsurgical contracted, short nose cannot be elongated to a level equal to patient expectations. It is crucial to have an adequate consultation before surgery. Th e st rategies for correct ing secon dar y sh or t n ose deform it y in clude skin envelope release th rough w ide un derm in ing, elongat ion an d derot at ion of th e t ip com pon en t , augm en t at ion of th e dorsum , an d u se of com posite graft m aterial to ll th e gap bet w een th e elongated skin envelope an d th e u n derlying vest ibular skin . In m ost cases of sh ort n ose correct ion , cost al cart ilage is n ecessar y for st ru ct ural suppor t an d on lay graft ing. A sept al exten sion graft st rongly su pp or ted w ith bilateral exten ded spreader grafts using rib cart ilage

■ Introduction Th e sh ort n ose, th e so-called sn ub n ose, is object ively de n ed as h aving a decreased n asal length w ith an abn orm ally in creased n ost ril sh ow from th e fron t al view (Fig. 10.1). Th e t ip is rotated cep h alically w ith a m ore obt use n asolabial angle on th e lateral view. Th e ast ute su rgeon sh ou ld also n ote th at a d eep n asofron tal angle con t ribu tes to th e subject ive appearan ce of a sh ort n ose, esp ecially w h en com bin ed w ith an obt u se n asolabial angle. The short nose can be congenital in origin, but is usually acquired secondary to traum a or from a previous rhinoplast y. In postsurgical cases, over-resection of the lower lateral cartilage is a frequent predisposing factor in Caucasian rhinoplast y. On the other hand, in East Asian patients, a postsurgical short nose deform ity arises from di erent m echanism s. Th e exact path ogen esis of sh or t n ose developing after rh in oplast y using an alloplast ic im plan t is u n kn ow n yet but capsular con t ract ion aroun d th e im plan t used for dorsal augm en tat ion , low er lateral car t ilage n ecrosis by longterm pressure from im plan t s, ch ron ic in am m at ion , an d

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is th e key st ruct u ral foun dat ion on w h ich th e low er lateral car t ilage can be reposit ion ed. An en d -to-en d t yp e septal exten sion graft h as th e advan t ages of align ing th e cen ter in to m idlin e an d avoiding caudal sept al deviat ion com pared w ith th e overlap p ing t yp e. Various on lay grafts over th e reposit ion ed low er lateral car t ilage can h elp to length en or augm en t th e t ip. A ch on drocu t an eou s com posite graft taken from th e cym ba con ch a is often needed to ll th e gap bet w een th e length en ed skin envelope an d th e vest ibu lar lin ing. A staged operat ion or even a foreh ead ap w ill be n ecessar y if th e skin sh ort age is severe in an ext rem ely con t racted or dest royed n ose. Warping of th e rib car t ilage u sed as a dorsal on lay graft can be m in im ized w ith prop er tech n iqu es but is n ot com pletely avoidable. It can be corrected w ith revision surger y after fu ll-blow n w arping h as occurred.

scar con t ract ion from m u lt ip le rh in op last ies are th ough t to be possible et iologies. Th is con dit ion is rath er com m on in pat ien t s w ith w eak low er lateral car t ilages w h o h ad m ult iple rh in oplast ies w ith silicon e im plan tat ion . Tech n iques to length en th e n asal t ip are orien ted to adding car t ilage graft s to th e cau dal sept u m to cau dally rot ate th e t ip, securing spreader grafts to a colu m ellar st rut , t ip graft s of various sh apes, an d placem en t of radix graft s to elevate th e n asion .1 Most post su rgical con t racted n oses h ave both st ru ct u ral problem s, su ch as w eak alar cart ilage an d decreased skin com plian ce cau sed by a dam aged skin – soft t issu e envelop e. Becau se of th ese feat u res, sh ort n ose correct ion h as becom e on e of th e m ost di cult procedures in rh in oplast y.

■ Patient Evaluation Th e pat ien t’s h istor y of previous su rger y n eeds to be qu est ion ed ver y th orough ly. Dates an d n um ber of surgeries, su rgeon s’ n am es, m aterials u sed, tech n iqu es u sed, an d any speci c reason s for m u lt ip le su rgeries, in clu ding com plica-

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Correction of the Short, Contracted Nose

w ith cot ton t ips, an d often a th in , m em bran ous posterior sept u m w ith m issing car t ilage can be felt . In ext rem e cases, th e caudal sept um is m issing, causing severe sh rin kage an d con t ract ion of th e t ip. In th ese cases, length en ing of th e nose is possible on ly after th e caudal sept um is restored. Elongat ing a sh or t , con t racted n ose is a ver y di cult job, an d even w ith exten sive st ruct ural groun dw ork, th e nose can be length en ed on ly by 3 to 4 m m . Th erefore, th e lim itat ion s of th e su rger y n eed to be explain ed th orough ly to th e pat ien t an d a reason able su rgical goal n eed s to be set . Often th e p at ien t s ten d to h ave u n realist ic expect at ion s, su ch as th at th e n ose w ill look n orm al an d m ore beaut iful com pared w ith it s preoperat ive st at us. Realist ic pat ien t expect at ion s an d a reason able surgical goal con sidering th e n asal stat u s an d th e su rgeon’s exp erien ce are th e m ost im p or tan t factors in th e su ccess of th e su rger y.

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Fig. 10.1 Typical postoperative short nose deformit y. (a) Abnormally increased nostril show and short nose are evident from the frontal view. (b) Lateral view shows excessively cephalically rotated nasal tip, low dorsum, acute nasofrontal angle, and obtuse nasolabial angle.

■ Surgical Techniques Strategies for Correction

t ion s, n eed to be evaluated. Th orough dat a are im port an t in p lan n ing su rger y. Th e extern al n ose is palpated carefully to evaluate th e skin , u n derlying bon e, an d cart ilage. W h en th e skin is too th ick or h as a scar th at decreases it s m obilit y, th e am oun t of lengthen ing of th e n asal t ip can be lim ited. A sen se of th e adequ acy of skin m obilit y can be gain ed by p ressing dow n on th e skin an d pulling on it (Fig. 10.2). Ext rem ely th in an d adh eren t skin m ay cau se di cu lt y in u n derm in ing an d w ill raise th e possibilit y of skin dam age. Ever y e or t sh ou ld be exerted n ot to dam age th e skin in th is case. Th e n asal cavit y, especially th e sept um , sh ould be th orough ly evalu ated. In revision cases, th ere is a h igh ch an ce th at sept al cart ilage h as already been used in th e previous su rger y an d n ot in frequ en tly th ere are sept al perforat ion s. Th e in t act-looking sept um n eeds to be carefully palpated

Fig. 10.2 Evaluation of skin mobilit y. Skin mobilit y is assessed by pulling the dissected skin and soft tissue envelope over the cartilage infrastructure during the surgery.

If th e degree of cep h alic rotat ion is m ild an d th e t ip su p port is st rong, adding car t ilage graft s on th e t ip an d th e dorsu m m ay give som e degree of caudal rot at ion of th e t ip an d th e illu sion of n asal length en ing by dorsal augm en tat ion . In a ver y sh ort n ose caused by severe ceph alic rot at ion of th e t ip -de n ing poin t , m erely raising th e n asion w ith an im plan t on th e n asal dorsum , or pulling dow n th e t ip -de n ing poin t sligh tly by placing a graft on th e n asal t ip has lim ited length en ing e ect . More radical reorgan izat ion an d rep osit ion ing of th e low er n asal fram ew ork an d skin envelop e are n ecessar y. Proper su rgical tech n iqu e is ch osen con sidering th e prior operat ive h istor y, pat ien t expect at ion s, th e degree of ceph alic rotat ion of th e n asal t ip presen t , skin m obilit y, an d th e am ou n t of available cart ilage for use as graft s. In m ost post su rgical con t racted , sh or t n ose, cau dal rot at ion of th e t ip -de n ing poin t an d raising th e n asion su p eriorly are t w o key su rgical goals. Cau dal rotat ion of th e t ip -de n ing poin t is obt ain ed by caudally readjust ing th e low er lateral cart ilage on th e septal exten sion graft w ith or w ith out addit ion al t ip on lay graft s (Fig. 10.3). To cau dally rot ate th e t ip w ith out losing project ion , a rm st ru ct ural su p p or t rein forcing an d length en ing all th ree legs of th e “t rip od” of th e n asal t ip is n eed ed . W h en th e cen t ral part of th e n ose (i.e., th e colu m ella an d th e t ip lobu le) is length en ed w ith a sept al exten sion graft , th e lateral cru s m oves ver t ically u pw ard an d so d oes th e alar m argin . Th e alar m argin s also n eed to be low ered to create a m ore balan ced n ost ril after th e p lacem en t of th e sept al exten sion graft . Sligh t im balan ce can be adju sted w ith a lateral cru ral on lay or st ru t graft . Placing a long lateral cru ral st ru t graft–lateral cru ral com plex in to a p ocket m ade in th e piriform ap er t u re m ay low er th e alar m argin in th e th in -skin n ed Caucasian pat ien t , but th is m an euver

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Fig. 10.3 Illustrations showing key techniques used to correct short nose deformit y. Septal extension grafts reinforced with extended spreader grafts and tip onlay grafts are used to lengthen the nasal tip. (a) End-to-end t ype. (b) Overlapping t ype. (c) Bilateral conchal composite grafts are applied when the elongated skin envelope and the vestibular lining cannot be primarily closed.

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10 is n ot as e ect ive for East Asian s, w h o h ave th icker skin . In m ost cases, th e st i an d in elast ic skin envelope an d de cien t vest ibular skin are th e m ost com m on ly en coun tered lim it ing factors du ring th e low ering procedu re of th e alar rim . Th e au th or p refers to u se con ch al com posite graft s from th e cym ba con ch a to ll th e gap bet w een th e elon gated skin envelope an d th e de cien t vest ibu lar m u cosa, at th e sam e low ering th e alar m argin (Fig. 10.3c). Many Asian p at ien t s w an t t ip augm en t at ion even in a sit u at ion th at calls for th e correct ion of sh ort , con t racted n ose; h ow ever, it is n ot easy to get both an im p roved p roject ion an d cau dal rot at ion of th e n asal t ip . W h en su cien t p roject ion is ach ieved, th e n ose is fou n d to be adversely rot ated cep h alically. Conversely, correct ing th e sh ort n ose w ith on ly caudal rot at ion usually en ds in in su cien t t ip p roject ion . Th u s, an adequate com prom ise bet w een augm en t at ion an d cau dal rot at ion of th e t ip n eed s to be fou n d.

Graft Material Harvesting In m ost cases, th e sept al car t ilage or con ch al car t ilage is in su cien t an d costal car t ilage is used. Before deciding to u se cost al cart ilage, it is p ru den t to ch eck th e rib series for p ossible calci cat ion of th e cart ilage. Not in frequen tly, you ng fem ale pat ien t s h ave severe calci cat ion of th e costal car t ilage.2 Calci cat ion m akes h ar vest ing an d car ving of th e car t ilage di cult . If th e cart ilage is tot ally calci ed, it is ver y di cu lt to u se as graft m aterial. The costal cart ilage graft is h ar vested m ostly from th e sixth or th e seven th rib for u se in rh in op last y. In fem ale p at ien t s, th e in cision is placed just above th e in fram am m ar y crease for bet ter cosm esis (Fig. 10.4). In m ale p at ien t s, th e in cision is m ade directly over th e ch osen rib. Th e proper car t ilage is located after palpat ion , an d th e cos-

Fig. 10.4 Harvest of rib cartilage. Rib cartilage is being removed from the small, inframammary incision. The incision can be minimized by exactly locating the costochondral junction by probing the cartilage using a 26-gauge needle.

Correction of the Short, Contracted Nose

toch on dral ju n ct ion is con rm ed by serial probing w ith a 26-gauge n eedle. Marking is usually 1.5 to 2.0 cm in length in th in -skin n ed pat ien ts an d 2.0 to 2.5 cm in th ick-skin n ed pat ien t s. A local an esth et ic is in lt rated at th e in cision site. Ten m in utes after inject ion , th e skin an d subcut an eous t issu e is in cised w ith a n o. 10 blade. Th e su bcu t an eou s fat is altern ately sep arated an d ret racted u sing Sen n ret ractors un t il th e fascia an d th e extern al oblique m uscle layer are exp osed . Th e fascia is th en in cised an d th e m u scle bers sep arated w ith Kelly or m osqu ito forcep s. To adequ ately exp ose th e su rgical eld, th e m u scle layer is ret racted w ith an Arm y-Navy ret ractor for bet ter visu alizat ion , in stead of cut t ing w ith a Bovie, to m in im ize postoperat ive pain . Th e perich on drium an d th e rib are su cien tly exposed after ret ract ing th e soft t issue an d m uscle. Tw o parallel in cision s are m ade on th e perich on drium of th e rib along th e superior an d in ferior borders, leaving th e cen t ral st rip of perich on drium on th e an terior surface in t act . Follow ing th is, several cut s are m ade perpen dicular to th e longit udin al in cision to facilitate circum feren t ial re ect ion of th e perich on drium , w h ich is th en dissected from th e rib w ith a Freer elevator. Th e st raigh t p ort ion of th e rib is often foun d to be of in su cien t length for dorsal im plan t at ion , n ecessitat ing exten sion of th e cart ilagin ous cut up to th e syn ch on drosis por t ion to obtain a longer piece of cart ilage. Har vest ing is facilit ated if an an terior cu t is m ade at th e m edial en d of th e cart ilage before com plet ing th e dissect ion of th e posterior su rface of th e cost al car t ilage. Th e perich on drium of th e posterior surface of th e rib is dissected o as m u ch as p ossible w ith a cu r ved elevator. Th e costoch on dral jun ct ion is iden t i ed visually or w ith th e help of a 26-gauge n eedle an d th e cart ilage cut is m ade. Th ere is a great risk of injuring th e un derlying pleura if a com plete cut is m ade using th e n o. 15 blade; th us, th e n al cut is com pleted w ith th e Freer elevator to preven t su ch an inju r y. After th e lateral cut , a sm all t w o-prong ret ractor is used to pu ll up th e cost al cart ilage to expose th e posterior su rface an d th e dissect ion is con t in u ed m edially. After com plete dissect ion of th e posterior perich on drium , th e cost al cart ilage is separated at th e m edial cut an d delivered out . A 3- to 4-cm length of cost al cart ilage is t ypically h arvested . Th e cen t ral st rip of p erich on d riu m is dissected an d preser ved for later u se. Th e h ar vested costal car t ilage is soaked in w arm salin e to assess for an d in duce w arping prior to car ving. Test ing for air leakage from th e pleura is perform ed by lling th e dissect ion pocket w ith salin e an d th en in it iat ing posit ive-pressure hyper ven t ilat ion . If n o air leakage in th e form of bu bbles is eviden t , th e don or site is packed w ith an t ibiot ic-soaked gauze un t il th e operat ion is com pleted. Addit ion al cost al car t ilage can be h ar vested during th e operat ion or th e cart ilage rem ain ing after grafting can be rein serted an d preser ved un der th e m uscle layer for use in fut ure revision surger y. If air leakage is n oted, a Nélaton cath eter is in serted at th e leakage site an d su t u red in a pu rse-st ring m an n er. After t igh t closure of th e subcu -

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II Rhinoplast y tan eous an d skin w oun d, th e Nélaton cath eter is rem oved w h ile sim ultan eously adm in istering in ten se posit ive-pressu re hyp er ven t ilat ion . Th e separated m uscles are t igh tly approxim ated to dim in ish postoperat ive pain an d th e w oun d is closed layer by layer using 4–0 Vicr yl sut ures. No drain is in serted. Th e skin m argin s are often bru ised w ith discolorat ion du e to excessive ret ract ion , an d th ese are t rim m ed an d su t u red w ith 6–0 nylon an d a com pressive dressing is applied. Th e nylon su t ures are rem oved on th e seven th to ten th postop erat ive day. Ordering a ch est X-ray to ch eck for p n eu m oth orax im m ediately after th e operat ion is n ot obligator y if th e su rgeon is con den t th at th ere w as n o air leakage th rough th e h ar vest w oun d. If th e pat ien t presen t s w ith sign s an d sym ptom s of p n eu m oth orax follow ing su rger y, th en a ch est X-ray is w arran ted. Rarely, a pn eum oth ora x can occu r even th ough th ere w as n o leakage during th e in t raop erat ive ch ecking. Mild pn eum oth orax can resolve spon t an eou sly w ith a serial follow -u p of ch est X-ray; h ow ever, a ch est t ube is in ser ted to expan d th e collapsed lung in n on resolving or severe cases.

Carving of Costal Cartilage Har vested au tologou s costal cart ilage is design ed an d car ved in to various form s depen ding on th e purposes of th e graft: d orsu m augm en t at ion , rein forcem en t of th e sept u m in th e form of bat ten or septal exten sion graft s, exten ded spreader graft s to rein force th e sept al exten sion graft , t ip on lay grafts, or as a prem axillar y graft . Cost al cart ilage con sists of a core an d periph eral region s surrou n ding th e core; a balan ce an d stasis are m ain t ain ed by th e in tern al st ress created by th e t w o com pet ing region s.3 Cen t rally cu t pieces of car t ilage w arp m ore qu ickly th an th e p erip h erally cu t p ieces; h ow ever, th e periph erally cut cart ilage w arps at a greater rate th an th e cen t rally cut segm en t .4 Side-to-side w arp ing is m ore clin ically eviden t du e to less soft t issue resist an ce in th is d im en sion .5 To prep are a n onw arp ing im p lan t for d orsal

augm en tat ion , th e p erip h er y of th e cost al car t ilage is sym m et rically cu t aw ay, leaving a cen t ral core of th e cart ilage. Th e cen t ral part of th e cart ilage is car ved w ith a n o. 10 scalpel an d u sed as a dorsal im plan t . First , an appropriate sh ape for th e dorsum is design ed. If a st raigh t piece of rib cart ilage w ith su cien t length is har vested, th is is th e ideal sit uat ion . In m ost cases, a sligh tly cur ved cart ilage is obtain ed an d a st rategic ap p roach an d design are n eeded to obtain a st raigh t graft . After cu t t ing aw ay th e p erip h eral cart ilage according to th e design , th e cen t ral p ar t is scu lpted in to th e target sh ape (Fig. 10.5). Th e car t ilage is periodically soaked in physiologic salin e for 10 to 20 m in u tes at a t im e, an d th en brough t ou t to con t in u e th e car ving w h ile w atch ing ou t carefu lly for sign s of w arping. On ce w arping is eviden t , th e rem ain ing periph eral con cave por t ion of th e cart ilage n eeds to be cut out . W h en th e im plan t is car ved in th is m an n er, postoperat ive w arping can be m in im ized.6 It takes abou t an h ou r to scu lpt ever y p iece of th e h ar vested car t ilage in th is m an n er to m in im ize th e risk of w arping. Th e com p leted, fu lly car ved cart ilage graft h as rounded m argin al part s an d progressively n arrow ed upper and low er part s, yielding a can oe-like sh ape from th e fron tal view. W h en seen from th e lateral view, it h as a sligh tly con cave side th at com es in to con tact w ith th e n asal dorsum , an d a dorsal side th at is sligh tly convex (Fig. 10.6). How ever, n ot w ith st an ding all th ese e ort s, ver y m in or w arping occur. Making several cut s in th e graft fur th er m in im izes th e w arping, alth ough th ese cut s m ay cause a poten t ial w arping deform it y later. A at , st raigh t p iece of car t ilage is n ecessar y for u se as a sept al exten sion graft an d exten ded sp reader graft . For th ese purposes, th e cart ilage is cu t an d car ved as a at piece an d soaked in w arm salin e to ch eck for any w arping before graft ing. To m in im ize w arping, th e car t ilage is cu t longit udin ally or t angen t ially, leaving periph eral por t ion s sym m et rically th ick on th e t w o sides of th e cen t ral p or t ion , w h ich coun teract s an d n egates the expected distor t ion on both sides (Fig. 10.7). Th is at , long piece of car t ilage is resist an t to w arping as long as the periph eral port ion s on th e sides rem ain sym m et rical.

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Fig. 10.5 Design for dorsal onlay graft. (a) A straight portion of the harvested rib cartilage is selected and marked. (b) After excising the peripheral portion, a central portion remains for additional carving.

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Fig. 10.6 Final shape of dorsal onlay graft. The completed, carved cartilage graft has a canoe-like shape from the frontal view. When seen from the lateral view, it has a slightly concave side that comes into contact with the nasal dorsum, and a dorsal side that is slightly convex. A perichondrium at tached to the cephalic side prevents movement of the graft.

Skin Undermining Wid e dissect ion of th e skin –soft t issu e envelop e is im p ortan t to allow th e skin to be m axim ally st retch ed w h en it is is redrap ed to th e elongated fram ew ork. Th e th ick scars, esp ecially th ose on th e low er lateral car t ilage an d ju n ct ion of low er an d u pper lateral cart ilages, n eed to be excised an d/or released to m ake th e skin m ore exible an d easily m an euvered. In a severely scarred case, in adverten t dam age to th e overlying skin m ay take p lace, in w h ich case a n e su t u ring of th e skin w ith an u n derlay of soft t issu e su ch as fascia h elps to h eal th e scar.

Elongating the Framew ork Th e suppor t ing st ruct ure to reposit ion an d x low er lateral cart ilages is th en con st ructed. After dividing th e low er lateral cart ilage an d elevat ing th e sept al ap , a septal exten sion graft is added. With th e overlap p ing t yp e, th e sept al exten sion graft is design ed to reach th e an terior n asal spin e in feriorly an d to project th e n asal t ip superiorly w h ile rot at ing it cau dally (Fig. 10.8a). Th e rem ain ing n asal sept al cart ilage an d th e graft placed n eed to be rm ly xed at th e an terior n asal spin e. Esp ecially in cases w h ere sept al cart ilage w as separated from th e anterior n asal spin e, su t ure xat ion n eeds to be m et icu lou sly p erform ed . Becau se th e redraping skin ten sion is h igh , th e n asal sept um an d th e t ip easily t w ist .

Correction of the Short, Contracted Nose

Fig. 10.7 Carving of rib cartilage for a at, straight piece. The cartilage is cut and carved as a at piece by cut ting in the longitudinal or tangential direction. Symmetric peripheral portions on the t wo sides of the central portion counteract and negate the expected distortion on both sides.

Th e sept al exten sion graft is rein forced w ith a sept al bat ten graft or exten ded spreader graft to preven t t w isting. Th e sept al cart ilage an d th e upper lateral cart ilage are sep arated in th e sam e p lan e, u sing th e sh arp sid e of a Freer elevator or w ith iris scissors. It is im port an t to en su re th at th e sept al m ucoperich on drium is dissected upw ard con t in uously un t il th e u pper lateral cart ilage is reach ed, to m ake su re th at accu rate sep arat ion of th e ju n ct ion of th e n asal sept u m an d th e u p p er lateral car t ilage is ach ieved. Th e cau dal en d of th e exten ded spreader graft n eeds to be t apered th in to preven t th icken ing of th e upper part of th e caudal sept u m , w h ich can lead to n asal obst ru ct ion .7 Th e graft is placed bet w een th e upper lateral cart ilage and th e n asal sept u m along th e u pp er side of th e sept u m an d th en xed tem porarily w ith a n eedle (Fig. 10.8b). Su t u ring w ith 5–0 or 4–0 PDS is used to x th e spreader graft to the n asal sep t um an d th e separated upper lateral cart ilage to th e sept al car t ilage–spreader graft com plex using h orizont al m at t ress su t u res (Fig. 10.8c). Care sh ou ld be t aken d u ring th e su t u ring to ensure th at th e upper lateral car t ilage on on e side is equ al in length to th e oth er side.

Tip Repositioning and Tip Grafts Th e low er lateral car t ilage is released from th e upper lateral car t ilage an d piriform ap ert u re an d reposit ion ed on th e n ew elongated n asal sept um (Fig. 10.9a). A length en ing e ect can be obt ain ed by low ering th e n asal t ip an d rot ating it caudally. Addit ion al length en ing can be gain ed th rough th e u se of various graft s on th e n ew ly exten ded low er lateral cart ilage. Sh ield grafts an d cap grafts are com m on ly used. For

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Fig. 10.8 Elongation of the framework. (a) An overlapping t ype of septal extension graft is xed to the caudal septum. The septal extension graft is designed to reach the anterior nasal spine inferiorly and to extend the nasal tip anteriorly while rotating it caudally. It can be xed to the anterior nasal spine for further stabilit y. (b,c) Bilateral extended spreader grafts are reinforcing the septal extension graft. 4–0 PDS sutures are used to x the grafts and reat tach the upper lateral cartilage to the graft complex.

a w eak lateral cru s, lateral cru ral on lay graft s are p laced to rein force it (Fig. 10.9b). If rot at ion an d p roject ion of th e n asal t ip are excessively adjusted, th e alar m argin can ap pear u n n at u ral, sligh tly ret racted, or collapsed. Alar rim graft s can be used to provide a sm ooth er n at ural con t in u at ion from th e n asal t ip to th e alar m argin an d to low er th e alar rim sligh tly (Fig. 10.9c). A soft t issu e d issec-

t ion along th e alar rim is m ade begin n ing at th e n asal facet using sh arp iris scissors. Dissect ion is perform ed close to th e alar rim m argin , w ith care t aken n ot to m ake th e pocket too big. A th in , at piece, 2 to 3 m m in w idth an d 12 to 15 m m in length , is design ed; th e m edial en d of th e graft is sligh tly bru ised u sing Brow n -Adson forcep s an d in serted in to th e pocket .

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Fig. 10.9 Repositioning of lower lateral cartilages and additional tip grafts. (a) Lower lateral cartilages are released from the upper lateral cartilage and piriform aperture and repositioned on the new elongated nasal septum. (b) Additional lengthening can be achieved with cap grafts and lateral crural onlay grafts. (c) An alar rim graft is being introduced into the pocket made along the alar rim.

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Dorsal Augmentation Car ved boat-sh aped graft s, u n like silicon e graft s, ten d to m ove over th e n asion an d th e rh in ion becau se th e sh ap e does n ot com pletely t over th e n asal bon e an d u pper lat eral car t ilage (Fig. 10.10). To redu ce graft m obilit y, a st rip of cost al perich on driu m is sut ured to th e un dersurface of th e n asion en d of th e car ved cart ilage after rasping of th e radix. Th e h ar vested perich on drium is also used on th e radix an d dorsu m to preven t step form at ion an d to create a sm ooth t ran sit ion bet w een th e dorsal graft an d glabella. Th e costal cart ilage is xed to th e cau dal par ts of th e upper lateral cart ilage an d n asal sept um w ith 5–0 PDS or 6–0 clear nylon su t u res. Th e graft is xed at th e n asion p ar t in side th e t igh t su bperiosteal pocket . Th e dorsal on lay graft exten d ed to in clu de th e n asion m akes th e n ose appear longer. Th e qualit y of cart ilage varies in dividually. Sligh tly h ard cart ilage w ith out any calci cat ion in th e m iddle-aged pat ien t is th e best m aterial. It is di cult to con t rol th e w arp ing com pletely in you ng pat ien t s, as th eir cost al car t ilage is often sh ort , th in , an d excessively w eak or soft . In calci ed

Fig. 10.10 Dorsal augmentation. A carved rib cartilage graft is being introduced to the dorsum.

Correction of the Short, Contracted Nose

cart ilage, on th e oth er h an d, car ving is di cult an d th e ossied port ion m ay resorb w ith t im e, leaving irregu larit ies on th e dorsum .2 In su ch sit u at ion s, th e cart ilage can be diced in to ver y sm all pieces, w rapped in tem poralis fascia, an d th en grafted to th e n asal dorsum . Th is is called th e “Turkish deligh t” m ethod an d h as th e advan tage of h aving n o risk of cart ilage distor t ion an d th e sh ape of th e dorsum appears n at u ral.8,9 How ever, th e tem poralis fascia n eeds to be in depen den tly h ar vested, an d m aking th e graft com pletely t th e sh ape of th e dorsum is n ot easy. Resorpt ion is kn ow n to be m in im al, bu t th e exact d egree is som ew h at di cu lt to p redict. After on e year, a 10 to 20% resorpt ion com p ared w ith th e im m ediate postoperat ive volum e is expected. Th is m ay in crease if th e origin al cart ilage is ver y soft .

Composite Graft and Skin Closure W h en th e length en ed skin an d vest ibular skin can n ot be prim arily sut ured togeth er, a ch on drocu tan eous com posite graft t aken from th e cym ba con ch a is pru d en tly u sed to ll th e gap, especially in th e area of th e soft t issu e t riangle. Th e nat ural cu r vat ure of car t ilage h ar vested from th e cym ba con ch a ts w ell w ith th e defect at th e in ten ded graft site, esp ecially at th e soft t issu e t riangle, an d th e resu lt ing don or site scar is u su ally n ot p rom in en t p ostoperat ively. Th e sh ape of th e in ten ded graft is m arked on th e skin , w h ich is th en in cised along th ose m arks togeth er w ith th e car t ilage, but sparing th e con t ralateral perich on drium an d skin . In lt rat ion of an esth et ic solu t ion directly over th e h ar vesting port ion is avoided to in crease th e viabilit y of th e graft . Dissect ing th is p erich on d riu m from th e posterior con ch al bow l to free th e graft com pletes h ar vest ing of th e con ch al com posite graft . A sm all don or site defect is closed prim arily; a full-th ickn ess skin graft , usually sourced from th e post auricu lar area, m ay be n ecessar y w h en th e th e defect is too big to close prim arily.10 W h en h ar vest ing post au ricu lar skin to graft any residual defect at th e cym ba con ch a, a sligh tly bigger area th an th e act u al defect size is h ar vested becau se th e skin usually con tracts on ce it is det ach ed from th e don or site. Rem oving th e subcu tan eous fat an d soft t issu e from th e skin graft in creases th e graft’s viabilit y after im plan t at ion . A com pression dressing is placed on th e cym ba con ch a for 3 to 4 days an d an an t ibiot ic oin t m en t ap plied to keep th e w ou n d m oist . Before prim ar y closu re of th e colu m ella, th e cau dal part of con ch al com posite graft is sut ured at th e m argin al in cision follow ed by th e cephalic part , w h ich is sut ured to th e vest ibular skin to ll th e defect (Fig. 10.11). After su t u ring th e com posite graft on the recipien t sites, th e graft is xed to th e recip ien t bed w ith gen tle pressu re eith er by packing or th rough -an d-th rough sut u res w ith silast ic sh eet ap plicat ion .

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■ Complications and Their Management

Skin Damage W h en th e skin envelope is st rongly adh eren t to th e un derlying scar t issue, in adver ten t skin dam age can occur du ring th e dissect ion . Dorsal skin t igh tly adh ering to un derlying scar t issu e is som et im es ext rem ely d i cu lt to dissect . Th e torn skin n eeds to be carefu lly su t u red an d th e soft t issu e or fascia un derlin ed for fur th er support .

Fig. 10.11 Adding a chondrocutaneous composite graft. When the skin of nasal vestibule and lengthened nasal skin cannot be sutured primarily, a chondrocutaneous composite graft is used to ll the gaps bet ween them.

■ Key Technical Points 1. A su cien t am oun t of cart ilage is n eeded to build a st able p latform to length en th e n ose. Usu ally, rib cart ilage h ar vest ing ser ves th is pu rpose. 2. Rib car t ilage car ving is st rategically t ailored according to th e sites w h ere graft s are u sed. For a dorsal on lay graft , th e cen ter of th e car t ilage is u sed; tangen t ially cu t car t ilage is u sed for exten ded spreader grafts or sept al exten sion graft s. 3. Wide un derm in ing of th e skin envelope is n ecessar y to redrape over th e length en ed platform . 4. An en d-to-en d t ype or overlapping t ype of septal exten sion graft to length en th e cau dal sept u m is a p latform to reposit ion th e low er lateral car t ilage. 5. Th e sept al exten sion graft is design ed con sidering th e rot at ion an d project ion of th e t ip an d n eeds to be st rongly supported w ith a bilateral exten ded spreader graft . 6. Th e low er lateral cart ilage n eeds to be released from th e u p per lateral cart ilage an d scar t issu e for rep osit ion ing to th e n ew dom e. 7. Th e n asion is m oved upw ard by adding a dorsal on lay graft in th e low dorsum . Addit ion al t ip on lay grafts are used to add to caudal rot at ion an d p roject ion of th e t ip. 8. Th e lateral crural on lay graft an d alar rim graft h elp to low er an d suppor t th e alar rim . 9. A ch on drocut an eous com posite graft from th e cym ba con ch a lls th e gap bet w een th e skin envelop e an d de cien t vest ibu lar lin ing.

Pneumothorax Pn eu m oth orax follow ing rib car t ilage h ar vest can be preven ted by carefu l h ar vest ing, leaving u n derlying p erich on driu m beh in d. In m ost cases, if n o air leakage w as iden t i ed w ith th e Valsalva m an euver after h ar vest ing, th ere is n o n eed to ch eck th e ch est X-ray after surger y un less th e pat ien t com plain s of ch est t igh t n ess w ith low oxygen sat u rat ion . If air leakage is n oted, a Nélaton cath eter is in ser ted at th e leakage site an d su t u red in a pu rsest ring m an n er. After t igh t closu re of th e su bcu t an eou s an d skin w ou n d, th e Nélaton cath eter is rem oved w ith sim u lt an eou s adm in ist rat ion of in ten se posit ive-p ressu re hyper ven t ilat ion .

Warping of Implanted Rib Cartilage Warping m ay occu r after replacing th e dorsal alloplast ic im plan t w ith rib car t ilage (Fig. 10.12). Even th ough th e au th or takes all p reven t ive m easu res to p reven t w arp ing, su ch as balan ced car ving u sing th e core of th e rib cart ilage, repeated im m ersion an d ch ecking of cur vat ure, creat ion of a t igh t pocket for in sert ion , an d su t u re xat ion on th e dorsum , it is st ill alm ost im possible to com pletely preven t w arping of cost al cart ilage. In su ch cases, th e au th or takes out th e cur ved rib graft an d car ves it st raigh t before rein ser t ing it in to place, w h ich solves th e problem in m ost in st an ces. If th at is n ot possible, th e auth or dices th e cur ved rib an d w rap s it in tem poralis fascia. In th e au th or’s exp erien ce, au togen ou s rib cart ilage is able to m ain tain it s origin al volu m e even years after th e su rger y. Adding som e soft t issue such as th e m astoid periosteum w ill h elp to re n e th e radix in th is case.

Movability of the Costal Cartilage Onlay Graft Movem en t of a cost al cart ilage on lay graft after revision is rare. Possible reason s for m igrat ion of th e im plan t in clu de a large an d w ide pocket created during dissect ion to rem ove

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Correction of the Short, Contracted Nose c

d

Fig. 10.12 Warping of dorsal onlay rib graft. (a) Warping developed after placement of dorsal onlay graft with autogenous rib cartilage. (b) Six months after revision, the nose is straight. (c) In revision surgery, the dorsal onlay cartilage was removed in pieces. (d) The warped portion was recarved and put together by wrapping with mastoid periosteum before reinsertion.

a large or st u bborn ly p lan ted allop last ic im p lan t arou n d th e radix area; residu al cap su le after silicon e im p lan t rem oval; an d in app rop riate xat ion of th e cost al cart ilage, especially at th e radix area. To preven t th is, com plete rem oval of th e u n derlying capsu le, rough en ing of th e radix w ith rasp , an d p erich on driu m applied on th e un dersurface of th e radix skin above th e graft are n ecessar y. In rare cases, a K-w ire xat ion of th e graft at th e radix p ar t is n eeded .

Nasal Obstruction Ap p lying a too-th ick sept al exten sion graft , esp ecially th e overlap p ing t ype, can m ake th e n ost ril in let sm all, cau sing n asal obst ru ct ion . An en d-to-en d t ype sept al exten sion graft w ith a th in , at p iece of car t ilage can preven t th is com plicat ion . Also, beveling an d th in n ing th e exten ded port ion of th e exten ded spreader graft bin ding to th e sept al exten sion graft is im port an t to p reven t th icken ing of th e caudal sept um . If th e septal exten sion graft is w eak, th e caudal sept um m ay buckle, causing deviat ion an d n asal obst ruct ion .

Tip Problems Too m uch ten sion exerted on th e skin , especially w hen th e sept al exten sion graft is m ade of sept al bon e or allop last ic m aterial such as Medpor, m ay cause pressure sen sit iv-

it y or pain in th e n asal t ip. In m ost cases, th is discom for t decreases w ith t im e; h ow ever, in som e cases th e graft needs to be rem oved. Asym m et r y of th e n ost rils m ay occu r w h en th e sept al exten sion graft is n ot exactly in th e m idlin e or if t ip on lay graft s are n ot sym m et ric.

■ Case Studies Case 1: Correction of Short Nose Due to Contracture after Multiple Rhinoplasties A 28-year-old fem ale presen ted w ith sh ort n ose an d left nasal obst ru ct ion (Fig. 10.13). Sh e h ad u n dergon e fou r rh inoplast ies using Gore-Tex t w ice, silicon e on ce, an d autologou s cost al car t ilage on ce over th e p ast 9 years, w ith th e m ost recen t su rger y 2 years previou sly. Sh e h ad a t ypical post surgical sh or t , con t racted n ose w ith exaggerated n ost ril sh ow in th e fron t al view an d severely ceph alic rotated nasal t ip w ith low -set n asion in th e lateral view. Her su rgical diagram sh ow s th at a sept al exten sion graft , d orsal on lay graft , bilateral exten ded sp read er graft s, lateral cru ral on lay graft s, sh ield graft , an d cap graft w ere placed using irradiated h om ologous cost al cart ilage. Bilateral con ch al ch on drocu t an eou s com posite graft s w ere used to ll th e gap bet w een length en ed skin an d vest ibular lin ing.

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Fig. 10.13 Case 1. (a,b) A short, contracted nose, developed after multiple rhinoplasties, is evident from the frontal and lateral views.

b

Her app earan ce 2 years after th e op erat ion sh ow ed im provem en t in th e con t racted an d sh or t n ose. Caudal rot at ion of th e n asal t ip, a decreased n asolabial angle, an d in creased h eigh t of th e n asal dorsu m m ake th e n ose appear sign i can tly longer th an p rior to revision (Fig. 10.14).

a

Fig. 10.14 Case 1. (a,b) Two years after revision surgery using rib cartilage, the nose looks much bet ter than before. Her dorsum is well elevated and the tip is caudally rotated.

b

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Case 2: Correction of Postsurgical Short Nose w ith Tw o -Stage Revisions A 26-year-old fem ale visited th e clin ic com p lain ing of n asal deform it y (Fig. 10.15). Sh e h ad h ad th ree rh in oplast ies before, w h ich in cluded silicon e dorsal augm en t at ion an d rem oval of th e silicon e im plan t . On physical exam in at ion , sh e h ad a st raigh t n ose, bu t th e d orsal h eigh t w as sh ort , an d th ere w as excessive n ost ril sh ow from th e fron t al view. Her t ip w as severely u pt u rn ed an d h ad skin dim p ling on th e t ip lobule.

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Correction of the Short, Contracted Nose

Sh e u n der w en t a t w o-st age op erat ion : At rst revision , length en ing of th e n ose using autogen ou s rib cart ilage w as t ried th rough an open approach . A sept al exten sion graft , dorsal on lay graft , bilateral exten ded spreader grafts, lateral cru ral on lay graft , an d t ip on lay grafts w ith a con ch al com posite graft w ere used. Th e secon d revision w as don e 1 year after th e rst revision . At th e secon d revision , h er t ip w as length en ed m ore u sing con ch al cart ilage on lay graft s on th e t ip th rough th e endon asal approach . On e year after th e secon d revision , h er n asal sh ape im proved in both th e fron t al an d lateral view s (Fig. 10.16).

Fig. 10.15 Case 2. (a) Frontal and (b) lateral views before the rst revision. Too much nostril show, colum ellar retraction, dimpling of tip skin, and short, scooped-out dorsum are evident.

Fig. 10.16 Case 2. (a,b) Photos taken 1 year after the second revision show much improved nasal shape from both the frontal and lateral views.

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References 1. Na cy S, Baker SR. Length ening th e sh ort n ose. Arch Otolar yngol Head Neck Su rg 1998;124(7):809–813

6. Adam s W P Jr, Rohrich RJ, Gunter JP, Clark CP, Robinson JB Jr. The rate of warping in irradiated and nonirradiated hom ograft rib cartilage: a controlled com parison and clinical im plications. Plast Reconstr Surg 1999;103(1):265–270

2. Sunw oo WS, Ch oi HG, Kim DW, Jin HR. Ch aracterist ics of rib cart ilage calci cat ion in Asian pat ien t s. JAMA Facial Plast Su rg 2014;16(2):102–106

7. Park JH, Mangoba DC, Mun SJ, Kim DW, Jin HR. Length en ing th e sh ort n ose in Asian s: key m an euvers an d su rgical results. JAMA Facial Plast Surg 2013;15(6):439–447

3. Fr y H. Nasal skelet al t raum a an d th e in terlocked st resses of th e n asal sept al cart ilage. Br J Plast Surg 1967;20(2): 146–158

8. Erol OO. Th e Turkish deligh t: a pliable graft for rh in oplast y. Plast Recon st r Su rg 2000;105(6):2229–2241, discu ssion 2242–2243

4. Harris S, Pan Y, Peterson R, St al S, Spira M. Car t ilage w arping: an experim en t al m odel. Plast Recon st r Surg 1993;92(5):912–915

9. Daniel RK, Calvert JW. Diced cartilage grafts in rhinoplast y surgery. Plast Reconstr Surg 2004;113(7):2156–2171

5. Kim DW, Shah AR, Torium i DM. Con cen t ric an d eccen t ric car ved cost al cart ilage: a com parison of w arp ing. Arch Facial Plast Surg 2006;8(1):42–46

10. Dan iel RK. Graft s. In : Dan iel RK. Mastering Rh in op last y: A Com preh en sive Atlas of Su rgical Tech n iqu e. New York, NY: Springer; 2004:225–267

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Management of Alloplast-Related Complications

Eunsang Dhong

Pearls • Th e perspect ive of using an alloplast ic im plan t in

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com plicated septorh in oplast y is com pletely di eren t from th at of u sing a sim p le dorsal augm en t at ion . Th e locat ion of th e pat ien t’s sellion is altered follow ing im plan t at ion . It m igh t be h igh er or low er th an th e origin al posit ion , an d it usually m igrates ceph alically from th e origin al site. A long-st an ding im p lan t dest roys n ot on ly th e bony dorsu m , but th e cart ilagin ous dorsum as w ell. The capsule surrounding a silicone im plant does not dissolve even after the im plant is extracted. Therefore, if a patient undergoes m ultiple revisions, various layers of the capsule can be seen during surgery. A h ealthy capsu le can be reu sed w h ile it is at t ach ed for th e su bst it ut ion of soft t issue in a secon dar y rh in oplast y. Con t ract ure aroun d th e capsule m oves th e n asal t ip ceph alically, w ith th e pat ien t en ding up w ith a sh or t

■ Introduction Th e m ost popular alloplast s in Asian rh in oplast y are polym eric silicon e, exp an ded polytet ra u oroethylen e (ePTFE, or Gore-Tex [W. L. Gore an d Associates]), porous h igh -den sit y p olyethylen e (pHDPE, or Med por), an d acellu lar h u m an derm is (AlloDerm ).1 Silicon e is th e m ost w idely used, follow ed by Gore-Tex. Medpor is preferred as th e st ru t for t ip plast y an d AlloDerm is used for various t ypes of soft t issue en h an cem en t . For m any decad es, th e conven t ion al m eth ods for prim ar y East Asian rh in oplast y h ave used th ese allop last s for dorsal augm en t at ion . Th e gen eral con sen su s h as been th at dorsal im p lan tat ion of silicon e or Gore-Tex is a n ovel tech n ique for augm en tat ion for a low n asion an d bony dorsum . Besides th e probable com plicat ion s of applying alloplast s, in m any cases of secon dar y rh in oplast y, th e sept u m an d th e con ch a car t ilage h ave already been u sed previously for th e don or grafts. Th erefore, u sually th e on ly don or site left for th e autograft is th e rib cart ilage. Som et im es th e su rgeon h as n o ch oice bu t to u se allop last s according to th e p at ien t’s dem an d . Even after several revision al operat ion s, pat ien t s are st ill left w ith th e u n correctable n asal deform it y.

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n ose deform it y. All con t racted t issu es, in clu d ing th e capsule, sh ould be rem oved to correct th is deform it y. Using Medp or (St r yker) as a sept al su p port or as a spreader graft becau se exten sion frequ en tly lead s to sept al p erforat ion . Mu lt ilayered AlloDerm (LifeCell) m ay form avascu lar scar t issu e in th e cen ter. Sin ce an alloplast ic im plan t for rh in oplast y h as a n ite lifespan , pat ien t s sh ou ld be in form ed abou t th e lim ited ben e ts of using an alloplast ic im plan t . Placing an allop last ic im plan t over an op en roof or dissected u pper lateral car t ilage from th e h igh sept u m m ay lead to disast rou s resu lts. Most im p lan t-related com plicat ion s resu lt from a sh or t age of prop er soft t issu e coverage. In su ch cases, im plan t s are often exposed to th e n asal cavit y th rough a con cealed m u cosal lacerat ion .

Th e com plicat ion rates in using silicon e im plan t s var y from 2 to 7%according to m any rep ort s. In oth er report s, th e rem oval rate for both Gore-Tex an d Medpor w as reported as 3.1%, w h ereas th e rem oval rate for silicon e im plan t s w as sign i can tly h igh er, at 6.5%.2,3 Th is an alysis m ay be accu rate for sim p le rh in op last y, w h ich con sists of pu t t ing an alloplast ic im plan t on th e n asal dorsum in less th an an h ou r. Yet th e con cept of sim ple “augm en t at ion rh in oplast y” h as long disappeared in Korea. In East Asian s, th e com plicated procedure of open septorh in oplast y is frequen tly perform ed. As th e in ciden ce of com p licated septorh in op last y in creases, th e rate of severe com plicat ion is also on th e rise. Th e sept al exten sion graft is ver y popular for th e correct ion of sh ort n ose in East Asia, in creasing th e average operat ion t im e. More severe com plication s h ave appeared recen tly in pat ien t s in w h om com plicated sept al su rger y w as perform ed w ith allop lasts in serted sim u lt an eou sly (Fig. 11.1). Th erefore, an alyzing th e com plicat ion rates of alloplast s according to past rep or t s is m ean ingless. Th e com p licat ion rates for variou s t yp es of allop lasts sh ou ld be classi ed according to th e com plexit y of th e op erat ion p erform ed . Th e perspect ive of using an alloplast ic im plan t in com plicated septorh in oplast y is com pletely di eren t from th at u sed for sim p le dorsal augm en t at ion . In th is ch apter, th e

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II Rhinoplast y 6. Th e in t ran asal environ m en t , in cluding th e in ferior t u rbin ate an d t races of previous subm ucosal resect ion of th e sept um , sh ould be iden t i ed u sing in t ran asal in sp ect ion in clu ding en doscop ic evalu at ion . 7. A lateral X-ray (n asal bon e view ) is h elpful for th e evalu at ion of th e origin al locat ion of th e n asion an d for m easu ring th e th ickn ess of th e im p lan t an d th e overlying skin ap .

Fig. 11.1 Popular techniques in East Asian rhinoplast y for dorsum and tip projection. Septal extension graft using septal cartilage after submucosal resection with dorsal silicone implanting.

m an agem en t of variou s p roblem s in u sing alloplast s w ill be d iscu ssed, w ith special at ten t ion to doctors out side of East Asia an d to begin n ers in rh in oplast y.

■ Patient Evaluation A carefu l assessm en t is n eeded for secon dar y rh in op last y, esp ecially w h en allop last s h ave been app lied. Th e presen ce of dest royed st ruct ures un der th e con cealed scar t issue is u su ally u npredict able. Secon dar y rh in oplast y t akes a differen t rou te from th e begin n ing, depen ding on w h eth er a pat ien t h as alloplast ic m aterials in th e n ose or n ot . Most allop last ic im plan t s in serted p reviou sly sh ou ld be rem oved in th e secon dar y operat ion . Th e an atom y un derlying th e allop lasts h as been dest royed ; th erefore, th e am ou n t of au tograft th at is n eeded in recon st ru ct ion is u su ally m u ch greater th an exp ected. In m ost cases of East Asian p rim ar y rh in oplast y, an alloplast ic im plan t is used w ith autograft s at th e n asal t ip . Th u s, in secon dar y procedu res, surgeon s en cou n ter a sh or t age of don or sou rce for au tograft s. Here is th e au th or’s person al ch ecklist for exam in ing a p at ien t: 1. Do n ot overlook any previou s h istor y of surger y. 2. Th rough close in spect ion , m ake a problem list . Pat ien t s w ill be m ore sat is ed w ith th e result s if th ey rst approve th e surgeon’s problem list . 3. Th e h ardn ess of th e scar an d th e soft t issue resilien ce arou n d th e n asal t ip sh ou ld be assessed w ith digit al p alp at ion , an d th is m ay in clude pu lling dow n on th e n ost rils. 4. Th e exten t of pocket dissect ion is determ in ed by th e h ardn ess an d th e exten t of scar m ass. 5. Th e caudal in t ran asal path ology m ay be determ in ed by sim ple rh in oscopic evaluat ion .

8. A long-st an ding im plan t dest roys n ot on ly th e bony dorsu m but also th e car t ilagin ous dorsum . For th e evalu at ion of bony dest ru ct ion u n d er th e im plan t , com puted tom ography (CT) in cluding 3D recon st ruct ion is h elpful. It is useful for pat ien t s su ering from n asal obst ruct ion an d for pat ien t s u n dergoing secon dar y septoplast y an d/or t u rbin oplast y. 9. It is di cu lt to p redict th e am ou n t of scarring arou n d an im p lan t an d th e severit y of th e dest ruct ion adjacen t to th e low er lateral car t ilage (LLC) an d upper lateral cart ilage (ULC), even after th e evalu at ion of CT scan s. Preop erat ive predict ion s m ay di er from th e act ual in t raoperat ive n dings. An im p lan t on th e n asion blu rs th e act u al locat ion of th e sellion . Th e th ickn ess of th e capsu le arou n d th e im p lan t also a ect s th e est im at ion of th e th ickn ess of th e overlying skin ap (Fig. 11.2). Th e locat ion of th e pat ien t’s sellion ch anges after im plan t at ion . It m igh t be h igh er or low er than it s origin al posit ion , an d it u sually m igrates ceph alically from th e origin al site. Alloplast s u sed on th e n asal t ip dest roy th e adjacen t cart ilage, an d th e t ip loses suppor t after th e rem oval of allop last s. Th e t ip project ion u su ally can n ot be m ain tain ed w ith out grafts du e to th e w eakn ess of th e rem ain ing LLC. On e of th e issu es in dealing w ith silicon e im p lan t s is the m an agem en t of th e capsule aroun d th e im plan t . Th ere are t w o cap su les arou n d th e silicon e im p lan t: th e an terior an d posterior cap su les (Fig. 11.3). Variou s layers of capsu les are fou n d in p at ien ts w h o w ere op erated on m any t im es previously. Th e capsu le surroun ding th e silicon e im plan t does n ot dissolve spon t an eously after im plan t ext ract ion (Fig. 11.4). A h ealthy capsu le can be reu sed w h ile it is at t ach ed for th e su bst it u t ion of soft t issu e in a secon dar y rh in oplast y. Th e an terior capsule is left alm ost in t act , so as n ot to en danger th e viabilit y of th e dorsal skin ap . Even th e posterior capsule m ay be reused if fou n d in a good state for soft t issu e rein forcem en t . Th e en t ire capsule sh ould be rem oved in th e case of im plan t calci cat ion an d capsular con t ract ure. Con t ract ure arou n d th e cap su le disp laces th e im p lan t cep h alically, an d result s in sh ort n ose deform it y (see Case 1). Rem oval of th e capsule an d th e adjacen t soft t issue con t ract ure results in soft t issu e de cien cy (Fig. 11.5).

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Fig. 11.2 Bone destruction after long-standing dorsal implanting. (a) The rhinion after 5 years’ presence of a silicone implant. (b) Another patient with a silicone implant for 14 years.

Fig. 11.3 Capsules after dorsal silicone implanting. There are t wo capsules around the silicone implant at the anterior (orange) and posterior (red) sides. Fig. 11.4 Multiple layers of capsules from quarterly revision. A capsule does not dissolve spontaneously postoperatively, even after more than 10 years.

Fig. 11.5 Removal of the capsule and the adjacent soft tissue contracture. Resection of capsules results in de ciency of soft tissue at the dorsum with thin dorsal skin.

There is no or ver y lit tle form at ion of capsule around Gore-Tex im plan ts. The soft t issue dest ruction found during im plant rem oval is less for Gore-Tex than for silicone or Medpor. The dissection around the Medpor im plan t is relat ively di cult, due to the soft tissue integrat ion in to the pores of the im plant. How ever, the rem oval of a Medpor im plant located in the subperichon drial space is easier th an for on e located in the supraperichondrial space. The use of Medpor in the caudal or anterior sept um for a septal extension graft or spreader graft frequ en tly leads to septal perforat ion (Fig. 11.6). Th is is du e to th e relat ive physical w eakn ess of the septal m ucosa. Even its application at the m em branous septum for colum ellar stru t is com plicated. Th e n asal tip is the m ost m obile port ion of the n ose. Frequent m ovem ent of the m em branous sept um cannot overcom e the physical tough n ess of Medpor, even if th e im plan tation du ring th e im m ediate postoperative period w as successful.

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Fig. 11.6 Septal perforation found after removal of intranasal Medpor. (a) Before removal of the Medpor in the left side of the nasal cavit y. (b) A huge defect at the high septum.

In th e n asal t ip area, rigid scar t issu e is frequ en tly fou n d . In m ost cases, it is th e resu lt of m u lt ilayered AlloDerm ap p licat ion . Th e cen t ral p ort ion of th e scar t issu e lacks vascu lar supply; h en ce, an avascu lar scar m ass form s (Fig. 11.7). Severe con t ract u re associated w ith im p lan t s is frequen tly foun d in pat ien ts w h o u n der w en t com plicated sept al su rger y sim u ltan eou sly. Sept al su p port is u su ally lost after su bm ucosal resect ion (SMR), an d the gravit y an d ten sion from th e alloplast ic im plan t m ay be t roublesom e over an op en roof or d issected ULC from th e h igh sept u m . Mu cocele is on e of th e frequ en t p ath ologic n dings resu lting from th is sit uat ion . Th is m ay be foun d in in t ran asal or ext ran asal areas (Fig. 11.8). Most of th e m u cocele m ay be related to th e sh or tage of proper soft t issue coverage

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un dern eath : an exposed n asal cavit y ben eath th e im p lan t or con cealed m ucosal lacerat ion after osteotom y of th e nasal bon e.

■ Surgical Techniques Correcting Noninfectious Conditions Deviated Implant If th e p ocket is dissected w ider th an th e act u al size of th e im plan t , th e im plan t h as a ten den cy to deviate to on e side of th e lateral n asal w all. Moreover, if th e im plan t is longer

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Fig. 11.7 Common nding in revision tip surgery. (a) Huge scar mass with conchal cartilage on the top of the tip. Underneath it m ultiple layers of Alloderm were found. (b) After removal of allograft s, the LLCs underneath were destroyed to some extent.

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Fig. 11.8 Mucocele formation by silicone implant. (a) Before the surgery. Epidermal cystlike protrusion at the right nasal root with blunted hard nasal tip. (b) After the surgery. The thin dorsal skin was salvaged after total extirpation of mucocele. Tip-plasty using conchal cartilage with dorsal dermal graft was also performed. (c) Thick peri- and intracapsular mucocele dissected after removal of the silicone implant.

th an th e dissected pocket , th e im plan t is distorted due to it s axial pressu re. Th e u n d erlying discrepan cy bet w een th e n asal bony axis an d car t ilagin ous a xis result s in deviat ion of th e im plan t even after careful sculpt ing of th e u n dersu rface. For correct ion , th orough bilateral capsulotom y is h elp fu l in re-im plan t ing if th e capsu le h as already form ed . A lateral n asal osteotom y an d h igh sept al sp reader graft are n eeded for th e discrep an cy bet w een th e bony axis an d h igh septal axis. In th ese cases, replacing th e im p lan t w ith a d erm ofat graft is st rongly recom m en d ed . Secu re t ap ing an d im m obilizat ion du ring th e im m ediate postop erat ive p eriod are cru cial.

Dorsal Skin Redness and Visible Implant In p at ien t s w h o h ave ver y th in skin , th e im p lan t m ay be visible u n der direct su n ligh t . Esp ecially in cases w ith GoreTex, th e dorsal con tour m ay be seen th rough th e dorsal skin . As for th e Gore-Tex, du e to it s lack of capsu le form at ion , th e im plan t h as a ten den cy to skeletonize an d sh rin k. Th e redn ess of th e dorsal skin can rem ain long after th e operat ion in th in -skin n ed pat ien ts. Subst it ut ion of im p lan t s w ith derm ofat graft s is n eeded in m ost cases. Wrap p ing th e im plan t w ith au tologou s su per cial tem poral fascia m ay be h elp fu l. How ever, w rapp ing th e im plan t w ith allograft is con t roversial due to poor vascu larizat ion an d h igh er ch an ces of postop erat ive in fect ion .

Mobile Implant If th e p ocket is dissected su bcu t an eou sly at th e bony dorsu m , th e silicon e im plan t h as a ten den cy to be m obile. Precise pocket dissect ion is perform ed subperiosteally for re-im plan t ing. Gore-Tex h as a lesser ten den cy tow ard m obilit y.

Implant Calci cation In long-st an ding allop last ic im plan t s, dyst roph ic calci cat ion arou n d th e im plan t an d capsule is occasion ally fou n d (Fig. 11.9). Th e m ech an ism of calci cat ion is st ill u n der debate, bu t degen erated t issu e aroun d th e capsule (den se scar) m ay p lay a role in calci cat ion .4 Com p lete ext irp at ion of th e an terior an d posterior capsules is n eeded, an d a derm ofat graft is su bst it u ted for th e im p lan t .

Implant Protrusion Most prot ru sion s resu lt from th e u sage of am ou n t s of alloplast ic im plan t s exceeding th e th resh old of skin ten sion . Th e im plan t sh ould be rem oved im m ediately. If th e im plan t is t ran sparen t but n ot prot ruded, th en th e operat ion can be perform ed as a single st age. How ever, if th e im plan t is already p rot ru ding, recon st ru ct ion sh ou ld be p erform ed sep arately.

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Fig. 11.9 Implant calci cation. (a) Removed calci ed silicone implant and entire capsules. (b) Double-layer dermal graft for the dorsum and cymba concha for the tip. (c) Before the surgery. Transparent implant through the skin with thinning and telangiectasia is noted. (d) After the surgery.

Hard Nasal Tip

Correcting Infectious Conditions

Th e applicat ion of AlloDerm h as been accepted in m any elds of facial plast ic su rger y as an opt ion for soft t issu e en h an cem en t .5,6 Bu t m u lt ilayered AlloDerm on th e n asal t ip frequen tly form s an avascular scar m ass. Th e cen t ral port ion of th e grafted AlloDerm is foun d to be avascular after scalp el in cision . Th e n asal t ip w ill feel ver y rigid w ith th is scar t issue. After rem oval of th is scar t issue, a large am ou n t of soft tissu e m u st be rep laced.

In ammation

Mucocele After h u m pectom y, th ere m ay be a sm all degree of exp osu re to th e n asal m u cosa, an d th e ingrow th of m u cosa in to th e dissected pocket m ay result in m ucocele form at ion (Fig. 11.10). Th e en doth elial ingrow th or m et ap lasia of th e capsular pocket is st ill un cert ain an d n eeds to be st udied fu rth er.7 On ce th e m u cocele is iden t i ed, tot al ext irp at ion is n eed ed.

Relapsing in am m at ion is n ot rare during th e im m ediate postoperat ive period. Rem oval of th e alloplast ic im plan t is usually recom m en ded; h ow ever, com plicat ion s m ust be ap proach ed on an in d ivid u al basis. In som e cases, delayed hem atom a at th e n asion m ay be m isdiagn osed as a u ct uat ion of in am m at ion , but th is can be salvaged by n eedle asp irat ion . Relapsing edem a, in m any pat ien ts, is du e to th e un st able scar (capsule) form at ion arou n d th e im plan t . Microcom m un icat ion bet w een th e extern al environ m en t an d th e in t ra-capsular area m ay result in th e u ct uat ion of sh ortterm edem a. Relapsing subclin ical in am m at ion does n ot drain pus an d m ay im prove w ith th e use of broad-spect rum an t ibiot ics. Th e decision on rem oving th e im plan t is a con t roversial on e. Alth ough con ser vat ive t reat m en t m ay be pursued in m ild in am m at ion , th is route frequen tly result s in un successful result s. Th e relapsing in am m at ion frequen tly result s in capsu lar cont ract ure.

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Fig. 11.10 Mucocele form ation after humpectomy with dorsal silicone implant. (a) Preoperative X-ray reveals previous humpectomy (dot s) with migrated L-t ype implant with thick scar. (b) Rem oved mucocele with thick capsules. (c) Before the surgery. Short nose deformit y in patient with mucocele, who su ered from relapsing edema and drainage of intranasal discharge. (d) After the surgery. After total extirpation of previous alloplast s, dorsal augmentation with autograft was performed (dermofat graft with concha cartilage graft).

Infected Implant

Correcting Short Nose Deformity

Th e rare acute in fect ion in septorh in oplast y m an ifest s as toxic sh ock syn d rom e, sep sis, m en ingit is, an d en docardit is. Drain age of pus th rough th e in cision al site is n ot a rare com plicat ion . Su rger y u sing alloplast s is com p licated an d p ron e to in fect ion , so p rophylact ic an d postoperat ive an t ibiot ic t reat m en t is essen t ial. Irrigat ion of th e pocket in t raoperat ively is m ore ben e cial th an t reat ing w ith an t ibiot ics. Segregat ing th e in st rum en ts th at w ere used w ith in th e n asal cavit y from th ose used for pocket dissect ion is also im portan t . Silicon e im plan ts th at w ere already in con t act w ith th e skin sh ould be clean sed by salin e or alcoh ol. Gore-Tex is bet ter prepared by soaking it in bet adin e. Im p lan ts drain ing pu s can n ot be salvaged an d sh ou ld be rem oved. If th e rem oval is delayed, th e st ruct u ral deform it y m ay get w orse. Recon st ru ct ion sh ou ld be p ost pon ed for at least 6 m on th s to a year un t il com plete resolu t ion .

In severe con t ract u re associated w ith sh or t n ose deform it y, th e dissect ion sh ould be m ade w ider (Fig. 11.11). Sim u lt aneous resect ion of th e capsule an d th e con t racted soft t issu e arou n d th e im plan t sh ou ld be perform ed. In rem oving th e cap su le th ere are t w o di eren t opt ion s, dissect ing th e an terior capsule rst or dissect ing th e posterior capsule rst . For tot al resect ion of th e an terior an d posterior capsu les, it is easier to dissect th e an terior cap su le rst . To dissect th e an terior capsu le rst: 1. Perform hydro-dissect ion bet w een th e skin ap an d th e an terior capsu le. 2. Tr y to ret ain th e in tegrat ion of th e an terior capsule u p to th e m ost cep h alic p or t ion . 3. Rem ove th e im plan t after th e com plet ion of an terior capsule dissect ion .

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Fig. 11.11 Correction of short nose deformit y. (a) Schematic of dissection: myotomy of the bilateral transverse nasalis, bilateral subperiosteal dissection around the bony pyramid, separation bet ween the septum and ULCs, caudal nasal bone and ULCs, and ULCs and LLCs (the scroll area) was performed incrementally. (b) Sculpted rib cartilage for septal reconstruction and rectus fascia for wrapping the diced cartilage. (c) Before the surgery. (d) After the surgery.

4. If th e ceph alic capsule w as n ot dissected com pletely, bilateral capsu lotom y sh ould be perform ed to rem ove any soft t issu e irregu larit ies th at m ay arise at th e n asion lateral to th e im plan t . 5. Dissect th e un dersurface of th e posterior capsule; th is plan e is usually adh eren t to th e periosteum . To reu se th e an terior capsule, th e posterior capsu le is dissected rst , after th e rem oval of th e ret ain ing im p lan t . To d issect th e p osterior capsule rst: 1. Perform a caudal capsulotom y, th en rem ove th e im p lan t . 2. Irrigate th e pocket vigorously. 3. Dissect th e un dersurface of th e posterior capsule; th is plan e is usually th e subperiosteal space. 4. Bilateral capsulotom y sh ould be perform ed th rough th e en t ire longit udin al plan e so as n ot to create any lateral ban d-like deform it y.

■ Key Technical Points 1. Con sider th e silh ou et te of th e skin ap rst . If th e skin ap is too th in , it is bet ter to reu se th e an terior capsule. If th ere is a relat ively th ick scar ban d lateral to th e im plan t , bilateral capsulotom y is n eeded. 2. Make a dorsal pocket subperiosteally for th e reim plan tat ion . 3. Com plete rem oval of th e capsu le is n eeded in cases of im plan t calci cat ion an d m u cocele. 4. Prepare proper autografts con sidering th e dest ruct ion of th e un derlying bony an d car t ilagin ou s st ru ct u res. Th e am ou n t of au tograft is m u ch greater th an expected w h en tot al ext irpat ion of th e capsule an d con t ract u re is p erform ed .

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11 5. After capsule m an ipulat ion , re-drape th e skin ap. If th e skin ap is n ot m oving freely, m yotom y of th e bilateral t ran sverse n asalis or bilateral subperiosteal d issect ion m ay be perform ed aroun d th e bony pyram id. 6. If th e skin ap looks u n n at u ral du e to th e scar ban d aroun d th e t ip, careful cross-h atch ing or m orselizat ion of th e an terior cap su le m ay be p erform ed. 7. If th e t ripod of th e t ip is n ot elongated w ell after th e posterior capsu lectom y, furth er dissect ion is p erform ed. Th e sept um an d ULCs, caudal n asal bon e an d ULCs, an d ULCs an d LLCs (th e scroll area) are d issected an d separated accordingly (Fig. 11.11a). 8. If th e t ip is not elongated even after all of th e e ort s listed, m et icu lou s vert ical scoring at th e su bperich on driu m of th e m em bran ou s sept u m m ay be perform ed. How ever, th is sh ould be don e w ith caut ion as it is a ver y h azardous procedu re.

■ Infections in Septorhinoplasty Th e in fect ion rate for rh in oplast y is reported as 1 to 4%, an d th at of septoplast y bet w een 2 an d 7%. How ever, th e in fect ion rate for septorh in oplast y varies from 2 to 14%, depending on w h eth er it is a prim ar y, secon dar y, or com plicated septorh in oplast y.8 Com p licated septorh in op last y is su rger y th at in cludes septal recon st ruct ion , osteotom y, subm ucosal resect ion , an d free t ran sp lan tat ion th at resu lt s in long operat ion t im e. Most East Asian rh in oplast ies u sing allop last s fall in to th is categor y. Perich on drit is an d sept al abscess are n ot rare in acute in fect ion . Th e m ajor con cern is th e cosm et ic ou tcom e after th e dest ruct ion of th e rem ain ing septal L-st rut . Th e pat ien t m ay com p lain of severe sadd le n ose deform it y an d sh ort n ose deform it y. Th e n orm al ora of th e n asal cavit y in clu des diph th eroids (Corynebacterium ), m icrococci (Staphylococcus epiderm idis), Staphylococcus aureus, St reptococcus (α , β, h em olyt ic), en terococci, yeast (Candida spp .), fu ngi, etc. Th ey are n ot alw ays path ologic.9 Meth icillin -resist an t Staphylococcus aureus (MRSA), m eth icillin -su scept ible Staphylococcus epiderm idis (MSSE), an d Enterobacter sp p. are poten t ially in fect iou s n asal ora (PINF), an d th e rout in e prophylact ic an t ibiot ics are useless if th e colony sprou ts. Som e 20 to 60% of th e n orm al populat ion are repor ted to h ave PINF in their n asal cavit ies. Th e predisposing factors of in fect ion are th e stat us of n asal

Managem ent of Alloplast -Related Com plications physiology of poor ciliar y clearan ce, con ch al hyper t rophy, an d disru pt ion of th e n asal m u cosal barrier. Long op erat ion t im e, n asal packing, w ide dissect ion , an d allo- an d autot ran splan tat ion are oth er in t raoperat ive factors th at predispose pat ien ts to in fect ion . On e rep or t on th e correlat ion of septorh in op last y an d bacterem ia revealed th at 15%of 53 cases of septoplast y an d septorh in oplast y sh ow ed bacterem ia postoperat ively, an d 16.9% did so after rem oval of n asal packing.10 In an oth er st u dy, it w as reported th at 3% of th e p at ien t s experien ced bacterem ia after septoplast y an d 13% after septorh in oplast y.11 In th e perspect ive of su rgical con t am in at ion , rh inoplast y w ith ou t septal w ork m ay be categorized as a clean su rger y, bu t septorh in op last y is categorized as a clean con tam in ated surger y.12 Regarding th e prophylact ic an t ibiot ic t reat m en t , a st u dy of 100 cases of revision rh in op last y revealed 5 pat ien t s w ith severe in fect ion an d 9 pat ien t s w ith localized in fect ion . Th ese pat ien t s w ere n ot covered by prophylact ic an t ibiot ics. On th e oth er h an d, in th e t reated group 1 sh ow ed severe in fect ion an d 3 sh ow ed localized in fect ion .13 An t ibiot ic packing p roved to be e ect ive in d ecreasing th e colony t w o to seven t im es com pared w ith placebo packing in a st udy of 110 cases of septoplast y.14 Th ere are debates on th e sen sit ivit y an d speci cit y of preoperat ive n asal sw abs. Th e auth or’s protocol depen ds on th e result s of colon izat ion an d sen sit ivit y test in preparing for com plicated septorh in op last y an d rh in op last y involving alloplast ic im p lan t ing. Th e prim ar y ch oice of an t ibiot ics in colon izing MSSA an d MSSE are rst- or secon d-gen erat ion cephalosporin s an d Augm en t in (Beach am Ph arm aceu t icals). In th e cases of MRSE, MRSA, an d Enterobacter, ap plying suscept ible an t ibiot ics h as been con sidered a prim ar y ch oice.

■ Case Studies Case 1 In a 38-year-old fem ale, rh in oplast y u sing an L-t ype silicon e im plan t h ad been perform ed 11 years previously (Fig. 11.12). Sh e com p lain ed of u pt u rn ed t ip an d sh ort nose. Th e operat ion w as perform ed an d in cluded low ering th e sellion , rem oving th e ent ire capsule, recon st ruct ion of th e rem ain ing L-st rut using cost al cart ilage, project ing th e dorsal soft t issue pro le w ith fascia of th e rect u s abdom inis, an d project ing th e n asal t ip using cost al cart ilage (Fig. 11.13). Resu lt s are sh ow n in Fig. 11.14.

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Fig. 11.12

Case 1. (a–c) Patient photos before the surgery.

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Fig. 11.13 Case 1. Operative procedures. (a) Original nasion (green arrow) and lowered sellion (yellow arrow). (b) Intraoperative removal of L-t ype silicone. (c) Septal reconstruction with costal cartilage and dorsal rectus fascia.

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Fig. 11.14

Managem ent of Alloplast -Related Com plications c

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Case 1. (a–c) Patient after the surgery.

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Case 3

In a 42-year-old fem ale, rhinoplast y using I-t ype silicone h ad been perform ed w ith a n asal tip onlay graft using con ch al cart ilage 8 years previou sly. Sh e w as dissat is ed w ith the dorsal dem arcat ion of th e silicone im plant an d long nose appearan ce. Th e operation in clu ded low ering th e sellion by ch anging th e silicon e im plan t an d sh orten ing th e n asal length (Fig. 11.15). Addit ion al procedures w ere reu sing th e posterior capsule to sm ooth out the dorsal dem arcation, an d grafting of th e folded cym ba con ch a at th e caudal sep t um as a septal strut to project the nasal t ip and to elevate the subnasale using cavum con cha at the dorsum . Folded Gore-Tex w as in serted to augm ent the alar crease jun ction.

In a 25-year-old fem ale, rh in op last y u sing an I-t yp e silicon e im plan t an d an un kn ow n m aterial (presum ably AlloDerm ) w as p erform ed t w ice by th e sam e su rgeon ; 1 an d 3 years previously (Fig. 11.16). Th e pat ien t su ered from relap sing in am m at ion an d con sequ en t drain age of pus from th e t ip. Th e form er surgeon h ad injected an cillar y ller to th e t ip, but th is resu lted in t ip deform it y. Th e pat ien t com plain ed of t ip deform it y an d h igh n asal dorsum . Mult ilayered capsu le w as rem oved an d th e radix w as redu ced . Th e dorsal silicon e im plan t w as ch anged to a th in n er on e. Tip plast y using th e cym ba an d cavum con ch a w as perform ed (Fig. 11.17). Resu lt s are sh ow n in Fig. 11.18.

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Fig. 11.15 Case 2. (a,b) Before the surgery. (c,d) After lowering the sellion, elevating the subnasale, and augmenting the alar crease junction.

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Managem ent of Alloplast -Related Com plications

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Fig. 11.16 Case 3. (a–c) Patient photos before the surgery.

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Fig. 11.17 Multilayered capsules, dorsal silicone implant, and columellar Medpor was rem oved, and the implant was changed with a thinner silicone; tip-plast y using the cymba and cavum concha cartilage, and a soft tissue graft using super cial m astoid fascia were performed.

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Fig. 11.18 Case 3. (a–c) Patient photos after the surgery.

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References 1. Ferril GR, Wudel JM, Win kler AA. Man agem en t of com plicat ion s from allop last ic im plan t s in rh in oplast y. Cu rr Op in Otolar yngol Head Neck Su rg 2013;21(4):372–378 2. Hong JP, Yoon JY, Choi JW. Are polytet ra uoroethylen e (Gore-Tex) im p lan ts an altern at ive m aterial for n asal d orsal augm en tat ion in Asian s? J Cran iofac Surg 2010; 21(6):1750–1754 3. Peled ZM, Warren AG, Joh n ston P, Yarem ch uk MJ. Th e use of alloplast ic m aterials in rh in oplast y surger y: a m et aan alysis. Plast Recon st r Surg 2008;121(3):85e–92e 4. Park CH. Histological st udy of expan ded polytet ra uoroethylene (Gore-Tex) im plan ted in th e h um an n ose. Rh in ology 2008;46(4):317–323 5. Gurn ey TA, Kim DW. Applicat ion s of porcin e derm al collagen (ENDURAGen ) in facial p last ic su rger y. Facial Plast Su rg Clin North Am 2007;15(1):113–121, viii 6. Bee YS, Alon zo B, Ng JD. Review of AlloDerm acellular h um an derm is regen erat ive t issu e m at rix in m u lt ip le t yp es of ocu lofacial plast ic an d recon st ruct ive surger y. Oph th al Plast Recon st r Su rg 2015;31(5):348–351

7. Sw elam W, Ida-Yon em och i H, Saku T. Angiogen esis in m ucou s reten t ion cyst: a h u m an in vivo–like m od el of en doth elial cell di eren t iat ion in m ucous subst rate. J Oral Path ol Med 2005;34(1):30–38 8. Georgiou I, Farber N, Men des D, Win kler E. Th e role of an t ibiot ics in rh in oplast y and septoplast y: a literat u re review. Rh in ology 2008;46(4):267–270 9. Haug RH. Microorgan ism s of th e nose an d paran asal sin u ses. Oral Maxillofac Surg Clin Nor th Am 2012;24(2): 191–196, vii–viii 10. Kaygu su z I, Kizirgil A, Karlidağ T, et al. Bacteriem ia in sep toplast y an d septorh in oplast y su rger y. Rh in ology 2003; 41(2):76–79 11. Oku r E, Yildirim I, Aral M, Ciragil P, Kiliç MA, Gu l M. Bacterem ia d u ring open septorh in op last y. Am J Rh in ol 2006;20(1):36–39 12. Cru se P. Su rgical in fect ion : in cision al w ou n ds. In : Ben n et t JV, Brach m an n PS, eds. Hosp ital In fect ion s. 2n d ed. Boston , MA: Lit tle, Brow n ; 1986:423–436 13. Schäfer J, Pirsig W. [Preventive antibiotic adm inistration in com plicated rhinosurgical interventions—a double-blind study.] Laryngol Rhinol Otol (Stuttg) 1988;67(4):150–155 14. Bandhauer F, Buhl D, Grossenbacher R. Antibiotic prophylaxis in rhinosurgery. Am J Rhinol 2002;16(3):135–139

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Double -Eyelid Surgery: Nonincisional Suture Techniques

Jin Joo Hong and Hae Won Yang

Pearls • Th e pat tern of skin fold form at ion in th e open ing

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ph ase of th e u pper eyelid is ch aracterist ic of th e East Asian in dividual. In a double eyelid, th e upper border of th e eye con sist s of t w o outlin es, as if th e u pp er eyelid w ere com posed of dual layers. The creation of an arti cial connection of skin (anterior lam ella) and levator (posterior lam ella) at a higher level is the m ain feature of the double-eyelid procedure. Non in cision al su t u re ligat ion creates a fold w ith ou t dissect ion . It is a sim ple, n on invasive, an d e cien t tech n iqu e to m ake a double fold, but it h as also m any con t rain dicat ion s. For exam p le, revision bleph aroplast y is perform ed to reduce th e h eigh t of th e fold, especially after a previou s in cision al bleph aroplast y. Th e n on in cision al su t ure tech n iqu e n eeds to be m odi ed con sidering variou s factors su ch as pu y eyelid, w eak levator fun ct ion , an d exoph th alm os. For a p u y eyelid, th e sept al fat sh ou ld be rem oved as m u ch as possible, an d th e n ew crease lin e design ed to be as low as p ossible. Too h igh a fold m ay h in der th e full open ing of th e apert u re an d yield open ing discom for t , especially in a subclin ical or clin ical ptot ic eyelid. If exoph th alm os is prom in en t , th e lin e of th e crease sh ould be low ered m ore th an usual to avoid an excessively h igh fold. Th e lid m argin m ay be closed (“in side fold”) or open (“out side fold”) at th e m edial en d according to w h eth er or n ot th e t w o upper ou tlin es of th e eye,

■ Introduction Double Eyelid and Single Eyelid On e of th e m ost im port an t fu n ct ion s of th e u pp er eyelid is to altern ately protect an d exp ose th e eye w ith it s rep et it ive sh u t ter-like excu rsion m ovem en t . Along w ith th e altern ating m ot ion of th e closing an d open ing ph ases, th e upper eyelid ch anges its extern al sh ape con t in u ously. In th e closing ph ase, th e lid is exten ded w ide to cover th e corn ea an d bulbar conjun ct iva of th e eyeball; in th e open ing ph ase, th e lid is ret racted to expose th em . During th e open ing period,

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th e edge of th e skin fold, an d th e t ru e lid m argin w ith th e eyelash es are join ed togeth er m edially. Th e m iddle port ion of th e double fold sh ould be su cien tly h igh er th an th e m ed ial an d lateral port ion s in th e closed state to preven t st raigh ten ing of th e dou ble fold w h en th e eyes are open . After p reop erat ive design , ve p u n ct u res or sm all slit s sh ou ld be m ade w ith a n eedle or n o. 11 blade. A 7–0 n on absorbable su t u re is p assed th rough th e skin to th e u pp er m argin of th e t arsu s an d ret u rn ed th rough th e sam e site of th e t arsu s to th e skin . Th en th e lid skin is xed on th e t arsal plate. W h en rem oving th e septal fat , th e posit ion of th e fat m u st be con sidered . Th e sept al fat m oves to an upper an d lateral area in th e supin e posit ion . For Mü ller m uscle t u cking, 7–0 nylon th read is in t roduced th rough th e skin to th e upper m argin of th e t arsu s. Th e sut ure is passed th rough th e tarsus to th e poin t of th e conju n ct iva n ear th e su p erior forn ix an d ret urn ed th rough th e sam e poin t on th e conjun ct iva to th e t arsus, t ucking th e Mü ller m uscle. Th e sut ure exit s th rough th e t arsus to th e skin an d is kn ot ted to t igh ten th e th read. W h en th e sut ure passes th rough th e t arsus, th e su t u re m ay ap p ear on th e conju n ct ival side, w h ich can in duce a foreign body sen sat ion an d severe pain . If th e p at ien t com p lain s of a foreign body sen sat ion , th e eyelid is everted an d th e t arsal plate is carefully scru t in ized.

th e enveloping cover (skin an d palpebral conjun ct iva) sh ou ld be folded to elim in ate red u n dan cy in tem p orar y coverage. Alth ough conju n ct ival folding is n ot obser ved w h en looking at th e face, th e pat tern of skin fold form at ion in th e open ing ph ase of th e upper eyelid is ch aracterist ic of each East Asian in dividu al.1 Th is p at tern an d m an n er of folding th e ou ter skin determ in es th e sh ape of th e eyes, part icularly in th e upper border of th e palpebral apert ure. Usu ally, th e skin is folded at the m iddle of th e eyelid, an d th e edge of th e skin fold is located above th e eyelash to expose th e corn ea com pletely in the fully open ed st ate. Th e edge of th e skin fold an d th e eyelid m argin w ith th e eyelash es parallel to each oth er form th e u p per border of th e palp ebral aper-

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t u re (dou ble eyelid) togeth er. In a double eyelid, th e upper border of th e eye con sist s of t w o outlin es as if th e upper eyelid w ere com p osed of du al layers (Fig. 12.1). In con t rast , th e single eyelid h as on ly on e bord er, because th e skin fold is form ed below th e lid m argin . Th e edge of th e skin fold h id es th e real lid m argin an d p u sh es th e eyelash es from above in th e open ing ph ase (Fig. 12.2). Com pared w ith th e double eyelid, th e palpebral apert ure is redu ced by th e low er skin fold. Th e single-lin ed upper border is a un ique feat u re of East Asian in dividuals (Korean , Ch in ese, Japan ese, an d Mongolian ), w h ile th e dou ble lin e is th e m ost prom in en t eyelid fold pat tern in Caucasian , African Am erican , an d South Asian in dividuals.

Anatomy of the Upper Eyelid Th e upper eyelid is a layered st ruct ure, divided in to th e an terior, m idd le, an d posterior lam ellae. Th e an terior lam ella is com posed of th e skin an d u n derlying orbicularis oculi m uscle. Th e posterior lam ella con sist s of th e tarsus an d u n d erlying conju n ct iva. Th e m iddle lam ella con sists of th e orbit al sept u m an d fat separat ing th e orbit al con ten t s from th e p resept al st ru ct u res.2 In th e sagit t al sect ion al

an atom y, th e inver ted t riangle-sh ap ed u pp er eyelid h as a th ick u pper por t ion w ith th ree dist in ctly separated lam ellae an d a th in distal lid m argin in w h ich th e an terior an d posterior lam ellae are at ten uated an d con den sed rm ly togeth er (th e skin , orbicu laris ocu li m u scle, an d tarsu s). Th e in ter ven ing orbit al sept um an d orbit al fat (m iddle lam ellae) exten d on ly to th e fusion lin e, w h ich can be iden t i ed as a skin crease on th e outer surface. Th e con den sed dist al lid m argin is at t ach ed to th e levator m ech an ism (levator ap on eu rosis, su p erior levator palp ebralis m u scle, an d Mü ller m u scle) an d act ively ret ract s at th e begin n ing of th e open ing ph ase (Fig. 12.3). Meanw h ile, th e an terior an d m iddle lam ellae above th e fu sion lin e (t ran sverse skin crease) are p assively fold ed according to th e op en ing m ovem en t . With th e su p erior levator p alpebralis m u scle con t racting, th e distal lid m argin (red-colored surface) directly con nected to th e levator m ech an ism begin s to ret ract upw ard , leaving th e upper an terior lam ella (above th e fusion lin e, green - an d blu e-colored su rface) st at ic in sit u . As th e degree of open ing in creases, th e an terior lam ella ju st above th e crease is passively lifted from its distal en d (green colored surface). At th is level, th e t ran sverse skin crease becom es prom in en t an d is folded furth er as open ing pro-

Fig. 12.2 Typical single eyelid of East Asian women. (a) In the opening phase, the skin is folded at a level too low, and the skin crease is hidden under the upper part of the palpebral aperture and (b) the eyelashes get pushed down. In comparison with the double eyelid, the palpebral aperture looks reduced by the distal skin fold, which lies at a lower level.

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12 Double-Eyelid  Surgery:  Nonincisional  Suture  Techniques th e fold lies above th e lid m argin an d does n ot obst ruct th e norm al visu al eld (Fig. 12.4).3,4

Nonincision Suture Ligation for Double -Eyelid Formation

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Fig. 12.3 Opening process of the upper eyelid. (a) In the resting phase, the outer skin of the upper eyelid is expanded. (b) At the beginning of eyelid opening, the skin just above the crease (green zone) is rolled up with the lid margin elevated. (c) In the fully opened phase, the green zone skin is completely behind the upper skin.

gresses. With furth er open ing, th e dist al skin of th e an terior lam ella (green ) is ip p ed u p an d en ters ju st beh in d it s u pp er skin (blu e-colored su rface) to create a fold . In th e single eyelid, th e m iddle lam ella is w ell developed an d abun dan t orbit al fat exten ds to a low er level. Th erefore, th e an terior an d posterior lam ellae fuse at a low er level th an th ey do in a dou ble eyelid, an d th e h eigh t of th e con den sed dist al lid m argin (red) is too low. As a con sequen ce, th e skin of th e an terior lam ella is folded at a m u ch low er level (low er t arsal crease) in th e open ing ph ase an d h ides th e en t ire lid m argin , in clu ding th e eyelash es. Fur th erm ore, th e u pper por t ion of th e palpebral aper t ure is p ar t ially eclip sed by th e skin fold, desp ite th e fu ll open ing of th e eyelid . Hen ce, in a severe case, th e fron t alis act s to lift th e eyelid skin fold to provide adequate vision , as in a p at ien t w ith a bleph aroptosis. Meanw h ile, in a dou ble eyelid, th e fold is form ed at a h igh er level an d th e edge of

Resting phase

Opening phase

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Th e m ost im port an t an atom ic di eren ce bet w een a single an d d ou ble eyelid is th e level of th e lid crease an d skin fold form at ion , w h ich is th e result of th e th in n ing an d fusion of th e an terior an d posterior lam ellae. In a double eyelid, th e skin fold lies w ith in th e lid above th e eyelash in a relaxed for w ard gaze, because th e fold-form ing lid crease is w ell de n ed an d su cien tly h igh . Th e creat ion of an art i cial con n ect ion of skin (an terior lam ella) an d levator (posterior lam ella) at a h igh er level is th e m ain feat ure of th e doubleeyelid procedure. Tradit ion ally, th e procedure can be divided in to t w o m ajor categories: n on in cision al su t u re ligat ion (bu ried su t u re tech n iqu e) an d th e extern al-in cision tech n iqu e. W h ile th e n on in cision al tech n ique con n ects th e skin an d th e deeper act ive levator m ech an ism w ith a sim ple th read loop, th e extern al-in cision tech n iqu e con sist s of reducing th e volum e of both lam ellae an d xing th em togeth er w ith scar adh esion . Th e extern al-in cision tech n iqu e also requ ires a bu ried su t u re to con n ect th e skin an d levator m ech an ism , so a su t u re loop ligat ion is com m on to both tech n iqu es. Regardless of th e u se of an in cision , a buried sut ure loop in th e lid is an essen t ial part of double-eyelid creat ion . In fact , th e n on in cision sut ure ligat ion tech n ique en t ails form ing a fold w ith sut ure ligat ion w ith ou t dissect ion . Various surgical approach es for n on in cision al sut ure ligat ion h ave been reported. Th e n on in cision sut ure ligat ion tech n ique h as been developed for correct ion of bleph aroptosis as w ell as for th e sim ple form at ion of th e double-eyelid fold. From th e conjun ct ival side, th e ret ractor can be plicated to in crease th e ten sion of th e levator m ech an ism .

Resting phase

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Opening phase Double eyelid

Fig. 12.4 Single and double eyelid. The most important anatomic di erence bet ween a single and double eyelid is the level at which the fusion bet ween the anterior and posterior lamellae occurs, and thus the level at which the anterior skin is folded. The pat tern of the skin fold in the opening phase determines the shape of the eye. (a) In a single eyelid of an Asian, the skin fold is formed at a lower level and the folding skin hides the real lid margin and eyelashes as well as the upper part of the palpebral aperture. (b) In contrast, the skin fold of a double eyelid lies at the upper level and the fold edge is formed far above the eyelashes.

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III Blepharoplast y th e cen ter of th e eyeball. If exoph th alm os is prom in en t , th e lin e of th e crease sh ou ld be low ered m ore th an usu al to avoid an excessively h igh fold.

■ Patient Evaluation With th e except ion of severe blep h aroptosis w ith w eak levator fu n ct ion or ext rem ely th ick lid soft t issue, th e n on in cision sut ure ligat ion tech n ique can be applied to t ran sform th e lid from single to dou ble in m ost pat ien t s. How ever, th e procedu re is selected based on th e speci c requ irem en ts of th e case an d th e an atom ic an d fun ct ion al con dit ion s of th e pat ien t .

Pu y Eyelid A st able adh esion of th e previou sly sep arated an terior an d posterior lam ellae at a h igh er level is th e prim ar y goal of double-eyelid su rger y. Th e in ter ven ing loose volum in ous t issue (orbicularis oculi m u scle an d presept al an d sept al fat) bet w een th e skin (an terior lam ella) an d levator m ech an ism (p osterior lam ella) is th e m ain h in dran ce to th e fu sion of th e lam ellae. Hen ce, excessive soft t issue in th e upper eyelid is an u n favorable factor for double-eyelid form at ion u sing eith er th e extern al-in cision or n on in cision al sut u re ligat ion p rocedure. W h ile th e sept al fat can be rem oved w ith a sm all in cision before sut ure ligat ion (part ial in cision su t u re ligat ion ), th e p resept al fat an d orbicu laris ocu li m u scle can n ot be reduced w ith out a full-length in cision al tech n iqu e. For a p u y eyelid, th e sept al fat sh ould be rem oved as m u ch as p ossible, an d th e n ew crease lin e sh ou ld be design ed to be as low as possible in a n on in cision sut ure ligat ion p rocedu re (st rictly speaking, th is sh ould be n am ed “p ar t ial in cision su t u re ligat ion ” becau se th e fat is rem oved th rough a sm all in cision before sut ure ligat ion ).

Weak Levator Function Alth ough Mü ller m u scle t u cking can resolve m ild blep h aroptosis, it is con t rain dicated in m ost cases of severe bleph aroptosis w ith a loose levator ap on eu rosis th at requ ires direct levator advan cem en t . Th e creat ion of a h igh er folding crease in creases th e load of th e dyn am ic par t of th e lid. Fu rtherm ore, th e upper por t ion of eyelid skin is th icker an d requ ires m ore force to fold. Too h igh of a fold m ay h in der th e fu ll open ing of th e aper t ure an d yield open ing discom fort , esp ecially in a subclin ical or clin ical ptot ic eyelid.

Exophthalmos Eyelid excu rsion is in u en ced by th e an atom y of th e n eigh boring st ruct ure, relat ive volum e of th e fat , depth of th e orbit , degree of eyeball prot rusion , an d oth er factors. Th e su sp en sion of th e skin fold is t igh ter in exop h th alm os th an in en op h th alm os because th e eyeball push es th e lid forw ard . Th e edge of th e fold is relat ively h igh an d th e u n derlying lid m argin is exposed at a h igh er level, especially in

Shape of the Lid Margin Exposure Double-eyelid surger y not only opens the h idden upper portion of the palpebral apert ure but also changes the upper border from having a single to a double outline. The new ly form ed outer line is determ ined by the edge of th e fold rather than by the supratarsal crease itself. The lid m argin (skin bet w een th e fold edge an d th e lid m argin ) is the fringe of the eye th at is an at t ract ive feat ure and a good place to add m akeup to m ake the eye appear w ider. Therefore, one of the m ain purposes of double-eyelid surger y is to obtain an adequ ate an d beaut ifu l lid m argin . Because th e lid m argin changes according to the view ing direct ion or degree of open ness in a gaze, it should be designed during a relaxed for w ard gaze. Th e lid m argin is th e area bet w een the height of the supratarsal crease an d th e vert ical depth of the fold. The fold is deepest at the m idpoin t due to th e m axim al vert ical open ing of th e apert u re, w h ich m ean s that the lid retracts higher in the m iddle than at both sides. Therefore, th e m iddle portion of the crease line sh ould be adequately elevated to avoid a n arrow lid m argin in th e m iddle (Fig. 12.5). Th e sh ape of th e lid m argin is determ in ed by the edge of th e fold and the distal border of the lid.

Inside and Outside Folds Th e lid m argin m ay be closed (“in side fold”) or open (“outside fold”) at th e m ed ial en d according to w h eth er or n ot th e t w o u pper outlin es of th e eye, th e edge of th e skin fold an d th e t rue lid m argin w ith th e eyelash es, are join ed togeth er m edially. In an eye w ith an in side fold, th e t ran sverse skin fold is conjoin ed to th e ep ican th al fold. To op en m edially, th e fold crease sh ou ld be located separately an d high er th an th e st ar t of th e epican th al fold. Curren tly, on e of th e m ost popular lid m argin sh apes is m idw ay bet w een th e in side an d out side folds. How ever, th ere can n ot be a posit ion m idw ay bet w een open an d closed. Th erefore, in th e “in /out” or “n eut ral” fold, th e m edial side is open w ith a sm all gap, but th e h eigh t of th e double lid gradually in creases laterally. Th u s, it is act u ally an ou t side fold, but because of it s m in im al opening m edially an d in creasing h eigh t laterally, it can be seen as an in side fold from a dist an ce (Fig. 12.6).

Revision Case Becau se th e an terior lam ella just above th e fusion lin e is passively folded by th e ret ract ion of th e posterior lam ella, even an un n ot iceable subcu tan eou s scar can disru pt th e con t in uit y of th e even skin fold. In a severe case, th e scar

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12 Double-Eyelid  Surgery:  Nonincisional  Suture  Techniques

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Fig. 12.5 Di erent shapes of lid margin. (a) The shape of the lid margin is determined by the edge of the fold and the distal border of the lid. If the middle portion of the lid margin is too wide, the shape of the eye looks too round or oval-shaped. (b) If the middle portion of the lid margin is too narrow, the eye appears as though it is frowning. (c) The upper and lower sides of the lid margin should be parallel or gradually grow farther apart.

sh ou ld be excised (u sing an in cision al tech n iqu e) or th e d esign ed lin e sh ould be put h igh er th an th e scar (using a n on in cision al tech n iqu e) to keep th e skin ju st above th e crease u n iform . For th is reason , th e n on in cision al m eth od can n ot be used to redu ce th e h eigh t of th e fold, especially after a p reviou s in cision al blep h arop last y.

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Suture Material Becau se n o dissect ion is perform ed during n on in cision al su t u re ligat ion , th e adh esion of th e an terior an d p osterior lam ellae is m ain t ain ed on ly by th e ten sile st rength of th e su t u re m aterial an d kn ot clam p ing. Th erefore, th e ch oice

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Fig. 12.6 Three t ypes of double fold. (a,b) The lid margin may be closed (“inside” fold) or open (“outside” fold) at the medial end according to whether or not the t wo upper outlines of the eye, the edge of the skin fold and the true lid margin with the eyelashes, join together medially. (c) In the “in/out” or “neutral” fold, the m edial side is open with a small gap, but the height of the lid margin is gradually increasing laterally. (d) Design of the outside fold (red), in/out or neutral fold (yellow), and inside fold (blue).

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III Blepharoplast y of sut ure m aterial is im port an t . Frequen tly u sed nylon (p olyam ide, 7–0 nylon ) is a n on absorbable, m on o lam en t su t u re m aterial. Alth ough a m on o lam en t nylon su t u re h as a great m em or y to ret u rn to its p reviou s sh ape an d a p roclivit y for kn ot slippage, it h as a low in fect ion rate. Un dyed t ran slucen t nylon is preferred for a n on in cision sut ure ligat ion procedu re, because un dyed nylon h as a greater ten sile st rength th an th e dyed form , w h ich in clu d es im p u rit ies. How ever, t ran slu cen t su t u re m aterial is h ard to n d in a revision procedu re.5,6

Choice of Needle Needle ch oice d ep en ds on th e an t icip ated locat ion of th e su t u re loop in th e eyelid t issu e. Con n ect ing loop (s) can be m ade by p erforat ing th e fu ll th ickn ess of th e lid or by p art ial t agging of th e lid skin to th e tarsus. For a perforat ion procedure, a long, circu lar n eedle is conven ien t (24 m m rou n d ⅜ circu lar n eedle w ith 7–0 w h ite nylon ). How ever, a sm aller n eed le is p referred for th e p ar t ial tagging procedure. A t riangu lar cut t ing n eedle can dam age large vessels, so a rou n d or rectangu lar cu t t ing n eed le is ch osen .

■ Surgical Techniques Nonincisional Suture Technique of a Double -Eyelid Operation It is bet ter to design a dou ble eyelid w ith th e clien t in an u prigh t p osit ion because th e sh ape of th e eyes an d th e double fold can ch ange in a supin e posit ion . Th e surgeon can bet ter predict th e surgical outcom e for th e pat ien t in an u p righ t posit ion . Th ere are th ree classi cat ion s for th e start ing poin t of th e double fold. An in side fold is on e in w h ich th e double fold lin e st ar t s below th e epican th al fold. It ten ds to be m ore n at u ral bu t th e eyes can look sm aller th an w ith oth er form s of fold. An out side fold is on e in w h ich th e double fold lin e start s above th e epican th al fold. Th e eyes look bigger th an w ith an in side fold, but th e appearan ce m ay be un n at ural. A n eu t ral fold or in /ou t fold is a t ype of out side fold in w h ich th e st art ing poin t is low er th an it is for th e classical out side fold . It looks n at ural an d th e eyes look bigger; m any Asian clien ts prefer th is fold (Fig. 12.6d).7 Th e preoperat ive design of th e double fold lin e sh ould be m arked w ith a sh arp surgical m arking pen along th e n at ural cu r vat u re of th e eyelid skin . Gen erally, th e m ean h eigh t of a dou ble fold is 6 to 8 m m from th e eyelash , an d th e h eigh t ranges from 4 to 10 m m . Th e range of tarsal w idth in Asian in dividu als is usu ally 6 to 8 m m , so a sut ure th at pen et rates th e skin can be xed on th e t arsal plate.8 Th e m iddle port ion of th e fold sh ould be h igh er th an th e m edial an d lateral por t ion s in th e closed st ate, to pre-

ven t st raigh ten ing of th e d ou ble fold w h en th e eyes open . If th e p at ien t h as th in eyelid skin an d good levator fu n ct ion , a h igh er double fold is possible. On th e con t rar y, if th e pat ien t h as th ick eyelid skin an d poor levator fu n ct ion , it is bet ter to m ake th e double fold lin e low er because it ten ds to look u n n at u ral if a h igh er fold is m ade in su ch a p at ien t . Th e ve m arkings vert ical to th e double fold lin e in terrupt an d divide th is lin e in to fou r areas (Fig. 12.7). Th e m edial en d sh ou ld be at or im m ediately lateral to th e u pp er en d of th e epican th al fold. Th e lateral en d sh ould be at th e lateral en d of th e p alp ebral ssu re. Th is surgical procedure is usually perform ed un der local an esth esia using 2% lidocain e m ixed w ith 1/100,000 ep in ep h rin e an d m ild in t raven ou s sedat ion . For skin an esth esia, sh allow in sert ion of a 26-gauge n eedle in to th e sub derm al layer is perform ed, because if th e n eedle is in ser ted deep, bleeding an d sw elling m ay occur an d th e su rgeon m ay n ot be able to predict th e ou tcom e of su rger y. Th e conjun ct iva is also an esth et ized w ith lidocain e inject ion . A 0.5% op h th alm ic solu t ion of p rop aracain e hyd roch loride is used to an esth et ize th e corn ea. A plast ic corn ea protector can be u sed to p rotect th e eyeball. Th e su rgical step s of th e n on in cision al sut ure tech n ique for a double-eyelid operat ion are sh ow n in Fig. 12.8. Du ring local an esth esia, th e poin t s previously m arked w ith gen t ian violet are pun ct ured w ith th e 26-gauge n eedle. Th ese tem porar y m arkings can in dicate th e en t ran ces an d exit s of th e 7–0 nylon su t u re. In stead of a pu n ct u re, a sm all st ab in cision can be m ade w ith a n o. 11 blade. If th e orbit al sept al fat volu m e is ver y bu lky an d th e upper eyelid appears pu y, sept al fat rem oval can be p erform ed th rough a sm all in cision on th e lateral port ion of th e dou ble fold. W h ile h olding th e sept um w ith tooth ed forceps, a sm all in cision is m ade on the sept um w ith sh arp scissors, an d th e sept al fat is ext racted w ith sm ooth forcep s.

Fig. 12.7 Preoperative design of the nonincisional suture technique. The m idportion of the fold should be higher than the medial and lateral portions in the closed state to prevent straightening of the double fold when the eyes open.

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12 Double-Eyelid  Surgery:  Nonincisional  Suture  Techniques

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Fig. 12.8 Surgical procedures for the nonincisional suture technique. (a) After local anesthesia using 2% lidocaine mixed with 1/100,000 epinephrine and mild intravenous sedation, the points previously marked with gentian violet are punctured with a no. 26G needle. These temporary tat toos can be the entrance and exit points for 7–0 nylon sutures. (b) Septal fat removal can be done through a small incision on the lateral portion of the double fold. (c) The suture is passed through the skin to the upper margin of the tarsus. As the suture is passed, the upper eyelid is everted with wide sm ooth forceps or other forceps for the tarsus. (d) The suture needle is returned through the same site at the tarsus to the skin. (e) The suture is passed through the subdermal layer to the next puncture of the skin. (f) The same procedure is repeated on the following punctures.

Th e ext racted fat is coagu lated w ith an elect rical coagulator an d th en cu t . Met icu lou s coagu lat ion is n ecessar y becau se th ere are sm all vessels w ith in th e sept um . A 7–0 m on o lam en t n on absorbable sut ure w ith a t apered 24-m m ⅜c n eedle is used. A roun d n eedle sut ure is u sed becau se an angled n eedle m ay cu t th e nylon accid en t ally. Th e su t ure is passed th rough th e skin to th e upper m argin of th e t arsu s an d ret u rn ed th rough th e sam e site of th e tarsus to th e skin . Th en th e lid skin is xed on th e t arsal plate. W hen th e sut ure is being passed, the upper eyelid is everted w ith a w ide sm ooth forceps, or another t ype of forceps for th e tarsus. Th ere are m any t ypes of forceps for h an dling th e tarsu s. To pen etrate th e tarsus in th e sh ortest distance, the needle should be vert ical to the tarsus. If the n eedle is n ot vert ical to th e tarsus, th e soft tissue ben eath the skin can be xed to th e tarsus an d unw anted dim pling w ill develop. The distance from the eyelid m argin to the h ole in th e skin side sh ou ld be sim ilar to th e distan ce from the eyelid m argin to the conjunct ival ent rance. If the length

of the skin side exceeds that of the conjunct ival side, the double fold w ill be deeper an d the eyelashes w ill be everted. If th e skin side is shorter th an the conjun ctival side, the skin below the double fold w ill sag. After the sut ure exits th e hole of the skin again , it is passed th rough th e subderm al layer to the n ext skin punct ure, w ith the procedure repeated on each punct ure. The sequence of the procedure can be ch anged. Nu m bering skin en tr y poin ts as 1 th rough 5 from m edial to lateral, th e au th ors proceed in th e order 5–3–1– 2–4–5. W h en the septal fat is rem oved, the order proceeds as 4–5–3–1–2–4 (Fig. 12.9). Th e en ds of th e sut u res are t ied at the lateral posit ion and the kn ot is buried w ithin the subderm al layer. The kn ot can be placed in any locat ion, but the cent ral area is avoided because the knots can be visible there. The skin incision is closed w ith nylon 7–0, or m ay not need to be closed w hen th e incision is ver y sm all. The patient opens his/her eyes and the surgeon checks the shape of the double fold and the sym m etry of both eyes. An ice bag is applied to the periorbital area for 2 days to reduce swelling. The skin stitches are rem oved 3 to 5 days later.

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Fig. 12.9 Typical sequence of needle passes in the nonincisional suture technique. Numbering skin entry points as 1 through 5 from medial to lateral, the authors proceed in the order 5–3–1–2–4–5. The ends of the sutures are tied at the lateral position and the knot is buried within the subdermal layer.

Transconjunctival Müller Tucking In th e u n ilateral or bilateral m ild ptosis case, t ran sconju n ct ival Mü ller t ucking can be don e w ith th e double-eyelid operat ion (Fig. 12.10). Th e preop erat ive design of th e dou ble fold lin e sh ould be perform ed along th e n at ural skin crease. Th e locat ion s of Mü ller t u cking sut ures are m arked on th e vert ical lin e of th e m edial an d lateral lim bi. Th e surgical p rocedu re is u su ally perform ed u n der local an esth esia u sing 2% lidocain e m ixed w ith 1/100,000 epin ep h rin e an d m ild in t raven ou s sedat ion . Sm all in cision s are m ade w ith a n eed le or n o. 11 blade on p oin t s th at th e n eedle w ou ld pen et rate. Ever t ing th e u pper lid, a t ract ion sut ure is m ade on th e upper m argin of th e t arsus w ith nylon 5–0. For Mü ller m uscle t ucking, 7–0 nylon th read is in t roduced th rough th e skin to th e upper m argin of th e t arsus. Th e sut ure is passed th rough th e t arsus to th e poin t of th e conjun ct iva n ear th e superior forn ix an d ret u rn ed th rough th e sam e poin t on th e conjun ct iva to th e tarsus, t ucking th e Mü ller m u scle. Th e su t u re exit s th rough th e t arsu s to th e skin an d is kn ot ted to t igh ten th e th read. Th e sam e p rocedure sh ou ld be perform ed at oth er sites of Mü ller m u scle t ucking, an d th en th e t ract ion sut ure is rem oved. Next , th e com m on procedu re for th e dou ble fold is perform ed. Th e kn ots of th e th reads sh ould be buried w ith in th e skin so th at th ey are n ot exposed.9,10

■ Key Technical Points 1. In th e design of th e double fold, th e h eigh t of th e m iddle por t ion of th e dou ble fold sh ould be su cien tly h igh er th an th e m ed ial an d lateral p ort ion s in the closed state to preven t st raigh ten ing of th e dou ble fold w h en th e eyes are open .

2. W h en rem oving th e sept al fat , th e posit ion of th e fat m u st be con sid ered . Th e sept al fat m oves to an u pp er an d lateral area in th e su p in e p osit ion . 3. During th e sut ure pass th rough th e t arsu s, an u nw an ted kn ot can be m ade on th e conju n ct ival side th at can in du ce a foreign -body sen sat ion an d severe pain . If th e pat ien t com plain s of th e sen sat ion of a foreign body, th e eyelid is everted an d th e t arsal plate is obser ved rst . 4. For t ran sconju n t ival Mü ller t ucking, an assist an t sh ou ld pu ll th e t ract ion su t u re an d pu sh th e eyelid in th e opposite direct ion w ith a cot ton sw ab to m ake th e procedu re easier to perform . 5. It is best if th e poin t of th e conjun ct iva at w h ich th e su t u re exit s is n ear th e su p erior forn ix.

■ Complications and Their Management

Relapse Becau se th ere is n o t issue adh esion bet w een th e an terior an d p osterior lam ellae of th e u pp er eyelid, u n like th e case in an in cision al bleph aroplast y tech n ique, the con n ect ion bet w een th e t w o st ruct ures depen ds on ly on th e sut ure loop in a n on in cision al tech n ique. A sut u re loop in evit ably loses it s h old on t issues over th e postoperat ive m on th s an d th e am oun t of t issu e h eld by each loop gradually reduces over t im e. Hen ce, th e xat ion bet w een th e t w o lam ellae loosen s, even w ith a t igh t relat ion sh ip at th e begin n ing. Alth ough m oderate loosen ing is a n orm al, n at u ral drift tow ard an equ ilibriu m , excessive loosen ing e aces th e skin fold or m akes m u lt iple skin folds in oth er creases (relap se). Th is relapse is th e m ain draw back of th e n on in cision sut ure ligat ion bleph aroplast y tech n ique. Various au th ors h ave

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Fig. 12.10 Transconjunctival Müller tucking. (a) Preoperative design for transconjunctival Müller tucking. The points 2 and 4 are for Müller tucking suture. The points 1, 3, 5, and 6 are for the double fold procedure. (b) A traction suture is located on the upper margin of the tarsus. (c) The suture is passed through the skin to the upper m argin of the tarsus. (d) The Müller tucking suture is passed through the tarsus to a point of the conjunctiva near the superior fornix. The surgeon’s assistant should pull the traction suture and push the eyelid in the opposite direction using a cot ton swab to facilitate the procedure. (e) The Müller tucking suture returns through the same point of the conjunctiva to the tarsus to tuck the Müller muscles.

rep or ted th eir ow n relapse rates, bu t th ese are n ot clin ically m ean ingfu l. In pat ien t s w ith u n favorable feat u res (e.g., th ose w ith pu y eyelids), th e rate of fold relapse in creases. Th e m ost com m on cause of relapse is a sut ure loop h olding t issu e w ith less brou s com p on en t s. Th eoret ically, th e surgeon sh ould dist ribute th e ten sion of each loop even ly, an d in clu de m ore brou s t issu e in each loop as a su p port ing st ru ct u re. An oth er cau se of relapse is w eakn ess of th e su t ure m aterial. Pure nylon is t ran slucen t an d ver y exten sible, bu t colored nylon m ixed w ith p igm en t loses its exten sibilit y an d breaks easily. How ever, a sim p le su t u re m aterial problem occu rs in frequ en tly.11,12,13

Irregular Fold Fold form at ion of th e upper lid skin during eye op en ing from th e closing p h ase p roceed s dyn am ically an d gradu ally. At th e begin n ing of th e op en ing, th e skin fold along

th e crease becom es gradually deeper as th e globe exposure w iden s. Becau se th e fold h angs over th e skin crease, a lin ear sh adow of th e fold ap pears parallel to th e crease an d fold . At th is t im e, u n less th e crease is parallel to th e relaxed skin ten sion lin e (RSTL), m u lt ip le part ial obliqu e folds can be created, disrupt ing th e con t in uit y of th is fold sh adow. Unw an ted obliqu e folds n ear the crease during th e open ing m ovem en t dim in ish th e n at u ral look of th e dou ble-eyelid crease. Th e crease sh ould be design ed perfectly parallel to th e RSTL in any case. Alth ough th e irregularit y of th e skin folds can be prom in en t at th e site of th e sut ure loop in th e im m ediate postoperat ive period due to local pin ch ed t issu e, th e skin can recoil an d th e irregularit y fades aw ay w ith in 3 m on th s. How ever, dim p ling in an area of scar t issu e can n ot easily fade aw ay becau se scar t issu e h as less recoiling pow er. In addit ion , a scar in th e skin p reven t s even fold form at ion , so th e scar sh ou ld be located below th e skin fold ing crease (Fig. 12.11).

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Lid Margin Tension Eversion

Fig. 12.11 Prominent scar. Dimpling in an area of scar tissue does not easily fade away because scar tissue has less recoiling power. In addition, a scar in the skin prevents even fold formation, so the scar should be located below the skin folding crease.

Th e h eigh t s of th e sut ure pen et rat ion sites from th e lid m argin on th e ou ter an d in n er su rfaces can di er. If th e level at th e posterior lam ella (apon eurosis or tarsus) is h igh er th an th at at th e anterior lam ella (skin ), th e skin below th e crease is st retch ed. With in a n orm al range, m ild st retch ing of th e skin looks good, w ith th e eyelash es lift ing u p sligh tly. How ever, in a severe case, th e st retch ed low er skin becom es too th in w h ile th e push ed upper skin becom es th ick. An abrupt di eren ce in skin th ickn ess along th e crease looks u nn at u ral an d art i cial (Fig. 12.12a). In addit ion , th e eyelash es m igh t be everted to a large exten t , an d th e h id den conju n ct ival m ucosa m igh t appear abn orm al (Fig. 12.12b). Ten sion is usu ally relieved w ith t im e, un like th e sit uat ion w ith th e in cision tech n ique. How ever, th e prospect ive crease w ould be low ered an d w ould un dulate in to an un n at ural cur ve (Fig. 12.12c). Ach ieving adequ ate skin ten sion of th e an terior lam ella is im port an t in m aking a dou ble-eyelid crease.

Strangulation

Stitch Abscess and Exposure of the Knot

Th e sut ure loop h olding th e t issu e preven t s n orm al blood circulat ion an d m ay cau se ven ou s or lym ph at ic congest ion . Sim ple lid m argin congest ion w ith out t issue injur y does n ot cau se long-term problem s, alth ough it causes tem porar y blep h aroptosis or p roblem s w ith eye op en ing in th e im m ediate p ostoperat ive period. It can delay recover y w ith th e w eigh t of th e lid m argin in creased. Th e am ou nt of t issu e en circled by loop s sh ou ld be m in im al an d th e ten sion sh ou ld be dist ribu ted even ly.

Becau se m on o lam en t nylon h as a long m em or y an d p oor kn ot securit y, it sh ould be t ied in m u lt iple squ are kn ots to preven t slipping or kn ot loosen ing. Th e m ult i-t ied bulky kn ot sh ould be buried in an appropriate deep site to avoid palpat ion or exposure. Becau se th e cen t ral port ion of th e eyelid is th in n er th an th e m edial an d lateral p ort ions d u e to th e oval sh ape of th e globe p rot ru sion ben eath th e u pp er eyelid in th e closing ph ase, a kn ot in th e m id port ion can be easily n ot iceable an d is exp osed m u ch m ore readily th an if it w ere in an oth er locat ion . Ch oosing a deep locat ion for th e kn ot is also im por tan t , an d it sh ould be placed ben eath th e orbicularis oculi m uscle layer. Im proper posit ion an d depth of kn ot s m ay cause st itch abscess or exposure, in w h ich case all lin ked st itch es sh ould be rem oved.

a

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Fig. 12.12 Tension eversion. (a) Lid margin skin tension should be adequate and considered in the design at the beginning of the procedure. An abrupt di erence in skin thickness along the crease looks unnatural and arti cial. (b) In addition, the eyelashes might be everted to a large extent, and the hidden conjunctival mucosa might appear abnormal. (c) The prospective crease would be lowered and would undulate into an unnatural curve.

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12 Double-Eyelid  Surgery:  Nonincisional  Suture  Techniques

Case 2: Transconjunctival Müller Tucking

■ Case Studies Case 1: Nonincision Suture Ligation for Double Fold Formation A 25-year-old fem ale p at ien t w ith a low an d asym m et ric double fold w an ted a n eut ral or out side fold an d a h igh er double fold (Fig. 12.13a). Sept al fat rem oval an d n on in cision su t u re ligat ion for dou ble-eyelid form at ion w as p erform ed. Sym m et ric an d sligh tly h igh er outside folds w ere obser ved after 6 m on th s (Fig. 12.13b).

A 35-year-old fem ale p at ien t presen ted w ith ptosis of th e left eyelid an d an asym m et ric double fold (Fig. 12.14a). Sh e h ad h ad an in cision al dou ble-eyelid op erat ion 1 m on th previously. Tran sconju n ct ival Mü ller t u cking w as don e on th e left side on ly. Th e h eigh t of th e dou ble fold w as n ot ch anged. After 2 w eeks, ptosis of th e left side resolved an d a sym m et ric dou ble fold w as ach ieved (Fig. 12.14b).

a

a

b

b

Fig. 12.13 Case 1. Nonincision suture ligation for double fold formation. (a) This 25-year-old female patient with a low and asym metric double fold wanted a neutral or outside fold and a higher double fold. (b) Six months after septal fat removal and nonincision suture ligation, she has a sym metric and higher double fold.

References

Fig. 12.14 Case 2. Transconjunctival Müller tucking. (a) A 35-yearold female patient with ptosis of the left eyelid and asymmetric double fold. She had an incisional double-eyelid operation 1 month previously. (b) Two weeks after transconjunctival Müller tucking on the left side only, the ptosis of the left side and asymm etry of the double fold have resolved.

pylene im plants used for augm entation of fascial repair in a rat m odel. Gynecol Obstet Invest 2007;63(3):155–162

1. Zide BM, ed. Surgical An atom y aroun d th e Orbit: Th e System of Zon es. Ph iladelph ia, PA: Lip pin cot t , William s & Wilkin s; 2006 2. Most SP, Mobley SR, Larrabee WF Jr. Anatomy of the eyelids. Facial Plast Surg Clin North Am 2005;13(4):487–492, v 3. Fralick FB. An atom y an d physiology of th e eyelid. Tran s Am Acad Op h th alm ol Otolar yngol 1962;66:575–581 4. Reid RR, Said HK, Yu M, Hain es GK III, Few JW. Revisit ing u pper eyelid an atom y: in t roduct ion of th e sept al exten sion . Plast Recon st r Surg 2006;117(1):65–66, discussion 71–72 5. Moy RL, Lee A, Zalka A. Com m only used suture m aterials in skin surgery. Am Fam Physician 1991;44(6):2123–2128 6. Lober CW, Fenske NA. Sut ure m aterials for closing th e skin an d subcut aneous t issu es. Aesth et ic Plast Su rg 1986; 10(4):245–248 7. Spelzini F, Konstantinovic ML, Guelinckx I, et al. Tensile strength and host response towards silk and type I polypro-

8. Ch o IC, Eed. The Art of Bleph aroplast y. Seou l, Korea: Koon ja; 2013 9. Wong JK. A m eth od in creat ion of th e superior palpebral fold in Asian s u sing a con t in uous buried tarsal st itch (CBTS). Facial Plast Su rg Clin North Am 2007;15(3): 337–342, vi 10. Park JW. Non -in cision t ran sconju n ct ival Mu ller t u cking in bleph aroplast y. Arch Aesth Plast Surg. 2012;18:31–34 11. Ah n YJ. Cases of m ild ptosis correct ion w ith su t u re-m eth od. Arch Aesth Plast Surg. 2012;18:15–20 12. Hom m a K, Mu tou Y, Mu tou H, Ezoe K, Fujit a T. In t raderm al st itch bleph aroplast y for orien t als: does it disappear? Aesth et ic Plast Su rg 2000;24(4):289–291 13. Ko RY, Baek RM, Oh KS, Lim JH. Com plicat ion of n on -in cision Orien t al bleph aroplast y: is disappearan ce of th e lid crease a fearful com plicat ion ? J Korean Soc Plast Reconst r Surg 2000;27:199–203

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Double -Eyelid Surgery: Incisional Techniques

Jae Woo Jang

Pearls • Th e East Asian upper eyelid h as several dist in ct

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an atom ic ch aracterist ics, in clu ding a low, poorly de n ed, or absen t eyelid crease; n arrow palpebral ssu re; an d ep ican th al fold. Th e goal of upper bleph aroplast y for th e Asian pat ien t is to m ake eyes fresh , you th ful, an d at t ract ive w h ile m ain t ain ing th eir eth n ic appearan ce by surgically creat ing a suprat arsal crease. Th e in dicat ion s for th e in cision al tech n iqu e are redu n dan t skin , bulky eyelids due to soft t issu e an d fat , disapp earan ce of th e eyelid crease after su t u re or par t ial in cision al tech n ique, an d reoperat ion due to various com plicat ion s after eyelid crease su rger y. Scarring is n ot a p roblem if th e tech n iqu e is delicately perform ed. Th e eyelid crease h eigh t in East Asian s is 6 to 8 m m in fem ales an d sligh tly low er in m ales. A 2- to

■ Introduction Upper lid bleph aroplast y is th e m ost com m on cosm et ic su rgical p rocedu re in East Asia (Korea, Jap an , an d Ch in a). Asian bleph aroplast y, also kn ow n as “dou ble-eyelid surger y,” involves th e su rgical creat ion of a su prat arsal crease. How ever, becau se th e creat ion of a su prat arsal crease does n ot act u ally involve th e form at ion of an oth er eyelid, th e term double eyelid is act u ally a m isn om er.1,2,3 It is gen erally agreed th at ~ 50%of Asian s are born w ith n at urally occu rring u pp er eyelid creases. How ever, for m ost of this populat ion , th e h eigh t of th e double-eyelid crease is low, an d w ell-de n ed double eyelids are presen t in on ly ~ 10% of Asian m en an d 33% of Asian w om en . Th e goal of bleph aroplast y for Asian s, w ith or w ith out related procedures, is fresh , youth ful, an d at t ract ive eyes th at retain th eir eth n ic appearan ce. Th e Asian u pper eyelid h as several dist in ct an atom ic ch aracterist ics, in cluding a low, poorly de ned or absen t eyelid crease; n arrow palpebral ssure; an d ep ican th al fold. Th e u p p er eyelid m argin of a single eyelid in East Asian s is in m ost cases covered by u p p er lid skin . Th erefore, w h en dou ble-eyelid su rger y is p erform ed, th e upper eyelid skin is pu lled upw ard, result ing in an ap paren t in crease in th e size of th e eyes. Dou ble-eyelid su r-

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3-m m pret arsal sh ow, 20 to 30% of th e length of th e in terpalpebral ssure, is opt im al in East Asian s. Th e h eigh t an d sh ape of th e eyelid crease sh ould be in dividualized depen ding on a pat ien t’s eyelid ssu re or ep ican th al fold . Th e favorite t yp es of eyelid creases are th e in side crease an d out side crease— fan t yp e or m ixed t ype—in East Asian s, esp ecially Korean s. Proper rem oval of th e orbicularis m uscle an d orbit al fat is n ecessar y to create a m ore secu re eyelid crease. Som et im es ret ro-orbicu laris orbital fat (ROOF) rem oval is required depen ding on th e pu n ess of th e in dividual’s eyelid. Ap p ropriately design ed d ou ble-eyelid h eigh t an d proper xat ion resu lt in a n at ural an d aesth et ically pleasing double eyelid.

ger y is con sidered by East Asian s to m ake th e eye app ear larger an d m ore aesth et ically pleasing.4 Eyelid crease su rger y is p erform ed n ot on ly for aesth et ic purposes, but also for th e correct ion of problem s su ch as en t rop ion , lash ptosis, p seu d optosis, an d ptosis. Most p at ien ts ten d to w an t th e su rgeon to p erform eyelid crease surger y sim ultan eously w h ile correct ing th ese oth er problem s. W h en pat ien t s w ith bleph aroptosis un dergo eyelid crease surger y, th e p alp ebral ssures becom e w ider an d can create a m ore p leasing eye sh ape.5 It is im p or tan t to recogn ize th at Asian u pp er bleph aroplast y is n ot a Western izat ion procedure, an d th e aim is to create an upper eyelid crease sim ilar to a n at urally occurring on e.

■ Anatomy of the East Asian Eyelid

Th e m ost obvious ch aracterist ics of th e Asian eyelid are th e absen t or ver y low lid crease, an d fuller upper eyelid. Asian eyelids w ith n o lid crease are referred to as “single eyelids.” Alth ough n ot visible, a sm all fold com m on ly exists un der th e overh anging eyelid skin . Cau casian eyelids t yp i-

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13 Double-Eyelid  Surgery:  Incisional  Techniques cally h ave an eyelid crease, but Asian eyelids can be categorized in to th ree t yp es: single eyelid, low eyelid crease, an d d ou ble eyelid. The causes of an absen t or low er crease in an Asian u pp er eyelid in clu de th e follow ing: (1) Th e orbital sept u m fu ses to th e levator ap on eu rosis below th e su perior t arsal border. (2) Preapon eurot ic fat pad prot rusion an d a th ick su bcu tan eou s fat layer preven t levator bers from exten ding tow ard th e skin n ear th e su p erior t arsal border. (3) Th e p rim ar y in sert ion of th e levator apon eu rosis in to th e orbicularis m uscle an d in to th e upper eyelid skin occurs closer to th e eyelid m argin in Asian s (Fig. 13.1).6,7 Asian single eyelids h ave m ore prom in en t subcut an eous and ret ro-orbicularis fat in th e suprat arsal region . Several com pon en t s, su ch as a su bm u scu laris bro-adip ose t issu e layer an d a low er-posit ion ed t ran sverse ligam en t , h ave been iden t i ed an d are fou n d exclu sively in th e Asian eye. Th e prim ar y goal of double-eyelid su rger y is n ot sim ply to create a suprat arsal crease but to create a crease th at is con sisten t w ith th e n at ural con gurat ion presen t in th e gen eral East Asian p op u lat ion .

■ When Should the Incisional Technique for Double -Eyelid Surgery Be Performed?

Th e t ypes of double-eyelid surger y in clude th e sim ple su t u re tech n iqu e, th e part ial in cision al tech n iqu e, an d th e in cision al tech n ique. Th e ch oice of tech n ique is based on pat ien t preferen ce, skin qualit y, an d th e volum e of fat t issue in th e upper eyelid. Th ere are advan t ages an d disadvan t ages to th e in cision al tech n iqu e an d n on in cision al tech n iqu es. Th e advan tages of n on in cision al tech n iques are

a

th at pat ien t s recover m ore quickly w ith n o scarring, w h ile th e disadvan tages in clu de th e in abilit y to rem ove pre-aponeurot ic fat an d soft t issue, w h ich leads to th e disappearan ce of th e dou ble fold. Th e in dicat ion s for th e in cision al tech n ique are (1) redu n dan t skin , (2) bulky eyelid due to soft t issue an d fat , (3) disappearan ce of th e eyelid crease after th e use of a non in cision al sut ure tech n ique or par t ial in cision al tech nique, an d (4) an addit ion al operat ion due to various com plicat ion s after eyelid crease surger y (Fig. 13.2). Th e m ajor disadvan tage to th e in cision al tech n ique is th e long recover y t im e (usually 1 w eek is required to reduce postoperat ive sw elling an d edem a). Scarring is n ot a prob lem w h en th e procedure is perform ed precisely an d delicately. Th e in cision lin e is m ore prom in ent w ith th e part ial in cision tech n ique com pared w ith th e in cision al tech n iqu e because th ere is an apparen t abrupt en ding w ith th e m ore lim ited in cision al m eth od.8

■ Patient Evaluation Most pat ien t s d esire p erm an en t an d n at u ral-looking eyelid creases. At th e in it ial con sult at ion , th e pat ien t’s goals an d exp ectat ion s sh ou ld be iden t i ed. Th e eyelid crease h eigh t usually depen ds on th e in terpalpebral ssure size an d tarsal p late h eigh t . Th e prop er eyelid crease h eigh t in East Asian s is 6 to 8 m m in fem ales an d sligh tly low er in m ales. Th e rst step is to sim ulate th e est im ated eyelid crease in fron t of th e m irror by push ing th e eyelid skin w ith devices such as a forceps, a lacrim al probe, a paperclip, or a w ooden cot ton -t ip ped app licator; th e di eren t sh ap es an d w idth s of th e eyelid crease can be created an d visualized using th ese tools. Th e h eigh t an d sh ape of th e eyelid crease requ ired for a n at ural look sh ould be decided via discussion w ith p at ien t . Sh ou ld th e p at ien t requ est a h eigh t an d sh ape th at d o n ot m atch th e eyelid sh ap e, a m ore th orough explan at ion w ill be required to assist in th e decision m aking p rocess. Som e p at ien t s m ay n ot fu lly express th eir desires, w h ich can m ake th ese cases ver y di cult to m an age. As m en t ion ed previously, m ost Asian s w an t a crease th at is con sisten t w ith th ose th at occur n at urally in th e popu lat ion .

b

Fig. 13.1 Di erences in upper eyelid anatomy bet ween (a) East Asians and (b) Caucasians. In Asians, the orbital septum fuses with the levator aponeurosis below the superior tarsal border. The protruded pre-aponeurotic fat and thick subcutaneous fat layer disturb extension from the levator aponeurotic bers toward the skin.

Fig. 13.2 A t ypical indication for the incisional technique for eyelid crease surgery. The eyelids show pu ness, skin laxit y, and an epicanthal fold in a 25-year-old woman.

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III Blepharoplast y Ptosis of the upper eyelid is assessed by m easuring the palpebral ssure w idth and m argin re ex distance 1 (MRD1, from th e ligh t re ex on th e pat ien t’s corn ea to th e cen t ral upper eyelid m argin). Lash ptosis or dow nw ard angulat ion of the lashes ow ing to relaxat ion of the anterior lam ella of the eyelid should also be noted and corrected during upper lid blepharoplast y.9 Early m yasth en ia gravis sym ptom s are sim ilar to th ose of ptosis an d require a di eren tial diagn osis. Periorbit al fat is im port ant for bleph aroplast y, especially w h en subbrow fat (ret ro-orbicularis orbital fat , or ROOF) is dist ributed up to th e orbital sept u m level an d fu lln ess in th e u p p er eyelid can be seen ; th is is dist ingu ish able from orbit al fat h ern iat ion .7 Th e orbital fat of th e u p p er eyelid is divided in to t w o groups: cen t ral an d m edial. Cen t ral orbit al fat h as a yellow, but ter color, w h ile m edial orbit al fat is w h it ish in color an d is com posed of sm aller lobu les. Blep h arop last y m ay be adapted according to th e qualit y of th e eyelid skin . Th e surgeon w ill con sider eyelid skin th ickn ess (th in or th ick), dehydrat ion of th e skin , an d th e loss of elast ic an d collagen bers, depen ding on th e degree of aging. With a greater degree of aging, bleph aroplast y for th ick eyelid skin requires that th e skin in cision be m ade at a low er level an d th e procedu re n ot involve excessive skin rem oval. Before su rger y, th e pat ien t’s eyebrow shape an d posit ion , th e appearance of th e eyelids an d degree of sagging, an d th e degree of fat bu lging sh ou ld be recorded u sing pain t ings or ph otograph s. Th ese records can also play an im port an t role in resolving any com plain ts or con icts th at m ay occu r follow ing su rger y.

■ What Is the Favorite Type of Double Fold in Asians in Relation to the Medial Epicanthal Fold?

Th e sh ape of an eyelid crease can be ch aracterized as n asally t ap ered, parallel, or sem ilun ar. Asians rarely h ave a sem ilu n ar sh ap e, w h ich is com m on in Cau casian s. Asian s

a Fig. 13.3

w ith a n at ural crease h ave eith er a n asally t apered crease or a parallel crease, as described in various repor t s. Ch en noted th at inside fold an d out side fold are less ap p rop riate term s; h ow ever, in Korean populat ion s, th e in side crease is w ell m atch ed w ith th e n asally tapered crease, bu t th e p arallel crease does n ot exactly m atch th e ou t side fold.2 Th erefore, in th is ch apter, th e au th or w ill u se th e term s inside crease an d out side crease in stead of nasally tapered crease an d parallel crease. 1. Inside crease. A n at u ral, low er crease th at converges tow ard th e m edial can th us an d run s parallel across th e ciliar y m argin , over th e cen t ral port ion , and ares aw ay from th e ciliar y m argin as it app roach es th e lateral can th us (fan t ype) (Fig. 13.3a). 2. Out side crease. Th e crease ru n s fairly p arallel to th e lash m argin from th e m edial can th us to th e lateral can th us. Th e ou tside crease is divided in to th ree t yp es: (a) fan t yp e, (b) fan -p arallel or m ixed t yp e (th e eyelid crease gradually ares aw ay from the lid m argin tow ard th e cen ter port ion an d th en run s parallel to th e ciliar y m argin tow ard th e lateral can th us), an d (c) parallel t ype (th e crease run s at th e sam e w idth from th e m edial to th e lateral can th u s) (Fig. 13.3b,c). Usu ally an in side crease becom es a fan t yp e an d an ou tside crease becom es a fan , fan -parallel, or p arallel t yp e. In gen eral, th ere is a greater ten den cy to create an in side crease th an an out side crease in pat ien ts w ith a st rong m edial ep ican th al fold. Th e in side fold is con sid ered to be m ore n at u ral an d con ser vat ive, w h ereas th e ou t side fold is con sidered to be m ore m odern an d outgoing. Alth ough th e h igh er ou t side-crease eye w as on ce t ren dy, it is u n n at u ral-, art i cial-, an d Western -looking (Fig. 13.4), East Asian s, esp ecially Korean s, p refer th e in side crease an d ou tsid e crease fan t ype or out side crease m ixed t ype. Moreover, it is n ow un com m on for East Asian s to ch oose a sem ilun ar crease like th at of Caucasian s. It is reported th at ep ican th al folds are fou n d in 50 to 80% of Sou th Korean s. Due to th e epican th al fold, in 70% of eyelids th e caru n cle an d lacrim al lake are n ot overtly vis-

b

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Variations of East Asian creases. (a) Inside crease. (b) Outside crease, fan t ype. (c) Outside crease, parallel t ype.

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13 Double-Eyelid  Surgery:  Incisional  Techniques

Fig. 13.5 Webbing of the crease. Webbing is noted at the medial canthus because the outside crease was m ade without epicanthoplast y. Fig. 13.4 The higher outside crease. The high outside creases may look cool, but they also look unnatural, arti cial, and Western.

ible. Th e sh ap e of th e eyelid crease dep en ds on th e h eigh t , th e degree, an d th e sh ape of th e epican th al folds. Th e eyelid crease m ay be t w o lin es at th e m edial can th us an d be operat ive in ap p earan ce if th e out side crease is m ade w ith out m edial ep ican th oplast y (Fig. 13.5). To m ake eyes larger an d m ore at t ract ive, m edial ep ican th oplast y is recom m en d ed at th e sam e t im e as th e dou ble-eyelid surger y, especially for m od erate to severe ep ican th al folds.

What Is the Best Height of the Double Eyelid?

it y of th e supratarsal skin draping th e crease an d pretarsal skin (Fig. 13.6b).11 Th e am ou n t of redu n dan t skin excision depen ds on th e pre-determ in ed pret arsal sh ow w h en th e in cision al tech n ique is perform ed. Even th ough design ed at th e sam e h eight as th e eyelid crease, th e h eigh t of th e crease is determ in ed according to th e am oun t of skin . If th e am ou n t of excised skin is large, th e eyelid crease w ill be h igh after eyelid crease su rger y. Th e dou ble-eyelid crease can be created w ith or w ith out a pret arsal sh ow by m an aging th e excised am oun t of th e skin as per th e pat ien t’s desires.

■ Surgical Techniques

Th e eyelid crease h eigh t usually depen ds on th e in terpalpebral ssure size an d t arsal plate h eigh t . Th e eyelid crease h eigh t of East Asian s is 6 to 8 m m in fem ales and sligh tly low er in m ales. In pat ien t s w ith a large in terpalpebral ssu re or th in eyelid skin , m aking a h igh er-set eyelid crease is bet ter. Oth er w ise, a low er-set eyelid crease is preferable for pat ien t s w ith a sm all in terpalpebral ssure. Eyeball p rot ru sion an d ver t ical/h orizon t al in terp alp ebral ssures are im port an t for determ in ing th e h eigh t of th e eyelid crease. If th e h orizon t al ssure of th e eye is sm all, th e h igh eyelid crease w ill appear un n at ural an d art i cial. A h igh er eyelid crease looks n at u ral in pat ien t s w ith a large h orizon tal ssu re of th e eye. How ever, h igh eyelid creases do n ot look n at ural in pat ien ts w ith th ick eyelid skin an d a large am ou n t of p ret arsal soft t issue. East Asian s often h ave prot ruding eyeballs; a h igh eyelid crease is st rong-looking in th ese cases. With regard to Asian eyelid creases, th e crease is part ially covered by th e fold of skin th at overlays it . Th e w idth of th e eyelid crease during eye open ing is called th e pretarsal sh ow (Fig. 13.6a).10 Th e h eigh t of th e eyelid crease (or design ed incision al lin e) is determ in ed from th e pret arsal sh ow. Th e p ret arsal sh ow in East Asian s is opt im al at ~ 2 to 3 m m or 20 to 30% of th e in terpalpebral ssure, but it m ay depen d on th e h eigh t of th e supratarsal fold an d th e lax-

Design of the Double -Eyelid Crease Th e m eth od for deciding th e heigh t of th e eyelid crease h as been described as follow s in previous repor ts. Th e upper lid is everted an d th e vert ical h eigh t of th e t arsus over th e cen t ral por t ion of th e lid is m easured using calipers. Th e poin t is m arked at th e sam e h eigh t as th e extern al eyelid skin . Th e au th or does n ot usually use calipers, but rath er determ in es th e n at u ral crease by sim p ly p u sh ing th e eyelid w ith a cot ton -t ipp ed ap p licator. In gen eral, a h igh -set crease m akes an ou tsid e crease, w h ereas a m oderate- to low -set crease m akes an in side crease. Th e sh ape of th e eyelid crease depen ds on th e epican th al fold. Th ere is a greater ten den cy to create an in side crease in pat ien t s w ith an epican th al fold. If a larger an d m ore pleasing eyelid crease is sough t , m edial epican th op last y is u su ally don e sim u ltan eously during eyelid crease surger y. After th e sh ape an d h eigh t of th e eyelid crease h as been determ in ed, th e proposed crease is m arked w ith a m arking pen or th e sh aved-o t ip of a cot ton -t ipped applicator dipped in gen t ian violet . Th e upper in cision lin e is m arked according to th e skin la xit y on a 1- to 2-m m st rip w ith ou t skin laxit y (Fig. 13.7). Th e m ed ial th ird of th e in cision lin e is m arked such th at it tapers tow ard th e m edial can th al area or m erges w ith th e epican th al fold . Th e lateral th ird

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Supratarsal crease Pretarsal show (width of double eyelid) Double eyelid fold x a

y z

Fig. 13.6 Pretarsal show. (a) The width of the eyelid crease during eye opening. (b) The pretarsal show depends on m anaging the amount of skin excised using the incisional technique: height of incision line (x) = 6–8 mm; pretarsal show (y) = 2 mm ; amount of skin excision is z × 2.

is u su ally m arked in a leveled or are con gu rat ion . Th e m arkings on th e opp osite eye sh ou ld be design ed to be as sym m et rical as p ossible.

Anesthesia Usually, surger y is perform ed un der local an esth esia. A m ixt ure of 2% lidocaine (Xylocaine, AstaZeneca) at a 1:100,000 dilut ion of epinephrine is com m only used. W hen a surgeon w an ts to use hyaluron idase, 10 m L of 2% lidocain e con tain ing a 1:100,000 dilution of epin eph rine is m ixed w ith 150 units of hyaluronidase. Hyaluronidase prom otes an esthetic dispersion and tissue perm eabilit y, w hich facilitates th e e ects of th e an esth etic an d redu ces th e am ou n t of an esthetic required. If the operation t im e is long, a 50:50 m ixt ure of 2% lidocaine and 0.5% or 0.75% bupivacaine is used. The anesthet ic is slow ly injected to reduce pain. Care is

b

taken to inject the anesthet ic solut ion only in the super cial area of th e orbicu laris oculi m u scle to avoid th e occu rren ce of a hem atom a due to m uscle injur y. To avoid bleeding, light pressure is applied to th e area w h ere th e needle en ters th e skin . Th e su rgeon takes care to adm in ister th e an esth et ic solution th rough out th e proposed lesion of in cised skin .

Skin Incision Th e in cision is m ade w ith a n o. 15 surgical blade (BardParker, Asp en Su rgical) along th e u pp er an d low er lin es. To reduce bleeding, a CO2 laser or radiofrequen cy w ave can be used on th e skin incision (Fig. 13.8a). Th e st rip of skin is excised w ith scissors or m on op olar cau ter y w ith a Colorado n eedle t ip (St r yker) just below th e subcut an eous plan e, th rough out th e plan ned in cision lin e.

Removal of Skin and Orbicularis Muscle

Fig. 13.7 Eyelid crease design and marking. The upper incision line is marked according to skin laxit y on a 1- to 2-mm strip without skin laxit y.

Th e orbicularis m uscle is excised togeth er w ith th e skin by th e st rip of m yocut an eous ap or excised after th e skin rem oval. Elevat ing th e skin w ith forceps can protect th e orbit al sept um from iat rogen ic dam age during th e excision . Excessive debulking of the orbicularis m uscle is n ot usually recom m en ded. Som e orbicu laris m u scle sh ou ld be left arou n d th e u p p er skin ap as a t rip le fold is com m on ly seen w h en th e en t ire orbicularis m uscle is rem oved aroun d th e upper skin ap (Fig. 13.8b).

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13 Double-Eyelid  Surgery:  Incisional  Techniques Fig. 13.8 Skin incision and orbicularis removal. (a) Skin incision with a CO2 laser. (b) Some orbicularis muscle (arrow) should be left around the upper skin ap to prevent a triple fold.

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If p ret arsal soft t issu e is abu n dan t , it s rem oval is n ecessar y to create ad equ ate ad h esion s. Care sh ou ld be t aken n ot to in cise th e tarsu s u pp er m argin to preven t dam age to th e term in al in terdigit at ion of th e levator apon eurosis w h en excising th e p retarsal soft t issu e. Excessive rem oval of p retarsal soft t issue m ay result in t igh t adh esion bet w een th e skin an d t arsu s, w h ich m ay lead to a st at ic dou ble-eyelid crease. If th ere is n ot su cien t pret arsal soft t issue in th e h igh eyelid crease, an ad dit ion al op erat ion su rger y from a h igh to low crease is ver y di cu lt an d t ricky.

Removal of Orbital Fat and ROOF The orbital sept um can easily be distinguished from th e prot ruded pre-aponeurotic fat by pressing th e eyeball gen tly w hen the eyes are closed. The upper eyelid should be ret racted t ightly anteriorly and slightly dow nw ard w hile forceps apply counter-t ract ion to tense the orbital sept um . The exposed orbital sept um is pen etrated by the tip of the scissors or Colorado n eedle to create a w in dow an d th e preapon eurotic fat is exposed th rough th e open ing (Fig. 13.9a). The orbital sept um is divided m edially and laterally w ith scissors or by cau ter y to expose th e levator apon eurosis an d pre-apon eurotic fat . Yellow ish central pre-aponeurot ic fat is obser ved w hen the orbital sept um is open ed. Th e fat p ad is grasp ed w it h a h em ost at an d excised across a closed h em ost at . Bleed in g is con t rolled to t h e en d of t h e excised fat p ad by en su r ing t h at t h e h em ost at is n ot loosen ed . Th e clam p is loosen ed on ly after ad equ ate h em ost asis. If a CO2 laser is u sed , t h e fat p ad is excised w it h ou t t h e h em ost at (Fig. 13.9b). To rem ove t h e m ed ial

a

fat p ad , t h e orbit al sept u m is in cised m ed ially. Th e color of t h e p rot r u d ing fat is m ore w h it ish t h an t h at of t h e cen t ral fat p ad . W h en rem ovin g t h e n asal fat p ad , care is t aken n ot to dam age t h e ar ter ies t h at are r u n n ing m ed ially, or t h e ar ter ies sh ou ld be cau ter ized in advan ce to avoid bleed in g. Su p p lem en t ar y local an est h esia inject ion is n eed ed for p ain con t rol before rem ovin g t h e n asal fat p ad . It is im p or t an t to rem ove t h e sam e am ou n t of fat p ad from each eye. Som et im es lateral-h alf ROOF rem oval is n ecessar y in pat ien t s w ith th ick redun dan t t issues even after rem oving th e pre-apon eu rot ic fat (Fig. 13.9c). Care sh ou ld be t aken not to rem ove th e ROOF th at is close to th e m uscle. Excessive rem oval of fat or th e pret arsal orbicularis m u scle along th e low er in cision lin e can cau se m u lt iple folds in you ng pat ien t s after th e in cision al eyelid crease su rger y. Th e su rgeon m ay t ap e th e fold or inject absorbable ller in m in or cases (Fig. 13.10).

Low er-Positioned Transverse Ligament The low er-positioned t ransverse ligam ent (LPTL) is the oth er tran sverse ligam en t in th e upper eyelid, w ith less elasticit y th an W hitnall’s ligam ent. It origin ates from the anterior su rface of th e t roch lea, exten ds in ferolaterally tow ard the w hite lin e, and is re ected onto the orbital sept um , inserting into the lateral orbital rim . The LPTL is th ought to prevent eyelid opening, and severing this ligam ent allow s furth er excu rsion of th e u pper eyelid an d is recom m en ded w h en perform ing eyelid crease surger y (Fig. 13.11).12,13

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Fig. 13.9 Opening of the septum and fat removal. (a) Tenting of the orbital septum during opening is necessary for preventing damage to the levator aponeurosis. After opening the septum, the glistening levator aponeurosis is seen under the orbital fat. (b) Orbital fat is removed with a CO2 laser. (c) Descended ROOF can be removed if desired.

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Fig. 13.10 Triple fold. (a) The triple fold occurred after eyelid crease surgery due to excessive orbicularis muscle excision. (b) The triple fold was managed by hyaluronic acid ller.

Fig. 13.11 Lower-positioned transverse ligament or LPTL (arrow). Severing this ligament helps further excursion of the upper eyelid and is recommended when performing eyelid crease surgery.

Fixation Suture of the Eyelid Crease Th e m eth ods for xat ion of th e eyelid crease depen d on th e surgeon’s preferen ce an d in clude (1) skin -levator-skin , (2) skin -t arsu s-skin , (3) levator apon eurosis to th e in ferior su bcu tan eou s p lan e (or orbicu laris m u scle), an d (4) t arsal plate to th e in ferior subcu tan eous plan e.13 Eyelid crease xat ion is perform ed eith er extern ally or in tern ally u sing 6–0 or 7–0 nylon or Prolen e (Eth icon ). In th e in tern al xat ion m eth od, th e 7–0 nylon or Prolen e is passed th rough th e subderm al t issue an d xed to th e tarsal plate or levator apon eu rosis; th e su t u re is t ied an d th en th e kn ot s are bu ried. In th e extern al xat ion m eth od, 6–0 nylon or Prolen e is passed th rough th e edge of th e low er skin in cision to th e t arsu s or levator ap on eu rosis, exit ing th rough th e edge of upper skin in cision .14 Th ere is n o differen ce in p erm an en ce or con t in u it y bet w een th ese m eth ods, bu t th e auth or prefers th e skin -levator-skin xat ion tech n iqu e (Fig. 13.12). Usu ally, th ree xat ion su t u res are requ ired, bu t in th e au th or’s pract ice m ore xat ion sut ures are p laced on each side to p reven t late obliterat ion . Th e xat ion su t u re to th e tarsus can result in a st rong eyelid an d a clearly visible crease during closing of th e eyes. In in tern al xat ion to th e t arsu s or levator ap on eu rosis, if th e eyelid

skin is th in , th e bu ried kn ot s m igh t be visible th rough th e skin . In m aking th e low eyelid crease, xat ion to th e t arsal plate can be m ore e ect ive th an xat ion to th e levator apo neurosis. Excessively h igh bite along th e levator apon eu rosis result s in a deep crease w ith lift ing of th e eyelash es due to th e pulling-up act ion of th e skin . Th is can produce a st rong im p ression an d m ake a su n ken groove w h en th e pat ien t closes th e eyes. If th e pat ien t h as proptosis, th e su rgeon n eeds to avoid creat ing a deep crease. Conversely, too low xat ion com p ared w ith th e design ed crease h eigh t can cau se w rin kles an d bulging (Fig. 13.13). Th e prom in en t depression or n otch ing w ill occur if th e in tern al or extern al xat ion s to th e levator ap on eu rosis are n ot ap prop riate an d are too h igh com p ared w ith oth er xat ion s. Appropriate eyelid crease xat ion can correct th e eyelash direct ion in pat ien t s w ith lash ptosis an d en t ropion . Th e degrees of lash direct ion sh ould be adjusted du ring th e xing of th e su t u res. In East Asian s, a h igh er xat ion w ith a low -d esign ed eyelid crease can p rodu ce m ore eversion of th e eyelash es. Th is m ay bring about an an atom ically in ap propriate or aesth et ically un desirable eyelid crease an d poor cosm et ic result . It is preferable to correct th e eyelash direct ion at ~ 90°. An appropriately design ed eyelid crease heigh t an d proper xat ion w ill resu lt in a n at ural an d aesth et ically pleasing double eyelid.

Fig. 13.12 Fixation suture for the eyelid crease and the skin closure. The wound is closed in skin-levator-skin xation fashion.

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13 Double-Eyelid  Surgery:  Incisional  Techniques

Fig. 13.13 Skin bulging after upper blepharoplast y. Too-low xation rather than the designed crease height can cause skin bulging.

Fig. 13.14 Interrupted skin closure was performed with 6–0 nylon sutures. In general, Asians require a higher number of sutures than Caucasians.

Skin Suture After xation of the eyelid crease, the eyelid skin suture is perform ed w ith a ne suture after con rm ation of complete hem ostasis. In Korea, the interrupted or continuous suture w ith 6–0 nylon or 6–0 fast-absorbing sutures are com m only used. The skin of Asians is di erent from that of Caucasians, w ith the form er requiring a greater num ber of sutures (Fig. 13.14).

Levator Advancement or Ptosis Correction In East Asia, w hen a patient w ith norm al levator function and w ithout pathologic ptosis desires the appearance of a larger eye, levator aponeurosis advancem ent or levator aponeurosis plication are com m only perform ed sim ultaneously during double-eyelid surgery.1 However, the e ect of plication of the levator is not predictable and disappears at long-term follow up. After dissection of the levator aponeurosis, the am ount of aponeurosis advancem ent is decided by observing the eyelid level and degree of sym m etry in the seated position. In asym m et ric or u n ilateral ptosis, th e h eigh t of th e eyelid crease sh ou ld be a lit tle less th an th at for a n orm al eyelid. In bilateral ptosis, th e h eigh t of th e eyelid crease is 1 or 2 m m less th an the n orm al 6 to 8 m m .5 If you do n ot

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carr y out full ptosis correct ion , it is bet ter n ot to m ake an eyelid crease. Oth er w ise, th e eyelid crease m ay be ver y h igh or fain t , giving th e appearan ce of sleepy eyes, w h ich is n ot aesth et ically accept able. Fu ll ptosis correct ion is m an dator y before eyelid crease su rger y (Fig. 13.15).

■ Key Technical Points 1. In gen eral, a h igh -set crease m akes an ou tside crease, w h ereas a m oderate- to low -set crease m akes an in side crease. Th e sh ape of th e eyelid crease also depen ds on th e epican th al fold; th ere is a greater ten den cy to create an in side crease in pat ien t s w ith an epican th al fold. Th e creat ion of out side crease fan -t ype or m ixed-t ype lids requires th e m odi cat ion or rem oval of th e ep ican th al fold . 2. Th e pret arsal sh ow in East Asian s is opt im al at 2 to 3 m m or 20 to 30% of th e in terpalpebral ssu re. Th e am ou n t of redu n dan t skin excision depen ds on th e pre-determ in ed pret arsal sh ow. 3. Appropriately design ed eyelid crease h eigh t an d proper xat ion result in a n at ural an d aesth et ically pleasing double eyelid.

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Fig. 13.15 The asymmetric eyelid crease after a nonincisional technique due to the missed ptosis. (a) The preoperative photo. (b) The right eyelid crease is high compared with the left eyelid crease after the nonincisional technique because blepharoptosis was missed. (c) After levator advancement of the right eye, the eyelid creases are symmetric.

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■ Postoperative Management After th e op erat ion , th e w ou n d is clean ed daily an d an t ibiot ic eye oin t m en t is applied for 3 w eeks. Th e pat ien t is in st ru cted to con t in ue ice com pression to reduce sw elling an d ecchym osis for 24 to 48 h ou rs after su rger y. Th e u se of oral an t ibiot ics for 3 days is usually n ot n ecessar y, but is often don e for th e preven t ion of un even tful in fect ion . Su t u res are rem oved w ith in 5 to 7 days dep en ding on th e su t u re m aterial. Eye m akeu p m ay be u sed after 2 w eeks. Som et im es a scar-redu cing oin t m en t (e.g., Con t rat u bex, Merz) or oral d rug (Rizaben capsu le, Kissel Ph arm aceu t ical) is u sed to preven t scarring after in cision su rger y in Korea.

■ Complications and Their Management

Asymmetry A com m on ly occu rring com p licat ion after dou ble-eyelid su rger y is asym m et r y, w h ich is cau sed by design fau lt , asym m et ric skin resect ion , asym m et ric fat rem oval, di eren t xat ion h eigh t of levator ap on eu rosis or t arsu s to create a dou ble-eyelid crease, or di eren ces in adh esion bet w een su bcu tan eou s t issu e an d levator ap on eu rosis. Th erefore, a su rgeon m u st alw ays keep in m in d th e variou s factors th at m ay cau se asym m et r y du ring th e op erat ion .

sion al m eth od, w h ich requ ires de-bu lking of th e fat an d un derlying soft t issue; th e surgeon m ust th en t igh tly su t u re th e levator apon eu rosis an d skin w ith m u lt iple kn ots. If th e pat ien t previously un der w en t th e in cision al m eth od, th e surgeon can con duct th e n on in cision al m eth od or th e in cision m eth od, w h ich requ ires st rong adh esion by t igh t xat ion su t u res. If th e p at ien t h as m ild ptosis, levator ap oneurosis advan cem en t sh ould be con du cted w ith th e dou ble-eyelid su rger y.

High or Low Eyelid Crease If t h e eyelid crease is too h igh , an u n n at u ral crease is m ad e, an d if t h e d ou ble eyelid is too low , th e crease m ay be u n clear. For low crease cor rect ion , creat ing a n ew fold above t h e p reviou s low crease is n eed ed . In th e case of a h igh fold , if th ere is en ough rem ain ing skin , t h e su rgeon w ill decide th e n ew crease h eigh t an d th en excise t h e skin toget h er w ith th e p reviou s in cision lin e. How ever, if th ere is n ot en ough skin , a fu ll-th ickn ess skin graft cou ld be n eeded. Du r ing th e operat ion , su rgeon s ten d to avoid m aking t h e h igh crease at t h e sam e level as is p revalen t in Western pract ice becau se correct ion su rger y from a h igh to a low crease is m ore com plex an d th e su rgical resu lt s are som et im es u n d esirable. An ad d it ion al op erat ion to cor rect a h igh ou t side crease to a low ou t side crease or in side crease is ver y di cu lt .

■ Case Studies Disappearance of the Eyelid Crease Th e fading or disappearan ce of th e eyelid crease is caused by in correctly xed su t ures from th e subderm al t issu e below th e skin in cision to th e levator apon eu rosis or tarsus, or by u n stable xat ion du e to postoperat ive h em atom a. Th is con dit ion is m ore com m on w ith sut ure tech n iques th an w ith th e in cision al tech n ique. If th e pat ien t h as previou sly u n d ergon e th e n on in cision al m eth od, th e su rgeon can perform th e n on in cision al m eth od again or th e in ci-

Case 1: Correction from the Short Inside Crease to the Outside Crease A 22-year-old w om an visited th e au th or’s clin ic for eyelid crease surger y (Fig. 13.16a). Sh e w an ted an ou t side crease. Sh e h ad a low an d sh or t in side crease in both eyes. In cision al blep h arop last y w ith m edial epican th op last y w as perform ed. After eyelid crease surger y, th e in side crease ch anged to an ou tside crease (Fig. 13.16b).

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13 Double-Eyelid  Surgery:  Incisional  Techniques

a

b

Fig. 13.16 Case 1. From the short inside crease to the outside crease with the incisional technique. (a) The preoperative photo revealed a short inside fold in both eyes. (b) The patient had an outside fold after the incisional technique with medial epicanthoplast y.

Case 2: Correction from High Crease to Low Crease A 22-year-old w om an visited th e au th or’s clin ic becau se of eyelid creases th at w ere too h igh (Fig. 13.17a). Sh e h ad u n dergon e eyelid crease su rger y via th e n on in cision al tech n iqu e 4 w eeks previously. Sh e w as ver y un h appy an d

a

c

w an ted to h ave a low er eyelid crease. First , th e au th or rem oved all of th e buried sut ure m aterials th at could preven t or redu ce th e adh esion . After 3 m on th s, th e righ t eyelid crease disappeared an d th e left h igh eyelid crease rem ain ed (Fig. 13.17b). Good, n at u ral-looking in side creases w ere m ade in an add it ion al operat ion u sing th e in cision al tech nique after 6 m on th s (Fig. 13.17c).

b Fig. 13.17 Case 2. From the high crease to the low crease with the incisional technique. (a) The high eyelid creases were made after nonincisional eyelid crease surgery. (b) The right eyelid crease disappeared and the left high eyelid crease still remained 3 months after removal of buried suture materials. (c) Good, natural-appearing inside creases were created after an additional operation with the incisional technique.

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References 1. Lee CK, Ah n ST, Kim N. Asian upper lid bleph aroplast y surger y. Clin Plast Su rg 2013;40(1):167–178 2. Ch en W PD, Park JDJ. Asian upper lid bleph aroplast y: an u pdate on indicat ion s an d tech n iqu e. Facial Plast Surg 2013;29(1):26–31

8. Lam SM, Karam AM. Suprat arsal crease creat ion in th e Asian u p p er eyelid . Facial Plast Su rg Clin Nor th Am 2010; 18(1):43–47 9. Lee TE, Lee JM, Lee H, Park M, Kim KH, Baek S. Lash ptosis an d associated factors in Asian s. An n Plast Surg 2010;65(4):407–410

3. Kang DH, Koo SH, Ch oi JH, Park SH. Laser bleph aroplast y for m aking dou ble eyelids in Asian s. Plast Recon st r Surg 2001;107(7):1884–1889

10. Park JI, Toru m i DM. Dou ble eyelid op erat ion : orbicu larislevator xat ion tech n iqu e. In : Park JI, Toru m i DM, eds. Asian Facial Cosm et ic Su rger y. Ph iladelp h ia, PA: Elsevier Saun ders; 2007:49–59

4. Scaw n R, Josh i N, Kim YD. Upper lid blepharoplast y in Asian eyes. Facial Plast Su rg 2010;26(2):86–92

11. Flow ers RS. Asian blep h arop last y. Aesth et Su rg J 2002; 22(6):558–568

5. Park DH, Kim CW, Shim JS. Strategies for sim ultaneous double eyelid blepharoplast y in Asian patients w ith congenital blepharoptosis. Aesthetic Plast Surg 2008;32(1):66–71

12. Kakizaki H, Malh ot ra R, Selva D. Up per eyelid an atom y: an u pdate. An n Plast Surg 2009;63(3):336–343

6. Jeong S, Lem ke BN, Dort zbach RK, Park YG, Kang HK. Th e Asian u p per eyelid: an an atom ical st u dy w ith com parison to th e Cau casian eyelid . Arch Op h th alm ol 1999;117(7): 907–912

13. Ban M, Mat su o K, Ban R, Yu zu rih a S, Kan eko A. Develop ed low er-posit ion ed t ran sverse ligam en t rest rict s eyelid opening an d folding an d determ in es Japan ese as being w ith or w ith out visible superior palpebral crease. Ep last y 2013;13:e37

7. Saonanon P. Update on Asian eyelid anatom y and clinical relevance. Curr Opin Ophthalm ol 2014;25(5):436–442

14. Wong JK. Aesth et ic su rger y in Asian s. Cu rr Op in Otolar yn gol Head Neck Su rg 2009;17(4):279–286

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14

Aging -Related Upper Blepharoplasty

Hokyung Choung and Namju Kim

Pearls • Un derstan ding an atom ic di eren ces an d

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• Many aged p eop le w h o w an t blep h arop last y m ay

involu t ion al ch anges in th e eyelids of East Asian s, w h ich are speci c to age an d gen der, is th e key to ach ieving opt im al resu lt s. Too m uch is as unw elcom e as too lit tle. Th e t ren d in Asian aging-related bleph aroplast y is tow ard con ser vat ive excision of skin an d fat , m aking a n at u ral-looking, low -posit ioned dou ble eyelid (or n ot m aking an art i cial double eyelid). It is im port an t to h ave a realist ic u n derstan ding of th e outcom e of bleph aroplast y th rough an in -depth d iscussion bet w een th e surgeon an d th e pat ien t before su rger y. Th e goal of aging-related bleph aroplast y is to restore th e in dividual’s you th fu l ap p earan ce w h ile ret ain ing th e eth n ic ch aracterist ics. Th is is especially t rue in th e case of t reat ing th e Asian upper eyelid. Th e upper crease is usually low or absen t in th e Asian eyelid. Sligh tly folded upper eyelid skin over th e double-eyelid crease, or a low double-eyelid crease (e.g., 3–4 m m in h eigh t) looks m ore n at ural an d blen ds w ell. Usu ally, a dou ble-eyelid crease over 7 to 8 m m in h eigh t looks ver y un n at ural in Asian s, even in fem ale pat ien t s. Brow ptosis usually occurs after m iddle age, an d derm atoch alasis an d bleph aroptosis m ay appear accen t u ated d u e to brow ptosis. Th erefore, th e su rgeon m u st recogn ize brow ptosis before su rger y an d decide w h eth er to p erform a brow lift in advan ce or do it in conjun ct ion w ith th e bleph aroplast y.

■ Introduction East Asian s are th e w orld’s largest eth n ic group, an d th e eyelids’ posit ion in th e cen ter of th e face is a dist inguish ing feat u re an d m akes a st rong im pression . Blepharoplast y is th e m ost com m on an d a rapidly grow ing cosm et ic su rger y procedure in Asia. Un derstan ding an atom ic di eren ces related to eyelid surger y is th e key to ach ieving opt im al result s. A t ypical Asian eyelid is a single eyelid w ith an ep ican th al fold or Mongoloid slan t . Im p roving a p at ien t’s

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have bleph aroptosis of som e degree but m ay not be aw are of it becau se it is con cealed by th e derm atoch alasis. If the patient com plains of ocular irritation sym ptom s, problem s w ith tear secretion such as dry eye syndrom e could be present. The surgeon should m ake the patient understand that ocular irritation m ay be aggravated after blepharoplasty and that such problem s need to be m anaged before blepharoplasty. Th e m ost di cult cases of aging-related bleph aroplast y in Asian s involve pat ien ts w h o h ad un dergon e previous bleph aroplast y w ith excessive skin an d fat rem oval, w ith a ver y h igh -posit ion ed double-eyelid crease. In th ese cases, au tologous fat or ller inject ion along th e brow an d upper eyelid com plex is m ore h elpfu l in im proving th e cosm et ic outcom e th an a bleph aroplast y. Th e lacrim al glan d is located laterally just beh in d th e orbit al rim , an d n orm ally it is n ot seen during bleph aroplast y. With aging it prolapses, w h ich m igh t be m istaken for lateral fat p rolapse, especially in Asian pat ien t s w h o have th ick skin over the lacrim al glan d. Com plicat ion s after aging-related bleph aroplast y are usually th e result of excessive skin or fat resect ion , lack of h em ostasis, an in adequate preoperat ive assessm en t , or careless postop erat ive m an agem en t . Ever y e or t sh ou ld be m ade to m in im ize or preven t com plicat ion s du ring or after bleph aroplast y by recogn izing kn ow n risk factors an d paying careful at ten t ion during an d after surger y.

ap pearan ce w h ile m ain t ain ing th e p erson’s eth n ic ch aracterist ics is th e goal of Asian eyelid su rger y.1 Th e goal of aging-related bleph arop last y is to restore th e in dividual’s you th fu l ap p earan ce, n ot to create a m orph ologic ch ange th at brings a novel look. Th is is especially t rue in th e case of t reat ing th e Asian upper eyelid. Loss of eth n ic iden t it y can result in a n egat ive react ion both from th e pat ien t as w ell as from h is or h er frien d s an d fam ily.2 In th e p ast it w as gen erally accepted th at Asian pat ien t s w an ted to h ave dou ble eyelids to p roject a m ore Western ap pearan ce, w h ich th ey fou n d m ore at t ract ive. How ever,

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III Blepharoplast y th e t ren d th ese days in Asian aging-related bleph aroplast y is tow ard con ser vat ive excision of skin an d fat , giving a n atu ral-looking, low -posit ion ed double eyelid an d n ot creat ing an art i cial-app earing dou ble eyelid. Now adays m ost aging Asian pat ien t s w an t to restore th eir youth ful appearan ce but at th e sam e t im e ret ain th eir eth n ic characterist ics, n ot Western ize th eir eyelids, th rough bleph aroplast y su rger y. Periorbit al ch anges w ith aging in clude derm atoch alasis, crow ’s feet , an d p eriorbit al fat p rolap se, an d th ese lead to ch anges in eyelid con tou r. Th e goal of blep h arop last y in aging p at ien t s is to correct th ese processes an d to allow th e pat ien t to look younger. Bleph aroplast y in elderly people is m ostly in cisional bleph aroplast y. To im prove th e periorbital w rin kles or superior h ollow n ess, ller or bot ulin um toxin inject ion s m ay follow. Periorbit al ch ange w ith aging is a dyn am ic process involving th e aging of facial t issu e an d bony st ruct ures, an d several ch anges are com m on . Epiderm al th in n ing an d decreased collagen cau se th e skin to lose it s elast icit y. Loss of fat , coupled w ith gravit y an d m uscle pull, leads to w rin kling an d th e form at ion of dyn am ic lin es. Th e aging process h as also been sh ow n to a ect facial bon es. Mult iple st udies suggest that bon e aging of th e orbit an d m idface occu r p rim arily du e to con t ract ion an d m orph ologic ch anges. Th is loss of bony volum e an d project ion m ay con t ribute to th e aged appearan ce. Th e e or t to u n derst an d each pat ien t’s in dividual involut ion al ch anges, w h ich are speci c to age an d gen der, is m an dator y. Th erefore, id en t ifying th e pat ien t’s person al n eeds an d select ing th e righ t t reat m en t accordingly is crucial for ach ieving th e best outcom e both for th e clin ician an d for th e pat ien t .3 The eyelid is im portant not on ly in its funct ional aspects such as tear distribut ion from blin king, but also in its cosm etic aspects because it greatly a ects other people’s im pressions by de ning one’s facial characteristics. The drooped brow an d eyelid skin can obscure one’s view and look heavy, and lateral eyelid skin can be folded and thus cause eczem a.4 Th e eyelid becom es pu y due to the prolapse of orbital fat from the loosening of the orbital sept um . Blep h aroptosis refers to d roop ing or in frat ran sp osit ion of th e u p per lid. Th e m ost com m on t ype of acqu ired

a

ptosis resu lt s from st retch ing or w eaken ing of th e levator palp ebralis du e to involu t ion al ch ange or disin ser t ion of th e levator apon eu rosis from th e t arsal plate. It cau ses n ot on ly cosm et ic p roblem s bu t also visu al d iscom for t su ch as obscu rin g th e view. Alt h ough th e su p erior visu al eld is p rim arily involved , m any p at ien t s com p lain of d ifcu lt y w it h read ing becau se th e ptosis is aggravated w it h dow n -gazing. Park et al rep or ted th at Korean s age 50 years or older sh ow ed a ver y h igh frequ en cy (54.9%) of ptosis, an d as th e age in creases, t h e frequ en cy of ptosis also in creases.5 Th e exam in er sh ou ld n ote t h e p at ien t’s h ead p osit ion , ch in -u p p osit ion , or brow p osit ion to d etect th e p resen ce of ptosis. Pat ien ts often involu n tarily at tem pt to com pen sate for derm atochalasis by ch ron ic u se of th e fron t alis m uscle an d th is can lead to h igh -posit ion ed eyebrow an d deep (prom in en t) t ran sverse fu rrow s in th e foreh ead (Fig. 14.1). Un like oth er areas of th e body, w h ere th ere is descen t of soft t issu es, th ere m ay be p aradoxical elevat ion of eyebrow s w ith aging, especially th e m edial an d m idbrow. So th e clin ician sh ou ld t r y to determ in e th e eyebrow m orp h ology an d posit ion of th e in dividu al pat ien t an d select ively elevate th e lateral brow to h ave a rejuven at ing e ect on th e upper th ird of th e fem ale face.6 On th e oth er h an d, brow ptosis frequ en tly accom p an ies derm atoch alasis, an d th e pat ien t can be over-diagn osed as h aving ver y severe droop ing of th e u pp er eyelid skin an d excessive excision of skin w ith su bsequ en t fu rth er dragging of th e eyebrow dow nw ard. Th erefore, th e exam in er sh ould ch eck for any h istor y of facial n er ve p alsy in case of unilateral brow ptosis (Fig. 14.2). Seo an d Ah n an alyzed th e m orph ologic ch anges of th e eyelid according to gen der am ong di eren t age grou ps in Korean s an d rep or ted th at th e degree of brow ptosis sh ow ed a st at ist ically sign i can t in crease from th e seven th decade of life in m en an d from th e sixth decade in w om en . In part icu lar, th e lateral brow drooped m ore th an th e cen ter brow. Th e lateral h ood w idth of the eyelid sh ow ed a st at ist ically sign i can t in crease from th e seven th decade of life in m en an d from th e sixth decade in w om en .7

b

Fig. 14.1 Typical pat tern of blepharoptosis in an aged female. Blepharoptosis caused elevated eyebrow by compensation and this resulted in forehead creases.

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Aging-Related Upper Blepharoplast y

The Degree of Blepharoptosis and Levator Function

Elderly p eop le com m on ly com plain of “blep h aroptosis,” but m ost cases are n ot real ptosis but rath er derm atoch alasis: sim p le skin an d m uscle drooping. To dist inguish real ptosis from sim ple derm atoch alasis, raise th e drooped skin an d ch eck th e p osit ion of th e eyelid m argin . Pat ien t s w ith sim p le derm atoch alasis sh ow n orm al eyelid h eigh t sim ilar to th at of you ng p eop le, an d th ose cases u su ally n eed excision of th e skin an d m u scle on ly.

Many aged p eop le w h o w an t blep h arop last y m ay h ave bleph aroptosis of var ying degrees. To ch eck th e degree of bleph aroptosis an d levator fun ct ion , th e pat ien t sh ould stay com for table an d sh ou ld n ot u se th e fron t alis m u scle. First , exam in e w h eth er th e p osit ion of th e low er lid is n orm al. Secon d, ch eck th e m argin -re ex dist an ce (MRD), th e dist an ce from th e upper eyelid m argin to th e corn eal ligh t re ex in th e prim ar y posit ion , w h ich is th e m ost e ect ive m easu rem en t in d escribing th e am ou n t of blep h aroptosis (Fig. 14.4). Pat ien t s w ith severe derm atoch alasis m ay also have bleph aroptosis; h ow ever, th ese pat ien ts can be overlooked because derm atoch alasis can con ceal th eir bleph aroptosis. Th e m ost sim ple an d e ect ive w ay to n d h idden bleph aroptosis is to curl up redun dan t skin an d n d th e real MRD from th e eyelid m argin to th e re ex, n ot th e m an ifest MRD, from th e skin m argin to th e re ex (Fig. 14.5). Th ird, m easure th e levator fun ct ion by determ in ing th e dist an ce (in m illim eters) th e upper eyelid m argin m oves from dow n -gaze to u p -gaze w h ile th e brow is xated w ith th e exam in er’s ngers (Fig. 14.6). Decreased lift ing force m igh t also explain lash ptosis, w h ich is n ot on ly p resen t in th e single eyelid but also in creases in prevalen ce in th e double eyelid w ith aging.10 Th e degree of lash ptosis correlates w ith th e degree of bleph aroptosis an d decreased lifting force of th e levator aponeurosis.11

Deep Superior Sulcus

Brow Position

Th e deh iscen ce of th e levator apon eurosis from th e upper tarsal plate can cause h igh placem en t of m ult iple creases an d h ollow su p erior su lcu s (Fig. 14.3). Deh iscen ce of th e levator also cau ses ptosis, an d subsequen t brow elevat ion to com pen sate for th is ptosis can aggravate su perior su lcus deepen ing.8,9 Som et im es p reviou s excessive fat rem oval m ay cau se a deep an d h ollow su p erior su lcu s w ith involu t ion al ch anges.

Th e brow is n orm ally posit ion ed at th e level of th e superior orbit al rim , an d th e m ale brow is low er th an th e fem ale brow. Brow posit ion an d con tour determ in e youth fu l ap pearan ce to som e degree. With aging, th e tem p oral brow start s to droop m ore prom in en tly becau se th e fron t alis

Fig. 14.3 Typical presentation of involutional blepharoptosis. Patients with involutional blepharoptosis frequently show highlocated multiple creases and hollow superior sulcus.

Fig. 14.4 Method of measuring margin-re ex distance (MRD). MRD is measured by the distance from the upper eyelid margin to the corneal light re ex in the primary position.

Fig. 14.2 Brow ptosis masquerading as blepharoptosis. A patient with prior left facial nerve palsy had left brow ptosis and an asym metric eyebrow.

■ Patient Evaluation Dermatochalasis

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a

b

c

d

Fig. 14.5 Di erentiation bet ween dermatochalasis and blepharoptosis. (a) Young male patient who worried about right blepharoptosis. (b) After curling up redundant skin, margin-re ex distances were symmetric and there was no real blepharoptosis. (c) Older female patient complained of “drooped skin” of the right upper eyelid. It looks like there is dermatochalasis in her right eye. (d) However, after curling up the right upper eyelid skin, margin-re ex distance was smaller than on the left side. This patient had both right upper blepharoptosis and dermatochalasis.

m u scle is n ot presen t in th e lateral brow area. Droop ing of th e brow is called brow ptosis. Brow ptosis occurs usually after m iddle age, an d derm atoch alasis an d blep h aroptosis m ay app ear accen t u ated du e to brow ptosis. Th e su rgeon m u st recogn ize th e brow ptosis accom p anying d erm atoch alasis as a cont ribut ing factor in th e pat ien t’s aged ap pearan ce before su rger y. In th e p resen ce of brow ptosis, th e su rgeon m u st decide w h eth er to perform a brow lift

a

in advan ce or in conjun ct ion w ith th e bleph aroplast y. Th e m edical h istor y m u st be ch ecked for facial n er ve palsy in cases of un ilateral brow ptosis or m ore prom in en t droop ing of th e un ilateral u pper eyelid skin . If brow ptosis w as overlooked , iat rogen ic p ostop erat ive lagop h th alm os can result from th e resect ion of too m uch skin an d m uscle. Th erefore, to get good result s, th e brow lift h as to precede bleph aroplast y.

b

Fig. 14.6 Method of measuring the levator function. It was de ned as the movement of the upper eyelid margin in millimeters from (a) down-gaze to (b) up-gaze while xating the brow with the examiner’s ngers.

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Upper Eyelid Crease Th e u p p e r eyelid crease is m a d e by at t a ch m e n t of t h e levat or a p on e u rosis ext e n d in g t h rou gh t h e orb icu la r is in t o t h e skin . Th e u p p e r eyelid crea se is h igh e r in fe m a les t h a n in m a les. Th e u p p e r eyelid crea se is u su a lly low or a bse n t in t h e Asian eyelid . Th e ave rage Asia n eyelid crea se is 2 m m low e r com p a re d w it h Cau casia n s,1 2 w it h a h e igh t of 6 t o 8 m m in fe m ales an d 4 t o 6 m m in m a les. Asym m et r ic h e igh t or m u lt ip le d ou b le - lid crea ses m ay refle ct st ret ch in g or d isin se r t ion of t h e levat or a p on e u rosis. Th e d ou b le - eyelid cre ase it self is u su a lly elevat e d w it h involu t ion al ch a n ges, b u t t h e ove rlyin g d e r m at o ch a la sis m ay con cea l t h at , esp e cially in t h e Asia n eld e rly. High d u p licat e d eyelid crea ses m ay in d icat e d isin se r t ion of t h e levat or a p on e u rosis. Th e Asian pat ien t w ith a double-eyelid crease created during previous surger y is t reated in th e sam e w ay as th e pat ien t w ith a n at ural crease. But th e m ost di cult com plicat ion in aging-related bleph aroplast y in Asian s is a ver y h igh -p osit ion ed dou ble-eyelid crease in th e pat ien t w h o un der w en t excessive skin an d fat rem oval at a young age, an d w h o is aging n ow. Th ese pat ien t s h ave lit tle skin rem ain ing to resect an d m ay h ave som e adh esion s w ith u n derlying t issu es. Th erefore, rem oving m ore skin or lift ing th e brow can m ake an un n at ural eyelid crease n ot iceable. If th e pat ien t h as som e drooping skin over th e eyelid crease, m aking th e “visible” eyelid crease look n at u ral an d n ot too h igh , it is bet ter n ot to do su rger y an d ju st leave it as it is. In stead, au tologou s fat or ller inject ion along th e brow an d u pp er eyelid com p lex m ay be h elpfu l in im proving cosm esis. On ly th e p at ien t w ith p rofou n d bleph aroptosis n eeds to u n dergo correct ive su rger y by levator advan cem en t or by resect ion to elevate th e eyelid an d to m ake th e visible eyelid crease look sm aller.

Aging-Related Upper Blepharoplast y

fat p ocket to exte n d late rally an d cove r t h e an t e r ior asp e ct of t h e lacr im al glan d . In a p reviou s st u d y b ase d on Korean age d p e op le, t h e eyelid fat w as m ost p rot r u d e d at t h e ce n t ral low e r p ar t .7

Corneal Protection Mechanism Ocu lar m ot ilit y an d Bell’s ph en om en on sh ou ld be ch ecked carefully before surger y. Con rm th at th e eyelid is com pletely closed w ith a blin k. Poor Bell’s ph en om en on can cause exposure kerat it is or corn eal ulcer postoperat ively. Bell’s ph en om en on m ust be n orm al.

Tear Secretion If t h e p at ie n t com p lain s of ocu la r ir r it at ion sym p t om s, it is likely t h at t h e p at ie n t h a s a p rob le m w it h t ea r se cre t ion su ch as d r y eye syn d rom e. Te ar film b rea ku p t im e, t h e p rese n ce of lagop h t h alm os, an d sym p t om s or sign s of d r yn ess sh ou ld also be a ssesse d p re op e rat ively. Dr yn ess can b e aggravat e d aft e r su r ge r y, esp e cia lly in t h e eld e rly p at ie n t . Th e su rge on w h o is n ot fam iliar w it h t h ose ocu la r exa m in at ion s ca n con su lt an op h t h a lm olo gist t o ch e ck t h e p rese n ce an d seve r it y of d r y eye. Also, t h e p at ie n t sh ou ld b e n ot ifie d t h at h is or h e r sym p t om s w ill n ot im p rove a n d m ay eve n b e aggravat e d a ft e r ble p h a rop la st y. So if t h e p at ie n t com p la in s of seve re sym p t om s of d r y eye, t h e su r ge on sh ou ld m ake t h e p at ie n t u n d e r st an d t h at ocu lar ir r it at ion m ay b e aggra vat e d a ft e r b le p h a rop la st y. Aft e r a t h orou gh d iscu ssion of t h e r isk fa ct ors, a d e cision sh ou ld b e m ad e on w h et h e r t o p roce e d w it h t h e b le p h a rop last y p roce d u re as p la n n e d or n ot .

Lacrimal Gland Position

Orbital Fat Prolapse Periorbit al fat is ver y im p or t an t in blep h arop last y, esp ecially in aged people. In som e pat ien t s, subbrow fat can droop dow n to th e orbit al septal area, an d it m akes for a pu y u pper eyelid appearan ce. It sh ould be di eren t iated from orbit al fat p rolap se. Th e p re -ap on e u rot ic fat p ocket s are im p or t an t su rgical lan d m arks, as t h ey id e n t ify t h e p lan e im m e d iately p oste r ior to t h e orb it al se p t u m an d im m e d iately an t e r ior to t h e levator ap on e u rosis. Th e re are t w o fat p ocket s in t h e u p p e r eyelid , on e m e d ial an d on e ce n t ral, se p arat e d by fascial con n e ct ion s con t in u ou s w it h t h e t roch lea . Th e m e d ial fat p ocket is w h it e r t h an t h e ce n t ral fat p ocket . W it h agin g, t h e se pt u m be com es t h in an d la x, resu lt in g in fat p rolap se an d p u y eyelid . Alt h ou gh it is ge n e rally kn ow n t h at t h e re is n o lat e ral fat p ocket in t h e u p p e r eye lid , it is qu ite com m on for t h e ce n t ral p re -ap on e u rot ic

Th e lacrim al glan d is located laterally just beh in d th e orbit al rim , an d n orm ally it is n ot seen du ring bleph aroplast y. With aging an d th e th in n ing of th e fascial system su pp orting th e lacrim al glan d, it prolapses an d m igh t be m ist aken for lateral fat prolapse, especially in Asian pat ien t s w h o have th ick skin over th e lacrim al glan d, an d th is prolapsed lacrim al glan d can be easily overlooked.

Eyelid Wrinkles Horizon t al an d ver t ical w rin kles from th e proceru s an d corrugator m uscles at th e glabella an d crow ’s-feet from th e orbicularis at th e lateral eyelid form w ith aging. Th ese w rin kles can be par t ially rem oved w ith bleph aroplast y, but m ost of th e t im e bot ulin um toxin or ller inject ion is necessar y.

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Skin Texture and Thickness Skin text ure ch ange in aging pat ien ts is h igh ly variable am ong in dividuals bu t is usually proport ion al to th e in dividual’s environ m en tal sun exposu re.13 Epiderm al thin ning an d decrease in collagen cau se skin to lose its elast icit y. Loss of fat , coupled w ith gravit y and m uscle pull, leads to w rinkling and the form ation of dynam ic lines. The aging process h as also been show n to a ect facial bones. In Asians, w ho h ave relat ively thicker skin, a low er double-eyelid fold and con ser vat ive skin resect ion are recom m en ded in such cases. Fig. 14.7 Surgical techniques of Asian upper eyelid blepharoplast y. The skin to be excised was demarcated by grasping redundant skin and marking.

■ Surgical Techniques Anesthesia Blep h arop last y can be perform ed un der gen eral, sedat ive, or local an esth esia, bu t local an esth esia is preferable. Recen tly, m on itored an esth esia care (MAC) h as been gain ing pop u larit y in bleph aroplast y. MAC is a plan n ed procedure during w h ich th e pat ien t un dergoes local an esth esia togeth er w ith sedat ion an d an algesia. Pat ien t s u n dergoing con sciou s sedat ion are able to an sw er to orders appropriately an d h ave th e eyelid h eigh t an d con tou r ch ecked in th e sit t ing posit ion during surger y. Tw o percen t lidocain e m ixed w ith epin eph rin e (1:100,000) is u su ally u sed as th e local an esth et ic. Local an esth esia is to be injected slow ly to redu ce pain du ring inject ion an d sh ou ld n ot be injected in to th e m u scle layer to avoid bleeding. After th e local an esth esia inject ion , ligh t com pression is applied to preven t pressure an d to dist ribute th e an esth et ic drug even ly to th e su rgical eld.

Designing the Eyelid Crease and Skin Excision The m ost im portant step in blepharoplast y is designing, w hich is deciding the am ount of skin and m uscle to be excised. It is im portant that the sam e am ount of skin bet w een the brow an d eyelid fold be kept in both eyes, rather than rem oving sym m etrical am ounts of skin (Fig. 14.7). After design ing th e eyelid crease lin e w ith th e pat ien t in th e su p in e posit ion , th e pat ien t is t urn ed to th e sit t ing posit ion . Th e surgeon grasps th e skin an d decides h ow m u ch of th e redu n dan t skin is to be excised w h ile th e pat ien t is asked to open an d close th e eye. W h en grasping th e skin to excise, developm en t of a 1-m m lagoph th alm os or sligh t eversion of th e eyelash is proper. Caut ion sh ou ld be t aken to leave at least 15 m m of skin bet w een th e eyebrow an d double-eyelid fold. In case of design ing a double lid, care sh ou ld be taken to en sure a sym m et ric h eigh t . Th e in cision lin e is m arked at 4 to 7 m m from th e eyelid m argin an d is recom m en ded n ot to exceed 10 m m . In cases w h ere

pat ien t s do n ot w an t an art i cial-looking crease, th e in cision lin e can be m arked ver y close to th e eyelid m argin . If th e pat ien t h as lateral h ooding of th e skin , th e in cision m ay be exten ded to th e lateral can th al area, but n o m ore th an 1 cm from th e lateral can th al angle. Th is design is in ten ded to excise m ore lateral skin th an skin from th e m edial or cen t ral side. Using sm ooth forceps, th e redu n dan t skin is grasp ed an d m arked. Lid ocain e m ixed w ith epin ep h rin e (1:100,000) is injected subcut an eously along th e previous m arking lin e. Th e in cision is m ade w ith a n o. 15 or 15T Bard-Parker blade or scissors Recen tly CO2 lasers an d radiofrequen cy w aves have been used to m in im ize bleeding.

Redundant Skin Excision Th e skin an d orbicu laris m u scle are in cised an d dissected from th e sept u m (Fig. 14.8). Th e skin an d orbicu laris are excised in on e layer. Th is skin -m u scle excision tech n iqu e causes less bleeding an d m akes it easy to protect th e orbit al sept u m . Care sh ou ld be taken n ot to cau se inju r y to th e orbit al sept um , w h ich is a w h it ish m em bran ous st ruct ure.

Fig. 14.8 Skin and orbicularis muscle were incised along previous marking and dissected from the septum.

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Fat Removal At th is poin t orbit al fat can be seen beh in d th e th in sept u m . Orbit al fat prolap ses easily w h en th e eyeball is com pressed (Fig. 14.9a). W h en th e sept u m is in cised, at ten t ion sh ou ld be paid to m ake sure th e in cision lin e is above th e lin e w h ere th e apon eurosis an d sept am are fused. A rake ret ractor is placed at th e u p per in cision m argin , p u lling th is edge u pw ard an d sligh tly elevat ing it , an d th e pat ien t is asked to open an d close th e eyes; th en th e dyn am ic dim pling lin e becom es visible. Th is lin e is w h ere th e apon eurosis an d sept u m are fu sed. Th e in cision sh ou ld be m ad e above th is lin e to avoid inju r y of th e levator apon eurosis. Th e orbit al sept um is th en par t ially open ed an d th e pre-apon eurot ic fat is exposed an d rem oved (Fig. 14.9b). Orbit al fat rem oval is n ot an in dispen sable procedu re an d depen ds on th e am oun t of fat prolapse presen t or th e in dividu al’s desire. It is also im port an t th at th e volu m e an d dist ribut ion of rem ain ing fat be alm ost th e sam e bilaterally. On ce th e fat is id en t i ed an d separated from su rrou n ding t issues such as th e sept um an d levator apon eurosis, it is clam ped w ith a n e-tooth ed m osqu ito forceps (Fig. 14.9c) an d cu t w ith scissors or elect rocau ter y n eed le t ip . Elect rocoagulat ion is applied to th e rem ain ing fat w hile th e clam p is st ill engaged (Fig. 14.9d). Th e grasp ing in st ru m en t is

Aging-Related Upper Blepharoplast y

th en rem oved after h em ost asis is secured. Th is procedure can cause pain ; th erefore, addit ional local an esth esia inject ion before fat rem oval is recom m en ded.

Eyelid Crease Formation Th ere are several w ays to approach eyelid crease form at ion , an d th e au th ors m ain ly u se on e of t w o m eth ods: levator xat ion or tarsal xat ion . We prefer tarsal xat ion : Non absorbable su t u res su ch as 7–0 nylon are app lied th rough th e skin , epitarsal t issu e, an d th e skin of th e opposite side (Fig. 14.10). In th e levator xat ion m eth od, su t u res are ap plied bet w een th e fu sed sept u m -levator en d an d th e su bcu tan eou s t issu e of th e low er in cision m argin .

Skin Closure Th e skin is closed w ith 6–0 or 7–0 n on absorbable su t u res an d an t ibiot ic oin t m en t is ap plied to th e w ou n d (Fig. 14.11). Before su t u ring th e skin , th e pat ien t sit s an d th e sym m et r y of th e eyelid con tour an d th e h eigh t of th e double lid are ch ecked by both th e pat ien t an d surgeon . Th e orbit al sept um sh ould n ot be sut ured.

a

b

c

d

Fig. 14.9 (a–d) The orbital septum was opened and orbital fat was identi ed. Orbital fat was grasped, cut, and cauterized using monopolar cautery.

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Fig. 14.10 A crease was made using tarsal xation suture: sutures are applied through the skin, epitarsal tissue, and the skin of the opposite side.

Fig. 14.11

■ Postoperative Care

■ Complications and

Ice p ack com p ression is app lied du ring th e rst 48 h ou rs after su rger y to m in im ize bleeding an d edem a. In n on diabet ic pat ien ts, in t raven ous steroid inject ion can be h elpful to decrease in am m at ion an d edem a. Th e skin su t u res are rem oved after 5 to 7 days.

■ Key Technical Points 1. Design of th e surger y is th e m ost im port an t step in bleph aroplast y. W h en determ in ing th e am oun t of skin an d m u scle to excise, it is im p or tan t th at th e sam e am ou n t of skin bet w een th e brow an d eyelid fold rem ain in both eyes, avoiding th e rem oval of an asym m et ric am ou n t of skin . 2. In th e case of design ing a double lid, th e in cision lin e is m arked at 4 to 7 m m from th e eyelid m argin an d is recom m en ded n ot to exceed 10 m m . 3. Fat is rem oved after grasping w ith a n e-tooth ed m osqu ito forcep s, an d elect rocoagu lat ion is ap p lied to th e rem ain ing fat w h ile keeping th e forceps engaged. Th e grasp ing in st ru m en t is rem oved after h em ostasis is con rm ed . 4. At th e n al st age of th e su rger y, th e p at ien t is asked to sit up an d sym m et r y of th e eyelid con tour an d h eigh t of th e dou ble lid are ch ecked by both th e p at ien t an d th e surgeon .

Skin was closed using a continuous running suture.

Their Management

Many di eren t blep h arop last y tech n iqu es h ave been in t roduced an d all of th ese are associated w ith cer tain preven table com p licat ion s. In th is sect ion , th e m ost com m on an d sign i can t com plicat ion s an d th eir preven t ion an d m anagem en t w ill be described.

Under-Correction or Patient Dissatisfaction Th e m ost com m on com plicat ion of bleph aroplast y in elderly people is un der-correct ion or pat ien t dissat isfact ion . It is im p ort an t to prom ote a realist ic u n derst an ding of th e outcom e of bleph aroplast y th rough an in -depth discu ssion bet w een th e surgeon an d th e pat ien t before th e surger y. Usu ally a dou ble-eyelid crease over 7 to 8 m m in h eigh t looks ver y un n at ural in Asian s, even in fem ale pat ien t s. Sligh tly folded u p p er eyelid skin over th e dou ble-eyelid crease or a low double-eyelid crease, such as 3 to 4 m m , looks m ore n at ural an d blen ds w ell. Som et im es, pat ien t s have di eren t or un realist ic expect at ion s; th us a th orough preoperat ive discussion of th e an t icipated results is crit ical. Su rgeon s sh ou ld exp lain reason able postop erat ive exp ectat ion s an d possible com plicat ion s before surger y. Most doctors w ou ld exp ect a p at ien t to be sat is ed w ith w ider vision after th e correct ion of obscu red vision due to upper eyelid drooping in an elderly pat ien t . How ever, pat ien t s w ere foun d to be sat is ed on ly w ith an excellen t cosm et ic outcom e even th ough th at w as n ot th eir prim ar y con cern prior to th e surger y. A sm all blun der in th e cosm et ic appearan ce postoperat ively can easily cause disappoin t m en t in a pat ien t even th ough th e visu al eld is greatly im proved, to th e exten t th at som e m ay even con sider th e su rger y a u seless on e.

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Asymmetric or Unnatural Eyelid Contour Severe derm atochalasis can obscure pre-existing eyelid asym m etry, and m any patients do not realize this before surgeons point it out to them . In these patients, cautious design is m andatory to m aintain sym m etric skin and fat, instead of rem oving a sym m etrical am ount of skin and fat. Surgeons should also pay attention to the position of the eyebrow, because asym m etric eyebrow can cause postoperative asym m etry or under-correction. Aging-related blepharoplast y is usually perform ed in conjunction w ith levator aponeurosis m anipulation, and xation sutures bet ween the levator aponeurosis and the tarsal plate can lead to an asym m etric or unnatural contour. To prevent this com plication the xation should be carefully placed.

Excessive Skin Removal Excessive rem oval of skin is a seriou s com plicat ion an d ver y di cult to correct . Th e auth ors h ave seen m any pat ien t s w h o h ad too m uch upper eyelid skin excised during cosm et ic bleph aroplast y, especially in th e elderly, an d are in agreem en t w ith Flow ers’s dict u m th at 20 m m of an terior lam ella is n ecessar y for n orm al fun ct ion ing of th e upper eyelid.14 If brow ptosis is presen t , th e su rgeon m u st con fer w ith th e pat ien t an d decide w h eth er to correct it or n ot; d ep en ding on th e result , th e am ou n t of skin resect ion th en h as to be decided.

Lagophthalmos Lagophthalm os is not a com plication but an unavoidable outcom e of aging-related bleph aroplast y, especially in patients w ith decreased levator function. A topical lubricant and oin tm ent are helpful during th e early postoperative stage, an d m any w ill resolve over tim e w ithout surgical interven tion. Skin grafts m ay be needed in cases of severe lagophthalm os and keratitis caused by excessive skin excision.

Orbital Hemorrhage An tiplatelet m edication s, aspirin , an d n on steroidal an tiin am m ator y agen ts are com m only used by oth er departm en ts in elderly pat ien ts. Th e m edical h istor y an d records sh ould be carefu lly ch ecked an d con sultation s sh ou ld be m ade about stopping drugs th at m ay a ect coagulat ion . It is also im portan t to ascertain that the pat ien t is norm otensive preoperat ively an d during surger y. It is also crucial to understand and identify th e anatom y of upper eyelid vasculat ure in the surgical eld. W hen rem oving and cauterizing pre-aponeurot ic fat, clam ping w ith a n e-toothed

Aging-Related Upper Blepharoplast y

m osqu ito forceps sh ou ld be m ain tain ed, an d after releasing the clam p, hem ostasis of the rem aining fat edge should be secured. Hem orrh age from th e orbital fat can cause retrobulbar hem orrhage and opt ic ner ve com pression, leading to visu al im pairm en t . If retrobu lbar orbital h em orrh age cau sing visual im pairm ent is suspected, the w ound should be opened up im m ediately, the bleeding focus should be found an d coagulated, an d th e drain sh ou ld be left for som e tim e.

Exposure Keratopathy Upper eyelid bleph aroplast y can a ect th e blin king fun ct ion , an d in elderly pat ien t s dr yn ess m ay be aggravated. Th erefore, it is im port an t to evaluate tear breaku p t im e an d Bell’s ph en om en on before m aking th e decision in favor of bleph aroplast y. Proper explan at ion an d m an agem ent of th e dr y eye syn drom e is m an dator y.

Lacrimal Gland Injury A p rolap sed lacrim al glan d m ay n ot be recogn ized preop erat ively, or in t raop erat ively. If p rolapse of a lacrim al glan d is iden t i ed, th e prolapsed glan d sh ou ld be ret urn ed to th e origin al posit ion by xat ing it to th e adjacen t periosteum an d sh ould n ot be excised. A n orm al lacrim al glan d is pale pin kish in color, h as a n ely lobulated st ruct u re, an d is rm er th an a fat com pon en t . If it is n ot corrected prop erly, lateral u p p er eyelid fu lln ess w ill be left after blep h aroplast y. Th erefore, if lacrim al glan d prolapse is n ot iceable after su rger y, th e p at ien t m ay be brough t back to th e operat ing room to h ave th e lacrim al glan d reposit ion ed.

Too -High Double -Lid Fold In Asian s, an absen t or low -p osit ion ed dou ble-eyelid fold is nat ural-looking. During det ailed preoperat ive con sult at ion , th e surgeon an d pat ien t sh ou ld decide w h eth er an eyelid crease w ill be m ade an d h ow h igh it sh ould be. Som et im es a tooth p ick an d a m irror are u sefu l in d eterm in ing th e heigh t of th e eyelid crease. Som e elderly Asian s w ill n ot w an t art i cial eyelid creases.

Deep Superior Sulcus Excessive fat rem oval is usually preven t able at th e t im e of su rger y. Now adays, p at ien ts w an t to h ave a n at u ral, sem ipu y, young-looking eyelid rath er th an a h ollow superior su lcu s; th erefore, fat rem oval sh ou ld be cau t iou sly p erform ed, w ith care t aken n ot to excise th e en t ire eyelid fat t y t issue. Moreover, excessive fat rem oval can cause m u lt iple eyelid creases an d it is h ard to correct due to th e st rong adh esion bet w een th e levator an d orbicu laris.

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■ Case Studies Case 1 A 65-year-old Asian m an w h o did n ot w an t th e creat ion of n ot iceable eyelid creases visited th e auth ors’ clin ic (Fig. 14.12a). He ju st w an ted to rem ove droopy eyelid skin an d to h ave a n at u ral eyelid crease so th at h e cou ld h ave a w ider visual eld.

a

His brow p osit ion w as sym m et ric an d h ad m in im al fat prolapse. Th e m ain problem w as droopy eyelid skin th at caused visual eld im pairm en t an d lateral can th al eczem a. In t raoperat ively, redu n dan t skin , in clu ding th e lateral can th al droopy skin , w as carefully rem oved, leaving sym m etric am ou n t s of skin bilaterally. After skin rem oval an d form at ion of a low -sit t ing eyelid crease, h e could see m ore com fort ably an d th e eczem a at th e lateral can th al angle also disappeared (Fig. 14.12b).

b

Fig. 14.12 Case 1. Blepharoplast y making a natural eyelid crease. (a) A 65-year-old man has a droopy eyelid skin that causes visual eld impairment and lateral canthal eczema. (b) After the excision of the droopy skin with low-sit ting eyelid crease formation, he could see more comfortably and the eczema at the lateral canthal angle disappeared.

Case 2 A 59-year-old m an d id n ot w an t to h ave an eyelid crease created, but just w an ted th e droopy skin rem oved an d to h ave th e eyelid h eigh t lifted (Fig. 14.13a). Th e m ain p rob lem w as droopy eyelid skin th at caused visual eld im pairm en t an d lateral can th al eczem a.

a

In t raoperat ively, redu n dan t skin , in clu ding th e lateral can th al angle skin droop, w as carefully rem oved to leave sym m et ric am ou n t s of skin bilaterally. A larger am ou n t of skin an d m u scle w as excised in th e lateral eyelid. After skin an d m u scle w as rem oved, th e skin w as closed w ith con t in uous sut ures w ith out m aking an eyelid fold (Fig. 14.13b).

b

Fig. 14.13 Case 2. Blepharoplast y without creation of an eyelid crease. (a) A 59-year-old man who has droopy eyelid skin with lateral canthal eczema. (b) After the skin and m uscle excision but without creation of an eyelid fold.

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Case 3 A 72-year-old Asian wom an wanted to have droopy lateral skin rem oved and to im prove skin eczem a (Fig. 14.14a). The preoperative picture showed asym m etry of the brow and m ore skin drooping over the right upper eyelid, w hich was not noticed by the patient before consultation w ith the surgeon. After thorough discussion, the authors found that she also wanted a distinct but natural crease and a younger and

a

Aging-Related Upper Blepharoplast y

m ore cheerful appearance. The operative plan was to rem ove the droopy skin beyond the lateral canthal angle and create an eyelid crease at 6 m m from the eyelid m argin w ith tarsal xation using nonabsorbable sutures. Additionally, levator aponeurosis advancem ent was planned to raise the eyelid level. After bleph aroplast y w ith levator advan cem en t sh e could see m ore com fort ably, an d th e eczem a of th e lateral can th al angle an d brow asym m et r y also im p roved (Fig. 14.14b).

b

Fig. 14.14 Case 3. Blepharoplast y with creation of a noticeable eyelid crease. (a) A 72-year-old Asian woman wanted to remove droopy lateral skin, improve skin eczema, and have a distinct but natural crease and a younger, cheerful appearance. During the surgery, droopy skin was removed beyond the lateral canthal angle, an eyelid crease was made at 6 mm from the eyelid margin, and levator aponeurosis advancement was performed. (b) After surgery, she could see more comfortably and the eczema of the lateral canthal angle and brow asymmetry also improved.

■ Conclusion

6. Mat ros E, Garcia JA, Yarem ch u k MJ. Ch anges in eyebrow posit ion and sh ape w ith aging. Plast Recon st r Surg 2009;124(4):1296–1301

In con clu sion , m aking th e e ort to u n d erst an d each pat ien t’s in dividual involut ion al ch anges, w h ich are speci c to a pat ien t’s age an d gen der, is m an dator y. Addit ion ally, iden t ifying th e pat ien t’s p erson al n eeds an d select ing th e righ t t reat m en t accordingly is crucial for ach ieving th e best outcom e both for th e clin ician an d th e pat ien t .

7. Seo HR, Ah n HB. Morph ological ch anges of th e eyelid according to age. J Korean Op h th alm ol 2009;50:1461–1467

References

8. Matsuo K, Kondoh S, Kitazawa T, Ishigaki Y, Kikuchi N. Pathogenesis and surgical correction of dynam ic lower scleral show as a sign of disinsertion of the levator aponeurosis from the tarsus. Br J Plast Surg 2005;58(5):668–675 9. Su lt an a R, Mat su o K, Yu zu rih a S, Ku sh im a H. Disin sert ion of the levator apon eu rosis from th e t arsu s in grow ing ch ildren . Plast Recon st r Surg 2000;106(3):563–570

1. Saonanon P. Update on Asian eyelid anatom y and clinical relevance. Curr Opin Ophthalm ol 2014;25(5):436–442

10. Malik KJ, Lee MS, Park DJ, Harrison AR. Lash ptosis in con gen it al and acqu ired bleph aroptosis. Arch Oph th alm ol 2007;125(12):1613–1615

2. Karam AM, Lam SM. Managem en t of th e aging upper eyelid in th e Asian pat ien t . Facial Plast Su rg 2010;26(3): 201–208

11. Lee TE, Lee JM, Lee H, Park M, Kim KH, Baek S. Lash ptosis an d associated factors in Asian s. An n Plast Su rg 2010; 65(4):407–410

3. Loeb R. An atom ical con siderat ion s. In : Loeb R, ed. Aesth etic Su rger y of th e Eyelids. New York, NY: Springer-Verlag; 1989:1–12

12. Liu D, Hsu W M. Orien t al eyelids. An atom ic di erence an d surgical con siderat ion . Oph th al Plast Recon st r Surg 1986;2(2):59–64

4. Lot t P, Caldiera AM, Lucas A, Grigalek G. Envejecim ien to facial. Papelde la órbit a sen il. Cir Plast Ibereo-lat in oam er 1996;22:21–30

13. Ben edet to AV. Th e environm en t an d skin aging. Clin Derm atol 1998;16(1):129–139

5. Park CY, Jeon SL, Woo KI, Ch ang HR. Th e frequen cy and asp ect s of ptosis in Korean old age. J Korean Oph th alm ol Soc 2007;48:205–210

14. Flow ers RS. Bleph aroplast y. In : Court iss EH, ed. Male Aesth et ic Su rger y. St Lou is, MO: Mosby; 1982

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Epicanthoplasty and Aesthetic Lateral Canthoplasty

Yongho Shin

Pearls • Cosm et ic epican th oplast y releases th e epican th al

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•

• •

fold an d m odi es th e m ed ial corn er of th e p alpebral ssu re, th u s revealing m ore of th e m edial p ort ion of th e eye an d decreasing th e in terepican th al distan ce. Th e lacrim al carun cle can be t riangu lar, roun d, or h ook-sh aped, an d th ese variat ion s n eed to be con sidered in select ing an ap proach for ep ican th op last y. W h en m odifying th e can th u s for aesth et ic reason s, a con ser vat ive ap p roach is recom m en ded becau se an over-corrected epican th u s is ext rem ely di cu lt to revise. Righ t an d left lacrim al caru n cles h ave di eren t scales of grow th an d direct ion , w h ich n eeds con siderat ion in th e design of epican th oplast y. W h en a double-fold operat ion is com bin ed w ith ep ican th op last y, redu n dan t skin from th e u pp er ap of th e dou ble eyelid sh ould be rotated tow ard th e

■ Epicanthoplasty Th e epican th al fold is excessive brous t issu e th at lies in a ver t ical, sem ilu n ar orien t at ion , an d it is a dist in ct ive feat ure of th e Asian eyelid. Cosm et ic epican th oplast y releases th e epican th al fold an d m odi es th e m edial corn er of th e palpebral ssure. Th e operat ion reveals m ore of th e m edial port ion of th e eye w h ile sim ult an eou sly decreasing th e in terepican th al dist an ce (Fig. 15.1). In East Asian p op u lat ion s, th e m ean in terep ican th al dist an ce is reported to be 3.48 to 3.6 cm .1 Am ong beaut y con testan t s in th e 2003 “Miss Korea” con test , th is dist an ce w as 3.17 cm on average, w h ich is sh or ter th an th e m ean valu e, an d th is im plies th at th e con test an ts p robably did n ot h ave h igh ly con spicu ou s epican th al folds. Th e in terep ican th al distan ce sh ould be in terpreted in the con text of th e overall relat ion sh ip bet w een th e ep ican th al fold an d th e rem ain der of th e eye. Ep ican th al folds appear m ost n at ural w h en less th an h alf of th e carun cle is covered. Usually, 80 to 90% exposure of th e carun cle is aesth et ically pleasing.1,2 The shape of the lacrim al caruncle can be triangular, round, or hook-shaped. Triangular caruncles account for 53% and are m ostly found am ong Asian patients. The round carun-

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de cien t skin on th e in n er part of th e low er eyelid to decrease th e risk of par t ial ect ropion . Th e t w o m ost frequen t com plicat ion s of ep ican th op last y are scarring an d th e aggravat ion of th e epican th u s inversus. Th ese risks can be redu ced by design ing th e skin in cision s along th e relaxed skin ten sion lin es an d avoiding a con n ect ion bet w een th e epican th oplast y an d bleph aroplast y in cision s. In aesth et ic lateral can th oplast y, n ot on ly h orizon t al palpebral exten sion but also proper posterior deepen ing is im port an t to m ain t ain a proper con t act bet w een th e eyeball an d palpebral conjun ct iva. Com bin ed lateral can th oplast y an d low ering of low er eyelid slan t w ill m ake th e eyes look m ild an d big. Mongolian slan t low ering can be d on e by su t u ring bet w een th e t arsu s an d cap su lopalp ebral fascia.

cles represent ~ 10%. The hook shape (37%) is accom panied by a dow n-pointing m edial palpebral com m issure (Fig. 15.2).3 For t riangular an d rou n d carun cles, th e exten t of ep ican th al release is determ in ed con sidering th e w h ole propor t ion of th e eyes. How ever, h ook-sh aped carun cles requ ire a di eren t app roach becau se epican th al ten don s ru n dow nw ard along th e ou ter cu r vat u re. If too m u ch of th is epican th al fold is elim in ated, th e outcom e w ill be an aggressive app earan ce th at w ill m ost likely to be u n acceptable to th e pat ien t . Th e size of visible caru n cle after ep ican th op last y is an im port an t con siderat ion . In East Asian pat ien ts, th e carun cle is visible for 3 to 5 m m at th e m edial side. If th e ep ican th al fold covers th e caru n cle an d th e extern ally visible par t of th e carun cle is 1 m m or less, a m ore drast ic in ter ven t ion m ay be requ ired. Epican th al folds can be divided in to four t ypes: epican th u s su praciliaris, epican th us palpebralis, epican th us tarsalis, an d epican th us inversus (Fig. 15.3).1 Epican th al fold s rep resen t a w ide spect ru m of soft t issu e con gu rat ion s w ith var ying et iologies, an d th us th ere can n ot be a single op erat ion th at is su ited for all pat ien t s an d sit u at ion s. Th e sh eer n um bers an d variat ion s of epican th oplast y tech n iqu es ser ve to dem on st rate th is fun dam ental con cept in epican th oplast y.

15

A B

Fig. 15.1 Distance bet ween the eyes. A, intercanthal distance; B, interepicanthal distance

Early in it s developm en t , epican th oplast y con sisted on ly of skin excision w ith th e idea th at epican th al folds w ere m an ifest at ion s of redu n dan t skin arou n d th e m edial can th u s. How ever, a com m on com plicat ion of th is m eth od w as visible scarring cau sed by excessive ten sion in th e skin , esp ecially in th e low er on e-th ird of th e m edial can th u s. On on e h an d, skin redun dan cy in th e upper th ird of th e epican th al fold is usually accom pan ied by a skin de cien cy of th e low er th ird. In su ch con gurat ion , th e redun dan t skin sh ou ld be u sed as a ap to relieve th e ten sion on th e low er th ird, w h ich is crucial in th e preven t ion of ect ropion along th e m edial por t ion of th e low er eyelid. On th e oth er h an d, skin redu n dan cy of th e low er sect ion in dicates th at th e ep ican th al fold is caused by m ult iple factors. Even if th e low er skin is n ot de cien t , u p per excessive skin excision sh ou ld be m in im ized in su ch cases.

Epicanthoplast y and Aesthetic Lateral Canthoplast y a m ore n at u ral-looking ep ican th u s w ith dou ble fold . East Asian s ten d to h ave th icker skin n ear th e n asal bridge an d ep ican th al area th an in th e u p p er eyelid, w h ich is m ore react ive an d pron e to hypert roph ic scarring after epican th op last y. Preop erat ively, p at ien t s sh ou ld alw ays be in form ed th at un der-corrected or asym m et ric epican th u s m ay develop as a com plicat ion . Each epican th al fold can be divided in to upper, m iddle, an d low er th irds. For each port ion , an atom ic feat ures sh ou ld be th orough ly exam in ed, su ch as skin redu n dan cy, exten t of skin h ooding, an d am ou n t of soft t issu e ten sion . Even in a single pat ien t , th e sizes of th e bilateral lacrim al carun cles m ay di er, so th e side of th e sm aller carun cle sh ou ld be op en ed m ore w idely to m ake for sym m et r y after ep ican th op last y. Th erefore, it is cru cial to p repare a p recise m edical exam in at ion an d diagn osis.

Double -Fold Operation and Epicanthoplasty In East Asian pat ien t s, th e dou ble-fold operat ion is com m on ly perform ed in conju n ct ion w ith ep ican th oplast y. In su ch a com bin ed op erat ion , th e redu n dan t skin from th e upp er ap of th e double eyelid sh ould be rot ated tow ard th e de cien t skin on th e in n er par t of th e low er eyelid. Th is redist ribut ion of soft t issue is h elpful in decreasing th e risk of par t ial ect ropion caused by epican th oplast y (Fig. 15.4). If ep ican th op last y is p erform ed w ith ou t th e d ou blefold operat ion , a dog-ear m igh t form on th e upper an d m edial p art s of th e ep ican th al fold an d w ill n eed excision . Occasion ally, th is excision can resu lt in a n ew, u nw an ted double-eyelid lin e. To preven t th is n ew double-eyelid lin e,

Patient Evaluation It is im p ort an t to m easu re th e in terep ican th al d ist an ce an d th e am oun t of exposed lacrim al carun cle. Pat ien t s w ith ext rem e ep ican th al fold an d w ide in terep ican th al distan ce can realize a dram at ic ben e t from th is procedu re. A pat ien t can in sp ect th e ch anges after epican th op last y by nger t ract ion of th e in n er can th us. Un der-correct ion is safer th an over-correct ion becau se an u n der-corrected ep ican th al fold can be revised m u ch m ore easily th an an over-corrected ep ican th al fold. Of th e fou r t yp es of ep ican th al folds, epican th u s t arsalis is m ost com m on in East Asian s. Not all epican th al fold s requ ire correct ion , an d ep ican th u s t arsalis allow s for

a

b

c

Fig. 15.2 Three shapes of lacrimal caruncle. (a) Triangular shape. (b) Round shape. (c) Hook shape.

a

b

c

d

Fig. 15.3 Classi cation of epicanthal folds as proposed by Johnson. (a) Epicanthus supraciliaris. (b) Epicanthus palpebralis. (c) Epicanthus tarsalis. (d) Epicanthus inversus.

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a

c

b

d

Fig. 15.4 The reverse Fuente's design. (a,b) The triangular ap from the inner upper part of the epicanthal fold is rotated toward the incision site of the lower eyelid to hide the scar. (c) A 19-year-old girl wanting epicanthoplast y and double-eyelid surgery. Medial epicanthoplast y with reverse Fuente’s design and incisional double-eyelid surgery were performed. (d) After surgery, more exposed caruncle with double eyelids makes the eyes more beautiful.

th e dog-ear sh ould be resected as close to th e upper cilia as possible. If th e skin is in su cien t on th e lid m argin of th e m edial carun cle, th e dog-ear port ion of th e upper ap sh ou ld be p reser ved an d t u rn ed in to a t riangu lar ap to be rot ated in to th e in n er por t ion of th e n ew can th otom y st ru ct u re (Fig. 15.5). An oth er p ossibilit y is to release th e ban d-sh aped epican th us inversus on th e low er par t of th e ep ican th al fold by rot at ing th e ap m ad e by th e dog-ear an d advan cing th e t riangu lar ap p erp en dicu larly to th e ep ican th u s inversu s.

Surgical Techniques Th ere is n o single tech n ique th at can address th e fu ll spect rum of epican th al folds, an d th e surgeon m ust rely on a set of tech n iques th at are applicable to speci c t ypes of epican th al folds. Most epican th oplast y tech n iques are variat ion s an d com bin at ion s of a few fu n dam en t al con cept s: sim ple skin excision , V-Y advan cem en t , Z-plast y, an d W-p last y. Th e follow ing ve quest ion s m ust be an sw ered before th e ap prop riate ep ican th op last y tech n iqu e can be ch osen . 1. How w ill I m an age th e skin redun dan cy an d d e cien cy? 2. How w ill I con t rol th e exten t of carun cle exposure?

3. Can th e t ran sverse in cision be placed in a n onvisible area or along a relaxed skin ten sion lin e? 4. Is it possible to leave a skin bridge bet w een th e ep ican th op last y in cision an d th e dou ble-eyelid in cision ? 5. Of th e appropriate operat ive tech n iques, w h ich am I m ost com for t able w ith ?

Simple Skin Excision Sim ple skin excision is not com plicated an d can be perform ed even by inexperienced surgeons. Alth ough skin-only excision can be suitable for som e cases, excessive tension in the low er ap is a con cern an d can result in postoperative scarring. To decrease ten sion , th e soft t issue m u st be dissected an d th e perpen dicular accessor y ber m ust be tran sected. Th is m eth od is n ot com m on ly perform ed n ow adays.

V-Y Advancement Methods Th ere are several kn ow n variat ion s of V-Y advan cem en t . Th e Roveda m eth od involves advan cem en t of th e n asal side skin an d rem oval of th e rem ain ing skin from th e top an d bot tom to preven t dog-ear. Uch ida m odi ed th e Roveda

15

Epicanthoplast y and Aesthetic Lateral Canthoplast y

y

x'

Fig. 15.5 Rotation of the triangular ap into the canthotomy site allows greater exposure of the caruncle.

m eth od, bu t th e Uch ida design w as too close to th e lacrim al carun cle to preven t n ot iceable scars. Th e Uch ida m eth od h as been fu rth er m odi ed to th e p ericiliar y ep ican th al fold in cision m eth od, w h ich involves a large V-sh ap ed in cision follow ed by dissect ion an d excision of th e su rrou n ding skin to com pletely h ide th e scar (Fig. 15.6).4

Z-Plasty Flap Th is is a frequen tly used tech n ique w ith m any variat ion s to allow for exibilit y in th e locat ion an d size of th e t w o skin ap s. Fu en te’s design in corporates h alf of a Z-p last y, w h ich takes th e t riangular ap from th e low er part of th e epican th al fold an d t ran sfers it to th e m iddle par t , an d exten ds th e double-eyelid fold in cision lin e tow ard the in n er upper part . Th is m eth od is recom m en ded for pat ien t s w ith a pre-existing dou ble-eyelid fold . How ever, resect ion of redun dan t skin is n ecessar y, if th e tech n iqu e is p erform ed sim u lt an eously w ith th e double-fold lin e operat ion (Fig. 15.7). Park’s m eth od is a m odi cat ion of Fuen te’s m eth od an d incorporates partial resect ion of redun dant skin bet w een the double-eyelid fold lin e and the epicanthoplast y site. This m eth od rotates skin from th e low er epican th al fold to th e m iddle portion . Th e redu n dan t skin in th e upper epican th al fold is resected. This procedure is suitable for patients w h o h ave th e redundant skin in th e low er epican thal fold w ith h igh ten sion in th e m iddle portion. The tech n ique is also useful in addressing th e dog-ear from the redundan t skin along th e u pper bleph aroplast y in cision lin e. Th e reverse design of Fuen te’s m eth od can be used for p at ien ts w ith redu n dan t skin on th e u pp er part of th e ep ican th al fold an d lack of skin on th e low er p art . In su ch cases, th e t riangular ap sh ould be m ade on th e u pper in n er part an d rot ated dow nw ard (Fig. 15.4). If less th an 1 m m of lacrim al caru n cle is visible, th en th e t riangu lar ap from th e u p p er p ar t of th e epican th al fold is rotated in to th e m edial can th otom y site (Fig. 15.5).

x

z

Fig. 15.6 Design of periciliary V-Y advancement epicanthoplast y. The innermost point of the lacrimal caruncle x becomes x’ after V-Y advancement. Extended skin incision along the upper and lower ciliary margin (y, z) is necessary for dog-ear removal.

Skin Redraping Method An oth er frequen tly u sed epican th oplast y tech n iqu e is th e skin redraping m eth od. It can be perform ed sim ultan eously w ith the double-eyelid fold operation. The skin redraping design w as origin ally rectilinear but the design needs to be m odi ed from a rect ilin ear lin e to a roun d or sligh tly trian gular lin e. Th is m odi cation can preven t ectropion at th e m edial side of th e low er eyelid (Fig. 15.8). W h en epican th oplast y is perform ed w ith out the double-eyelid fold operation , th e t riangular ap should be placed as close to the ciliar y line as possible. In addition, the incision should be extended to allow adequate resection of the redun dant skin. Un derdeveloped lacrim al caru n cle cases are ext rem ely ch allenging to address. In such pat ien t s, th e m edial can th al ten don requires plicat ion to reveal m ore of th e m edial corner of th e eye. Th e can th al ten don can be secured th rough a hole drilled th rough th e n asal bon e u sing eith er m et al w ire or th ick nylon su t u re.5

■ Complications and Their Management

Th e t w o m ost frequen t com plicat ion s of epican th oplast y are scar an d th e aggravat ion of th e epican th u s inversu s. Th e risk of th ese com plicat ion s can be reduced by design ing th e skin in cision s along th e relaxed skin ten sion lin es an d avoiding a con n ect ion bet w een th e epican th op last y an d blep h arop last y in cision s. It is bet ter to sep arate ep ican th op last y an d blep h arop last y in cision lin es becau se th e m ovem en t of th e u pp er eyelid can t ran sm it ten sion from th e upper bleph aroplast y in cision to th e epican th oplast y in cision in case th ese t w o in cision s are con t in uou s. Rotat ion of th e redu n dan t upper skin to th e low er por t ion of th e ep ican th u s redu ces th e ten sion ect ropion . Iat rogen ic ep ican th u s inversus is aggravated by perpen dicular ten sion ,

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Modified Uchida’s m ethod

x' w

Mat sunaga’s m odified “M”-plast y m ethod

x

y

z

a

Fuente’s transposition flap x' w

Jordan’s “a deep tissue approach” method

Yoon’s “one-arm ed jum ping m an” m ethod

x' w

Wu’s square-flap m ethod

x

y z

b

Park’s “Z-plast y” m ethod

Fig. 15.8 (a,b) Skin redraping method of epicanthoplast y. To avoid ectropion, the skin redraping design is modi ed from a rectilinear line to a round or slightly triangular line. For example, the point x is moved to x′ to avoid ectropion.

Fig. 15.7 Various t ypes of epicanthoplast y commonly used in Asian patients

an d is p reven ted by t ran sect ing th e accessor y ber of th e orbicularis m uscle. Th e t ran sected bers sh ould be reorien ted by advan cing th e skin ap t ran sversely. Th e postoperat ive scar sh ould be placed in a h idden area, as m u ch as th e su rgical design allow s. Th e ten sion across th e su rgical w ou n d sh ou ld be h eld by absorbable d erm al su t ures, n ot by sup er cial skin su t u res. Th e skin layer sh ould be closed w ith th e th in n est sut ure n eeded (i.e., 7–0) un der th e surgical lou pe.

Th e epican th oplast y site is t reated w ith topical steroid oin tm en t for 6 w eeks after surger y to lim it th e proliferat ion of broblast s bet w een 2 to 6 w eeks. Pat ien t s w ith a h istor y of hypert ropic scar or keloid are prescribed t ran ilast (oral T-cell grow th factor [TGF] β-in h ibitor) for 6 to 12 w eeks. Un der-corrected epican th al folds can be revised w ith in th e rst w eek of th e in it ial operat ion . Beyon d th is period, h ow ever, revision s sh ou ld n ot be at tem pted u n t il after 6 m on th s, or u n t il th e hypert roph ic resp on se h as su bsided . Frequen tly, revision s are required due to asym m et r y in

15 th e n al sh apes of th e epican th al fold an d m edial can th al angle. To preven t u n n ecessar y recon st ru ct ive su rgeries, p at ien t s sh ould be provid ed w ith su cien t explan at ion s abou t h ow th e t w o lacrim al caru n cles h ave d i eren t scales of grow th an d direct ion . Hyp ert rop h ic scar is t reated w ith t riam cin olon e inject ion , but th e t riam cin olon e m ust be diluted four t im es m ore th an th e u su al dose. Oth er w ise, th ere cou ld be som e visible w h ite pow ders appearing th rough t ran slucen t skin for a long p eriod . With ou t dilu t ion of th e t riam cin olon e, d erm is at rop hy an d telangiect asia m ay develop .

Reconstructive Epicanthoplasty If the interepicanthal distance is less than 3 cm , then the eyes look too close together. In addition, if m ore than 5 m m of lacrim al caruncle is exposed on both sides, it could cause an uncom fortable look. Besides excessive exposure of the lacrim al caruncle, there could be som e prom inent epicanthoplasty scarring. Reconstructive epicanthoplasty reduces and conceals this scarring and changes the unnatural parallel fold (outfold) into a m ore favorable natural-shaped epicanthal fold. A fu n dam en t al w orkh orse for recon st ruct ive epican th oplast y is th e V-Y advan cem en t ap. Mostly, th e epican th u s inversus appears arou n d th e low er par t of th e ep ican th u s du e to p erp en dicu lar ten sion of th e u pp er part . On e m eth od to t reat su ch a con dit ion cou ld be a back-cu t skin in cision in th e low er p art of th e ep ican th u s (Fig. 15.9). An oth er m eth od is to m ake a long, in feriorly directed V- ap in th e V-Y advan cem en t ap d esign to p reven t ep ican th us inversus. Th e low er in cision of th e V- ap start s from th e m ore lateral sid e of th e back-cu t site an d passes parallel to th e low er cilia an d exten ds to th e m edial side. In stead of th e back-cu t design , th e V- ap is rot ated an d lls th e skin de cien cy. By th is V- ap rot at ion , th e su rgeon

a

d

Epicanthoplast y and Aesthetic Lateral Canthoplast y preven t s back-cut scars an d avoids th e relapse of excessive exp osu re of th e lacrim al caru n cle (Fig. 15.10). Even after recon st ru ct ive epican th op last y, recu rren ce of skin exten sion an d asym m et r y of th e eyes m ay develop. Th us, it is st rongly recom m en ded th at th e surgeon in form pat ien t s about th e possibilit y of developing m icro di eren ce bet w een th e left an d th e righ t , th e p ossibilit y of ad dit ion al operat ion s, an d th e lim it s of th ese operat ion s before su rger y.2

■ Aesthetic Lateral Canthoplasty Gen erally, lateral can th oplast y refers to all of th e su rgeries t ran sform ing th e lateral can th u s. Notably, a lot of Western st u dies h ave com m on ly in t rodu ced lateral can th op last y as a su rgical m eth od th at correct s can th al laxit y or low er lid m alp osit ion an d relieves aging-related sign s on th e low er eyelid an d m idface. “Lateral can th u s exten sion ” surger y perform ed for Asian s as a cosm et ic procedure is also con sidered lateral can th op last y. How ever, to be p recise, lateral can th oplast y is an expan sion of th e lateral can th us an d a resh aping of th e lateral can th al area in clu ding th e angle of lateral can th us. Sin ce th e eyeball is sph erical in sh ape, th e palpebra is a th ree-dim en sion al st ru ct ure. For cosm et ic lateral can th op last y, n ot on ly h orizon t al p alpebral exten sion , but also proper posterior deepen ing sh ould be perform ed so th at a p roper con t act bet w een eyeball an d palp ebral conjun ct iva can be m ain t ain ed.6

Patient Evaluation As w ith ever y cosm et ic eyelid su rger y, it is n ecessar y to ch eck th e pat ien t’s eye con dit ion before u n dergoing lateral can th oplast y. Con siderat ion s in th e select ion of good can -

b

c

e

Fig. 15.9 V-Y advancement and low back-cut design for epicanthal reconstruction. (a) Design without skin traction. (b) Design with skin traction. (c) Sutured state after V-Y advancement. (d) Back-cut for avoiding epicanthus inversus. (e) Sutured state with no skin tension.

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III Blepharoplast y

Surgical Techniques

a

b

Western literat ure h as detailed th e surgical m eth ods for exp an sion of th e lateral can th u s an d h orizon t al exp an sion of th e p alpebral ssu re. Becau se lateral can th oplast y h as been in t roduced as a t reat m en t for bleph aroph im osis an d recon st ru ct ive su rger y, som e su rgical m eth ods are n ot su it able for Asian s w h o w an t th is su rger y for cosm et ic im provem en t on ly.

Von Ammon’s Method c

d

Fig. 15.10 Epicanthal reconstruction with V-Y advancement and rotation ap. (a) V ap design with skin traction. (b) V-Y ap partial advanced state. (c) Rem nant ap rotation. (d) The rotated ap was inset and sutured.

d idates in clu de th e degree of exoph th alm os an d th e locat ion of orbital bon e an d cilia. Gen erally, people w h o h ave exop h th alm ic eyes h ave bet ter at t ach m en t bet w een eyeball an d p alp ebral conju n ct iva after lateral can th op last y th an p eop le w h o h ave en op h th alm ic eyes. In addit ion , pat ien t s w ith exoph th alm ic eyes sh ow m ore visible expan sion of th e lateral can th us from th e front al view. W h en th e dist an ce bet w een th e lateral can th u s an d th e lateral orbit al rim is ver y sm all, p at ien t s h ave low er sat isfact ion after su rger y du e to th e d ecreased h orizon tal expan sion e ect . Lateral can th oplast y is n ot recom m en ded in p at ien ts w h o h ave severe ptosis becau se th e pow er of th e vector occu rring from th e lateral an d p osterior exten sion of th e can th u s ten ds to aggravate upper eyelid ptosis.7,8 Good can didates for aesth et ic lateral can th oplast y are pat ien t s w ith (1) exoph th alm ic eyes, (2) a dist an ce of 4 m m or m ore bet w een th e lateral can th us an d lateral orbit al rim , an d (3) a lateral forn ix deep er th an 3 m m .9

a

Von Am m on’s m eth od is th e oldest procedu re for lateral can th u s expan sion an d h as been used as a lateral can th oplast y m eth od for Asian s. In cise th e full layer of lateral can th us h orizon t ally as desired. Elevate th e conjun ct ival ap m edially from th e lateral en d (Fig. 15.11a). Pu ll th e en d of th e conjun ct ival ap an d sut ure it to th e skin of th e lateral corn er. Th e rem ain ing skin in cision is closed separately. A double-arm ed sut u re is passed th rough th e conjun ct iva at th e can th us, brough t out lateral to th e can th us, an d t ied over a peg (Fig. 15.11b). Th is w ill preven t th e n ew ly form ed forn ix from get t ing roun d an d at an d w ill m ake th e n ew lateral can th u s deeper. Disadvan t ages of th is m eth od are th e exposure of red conjun ct iva w h en th e conju n ct iva is pulled too m uch an d a visible scar at th e lateral part of th e low er eyelid.10

Blaskovics’ Method To perform Blaskovics’ m ethod, m ake a V-shaped incision on the lateral canthus and lean the triangular ap upward (Fig. 15.12a). Make a full-layer incision of the lateral canthus horizontally as in Von Am m on’s m ethod (Fig. 15.12b). Suture the wedge-shaped incision site m ade by elevation of the triangular ap. Trim the skin of the triangular ap and suture to

b

Fig. 15.11 Von Ammon’s method for lateral canthoplast y. (a) After a lateral canthal incision, the conjunctiva is undermined. (b) The conjunctiva is pulled out and sutured to the skin edges. Double-armed sutures are passed through the conjunctiva, brought out lateral to the canthus, and tied over a peg.

15

a

Epicanthoplast y and Aesthetic Lateral Canthoplast y

b

c

Fig. 15.12 Blaskovics’ method for lateral canthoplast y. (a) The lateral canthus is incised as a V shape and a skin ap is made. (b) The skin ap is elevated and the transverse incision is made. (c) The wedge-shaped incision site on the lower lid is closed. The upper eyelid lateral skin ap is trim med and sutured.

the upper and lateral part of the upper eyelid (Fig. 15.12c). Because this surgical m ethod uses skin tension only in the lateral canthus, the e ect of expansion is not dram atic.

Fox’s Method To apply Fox’s m eth od, select a desired lateral exten sion poin t ~ 4 m m aw ay from th e in digen ous lateral can th us (Fig. 15.13a). Split on e-qu ar ter of th e lateral p art of th e u pp er an d low er eyelids bet w een th e an terior an d p osterior lam ellae. Exten d th e sp lit u pp er palp ebral lin e 4 m m m ore follow ing th e exten sion lin e of th e u p p er p alpebral border. Con n ect th e th ree poin t s of x, y, z an d elevate th e ap (Fig. 15.13b,c). Pu ll y to x an d su t u re th em . Elevate th e low er eyelid ap con sidering x′ as th e vertex an d p u ll x′ to z an d su t u re th em . Elevate a conju n ct ival ap of ap prop riate size from th e lateral an d su t u re to th e skin (Fig. 15.13d,e ).

can th oplast y is perform ed on pat ien ts w ith Mongolian slan t , th e lateral can th u s w ill n ot seem to be exten d ed en ough an d th e eyes w ill look m ore slan ted. Com bin ing low ering of th e slan t w ith lateral can th op last y w ill m ake th e eyes look bigger an d m ilder at th e sam e t im e an d en h an ce pat ien t sat isfact ion . How ever, th ese procedu res sh ou ld be ap plied on ly to th e p at ien ts w h o h ave eyes w ith steep Mongolian slan t .

x

y

x' z

a

Shin’s Method

xz

xz In Sh in ’s m et h od , 2 m m of t h e u p p e r cr u s a n d 3 m m of t h e low e r cr u s of t h e lid m a r gin are elevat e d for a rot at ion fla p (Fig. 1 5 .1 4 a,b). Th e elevat e d fla p is u se d for low lat e ral lid ext e n sion . Th e lat e ral e n d of t h e ele vat e d flap is su t u re d t o t h e p e r iost e u m w it h n ylon 6 – 0 t o ext e n d t h e lat e ra l can t h u s lat e ra lly a n d d ow nw ard (Fig. 1 5 .1 4 c). Close all t h e in cision s of t h e lat e ral can t h u s a n d t h e conju n ct iva (Fig. 1 5 .1 4 d). Eve n t u ally, t h e lat e ra l can t h u s w ill b e ext e n d e d lat e ra lly a n d d ow n w a rd . Th is p roce d u re is relat ively sim p le a n d com p lica t ion s a re n ot fre qu e n t ; h ow eve r, t h e lat e ra l ca n t h u s w ill b e low e re d in eve r y p at ie n t .

Lateral Canthoplasty Combined w ith Mongolian Slant Low ering East Asian s are m ore likely to h ave u pw ard-slan ted eyes com pared w ith European s. In dividuals w h o h ave Mongoloid slan t m ay give th e im pression of being angr y. If lateral

x'

yx' y

d

b

xz yx' c

y e

Fig. 15.13 Fox’s method of lateral canthoplast y. (a) Find a desired lateral extension point y ~ 4 mm away from the indigenous lateral canthus. Split one-quarter of the lateral part of the upper and lower eyelids bet ween the anterior and posterior lam ellae. Extend the split upper palpebral line 4 m m more following the extension line of the upper palpebral border. (b,c) Connect the three point s of x, y, z and elevate the ap. Pull z to x and suture them. (d,e) Elevate the lower eyelid ap considering x′ as vertex, and pull x′ to y and suture them. Elevate a conjunctival ap of appropriate size from the lateral end of the conjunctiva toward the m edial side and suture the the end of the ap to y.

191

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III Blepharoplast y

Palpebral conjunctiva 2 mm Cornea

3 mm 5 mm

a

d

Lateral can th al exten sion w ith low ering of th e Mongolian slan t is possible if a t riangu lar ap can be m ade on th e u pp er, lateral par t of th e lateral can th u s as in Sh in’s m eth od of lateral can th oplast y. Usu ally, it is n ot easy to m ake th e t riangular ap in revision cases due to scar. Even in prim ar y su rger y, it is h ard to m ake th e t riangu lar ap if th e distan ce bet w een th e lid m argin an d cilia is too close or if th e cilia are located in th is area. Use th e follow ing tech n iqu e: 1. According to th e slope bet w een th e lateral part of th e upper eyelid an d th e lateral can th us, perform an obliqu e can th otom y st ar t ing from th e lateral can th u s an d exten ding laterally an d in feriorly. Th e length of th e in cision is usually 4 to 5 m m , alth ough it can be longer or sh orter based on th e desired exten ded length (Fig. 15.15). 2. In cise th e conjun ct iva less th an 1 cm at 1–2 m m low er par t of th e tarsal plate of th e low er eyelid. Du ring th e p rocedu re, coagu late th e visible vessels. 3. Make a dissect ion bet w een th e orbicularis ocu li m u scle an d th e orbit al sept u m to secu re a clear view, an d m ake a m in im al in cision of th e orbital sept u m so th at th e lateral orbital fat can be exp osed. 4. W h ile an assist an t t akes th e exposed orbit al fat d ow nw ard, n d th e capsulop alpebral fascia (CPF) at th e rear of th e exposed orbit al fat an d grab it w ith th e forceps.

b

c

Fig. 15.14 Shin’s cosmetic lateral canthoplast y. (a) The palpebaral conjunctiva is exposed with traction. (b,c) Two m illim eters of the upper crus and 3 mm of lower the crus of the lid margin were elevated for the rotation ap. The elevated ap is used for low lateral lid extension. The lateral end of the elevated ap is sutured to the periosteum with nylon 6–0 (star) to extend the lateral canthus laterally and downward. (d) After closure.

5. Penet rate th e CPF using nylon 7–0 an d th en pen et rate th e area you w ish to low er on th e low er border of th e tarsus from side to side, an d su t ure th em .8,11 Th e xat ion locat ion can be ch anged d epen ding on th e am oun t of desired lid low ering. Usu ally, t w o areas of th e CPF are xed on th e tarsal plate (Fig. 15.16). 6. Sut ure the in cision site of th e u pper eyelid m argin exp osed by can th otom y an d x th e lateral en d of th e low er eyelid to th e periosteum of th e lateral orbit al rim using nylon 6–0. En sure th at a n ew lateral can th u s is form ed as desired. 7. To rem ove th e dog-ear skin surroun ding th e lateral can th u s, m ake th e m in im ual in cision follow ing th e cilia on th e low er eyelid, resect th e rem ain ing skin , an d close th e w ou n d.12,13

Postoperative Care Du e to th e n at u re of th e lateral can th al area, th e dressing of a lateral can th op last y is d i cu lt . App lying oin t m en t to th e su rgical site is en ough as p ostop erat ive care. St itch rem oval is perform ed on p ostop erat ive day 7 or 8.

15

Epicanthoplast y and Aesthetic Lateral Canthoplast y

a

b

Cant hotom y

Lowering Enlargem ent of lateral scleral triangle c

d

Lateral cant hal expansion & Mongoloid slant change

Mongoloid slant change

Fig. 15.15 Cosmetic lateral canthoplast y and Mongolian slant lowering. (a) The area of lateral scleral expansion is triangular and colored pink. (b) Following the slope of the upper eyelid, a lateral oblique canthotomy with preseptal dissection is performed. The lateral part of the lower eyelid tarsal plate is xed to the capsulopalpebral fascia (CPF) in t wo sites, using nylon 7–0. (c) Fix the lateral end of lower eyelid to the periosteum of lateral orbital rim using nylon 6–0. The slope of palpebral ssure becomes less steep (from pink to red line). (d) The lateral canthus is extended laterally and downward exposing more sclera.

IO 3.1

IO 3.1

TM

5.4

5.4

CPF

CPF OS

a

Dissection plane

TM

OS

b

Lid lowering

Suture

Fig. 15.16 Mongolian slant lowering. (a) Open the lateral orbital septum and reach the capsulopalpebral fascia (CPF) using the transconjunctival preseptal approach (blue line). (b) Suture the CPF and lower border of the tarsus with nylon 7–0 to lower the lower eyelid (red line).

193

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III Blepharoplast y

■ Case Studies Case 1: Epicanthal Reconstruction A 24-year-old w om an com p lain ed of over-exp osed caru n cle w ith a n ot iceable depressed scar after m edial epic-

a

an th op last y (Fig. 15.17a). Ep ican th al recon st ru ct ion w as don e w ith V-Y advan cem en t an d a rot at ion ap. Th e ap w as elevated from th e dep ressed scar of th e n asal side. After su rger y, a decreased caru n cle exposu re an d m ore n at u ral-looking in tercan th al area w ith ou t n ot iceable scar are obser ved (Fig. 15.17b).

b

Fig. 15.17 Case 1. Before (a) and after (b) epicanthal fold reconstruction. A 24-year-old woman with noticeable depressed scar after medial epicanthoplast y had epicanthal reconstruction with V-Y advancement and a rotation ap. After surgery, caruncle exposure decreased and the intercanthal area looks natural without noticeable scar.

Case 2: Lateral Canthoplasty w ith Mongoloid Slant Low ering A 26-year-old w om an w an ted to m ake h er eyes m ore beau t iful. A physical exam sh ow ed sm all eyes w ith an invisible caru n cle by th e ep ican th al fold, n o double fold, an d

a

Mongolian slan t ing (Fig. 15.18a). Ep ican th oplast y w as perform ed w ith Z-plast y (reverse Fuen te’s design ). Doubleeyelid surger y w as p erform ed u sing th e in cision al m eth od. A lateral can th al exp an sion w ith Mongoloid slan t low ering w as also d on e. After su rger y, th e caru n cle is m ore visible an d h er eyes look bigger an d m ild er th an before su rger y (Fig. 15.18b).

b

Fig. 15.18 Case 2. Lateral canthoplast y and Mongoloid slant lowering. (a) A 26-year-old woman with epicanthal fold, no double fold, and Mongolian slanting had an epicanthoplast y, double-eyelid surgery, and lateral canthoplast y with Mongoloid slant lowering. (b) After surgery, the caruncle is more visible and her eyes look bigger and milder than before surgery.

15

Epicanthoplast y and Aesthetic Lateral Canthoplast y

1. Ch o IC, ed. Th e Art of Bleph aroplast y. Seoul: Koonja; 2013

8. Hw ang K, Ch oi HG, Nam YS, Kim DJ. An atom y of arcu ate exp an sion of cap su lop alpebral fascia. J Cran iofac Su rg 2010;21(1):239–242

2. Baek BS, Park DH, Nah ai F. Cosm et ic an d Recon st ruct ive Ocu loplast ic Su rger y. 3rd ed . Seou l: Koonja; 2009:29

9. Fox SA. Op h th alm ic Plast ic Su rger y. 5th ed. New York, NY: Gru n e & St rat ton ; 1976:223–225

3. Kao YS, Lin CH, Fang RH. Epican th oplast y w ith m odi ed Y-V advan cem en t p rocedu re. Plast Recon st r Su rg 1998; 102(6):1835–1841

10. Von Am m on FA. Klin ish edarstellu ngen der angeh oren en kran kh eiten u n d bildlu ngsfh ler des m en sch lich en der auges u n d der augen lider. Berlin , Germ any: G. Reim er; 1841:6

4. Sh in YH, Hw ang PJ, Hw ang K. V-Y an d rot at ion ap for recon st ruct ion of th e ep ican th al fold. J Cran iofac Su rg 2012;23(4):e278–e280

11. Hw ang K, Kim DJ, Hw ang SH, Ch ung IH. Th e relat ionsh ip of capsu lop alp ebral fascia w ith orbit al sept u m of th e low er eyelid: an an atom ic st udy un der m agn i cat ion . J Cran iofac Surg 2006;17(6):1118–1120

References

5. Oh YW, Seul CH, Yoo W M. Medial epican th oplast y using th e skin redrap ing m eth od . Plast Recon st r Su rg 2007;119(2):703–710 6. Sh in YH, Hw ang K. Cosm et ic lateral can th oplast y. Aesth et ic Plast Su rg 2004;28(5):317–320 7. Baek BS, Park DH, Nah ai F. Cosm et ic an d Recon st ruct ive Ocu loplast ic Su rger y. 3rd ed . Seou l: Koonja; 2009:300

12. Park DH. Anthropom etric analysis of the slant of palpebral ssures. Plast Reconstr Surg 2007;119(5):1624–1626 13. Hiroh i T, Yoshim ura K. Vertical enlargem ent of th e palpebral aperture by static shortening of the anterior and posterior lam ellae of th e lower eyelid: a cosm etic option for Asian eyelids. Plast Recon str Surg 2011;127(1):396–406

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16

Low er Blepharoplasty

Yoon-Duck Kim and Kyung In Woo

Pearls • Th e surgical procedure of low er bleph aroplast y

•

•

•

evolved from fat an d skin excision in to volum e en h an cem en t . A cu stom ized app roach con sid ering each pat ien t’s low er eyelid con gu rat ion is essen t ial to th e su ccess of su rger y. Su rgeon s m u st discu ss w h at th ey can or can n ot do w ith pat ien t s. Fin e or dyn am ic w rin kles, local skin pigm en t at ion , or skin scars can n ot be addressed w ith low er bleph aroplast y, an d th is sh ould be ackn ow ledged to th e p at ien ts w h o w an t low er bleph aroplast y. Th e surgeon sh ou ld ch oose an approach : t ran sconjun ct ival versus t ran scut an eous. A t ran sconjun ct ival approach is ideal for pat ien t s w h o sh ow fat prolapse w ith out skin or eyelid laxit y. A t ran sconju n ct ival ap p roach is also app licable for th ose w h o don’t w an t a skin scar, w h o are u n dergoing reoperat ion for fat prolapse, or w h o h ave a ten den cy to d evelop hyp erp igm en tat ion on a skin in cision site. Th e surgeon m ust decide h ow m uch orbit al fat is to be rem oved or redist ributed. If tear t rough depression is eviden t relat ive to fat prolapse, fat redist ribu t ion is recom m en ded to avoid a postoperat ive h ollow appearan ce. Gen tle pressure to th e globe is h elp fu l in deciding w h eth er or h ow m u ch fat excision is n eeded becau se lying dow n on a su rgical t able does n ot sim u late th e con dit ion s of sit t ing u p .

■ Introduction Th e dem an d for bleph aroplast y am ong person s of East Asian descen t is in creasing in the Un ited States. In a 2013 plast ic surger y stat ist ics report , Asian s/Paci c Islan ders accou n ted for 6.2% of all cosm et ic blep h arop last y procedures in th e Un ited States; th e proport ion for th is procedure w as th e h igh est am ong all cosm et ic su rgical p rocedu res.1 For successful bleph aroplast y for Asian s, un derstan ding of th e ch aracterist ic feat u res of th e eyelid is m ost im port an t . Asian faces h ave m ore m elan in pigm en t an d th icker skin , so th e in cision scar from surger y can be hypert roph ied or hyperpigm en ted.2 Low er eyelids of Asian s are

196

• Th e surgeon m ust assess th e degree of low er eyelid

•

•

•

•

laxit y w ith a sn ap -back test or a lid dist ract ion test an d m ust perform a h orizon tal lid t igh ten ing procedure if th e laxit y is sign i can t en ough to a ect postoperat ive low er lid ret ract ion . Du ring th e fat red ist ribu t ion procedu re, ocu lar m ovem en t sh ou ld n ot be rest ricted on a fat an ch oring su t u re. If th ere is m ovem en t rest rict ion , release th e sut ure, perform fur th er dissect ion , an d con rm th at m ovem en t is n ot h in dered by a rexat ion su t u re. Proper h em ost asis is n eeded during orbit al fat resect ion to avoid th e disast rous com plicat ion of orbit al h em orrh age. Tract ion on th e fat t issue sh ou ld be m in im ized to avoid h em orrh age from th e deeper orbit , an d a clam p -cut-cauter y tech n ique is recom m en ded for resect ion of th e m edial fat p ocket h arboring relat ively large-bored blood vessels. Th e skin excision sh ould be con ser vat ive to avoid low er eyelid ret ract ion during t ran scu t an eou s bleph aroplast y. It is h elpful to h ave th e pat ien t open h is or h er m ou th an d look up w h en th e skin excision am ou n t is m easu red w ith a drap ing m eth od, to m in im ize skin over-resect ion . Postop erat ive cau t ion sh ou ld be st ressed to th e pat ien t to preven t orbit al h em orrh age. Cold com pression is recom m en ded for 48 h ours, an d avoidan ce of h ead dow n posit ion ing an d of physical exert ion sh ou ld be em p h asized.

ch aracterized by a fuller appearan ce th an th ose of Caucasian s, w h ich is cau sed by p rot ru ded orbital fat .3 Asian s h ave heavier soft t issue an d larger am oun t s of m alar fat , w h ich are su bjected to greater gravit at ion al force.2 Th e eyelid an d adjacen t st ru ct u res are t igh t; som et im es w ider in cision s an d exp osu res h ave been advocated in periocu lar su rgeries for Asian pat ien ts.4,5 Th erefore, preoperat ive evalu at ion , judiciou s skin m an ipulat ion , an d proper postoperat ive care are im port an t to en su re a good su rgical ou tcom e for Asian low er eyelid bleph aroplast y. Th e con cept of aging in low er bleph aroplast y h as been ch anged. In conven t ional th ough t , th e periocu lar aging ch ange w as regarded as th e result of th e descen t of m idface, un opposing, w eaken ed supp or t ing st ruct u res an d orbit al

16 fat p rolapse. After th e volu m e de at ion con cept w as in t rod u ced in th e in terpret at ion of th e aging process, aesth et ic ap proach es to p at ien ts h ave been m odi ed t rem en dou sly. In th e h istorical view of su rgical m an agem en t of th e low er eyelid aging process, th e protot yp e procedu re w as orbit al fat excision w ith a t ran scut an eous approach . Low er lid t igh ten ing p rocedures w ere developed to preven t or t reat eyelid m alposit ion , w h ich w as th e m ost com m on com plicat ion of th e conven t ion al tech n ique.6,7,8 Th e t ran sconjun ct ival approach subsequen tly becam e popu lar in bleph aroplast y, as it could preven t postoperat ive eyelid ret ract ion an d leave n o visible scar w h ile providing w id e exposu re.9 Sin ce th e t ran sconju n ct ival app roach w as ap p licable on ly to pat ien t s w h o did n ot n eed skin excision , th e con com itan t skin pin ch tech n iqu e w as used to address th e excess skin in t ran sconju n ct ival blep h arop last y. How ever, for p at ien ts w h o h ad p seu doh ern iat ion of th e fat an d tear t rough depression , rem oving low er eyelid fat can create a con cave con tour deform it y of th e low er eyelids an d cau se a h ollow ap pearan ce.10 In addit ion , deep en ing of th e superior sulcu s h as been n oted after th e orbit al fat rem oval p rocedu re.11 Th erefore, volu m e en h an cem en t h as becom e an im por t an t issue in rejuven at ion of the low er eyelid . Con sequen tly, a custom ized app roach to each p at ien t is essen t ial; th e sp eci c con gu rat ion of each pat ien t n eeds to be assessed an d addressed.12

■ Patient Evaluation Goldberg et al analyzed the con gurat ion of aging low er eyelids in patien ts seeking aesth et ic surger y an d revealed an atom ic factors con t ributing to eyelid bags.12 They assessed patients in six anatom ic categories; tear trough depres-

Lower Blepharoplast y

sion w as th e m ost sign i can t con tribu ting factor, follow ed by orbital fat prolapse, loss of skin elast icit y, eyelid uid, orbicularis prom inence, and t riangular m alar m ound. In an an alysis of low er eyelid aging in an Asian populat ion , Asian s sh ow ed a ten den cy tow ard less con t ribut ion of tear trough defect and m ore con tribut ion of fat prolapse to eyelid bags com pared w ith Caucasian pat ien ts.13 The periocular aging changes can be assessed by analyzing th ese categories.

Tear Trough Depression and Palpebromalar Groove Tear t rough depression occurs at th e in ferom edial aspect of th e low er eyelid. With aging, th is deform it y is seen m ore prom in en tly (Fig. 16.1). Tear t rough dep ression is kn ow n to be ch aracterized by loss of su bcu t an eou s fat an d skin th ickn ess along w ith th e in ferom edial orbit al rim , w h ich is accen t uated by fat prolapse an d ch eek descen t .14 In a m icroscopic st u dy com p aring th e you ng an d th e aged, th e elderly in d ividuals sh ow ed sign i can t t issu e at rop hy in variou s layers, m alar fat at rop hy an d d escen t , an d orbit al fat bu lging.15 To correct tear t rough depression , various tech n iques h ave been t ried, in clu d ing fat redrap ing blep h aroplast y, variou s inject ion s, an d tear t rough im p lan ts of variou s design s. Fat inject ion is n ot a recom m en ded procedure for th is region becau se injected fat ten ds to leave sm all, rm n odules of fat an d scarring, an d p rovides irregu larit y an d sh adow s. Filler inject ion su ch as hyalu ron ic acid gel is in creasing in th is region an d get s favorable result s; h ow ever, repeated inject ion s are n eeded.16 The volum e change in the tear trough area was addressed by Ham ra w ith fat preservation blepharoplasty, w hich corre-

c

a

b

d

Fig. 16.1 Aging changes in the lower eyelid. (a) Orbital fat prolapse is prominent. Tear trough depression (black arrows) and palpebromalar groove (open arrows) are noted. (b) Negative vector con guration with pseudoherniation of fat. Malar depression is noted (arrowhead). (c,d) Oblique line (arrow) is accentuated with facial expression due to prom inent orbicularis oculi muscle.

197

198

III Blepharoplast y sponded to an epoch in lower blepharoplasty.10 Since then, several m odi cations have been introduced. The procedure can be perform ed transconjunctivally or transcutaneously, and the fat can be transposed subperiosteally or supraperiosteally.4,17,18,19,20 To address th e palpebrom alar groove, an orbit al rim depression of th e cen t ral to lateral region , orbital ret ain ing ligam en t release is an im port an t step th at can be com bin ed w ith suborbicularis oculi fat (SOOF) elevat ion or th e orbicularis t igh ten ing procedure.15,19 Sin ce Asian pat ien ts h ave relat ively th icker skin an d su bcu tan eou s t issu e at th e tear t rough or palp ebrom alar region , th e fat resect ion p rocedure alon e can ach ieve a good cosm et ic ou tcom e in selected cases.21

Orbital Fat Prolapse Three orbital fat com partm ents are separated by inferior oblique and arcuate expansion. The pockets are called m edial, central, and lateral fat pockets. It is im portant to have the patient look up during exam ination because the fat pockets are m ore noticeable w hen the patient is looking up. It is also useful to have the patient lie dow n, m im icking intraoperative state, and to see the degree of retroposition of fat preoperatively. Th e tot al volum es of in t raorbital fat an d fat an terior to th e in ferior orbit al rim h ave been sh ow n to in crease u n t il 60 years of age an d th en decrease, in a st u dy of com puted tom ography (CT) an alysis for Korean s.22 Th erefore, an in crease in orbit al fat volu m e is con sidered to con t rib u te to low er eyelid p rom in en ce in Asian p at ien ts. As Asian p at ien t s h ave su bst an t ially m ore prot ru ded orbit al fat , m any art icles h ave asserted th e im p ort an ce of fat resect ion d u ring low er bleph aroplast y for Asian s.15 Fat rem oval w as also st ressed in an oth er grou p , saying th at an Asian pat ien t w ith a brach ioceph alic face m ay n ot be a good can didate for th e fat t ran sp osit ion p rocedu re u n less it is m odi ed by m ore fat rem oval.5 Of n ote, fat resect ion sh ould be p erform ed ju diciou sly, esp ecially for th e aged, to avoid a h ollow look postoperat ively.

Loss of Skin Elasticity Th e low er eyelid skin sh ow s w rin kles an d grooves resulting from sun dam age an d su bcu t an eous volum e loss. A skin t igh ten ing procedure is con sidered if a sign i can t am oun t of skin laxit y is en cou n tered, in cluding surgical resect ion , ch em ical peeling, or laser skin resurfacing. In Asian pat ien ts, skin er yth em a an d hyp erp igm en tat ion can resu lt from skin su rface ablat ion t reat m en t; th erefore, care sh ou ld be taken in deciding th e t reat m en t m odalit y for each p at ien t .23

Eyelid Fluid If u id is accu m u lated in th e low er eyelid from system ic or local edem a, it can m im ic fat prolapse. It can be dist in gu ish ed by its di u se n at u re, u ct u at ion in degree, lack of com par t m en talizat ion , or purplish color w h en it is severe.12

Even th ough th e p resen tat ion of eyelid u id w as fou n d to be ver y rare in a Korean st u dy, it sh ou ld be on e of th e differen t ial diagn oses of fat p rolap se in Asian p eop le.13

Orbicularis Prominence Orbicu laris ocu li p rom in en ce also con t ribu tes to low er eyelid aging feat ures, w ith st at ic an d dyn am ic w rin kles. Horizon t al or oblique lin es accen t uated w ith facial expression s can be n ot iced in m any pat ien ts, an d m ay be m ore com m on in Asian p at ien t s (Fig. 16.1c,d).13,24 Orbicu laris prom in en ce can be dealt w ith by th e orbicularis oculi suspen sion procedure in bleph aroplast y.

Triangular Malar Mound Th e t riangular m alar m ou n d is a uid sponge boun d above by th e orbit al rim ligam en t an d below by th e orbitozygom at ic ligam en t .13 Th is is relat ively rare in Asian p at ien ts.13

Position of the Globe and the Inferior Orbital Rim Th e relat ive posit ion of th e globe an d in ferior orbit al rim sh ou ld be exam in ed p reop erat ively becau se th is is h elp fu l in d eciding w h ich p rocedu re is ap p ropriate for each pat ien t . In th e sagit t al plan e, w h en th e an terior m argin of th e in ferior orbital rim is posterior to th e an terior-m ost poin t of th e corn ea, th e pat ien t h as a n egat ive vector an atom y (Fig. 16.1b). Pat ien t s w ith a n egat ive vector ten d to h ave preoperat ive scleral sh ow du e to m idfacial hypoplasia. Sim p le excision of th e orbit al fat often leads to exacerbat ion of th e tear t rough depression an d in creased scleral sh ow. Pat ien ts in th is categor y sh ou ld be con sidered for fatpreser ving bleph aroplast y. If th e an terior m argin of th e in ferior orbit al rim is an terior to th e an terior-m ost p oin t of th e corn ea, th e p at ien t h as a posit ive vector an atom y. For a pat ien t w ith posit ive vector, con ser vat ive excision of fat is recom m en ded.

Low er Eyelid Laxity Th e m ost sign i can t com plicat ion related to low er bleph aroplast y is eyelid m alp osit ion su ch as ret ract ion or ect ropion .6 To preven t th ese com plicat ion s, preoperat ive evaluat ion of th e low er eyelid laxit y is im por tan t .8 First of all, the eyelid position needs to be recorded as m argin-to-re ex distance 2 (MRD2), w hich is de ned as the distance from the lower eyelid to the corneal light re ex, to docum ent the am ount of preoperative eyelid retraction, if present. Eyelid laxit y can be determ in ed by th e sn ap -back test or the dist ract ion test . With a sn ap -back test , th e restoring force of th e low er eyelid can be assessed after dow nw ard eversion of th e eyelid. If th e eyelid goes back to its n orm al posit ion in st an tly, th e h orizon t al t igh ten ing procedu re

16 w on’t be n ecessar y. If th e eyelid goes back after blin king, h orizon tal t igh ten ing p rocedures such as orbicu laris ocu li su sp en sion m igh t be n eeded. If th e eyelid does n ot go back even after blin king, a lateral t arsal st rip p rocedure is recom m en ded to avoid eyelid ret ract ion after bleph aroplast y. With a dist ract ion test (for w ard t ract ion test), m edial an d lateral can th al ligam en t an d eyelid laxit y can be assessed. If th e eyelid can be p u lled over 8 m m from th e corn ea w ith for w ard t ract ion of th e eyelid, a h orizon t al t igh ten ing procedu re is recom m en ded.

Surgical Considerations in Asian Patients For pat ien t s requiring low er eyelid bleph aroplast y, sign i can t factors in th e aging process in each pat ien t sh ould be assessed an d suggest ive su rgical m eth ods discu ssed w ith th e pat ien t .25 If a p at ien t sh ow s fairly good skin ton e, sim p le fat excision w ith th e t ran sconju n ct ival app roach is th e rst ch oice for prim ar y eyelid bags.21,25 If a pat ien t h as redun dan t skin an d w rin kles w ith ou t sign i can t laxit y of th e eyelid, t ran sconjun ct ival fat rem oval w ith pin ch skin excision or t ran scut an eous fat excision bleph aroplast y can be perform ed.24 Th e orbicularis m u scle t igh ten ing procedure can be added to t ran scu t an eou s bleph aroplast y for th ose w h o sh ow m oderate eyelid la xit y. If a pat ien t h as a tear t rough d ep ression an d m idface sagging resu lt ing in sign i can t volu m e dep let ion at th e in ferom edial orbit al rim , fat t ran sposit ion bleph aroplast y is n eeded t ran sconju n ct ivally or t ran scu t an eously.26 If th e p at ien t sh ow s sign i can t palpebrom alar groove, orbicu laris ret ain ing ligam en t release an d orbicu laris susp en sion an d/or SOOF lift are recom m en ded. Ph otograp h s sh ou ld be t aken p reop erat ively w ith eyelid closed an d open an d w ith th e p at ien t looking up an d d ow n . Th ese p h otos are for legal protect ion or in case of p ostop erat ive p at ien t dissat isfact ion .

Lower Blepharoplast y

th e subconjun ct ival space an d fat pockets. Make a conju n ct ival in cision 3 to 4 m m below th e in ferior m argin of th e tarsus (Fig. 16.2), an d proceed to dissect tow ard th e in ferior orbital rim u n t il th e orbit al fat p ocket s are exp osed (Fig. 16.3). With th is ap p roach , th ere is n o scar form at ion on th e orbit al sept um because th e sept um is n ot violated. Th is ret rosept al t ran sconjun ct ival approach can avoid th e com m on com plicat ion s of low er lid bleph aroplast y su ch as eyelid ret ract ion an d scleral sh ow. A preseptal t ran sconjun ct ival low er bleph aroplast y is also p erform ed by som e su rgeon s: a conju n ct ival in cision is m ade below th e tarsu s, dissect ion th en proceeds in feriorly, an d a presept al space is assessed. Th e orbital sept um is open ed to expose th e orbital fat . Propon en ts of th e presep tal approach suggest th at th e scar form at ion on th e sept um m ay bolster again st th e pseu do-h ern iat ion postoperat ively. No sign i can t di eren ce in eyelid p osit ion bet w een p rean d ret ro-sept al ap proach es h as been rep or ted.27,28

Fig. 16.2 Surgical procedure for transconjunctival fat resection and skin resection with the pinch technique. Conjunctiva is incised 3 to 4 mm below the tarsus (arrowheads).

■ Surgical Techniques Transconjunctival Fat Excision Blepharoplasty With th e t ran sconju n ct ival ap p roach , th e in tegrit y of th e orbicularis m uscle an d th e orbit al sept u m can be m ain tain ed. Equal exposu re to th e fat pads is provided w ith th e t ran scut an eous approach , an d th e skin pin ch tech n ique is allow ed for redu n dan t skin .

Conjunctival Incision Before su rger y, assess th e am ou n t of prolapsed orbit al fat from each com p ar t m en t w h ile th e p at ien t sit s u p . Wait 15 m in u tes for h em ost asis after local an esth et ic inject ion in to

Fig. 16.3 Capsulopalpebral fascia and conjunctiva are pulled with forceps and the lower eyelid is retracted with a Desmarres retractor to expose orbital fat.

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Fat Pocket Exposure

A base of h ern iated orbital fat is clam p ed w ith h em ostat s, an d fat t issu e is cu t w ith scissors an d cau terized w ith a bipolar cauter y (Fig. 16.6). Th e base of fat pedicle

is grasped w ith forceps before releasing th e clam p, an d sh ou ld be ch ecked for bleeding on clam p release. Th e fat pedicle can also be resected w ith a m on opolar cauter y; th e fat p edicle sh ou ld be drap ed on a cot ton sw ab to p rotect th e t issues below an d excised w ith a m on opolar cauter y u sing a Colorado n eedle t ip (St r yker). Th orough h em ostasis is im port an t . If sm all vessels in th e fat pocket ret ract an d bleed in side th e orbit , it is h ard to n d an d t reat th e bleeding focu s. Gen tle pressu re to th e globe is h elpfu l in determ in ing w h eth er an d h ow m uch fat excision is n eeded becau se lying dow n in a su rgical table does n ot represen t th e con dit ion s of sit t ing up. Th e am oun t of fat resect ion from each pocket sh ould be determ in ed by ch ecking preoperat ive ph otograph s an d in t raoperat ive obser vat ion . Th e am oun t s of rem oved fat are com pared bet w een com par t m en t s for sym m et r y of th e eyes. Th e conju n ct ival in cision is closed

Fig. 16.4 Gentle pressure to the eyeball facilitates fat extrusion. Fascial tissue bet ween t wo fat pockets is visible (arrow).

Fig. 16.5 Inferior oblique muscle (arrow) is identi ed with dissection bet ween t wo fat pockets.

In cising th e conju n ct iva an d p u lling it back w ith a low er eyelid ret ractor, fat pocket s becom e visible, especially m edial an d cen t ral fat p ocket s. W h en th e globe is p ressed gen tly, th e orbit al fat can be easily accessed .28 Th ree fat pocket s are iden t i ed w ith fascial dissect ion bet w een th e pocket s (Fig. 16.4). Th e in ferior obliqu e m u scle, w h ich sep arates th e m ed ial an d cen t ral fat p ads, sh ou ld n ot be dam aged to avoid postoperat ive d iplopia (Fig. 16.5).

Fat Excision

a Fig. 16.6

b (a) Medial fat pedicle is clamped with a hemostat. (b) The pedicle is excised and the cut end is cauterized for hemostasis.

16 in terru ptedly w ith 6–0 plain gut or 7–0 Vicr yl (Eth icon ) in a bu ried fash ion so as n ot to irrit ate th e eyeball.

Pinch Skin Excision For th e pat ien t s w h o h ave redun dan t skin after t ran sconjun ct ival bleph aroplast y, th e excessive skin can be addressed u sing th e pin ch tech n iqu e skin excision w h ile preser ving th e orbicularis m uscle.29 Th is tech n iqu e is suited to Asian pat ien t s at risk for pigm entar y ch anges w ith laser or ch em ical peel resu rfacing. Using t w o n e Brow n -Ad son forcep s, th e excess skin is rm ly p in ch ed, creat ing a skin fold from th e lateral can th u s exten ding m edially (Fig. 16.7). Th e fold form s a m axim u m h eigh t below th e lateral can th u s, an d is t ap ered m edially an d laterally. Th rough ou t th is p in ch ing procedu re, th e p osit ion of th e low er eyelid sh ould n ot be draw n dow nw ard. If th e eyelid posit ion is ch anged, th e am oun t of skin pin ch ed sh ou ld be red u ced. St raigh t scissors are u sed to excise th e skin fold, leaving th e orbicu laris m u scle in tact (Fig. 16.8). After h em ostasis, th e skin is closed con t in uously w ith a 6–0 fast-absorbing plain gut or a 7–0 nylon sut ure.

Postoperative Care For postoperat ive care, cold com pression is recom m en ded for 24 to 48 h ou rs to con st rict blood vessels sh ow ing in creased perm eabilit y from su rger y. Pat ien t s sh ou ld take a rest w ith th e h ead elevated an d sh ou ld ch eck th eir vision for 24 h ou rs by self-exam . Th ereafter, w arm com pression is recom m en ded to decrease edem a an d bruising because vascu lar perm eabilit y recovers at th at m om en t . An t ibiot ic eye drops w ith cort icosteroid are adm in ist rated for 1 w eek.

Fig. 16.7 Excess skin is rmly pinched to create a skin fold from the lateral canthus to the medial side.

Lower Blepharoplast y

Transcutaneous Approach The t ranscutaneous approach can be used w hen there is extensive skin excess, m alar bags, or festoon form at ion. W hen concurrent lid tightening procedures are planned, the transcutaneous approach is preferred by m any surgeons.28 After local an esth et ic is injected, a su bciliar y skin in cision is m ade 1 m m below th e lash lin e (Fig. 16.9). Sin ce a su rgical scar over 10 m m lateral to th e lateral can th u s can be not iceable, th e lateral exten sion sh ou ld be m in im ized to an am ou n t ju st su itable to rem ove th e redu n dan t skin an d orbicularis m uscle. Th e lateral por t ion of th e in cision t akes a h orizon tal or dow nw ardly in clin ed path to th e w rin kle lin es, keeping a m in im u m of 5 m m distan ce from th e upper skin in cision lin e to avoid w ebbing in case u pp er blep h aroplast y is con com it an tly perform ed. Th en , a skin -m u scle ap is raised an d dissected from th e orbit al sept u m u sing blu nt an d sh arp dissect ion (Fig. 16.10). Th e th ree com p ar tm en t s of orbital fat are su bsequ en tly exp osed by in cising th e sept um (Fig. 16.11). Th e orbit al fat is in lt rated w ith th e anesth et ic solu t ion an d rem oved u p to th e am oun t w h ere gen tle globe pressu re sh ow s th e an terior surface of th e fat to be th e sam e as th e in ferior orbital rim level. A sm all am ou n t of low er lid pretarsal skin can th en be judiciously excised. It is recom m en ded th at th e su rgeon h ave th e pat ien t look u p an d open th e m ou th w h ile d eterm in ing th e am ou n t of resect ion to avoid over-resect ion (Fig. 16.12). Buried closure w ith a 6–0 absorbable sut ure is n eeded at the lateral can th al region to align th e skin -m u scle aps an d to lessen skin ten sion . Skin m argin s are th en closed con tin uou sly w ith a 7–0 nylon su t ure; m et iculous closure is requ ired for th e lateral por t ion to m in im ize scar form at ion. Th e su t u res are rem oved 4 to 5 days after surger y.

Fig. 16.8

Straight scissors are used to excise the skin fold.

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Fig. 16.9 Transcutaneous lower eyelid blepharoplast y. Skin incision is made with a no.15 B-P blade.

Fig. 16.10

Fig. 16.11

Fig. 16.12 Excessive skin is excised judiciously while the patient is looking up.

The fat pocket is excised with a monopolar cautery.

A skin muscle ap is raised and dissected.

Fat Preservation Blepharoplasty

Subperiosteal Transposition

Fat preser vat ion bleph aroplast y is ben e cial, especially for th ose w h o h ave n egat ive vector an d tear t rough depression . Ham ra origin ally described a sept al reset p roced u re for fatpreser ving bleph aroplast y, w h ich h as been m odi ed.10,20 For th e fat t ran sposit ion procedure, su rgical dissect ion proceeds to th e in ferior orbit al rim after conjun ct ival or t ran scut an eous in cision , an d the orbit al sept um is open ed in feriorly. Th e m edial an d cen t ral fat pocket s are to be t ran sposed over th e orbital rim , an d usually a lateral pocket n eeds to be resected. After fat t ran sp osit ion , com plete sep tal release is recom m en ded to preven t sept al teth ering.19 Th ere are t w o approach es to fat t ran sposit ion .

A su bp eriosteal app roach is claim ed to provide easier dissect ion in th e su bp eriosteal p lan e, w ith less ch an ce of bleeding an d bet ter con tour after fat t ran sposit ion com pared w ith th e supraperiosteal approach .17 After reach ing th e in ferior orbit al rim , a periosteal in cision is m ade w ith a m on op olar cau ter y. Su bp eriosteal dissection is th en p erform ed below th e in fraorbit al rim an d lateral to th e poin t w h ere fat t ran sfer is n eeded. If excess fat is p resen t , p art ial resect ion is p erform ed to im p rove con touring. Sin ce orbital fat is con n ected w ith th e orbit al fascial system –related ocu lar m ot ilit y system , care sh ou ld be t aken n ot to cause any rest rict ion in fash ion ing fat ped-

16 icles. A forced du ct ion test sh ould be adm in istered before t ran sposit ion to verify th at th ere is n o ext raocular m ot ilit y abn orm alit y. Th en t w o m at t ress percu tan eous 4–0 or 5–0 sut ures are n eeded to secure th e fat pedicles in feriorly. Con rm ing th e adequacy of e acem en t of th e tear t rough by th e t ran sposed fat , th e sut ures are t ied over bolsters. Th e su t u res an d bolsters are rem oved in 1 w eek.

Supraperiosteal Transposition A ben e t of th e su praperiosteal approach is easier an esthesia an d dissect ion com pared w ith the subperiosteal approach becau se subperiosteal dissection along th e orbital rim is n ot easy.18 For the supraperiosteal approach , dissect ion is perform ed dow n to the inferior orbital rim after t ran scon ju n ct ival or transcu tan eou s incision . Then careful blunt dissection is com pleted in the plane of th e suborbicularis oculi fat (SOOF) to a level 8 to 12 m m below the orbital rim (Fig. 16.13). Preser vation of th e zygom at ic bran ch of the facial n er ve during dissection is essent ial; the critical zone is a circle w ith a diam eter of 1 cm located 2.5 cm aw ay from th e lateral can th us at an angle of 30 degree.30 If the dissection is don e too far in feriorly, orbicularis den er vation an d ect ropion m igh t resu lt .18 Th e vascularit y of th is plan e necessitates proper hem ostasis; in fact, it is claim ed th at this m ay cont ribute to in creased sur vival of the fat pedicle.18 Each fat pocket is open ed, an d th e fat is allow ed to prolapse over th e in ferior orbit al rim . Part ial fat excision is d on e as n ecessar y. On e or t w o m at t ress 5–0 sut ures are ap plied to th e fat p edicle an d p eriosteu m or SOOF p ocket

Fig. 16.13 Surgical procedures of fat repositioning blepharoplast y. A blunt dissection is made below the orbital rim.

Lower Blepharoplast y

(Fig. 16.14). Du e to th e su p er cial p lan e of dissect ion , orbit al fat can be m ore apparen t or lum py after surger y. Th is sh or t-term h arden ing of th e t ran sposed fat resolves w ith t im e an d in t ralesion al steroid inject ion .

SOOF Lifting Th is procedure is ver y useful for palpebrom alar groove correct ion . A palpebrom alar groove is exacerbated by th e descen t an d decreased volum e of th e m alar fat pads an d SOOF. Th erefore, th e SOOF lift p roced u re along w ith an orbicularis-retain ing ligam en t release tech n ique can ll th e defect .19,27

Orbicularis-Retaining Ligament Release and Orbitomalar Suspension After reach ing th e in ferior orbital rim , th e orbicu larisretain ing ligam en t is released; th e at t ach m en t s of th e orbicularis-retain ing ligam en t are liberated in feriorly an d laterally w ith blun t dissect ion an d cut t ing cauter y in th e preperiosteal plan e. Th e origin of the orbicularis-retain ing ligam en t an d SOOF can be su spen ded w ith a 5–0 Prolen e (Eth icon ) sut ure to th e su perior-m ost par t of th e lateral orbit al rim . Th ey can also be su spen ded to th e superolateral orbit al rim of th e lateral orbital w all via th e u pp er eyelid bleph arop last y in cision in case u pper blep h aroplast y is perform ed sim ult an eously. More su t ure resuspen sion is perform ed to th e presept al orbicularis in case sign i can t orbicularis laxit y is fou n d.19

Fig. 16.14 The fat pedicle is transposed and periosteum.

xed to the

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Horizontal Laxity Correction Procedures For pat ien t s w ith preoperat ive eyelid laxit y or eyelid m alposit ion such as low er scleral sh ow, a low er eyelid t igh ten ing p rocedu re sh ou ld be p erform ed at th e sam e t im e as low er bleph arop last y. Am ong th e variou s m eth ods p erform ed for h orizon t al laxit y correct ion , som e easily applicable an d e ect ive procedures are described n ext . Orbicu laris ocu li su spen sion is an e ect ive m eth od for th e pat ien t w ith m ild low er eyelid laxit y an d is an adjun ct ive procedu re to t ran scutan eous approach bleph aroplast y. Min im ally invasive lateral can th op last y is an oth er good procedure, on e w h ich doesn’t violate th e an atom y of th e m u cocu tan eou s lateral can th al angle. If m ore sign i can t low er eyelid laxit y is fou n d, a h orizon tal eyelid st rength en ing p rocedu re su ch as th e lateral t arsal st rip p rocedu re is n eeded to preven t postoperat ive eyelid ect ropion or ret ract ion .

Orbicularis Oculi Suspension Mild h orizon t al laxit y can be add ressed by th is procedu re w ith th e t ran scut an eous approach . After orbit al fat resect ion or th e t ran sposit ion m an euver is com pleted, th e skin m u scle ap is drap ed an d orbicu laris m u scle su spen sion is perform ed. Th e presept al orbicularis m u scle is sut u red to th e periosteu m of th e lateral orbit al rim w ith a 5–0 m on o lam en t su t u re. Th e ten sion an d xat ion p oin t of th e orbicularis sh ould be tailored so as n ot to result in lateral can th al posit ion abn orm alit y.

Minimally Invasive Lateral Canthoplasty Th is procedure can be added to eith er th e t ran sconjun ct ival or t ran scu t an eou s app roach . Th rough a sm all lateral or stan dard u p per crease in cision for u p p er bleph aroplast y, th e lateral orbit al rim an d th e lateral can th al ten don are exp osed . Th en th e lateral can th al ten don is dissected from it s p eriosteal at t ach m en t . If lateral fat is prom inen t , th e orbit al fat pad can be debulked th rough th e sam e in cision . If eyelid laxit y is sign i can t , th e lateral low er tarsu s is t rim m ed. A d ouble-arm ed, 4–0 absorbable su t ure is used to re-at tach th e lateral can th u s to W h it n all’s t u bercle. After t w o n eedles are passed th rough th e sam e spot of th e lateral p ar t of th e low er eyelid at th e gray lin e, on e arm p asses th e low er h alf of th e t arsus an d th e oth er, m ore super cial arm p asses th e u p per t arsu s. Th e su t u res are th en t ied an d secu red below th e crease skin in cision .31

Lateral Tarsal Strip Procedure Th e lateral tarsal st rip procedu re is a t radit ion al m eth od of h orizon t al laxit y correct ion . A lateral can th al in cision is m ade, w h ich is follow ed by release of th e in ferior cru s of th e lateral can th al ten don to m obilize th e low er eyelid com pletely. Th e proper am ou n t of t arsus to sh or ten is m arked an d th e lateral t arsal st rip is m ade; th e eyelid m argin is t rim m ed, th e low er tarsal border is severed from th e eyelid ret ractor, an d th e t arsal conju n ct iva is scrap ed o . Th e tarsal st rip is resu spen ded to th e periosteum ju st in side th e lateral orbital rim w ith 5–0 Prolen e su t u re. Lateral can th al form ing sut ure, a buried sut ure re-align ing th e gray lin es of th e upper an d low er eyelids, is th en placed w ith 7–0 Vicr yl.

■ Key Technical Points 1. As East Asian pat ien t s ten d to h ave th icker an d darker skin th an Caucasian s, skin m an ipulat ion sh ou ld be m in im ized to avoid hyp ert rop h ic scar form at ion . 2. Skin resect ion sh ould be con ser vat ive du ring t ran scut an eous bleph aroplast y. Having th e pat ien t gaze u pw ard w ith th e m ou th op en is a valu able m an euver to p reven t skin over-resect ion . 3. Orbital fat is covered w ith th in sh eath s con tain ing blood vessels. Tract ion on orbit al fat can tear deep orbit al vessels an d m ay precipit ate orbit al h em orrh age. 4. Fat over-resection should be avoided. Under-corrected fat can be addressed w ith a second procedure; how ever, overzealous rem oval results in a hollow appearan ce and precludes furth er corrective surger y. 5. Orbicu laris su spen sion is a useful tech n ique for Asian pat ien t s n ot on ly for h orizon t al laxit y correct ion , bu t also for cosm et ic ou tcom es. Th is is du e to th e ver y large n um ber of Asian s h aving severe laxit y of th e orbicularis m u scle an d deep skin w rin kles associated w ith it . 6. An in t raoperat ive sit t ing posit ion for th e pat ien t is h elpfu l to ch eck for th e presen ce of ect rop ion , ret ract ion , or th e presen ce of residual fat because th ese con dit ion s can be cam ou aged in a su pin e posit ion . 7. Th e essen t ial factors in m in im izing th e com plicat ion of low er eyelid m alposit ion in a t ran scutan eous bleph aroplast y are m axim izing pret arsal orbicularis, con ser vat ive excision of low er eyelid skin, correct ing eyelid laxit y, an d su sp en sion of th e orbicu laris m u scle to th e lateral orbit al rim .27

16

■ Complications and Their Management

Com plicat ion s of low er bleph aroplast y sh ould be preven ted during surger y an d t reated properly if th ey occur. Th e m ost frequ en t com p licat ion resu lt ing from low er blep h aroplast y is eyelid m alposit ion , alth ough m ore seriou s com plicat ion s su ch as visu al loss h ave been rep or ted.

Eyelid Retraction Eyelid ret ract ion can resu lt from several factors related to low er bleph arop last y. Pat ien t s w h o h ave n egat ive vector con gurat ion are predisposed to eyelid ret ract ion , an d loss of orbicularis m uscle fun ct ion from surgical in ter ven t ion also con t ribu tes to th e eyelid posit ion . Fu rth erm ore, m id dle eyelid lam ellar sh orten ing an d t igh ten ing from surger y also a ect low er eyelid p osit ion .32,33 As t im e elapses after surger y, eyelid sw elling an d in am m at ion su bside an d orbicularis ton e is gain ed. Th erefore, su p port ive care is im p or t an t in th e early postoperat ive period, in cluding eyelid taping, steroid inject ion , an d th e use of an an t i-in am m ator y agen t . If th e ret raction is associated w ith sign i cant m iddle lam ellar shortening and tightening, surgical inter vent ion is unavoidable. Forced upw ard t raction testing to see if the eyelid can be elevated w ith a surgeon’s nger is im portan t to evalu ate th e tigh t ness in th e m iddle lam ella. In case m iddle lam ellar con tract ure is evident , m iddle lam ellar release and a spacer graft to relieve th e vertical tigh t n ess are n eeded. For a m iddle lam ellar spacer, hard palate, ear cartilage, or a cellular derm is (AlloDerm , LifeCell) is frequently used.

a

Lower Blepharoplast y

Ectropion Ect ropion can occur tem porarily du e to low er eyelid sw elling in case of eyelid laxit y, or perm an en tly w ith th e an terior lam ellar sh or tage from excessive skin excision (Fig. 16.15). Ju diciou s skin excision du ring su rger y is essen t ial as a p reven t ive m easu re. If ectropion occurs a few days after surgery w ith in am m atory signs, upward eyelid taping and an intrafat pad steroid injection can lessen the condition, reducing the postsurgical in am m ation reaction. If ectropion persists, watchful waiting w ith m assaging and use of steroid ointm ent is recom m ended for 3 to 6 m onths before surgical correction is perform ed. Horizon t al eyelid t igh ten ing procedu res are n eeded if low er eyelid laxit y is sign i can t . A SOOF lift or skin graft can be applied to an terior lam ellar length en ing. Th e SOOF lift procedure sh ould be t ried prim arily, if possible, because a skin graft m ay leave cosm et ic blem ish an d u n accept able scarring in th e Asian p op u lat ion .

Asymmetric or Lumpy Appearance Fault y est im at ion of fat prolapse preoperat ively or im proper debu lking of fat pads during su rger y m ay resu lt in an asym m et ric ap pearan ce bet w een th e t w o eyelids. Residu al fat prolapse can be corrected w ith furth er resect ion after 6 to 8 w eeks, w h ile a sun ken appearan ce can be revised w ith a fat graft from th e con t ralateral fat p ad or elsew h ere. A prom in en t lateral fat pad m ay be foun d after t ran sconjun ct ival bleph aroplast y for pat ien t s w h o h ave excessive fat p rot ru sion in th e lateral fat p ad. Reresect ion th rough a n ew, sm all skin in cision at th e lateral can th al area m ay relieve th e lu m py ap p earan ce.

b

Fig. 16.15 Ectropion complicated lower blepharoplast y on the left eye. (a) SOOF lift and lateral tarsal strip were performed to correct anterior lam ellar shortage and horizontal laxit y. (b) Three months after surgery.

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III Blepharoplast y

Diplopia Dip lop ia can resu lt , tem p orarily, from sw elling of ext raocular m uscles or from e ects of local an esth et ics, w h ich t yp ically reverse postop erat ively. If diplop ia persist s in th e postoperat ive period, th e causes of diplopia sh ould be assessed w ith com plete exam in at ion s. In ferior obliqu e m u scle inju r y can resu lt from in adverten t m edial an d cen t ral fat pad excision because th e m uscle is located bet w een t w o fat p ockets. In ferior rect us paresis an d m ech an ical rest rict ion h ave also been reported .34,35 In fat p reser vat ion blep h aroplast y, ext raocu lar m ovem en t abn orm alit y also h as been reported in relat ion to fat ped icle t ran sposit ion .36 A forced duct ion test n eeds to be perform ed after fat pedicle xat ion to avoid th is com p licat ion . If a rest rict ion on eyeball m ovem en t is foun d in t raoperat ively, th e xat ion sut u re ough t to be released an d fu rth er d issect ion sh ou ld be p erform ed. Th en a re xat ion su t u re is placed. If the rest rict ion is n ot iced after th e su rger y, m ild sym ptom s w ill u su ally be relieved by ver t ical forced ocular m ovem ent exercise an d w ait ing. In case th e rest rict ion is n ot recovered, th e fat pedicle an d adjacen t t issues can be released or st rabism us surger y m ay be p erform ed.34 Mech an ical oscillop sia h as also been rep orted after t ran scut an eou s fat reposit ion ing blep h arop last y, an d can be am eliorated by severing th e cicat rix bet w een th e in ferior obliqu e m u scle an d th e an terior sup er cial m u sculo-apon eurot ic system .37

Conjunctival Chemosis Th e m an age m e n t of p e rsist e n t conju n ct ival ch e m osis aft e r low e r b le p h arop last y is ch alle n gin g. Low e r ble p h arop last y u sin g e it h e r a t ran sconju n ct ival or a t ran scu t an e ou s ap p roach can be com p licat e d w it h ch e m osis. Th ough t h e exact m e ch an ism h as n ot be e n est ablish e d , in crease d vascu lar p e r m eab ilit y aft e r su rge r y an d b lockage in lym p h at ic an d ve n ou s d rain age are con sid e re d to e e ct conju n ct ival ch e m osis. Th e r isk fact ors for d evelop in g d r y eye sym p tom s an d ch e m osis w e re re p or t e d to in crease w it h in t raop e rat ive can t h op exy, p ostop e rat ive te m p orar y lagop h t h alm os, con cu r re n t u p p e r an d low e r ble p h arop last y, an d t ran scu t an e ou s ap p roach es violat in g t h e orb icu lar is m u scle.38 In th e early p ostop erat ive period, a p ressu re patch w ith steroid eye oin t m en t an d oral steroid m edicat ion can h elp to lessen an in am m ator y react ion . As m ost cases recover in several w eeks to m on th s, art i cial tear drops an d oin tm en t u sage are requ ired w ith ou t sp eci c t reat m en t in th e early postop erat ive p eriod .

If ch em osis p ersists, su rgical in ter ven t ion is w arran ted . Treat m en t s in clud ing perilim bal n eedle m an ipulat ion an d conjun ct ivoplast y h ave been reported.39,40 High -frequen cy radio w ave elect rosu rger y h as been p erform ed for p ersisten t ch em osis, w ith en cou raging result s.41

Orbital Hemorrhage The m ost detrim ental com plicat ion of cosm et ic blepharoplast y is visual loss related to orbital hem orrh age, w hich can occur in 1 of 22,000 surgeries.42 Preoperative evalu ation of m edicat ion histor y is im portant , and ant icoagulat ion drugs and h erbal supplem ents should be discon tinued to prevent th is problem . Intraoperatively, gentle m anipulat ion is required as orbital h em orrh age can result from vascular rupt ures in th e deeper orbit from in adverten t dragging of the fat pedicle. Pat ients sh ould be inform ed of th e need for em ergen cy care if orbital pain an d visual im pairm en t occu r. Presept al h em atom a m ay occu r after low er bleph arop last y an d is m an aged w ith local cold com p ression an d h ead elevat ion w ith ou t h em atom a drain age.43 Usu ally, p resept al h em atom a d oes n ot a ect visu al acu it y or th e n al outcom e un less a ret robulbar h em atom a coexists. Ret robulbar h em atom a can a ect vision from ret in al vascu lar com p rom ise or opt ic n er ve com p ression du e to in creased in t raorbital pressu re. Severe pain , exop h th alm os, visu al im p airm en t , lim itat ion of ext raocu lar m ovem en t , an d in creased in t raocu lar p ressu re can be m an ifested . If cen t ral ret in al ar ter y occlusion is detected w ith fun du s exam in at ion , em ergen cy care sh ou ld be p rovided w ith ou t delay, because th is is a t rue oph th alm ic em ergen cy an d is associated w ith poor p rogn osis for visu al recover y. If a t e n se orb it from ret rob u lb ar h e m atom a is p rese n t , e m e rge n t late ral can t h ot om y an d in fe r ior can t h olysis sh ou ld be p e r for m e d to d e com p ress t h e orbit al p ressu re; t h e n su rgical w ou n d exp lorat ion sh ou ld b e d on e.4 3 A syst e m ic cor t icost e roid can be ad m in ist e re d to p reve n t or m an age isch e m ic op t ic n e u rop at h y. If visu al acu it y is n ot regain e d , b ony orbit al d e com p ression can b e con sid e re d .

■ Case Studies Case 1 A 62-year-old fem ale pat ien t h ad fat prolap se an d prom in en t orbicularis w ith out sign i can t skin or eyelid laxit y. Sh e u n der w en t fat rem oval an d orbicu laris su sp en sion w ith th e t ran scut an eous approach (Fig. 16.16).

16

a

Lower Blepharoplast y

b

Fig. 16.16 Case 1. Transcutaneous blepharoplast y with the orbicularis oculi suspension procedure was done in a 62-year-old female. (a) Preoperative photo showing prominent orbicularis (arrow). (b) One year after surgery.

Case 2 A 58-year-old fem ale p at ien t sh ow ed tear t rough dep ression , p alp ebrom alar groove, an d m ild orbicu laris p rom in en ce. Each com pon en t w as addressed. Fat reposit ion ing, orbitom alar ligam en t release an d SOOF lift to th e upper part of th e lateral orbit al w all, an d orbicularis m uscle resuspen sion w ere perform ed (Fig. 16.17).

a

b

Fig. 16.17 Case 2. A 58-year-old female patient with a negative vector con guration. Fat repositioning, SOOF lift, and orbicularis m uscle anchoring with the transcutaneous approach were performed. (a) Before the surgery. (b) One year after the surgery. A skin wrinkle line is moved upward with this procedure (arrows).

207

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References 1. Am erican Society of Plastic Surgeons. 2013. Plastic Surgery Statistics Report. Available at: http://w w w.plasticsurgery.org/ Docum ents/news-resources/statistics/2013-statistics/plasticsurgery-statistics-full-report-2013.pdf. Accessed 2015 2. Shirakabe Y, Suzuki Y, Lam SM. A new paradigm for the aging Asian face. Aesthetic Plast Surg 2003;27(5):397–402 3. Carter SR, Sei SR, Gran t PE, Vign eron DB. Th e Asian low er eyelid: a com parat ive an atom ic st u dy using h igh -resolut ion m agn et ic reson an ce im aging. Op h th al Plast Recon st r Surg 1998;14(4):227–234 4. Liao SL, Wei YH. Fat reposit ion ing via supraperiosteal dissect ion w ith in tern al xat ion for tear t rough deform it y in an Asian popu lat ion . Graefes Arch Clin Exp Ophth alm ol 2011;249(11):1735–1741 5. Kaw am oto HK, Bradley JP. Th e tear “TROUF” procedure: t ran sconju n ct ival rep osit ion ing of orbital u n ip edicled fat . Plast Recon st r Su rg 2003;112(7):1903–1907, discu ssion 1908–1909 6. McCord CD Jr, Shore JW. Avoidan ce of com plicat ion s in low er lid blep h arop last y. Oph th alm ology 1983;90(9): 1039–1046 7. Shorr N, Fallor MK. “Madam e Butter y” procedure: com bined cheek and lateral canthal suspension procedure for post-blepharoplast y, “round eye,” and lower eyelid retraction. Ophthal Plast Reconstr Surg 1985;1(4):229–235 8. Jacobs SW. Prophylactic lateral canthopexy in lower blepharoplasties. Arch Facial Plast Surg 2003;5(3):267–271 9. Zarem HA, Resn ick JI. Expan ded applicat ion s for t ran sconju n ct ival low er lid bleph aroplast y. Plast Recon st r Su rg 1991;88(2):215–220, discussion 221 10. Ham ra ST. Arcu s m argin alis release an d orbit al fat p reser vat ion in m idface rejuven at ion . Plast Recon st r Surg 1995;96(2):354–362 11. Sch iller JD, Lin S, Neigel JM. Deep en ing of th e su p erior su lcu s after isolated low er t ran sconju n ct ival blep h arop last y. Op h th al Plast Recon st r Su rg 2004;20(6):433–435 12. Goldberg RA, McCan n JD, Fiasch et t i D, Ben Sim on GJ. W h at causes eyelid bags? An alysis of 114 con secut ive pat ien t s. Plast Recon st r Su rg 2005;115(5):1395–1402, discu ssion 1403–1404 13. Lee H, Ah n SM, Ch ang M, Park M, Baek S. An alysis of low er eyelid aging in an Asian pop u lat ion for cu stom ized low er eyelid bleph arop last y. J Cran iofac Su rg 2014;25(2): 348–351 14. Flowers RS. Tear trough im plants for correction of tear trough deform it y. Clin Plast Surg 1993;20(2):403–415 15. Yang C, Zh ang P, Xing X. Tear t rough an d p alp ebrom alar groove in you ng versu s elderly adu lt s: a sect ion al an atom y st u dy. Plast Recon st r Su rg 2013;132(4):796–808 16. Lam bros V. Models of facial aging an d im p licat ion s for t reat m en t . Clin Plast Su rg 2008;35(3):319–327, discu ssion 317 17. Goldberg RA. Tran sconju n ct ival orbit al fat rep osit ion ing: t ran sposit ion of orbit al fat pedicles in to a subperiosteal pocket . Plast Recon st r Su rg 2000;105(2):743–748, d iscu ssion 749–751

18. Moh adjer Y, Holds JB. Cosm et ic low er eyelid blep h aroplast y w ith fat reposit ion ing via in t ra-SOOF dissect ion: su rgical tech n iqu e an d in it ial ou tcom es. Op h th al Plast Recon st r Surg 2006;22(6):409–413 19. Korn BS, Kikkaw a DO, Coh en SR. Tran scu t an eou s low er eyelid bleph aroplast y w ith orbitom alar su spen sion : retrosp ect ive review of 212 con secu t ive cases. Plast Recon st r Surg 2010;125(1):315–323 20. Ham ra ST. The role of the septal reset in creating a youthful eyelid-cheek complex in facial rejuvenation. Plast Reconstr Surg 2004;113(7):2124–2141, discussion 2142–2144 21. Kim SW, Kim WS, Cho MK, W hang KU. Transconjunct ival laser bleph aroplast y of low er eyelids: Asian experien ce w ith 1,340 cases. Derm atol Su rg 2003;29(1):74–79 22. Lee JM, Lee H, Park M, Lee TE, Lee YH, Baek S. Th e volu m etric ch ange of orbit al fat w ith age in Asian s. Ann Plast Surg 2011;66(2):192–195 23. Rich ter AL, Barrera J, Marku s RF, Brisset t A. Laser skin t reat m en t in n on - Cau casian pat ien t s. Facial Plast Su rg Clin North Am 2014;22(3):439–446 24. Ren L, Yang D, Song Z, Ying L. Tran sconju n ct ival low er bleph aroplast y for Ch in ese pat ien t s com bin ed w ith a subciliar y in cision for skin rem oval. Aesth et ic Plast Surg 2011;35(4):677–680 25. Gu o L, Bi H, Xu e C, et al. Com p reh en sive con siderat ion s in bleph aroplast y in an Asian populat ion : a 10-year experien ce. Aesth et ic Plast Surg 2010;34(4):466–474 26. Mom osaw a A, Ku rit a M, Ozaki M, et al. Tran sconju n ct ival orbit al fat reposit ion ing for tear t rough deform it y in you ng Asian s. Aesth et Su rg J 2008;28(3):265–271 27. Gran t JR, Laferriere KA. Periocu lar rejuven at ion : low er eyelid bleph aroplast y w ith fat reposit ioning an d th e suborbicu laris oculi fat . Facial Plast Surg Clin North Am 2010;18(3):399–409 28. Peng GL, Jacon o A, Massr y GG. Globe ret ropu lsion an d eyelid depression (GRED)—a surgeon -con t rolled, un im an ual m an euver to access p ost sept al fat in t ran sconjun ct ival low er blep h aroplast y. Op h th al Plast Recon st r Su rg 2014;30(3):273–274 29. Rosen eld LK. Th e pin ch bleph aroplast y revisited. Plast Recon st r Surg 2005;115(5):1405–1412, discu ssion 1413–1414 30. Hw ang K. Su rgical an atom y of th e low er eyelid relating to low er bleph aroplast y. An at Cell Biol 2010;43(1): 15–24 31. Taban M, Nakra T, Hwang C, et al. Aesthetic lateral canthoplast y. Ophthal Plast Reconstr Surg 2010;26(3):190–194 32. Goldberg RA. Review of p rophylact ic lateral can th opexy in low er bleph aroplast ies. Arch Facial Plast Surg 2003; 5(3):272–275 33. McCord CD, Bosw ell CB, Hester TR. Lateral can th al an ch oring. Plast Recon st r Su rg 2003;112(1):222–237, discu ssion 238–239 34. Syn iu t a LA, Goldberg RA, Th acker NM, Rosen bau m AL. Acquired st rabism us follow ing cosm et ic bleph aroplast y. Plast Recon st r Su rg 2003;111(6):2053–2059 35. Pirou zian A, Goldberg RA, Dem er JL. In ferior rect u s pu lley h in dran ce: a m ech anism of rest rict ive hypert ropia follow ing low er lid su rger y. J AAPOS 2004;8(4):338–344

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36. Goldberg RA, Yuen VH. Rest ricted ocu lar m ovem en t s follow ing low er eyelid fat rep osit ion ing. Plast Recon st r Su rg 2002;110(1):302–305, discussion 306–308

40. Jon es YJ, Georgescu D, McCan n JD, An d erson RL. Sn ip con jun ct ivoplast y for postoperat ive conju n ct ival ch em osis. Arch Facial Plast Su rg 2010;12(2):103–105

37. Th in da S, Vaph iades MS, Maw n LA. Mech an ical oscillopsia after low er eyelid blepharoplast y w ith fat reposit ion ing. J Neu rooph th alm ol 2013;33(1):71–73

41. Woo KI, Ch oi CY. High -frequ en cy radiow ave elect rosu rger y for persisten t conju nct ival ch em osis follow ing cosm et ic bleph arop last y. Plast Recon st r Surg 2014;133(6): 1336–1342

38. Prisch m ann J, Sufyan A, Ting JY, Ru n C, Perkins SW. Dry eye sym ptom s an d chem osis follow ing blepharoplast y: a 10-year retrospective review of 892 cases in a single-surgeon series. JAMA Facial Plast Surg 2013;15(1):39–46 39. Cheng JH, Lu DW. Perilim bal needle m anipulation of conjunctival chem osis after cosm etic lower eyelid blepharoplast y. Ophthal Plast Reconstr Surg 2007;23(2):167–169

42. Hass AN, Pen n e RB, Stefanyszyn MA, Flan agan JC. In ciden ce of postbleph aroplast y orbit al h em orrh age an d associated visu al loss. Op h th al Plast Recon st r Su rg 2004;20(6): 426–432 43. W h ip p le KM, Korn BS, Kikkaw a DO. Recogn izing an d m an aging com p licat ion s in blep h arop last y. Facial Plast Su rg Clin North Am 2013;21(4):625–637

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17

Correction of Ptosis

Woong Chul Choi and Juwan Park

Pearls • Margin -re ex d ist an ce 1 (MRD1, distan ce from th e

• •

• •

210

corn eal ligh t re ex to th e upper lid m argin ) in a sit t ing p osit ion is th e m ost im p or tan t param eter for ptosis evaluat ion . Histor y, levator fu n ct ion test , an d m easu rem en t of lid lag on dow n -gaze help di eren t iate bet w een ap on eu rot ic an d congen ital ptosis. Levator fu n ct ion is th e m ost im port an t p aram eter in determ in ing th e su rgical m eth od (levator advan cem en t , fron t alis sling, etc.) an d th e m ost reliable predictor of surgical respon se. Mild ptosis w ith good levator fu n ct ion can be t reated w ith conju n ct ivo-Mü llerectom y. Bilateral su rger y is m ore likely to be predict able an d reliable th an un ilateral surger y, especially in elderly pat ien t s or pat ien t s w ith poor levator fun ct ion .

• Th e burden factors such as redun dan t skin,

•

• • •

orbicularis m u scle, an d fat sh ould be addressed because th ey can aggravate th e ptosis or cause su bclin ical ptosis. St ru ct u ral w eakn ess an d th e pretarsal fat pad are m ore easily seen in th e m edial part am ong eld erly East Asian s, an d an e or t to overcom e th ose factors is required for bet ter resu lt s. Addit ion al p rocedu res to form a lid crease after ptosis correct ion are usually required for a du rable lid crease form at ion in Asian pat ien t s. Met icu lou s h em ostasis an d in t raop erat ive cooling are h elpfu l in im proving th e accuracy of in t raoperat ive adjust m en t . Asym m et r y after ptosis repair can be xed in th e early postop erat ive p eriod of a w eek or so.

■ Introduction

■ History of Ptosis Surgery

Up p er eyelid ptosis is evalu ated by m argin -re ex d ist an ce 1 (MRD1), w h ich is t h e d ist an ce from t h e cor n eal ligh t re ex to t h e u p p er lid m argin an d n or m ally ran ges from 3.5 to 4.5 m m in Cau casian s. How ever, MRD1 dep en d s on age, sex, an d race an d ten d s to sh ow low er valu es in t h e eld erly, m ales, an d Asian s. Un ilateral ptosis is d iagn osed w h en on e eyelid is p osit ion ed over 2 m m low er t h an t h e ot h er eyelid . Th e levator p alp ebral m u scle is t h e p r im ar y u p p e r eyelid ret ract or. Th e Mü lle r an d fron t alis m u scles are also in volve d in lift in g t h e u p p e r eyelid . Fu n ct ion al or an atom ic abn or m alit ies of t h e u p p e r eyelid ret ractors (m ost ly t h e levator m u scle an d ap on e u rosis) are t h e m ain reason s for ble p h arop tosis. Pat ie n t s w it h p to sis u su ally sh ow brow elevat ion be cau se t h e fron t alis m u scle is ove r u se d to com p e n sate for t h e w eak p r im ar y u p p e r eyelid ret ractor. In con t rast to t ru e blep h aroptosis, pseu doptosis is n ot associated w ith abn orm alit ies of th e ret ractors. Com m on causes of pseudoptosis are con t ralateral lid ret ract ion , hypot ropia, en oph th alm os or con t ralateral exoph th alm os, pu y lid in Asian s, an d derm atoch alasis (skin redun dan cy w ith out apon eu rot ic ptosis).

Ptosis surger y has show n m any revolut ionar y changes as our know ledge of anatom ic and physiologic processes h as expanded. In addit ion, expansion of the variet y of m aterials h as revolut ion ized th e eld of ptosis surger y sin ce its an cien t h istor y. Referen ces sh ow th at th e earliest t reatm en ts w ere perform ed by an cien t Arabian oph th alm ologists. More recen t descript ion s w ere provided by Scarpa, an Italian an atom ist and su rgeon, in 1806.1,2 How ever, th e referen ces from th e early days regarding th e treatm en t of ptosis, resecting the upper part of the eyelid, were insu cient and of only tem porar y relevance. Therefore, altern ative w ays to elevate th e eyelid had to be researched an d developed. Th e levator m uscle an d apon eurosis, Mü ller’s m uscle, an d th e fron t alis m u scle are th e u pp er lid ret ractors th at are th e prim ar y t issu es targeted du ring ptosis su rger y. Ptosis surger y restores or rein forces th e n at ural pow er of th e eyelid ret ractor m uscles (levator m uscle or Mü ller m u scle resect ion ). It can also produ ce n ew m ech an ical lift ing p ow er (front alis suspen sion ) w ith or w ith out an cillar y procedures to sh or ten th e eyelid length or to redu ce th e burden factors (t arsus, skin , an d fat resect ion ). Surgical tech n iqu es along w ith an atom ical discoveries an d surgical m aterials h ave developed as follow s.

17

Frontalis Sling Dran sart adapted exogen ou s m aterial as a su spen der an d ap plied it to bu ried catgu t su t u res in 1880. Hess in t rod u ced a tem p orar y p lacem en t of silk su t u re in 1893.3,4 De Wecker em ployed th e rst au togen ou s sling w ith a com bin at ion of skin , orbicu laris m u scle, an d silk su t u re as a su sp en der.5 In 1909 Payr in t rodu ced a th igh fascia th at m arked a sign i can t advan ce in fron t alis slings an d st ill rem ain s on e of th e gold st an dard m aterials.5 Yasu n a described a fron t alis sling u sing cadaveric fascia lata, w h ich received exten sive at ten t ion du ring th e 1970s.6,7,8,9,10,11 In 1966 Tillet recom m en ded th e u se of silicon e st rip s, w hich received fu rth er at ten t ion an d are st ill in u se. In 1986 An derson suggested th at sling m aterial be p laced beh in d th e sept u m . Th is resulted in a m ore cosm et ically accept able appearan ce an d a m ore n at u ral-looking lid crease.12

Levator Muscle and Aponeurosis Repair Levator su rger y did n ot gain p op u larit y u n t il th e en d of th e 19th cen t u r y. More reliable altern at ives such as th e fron t alis sling w ere preferred. It w as Bow m an w h o t argeted th e ret ractor m uscle in stead of w eaken ing th e prot ractor m uscle for th e rst t im e.13 In 1857 h e resected both th e levator m u scle an d th e t arsu s u sing an in tern al/extern al ap proach . In terest in levator su rger y w as revived w ith th e in t roduct ion of an extern al approach , levator t ucking, by Everbusch an d levator apon eurosis resect ion by Sn ellen in 1883.14,15 In 1896 Wol devised a procedure for isolat ing, m obilizing, an d advan cing th e levator m u scle.16 On th e oth er h an d, Blaskovics suggested an in tern al ap p roach w ith excision of th e t arsu s an d levator in 1909.17 In terest in th e extern al ap p roach w as con t in u ed by Jon es, w h o devised a su rger y th at advan ces th e levator ap on eu rosis w h ile preser ving Mü ller’s m u scle in 1960.18 An d erson , a great invest igator of levator su rger y, p u blish ed h is w ork exten sively on eyelid an atom y an d levator ap on eu rosis su rger y in n eu rom yop ath ic, involu t ion al, an d m ild cases of congenit al ptosis, m aking th e 1980s “th e Age of Ap on eu rot ic Aw aren ess.”19,20,21,22 Du ring th is period, variou s tech n iqu es w ere in t rodu ced, in cluding th e m an n er of apon eu rot ic rep air, th e n u m ber of xat ion su t u res, adju stable su t u re tech n iqu es, an d altern at ives in th e size or locat ion of th e in cision m ade by a variet y of in st rum en t s.21,22,23,24

Müller Muscle Surgery Conju n ct ival t arsal Mü llerectom y, oth er w ise kn ow n as th e Fasan ella-Ser vat procedure, w as in t rodu ced in 1961.25 It w as regarded as a t ype of levator resect ion in it ially bu t w as later u n derstood to w ork du e to it s act ion on Mü ller’s m u scle. In 1972 Pu t term an devised a clam p an d rep orted

Correction of Ptosis

a m odi cat ion th at resect s Mü ller’s m u scle an d conju n ct iva w h ile sparing th e t arsus (Mü ller’s m uscle conjun ct iva resect ion , or MMCR).26,27 To avoid corn eal irrit at ion by sut ures, Lauring reported a sut u reless Fasan ella-Ser vat operat ion an d Bodian u sed extern al secu ring w ith 5–0 nylon su t u re.28,29,30 W h ile Wein stein d escribed a m arking su t u re to m ore easily isolate Mü ller’s m u scle an d p lace th e Pu t term an clam p , Ili in corporated levator apon eu rosis in to th e operat ive site w ith a Fasan ella-Ser vat-like approach .31,32

■ Patient Evaluation In blep h aroptosis evalu at ion , n ot on ly t h e lid bu t also t h e w r in kles on t h e foreh ead , h eigh t of bot h eyebrow s, an d t h e p resen ce of lid crease sh ou ld be evalu ated . If t h ere is a lid crease, ch ecking w h et h er t h e crease is d ist in ct or m u lt ip le is n ecessar y. Occasion ally, ptosis is m asked by redu n dan t eyelid skin or fat bu lge, lead ing to an ap p aren t ptosis after sim p le u p p er blep h arop last y. Moreover, in p at ien t s w h o h ave ptosis in t h e d om in an t eye, t h e ot h er eye m igh t h ave ret racted d u e to Her in g’s law . Th erefore, it is im p ort an t to evalu ate t h e p at ien t carefu lly p r ior to t h e su rger y to d etect any m asked p roblem s an d t h u s red u ce t h e rate of revision . An atom ic st ruct u res of Asian lids w ith out creases (low er orbit al sept u m –levator fu sion level w ith p re-aponeurot ic fat h anging over th e tarsal plate; m ore prom in en t su bcu tan eou s, su bderm al, su borbicu laris, an d pretarsal fat; an d low er p rim ar y in sert ion of th e levator ap on eu rosis on to th e u p per lid derm is) in terfere w ith eye open ing an d can be regarded as a categor y of ptosis.33 By rem oving th ose burden factors in stead of doing levator surger y, th e su rgeon can obt ain excellen t cosm et ic im provem en t on a pu y, sm all, an d droopy Asian lid.

History Taking and Physical Examination In severe u n ilateral ptosis, th e eyebrow on on e sid e can be elevated relat ive to th e oth er w ith predom in an t foreh ead w rin kles. In addit ion to th e pat ien t’s h istor y an d age, u pper lid lag is a h elpful clue in dist inguish ing congen ital ptosis from ap on eu rot ic ptosis. If a dow n -gaze m akes on e eyelid bigger th an th e oth er, or if an up -gaze m akes th e eyeball hide beh in d th e upper eyelid, congen ital ptosis w ith poor levator fu n ct ion can be suspected (Fig. 17.1). Su ch a p h enom en on occu rs because of th e levator m uscle’s in h eren t in abilit y to relax du e to dysgen esis an d brofat t y degen erat ion . Pat ien t s w ith apon eu rot ic ptosis can h ave a deep su p erior su lcu s du e to th e ret ract ion of th e pre-ap on eu rot ic fat pad. Th e lid crease of an eye w ith ptosis get s h igh er due to th e levator’s st retch or deh iscen ce (Fig. 17.2).

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III Blepharoplast y

a

b

c

Fig. 17.1 Congenital ptosis. This 13-year-old boy who has (a) right congenital ptosis (b) shows poor levator function on up-gaze and (c) lid lag on down-gaze.

Diagnosis of Ptosis

Fig. 17.2 Aponeurotic ptosis. This 65-year-old female has aponeurotic ptosis of the right eye and shows right eyebrow elevation, multiple lid creases, and a deep superior sulcus.

Sin ce Asian s often h ave m ed ial ep ican t h al fold s, m ed ial ep ican t h op last y can be p er for m ed at t h e sam e t im e as t h e ptosis su rger y. It is essen t ial to t ake p h otos before t h e su rger y for d ocu m en t at ion , review, ed u cat ion , an d m edicolegal p u r p oses. Pat ien t s n or m ally d o n ot rem em ber t h eir p reop erat ive feat u res. By com p ar in g t h e p reop erat ive an d p ostop erat ive p h otos, t h e resu lt s of t h e su rger y can be object ively an alyzed an d evalu ated . Th is h elp s to est ablish t r u st bet w een t h e p at ien t an d t h e su rgeon . W h en t h e p at ien t com p lain s, review t h e p h otos; if som et h in g is fou n d lackin g, d iscu ss it w it h t h e p at ien t an d con sid er p er for m ing a revision su rger y for bet ter resu lt s. If a p at ien t d oes n ot w an t p h otos to be t aken before t h e su rger y, t h e op erat ion sh ou ld be recon sid ered . Ph otos are t aken w h ile t h e p at ien t is looking ah ead , u p , an d d ow n . To ch eck t h e con dit ion s of t h e eyelash es, ad d it ion al lateral view p h otos sh ou ld be t aken . If t h ere are any im p or t an t or u n iqu e occu r ren ces du r ing t h e su rger y, in t raop erat ive p h otos sh ou ld be t aken as w ell. To evalu ate t h e p rogress of t h e su rger y, p h otos are t aken 1 w eek, 1 m on t h , an d 3 m on t h s after t h e su rger y.

It is im p or t an t to m easu re t h e MRD an d levator fu n ct ion to obt ain p rop er evalu at ion s. MRD1 is kn ow n to be t h e m ost p red ict able m easu rem en t for p tosis evalu at ion .34 MRD1 m u st be exam in ed w it h t h e p at ien t in a p r im ar y p osit ion w it h n o excessive u se of t h e fron t alis m u scle or orbicu lar is m u scle. For an accu rate exam , a ligh t sou rce (a p en ligh t or ash ) m u st be p osit ion ed at t h e sam e h e igh t as t h e p at ien t ’s eyes. MRD1 is t h e d ist an ce from t h e corn eal ligh t re ex to t h e u p p er eyelid m argin , n ot t h e h an gin g skin m argin . If t h e h an gin g u p p er lid skin is cover in g t h e u p p er lid m argin of a p at ien t w it h d e r m atoch alasis, t h e skin sh ou ld be ge n t ly p u lled u p an d t h e lid m argin sh ou ld be obser ved d u r in g t h e exam . MRD2 (d ist an ce from t h e cor n eal ligh t re ex to t h e low e r lid m argin ) d ep en d s on t h e p osit ion of t h e low er lid . Th e su m of t h ese t w o is t h e in ter p alp ebral ssu re (IPF). Th e levator fu n ct ion is d eter m in ed by m easu r ing t h e excu rsion of t h e eyelid m argin , or t h e tot al d ist an ce t raveled by t h e lid m argin from dow n -gaze to u p -gaze. A n or m al levator fu n ct ion is ~ 15 m m . Levator excu rsion is con sid ered to be p oor w h en t h e d ist an ce is less t h an 4 m m , m oderate w h en t h e d ist an ce is bet w een 5 an d 10 m m , an d good w h en t h e d ist an ce is above 10 m m . To p reven t fron t alis recr u it m en t d u r in g t h ese m easu rem en t s, it is advisable to eit h er h ave t h e foreh ead lean in g on a su p p or t bar or u sin g on e’s h an d s to h old t h e foreh ead . By u sin g a r u ler at t ach ed to t h e sid e bar of t h e slit lam p , t h e valu es of MRD1, IPF, levator fu n ct ion , an d lid lag are record ed in d et ail (Fig. 17.3). Usin g t h ese kin d of reliable record s to object ively exp ress p at ien t s’ st at u s often bu ild s p at ien t s’ t r u st . Th e m ost com m on clin ical ptosis occurs from st retch ing an d deh iscen ce of th e levator apon eurosis. Typical apon eu rot ic ptosis is fou n d in cases of frequ en t eye ru bbing due to atopy or w earing con t act len ses for a long t im e, an d sen ile ch anges du e to aging. Sim ilar cases can be fou n d in pat ien t s after oph th alm ic surger y, t raum a, or frequen t lid

17

a

Correction of Ptosis

b

Fig. 17.3 Measuring MRD1, MRD2, IPF, and levator function. (a) Precise measurements of levator function using a ruler at tached to the slit lamp. (b) The blue line is MRD1, and the yellow line is MRD2. The sum of these t wo is IPF.

sw elling.35,36 Gen eral clin ical ch aracterist ics of apon eurot ic ptosis in clude • • • • •

Eyebrow elevat ion of th e a ected eye Deep su p erior su lcu s High er or m u lt ip le lid creases Lid drooping Good levator fu n ct ion

Th e lid crease h eigh t is th e dist an ce bet w een th e lid m argin an d th e crease form ed by th e at t ach m en t of levator ap on eu rosis bers to th e su bcu t an eou s t issu e. Th is can var y am ong races an d by sex. Lid crease h eigh t m ay in crease

a

d

b

in sit uat ion s of ptosis ow ing to apon eurot ic deh iscen ce.37 Levator fu n ct ion in p at ien t s w ith ap on eu rot ic ptosis is good in gen eral. How ever, if th e levator apon eu rosis tot ally det ach es from th e t arsal plate, th e levator fun ct ion w ill be ver y poor.38 Th is is especially t rue for elderly pat ien t s w h o h ave h ad oph th alm ic surger y several t im es an d w h ose levator apon eurosis is often totally det ach ed from th e tarsal plate (Fig. 17.4). Most apon eu rot ic ptosis resu lts from aging an d is com m on ly detected in elderly pat ien t s. On th e oth er h an d, con gen ital ptosis is th e m ost com m on t yp e in ch ild ren . Un like ap on eu rot ic ptosis, congen ital ptosis sh ow s poor to fair levator fu n ct ion an d lid lag on dow n -gaze due to th e loss of

c

Fig. 17.4 (a–c) Poor levator function in aponeurotic ptosis. This 72-year-old female shows very poor levator function on upward gaze and severe lid drooping on downward gaze. (d) Operative dissection shows a total detachment of the levator aponeurosis from the tarsal plate.

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III Blepharoplast y levator m u scle elast icit y. In som e cases, in com plete lid closu re (lagop h th alm os) is also presen t . Th e h istologic n d ing of congen it al ptosis is dyst rophy of th e st riate m u scle bers.39 Som e pat ien t s w ith m ild congen ital ptosis are n ot d iagn osed t ill adu lth ood.

Contact Lens–Induced Ptosis Prolonged con t act len s u sage is w ell kn ow n to poten t ially cause acquired ptosis.40,41 Th e clin ical feat ures of apon eu rot ic blep h aroptosis in du ced by th e u se of con t act len ses do n ot d i er from th ose related to oth er cau ses. Con t act len sin du ced ptosis can be caused by an allergic react ion to th e p reser vat ives in th e con t act len s solut ion , t arsal conjun ct ival irritat ion by th e con t act len s edge, an d levator ap on eu rosis dam age by p hysical op en ing of th e eyelid for con t act len s placem en t . Ptosis in duced by h ard con t act len ses is caused by brosis of th e Mü ller m u scles.42 In m ost cases of con tact len s–in du ced ptosis, th e levator apon eu rosis is con n ected to th e tarsal p late sin ce su rgeries are p erform ed in you ng an d m iddle-aged pat ien t s. Tem porar y ptosis caused by con t act len s usage is t reated by prohibit ing th e use of con t act len ses an d prescribing an t iin am m ator y eye drop s to redu ce conjun ct ival sw elling. Alth ough d eh iscen ce or rarefact ion of th e levator apon eu rosis is m ore often foun d in pat ien t s w ith con t act len s– in duced ptosis, gross n dings of ap on eurot ic disin sert ion or defect s can be obser ved (Fig. 17.5).

rin e is in st illed in cases of m ild ptosis w ith good levator fu n ct ion . On ce th e eyelid goes u p to a n orm al p osit ion , it is regarded to be a good can didate for a conjun ct ivo-Mü llerectom y. Th is m eth od is advan t ageous for pat ien ts w h o n eed u n ilateral surger y an d do n ot w an t skin excision or any ch an ce of get t ing a skin scar.

■ Preoperative Considerations Eye Protective Function Sin ce ptosis surger y basically pulls th e upper lids upw ard, lagoph th alm os m ay occur tem p orarily in th e early p ostoperat ive stage or becom e perm an en t . To avoid th is com plicat ion , on e sh ould ch eck th e pat ien t’s eye protect ive m ech an ism s an d in form th e p at ien t of in evit able p roblem s su ch as lid lag an d lagop h th alm os. Con dit ion s su ch as sign i can t dr y eye syn drom e, facial palsy, dysfu n ct ion of th e su p erior rect u s m u scle, an d absen ce of Bell’s ph en om en on m u st be ch ecked prior to th e su rger y. If th e protect ive fu n ct ion is w eak or absen t , overcorrect ion sh ould be avoided.

Visual Field Test A visu al eld test is often n eeded for in su ran ce coverage purposes in th e Republic of Korea. Surger y on a droopy u pp er lid blocking th e pupil is covered by in suran ce th ere.

Phenylephrine Test

Hering’s Law and Latent Ptosis

It w as Dort zbach w h o fou n d th at a p h enylep h rin e test is u sefu l to p red ict th e postoperat ive lid posit ion after Mü ller’s m uscle resect ion .43 A d rop of 10% or 2.5% p h enylep h -

Th e levator m uscles are yoke m uscles, w h ich en able th em to w ork in syn ch rony w ith each oth er. As a resu lt , a eren t inp u t from on e eyelid can a ect th e p osit ion of both eyelids. W h en th e degree of ptosis di ers bet w een th e t w o eyes, th ere is an excessive n er ve im pu lse to open th e m ore ptot ic eye. Due to Hering’s law, th e less ptot ic eye w ill seem like a n orm al eye. How ever, th is eye w ill sh ow a droop ing ph en om en on (laten t ptosis) after surger y on th e eye w ith m an ifest ptosis.44,45,46 There is a low er inciden ce of bleph aroptosis in th e dom in an t eye an d a h igh er in ciden ce of p ostoperat ive con t ralateral eyelid droop w h en th e dom in an t eye is ptot ic. Th ese n dings su p port th e hyp oth esis of in creased in n er vat ion to th e dom in an t eye.47 Hering’s law dependence can be assessed by gentle m echanical elevation of the ptotic eyelid w ith the patient’s eye xed on a distant target. The contralateral eyelid is then assessed for any changes in position. Any decrease in the MRD1 can be considered as a positive test, and the new MRD1 should then be docum ented. If there is no change in the eyelid position after 30 seconds, the test is considered to be negative.48 An oth er m eth od to d iagn ose laten t ptosis is to occlu de th e ptot ic eye for m ore th an 15 secon ds an d in st ill 10% or 2.5% ph enyleph rin e to th e ptot ic eye. If th e opposite eyelid droops at th is t im e, it is bet ter to correct both eyelids.

Le vat or ap one urosis Mü lle r m uscle

Sup e rior b ord e r of t arsal p lat e

Fig. 17.5 Contact lens–induced ptosis. This 53-year-old female has a history of 40 years of hard contact lens wearing. Operative ndings show levator aponeurosis disinsertion from the tarsal plate.

17

Correction of Ptosis

Desp ite a n egat ive Hering’s test , th ere are p at ien ts w h o st ill develop a postop erat ive decrease in th eir MRD an d resu lt ing ptosis.43,44,45,46,47,49

Unilateral or Bilateral Surgery? In patients w ith asym m etric or unilateral ptosis, latent ptosis of the norm al-appearing eye should be identi ed by elevating, closing, or instilling phenylephrine to the ptotic eye. Any decrease in the contralateral lid position is considered to be a positive test. In such a case, the patient should be inform ed of the increased likelihood of postoperative ptosis in the contralateral eye, and bilateral ptosis surgery should be considered.44 W h en th ere is n o laten t ptosis in th e opposite eye after th e screen ing test s, you can correct on e side on ly. In cases of un ilateral surger y, 1.0 to 2.0 m m of overcorrect ion is n eeded com p ared w ith th e n onptot ic eye. Th is is don e both to com p en sate for th e e ect of local an esth et ics m ixed w ith ep in ep h rin e to p aralyze th e orbicu laris m u scle an d st im u late th e Mü ller m uscle, an d to coun teract th e postoperat ive fall after ptosis repair. How ever, bilateral ptosis su rger y provides fun ct ion al an d cosm et ic advan t ages because a pat ien t w ith un ilateral ptosis an d a n egat ive Hering’s test m ay develop postoperat ive con t ralateral ptosis.

Direction of the Eyelashes Harrison categorized th e direct ion of eyelash es in to fou r t yp es (n orm al, m ild, m od erate, severe) in Cau casian s.50 Bu t th e eyelash es of Korean s are usu ally classi ed in to grades 1 to 5, w ith 15-degree in crem en t s in each grade (Fig. 17.6). Grade 1 is w h ere eyelash es p rot ru de perp en dicu larly to th e ver t ical p lan e of th e face. Grade 5 is th e case w h ere th e eyelash es are p osit ioned 60 degrees dow nw ard. Lash ptosis is m ore com m on ly n oticed in ptot ic eyes than in norm al ones,51 an d th us it should be veri ed that the lash ptosis has been corrected by obser ving the direct ion of the eyelashes at the end of the surger y. Sat isfactor y postoperat ive results can be con rm ed by checking th e lash direct ion in the supine position , w here it should appear sligh tly over-corrected, in stead of ch ecking it in th e sit ting posit ion during the operat ion. It is fairly com m on for m edial lash ptosis in Asians to be aggravated by epican th al folds as w ell as by loosen ing of m edial st ruct ures such as m edial pretarsal m uscle at tachm ents to the tarsus. Therefore, addit ion al at tent ion to m edial lash ptosis is required, and if necessar y, m edial epican thoplast y w ith a preferred tech n iqu e to reduce the burden factor should be considered.

Selection of Repair Method In gen eral, th ere are th ree t ypes of su rger y in ptosis correct ion : (1) levator surger y—t ucking, advan cem en t , resect ion ; (2) conjun ct ivo-Mü llerectom y (MMCR or th e Fasan ellaSer vat p rocedu re); an d (3) th e fron talis sling.

1

15°

2 3 4

5

Fig. 17.6 Grading of lash ptosis in Koreans. Grades have a 15-degree di erence.

Alth ough levator su rger y is th e m ost p opu lar tech n iqu e to correct ptosis, on e sh ou ld con sider p erform ing a fron t alis sling if th e levator fu n ct ion is p oor (LF < 4 m m ). MMCR can be ch osen for pat ien t s w ith m ild ptosis an d good levator fu n ct ion (LF > 10 m m ). In t raoperat ively, th e con d it ion of the levator is exam in ed from t arsal plate to W h it n all’s ligam en t , regardless of th e levator fun ct ion an d ptosis degree. In a case w h ere it is h ard to expect good resu lt s due to severe fat t y degen erat ion an d brot ic ch anges, im m ediate conversion to a fron t alis sling is advised. Th erefore, in case of severe ptosis or poor levator fu n ct ion , th e surgeon sh ould d iscu ss w ith th e p at ien t p reop erat ively th e possibilit y of ch anging th e su rgical p lan . Even th ough som e pat ien t s w orr y about scarring above th e eyebrow, scar is usu ally n ot a m ajor con cern sin ce it w on’t be n ot iceable 2 to 3 m on th s after th e su rger y.

■ Surgical Techniques Instruments In st ru m en t s u sed in clu de a calip er, Wescot t an d Steven s scissors, n e t issu e forceps, locking n eed le h older, an d st raigh t h em ostat (Fig. 17.7).

Preoperative Preparation Th e auth ors design th e in cision lin e preoperat ively w ith th e pat ien t in a sit t ing posit ion . After m akeup rem oval, th e desired in cision lin e is m arked, using a n e m arking pen ,

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Fig. 17.8 Surgical techniques of ptosis correction. With a lid crease maker and a very ne marking pen, the lid crease line is designed where the patient wants it. Fig. 17.7 Instrum ents used in ptosis surgery: Castroviejo caliper, 6–0 nylon suture material, straight hemostat, Castroviejo needle holder, Westcot t tenotomy scissors, Adson micro tissue forceps, Castroviejo suturing forceps, surgical blade holder (in a clockwise direction from the left upper corner).

w h ere th e pat ien t w an t s h is or h er eyelid crease (Fig. 17.8). If th e p at ien t h as ptosis in on e eye, th e lid crease lin e is m ade 0.5 m m sm aller on th e eye w ith ptosis sin ce th e u pp er lid level w ill go dow n as t im e goes on .

Anesthesia

Th e an atom ic st ruct ure th at is foun d after th e skin in cision is th e orbicularis m uscle. An orbicularis m u scle st ran d is rem oved to approach th e orbital sept u m (Fig. 17.10). W h en excising th e orbicu laris m u scle, an obliqu e su p erior direct ion sh ould be used to preven t levator apon eu rosis injur y. Th e n ext st ru ct ure th at can be obser ved is th e orbit al sep t um (Fig. 17.11).

Dissection Th e surgeon an d an assist an t sh ould h old th e in ferior ap an d su p erior aps w ith n e t issu e forcep s an d ap p roach th e sept u m carefu lly to avoid any dam age to th e levator apo-

Ptosis su rgeries can be perform ed using local an esth esia for adu lts. If th e p at ien t is too n er vou s, in t raven ou s sedat ive m edicin e su ch as m idazolam (dosage based on pat ien t’s age an d w eigh t) can be adm in istered. Th e sam e an esth esia th at is u sed for a d en t al p roced u re, con sist ing of a m ixt ure of 2% lidocain e an d 1:100,000 epin eph rin e, is used. If th e su rger y is exp ected to take longer, bu p ivacain e can be added. How ever, it is usually en ough to use lidocain e m ixed w ith epin eph rin e, as ptosis su rger y u su ally does n ot take too long. W h en local an esth esia is perform ed, inject slow ly from th e lateral side u sing a n e 30-gauge n eedle (Fig. 17.9). Norm ally 1.0 to 1.5 m L p er eyelid is injected.

Incision Th e surgeon uses th e ngers to st retch th e eyelid out w ard an d in cises th e skin in on e sm ooth step u sing a Bard-Parker (Aspen Su rgical) n o. 15 kn ife, to avoid a zigzag in cision .

Fig. 17.9 Injection of local anesthetic subcutaneously with a 30-gauge needle from the lateral side.

17

Correction of Ptosis

Fig. 17.10 Removal of the orbicularis muscle strand with Westcot t scissors.

Fig. 17.11 After removal of the orbicularis muscle, the orbital septum is revealed.

n eu rosis. Th e n ext st ru ct u re ben eath th e orbit al sept u m is th e pre-apon eurot ic fat . If th ere is di cult y in n ding th e fat , th e eyeball can be gen tly p ressed w ith a nger from th e low er eyelid. Th en th e fat w ill bu lge out . Th e surgeon n eeds to rem ove on ly th e fat th at n at urally com es out at th is t im e (Fig. 17.12). A deep su p erior su lcu s w ill resolve after th e ptosis correct ion becau se th e eyebrow s w ill go dow n after th e surger y, except in cases of severe fat de cien cy. Sau sage deform it y, w h ich m igh t occu r after th e su rger y, can be preven ted by rem oving th e pretarsal orbicularis m uscle. Th is procedure sh ould especially be perform ed on Asian s, w h o h ave ver y th ick eyelids. After th e su rgeon lift s th e ap on eu rosis, w h ich is loosely at t ach ed to th e an terior tarsal su rface, an d delam in ates it u sing scissors in an u pw ard d irect ion up to th e su perior tarsal border, th e p eriph eral p alp ebral arcad e can be obser ved, w h ich run s on th e Mü ller m u scle (Fig. 17.13).

If the surgeon needs m ore levator advancem ent, then the aponeurosis can be further delam inated up to the level of W hit nall’s ligam ent. The Mü ller m uscle tends to bleed, so you sh ou ld coagulate th e vessels carefully to preven t bleeding before dissection (Fig. 17.14). If cauter y of th e Mü ller m uscle is con ducted w ith a corn eal protector in place, it w ill not cause inadvertent th erm al dam age to the cornea. Alternat ively, th e surgeon should pull the eyelid up w ith forceps to distan ce it from th e corn ea before u sing th e cauter y.

Fig. 17.12 After opening of the septum, bulging fat is clamped with a hemostat and resected.

Fixation of Levator-Müller Muscle Flap W h en perform ing a levator advan cem en t , th e su rgeon sh ou ld sep arate th e levator ap on eu rosis rst from th e tarsal plate, an d th en from th e Mü ller m u scle w ith Westcot t

Fig. 17.13 Dissecting the levator aponeurosis up to the superior border of the tarsal plate after lifting the levator aponeurosis that is loosely at tached to the tarsal plate.

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III Blepharoplast y low, eyelash ect ropion w ill occur. If th e sut ure is placed too h igh , en t ropion w ill occur. A sh allow xat ion to th e t arsal plate m ay result in easy loosen ing or u n der-correct ion . Th erefore, w h en sut uring to th e t arsal plate, it is bet ter to an ch or w ith levator apon eurosis 3 to 4 m m in w idth . If th e sut ure is p assed th rough th e tarsal plates too deeply, it m ay pen et rate th e t arsal plates. It can be ch ecked w h eth er th e n eedle h as passed th rough th e tarsal plate or n ot by evert ing th e eyelid during th e surger y (Fig. 17.17).

Photographs in Sitting Position Fig. 17.14

Dissecting a larger portion of the levator aponeurosis.

scissors w h ile carefu lly cau terizing th e large vessels in th e Mü ller m u scle. Th e su rgeon can advan ce th e levator-Mü ller com plex 3 to 4 m m , at t ach ing it to th e superior t arsal bord er m edial to th e pup il rst an d th en lateral to th e lim bus u sing 6–0 n on absorbable su t u re m aterial. Th e rst su t u re sh ou ld be placed m edially to th e pu p il. Th is area is th e h igh est p ar t of th e u p per lid. W h en dealing w ith involu t ion al pat ien t s w h o h ave lateral displacem en t of th e tarsal p late, it is advisable to su t ure m ore m edially to th e tarsal p late to avoid lateral aring. Pass m at t ress su t u res bet w een th e levator apon eurosis an d tarsal plate u sing 6–0 nylon , 6–0 Prolen e (Eth icon ), or 5–0 Vicr yl (Eth icon ) (Fig. 17.15). Th e sut ure bites sh ould be ~ 3 to 4 m m to preven t loosen ing an d sh ould n ot be too super cial to en su re th at th ey secu rely xate on to th e t arsal p late (Fig. 17.16). Th e n ext su t u re is p laced bet w een th e p u p il an d th e lateral lim bu s. Both su t u res sh ou ld be placed 3 to 4 m m below th e su p erior border of th e t arsal p late. If th e su t u re is p laced too

Fig. 17.15 A needle is passed through the levator aponeurosis at the part medial to the pupil.

Have t h e p at ien t sit u p after su t u r in g t h e t w o p ar t s, an d let t h e assist an t t ake p ict u res u sing a d igit al cam era w it h t h e ash on w h ile asking t h e p at ien t to look st raigh t an d t h en d ow n (Fig. 17.18). En large t h e p ict u res an d evalu ate w h et h er t h e degree of cor rect ion an d con tou r ing of t h e eyelid s are p rop er or n ot . If t h e h eigh t or con tou rin g is n ot sat isfactor y, release t h e bow t ie an d t r y again . On ce a sat isfactor y lid h eigh t an d con tou r are obt ain ed , t h e excessive ap on eu rot ic rem n an t s sh ou ld be t r im m ed below t h e xat ion p oin t s after t h e levator advan cem en t . It is bet ter to rem ove t h e fat t h at n at u rally bu lges after levator advan cem en t to avoid u p p er lid p u n ess. Th e brow an d ret roorbicu lar is ocu li fat (ROOF) w ill com e d ow n after t h e ptosis correct ion .

Lash Ptosis Correction At th e en d of th e su rger y, lash ptosis sh ou ld be ch ecked an d corrected to obt ain a bet ter cosm et ic resu lt . In case of severe lash ptosis, th e surgeon sh ou ld sut ure th e t arsal p late to th e in ferior ap of th e orbicu laris m u scle an d overt u rn th e direct ion w ith bu ried su t u res. Th e lash ptosis

Fig. 17.16 The levator is sutured to the tarsal plate not super cially, but deeply, and tied with mat tress suture.

17

Correction of Ptosis

a

Fig. 17.17 Check whether the needle has passed through the tarsal plate by everting the lid.

b

can be corrected by m aking skin –levator apon eu rosis–skin su t u res. Th is also acts as a secu rit y su t u re for longevit y of th e upper lid crease.

Fig. 17.18 Photographs taken at the sit ting position during the correction of congenital ptosis in a 25-year-old woman show (a) 1 to 1.5 mm over-correction of the right eye on prim ary gaze and (b) lid lag on down-gaze.

Levator Resection Th e di eren ce bet w een levator resect ion an d levator advan cem en t is a vert ical in cision of th e m ed ial an d lateral h orn s to release an d advan ce th e levator m u scle m ore. Th e su rgeon sh ou ld rem ove rem n an t s of th e levator ap on eu rosis at th is t im e.

Conjunctivo -Müllerectomy Th e sim plicit y an d predict abilit y of th is procedure m ake it at t ract ive. Th is tech n iqu e is preferred in m ild ptosis correct ion .27,52,53 If th e eyelid rises to th e level of th e opposite, n orm al eyelid after th e in st illat ion of 2.5% or 10% p h enylep h rin e eye drop s an d sh ow s good fu n ct ion of th e levator m u scle, good p ostop erat ive resu lts w ith th is tech n iqu e can be expected. In con t rast to levator su rger y, w h ich requires a skin in cision , th is tech n iqu e w ill n ot leave an extern al scar. In addit ion , a relat ively p recise resu lt can be p redicted . Inject 1 m L of 2% lidocain e in to th e su bconju n ct ival space an d 0.5 m L in to th e lateral th ird of th e u p p er eyelid. Ever t th e u pper eyelid, an d th en m ark th e am oun t of conjun ct iva to be excised. Hold th e conju n ct iva w ith a Pu t term an clam p or t w o h em ost at s. Make a st ab in cision th rough th e skin tem p orally. Pass a 6–0 nylon su t u re th rough th e st ab in cision an d w eave a con t in uou s su t u re 1 m m below th e clam p from tem poral to m ed ial. Rem ove th e clam p after cu t t ing below it , th en su t u re th e cu t st u m p by con t in u ing th e su t u re, n ow w eav-

ing from m edial to tem p oral an d th en exit ing th rough th e tem poral skin st ab in cision . Tie th e sut u re en ds, an d rem ove th e st itch es in a w eek.

Frontalis Sling Fron t alis sling is a ver y e ect ive surger y for revision cases after m u lt ip le levator su rgeries or in cases sh ow ing p oor levator fu n ct ion below 4 m m (Fig. 17.19). Th ere are diverse sling m aterials su ch as au tologou s fascia lata, preser ved fascia lat a, silicon e rod, Su pram id (S. Jackson ), exp an d ed polytet ra u oroethylen e (ePTFE, or Gore-Tex [W. L. Gore]), an d oth ers. Th e au th ors p refer th e single rh om boid sling m eth od w ith ePTFE su t u res (Gore-Tex CV-3). Th e surgeon in cises th e skin 3 to 5 m m above th e lid m argin , exp oses th e t arsal p lates, an d p asses th e Gore-Tex su t u re h orizon tally th rough th e tarsal plate ~ 3 m m in ferior to th e su p erior t arsal border. Th e n eedle sh ou ld be passed un der th e an terior surface of th e t arsal plate deep en ough to p reven t loosen ing of th e su t u re. How ever, if th e su t u re is passed too deeply, th e n eedle w ill pen et rate th e t arsal conjun ct iva. Th erefore, th e upper eyelids sh ou ld be everted to ch eck w h eth er th e sling m aterial is exp osed or n ot . Th e sling m aterial p assed th rough th e tarsal p late is xated w ith 6–0 nylon sut ures at th e m edial an d tem poral sites. Th is preven t s loosen ing after th e surger y.

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220

III Blepharoplast y 6. Make a levator-Mü ller m u scle ap w h ile ver y carefully cauterizing th e large vessels in th e Mü ller m u scle. 7. Advan ce th e levator-Mü ller com plex 3 to 4 m m , at t ach ing it to th e su perior t arsal border m edial to th e pupil rst an d th en lateral to th e lim bus.

a

8. Ever t th e upper eyelid an d ch eck w h eth er th e n eedle h as passed th e t arsal p late n ot in fu ll th ickn ess, bu t in par t ial th ickn ess. 9. Take ph otos to evaluate lid h eigh t (MRD1), contour, an d lid lag in th e sit t ing p osit ion .

■ Postoperative Care b Fig. 17.19 Frontalis sling to correct ptosis. (a) This 35-year-old woman has had t wo previous ptosis surgeries and still has ptosis. (b) Postoperative photo shows correction of ptosis after use of bilateral ePTFE (Gore-Tex CV-3) frontalis slings.

Th e surgeon creates m edial, cen t ral, an d tem poral slit in cision s above th e eyebrow. Using a Wrigh t n eedle, each en d of th e sling m aterial from th e tarsal p late is passed deeply in fron t of th e foreh ead periosteu m th rough th e m edial an d tem poral brow in cision s. Th en th e en d s are passed th rough th e cen t ral brow in cision . Th e upper eyelid in cision is closed w ith 6–0 nylon before t ying th e sling m aterial at th e cen t ral brow in cision . Th e sling m aterial is t ied at th e cen t ral brow incision an d st itch kn ots using 5–0 Vicr yl su t ures are used to preven t loosen ing. Th e skin in cision above th e eyebrow is closed w ith deep 6–0 nylon or Prolen e sut ures so th at th e sling m aterial is n ot exposed.

■ Key Technical Points 1. On e-sm ooth -step skin in cision is recom m en ded to avoid creat ing a zigzag in cision . 2. Excise the orbicularis m uscle in an oblique superior direction to prevent indeterm inate aponeurosis injury. 3. To n d th e fat , gen tly push th e eyeball by pressing th e low er eyelid w ith th e ngers. 4. Iden t ify th e levator apon eurosis un der th e p reapon eu rot ic fat . 5. Hold th e levator apon eurosis, w h ich is loosely at t ach ed to th e t arsal plate an d dissect it u p to th e su p erior border of th e t arsal p late.

An t ibiot ic oin t m en t is app lied to th e in cision after th e su rger y an d an ice p ack is h eld to th e closed eyelid for 20 to 30 m inu tes in th e recover y room . If th e am oun t of levator advan cem en t is large or th e pat ien t h as severe lagoph th alm os du e to a fron t alis sling, ar t i cial tears an d lu brican t oin t m en t are ben e cial. Th e surgeon sh ould advise th e pat ien t to apply art i cial tears frequen tly an d lift up th e low er eyelid to dist ribu te th e tears even ly on to th e corn ea during th e day, as w ell as put t ing th e oin t m en t in to th e eyes before sleep. Th e pat ien t is advised to use a plast ic eye sh ield to preven t ru bbing of th e eyes by th e h an d s du ring sleep. St itch es are n orm ally rem oved 6 to 7 days after th e su rger y, an d an an t ibiot ic oin t m en t is ap plied for an ad dit ion al 3 to 4 days follow ing th e rem oval of th e st itch es.

■ Complications and Their Management

Over-correction and Under-correction Over-correct ion is m ore com m on in pat ien t s w ith good levator fu n ct ion , in revision cases, an d in post t raum at ic ptosis. Postoperat ive dow nw ard t ract ion m assage w ill easily overcom e a m ild over-correct ion (less th an 1 m m ). If th e eyelid is sligh tly over-corrected postop erat ively, st retch ing th e upper lid dow nw ard in th e early postoperat ive period w ill correct such a m ild over-correct ion . Un der-correct ion can occur in cases of poor levator fu n ct ion . Possible reason s for u n der-correct ion are im proper xat ion of th e levator-Mü ller m uscle ap on to th e tarsal plate an d loosen ing of sut ure kn ot s. Perform ing a revision at 1 w eek after levator advan cem en t is recom m en ded if th e eyelid is 1.0 m m above or below th e target h eigh t , or if th ere is asym m et r y bet w een th e t w o eyelids of 1.0 m m or m ore (Fig. 17.20).

17

Correction of Ptosis

Keratitis

a

Th e causes of kerat it is after ptosis surger y are corn eal exp osu re an d p oor corn eal p rotect ive m ech an ism s (dr y eye syn drom e, facial n er ve palsy, poor or absen t Bell’s p h en om en on ). Lu brican t s sh ou ld be prescribed an d Frost su t u res can be perform ed to lift up th e low er lid.

Conjunctival Prolapse

b

Conjunctival prolapse can be seen in cases of signi cant levator advan cem en t. It is caused by dam age to th e suspensory ligam ent in the superior fornix. If it does not im prove w ith pressure patching, partial conjunctival resection is needed.

Early Postoperative Revision

c Fig. 17.20 Under-correction and early postoperative revision. (a) A 27-year-old patient had levator advancement for contact lens– induced ptosis. (b) On day 7 after surgery, the right eyelid was a little droopy. (c) After early postoperative revision (re-advancement) on the right eye, the eyelids look symmetric.

Contour Deformity Con tour deform it y is cau sed by an in correct xat ion of th e levator-Mü ller m uscle ap on to th e t arsal plate or un even ten sion on th e t arsal plate in cases of m axim um levator advan cem en t . W h en a con tou r deform it y occu rs, it can be t reated by early postoperat ive revision .

If th e lid levels of th e t w o eyes are n ot even after u p p er bleph aroplast y or ptosis surger y, sim ple revision m igh t be n eeded at 1 w eek postoperat ively. As suppor ted by th e long-term n dings of m any oth er repor ts, 1 w eek postop erat ive lid h eigh t is a reliable in dicator of th e n al resu lt .48 For early revision surger y, th e surgeon does n ot n eed to use local an esth esia. How ever, if a p at ien t is n er vou s or com plain s of pain during th e surger y, inject ion of a sm all am ou n t of lidocain e w ith ou t epin eph rin e is st an dard . Th e revised eyelid h eigh t is gen erally ver y accurate because th ere is lit tle sw elling. Th e gen eral recover y period after a revision is n ot sign i can tly di eren t from th at follow ing th e prim ar y su rger y. Postoperat ive dow nw ard t ract ion m assage w ill easily overcom e a m ild over-correct ion (less th an 1 m m ). If th e eyelid is sligh tly over-corrected postop erat ively, st retch ing th e u pp er lid dow nw ard in th e early postoperat ive period m igh t x th e problem . How ever, in th e case of persisten t asym m et r y over 3 m on th s, revision su rger y sh ou ld be con sidered.

■ Case Studies Entropion and Ectropion Entropion and ectropion occur w hen the levator-Müller m uscle ap is xated too high or too low, respectively, onto the tarsal plate. Changing the xation point can solve these problem s. Mild lash ptosis can be xed w ith buried lash eversion sutures (aponeurosis–inferior ap of orbicularis sutures).

Lid Lag and Lagophthalmos Lid lag an d lagoph th alm os are in evit able com plicat ion s after m axim u m levator advan cem en t an d fron t alis sling procedures. Pat ien t s sh ould be in st ructed to use art i cial tears an d oin t m en t frequ en tly.

Case 1 A 27-year-old m ale pat ien t visited th e clin ic w ith a t ired look an d prom in en t foreh ead w rin kles (Fig. 17.21a). An eye exam in at ion sh ow ed MRD1 of –1 m m w ith out fron t alis act ion an d levator fu n ct ion of 10 m m in both eyes. His real MRD1 w ith lift ing of th e u p per red u n dan t skin sh ow ed 1.5 m m in both eyes. His brow elevat ion w as du e to th e p resen ce of bleph aroptosis an d lash ptosis. Bu rden factors w ere rem oved, levator advan cem en t w as p erform ed, an d lash ptosis w as rep aired in both eyes. Postop erat ively, th e p at ien t h ad larger in terpalp ebral ssu res, n o longer n eeded to u se h is fron t alis m u scle for lid elevat ion , an d w as m ore com for table (Fig. 17.21b).

221

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III Blepharoplast y

a

b

Fig. 17.21 Case 1. (a) A 27-year-old male with a tired look and prominent forehead wrinkles with brow elevation due to bilateral blepharoptosis and lash ptosis. (b) After levator advancement and lash correction, he does not use his forehead muscle any more and feels comfortable.

Case 2 A 25-year-old fem ale p at ien t p resen ted to th e clin ic w ith a droopy righ t lid sin ce bir th an d con st an t brow elevat ion (Fig. 17.22a). Sh e com plain ed of a gh ost-like appearan ce due to h er in ferior scleral sh ow. Sh e h ad ptosis surger y w h en sh e w as 9 years of age. Eye exam in at ion sh ow ed

a

MRD1 of 0 an d 2.5 m m , levator fu n ct ion of 8 an d 12 m m , an d lid lag of 5 an d 4 m m for th e righ t an d left eyes, respect ively. Th e auth ors perform ed levator advan cem en t of th e righ t eye an d u p p er blep h arop last y of both eyes. Postop erat ively, h er righ t droopy lid w as im p roved, h er in ferior scleral sh ow w as resolved, an d both eyebrow s w ere n o lon ger elevated (Fig. 17.22b).

b

Fig. 17.22 Case 2. (a) A 25-year-old female with congenital ptosis. She has a history of ptosis correction at 9 years old. (b) After levator advancement of the right eye and bilateral upper blepharoplast y, the right, droopy lid improved, inferior scleral show resolved, and both eyebrows are down.

■ Conclusion A p rop er p reop erat ive evalu at ion of ptosis w ill gu ide th e ap prop riate su rgical m an agem en t . It is n ecessar y to evalu ate th e p at ien t’s protect ive fun ct ion s, such as dr y eye syn drom e, facial p alsy, dysfu n ct ion of th e su p erior rect u s m u scle, an d absen ce of Bell’s p h en om en on . In cases of asym m et ric ptosis, th e su rgeon m u st evalu ate for con t ralateral ptosis by perform ing a m an ual elevat ion test , occlusion test , or p h enylep h rin e test . W h en th ere is a posit ive Hering’s test on p reop erat ive exam in at ion , th e su rgeon sh ou ld con sider bilateral ptosis rep air.

Gen erally, th ere are th ree t ypes of surger y in ptosis correct ion : levator surger y, conjun ct ivo-Mü llerectom y (MMCR or th e Fasan ella-Ser vat procedure), an d fron t alis sling. Select ion of th e rep air m eth od is based on con siderat ion of th e degree of ptosis an d levator fu n ct ion . Th e possibilit y of revision is alw ays presen t due to n u m erou s in t raoperat ive an d postop erat ive variables as w ell as p at ien t-related factors. Obt ain ing opt im al h eigh t an d con tou r for both eyelids can be di cu lt in ptosis su rger y. For th e m ost sat isfying resu lt s, th e su rgeon sh ou ld t r y to m in im ize th e con t rollable variables as m u ch as possible. If th e levels of th e t w o eyelids after ptosis correct ion are n ot sym m et ric, postop erat ive revision sh ou ld be p erform ed at 1 w eek postoperat ively to ach ieve good result s.

17

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III Blepharoplast y 43. Bodian M. Lip droop follow ing con t ralateral ptosis repair. Arch Oph th alm ol 1982;100(7):1122–1124 44. Lyon DB, Gon n ering RS, Dort zbach RK, Lem ke BN. Un ilateral ptosis an d eye dom in an ce. Op h th al Plast Recon st r Surg 1993;9(4):237–240 45. Worley MW, Gal O, An derson RL, al Hariri A. Eye dom in an ce and Hering’s law e ect on bilateral blepharotosis repair. Ophthal Plast Reconstr Surg 2013;29(6):437–439 46. Erb MH, Kersten RC, Yip CC, Hudak D, Kulw in DR, McCulley TJ. E ect of u n ilateral blep h aroptosis repair on con t ralateral eyelid posit ion . Op h th al Plast Recon st r Su rg 2004;20(6):418–422 47. Malik KJ, Lee MS, Park DJJ, Harrison AR. Lash ptosis in con gen it al and acqu ired blep h aroptosis. Arch Oph th alm ol 2007;125(12):1613–1615 48. Lee TE, Lee JM, Lee H, Park M, Kim KH, Baek S. Lash ptosis an d associated factors in Asian s. An n Plast Su rg 2010; 65(4):407–410

49. Morris CL, Morris W R, Flem ing JC. A h istological an alysis of th e Mü llerectom y: rede n ing it s m echan ism in ptosis repair. Plast Recon st r Surg 2011;127(6):2333–2341 50. Jang SY, Ch in S, Jang JW. Ten years’ exp erien ce w ith u n ilateral conju n ct ival Mu llerectom y in th e Asian eyelid. Plast Recon st r Su rg 2014;133(4):879–886 51. Steinkogler FJ, Kuchar A, Huber E, Arocker-Met t inger E. Gore-Tex soft-tissue patch fron talis su spen sion tech n iqu e in congenital ptosis and in blepharoph im osis-ptosis syn drom e. Plast Recon st r Su rg 1993;92(6):1057–1060 52. Karesh JW. Polytet ra u oroethylen e as a graft m aterial in oph th alm ic plast ic an d recon st ru ct ive su rger y. An experim en t al an d clin ical st u dy. Op h th al Plast Recon st r Surg 1987;3(3):179–185 53. Bajaj MS, Sast r y SS, Gh ose S, Beth aria SM, Pu sh ker N. Evalu at ion of polytet ra u oroethylen e su t u re for fron t alis suspen sion as com pared to polybut ylate-coated braided polyester. Clin Experim en t Oph th alm ol 2004;32(4): 415–419

18

Management of Double -Eyelid Surgery Complications

In-chang Cho and Aram Harijan

Pearls • Ident ify an d nd w ays to avoid th e origin al m istake. • •

• •

Oth erw ise, secon dar y an d tert iar y operat ion s w ill only com pound th e problem from the rst operat ion. Railroad scar from d elayed rem oval of st itch es sh ou ld n ever h ap p en . Mech an ical resistan ce to fold ing of th e eyelid skin varies from pat ien t to pat ien t . Th is resist an ce is evaluated by obser ving h ow long a tem p orar y crease stays after u sing a bougie. Deeper folds u su ally accom p any h igh creases, bu t crease h eigh t is n ot th e sam e as fold depth . In secon dar y eyelid operat ion s, th e rst goal sh ou ld be decon st ruct ion of layers th rough release of adh esion an d sep arat ion of app rop riate p lan es.

■ Introduction Aesth et ic st an dards for eyelids var y across eth n ic grou p s an d cu lt u res. W h ile a cert ain con tem porar y aesth et ic st an dard m ay be sat isfactor y to a large n u m ber of pat ien t s, com plicat ion s after dou ble-eyelid operat ion s are speci c to th e in dividual pat ien t . Th erefore, th e authors believe th at an ou tcom e th at fails to m eet realist ic p at ien t expect at ion s qu ali es as a pract ical de n it ion for a com plicat ion of an aesth et ic op erat ion . In th e con text of East Asian blep h arop last y, th e m ost com m on com plicat ion s are problem s of crease h eigh t (low versu s h igh ), fold d epth (sh allow versu s deep), ext ran eous creases (t riple folds), pret arsal fulln ess, ptosis, an d asym m et r y arising from any n u m ber of previou s con dit ion s.1 Th is ch apter w ill id en t ify th e m ist ake or th e p rob lem beh in d each com plicat ion an d presen t th e solu t ion th e sen ior au th or h as developed over h is career as an ocu lop last ic su rgeon .

■ Patient Evaluation Proper operat ion depen ds on proper in dicat ion . An d proper in dicat ion origin ates from proper diagn osis. In each n ew preop erat ive con sult at ion , th e surgeon m u st un derstan d th e cou rse of even ts th at p rom pted th e pat ien t to

• Th e secon d goal is th e preven t ion of fur th er • •

•

com plicat ion s. Th e th ird goal is to create th e desired eyelid sh ape, in cluding n ew crease h eigh t an d fold depth . Th e problem beh in d pretarsal fulln ess is in th e h eigh t (n ot th e volum e) of th e pretarsal com par t m en t . Rath er th an rem oving soft t issue, th e h igh crease sh ould be replaced w ith a low er on e. It is t h e su rgeon ’s job to h elp t h e p at ien t u n d erst an d t h at t h ere is n o w ay to rem ove an eyelid crease an d m ake t h e eyes look like t h eir or igin al for m s. A bet ter solu t ion is to low er t h e crease to t h e eyelid m argin an d to bu r y t h e in cision scar w it h in t h e fold .

seek fu rth er su rgical t reat m en t . Th is u n derstan ding com es on ly if th e pat ien t is given am ple oppor t un it ies to tell th e stor y. Physical exam in at ion m u st correlate w ith th e h istor y. Any d iscrepan cies bet w een th e stor y an d p hysical n ding sh ou ld ser ve as a w arn ing, an d th e su rgeon m u st perform due diligen ce in at tem pt ing to rediscover per t in ent aspect s of th e pat ien t’s m edical an d surgical h istor y. More often th an n ot , th e p at ien t w ith an u n sat isfactor y ou tcom e w ill h ave m u lt ip le com p lain t s. In assessing an d cou n seling th e pat ien t , th e su rgeon m u st t r y to o er th e ideal operat ion , w h ich is th e one th at addresses all of th ese com plain ts at on ce. If n o such operat ion is possible, th e su rgeon m ust then o er th e opt im al solut ion , w h ich w ill address as m any of th e problem s as possible at on ce. For exam ple, a pat ien t m ay presen t w ith a h igh crease, deep fold, an d excessive pretarsal fulln ess of th e upper eyelid. If th e su rgeon un derst an ds th at both deep fold an d pretarsal fu lln ess are in t rin sically t ied to th e p roblem of h igh crease, he or sh e can appreciate th at all th ree of th e problem s m ay be solved by a single procedure: low er th e crease.2 On ce th e sim p lest solu t ion h as been id en t i ed, th e su rgeon m u st sh are th is in form at ion . Th e p at ien t sh ou ld un derst an d th at th e in ten t ion is to im prove all of th e un desirable feat u res to an acceptable d egree, rath er th an to com pletely solve on ly a sm all fract ion of th e problem s. If th e surgeon can o er an approach an d th e pat ien t accept s it , m eet ing th e expect at ion becom es a m ere problem of techn icalit y.

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■ Surgical Techniques Scar Eyelid skin d oes n ot d evelop hypert roph ic resp on se in m ost cases. W h en hypert roph ic respon se is obser ved after an eyelid operat ion, th e fu n dam en t al problem could be th e pat ien t’s ten den cy to develop hypert roph ic scar. In m any in st an ces, h ow ever, th e problem is n ot w ith th e pat ien t but w ith th e surgeon w h o perform ed th e in dex operat ion . Th e m ost com m on tech n ical m ist ake is a lack of un derstan ding of th e d ist ribu t ion of th e su p erior-p osterior force vector of th e levator m u scle. If th is vector is u n equ ally dist ributed to th e low er ap, it is possible to dislocate th e low er ap from th e u pp er ap (Fig. 18.1). Th is occu rs m ore frequ en tly in th e lateral p or t ion of th e u p per eyelid becau se th e apon eurosis is deeper in th e t issue. To m in im ize such a risk, th e su rgeon m u st en su re th at th e u pw ard p u ll of th e levator is t ran sferred to th e t arsu s—n ot th e skin —via a su cien t n um ber of bites of th e plate. In younger pat ien t s, skin excision s do n ot h ave to be exten ded along th e fu ll length of th e eyelid to create a crease of desirable length ; a sh orter in cision design is usu ally su cien t . A less tech n ical bu t st ill com m on m ist ake is leaving su t u res in for m ore th an 5 days; epith elial t un n els form aroun d sut ures on ly 7 days after op erat ion . Railroad t rack scars from delayed su t u re rem oval are u n accept able. Eyelid scars are m ore n ot iceable w h en th ey are depressed. Such scars result from excessive rem oval of th e orbicu laris m u scle, con n ect ive t issu e (Fig. 18.2), or deep fold (Fig. 18.3).3,4 An eyelid scar revision m u st obey th e w ou n d h ealing prin ciples th at govern all aspect s of surgical care. Th e operat ion m ust be asept ically possible. Both surgeon an d in st ru m en t m ust be at rau m at ic w ith respect to th e eyelid t issues. All layers—n ot just skin —sh ould be approxim ated w ith as lit tle ten sion as possible. Excision an d re-approxim at ion of th e skin does n oth ing to address scars th at are depressed. Th e m issing layer of orbicu laris oculi m ust be recon st ructed by un derm in ing an d advan cing th e m u scle edges from both u pper an d low er aps. Su ch un derm in ing is also ben e cial if th e problem is th at th e skin adjacen t to th e pre-exist ing scar is inverted. W h en approp riate, u n derm in ing of th e skin aps sign i can tly m it igates th e ten sion p laced directly across th e derm is (Fig. 18.4). Sim p le con t in u ou s su t u re can p lace diagon al ten sion across th e w oun d. An in terlocking con t in u ou s su t u re w ill m ain t ain an even perpen dicular ten sion . In clu sion cysts resu lt from a p rolonged foreign body react ion to th e su t u re placed bet w een th e up per an d low er skin ap s or from sebaceou s glan d act ivit y. Th ese cyst s m ay d evelop over w eeks to m on th s after an op erat ion an d sh ould be excised if th ey do n ot resolve sp on t an eou sly (Fig. 18.5). In clu sion cyst s are best avoid ed by u sing th e orbicularis m uscle—n ot th e derm is it self—as th e an ch oring point for th e su t u res.

Fig. 18.1 On opening the eyes, the lower ap is dislocated as it is pulled inward by the xation suture there. For prevention, skin sutures must be done closely to su ciently bite the tarsal plate.

Fig. 18.2 Depressed scars from excessive removal of orbicularis muscle. Depression is seen beneath the fold from removal of orbicularis muscle.

Fig. 18.3 Depressed crease line from ectropion. The lower ap is stretched upward.

Loss of Fold All su rgically created eyelid creases at ten u ate du ring th e rst few m on th s. Th is ch ange m igh t be m in im al, or th e fold m igh t disap p ear altogeth er. Th e degree to w h ich a p ostop erat ive fold soften s is d eterm in ed by p at ien t ch aracterist ics an d su rgical tech n iqu e.

18

a

Managem ent of Double-Eyelid Surgery Com plications

b

Fig. 18.5 Inclusion cyst. If anchoring is done on the dermis, and inclusion cyst may be formed from foreign body reaction, due to the thin nature of the upper eyelid skin.

Th e pat ien t-related factors th at prom ote soften ing or loss of crease are as follow s: (1) th ick skin an d abun dan t soft t issu e, (2) blep h aroptosis, (3) su n ken eyelid, (4) en op h th alm os, (5) h istor y of failed double-eyelid operat ion , (6) you nger age, (7) low -lying p reop erat ive crease, (8) p resen ce of epican th al fold, an d (9) ext rem e w eigh t gain . Operat ive factors associated w ith tech n ical failu re are as follow s: (1) in accu rate approxim at ion of con n ect ive t issue, (2) in su cien t xat ion to t arsal plate, (3) low -set xat ion , an d (4) loosen ing of th e xat ion due to h em atom a or ed em a. In adequ ate soft t issu e rem oval along th e top m argin of th e t arsal plate can preven t close approxim at ion of th e con n ect ive t issue as w ell as bun ch ing of fat t issue in to th e loop of th e su t ure. Fat t issu e w ith in th e loop can in t rodu ce m ech an ical red u n dan cy w ith exp an sion from ed em a an d / or h em atom a an d subsequen t disappearan ce of th e surgically created crease. Alth ough th e im p or tan ce of su t u res can n ot be overem p h asized , a n e dist in ct ion m u st be m ade bet w een a st rong xat ion an d a prop er xat ion . A su rgically created eyelid fold is a con sequen ce of th e adh esion bet w een th e an terior an d p osterior lam ellae. Postop erat ive folds soften

c

Fig. 18.4 Correction of depressed scar. (a) The incisional scar is resected. (b) The upper orbicularis muscle ap is minimally undermined. (c) Skin and muscle are repaired together.

an d/or disapp ear over t im e becau se th e rep et it ive m ovem en t an d sh ift ing of variou s layers are en ough to disru pt th is adh esion bet w een th e layers. To preven t such ch anges, th e adh esion s—n ot th e sut ure m aterial—m ust be st ronger.4 Th e resist an ce of an eyelid again st form ing a fold is est im ated d u ring th e p reop erat ive con su ltat ion . Fold-resist an t eyelids ten d to require sign i can tly m ore force w h en using th e st ylus, an d th e created fold disappears rath er qu ickly com pared w ith th e eyelids, w h ich m ain tain postoperat ive creases w ith out sign i can t ch anges. Pat ien t factors th at predict h igh resist an ce to fold form at ion in clu de th ick skin , abu n dan t soft t issu e, blep h aroptosis, h igh ly elast ic skin in you nger p at ien t s, su n ken eyelids, en op h th alm os, h istor y of failed double-eyelid operat ion , an d adh ered low er ap. Eyelids w ith ep ican th al fold s sh ow h igh resist an ce along th e m edial side. Th ough th is is n ot a preoperat ive pat ien t factor, w eigh t gain in th e in term ediate p ostoperat ive p eriod can precipit ate loss of a surgically created fold. To preven t loss of folds, th e surgeon m ust t ie th e sut u re w h ile avoiding th e in t rusion of soft t issu e bet w een th e levator apon eu rosis an d derm is or th e orbicularis m u scle in to th e loop . If a pat ien t h as fold-resist an t eyelids, it is im port an t to create a fold th at is deep en ough to resu lt in th e sligh test ect ropion th at w ill subside after a sh or t postoperat ive du rat ion . Excessively deep xat ion s can resu lt in persisten t ect ropion , even if th e fold becom es sh allow er over t im e.

Shallow or Deep Fold Shallow Fold At tim es, th ere is ext ran eous fat or con n ective t issu e in th e pretarsal space. This is especially com m on on the m edial side of th e u pper eyelid, w h ere pretarsal fat is abun dan t. Part ial resection of th is con n ective tissue can aid in form ing an adhesion. If a patient has blepharoptosis or a de nite epican th al fold, th ese elem en ts m u st be dealt w ith rst to reduce fold resistance. Other w ise, a deeper fold is n ecessar y.

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III Blepharoplast y If th ere is adh esion in th e low er ap w ith soften ing of th e fold, th e adh esion w ill in terfere w ith th e form at ion of a n ew crease. In su ch cases, th e low er ap m u st be released an d redrap ed p rior to tarsal xat ion . In pat ien t s w h ose eyelid skin lacks elast icit y after th e previou s op erat ion , th e n ew ly created fold sh ou ld be deeper th an u su al to p reven t a rep et it ive loss of fold (Fig. 18.6).

Deep Folds or Ectropion Deep folds an d ect ropion are cau sed by creases th at w ere xated too h igh on th e eyelid. Th is p laces an u n du e u pw ard ten sion on th e low er ap an d ever t s th e eyelid m argin . A pat ien t often com plain s about th e un in ten ded im pression of aggression conveyed by th e ever ted eyelids. Th e depressed scar is visible w h en th e eyes are closed. Th e pat ien t m ay also com plain of a t ugging sen sat ion in th e eyelids. Th e palp ebral ssu re m ay becom e larger. Th e skin ju st su perior to th e fold ten ds to bu lge. High xat ion s in adverten tly in crease th e p alpebral ssu re becau se th e levator ap on eu rosis is p licated w h en th e low er ap is xed at a h igh p oin t on th e levator apon eu rosis. In case of severe ect rop ion , th e conju n ct iva is exposed . Th e m ucocut an eous jun ct ion becom es kerat in ized, leading to dr y eye syn drom e. Th e rst step in correct ing th e deep fold is to release th e adh esion s an d re-approxim ate th e layers at a low er poin t along th e eyelid. If th is part of th e operat ion does n ot resolve th e ect ropion , th e low er ap m ust be un derm in ed an d redrap ed over th e t arsal p late to d ecrease th e ever t ing force of th e ad h esion in th e low er ap. Th e secon d por t ion of th e operat ion is to preven t th e form at ion of t riple folds. Th e surgeon m ust t ake care n ot to allow re-adh esion by in t roducing th e orbit al fat in to th e sp ace bet w een th e apon eurosis an d orbicularis m uscle. Deep crease is often accom p an ied by a h igh fold, an d th e operat ion s to correct th ese t w o feat ures are ver y sim ilar. Th e on ly sign i can t di eren ce bet w een th e t w o correct ion m eth ods is th at th e locat ion of th e previou s crease is m ain t ain ed in cases of d eep crease w ith ou t h igh fold, th e n ew crease is design ed low er th an th e previou s crease, an d th e skin in bet w een is excised in cases of h igh fold alon e. Correct ion of deep crease w ill be described again along w ith correct ion of h igh fold in th e follow ing sect ion .

Adhesion

Fig. 18.6 Correction of a shallow crease. Release the previous adhesion at the pretarsal area. Since elasticit y is compromised from brous change and a relapse is common, xate at a higher point than usual.

Th ere are th ree approach es to correct a low fold. Th e rst is an open blep h aroplast y by w h ich th e skin an d orbicularis m uscle are excised above th e previous crease. Th e secon d ap p roach is to create a m ech an ically overriding crease above th e previous on e. Th e th ird com bin es soft t issu e excision an d m ech an ical xat ion above th e prior crease (Fig. 18.8).4 Th e rst approach (open bleph aroplast y) can in corporate scar revision an d allow s for excision of redun dan t skin in old er pat ien t s. How ever, th e su rgeon m ust leave en ough eyelid skin to m in im ize th e risk of postbleph aroplast y brow ptosis. In pat ien ts w ith out sign i can t redun dan cy of eyelid skin , excision of th e orbicu laris m u scle above th e old crease is m ore im port an t th an excision of th e skin . Maxim u m elevat ion of th e eyebrow s sh ou ld resu lt in 80 to 90% elevat ion of the upper eyelid m argin in pat ien t s w ith an appropriate am ou n t of skin excised. Th is is an im p or tan t par t of th e preoperat ive an d in t raoperat ive guidelin e on est im at ing h ow m u ch of th e u p per eyelid skin is redu n dan t . Th e secon d approach (t arsal xat ion ) allow s con siderable elevat ion of th e fold crease bu t w ill create an addit ion al scar, if secon dar y in cision s are n ecessar y. Th is ap p roach

Low Crease In a crease th at is too low, ver y lit tle skin w ill sh ow bet w een th e eyelid m argin an d th e crease. Th is is usu ally a problem of th e act ual crease design being too low, but a sh allow fold can som et im es give th e appearan ce of a low crease (Fig. 18.7). Red u n dan cy of skin can also m ake a crease ap pear low er th an it really is.

Fig. 18.7

Low fold due to a shallow crease.

18

Managem ent of Double-Eyelid Surgery Com plications

Skin and OOM excision

Soft tissue excision

New line

New line

Previous incision line

a

b

c

Fig. 18.8 Methods of raising low fold. (a) The skin and orbicularis oculi m uscle (OOM) are removed around the previous incision line. (b) A new crease is made above the previous incision line, by a buried suture method or a short incision method. (c) Combination of a and b methods; excision of soft tissue is performed above the previous incision line.

is m ore ap prop riate for pat ien t s w h o h ave in con spicuous scars from th e rst op erat ion an d w ish for th e eyelid fold to be h igh er. If th e previous fold is st rongly de n ed (i.e., too d eep ), th en a sim ple m ech an ical xat ion m ay resu lt in m ult iple eyelid folds. To m in im ize such risk, th e low er ap can be un derm in ed th rough a sm all in cision w in dow. Th is can sign i can tly at ten u ate th e p rim ar y fold to a fain t ap pearan ce. Pat ien t s sh ou ld be w arn ed of th e p oten t ial for p ret arsal fu lln ess from th e scar t issu e after th e in it ial op erat ion . Th e com bin ed approach of open bleph aroplast y an d m ech an ical xat ion is reser ved for p at ien ts w ith ver y low folds an d great redu n dan cy of skin .

High Crease In m any East Asian cu lt u res, h igh eyelid crease is associated w ith an aggressive or an tagon ist ic person alit y. High creases are u su ally accom pan ied by deep folds, an d p at ien ts com plain of u n n at ural appearan ce, depressed scar, an d excessive eversion of th e eyelash es. Pat ien t s m ay also com plain abou t pretarsal fu lln ess th at h as n ot im proved w ith t im e. Sligh t bleph aroptosis can be seen in p at ien t s w ith an ad h esion bet w een th e skin an d levator ap on eu rosis th at p reven t s recu rsion of th e levator m u scle.

Causes High creases can be cau sed by h igh -p osit ion ed skin crease design , h igh xat ion , excessive skin excision , un in ten ded adh esion , blep h aroptosis, or su n ken eyelid . Am ong th ese, h igh crease design from th e in it ial operat ion is th e m ost com m on . Fixat ion of th e low er ap to a h igh poin t can result in h igh folds w ith ect ropion . Th e problem can also result from excessive skin resect ion , w h ich leaves in su cien t skin to cover th e crease. Pat ien ts w ith bleph aroptosis ten d to develop h igh folds after an eyelid fold operat ion

th at failed to address th e m ech an ical et iology beh in d th e ptosis (Fig. 18.9). High creases can be obser ved w ith deep, n orm al, or sh allow fold depth s. Th e m ost com m on form is a fold th at is both high an d deep, w h ich is often accom pan ied by ect ropion . At t im es, pat ien t s m igh t h ave folds of var ying depth (e.g., a fold th at is sh allow on th e m edial side but deep over th e pupils).4

Correction of High Creases Like oth er com plicat ion s, h igh creases sh ould be corrected according to th e cau se. Gen erally, th e secon dar y op erat ion in corporates an op en bleph aroplast y w ith skin excision . Th e u pper m argin of th is excision is along th e fold th at is to be revised, an d th e low er m argin m arks th e n ew crease heigh t . If th e skin lacks redun dan cy an d lagop h th alm os is expected, skin is n ot resected. Rath er, a low er in cision can be used to u n derm in e th e upper ap an d release th e high fold th rough eith er th e pre-apon eurot ic layer or p resept al layer. Releasing th e fold th rough th e p re-apon eu rot ic layer m in im izes th e risk of re-adh esion becau se it is in th e deeper layer. In pat ien t s w ith bleph aroptosis, th is deeper dissect ion plan e is a n at ural ch oice, as it allow s th e operator to access th e levator m ech an ism . For th e sam e reason , how ever, th is plan e of dissect ion can injure th e levator ap on eu rosis an d resu lt in postoperat ive blep h aroptosis. In con t rast , releasing th rough th e pre-sept al layer m in im izes th is risk but is associated w ith in creased risk for t riple fold form at ion . Deep folds respon d bet ter to dissection of th e upper ap through the deeper plane. How ever, a deep fold m ay rem ain, even w ith adequate release ben eath th e upper ap. In su ch sit uation s, th e low er ap m igh t also con t ribute to fold depth an d sh ould be released from th e un derlying tissue. Th e low er ap should then be xed at the desired height . This also addresses th e problem of ect ropion , if presen t .

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a

b

c

d

Fig. 18.9 Causes of high fold. (a) High incision line. (b) High fold from ectropion. (c) High fold from blepharoptosis. (d) High fold from sunken eyelid.

High creases w ith n eu t ral fold depth can be ad dressed by sim ple open bleph aroplast y, as described previou sly. Sh allow eyelid folds are corrected in a sim ilar m an n er to n eu t ral folds, by op en blep h arop last y. Even w ith a com p lete loss of fold, h ow ever, th e low er ap can st ill h ave severe adh esion s an d requ ire ad h esiolysis. If n o su ch adh esion s are p resen t , th e low er ap sh ou ld h ave en ough laxit y to allow adequate xat ion at th e desired h eigh t .1

Failures after Correction of High Crease Th e t w o m ajor problem s th at occur after h igh fold correct ion are ect ropion an d m ult iple folds. Failu re rates for h igh fold correct ion can be un accept ably h igh for su rgeon s w h o do n ot grasp th e fun dam en tal prin ciple beh in d secondar y op erat ion s: th at u nw an ted adh esion is th e en em y. Th e prim ar y reason of failure in revising th e h igh lid crease is an in com p lete release of th e t issu e arou n d th e old eyelid crease. Th e failure m ay also be caused by re-adh esion of th e t issue th at w as adequ ately freed. In com p lete lysis of adh esion s or re-adh esion m ay resu lt in ect ropion w ith an eyelid crease th at appears to ch ange h eigh t w ith m ovem en t . With th e eyes closed, th e crease w ill appear low ered, as in ten ded. How ever, th e sam e crease does n ot appear low ered w h en th e eyes are open because th e skin is expan ded an d bun ch ed from th e ever ted eyelid. Mu lt ip le eyelid creases can form after correct ion of h igh creases. In such post secon dar y bleph aroplast y pat ien t s, each crease represen ts th e xat ion s perform ed in

prim ar y an d secon dar y operat ion s, w h ere th e low er crease is th e desired crease an d th e h igh er crease reappeared at th e site of th e in it ial operat ion . Even after com plete adh esiolysis, th e p osterior lam ella can re-adh ere to th e an terior lam ella. Th e problem s of t riple folds are so com m on th at it is discussed as a dist in ct topic in a later part of th is ch apter. To preven t th ese secon dar y com plicat ion s, th e surgeon m u st m ain tain su cien t t issu e volu m e, th orough ly free th e adh ered t issu e p lan es, an d m ake e ort s to p reven t re-adh esion . To accom plish th ese goals, it is im port an t to abide by th e follow ing gu idelin es: 1. Resect on ly th e skin an d leave th e scar t issue to rein force th e u pper ap (Fig. 18.10). 2. If the upper ap lacks su cient soft tissue bulk, the orbital fat along w ith the septum can be lowered to add volum e to the upper ap and also provide a gliding m em brane bet ween the orbicularis oculi and the levator aponeurosis. This latter function of interposition ap is extrem ely im portant in preventing re-adhesion of separated elem ents (Fig. 18.11). 3. In th e sam e m an n er, th e orbicularis m uscle can be u sed as an in terp osit ion ap (Fig. 18.12). 4. If th ere is in su cien t orbital fat or orbicu laris m u scle, a con n ect ive t issu e ap can be elevated for rein forcem en t . Derm ofat graft , fat graft , or m icrofat inject ion deep to th e orbicularis oculi are possible altern at ive solu t ion s an d are also e ect ive in low ering th e risk of re-adh esion .

18

a

Managem ent of Double-Eyelid Surgery Com plications

c

b

Fig. 18.10 Correction of high fold. (a) Resection of skin down to the newly created lower crease. Resect only the skin, without resecting any scar tissue. (b) Adhesiolysis at the preaponeurotic layer. (c) Con rm complete adhesiolysis by holding the upper skin ap. If eversion remains, undermine the lower ap. (d) Fixate the lower ap at a lower point and close the skin.

d

Fig. 18.11 Failure in high fold correction. (a) If the previous adhesion is incompletely lysed, eversion of eyelid develops because the lower ap is pulled up and adhered. (b) Triple fold may also develop due to readhesion of the previous adhesion site. Previous adhesion site

Previous adhesion site

New fixation site

a

New fixation site

b

5. To increase the resistance to inward folding of skin at the initial operative site, a bulky roll of upper ap can be m ade by suturing the skin and orbicularis together after skin closure. The needle is passed through the skin and orbicularis oculi beneath the new crease, then through the orbicularis oculi and skin of the upper ap. In addition to increasing eyelid resistance along the length of the old crease, it separates the anterior lam ella from the posterior lam ella (Fig. 18.13). 6. DuoDERM dressing (ConvaTec) an d adh esive t ape can be used as a splin t to in crease fold resist an ce over th e low er edge of th e u p per ap (Fig. 18.14). a

b

Fig. 18.12 Remove only the skin and use the resected orbicularis muscle and scar tissue as an interposition ap to reinforce the upper ap volume.

7. If correct ion of eversion is di cu lt du e to severe adh esion , inject ing or spraying dilu ted steroids m ay h elp in th e postop erat ive period .

231

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III Blepharoplast y

Fig. 18.13 Correction or prevention of triple fold. Creating a skin– orbicularis oculi roll prevents re-adhesion.

8. Excessive skin excision w ill result in th e low er crease being pulled up tow ard th e eyebrow s, result ing in eversion . To preven t th is, th e low er ap can be xed by secu ring it to a par t ial purch ase in th e t arsal plate during closure. Th is is e ect ive in coun teract ing th e upw ard pull from th e t igh t eyelid skin (Fig. 18.15). 9.

Skin de ciency can be partially o set by un derm ining a 2-m m m argin of skin in the upper ap.

Fig. 18.14 Adhesive tape or DuoDERM dressing can be used as a splint to increase fold resistance over the lower edge of the upper ap.

Partially High Crease or Undesirable Curvature A com m on m ist ake in correct ing a part ially h igh crease is to part ially address th e problem . For exam ple, a part ial revision of on ly th e m ed ial side w ill in t rodu ce a kin k to th e cu rvat u re of th e crease su ch th at th e ou ter p or t ion w ill ap pear h igh er th an th e m edial port ion . Th is could also in t rodu ce a t riple fold appearan ce along th e m edial side. Part ially h igh creases sh ould be repaired using th e sam e prin ciples as h igh crease correct ion : skin excision , lysis of adh esion s, an d xat ion . Th e n ew crease sh ou ld be allow ed to p ar t ially overlap th e cou rse of th e p reviou s crease.

Pretarsal Fullness

Fig. 18.15 To prevent eversion in eyelids with de cient skin, x the lower ap to the tarsal plate by biting through the tarsal plate partially during skin closure.

Com m on ly obser ved w ith h igh creases, pretarsal fulln ess is also described as “sau sage eyelid” am ong Korean p at ien t s. It refers to th e u nw an ted soft t issu e p roject ion in th e area over th e tarsal p late in p ostbleph arop last y eyelids. Preop erat ive factors th at p redict pretarsal fu lln ess in clu de th ick eyelid skin an d orbicularis m uscle. Pat ien t s w ith th ese feat ures sh ou ld receive eyelid folds th at are design ed low er th an usual to coun teract th is propen sit y. Pretarsal fulln ess in creases in propor t ion to th e squ are of th e h eigh t of th e p ret arsal soft t issu e com partm en t , w h ich im plies th at sm all ch anges in h eigh t can resu lt in great ch anges in th e volum e of th is com par t m en t (Fig. 18.16). For exam p le, an eyelid crease th at ch anges h eigh t from 4 to 3 m m w h en open ing th e eye w ill h ave a volu m e redu ct ion close to 50% (9/16).

18

Managem ent of Double-Eyelid Surgery Com plications

F = ∂H² F: fullness ∂: tissue variabilit y H: height

H

F

F

H F

F a

b

Fig. 18.16 Relation bet ween height and fullness of pretarsal tissue. Fullness of the pretarsal tissue is proportional to the square of the height. The ∂ variable signi es the characteristic di erences in individual eyelids, such as thickness of skin or amount of orbicularis oculi muscle mass. (a) Eyes that are prone to develop fullness. (b) Eyes that are less prone to develop fullness.

A com m on m iscon ce pt ion is t h at p ret arsal fu lln ess can be cor rected by re m ovin g t h e con ten t s of t h e p ret arsal com p ar t m en t , su ch as t h e p ret arsal p or t ion of t h e orbicu lar is m u scle. Th is at te m pt at red u cin g volu m e is fu t ile for seve ral reason s. For on e, t h e rem oved volu m e is rep lace d w it h brou s con n ect ive t issu e. An ot h er reason is t h at t h e brou s t issu e in ter feres w it h t h e accord ian e e ct of fold h eigh t be in g red u ced w it h op en in g of t h e eye. Th is d e crease in elast icit y resu lt s in st at ic fu lln ess of t h e com p ar t m en t . Th e t h ird reason is t h at t h e act u al soft t issu e t h at re p rese n t s p ret arsal fu lln ess is t h e low e r m ost 2 to 4 m m of an op en eyelid . Rem ovin g soft t issu e in t h is area is fraugh t w it h d i cu lt y becau se of t h e eyelash follicles an d t h e m argin al ar ter ial arcad e. To decrease th e soft t issue volum e in th e pret arsal area, on e m u st recogn ize th e h eigh t-volu m e relat ion sh ip m en t ion ed p reviou sly. On ce th is p rin cip le is u n derstood, th e tech n ical solut ion is to perform a secon dar y operat ion (open bleph aroplast y) to low er th e crease an d e ect ively red u ce th e h eigh t an d volu m e of th e pretarsal soft t issu e com part m en t .

Asymmetry From th e perspect ive of clin ical m an agem en t , th ere are t w o m ain cau ses of p ostop erat ive eyelid asym m et r y. In exp erien ced su rgeon s often operate on a pre-exist ing asym m et r y th at w as n ot n ot iced during th e preoperat ive exam in at ion . A th orough exam in at ion sh ou ld in clu de p alpebral ssu re h eigh t , redun dan cy of th e eyelid skin , h eigh t of th e brow, an d u n equ al eyelash es.

A less com m on cause of eyelid asym m etry is techn ical failure on the part of the surgeon. Operative m aneuvers m ust be self-consistent from the left to th e righ t eyelid. Sligh t variations in design, incision, soft tissue rem oval, and xation can result in signi cant di erences in overall outcom e. Con t ribut ing factors for pre-exist ing asym m et r y in clude on e-sided bleph aroptosis an d di eren ces in eyelid laxit y, brow h eigh t , crease h eigh t , an d crease sh ape. Pat ien t s are u su ally m ore sen sit ive to th e d i eren ce bet w een th e h eigh t s of eyelid creases th an to th e di eren ce bet w een th e p alpebral ssu re h eigh ts. Any exist ing bleph aroptosis sh ould be corrected before double-eyelidplast y, but if th e di eren ce is m in im al an d th e pat ien t does n ot w an t a blep h aroptosis correct ion , th e n ew eyelid crease sh ould be m ade low er for th e ptot ic eyelid. Un equal skin redun dan cy sh ould be addressed by a greater am ou n t of skin excision , of cou rse. W h ile d oing so, it is im p or t an t to adju st th e low er m argin su ch th at th e crease h eigh t is equal on both eyelids. Correct ion of asym m etr y by var ying crease h eigh t is n ot recom m en ded, sin ce it is tech n ically dem an ding. Even if th e result ing crease h eigh ts ap pear equ al on p rim ar y gaze, th ere w ill be a differen ce on dow nw ard or u pw ard gaze. Addit ion ally, dow n w ard gaze w ill accen t u ate pretarsal fu lln ess on th e side w ith skin redun dan cy. Any brow asym m et r y sh ou ld be ad dressed before or at th e tim e of bleph aroplast y. How ever, if th e pat ien t does n ot w ish for an addit ion al operat ion or if th e asym m et r y is n ot great en ough to w arran t an op erat ion , th en excising skin on the elevated side m ay be a pract ical solut ion in a clin ical set t ing, p rovided th at th e p at ien t is cou n seled adequ ately regarding postoperat ive outcom es. W h en both eyelid creases are h igh er th an usual, sm all di eren ces in crease h eigh t usu ally do n ot lead to n ot iceable asym m et r y. In con t rast , low creases ten d to exacerbate di eren ces in h eigh t an d th e eyelids w ill appear drast ically asym m et ric. Th e palpebral ssu re w ith a low er fold, or n o fold at all, w ill appear sm aller because th e skin appears droopy. Th is sit u at ion is often overlooked or m ist aken for u n equ al or un ilateral bleph aroptosis. W h en asym m et r y of th is t ype is su spected, th e palp ebral ssu re sh ou ld be com p ared from left to righ t w h ile u sing a st ylus to create equal eyelids. Th e operat ion sh ou ld be perform ed in th e u sual m an n er— ign oring th e illusion of asym m et r y—by design ing both fold s at th e sam e h eigh t .

Multiple Creases (Triple Folds) Mu lt ip le eyelid creases, or t rip le folds, can form for various reason s an d can be classi ed by clin ical presen t at ion (Fig. 18.17). Prim ar y t riple folds are foun d in pat ien ts w ith ou t any prior su rgical h istor y an d are caused by th e loss of fat vol-

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III Blepharoplast y

a b c

Fig. 18.17 The height of extra folds corresponds to the underlying cause. (a) De ciency or excess removal of orbital fat. (b) Excess removal of connective tissue and/or ROOF. (c) Excess removal of orbicularis oculi muscle. Fig. 18.18 Triple fold from excision of connective tissue. Removal of the oculi muscle in the upper ap (upper arrow) can result in triple fold. This is especially true when the oculi muscle excision is further away from the xation point (bottom arrow, loop).

u m e (su bcu t an eou s or deep fat) in th e u p per eyelid above a n at u rally exist ing su p ratarsal fold. Th is p resen tat ion is w ith in th e spect rum of sun ken eyelids an d develops over a relat ively long t im e p eriod . Most often , prim ar y t rip le folds are p resen t ing sym ptom s in eld erly p at ien ts an d in p at ien t s w h o h ave lost sign i can t body w eigh t . Secon dar y t riple folds are p resen t in p at ien ts after th e in dex blep h aroplast y. Overzealou s soft t issue rem oval in th e upper ap can create adh esion an d subsequen tly result in an ext ra eyelid crease above th e su rgically created fold. In p ar t icu lar, rem oval of th e m ed ial ret ro-orbicu laris ocu li fat (ROOF) m ay lead to t riple fold an d sh ou ld be avoided. At t im es, pret arsal or pre-apon eurot ic soft t issue is rem oved to facilitate adh esion an d form at ion of th e eyelid crease. How ever, rem oval of th is t issu e above th e poin t of xat ion sh ou ld be avoided becau se it m ay resu lt in t rip le fold form at ion (Fig. 18.18 an d Fig. 18.19). Tert iar y t riple folds form after secon dar y operat ion s for correct ion of h igh fold, ect ropion , or eyelid ret ract ion . Th e ext ra creases are all con sequ en ces of re-ad h esion from p revious operat ion s (Fig. 18.20 an d Fig. 18.21). If th e ext ran eou s crease is sh allow, fat inject ion alon e m igh t be en ough to bolster th e skin an d preven t fu r th er p rogression of th e crease. Min or adh esion s can be released u sing an 18-gauge n eedle su bcision , bu t th is does n ot allow for in terposit ion ap s. In m ost cases, open access is requ ired for m et iculous release of adh esion s an d to perform p reven t ive m easu res. The upper ap should be released bet ween the levator aponeurosis and orbital septum . Usually, this division alone is su cient in releasing the adhesion form ing the extraneous crease. If this is not the case, however, the space bet ween the postorbicularis fascia and the orbital septum should be cleared for additional separation of outer and inner elem ents. The later plane of dissection should be m ore extensive and extend superiorly. Re-adhesion is prevented by inferior dis-

placem ent of well-organized septum and orbital fat bet ween the orbicularis oculi and the levator aponeurosis. The postorbicularis fascia and m uscle are lowered from the previous site of adhesion and anchored to the tarsal plate (Fig. 18.22).

Area of fixation Area of soft tissue rem oval

a

A line in high risk of triple fold form ation Area of soft tissue rem oval Area of fixation

b Fig. 18.19 Soft tissue removal and area of xation. (a) Fixation should be done at the highest point of soft tissue removal. (b) If xation is done lower than the area of soft tissue removal, a triple fold can be formed at the area of soft tissue removal.

18

Managem ent of Double-Eyelid Surgery Com plications

Previous fixation level New fixation level

a

Fig. 18.20 In case high xation is lowered, a triple fold can develop because a double fold can easily develop at the area of the previous xation site.

b Fig. 18.21 Triple fold formation by absence of xation point. (a) Point of xation (x) descends after blepharoptosis correction, which has the e ect of correcting and preventing triple fold. (b) On the other hand, and by the same principles, the absence of a xation point by levator muscle recession during the correction of retracted eyelid can result in triple fold.

a

b

c

Fig. 18.22 Correction or prevention of triple fold. (a) If the release of the upper ap bet ween the levator aponeurosis and the orbital septum is not su cient to correct the triple fold, the space bet ween the postorbicularis fascia and the orbital septum should be dissected extensively and superiorly for additional separation of outer and inner elements. (b) Re-adhesion can be prevented by inferior displacement of well-organized septum and orbital fat bet ween the orbicularis oculi and the levator aponeurosis. (c) The postorbicularis fascia and muscle are lowered from the previous site of adhesion and anchored to the tarsal plate.

235

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III Blepharoplast y An oth er m eth od to p reven t re-adh esion is to create a roll w ith th e skin an d orbicu laris ocu li m u scle of th e u pper ap . Th e m eth od is to pass th e n eedle th rough th e skin an d orbicu laris ocu li ju st ben eath th e crease, th en th rough th e orbicularis oculi an d skin of th e upper ap, creat ing a sligh tly bu n ch ed kin d of roll (Fig. 18.13). Postop erat ive blep h aroptosis can coexist w ith m u lt iple creases. In such cases, early correct ive operat ion for ptosis is e ect ive in separat ing th e an terior and posterior layers, w h ich w ere previously adh ered.5

Sunken Eyelid/Primary Triple Fold Su n ken eyelid s occu r from de cien cy of orbit al fat or soft t issue an d rarely from adh esion bet w een super cial an d deep st ruct ures. For th is reason , prim ar y t riple fold an d su n ken eyelids can be th ough t of as a single clin ical en t it y. As su ch , t reat m en t for sun ken eyelid is sim ilar to t reat m en t for p rim ar y t rip le fold. The lost volum e of soft t issue can be replenished by fat injection , derm ofat graft , or grafting of oth er soft tissu es such as m u scle fascia (Fig. 18.23 an d Fig. 18.24). Fat inject ion to th e subcutan eous layer or oculi m uscle layer can create irregularit y in text ure. Microfat inject ion in the deeper plane bet w een the orbicularis oculi m uscle and the sept um redu ces th e poten tial for surface irregularit y. How ever, inject ing into th e deeper layer h as the poten tial for levator m uscle injur y, w hich w ould result in bleph aroptosis. Injection in to the ROOF can also cause blepharoptosis from the added w eight, although this is usually t ransient . Nevertheless, th e risk of this com plication can be m inim ized by inject ing the fat just above the periosteum w hile the upper eyelid is pulled upw ard and th e eyes are w ide open . This

w ill en sure th at th e levator m uscle is w ell w ithin the orbital rim an d w ill decrease th e w eigh t bu rden on th e m u scle. Inject ing fat in to th e orbicu laris ocu li m u scle can be e ect ive for a t rip le fold cau sed by an adh esion w ith in a su p er cial layer. In m ost cases, h ow ever, th is can n ot be recom m en ded becau se of th e problem w ith surface irregularit ies. Fat can be injected ben eath th e orbital sept u m if th e sept u m can be visu alized by an in cision . Th e graft su r vival rate is relat ively h igh , w ith m in im al risk of surface irregularit y or lum p form at ion w ith closed eyelid s. It is, h ow ever, n ot a w idely pract iced tech n ique an d m ay rep resen t a ch allenge in term s of tech n ical kn ow h ow.

Blepharoptosis In th e im m ediate postop erat ive p eriod, m ild to m oderate blep h aroptosis m ay sim p ly be due to edem a, w h ich is t ran sien t an d w ill disap pear. If a m oderate to severe bleph aroptosis does n ot recede w ith edem a, th e surgeon m u st su spect inju r y of th e levator apon eu rosis as a cau se (Fig. 18.25).

a

b a

c b Fig. 18.23 (a) Preoperative sunken eyelid is (b) corrected with microfat injection.

Fig. 18.24 Correction of sunken eyelid by dermofat graft. (a) A sunken eyelid is marked on the left upper eyelid. (b) Intraoperative view shows dermal fat before graft. (c) Postoperatively, the sunken eyelid is corrected.

18

Managem ent of Double-Eyelid Surgery Com plications

a

If levator m uscle injury is recognized, the surgeon should consider w hich tissue to advance and by how m uch. This advancem ent w ill stretch out the levator or the Müller m uscle, so it is im portant to assess the tension through the full thickness of the levator m echanism . The injured tissues should be approxim ated and plicated m inim ally so that the Müller m uscle is m inim ally stretched. If the injury was to the upper septum w ith resultant adhesion, sim ply releasing the adhesion m ay free the levator and correct the blepharoptosis.4,6 In iat rogen ic blep h aroptosis cases, th e p at ien t m u st un derst an d beforeh an d th e goals an d lim it at ion s of th e operat ion . Th e goal is to ach ieve a n orm al an d sym m et ric eld of vision on p rim ar y gaze. How ever, th e levator m u scle m ay lack th e n orm al range of m ot ion from brot ic ch anges, an d th e pat ien t m u st u n derst an d th at lid lag or lagop h th alm os can p ersist after w ard.

b

Removal of the Eyelid Fold

c Fig. 18.25 Correction of postoperative blepharoptosis. (a) The patient su ered from bilateral high fold and traumatic blepharoptosis following blepharoplast y. (b) Intraoperative nding of the dehiscent levator aponeurosis from the tarsus. (c) Postoperative photo.

Th e m ost com m on locat ion at w h ich th e levator m ech an ism is violated is at th e ju n ct ion bet w een th e levator apon eurosis an d th e u pper border of th e t arsal plate. W h ile soft t issue excision along th e top m argin of th e t arsal p late is n ecessar y at t im es to in d uce derm ot arsal xat ion , rem oval of soft t issue su perior to th e tarsal p late can violate th e bers con n ect ing th e apon eurosis to th e plate. Th e resu lt ing bleph aroptosis m ay n ot be n ot iced in th e im m ed iate p ostop erat ive p eriod becau se of th e edem a an d th e com pen sat ion by th e Mü ller m uscle. Over th e n ext several years, th e Mü ller m u scle u n dergoes m ech an ical failu re from th e dem an d of op en ing th e eyelid w ith ou t th e h elp of th e levator apon eurosis. Th is is th e m ost likely scen ario for delayed blep h aroptosis in p at ien t s w h o h ave h ad dou ble eyelid op erat ion s m ore th an a decade ago. The levator function test is especially im portant for elderly patients. Com pensating by brow elevation m ay also m ask m in im al blepharoptosis. As stated previously, m inor unilateral blepharoptosis can easily be m issed and becom e a cause for unexpected postoperative asym m etry. Likew ise, it is im portant to distinguish bet w een true ptosis (levator failure) and derm atochalasis (drooping skin) in elderly patients.

Several fact s m u st be p resen ted by th e su rgeon , an d th ose fact s sh ou ld be u n derstood by th e p at ien t before rem oval of a su rgically created eyelid fold . Th e rst is th at a visible scar w ill be presen t even w h en th e eyes are open . Th e secon d is th at th e fold can reappear w ith t im e. Th e th ird is th at th e eyelid m ay appear an d feel bulkier du e to th e scar t issu e, inject ion of fat graft , or in ferior disp lacem en t of fat an d sept u m dow n to th e area in risk of re-adh esion .6 Becau se of th ese poten t ial issues, th e auth ors u sually recom m en d an in n er eyelid fold rath er th an tot al rem oval of the eyelid fold. In n er eyelid folds are created in a m an n er sim ilar to th e op erat ion of correct ing h igh creases. Th e adh esion form ing th e exist ing crease is decon st ru cted, an d orbit al fat an d sept u m are in terposed bet w een th e layers to preven t re-adh esion . Eversion sh ou ld be ach ieved d u ring skin closu re. Th e in cision site is t aped for a m in im um of one w eek.

■ Key Technical Points 1. To preven t loss of folds, th e sut ure m ust be t ied w h ile avoiding th e in t ru sion of soft t issue bet w een th e levator apon eurosis an d derm is. 2. Correct ion of h igh crease can involve dissect ion th rough eith er th e pre-apon eurot ic or pre-sept al layer. Despite th e poten t ial injur y to th e Mü ller m u scle or levator ap on eu rosis, th e p re-apon eu rot ic space is associated w ith low er rates of t rip le fold form at ion an d allow s a ptosis op erat ion . 3. Preven t ion an d correct ion of t riple fold are th e sam e: Th e su rgeon m u st separate th e an terior an d posterior lam ellae by all m ean s available—in cluding th e in terposit ion of orbit al fat in to th is space.

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III Blepharoplast y

■ Case Studies Case 1: Triple Fold and Ptosis A 49-year-old fem ale h ad u n d ergon e a dou ble fold op erat ion 11 years previously, w h ich resu lted in t riple fold of th e righ t upper eyelid 3 m on th s after th e in it ial operat ion . Recen tly, th e pat ien t h ad un dergon e u pper bleph aroplast y to address th e t rip le fold bu t exp erien ced im m ediate postoperat ive ptosis w ith persisten t t riple fold an d eccen t ric crease. On exam in at ion , th e pat ien t w as foun d to h ave a ptot ic u pper eyelid w ith part ial pupil coverage on th e righ t side (Fig. 18.26a). Th e di eren ce in MRDs w as 2 m m . Th e pat ien t con sen ted an d un der w en t an open u pper bleph aroplast y w ith ptosis correct ion of th e righ t eye. Th e t riple fold w as addressed as described previously, w ith adh esiolysis an d in terp osit ion of fat bet w een th e an terior an d p osterior lam ellae. A bu lky su bcu tan eou s roll w as created w ith th e orbicularis oculi m uscle to in crease fold resistan ce above th e n ew ly establish ed crease. Th e upper ap w as sp lin ted w ith Du oDERM to preven t inw ard folding of th e skin . A postoperat ive ph otograph at 6 m on th dem on st rates resolu t ion of th e t rip le fold w ith acceptable sym m et r y of th e u p per eyelid m argin s (Fig. 18.26b).

Case 2: Triple Fold and Deep Fold A 46-year-old fem ale w ith a h istor y of m u lt ip le u p per an d low er bleph aroplast ies presen ted w ith variou s com plicat ion s. Her h istor y is m ost relevan t for th e double-eyelid operat ion 3 m on th s prior, w ith a h igh crease in th e righ t eye as th e m ajor com plicat ion . Th e pat ien t un der w en t an u n successfu l revision , an d presen ted 2 w eeks after w ard. On exam in at ion , th e righ t eyelid w as n ot able for m u lt ip le creases an d ptosis. Th e left eyelid fold w as deep an d sh ow ed a sligh tly ect ropic feat u re (Fig. 18.27a). The recom m en dat ion w as to correct th e im m ediate fu n ct ion al p roblem in th e righ t eyelid an d to address th e deep fold in th e left eye at a later t im e. Du ring th e in t raop erat ive explorat ion of th e righ t lid, th e levator ap on eu rosis w as fou n d n ot to be in con t in u it y w ith th e tarsal plate. Th e adh esion s respon sible for m ult iple creases w ere lysed, an d th e m edial sept al fat w as m obilized an d in terp osed bet w een th e an terior an d posterior layers. Th e upper ap w as sp lin ted w ith Du oDERM CGF u pon skin closu re. Th e outcom e w as sat isfactor y. Th e ptosis w as corrected, an d th e m ajorit y of ext ran eou s folds did n ot reap p ear. Six m on th s later, th e pat ien t un der w en t a su ccessfu l bleph aroplast y of th e left eyelid, w ith resolut ion of th e deep fold an d ect ropion (Fig. 18.27b).

a

b Fig. 18.26 Case 1. Revision of triple fold and ptosis. (a) A 49-yearold female patient presented with eccentric crease and ptosis of the right upper eyelid after revision upper blepharoplast y. The patient underwent adhesiolysis and interposition of septal fat bet ween the anterior and posterior lamellae. A bulky subcutaneous roll was created with orbicularis oculi muscle to increase fold resistance above the newly established crease. (b) Postoperative photograph at 6 months demonstrates resolution of the triple fold with acceptable symmetry of upper eyelid margins.

a

b Fig. 18.27 Case 2. Revision of triple fold and deep fold. (a) A 46-year-old female patient presented with a high, triple fold with ptosis in the right eye and deep, slightly ectropic left eyelid after multiple upper and lower blepharoplasties. In the right eye, the adhesions were lysed and the medial septal fat was mobilized and interposed bet ween the anterior and posterior layers. Correction of deep fold and ectropion of the left eye was done 6 months after right eye surgery. (b) Six-month postoperative view shows resolution of the preoperative problems.

18

Managem ent of Double-Eyelid Surgery Com plications

■ Conclusion Com plicat ion s after bleph aroplast y are too n um erous an d varied to allow a com p reh en sive discu ssion w ith in th is ch apter, but th e basic prin ciples of recon st ruct ive surger y are app licable to a m ajorit y of th ese com p licat ion s. Th e rst p rin cip le is to u n derst an d th e n orm al an d abn orm al fu n ct ion an d an atom y of th e eyelid. Th e secon d prin ciple is to u n do, or decon st ru ct , th e postoperat ive t issu e ch anges causing th e com plicat ion . Th e th ird prin ciple is to redo th e in it ial op erat ion w ith out m aking th e sam e m ist ake.

References 1. Kim YW, Park HJ, Kim S. Secondary correction of unsatisfactory bleph aroplast y: rem oving m ultilam inated septal struct ures and grafting of preaponeurotic fat. Plast Reconstr Surg 2000;106(6):1399–1404, discussion 1405–1406 2. Ch en W P. Th e con cept of a glide zon e as it relates to upper lid crease, lid fold, an d ap p licat ion in u p per blep h arop last y. Plast Recon st r Su rg 2007;119(1):379–386 3. Kim YW, Park HJ, Kim S. Revision of un favorable double eyelid operat ion by reposit ion ing of preapon eurot ic fat . J Korean Soc Plast Recon st r Su rg 2000;27(2):99–104 4. Ch o IC. Th e Art of Bleph aroplast y. Seou l, South Korea: Koonja Pu blish ing; 2013:84–124 5. Lew DH, Kang JH, Ch o IC. Surgical correct ion of m ult iple u pper eyelid folds in East Asian s. Plast Recon st r Surg 2011;127(3):1323–1331 6. Ch ang SH, Ch en W P, Ch o IC, Ah n TJ. Com preh en sive review of Asian cosm et ic upper eyelid oculoplast ic surger y: Asian bleph aroplast y an d th e like. Arch Aesth et ic Plast Surg 2014;20(3):129–139

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IV Facial Bone Surgery

19

Zygoma Reduction

Sanghoon Park and Jihyuck Lee

Pearls • The aim of zygom a reduction is to reduce the w idth

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of the cheekbone, thus changing the boxy at facial shape into a three-dim ensional contour and achieving a sm ooth, fem inine facial line. Bizygom at ic w idth an d volu m e an d th e posit ion of th e zygom at ic body are th e key variables to be evaluated, an d th e am ou n t of body ostectom y is determ in ed during th e surger y. Th e zygom at ic body an d arch are usually m oved m edially, posteriorly, an d som et im es su periorly during th e surger y; th e poin t of m axim al m alar project ion is m arked an d it s n ew posit ion carefu lly plan n ed. In zygom a red u ct ion overall facial sh ap e, in clu ding m an dible p rom in en ce an d facial h eigh t , sh ou ld be

■ Introduction Asian people ten d to h ave a sh orter an d w ider facial con tour com pared w ith Western ers. Th e prom in en t m alar com plex com bin ed w ith th e prot ruding angled part of th e low er jaw creates a boxy rath er th an oval-sh aped face. W h en view ed from below, th e at m idface an d w id e ch eekbon es also create a boxy appearan ce. Th ese facial ch aracterist ics are t yp ical of th e Mongoloid face (brachyceph alic face), w h ile th e Caucasian face is slim an d prot ruding in an an teriorposterior dim en sion (dolicoceph alic face) (Fig. 19.1). Con ven t ion al st an dards of beau t y var y across di eren t cu lt u res an d eth n icit ies. How ever, aesth et ic st an dards in th e cou n t ries of East Asia h ave becom e m ore “global” an d in uen ced by Caucasian st an dards. Asian s seek a slim m er face w ith a th ree-dim en sion al appearan ce. Th is discrepan cy in racial ch aracterist ics an d ch anges in beau t y st an dards led to a rise in in dividu als desiring to ch ange th eir facial con tou r an d sh ape. In East Asian coun t ries su ch as Korea, Ch in a, an d Japan , facial con tou ring su rger y is ver y pop ular an d com m on ly perform ed to at t ain a m ore slen der an d sm ooth facial con tou r. Recen tly, th is t ren d h as spread to oth er par ts of Asia and am ong th e Asian s living in Western coun t ries. However, sim ply ch anging the Mongoloid face in to a Caucasian face does not guarantee a satisfactory result in Asian countries, because Asians have di erent aesthetic goals and di erent cultural backgrounds. For exam ple, prom inent high

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con sidered. Cau t ion sh ou ld be taken for pat ient s w ith a long face, as th ere is a risk for th e face to ap pear longer after th e su rger y. Reduct ion m alarplast y can be perform ed solely or in com bin at ion w ith m an dible reduct ion , gen ioplast y, or foreh ead augm en tat ion . Soft t issu e p lays a great role in redu ct ion m alarp last y. In p at ien ts w ith abu n dan t ch eek fat , th e slim m ing e ect is less obviou s an d ch eek drooping is m ore probable. Th e follow ing ve factors are con sidered h igh risk for skin an d soft t issue sagging: (1) over 40 years of age, (2) abu n dan t ch eek fat , (3) th in skin an d skin laxit y, (4) class II m an dible or ill-de n ed m an dible n eck line, (5) deep n asolabial fold or jow l.

ch eekbones are considered a sym bol of youth an d adm ired in Western countries. How ever, the sam e prom inent cheekbones are considered aesthetically unpleasing for Asian wom en as th is feature gives a h arsh, strong im pression. Therefore, before the surgery, surgeons should be well aw are of the goals of zygom a reduction in Asians. Pat ien t s w h o seek zygom a redu ct ion are th ose w h o desire a slim an d slen der oval face w h en view ed from th e fron t . Peop le w ith a brachycep h alic face ch aracterized by a at foreh ead an d m id face describe th eir face as boxy in sh ape. Th ey desire a th ree-dim en sion al an d volu m in ou s face. Peop le w ith prom in en t h igh ch eekbon es com p lain th at th ey look “too st rong,” “o en sive,” “old,” “t ired,” an d “m ascu lin e,” an d th ey w an t to ch ange th eir faces to h ave a m ore “soft ,” “you ng,” an d “fem in in e” app eal. Th e object ives of zygom a reduct ion are as follow s: 1. Reduct ion of facial w idth for slender facial con tour. First an d forem ost , th e aim of zygom a reduct ion is to acquire a m ore slender and n arrow facial contour. Usually facial w idth is determ in ed by th e bizygom atic distance w hich links the articular t ubercles on the t w o sides. Reduction or t ran sposition of the zygom atic arch is an e ect ive m ethod to reduce facial w idth . As th e zygom atic body is usually hypert rophied together, reducing only the zygom atic arch m ay lead to a boxy appearan ce; th u s, com bin ed an d h arm on ious reduct ion of arch w idth an d zygom atic body is essential.

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IV Facial Bone Surgery

■ Patient Evaluation

a

b

Fig. 19.1 Bony facial morphology at the level of the cheekbone in axial section. Compare the (a) dolicocephalic Caucasian face and the (b) brachycephalic Asian face.

2. Ch ange a boxy at facial sh ape in to a th reedim en sion al con tour. Even if facial w idth is reduced, th e face can st ill appear squ are.1 Asian faces h ave a brachyfacial ch aracterist ic w ith a at su borbit al area. W h en view ed from below, th e lack of m alar project ion result s in th e suborbit al area an d zygom at ic arch form ing a 90-degree angle th at len ds a boxy app earan ce. In th is case, th e face ap p ears at an d t w o-dim en sion al, an d even w ider th an it ap pears from th e fron t . Th erefore, ch anges in th e sh ape an d p osit ion of th e zygom at ic body are n eeded to create a m idface fu lln ess th at ap pears m ore th reedim en sion al an d youth ful. 3. At t ain a sm ooth facial lin e th at looks m ore fem in in e an d you ng. An angu lar face lin e n eeds to be m ade soft . In th e case w h ere th e ch eekbon es prot ru de out w ardly, th e facial lin e con n ect ing th e tem plezygom a-ch eek-m an dible angle con st it u tes a ver y convoluted lin e (Fig. 19.2). In th e case of Western ers, prom in en ce of th e zygom at ic body is a sym bol of beaut y an d you th fuln ess. How ever, for Asian s this prom in en ce result s in an obst in ate an d m asculin e look, w h ich gives a n egat ive im pression . High ch eekbon es are n ot an ideal look in Asian cu lt ures; th erefore, reduct ion is n eeded to m ake th e face soft an d fem in in e. For th ose over th e age of 35, facial soft t issu e decreases an d skin start s to droop ; m alar em in en ce looks even m ore pron ou n ced an d cau ses grooves in th e ch eek an d tem ple, gradu ally resu lt ing in a t ired an d aged look. Fat inject ion s to su ch h ollow areas can be an easy opt ion , bu t th e resu lt is n ot predict able or perm an en t . Zygom at ic reduct ion is a good opt ion for th e m idd le-aged w om an w h o desires a you th fu l, soft , an d fem in in e facial con tou r.

Direct physical exam in at ion is th e key p rocess to evalu ate th e pat ien t’s problem s an d establish a surgical p lan . Clin ical ph otos are n ecessar y, as is radiologic exam in at ion in cluding fron t al view, lateral view, subm en tover tex view, an d Waters’ view. A com p u ted tom ograp hy (CT) scan w ith 3D view is also essen t ial to evaluate th e sh ape of th e zygom at ic com plex. Th e volum e an d posit ion of th e zygom at ic body, an d th e bizygom at ic w idth are key variables to be con sidered. Th e volum e of th e zygom at ic body determ in es th e am oun t of ostectom y requ ired during th e su rger y. If th e volum e is large, a w ider resect ion of th e zygom at ic body sh ou ld be plan n ed. How ever, over-zealous reduct ion results in a at or de cien t look. Th erefore, keeping an adequ ate volum e of th e zygom at ic body in th e an tero-posterior dim en sion an d t ran sverse plan e is essen t ial. Th e posit ion of th e zygom at ic body is m easured both at it s m ost lateral m argin and in it s m axim al project ion . Th e outer m argin of th e zygom at ic body is obser ved in conjun ct ion w ith tem ple an d ch eek. To n arrow th e an terior m idfacial w id th , th e lateral m argin of th e ch eekbon e sh ou ld

Fig. 19.2 Anterior and posterior facial contour lines. The anterior facial contour line connects the temple, zygomatic body, cheek, and mandible body (red line), while the posterior facial contour line connects the temple, zygomatic arch, m andible angle, and chin (blue line). If the anterior contour line is too convoluted, the patient gives a “strong,” “o ensive,” “old,” “tired,” “m asculine” impression. The posterior contour line re ects the facial width and facial size.

19 be t rim m ed or m oved inw ard. If th e outer m argin of th e ch eekbon e is placed w ide, th e am oun t of n arrow ing an d m edializat ion sh ou ld be m axim ized an d ostectom y sh ou ld be com bin ed. The poin t of m axim al m alar project ion (MMP) is the point w here the outer contour of the zygom atic com plex prot rudes m ost in the basal three-quarters view. If the reduction of th e zygom atic body is perform ed by sh aving, or the osteotom y is placed lateral to the MMP, this point stays u n ch anged w h ile th e outer m argin of th e zygom at ic body is n arrow ed, result ing in an unn at u ral, box-sh aped cheekbone. As stated before, the purpose of reduction m alarplast y is not resection of th e projection ; therefore, adequate projection and posit ion of the MMP is the key postoperat ive result. The point of MMP is m arked and the surgeon decides w here to m ove this point three-dim ension ally. The am oun ts of m edial reposition ing an d ostectom y are closely related to th e reduct ion of anterior facial w idth . Th e ideal posit ion of th e MMP m ay var y am ong differen t eth n icit ies; h ow ever, th e follow ing are t w o sim p le m eth ods of determ in ing th e ideal posit ion of th e MMP (Fig. 19.3). 1. Hinderer analysis. Th e MMP is determ in ed at th e p oin t of in tersect ion of t w o lin es, w h ere th e rst lin e con n ect s th e lateral can th u s an d th e oral com m issure, an d th e secon d lin e con n ect s th e n asal alar base an d th e t ragu s lin e. Th e n ew locat ion is a p oin t p laced in ju xt ap osit ion to th e crossed lin es in th e upper outer quadran t .2 2. W ilk inson analysis. A lin e is d rop p ed vert ically d ow nw ard from th e lateral can th u s to th e in ferior border of th e m an dible. Th e MMP is located at on eth ird th e dist an ce from th e lateral can th us to th e angle of th e m an dible.3

a Fig. 19.3

Zygom a Reduction

On ce th e su rgical variables for th e zygom at ic body are evaluated, th e bizygom at ic w idth is m easured, an d th e requ ired am ou n t of arch m edializat ion , w h ich is crit ical in th e reduct ion of posterior facial w idth , sh ould be decided. Th e posterior basal por t ion of th e arch , w h ich is posterior to th e osteotom y, can n ot be m edialized an d sh ou ld be carefu lly sh aved to p reven t visible step . Too m u ch arch redu ct ion w ith th e rem ain ing zygom at ic body w ill resu lt in a at , boxy face. To avoid th is outcom e an d create a full m idface con tour, th e redu ct ion of th e zygom at ic body an d arch sh ou ld be coordin ated an d balan ced. Th ere are m any variables th at n eed con siderat ion during surger y, an d th ese sh ould be decided by th e abovem en t ion ed evalu at ion . Variables of th e zygom at ic body are (1) am oun t of ostectom y, (2) am oun t of m edializat ion , (3) am ou n t of setback, an d (4) su p erior or in ferior posit ion ing. Variables of th e zygom at ic arch are th e am oun t of arch m edializat ion an d th e sh aving qu an t it y of th e p osterior area of th e ar t icu lar t u bercle. Facial soft t issu e is an im port an t aesth et ic com pon en t in zygom a redu ct ion an d sh ou ld be con sid ered before an d during th e surger y. If th e pat ien t h as th in fair skin w ith m in im al ch eek fat , th e ch anges after bon e su rger y w ill be obvious an d th e ch an ce of soft t issu e drooping is m in im al. Th is pat ien t is a good can didate for zygom a reduct ion . How ever, bony step , especially arou n d th e orbit , m ay be visible an d th e p late m ay be palp able th rough th e th in skin . Su rgeon s sh ou ld t ake ext ra e or t to en su re a sm ooth t ran sit ion bet w een bony osteotom y. If th e p at ien t h as abu n dan t ch eek soft t issu e, or th ick skin , th ere is a h igh risk of ch eek drooping. Th e pat ien t sh ould be in form ed about th e possibilit y of ch eek drooping an d appropriate adjun ct ive m easu res, in clu d ing liposu ct ion or lift ing p rocedu res. If th e pat ien t h as a th ick m alar fat pad, th e zygom at ic body sh ould be sligh tly over-corrected to preven t un der-correct ion .

b

Determ ining the ideal position of the maximal malar projection (MMP). (a) Hinderer analysis. (b) Wilkinson analysis.

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246

IV Facial Bone Surgery Overall facial shape, in cluding m andible prom inen ce an d facial length, sh ould be considered (Fig. 19.4). Zygom a reduction can be perform ed solely or in com bination w ith m andible reduction. If the patient has a prom inen t m an dible, reduction m alarplast y alone m ay not be able to balance bigonial and bizygom atic w idth, and com bined m andible reduction should be recom m ended. If a patient has a long face w ith prom inent ch eekbones, a reduction in bizygom atic distance deteriorates the excessively narrow ed long face and leads to “cucum ber face.” It is advisable to focus on the setback of the zygom atic body instead of the m edialization of body and arch, and selectively create a soft facial contour.

■ Surgical Techniques Th e surgical tech n ique an d approach for zygom a reduct ion w as developed in 1983 w h en On izu ka et al4 in t rodu ced th e ch iseling an d sh aving m eth od for th e protru ding por t ion of th e m alar bon e via in t raoral in cision . Di eren t surgical tech n iqu es h ave been devised, such as bone sh aving, in fract u re of th e zygom at ic arch ,5 an d osteotom y/ostectom y of th e zygom at ic body.2,6,7,8,9 Bon e sh aving is th e sim plest an d m ost st raigh tfor w ard m eth od, an d can be u sed for lim ited, localized prot ru sion of a zygom at ic body. How ever, sh aving of th e zygom at ic body m ay lead to th e exp osu re of can cellous bon e, result ing in u npredictable resorpt ion an d p ostop erat ive irregularit y 10 ; th u s, th ere is a lim it at ion on th e am oun t of resect ion , and th e overall size of th e zygom at ic body can n ot be redu ced w ith th is m eth od. Du e to th e th ickn ess of th e in st rum en t, th e sh aving m eth od can n ot be ap plied to th e zygom at ic arch to red u ce th e overall facial w idth .11 Th e in -fract u re tech n ique 5 is a useful m eth od in redu cing th e p rot rusion of th e zygom at ic arch . Su rgeon s u su ally con du ct osteotom y of th e zygom at ic arch , avoiding a full-d epth cut an d m ain tain ing th e con t in uit y of th e periosteum (green st ick),10 an d push ing th e zygom at ic segm en ts m edially. Its m ajor advan t ages are sim plicit y an d sp eed; h ow ever, it carries th e risk of an u n con t rolled am ou n t of in -fract u ring in th e zygom at ic arch , an d it h as a lim ited e ect on a prom in en t zygom at ic body. An L-sh ap ed osteotom y of th e zygom at ic body is th e preferred m eth od for pat ien ts w ith m oderate to severe m alar p rot ru sion du e to w ide zygom at ic arch an d prom in en t body. An L-sh aped osteotom y is m ade in th e an terior part of th e zygom at ic body an d a separate osteotom y is m ade in th e posterior p art of th e zygom at ic arch . With or w ithout rem oval of bon e,6 a zygom at ic segm en t is m oved to th e desired p osit ion an d xed w ith w ires or p lates an d screw s. Th e L-sh ap ed osteotom y tech n iqu e can ch ange both th e zygom at ic body an d arch an d h as th e advan tage of con t rolling th e degree of reduct ion as w ell as th e sh ape after red u ct ion . As p at ien t s u su ally d esire ch ange in th e zygom at ic body an d arch , L-sh aped osteotom y is curren tly th e m ost frequ en tly used an d preferred m eth od in zygom at ic redu ct ion (Fig. 19.5).

Tr

Ft

Ft

Zy

Zy

Go'

Go'

Me' Zy – Zy = 70 – 75% Tr – Me' Ft – Ft = 80 – 85% Zy – Zy Go' – Go' = 70 – 75% Zy – Zy Fig. 19.4 Evaluation of facial harm ony. Facial harmony should be considered bet ween midfacial width (Zy–Zy) and lower facial width (Go′–Go′), and bet ween midfacial width and upper facial width (Ft– Ft). The ratio bet ween the height (Tr–Me′) and the width of the face should be in proportion.

Th e approach for zygom a redu ct ion can be sim ply divided in to t w o part s: th e extern al approach (coron al in cision , tem p oral in cision , p reau ricu lar in cision ) an d th e in t raoral approach . Th e extern al an d th e in t raoral approach es h ave th eir resp ect ive advan t ages an d draw backs.11 As zygom at ic reduct ion developed from th e t reat m en t of zygom at ic fract u re, th e coron al approach w as rst used to exp ose th e en t ire zygom at ic body an d arch . How ever, it requ ires a long operat ion t im e, an d it m ay cause bleeding an d visible scarring. Th e in t raoral ap proach h as th e advan tage of h idden scars, lim ited bleeding, an d sh ort operat ion t im e. How ever, it provides lim ited operat ive exposure, result ing in di cu lt osteotom y, lim ited space for xat ion, an d th e risk of in fra-orbital n er ve injur y. Side e ect s in clude ch eek drooping due to w ide dissect ion an d volu m e reduct ion , w h ich can be avoided by m in im izing th e dissect ion. Th e osteotom ized segm en t sh ould be rigidly xed an d postoperat ive elast ic dressing provided to preven t ch eek drooping. Th e in t raoral approach can be u sed solely; h ow ever, it is usu ally com bin ed w ith pre-au ricular in cision or tem ple in cision to m in im ize th e dissect ion an d th e possibilit y of ch eek drooping.

19

Fig. 19.5 Design of bone cuts in malar reduction. An inverted L-shaped osteotomy line is marked over the malar eminence. A second, parallel line is drawn lateral to the rst line to represent the strip of bone to be resected. A posterior bone cut is made ~ 2 to 3 cm anterior to the tragus.

Zygom a Reduction

the zygom at ico-m axillar y but t ress. Great at tent ion m ust be paid to avoid injur y to the orbital contents or infraorbital ner ve. A second, parallel lin e is draw n lateral to the rst line to represen t th e st rip of bon e to be resected, allow ing in set of th e fragm ent .12 The distan ce of the second lin e from th e rst lin e depen ds on th e patien t’s preferen ce an d th e w idth of the zygom at ic body. A w ider parallel osteotom y can be m ade for greater reduction ; h ow ever, th e usual w idth of th e strip at th e au th ors’ h ospital is ~ 3 to 5 m m . Th e sh ort lim b of the osteotom y m ust be high enough to avoid th e den tal roots. Carefu l dissect ion is required in the zygom at ic-pter ygoid space to preven t inju r y to th e vessel, w h ich m ay lead to profuse bleeding and postoperat ive bruising. Mu lt ip le ret ractors are p laced an d th e cu ts are m ade w ith a reciprocat ing saw st ar t ing from th e su perior lateral lim b of th e osteotom y. Superior m edial lim b an d n ally in ferior t ran sverse cut s are m ade, an d th e in ter ven ing bon e fragm en t is rem oved .

Posterior Osteotomy As th e in t raoral approach is th e m ost w idely used m eth od th ese days, zygom a redu ct ion via th e in t raoral ap proach w ith an L-sh ap ed osteotom y is th e m ost p referred m eth od to correct facial im balan ce in pat ien t s w ith prom in en t zygom at ic body and arch .

Anesthesia and Approach All patien ts are given gen eral an esth esia. Orotrach eal in t ubation is preferred at the auth ors’ hospital, but nasotracheal int ubation can be used. A ~ 3-cm labiobuccal vestibular incision is m ade on each side of th e m axilla.7 Th rough th is in cision , th e soft t issues are elevated su periorly an d laterally at the subperiosteal plane. Dissect ion is lim ited to the area of the zygom at ic body, th e anterior w all of the m axillar y sinus, an d th e lateral an d in ferior orbital rim . As th e dissect ion exten ds superolaterally over th e m alar em in en ce, a portion of the origin of the zygom at ic m ajor an d zygom at ic-cutaneou s ligam ents m ay be partially divided from the bony su rface.

Anterior Osteotomy An inverted L-sh aped osteotom y lin e is m arked over th e m alar em in en ce (Fig. 19.5). Th is lin e gen erally exten ds m edially from th e lateral border of th e orbital rim to just below the in fraorbital foram en. Be careful not to start the osteotom y too low from w here the arch changes from a vert ical to a h orizon tal direct ion , w h ich m ay result in in sufcien t volum e reduct ion in th e zygom atic body. Th e sh ort lim b of the osteotom y th en t urns at about a 90° angle tow ard

Up on exp osin g t h e p oster ior p ar t of t h e zygom at ic arch , t h e cou rse of t h e fron t al bran ch of t h e facial n e r ve an d t h e zygom at ic arch is m arked on t h e skin . A ~ 1-cm ve r t ical in cision is m ad e w it h in t h e sid ebu r n ,12 2 to 3 cm an ter ior to t h e t ragu s. Th is in cision sh ou ld lie p oster ior to t h e cou rse of t h e n er ve. Th e arch is id en t i ed after t h e d issect ion of t h e p er iosteu m , an d n e elevators are p assed over t h e top an d beh in d t h e arch an d as far p oster iorly as p ossible to en su re t h at t h e oste otom y is st ill an te r ior to t h e tem p orom an d ibu lar join t . A recip rocat in g saw is u sed to m ake t h is ver t ical oste otom y. W h en t h e p oste r ior osteotom y is com p leted , t h e zygom at ic segm e n t sh ou ld be fre e to m ove w h ile rem ain in g at t ach ed to t h e m asseter. Ad d it ion al bon e d ist al to t h e osteotom y m ay be bu r re d if n ecessar y.12

Fixation Th e osteotom ized body an d arch are posit ion ed posteriorly an d m edially as a resu lt of th e osteotom y, an d th e in ter ven ing segm en t is rem oved. According to the pat ien t’s desired outcom e an d preoperat ive plan n ing, th e th ree-dim en sion al locat ion of th e segm en t is determ in ed w h ile good con t act of bony surfaces is m ain t ain ed. Six-h ole m in iplates w ith screw s are placed to x th e an terior port ion of th e segm en t , an d t w o- or th ree-h ole m in ip lates w ith screw s are u sed to x th e zygom at ic arch (Fig. 19.6). Posit ion ing of th e osteotom ized segm en t is th e m ost crit ical step for postoperat ive resu lt s, an d th e n al segm en t posit ion is adjusted based on pre-exist ing asym m et r y an d in t raoperat ive appearan ce to ach ieve th e desired n al ou tcom e. An id en t ical p rocedu re is th en p erform ed on th e con t ralateral side. Stan dard tech niqu es are used to close th e in t raoral an d skin in cision s.

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a

Fig. 19.6 Rigid xation of malar complex using t wo miniplates. (a) Applying a prebending miniplate to the zygomatic arch. (b) Applying miniplates to the zygoma body.

■ Key Technical Points Shape of the Osteotomy: “I” versus “L” Th ere are t w o m ain osteotom y pat tern s used for th e zygom at ic body: I-sh aped osteotom y an d L-sh ap ed osteotom y.11 Baek et al13 described I-sh aped osteotom y as a tech n iqu e to rem ove th e m alar com plex. Th is osteotom y is placed lateral to th e m axim al m alar p roject ion an d u su ally can n ot in clude th e volu m e of m alar p roject ion . Th e osteotom ized segm en t m ay drift dow nw ard as th e m asseter m u scle p u lls th e fragm ent . Th e L-sh ap e d osteotom y, w h ich evolved from t h e I-sh ap ed osteotom y, h as t h e key ad van t age of in clu d in g t h e volu m e of t h e m alar p roject ion . Fragm en t d isp lacem en t is avoid ed an d t h e m asseter m u scle can n ot d rag t h e fragm en t d ow nw ard becau se of t h e cou n terch e ck of t h e in fer ior bord er.11 Fu r t h er m ore, t h e L-sh ap ed osteotom y h as a large r con t act su r face t h an t h e I-sh ap ed osteotom y. Th e greatest advan t age of t h e L-sh ap e d osteotom y is from t h e aest h et ic p oin t of view , as t h e osteotom y is e e ct ive in red u cin g t h e w id t h of t h e zygom at ic body an d rep o sit ion in g t h e MMP p oin t . For m a xim izin g t h e d egre e of red u ct ion , t h e au t h ors ch oose to p osit ion t h e su p e r ior osteotom y lin e as close to t h e orbit al r im as p ossible. Care m u st be t aken to avoid inju r y to in t raocu lar an d p er iorbit al st r u ct u res.

b

Ostectomy versus Osteotomy In p at ien t s w ith a oversize zygom at ic body, rep osit ion ing th e zygom at ic body alon e can n eith er slim th e overall face n or sm ooth th e m idface con tour. Th erefore, a p at ien t w h o h as p rom in en t zygom at ic body requires th e approp riate ostectom y an d reduct ion of bony volum e togeth er. How ever, as ostectom y m ay lead to acciden t al bony gap, surgeon s m u st t ake great care th at ostectom y is carried ou t in th e sagit t al dim en sion as m uch as possible an d m axim ize th e bon e-to-bon e con t act to preven t th e bony gap.

Vector of Transposition Reposit ion ing of th e osteotom ized zygom at ic com plex is th e single m ost im por tan t step in reduct ion m alarplast y. Th e MMP poin t is determ in ed before surger y th rough th orough con su ltat ion an d physical exam in at ion . If the patient’s chief com plaint is facial w idth, the zygom atic segm ent should be transposed m edially, and if patien ts seek im provem ent in a prom inent zygom atic body to give a less harsh im pression, the zygom atic com plex should be transposed m edially and posteriorly, w ith m ore reduction in the zygom atic body than in the zygom atic arch. By controlling the am ount of transposition of the zygom atic body and arch, and by com bining the m edial and posterior transpositions, a harm onious and balanced face can be attained.

19

Zygom a Reduction

Fixation

Nonunion

Alth ough xat ion m ay n ot be essen t ial in m alar red u ct ion u sing th e in -fract u re m eth od, rigid xat ion is n ecessar y w h en on e or m ore osteotom ies are con ducted. On ly rigid xat ion to both th e zygom at ic body an d arch can gu aran tee precise reposit ion ing an d st abilit y. If rigid xat ion is n ot u sed after osteotom y, u n der-correct ion , asym m et r y, or relapse after surger y can occu r. It is a seriou s sh or tcom ing th at surgeon s are un able to con t rol th e exact degree an d posit ion of m ovem en t , especially in th e eld of aesth et ic su rger y. Rigid xat ion is also crit ical to preven t n on u n ion an d p ostop erat ive p ain . As th e m asseter m uscle fun ct ion s as a depressor an d a m edial rot ator for th e zygom at ic segm en t after osteotom y, th ree-p oin t xat ion is n ecessar y for th e zygom at ic body, orbital rim an d zygom at ic arch to preven t th reedim en sion al rot at ion . How ever, xat ion in th e orbit al rim requ ires addit ion al in cision . To avoid addit ion al in cision an d xat ion in th e orbit al rim , th e au th ors recom m en d u sing dou ble-squ are m idplate in th e zygom at ic com plex as a ver y sim p le an d easy m eth od to p reven t rot at ion w h ile m in im izing th e in cision s.

Nonunion is a source of under-correction and cheek drooping, and is one of the reasons for unidenti ed pain in long-term follow -up. Though radiology can reveal breakage of xation m aterial and separation of bony segm ents, exam inations m ay at tim es be unable to detect de nite signs of m alunion. Partial separation of bone, especially in the supero-lateral position of the orbital rim , is often found but is not considered non union if one-third of the bone is healed in continuit y. Possible causes of nonunion are excessive resection of bone, unstable xation, excessive m ovem ent (e.g., w hen chew ing), m uscle pull, and traum a in the im m ediate postoperative period. Conservative treatm ent can be tried initially to relieve pain and cam ou age soft tissue depression. Soft tissue depression can be corrected w ith fat injections, although frequent relapse can occur. In cases of repeated relapse after fat injection, onlay Medpor (Stryker) insertion to create continuit y over the gap is an option. Indications for m ajor surgery include a severe recurrent pain, and aesthetic problem s such as obvious bony gap, asym m etry, and sagging of the m alar com plex. Repositioning of the zygom a com plex is ideal, though very di cult if bone loss is extensive, and additional bone graft or alloplastic m aterial m ay be necessary.

■ Complications and Their Management

Sagging of Soft Tissue As re d u ct ion m alar p last y involves re d u ct ion of bon e as w ell as t ran sp osit ion , saggin g of soft t issu e m igh t be in evit able an d n e e d s to b e ad d resse d d u r in g t h e p ro ce d u re. Previou sly, an in fe r iorly p osit ion e d zygom at ic com p lex or m obile bon e segm e n t w as a m ajor cau se of soft t issu e saggin g. Th is com p licat ion can be p reve n t e d by r igid xat ion . Wid e dissect ion an d excess soft t issu e are poten t ial reason s for sagging of soft t issue. Min im izing th e dissect ion an d preser ving th e origin of th e m asseter m u scle in th e zygom at ic body can m in im ize unw an ted soft t issue prob lem s. Th e st at us of soft t issue also plays a role in soft t issue sagging. High -risk factors for skin an d soft t issu e sagging in clu de (1) age over 40 years, (2) abun dan t ch eek fat , (3) th in skin an d skin laxit y, (4) class II m an dible or ill-de n ed m an dible n eck lin e, an d (5) p red isp osing deep n asolabial fold or jow l. In th ese h igh -risk groups of p at ien t s, p reoperat ive explan at ion s about th e possibilit y of ch eek drooping are n ecessar y, an d sp ecial at ten t ion sh ou ld be paid before an d du ring th e p rocedu re to t r y to overcom e th is com p licat ion . Midface lift , th read lift , buccal fat rem oval, an d paran asal augm en t at ion are h elpfu l adju n ct ive p rocedures an d can be com bin ed or perform ed separately.

Infraorbital Nerve Injury and Paresthesia Du ring zygom at ic redu ct ion , inju ries to th e orbit , orbit al con ten ts, in fraorbit al n er ve, an d tem poral bon e are possible. To preven t injur y to th ese st ru ct ures, th e surgeon m u st be carefu l and acutely aw are at all t im es regarding th e locat ion of th e saw.12 Excessive pull by ret ractors are a com m on sou rce of paresth esia after su rger y. Plate an d screw s m ay cau se th e paresth esia if th ey are placed too close to th e in fraorbit al foram en .

Trismus Com pression of th e tem poralis m u scle due to inw ard m ovem en t of th e zygom at ic arch can cau se t rism u s. It w ill im prove w ith in 1 to 2 m on th s after surger y, an d m outh open ing exercises are h elpful to relieve th ose sym ptom s.

Asymmetry As m ost pat ien ts w h o com plain of asym m et r y postoperat ively already h ad asym m et r y prior to surger y, a careful an d th orough p reop erat ive exam in at ion is crit ical, follow ed by com m u n icat ion regarding th e possibilit y of asym m et r y an d lim itat ion s of su rger y.

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Under-correction

■ Case Studies

From th e pat ien t’s aesth et ic poin t of view, th e m ost com m on com p lain t after zygom at ic redu ct ion is u n der-correct ion . In adequate reduct ion of th e zygom at ic body or in ap propriate posit ion ing of th e m axim u m m alar project ion is a com m on cau se for dissat isfact ion . Th erefore, proper pat ien t select ion is required an d pat ien ts’ expect at ion s sh ould be realist ically addressed an d adjusted.

a

b

Case 1: Zygoma Reduction A 32-year-old w om an com plain ed of p rom in en t zygom a an d w ide m idface (Fig. 19.7). An inverted L-sh aped ostectom y w ith a 5-m m redu ct ion of each zygom a w as con du cted to redu ce th e p rot ru sion of h er zygom a. Th e p osterior p ar t of th e zygom at ic arch w as divided w ith com plete ostectom y. After th e osteotom ized zygom a w as sh ifted m edially (5 m m ) an d posteriorly (3 m m ), it w as xed w ith m in iplates an d screw s. Th e body of th e zygom a w as xed w ith a double-bridged plate to provide st abilit y again st th e torque from th e m asseter m u scle. Th e arch of th e zygom a w as xed w ith a p re-ben ding p late to ach ieve an accu rate p osit ion as w ell as st abilit y (Fig. 19.8). Th e m alar p rom in en ce an d m idfacial w idth w ere redu ced m arkedly at 12 m on th s postoperat ively (Fig. 19.9).

Fig. 19.7 Case 1. Preoperative (a) frontal and (b) oblique photographs of the patient.

19

a Fig. 19.8

a

Zygom a Reduction

b Case 1. (a) Preoperative and (b) postoperative radiographic showing posteromedial repositioning of the zygoma.

b

Fig. 19.9 Case 1. Twelve-month postoperative (a) frontal and (b) oblique photographs.

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Case 2: Combined Zygoma Reduction and Mandible Contouring A 28-year-old w om an com plain ed of m alar prot ru sion an d prom in en t m an dibular angle (Fig. 19.10). Sh e u n der w en t redu ct ion m alarplast y an d m an dible con touring su rger y

a

(Fig. 19.11). After com p lete ostectom y w as app lied to th e an terior an d posterior p ar t of th e zygom a, th e zygom a w as rep osit ion ed p osteriorly an d m edially. Narrow ing gen iop last y an d con com itan t m an dible con tou ring su rger y w ere p erform ed to correct h er squ are low er face. Fou r teen m on th s after th e op erat ion , th e p at ien t’s facial con tou r ap pears soft an d slen d er (Fig. 19.12).

b

c

Fig. 19.10 Case 2. Preoperative (a) frontal, (b) oblique, and (c) basal photographs. Zygoma reduction and mandible narrowing surgery were done simultaneously.

a Fig. 19.11

b Case 2. Three-dimensional CT images: (a) preoperative and (b) 8 months postoperative

19 a

Fig. 19.12

b

Zygom a Reduction

c

(a–c) Case 2. Fourteen-month postoperative photographs.

References 1. Kang JS, ed. Plast ic Surger y. Seoul, Korea: Koonja; 2004

7. Kim YH, Seul JH. Reduct ion m alarplast y th rough an in t raoral in cision : a n ew m eth od. Plast Recon st r Su rg 2000; 106(7):1514–1519

2. Hinderer UT. Malar im plants for im provem ent of the facial appearance. Plast Reconstr Surg 1975;56(2):157–165

8. Agban GM. Augm en t at ion an d correct ive m alarplast y. An n Plast Su rg 1979;2(4):306–315

3. Wilkin son TS. Com plicat ion s in aesth et ic m alar augm en t at ion . Plast Recon st r Su rg 1983;71(5):643–649

9. Uhm KI, Lew JM. Prom inent zygom a in Orientals: classi cation and treatm ent. Ann Plast Surg 1991;26(2):164–170

4. On izuka T, Watan abe K, Takasu K, Keyam a A. Reduction m alar plast y. Aesth et ic Plast Surg 1983;7(2):121–125

10. Kook MS, Ju ng S, Park HJ, Ryu SY, Oh HK. Red u ct ion m alarplast y using m od i ed L-sh aped osteotom y. J Oral Maxillofac Su rg 2012;70(1):e87–e91

5. Yang DB, Park CG. In fract ure tech n ique for th e zygom atic body an d arch reduct ion . Aesth et ic Plast Surg 1992; 16(4):355–363 6. Ch o BC. Reduct ion m alarplast y using osteotom y an d reposit ion ing of th e m alar com plex: clinical review and com p arison of t w o tech n iques. J Cran iofac Su rg 2003;14(3): 383–392

11. Hong SE, Liu SY, Kim JT, Lee JH. In t raoral zygom a redu ct ion u sing L-sh ap ed osteotom y. J Cran iofac Su rg 2014; 25(3):758–761 12. Morris DE, Moaven i Z, Lo LJ. Aesth et ic facial skelet al con tou ring in th e Asian p at ien t . Clin Plast Su rg 2007; 34(3):547–556 13. Baek SM, Ch u ng YD, Kim SS. Redu ct ion m alarp last y. Plast Recon st r Su rg 1991;88(1):53–61

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20

Mandible Reduction

Sanghoon Park and Seungil Chung

Pearls • “Angle reduct ion ” is th e old n am e for th is procedure

•

•

•

an d rep resen t s a m ajor m iscon cept ion regard ing w h at th e su rger y is for. Th e pu rpose of m an dible redu ct ion is to m ake th e low er face appear slim in th e fron tal view an d to ach ieve a sm ooth con tour in th e lateral view. Ch anging th e m an dibu lar plan e an d con touring th e w h ole low er border of th e m an dible are crit ical step s. On th e oth er h an d, angle red u ct ion w ith rem oval of t riangular bon e w ill in evit ably leave an u n n at u ral low er con tou r of m an dible w ith a secon dar y angle. Becau se sh ap ing th e lateral con tour of th e m an dible alon e m ay resu lt in m in im al im p rovem en t in th e fron t al view, su rgical tech n iqu es to red u ce th e w idth of th e low er face via bu rring or ostectom y of th e lateral cortex sh ou ld u su ally also be don e. Th e ch in plays an im port an t role in creat ing a beaut iful facial lin e an d overall con tour; th erefore, gen iop last y sh ou ld be con sidered in con t in u it y w ith m an dible redu ct ion . Th e relat ion sh ip bet w een th e m axilla an d th e m an dible in p ro le view sh ou ld be obser ved. In class II, or class III pro le, orthogn ath ic surger y is rst con sidered. How ever, in pat ien t s w ith m ild deform it y, or in pat ien t s w h o do n ot w an t or th ogn ath ic su rger y, m an dible reduct ion sh ould be plan n ed to preven t th e exist ing problem s from deteriorat ing.

■ Introduction Th e overall Asian facial st ruct ure is t ypically classi ed as brachyceph alic or m esoceph alic, w ith a w iden ed m an dibular arch an d broad low er facial skeleton . In cou n t ries su ch as Korea, Ch in a, an d Jap an , th ese ch aracterist ics are often view ed as m ascu lin e an d u n at t ract ive; th u s, both m en an d w om en often w ish to m ake th eir faces app ear m ore slim an d slen der. Th e w idt h of t h e low er t h ird of t h e face is d eter m in ed by t h e w idt h of t h e m an dible it self, w h ich is su r rou n d ed by m u scles an d su bcu t an eou s fat t issu es. Gen erally, t h e cau se of p rom in en t m an d ibu lar an gle in Asian s is t h e

254

• Th e in ferior alveolar n er ve is th e m ost im port an t

•

•

st ru ct u re d u ring m an dible redu ct ion , an d it sh ou ld be carefu lly exam in ed preoperat ively in pan oram ic view as w ell as in a com p u ted tom ograp hy (CT) scan . It is t yp ically located at least 20 m m aw ay from th e upper border of th e m an dible, w h ich sh ould be kept in m in d w h en design ing an d con du ct ing th e osteotom y. Th e m ost com m on cause of paresth esia is n ot a direct cut bu t a blu n t inju r y to th e n er ve by ret ractors com ing out of th e m en tal foram en . Osteotom y sh ou ld be con du cted at least 3 m m aw ay from th e m en tal foram en . Th e in cid en ce of m ajor in t raop erat ive h em or rh age h as d ecreased d u e to advan ces in su rgical tech n iqu e an d t h e u se of a hyp oten sive an est h et ic p rotocol. If t h e ret rom an d ibu lar vein or t h e facial ar ter y is tor n d u r in g a p roced u re, ad equ ate h em ost asis w it h elect rocau ter y m ay n ot be easy, an d t h is m ay lead to excessive blood loss. Ap p licat ion of h em ost at ic su bst an ces an d exter n al m an u al com p ression for m ore t h an 30 m in u tes can h elp to stop t h e bleed in g. Follow ing th e com plet ion of surger y, th e soft t issu es of th e ch eek an d th e n eck sh ould be ch ecked for any sign s of bleed ing or sw elling. Any sign of sw elling or bleeding n ear th e th roat is a serious com plicat ion an d sh ou ld be t reated im m ed iately as it m ay cau se breath ing problem s.

lateral p rot r u sion of t h e m an dibu lar angle rat h er t h an soft t issu e con t r ibu t ion su ch as hyp er t rop h ied m asseter m u scle.1,2 An t h rop ologic st u d ies h ave sh ow n sign i can t qu an t it at ive facial an t h rop om et r ic d i eren ces am ong d i eren t et h n ic backgrou n d s; on e su ch d i eren ce bein g t h at Korean s, in com p ar ison to Cau casian s, ten d to h ave a m ore d evelop ed low er face.3 In ad d it ion , t h e average bigo n ial d ist an ce in Cau casian w om en is 105 to 109 m m ,4,5 w h ereas in Korean w om en t h e average d ist an ce is 118 to 125 m m .3 Sin ce Korean s h ave a greater bigon ial d ist an ce an d m ore ared m an d ibu lar an gle, t h ey often u n d ergo m an d ible red u ct ion to slen d er ize t h e low er facial con tou r, w h ereas Cau casian s p refer m an d ible augm en t at ion to cor rect w eak jaw lin es.6

20

Resection of the Mandibular Angle In 1949 Adam s in t rod u ced a su rgical tech n iqu e for resect ing m an dibu lar bon e an d m asseter m u scle via th e t ran scu t an eous approach , an d Converse perform ed th e sam e procedure th rough an in t raoral approach in 1959.7 In 1989 Baek in t rod u ced m an dibu lar angle redu ct ion for Asian pat ien ts via th e in t raoral approach . In 1991 Yang an d Park in t roduced a su rgical tech n iqu e for con tou ring th e m an dibu lar body an d th e sym p hysis w ith a sequ en t ial resect ion of th e bon e. Sin ce th e late 1990s on e-stage, long cur ved ostectom y h as been w idely used to con tour th e m an dible.8

Narrow ing the Width Th e conven t ion al ostectom y, w h ich resect s th e in ferior border of th e m an dibular angle an d body, can bring a sat isfactor y con tou r from th e sid e view ; h ow ever, it fails to sh ow im p rovem en t in th e fron tal facial con tour du e to it s in abilit y to n arrow th e broad low er face. To ach ieve th e desired ap pearan ce of th e fron t al view facial con tou r, a variet y of su rgical tech n iqu es w ere develop ed. In 1997, Degu ch i et al reported th at th e w idth of th e low er face cou ld be n arrow ed by a tech n ique th at sh aves th e lateral cor tex an terior to th e in ferior alveolar n er ve an d sp lit s th e angle p osterior to th e n er ve.9 In 2001 Han an d Kim e ect ively reduced th e bigon ial w idth th rough lateral cor tex ostectom y w ith out a m an dibular angle reduct ion .10 In 2004, Hw ang et al in t rodu ced sim u lt an eou s u t ilizat ion of th e t w o di eren t tech n iqu es.11

Creating an Ideal Shape and Adding Dimension to a Flat Face Alth ough th e p reviou sly m en t ion ed m an dible red u ct ion tech n iqu es h ave m any advan t ages, th ey fail to correct th e broad an d blun t appearance of th e ch in . Th e ch in is a m ajor determ in an t of an at t ract ive low er facial con tour. Th u s, th e auth ors h ave reported th at n arrow ing th e w idth an d

a

b

Mandible Reduction

m odifying th e sh ape of th e ch in , in conju n ct ion w ith m an dible reduct ion , is essen t ial to ach ieve a slim m er an d ovalsh aped con tou r.12,13,14 Th e au th ors’ cu rren t tech n iqu es for a p rom in en t m an dible are (1) con t rolling th e slope of th e m an dibu lar p lan e by resect ing th e m an dibu lar angle an d con t rolling th e in ferior border of th e body via a long cur ved resect ion tech n ique, (2) reducing th e w idth of th e low er face via bu rring or ostectom y of th e lateral cortex, an d (3) n arrow ing gen iop last y according to th e p at ien t’s speci c dem an ds. Sin ce th e auth ors in t roduced th e tech n iqu e in 2008, sim ultan eous perform an ce of n arrow ing genioplast y an d m an d ible red u ct ion h as been w id ely called “V-lin e su rger y” sin ce th e sh ap e of th e con tou red jaw lin e looks like th e let ter V (Fig. 20.1). V-lin e su rger y n ot on ly n arrow s th e w idth of th e m an dible an d con tours the jaw lin e, but also reduces th e size an d con t rols th e p osit ion of th e ch in in both th e ver t ical an d an terior-p osterior d irect ion s, m aking a sm aller an d m ore fem in in e oval facial con tou r p ossible. On th e basis of tech n ical perfect ion , th e est ablish m en t of appropriate surgical in dicat ion s for each tech n ique is m an dator y to ach ieve aesth et ically p leasing resu lt s. An alysis of th e in dividu al’s en t ire face sh ou ld com e from a th orough un derst an ding of low er facial t ypes. Th e auth ors classify th e sh ape of th e low er face according to th e sh ape of th e ch in , w h ich is h elpfu l in establish ing the t reat m en t plan (Fig. 20.2).15

■ Patient Evaluation Diagnosis Th e con dit ion m ay easily be diagn osed by clin ical n dings an d rad iologic exam in at ion . Th e degree of p rot ru sion of th e m an dible, asym m et r y, m asseter m u scle hyper t rophy, an d am ou n t of th e su bcu t an eou s fat sh ou ld be evalu ated. Th e degree of hypert rophy of th e m asseter m uscle can be iden t i ed by palpat ing th e t igh ten ed versu s relaxed stat us of th e jaw. Hyperostosis, m ostly aroun d th e m an dible angle, is n oted in th e radiologic st u dies. Tw o-th irds of th e cases

c

Fig. 20.1 Mandible reduction surgery has evolved from (a) simple resection of the angular portion to (b) contouring of the total mandible shape as the desire for a slim and small face has increased. Recently, (c) narrowing genioplast y was introduced to achieve a slim and oval-shaped jaw using the conventional surgical method.

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IV Facial Bone Surgery

Fig. 20.2 The shapes of the lower face in the frontal view are diverse. Because the chin should be designed based on the individual patient’s preference, this classi cation system helps patients to compare the shapes of the chin and consult with the surgeon in detail.

sh ow m ild to m oderate in crease in bigon ial dist an ce du e to lateral aring of the m an dible angle. How ever, th e rem ain ing th ird sh ow s tot al m an dibu lar hyper t rophy an d accen t uated square con tour of th e w h ole low er face. Th e sh ape an d w idth of th e low er face in th e fron t al view can be classi ed as in Fig. 20.2. Th e p ro le as w ell as th e h eigh t of th e ch in sh ould be t aken in to con siderat ion . Th e stat us of soft t issue in cluding m uscle an d fat sh ould be con sidered as w ell.

be iden t i ed. Th e ideal gon ial angle is w ith in th e range of 105 to 115 degrees, an d th e MP-SN angle is 30 to 40 degrees. After m easu ring an d u n derst an ding th e accu rate balan ce of th e upper an d m idface, th e am ou n t of reduct ion , length en ing, an d ver t ical/h orizon tal advan cem en t or ret rusion (setback) of th e m an dible in th e an terior-posterior direct ion w ill be determ in ed.

Preoperative Evaluation and Surgical Planning

Th ree-d im en sion al CT or t h e ce r vical-ver tex view is u sed to id e n t ify t h e t ran sve rse sh ap e of t h e m an d ible (Fig. 20.3). Th e an gle of d ive rgen ce an d convexit y of t h e m an d ible are obser ved . In cases w it h an inw ard -cu rled an gle w it h a convex t ran sverse sh ap e, sagit t al resect ion of t h e body w ill h elp to red u ce t h e w id t h of t h e m an d ible m ore e ect ively.

The auth or rout inely obtains a pat ient’s ph otographic docum entat ion and radiologic exam inat ion that includes panoram ic view, skull lateral view, postero-anterior (PA) cephalogram , and 3D CT im age. For precise surgical planning an d preven t ion of postoperative asym m etr y, th ree-dim en sion al an alysis of th e ph otograph s an d th e radiograph s in the frontal, sagit tal, an d transverse planes is im portant. Exam ination of the shape and sym m et r y and understanding the overall balance of the face are m andator y.

Transverse Plane

Frontal Plane Using th e PA cep h alogram an d 3D CT, th e degree of p rot rusion or aring of th e m an dible angle, sym m et r y, con vexit y of th e body, deviat ion , an d sh ap e of th e ch in sh ou ld be exam in ed. Th e am oun t of n arrow ing an d lateralizat ion (con sidering th e degree of asym m et r y), an d th e am ou n t of angle an d in ferior border resect ion are determ in ed after ch ecking th e cou rse of th e in ferior alveolar n er ve. A pan oram ic view is h elpful in determ in ing th e am oun t of ostectom y of th e m an dibular angle an d body, as w ell as th e posit ion of its ostectom y lin e.

Sagittal Plane Using th e lateral ceph alogram , th e gon ial angle, th e m an dibular plan e–sellar n asion angle (MP-SN angle), an d th e ver t ical an d an terior-p osterior p osit ion of th e ch in sh ou ld

Fig. 20.3 Analysis of the transverse plane. The exact region and amount of sagit tal resection can be determined by thorough evaluation of the angle of divergence and convexit y of the mandible from this view.

20

Mandible Reduction

Consideration in Surgical Planning

Asymmetry

The Chin

Den t al occlu sion an d overall facial con form at ion sh ou ld be con sidered to an alyze asym m et r y of th e face. Special care sh ould be t aken if a m ism atch is obser ved bet w een th e act ual ph otograph s an d th e radiograph s. If facial asym m et r y is du e to skelet al factors, th e degree an d exten t of asym m et r y sh ou ld be evalu ated . If th ere is can t ing d u e to m axillar y vert ical d iscrepan cy, th en th e p at ien t sh ou ld fu lly u n derst an d th e lim itat ion s of m an dibu lar con tou ring su rger y. Man dibular asym m et r y of m ild to m oderate degree can be im proved by disproport ion ate resect ion of th e m an dible border an d elaborate th ree-dim en sion al sh aving. Asym m et ries con n ed to th e ch in relat ive to th e face are m ost frequ en tly en cou n tered. For in dividu als w h ose ch in sh ifts to on e side, m an dible reduct ion m akes th e ch in asym m et r y m ore obvious, an d con com itan t h orizon t al osteotom y of th e ch in an d t ran sverse m ovem en t m ay be requ ired.

The term chin refers to both th e bon e an d the surrounding soft tissues. The chin is a very im portant com ponent in lower facial m orphology, and full at tention should be given to th e procedure of lower facial contouring surgery. In som e patients, resection of the m andible alone does not m ake the face appear slender. Th is is m ain ly attributed to a w ide, at ch in and a U-shaped lower facial m orph ology. Therefore, to create a slim and at tractive face, reducing the w idth of the ch in and m odifying its sh ape and position is n ecessary in addition to resection of th e m andible. The am ount of central resection should be individualized depending on the w idth of the chin and the patient’s n eed. In th e auth ors’ practice, resection of the central strip ranges from 6 to 12 m m (average 9.1 m m ). In m ost cases, this am ount of resection produces the desired shape and w idth of the chin. Advancem ent or setback (retrusion) of th e chin sh ould also be considered if a ch ange of pro le is required. The ideal aesthetic chin position should be determ ined in the pro le view, considering the positions of the nasal tip and the upper and low er lip. However, critical decisions w ith regard to the chin position are m ade w hen view ing the patient “face to face,” considering the varying perspectives in repose and w ith broad sm ile.

Abnormal Skeletal Relationship betw een the Maxilla and Mandible Th e relat ion sh ip of th e m an dible w ith th e m axilla sh ou ld be u n derstood, because n ot all pat ien t s h ave a n orm al in term a xillar y skelet al relat ion sh ip. In cases w ith p rot ru ding m an dible sh ow ing class III occlu sion , or th ose w ith relat ive u n derd evelop m en t of th e low er jaw sh ow ing class II occlusion , or th ogn ath ic su rger y m ay be n eeded to im prove th is disorder. If m an dibular con touring surger y is to be don e w ith out correct ing class II or class III skelet al problem s, certain ch aracterist ics sh ould be con sidered to avoid aggravating th e in term axillar y p roblem s. In cases w ith p rom inen t m an dible sh ow ing a skelet al class III relat ion sh ip , a long jaw lin e m ay app ear m ore accen t u ated if th e angle is resected too m u ch du ring m an dible redu ct ion . Th erefore, th e angle sh ou ld be con ser vat ively resected an d sagit t al sh aving sh ou ld be p rop erly p erform ed to m in im ize aggravat ion of progn ath ic appearan ce. In pat ien t s w ith a ret ruded m an dible sh ow ing a class II pro le, excessive resect ion of th e m an dible angle cau ses a m ore obscu re cer vico-facial lin e. Th erefore, con ser vat ive m an dible resect ion an d m axim al sagit t al sh aving of th e body of th e m an dible, com bin ed w ith advan cem en t gen ioplast y are recom m en ded. In a long face, angle resect ion sh ou ld be perform ed in a lim ited w ay to p reven t th e aggravat ion of steep m an dibu lar p lan e.

Soft Tissue Contribution A hyper t roph ied m asseter m u scle, w h ich is a crit ical factor for determ in ing th e w idth of th e face, sh ou ld be corrected. Gen erally, det ach m en t of th e m asseter from it s in ser t ion to th e m an dible alon e can redu ce th e volu m e of th e m u scle, an d addit ion al resect ion of th e m u scle is n ot recom m en ded . In cases w ith severe hyper t rop hy of t h e m asseter m u scle, bot u lin u m toxin inject ion or a p ar t ial resect ion of th e m edial asp ect of th e m asseter m u scle can be don e. How ever, th is in creases sw elling an d t h e risk of n er ve inju r y or in am m at ion by n ecrot ic m u scle d ebris. Bu ccal fat rem oval m ay be com bin ed for excessive ch eek fat . A lift in g p roced u re is requ ired for skin an d soft t issu e saggin g, after ch ecking th e p at ien t s’ age an d skin elast icit y. Th e h igh -risk factors for skin an d soft t issu e sagging are (1) age over 40, (2) abu n dan t ch eek fat , (3) th in skin an d skin la xit y, an d (4) class II occlu sion or ill-d e n ed m an dible n eck lin e.

Ethnic Variation and Cultural Background Th e ideal facial sh ap e m ay di er dep en ding on p erson al preferen ce, as w ell as eth n ic or cu lt u ral backgrou n d. Esp ecially w h en con su lt ing p at ien t s w ith di eren t n at ion al or et h n ic backgrou n d s, carefu l at ten t ion sh ou ld be p aid to th eir ideal or desirable facial sh ape. For exam p le, Ch in ese pat ien t s p refer a p oin ted ch in , Japan ese p refer a rou n d ch in , an d Korean s p refer a m oderately t rap ezoidal ch in . In th e case of fem in izat ion su rger y for t ran sgen ders, to sat isfy th eir special n eed s, m axim izing th e fem in in e ch aracterist ics, rath er th an sim p ly redu cing th e w idt h an d size of th e m an dible, is essen t ial.

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IV Facial Bone Surgery of a cur ved ostectom y m ay be exten ded to just below th e m en t al foram en dep en ding on a pat ien t’s facial m orp h ology. Sim u lt an eou s redu ct ion of th e m an dibu lar angle an d body can result in a m uch sm aller low er facial con tou r.

■ Surgical Techniques Approach: Intraoral versus External Approach

Tangential Ostectomy w ith a Reciprocating Saw (Lateral Cortex Ostectomy)

Man dible angle redu ct ion can be d on e u sing th e in t raoral approach or th e extern al approach . Tradit ion ally, m an dible angle ostectom y h as been p erform ed u sing th e in t raoral app roach w ith an oscillat ing saw.16 Th is ap p roach involves m in im al space to w ork along w ith poor visibilit y, an d it requ ires tech n ical skill in m an ip u lating th e oscillat ing saw. Becau se som ew h at blin d rem oval of th e m an dible is requ ired, ostectom y m ay be facilit ated by burring th e ram u s area or by using in direct m irrors, especially in pat ien t s w ith inw ardly cur ved angles. An extern al ap proach w as p reviou sly u sed becau se it w as easy an d allow ed direct access to th e m an dibu lar angle.17 Th e extern al approach can be used w ith ch in in cision or p ostauricu lar in cision . With th e post auricular ap proach , scar is h idden an d th e op erat ion t im e is sh or ter. Becau se p oor visibilit y of th e an terior p ar t of th e m an dible causes un sat isfactor y outcom es, th is approach sh ould be ap plied on ly to a lim ited p op u lat ion of pat ien t s w h o h ave m an dible angle prom in en ce.

Th is procedure rem oves th e extern al cortex of th e m an dib u lar ram us by m ean s of a reciprocat ing saw. It is perform ed to n arrow th e bigon ial dist an ce in th e laterally ared angles of th e m an dible or to reduce th e th ickn ess of th e body of th e m an dible in th e fron tal view.9,10,11 How ever, th is procedure is n ot recom m en ded due to the h igh risk of n er ve inju r y, soft t issu e adh eren ce to th e bony m edulla, an d di cult y in sh aping. Th e auth ors recom m end sagit t al resect ion w ith burring, leaving a th in lm of outer cor tex, in w h ich it is easy to con t rol th e sh ape of th e m andible an d a n at ural h ealing p rocess is en su red .

General Procedure In Korea m ost m an dibu lar angle redu ct ion is perform ed by long cur ved ostectom y using in t raoral in cision w ith burring. If p at ien t s w an t a m ore V-lin e ch in , th e auth ors add th e n arrow ing gen ioplast y p rocedu re.12 Th e gen eral procedure is as follow s (Fig. 20.5):

Types of Ostectomy: Curved Ostectomy versus Tangential Ostectomy

1. Man dibular reduct ion is perform ed un der gen eral an esth esia. Eith er n asot rach eal or en dot rach eal in t ubat ion can be u sed. Th e auth ors gen erally use en dot rach eal in t u bat ion w ith a t u be an ch ored in th e rst p rem olar teeth w ith a 3–0 nylon su t u re.

See Fig. 20.4 for th e t w o t yp es of osteotom y.

Curved Ostectomy w ith an Oscillating Saw Th is procedure can be applied to m ost pat ien t s w ith prom in en t m an dibu lar angle.8 It redu ces th e p ostero-in ferior m an dibu lar angle in th e lateral view. Th e an terior exten t

a

2. Th e pat ien t is posit ion ed su pine w ith a t ran sverse roll ben eath th e sh ou lders to exten d th e n eck. Th e en t ire face is p repp ed w ith betadin e solu t ion . Th e

b

Fig. 20.4 Types of ostectomy for m andible reduction. (a) Curved ostectomy with an oscillating saw. (b) Tangential ostectomy with a reciprocating saw (lateral cortex ostectomy).

20 a

b

d

e

Mandible Reduction

c

Fig. 20.5 Operative procedures. (a) The incision line is designed. (b) Subperiosteal elevation with periosteal elevator. The lateral aspect of the mandibular body is exposed. (c) The desired level of the osteotomy line is marked on the bone with a marking pencil. The marked line is checked by using dental mirrors. (d) A long curved ostectomy is performed. A 110-degree oscillating saw is used for the ostectomy. (e) Dividing the at tachment of muscle to the medial part of the mandible. A large elevator or Bovie electrocautery is used to divide any remaining medial pterygoid muscle bers from the medial surface of the osteotomized segment.

oral cavit y an d th e teeth are brush ed w ith dilute aqu eou s bet adin e solu t ion . Th e op erat ive eld is d raped to assist w ith in t raoperat ive evalu at ion of sym m et r y. Su rger y is p erform ed in th e in t raoral area in a dark eld; h en ce, w earing a h eadligh t is h elpful in perform ing th e surgical p rocedu re. 3. A rubber open er is placed bet w een th e upper an d th e low er teeth . Th e in cision lin e is design ed using a gen t ian violet solu t ion . A bu ccal vest ibu lar in cision d esign is m ade from th e ram us exten ding an teriorly to th e rst m olar or secon d prem olar w h ile leaving a 7- to 8-m m m u cosal cu . Th is m u cosal cu h elps to close th e sut ure in an easy m an n er. Th e operat ive eld is in lt rated w ith 0.25% lidocain e w ith 1:200,000 dilu ted epin eph rin e solut ion . 4. Th rough a subperiosteal elevat ion w ith th e p eriosteal elevator, th e lateral aspect of th e m an dibu lar body is exp osed. Th e d issect ion con t in ues superiorly along th e vert ical ram us to adequately expose th e area of resect ion . Th e m asseter bers are st ripp ed from th e low er border of th e body, angle, an d posterior border of th e ram u s w ith an angle st ripper to secure a good operat ive eld. Su bp eriosteal dissect ion p reven ts bleeding from th e m asseter m u scle. Du ring th e dissect ion th e m en t al n er ve, th e m argin al m an dibu lar bran ch of th e facial n er ve, th e ret rom an dibular vein , an d th e facial arter y sh ou ld be p rotected.

5. Using a specialized angle ret ractor, th e m an dibular angle is h ooked, an d th e desired level of th e osteotom y lin e is m arked on th e bon e w ith a m arking p en cil. Th e m arked lin e is th en ch ecked w ith den tal m irrors. 6.

Usually, a long curved ostectomy is perform ed. A 110-degree oscillating saw is used for the ostectomy. We use a set of oscillating saws of di erent lengths. If the ostectomy is done w ith full thickness, the bone segm ent m oves freely. When patients request angle reduction, the authors em ploy the curved ostectomy technique, and for a V-line face, a long curved ostectomy technique w ith narrow ing genioplasty is perform ed.

7. After th e ostectom y, th e at t ach m en t of m uscle to th e m edial p art of th e m an d ible u su ally rem ain s. A large elevator or Bovie elect rocauter y is used to divide any rem ain ing m edial pter ygoid m u scle bers from th e m edial su rface of th e osteotom ized segm en t , allow ing it s rem oval. 8. Fin ally, a h igh -speed bur is used to rem ove any addit ion al bon e from th e lateral cor tex an d to m ake a sm ooth t ran sit ion . Th is p rocedu re preven t s th e ch an ce of secon dar y angle. 9. An iden t ical procedu re is perform ed on th e con t ralateral side. Here any preoperat ive asym m et r y in th e degree of angle prom in en ce sh ou ld be t aken in to accoun t an d a relat ively greater or lesser am ou n t of m an dibular bon e resected.

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IV Facial Bone Surgery 10. Th e bilateral w oun ds are irrigated by salin e an d h em ostasis secu red. Th e w ou n ds are closed in t w o layers (periosteu m an d m ucosa) w ith a 4–0 absorbable su t u re. Bilateral su ct ion d rain s are left in p lace overn igh t . Com p ression w ith a facial ban dage is u sed .

determ in ed preoperat ively, depen ding on the w idth of ch in an d th e pat ien t’s desire. Th e t w o segm en t s are app roxim ated cen t rally an d xed w ith m icrop lates an d screw s. Advan cem en t of th e t w o segm en t s is also possible if correct ion of th e pro le is required. Th e resect ion of th e cen t ral st rip ranges from 6 to 12 m m .

Combined Narrow ing Genioplasty

Postoperative Care

Narrow ing gen ioplast y, eith er as a single p rocedu re or in com bin at ion w ith m an dible reduct ion , m akes th e low er face ap p ear slen der or p rodu ces a m ore fem in in e ch in con tou r.12 Th e soft t issu e at t ach m en t of th e ch in is m ain tain ed to produce a m axim um n arrow ing e ect an d to m ain t ain blood ow to th e bony segm en t s. A h orizon tal osteotom y an d t w o vert ical osteotom ies are design ed as sh ow n in Fig. 20.6. Th e am ou n t of resect ion in th e cen t ral segm en t is

After th e su rger y, th e pat ien t’s vital sign s are m on itored to en su re st abilit y 4 to 6 h ou rs p ostop erat ively. Th e p at ien t m ay drin k w ater after st abilit y h as been con rm ed; th is progresses to a liqu id diet . To redu ce sw elling or bleeding, th e pat ien t is pu t in a sem i-Fow ler p osit ion . Gen erally, pat ien t s are h ospit alized for on e n igh t after th e surger y. Blood drain age t ubes are kept for on e n igh t to drain possible bleeding from th e op erat ion site.

■ Key Technical Points 1. Im por tan t an atom ic st ruct ures m ust be respected. Previou s an atom ic st udy h as dem on st rated th at th e in ferior alveolar n er ve t ypically courses at least 20 m m aw ay from th e u p per border of th e m an d ible, w h ich sh ou ld be kept in m in d w h en design ing th e osteotom y. As a rule of th um b, th e osteotom y lin e sh ou ld be at least 1 in ch (2.5 cm ) aw ay from th e u pp er border of th e m an dible at th e rst m olar. a

2. Th e surgeon accu rately determ in es th e posit ion an d quan t it y of m an dibular bon e to be rem oved th rough a com bin at ion of clin ical assessm en t , exp erien ce, an d kn ow ledge of m an dibu lar an atom y. 3. Th e superior lim it for resect ion is th e occlusal plan e; th e an terior lim it is th e convergen ce of th e m an dibu lar obliqu e lin e w ith th e low er m an d ibu lar border.

b Fig. 20.6 (a,b) Narrowing genioplast y combined with m andible reduction is required in patients with wide or blunt chin, and it greatly improves the slimming e ect in mandible reduction. A horizontal osteotomy and t wo vertical osteotomies are designed. The central segment is resected, and t wo lateral segments are approximated centrally and xed with miniplates and screws.

4. Th e resected segm en t t ypically h as an elongated sem ilu n ar sh ap e in stead of being t riangu lar; w h en rem oved, it leaves a gen tly cur ved low er m an dibu lar border. Th e oblique h eigh t of th is segm en t is t yp ically in th e range of 10 to 20 m m , w ith length ranging 30 to 70 m m . 5. If an osteotom y is too st raigh t an d fails to form a sm ooth t ran sit ion , it w ill leave a “secon dar y angle.” Th e secon dar y angle can be palpated or st icks out extern ally. If secon dar y angle is obviou s, it m ay require burring or an addit ion al osteotom y.

20

■ Complications and Their Management

Hemorrhage and Hematoma Th e in ciden ce of m ajor in t raoperat ive h em orrh age h as decreased over th e years, prin cipally because of advan ces in su rgical tech n iqu e an d th e u se of hypoten sive an esth et ic protocols (m ean systolic blood pressure of 65 m m Hg). Hypoten sive an esth esia cou p led w ith inject ion of local an esth et ic w ith vasocon st rictor m in im izes blood loss an d in creases visu alizat ion of th e operat ive eld. If th e ret rom an dibu lar vein or facial ar ter y is torn du ring th e p rocedure, at tem pts to secure h em ost asis often fail because elect rocauterizing th e bleeding vessel is n ot easy. Un su ccessful h em ost asis m ay lead to excessive blood loss. Applicat ion of a h em ostat ic subst an ce like Su rgicel (Eth icon ) or extern al m an u al com pression for at least 30 m in u tes can h elp to stop th e bleeding.16 Follow ing th e com p let ion of su rger y, th e soft t issu e of th e ch eek an d th e n eck sh ou ld be ch ecked for any sign s of bleeding or sw elling. Any sign s of sw elling or bleeding n ear th e th roat sh ould prom pt ext rem e aw aren ess an d alarm becau se it m ay cau se a breath ing problem , possibly leading to a fat al outcom e.

Nerve Injury If th e cu r ved osteotom y is m ade too h igh on th e m an d ibu lar body, th e in ferior alveolar n er ve m ay be inju red. Prior to su rger y, a p an oram ic X-ray is taken to locate an d ch eck th e course of th e in ferior alveolar n er ve. Th e surgeon m u st accu rately de n e th e cou rse of th e in ferior alveolar n er ve during th e surger y by m easuring its course from th e low er border of th e m an dible. Th e osteotom y sh ould be at least 3 m m aw ay from th e in ferior alveolar can al an d m en tal foram en .18 Sp ecial care sh ou ld be t aken w h en p erform ing osteotom y cut s, an d drilling sh ou ld be accom pan ied by copiou s irrigat ion to preven t h eat injur y. If it app ears th at th e n er ve h as been dam aged or am pu t ated, th en a 7–0 nylon n eu rorrh ap hy n eeds to be p erform ed to secu re p ossible recover y of th e ner ve.

Fracture Du ring an angle redu ct ion , a precise ostectom y arou n d th e posterior border of th e m an dible is im por tan t to avoid a con dylar fract ure. W h en u sing th e oscillat ing saw, adequate periosteal dissect ion is essen t ial to adequately visualize th e posterior m an dibu lar border. Th e surgeon m ust n ot allow

Mandible Reduction

th e osteotom y to becom e ver t ical as it courses posteriorly up th e ram u s, as th is m ay cause a ram us, su bcon dylar, or con dylar fract ure. Such fract ures are t reated as described elsew h ere, u sing open reduct ion w ith in tern al xat ion or in term axillar y xat ion as in dicated.19

Infection and In ammation Th ough w oun d in fect ion follow ing surger y is un com m on , problem at ic issu es m ay arise due to th e follow ing condit ion s: poor pre- an d postoperat ive oral hygien e, im prop erly sealed w ou n d, in su cien t u sh ing, bon e fragm en t s or du st left beh in d in th e w oun d, dam aged salivar y glan ds, or periodon t al disease. To preven t th e risks of postoperat ive in fect ion , in t raven ous an t ibiot ics are adm in istered on adm ission . After disch arge, oral an t ibiot ics are p rescribed to th e pat ien t .

Unfavorable Aesthetic Outcomes Caution should be taken to avoid rem oving too m uch bone from th e jaw lin e, or else the con tour m ay appear too sharp or the cheeks m ay look too h ollow. Prior to surger y, the design of the osteotom y should be carefully planned, and accurately m easured and m arked so that the procedure is perform ed w ithout any com plications.20 Fat grafting m ay be perform ed to cover and cam ou age any areas of over-correction. Changes in the skeleton are re ected favorably or unfavorably by th e overlying soft tissues. Careful preoperative facial analysis of both h ard and soft tissues w ill m axim ize favorable aesth etic outcom es.21 Other com plications unique to m an dible reduction are best dealt w ith by prevention .

■ Case Studies Case 1 A 20-year-old w om an com p lain ed of h er p rom in en t m an dibular angles (Fig. 20.7). Sh e desired a slen der an d sm ooth low er facial con tour. Th e in tergon ial distan ce w as large, an d th is, in com bin at ion w ith lateral aring of th e angle, m ade h er low er face app ear broad, squ are, an d st rong. After a fu ll-th ickn ess ostectom y of a low er border of th e m an dibular body-angle region , sh aving of th e ou ter cortex w as accom plish ed (Fig. 20.8). After th e m an dible con tou ring su rger y, th e gon ial angle an d th e m an dibu lar plan e angle in creased (Fig. 20.9). Ten m on th s follow ing th e operat ion , th e con tour of h er low er face appeared soft an d slen der (Fig. 20.10).

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Fig. 20.7 Case 1. Preoperative (a) frontal and (b) oblique photographs of the patient.

b

a

b Fig. 20.8

Case 1. Bone fragments resected by ostectomy.

Fig. 20.9

Case 1. Cephalograms (a) before and (b) after the surgery.

20 a

b

Case 2 A 25-year-old fem ale w ith an angulated low er face w an ted to m ake h er facial con tour slen der, sm ooth , an d “egg sh aped” (Fig. 20.11). A com plex gen ioplast y com bin ed w ith m an dibu lar con touring w as perform ed. Th e com plex gen ioplast y consisted of 8 m m horizontal reduction, 2 m m vertical reduct ion , and cen tering genioplast y. Absorbable plates

a

b

Mandible Reduction

Fig. 20.10 Case 1. Ten-month postoperative photographs. Postoperative (a) frontal and (b) oblique.

an d screw s w ere u sed for xation . To obtain a sm ooth curvat ure of th e m an dibular low er border, th e m argin al part of the m andibular body-angle region w as trim m ed using an oscillating saw an d bu r (Fig. 20.12). After m an dibu lar con touring surger y, th e patien t requested correction of h er m alar prom in en ce an d un der w en t reduction m alarplast y. Tw ent y m onths follow ing the rst operat ion, the contour of her low er face appeared soft and slim m er (Fig. 20.13).

Fig. 20.11 Case 2. Preoperative (a) frontal and (b) oblique photographs of the patient.

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b

Fig. 20.12 Case 2. Bone fragments resected by ostectomy: (a) mandibular contouring; (b) zygom a reduction.

a

b

Fig. 20.13 Case 2. (a) Frontal and (b) oblique postoperative photographs of the patient at twenty months after mandible reduction and eleven months after malar reduction.

20

Case 3 A 20-year-old w om an requ ested th at h er p rom in en t m an dibular angle an d zygom a be corrected (Fig. 20.14). Th e zygom at ic com p lex w as prot ru ded an d th e m an dible w as

a

b

Mandible Reduction

angu lated, w h ich m ad e h er look m u scu lar. Sh e u n der w en t m an dible an d zygom a red u ct ion su rger y sim u lt an eou sly. After th e m an dible con tou ring su rger y, th e gon ial an d m an dible plan e angle in creased (Fig. 20.15). Six m on th s follow ing th e operat ion , th e con tou r of h er low er face appeared soft an d slim m er (Fig. 20.16).

Fig. 20.14 Case 3. Postoperative (a) frontal and (b) lateral photographs of the patient.

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b

c

d

Fig. 20.15

Case 3. Three-dimensional CT scans (a,b) before and (c,d) after the surgery.

20 a

b

References 1. Baek SM, Kim SS, Bin diger A. Th e prom in en t m an dibular angle: preoperat ive m an agem en t , operat ive tech n ique, an d result s in 42 pat ien t s. Plast Recon st r Su rg 1989;83(2): 272–280 2. Yang DB, Park CG. Man dibu lar con touring surger y for pu rely aesth et ic reason s. Aesth et ic Plast Su rg 1991;15(1) :53–60 3. Park CG, Lee ET, Lee JS. Facial form analysis of th e low er an d m iddle face in young Korean w om en . J Korean Soc Plast Recon st r Su rg 1998;25(1):7–13 4. W h it aker LA, Bartlet t SP. Aesth et ic surger y of th e facial skeleton. Perspect Plast Surg 1988;1:23–69 5. W h it aker LA. Aesth et ic con touring of th e facial support system . Clin Plast Surg 1989;16(4):815–823 6. W h it aker LA. Aesth et ic augm en t at ion of th e posterior m an dible. Plast Recon st r Su rg 1991;87(2):268–275 7. Adam s W M. Bilateral hypert rophy of th e m asseter m uscle; an operat ion for correct ion; case report . Br J Plast Surg 1949; 2(2):78–81 8. Gui L, Yu D, Zh ang Z, Ch angsh eng LV, Tang X, Zh eng Z. In t raoral on e-stage cur ved osteotom y for th e prom in en t m an d ibu lar angle: a clin ical st u dy of 407 cases. Aesth et ic Plast Surg 2005;29(6):552–557 9. Deguch i M, Iio Y, Kobayash i K, Sh irakabe T. Angle-split t ing ostectom y for redu cing th e w idth of th e low er face. Plast Recon st r Su rg 1997;99(7):1831–1839 10. Han K, Kim J. Redu ct ion m an dibu lop last y: ostectom y of th e lateral cortex arou n d th e m an d ibu lar angle. J Cran iofac Surg 2001;12(4):314–325 11. Hw ang K, Lee DK, Lee W J, Ch u ng IH, Lee SI. A sp lit ostectom y of m an dibu lar body an d angle redu ct ion . J Cran iofac Surg 2004;15(2):341–346

Mandible Reduction

Fig. 20.16 Case 3. Six-month postoperative (a) frontal and (b) lateral photographs of the patient.

12. Park S, Noh JH. Im portance of the chin in lower facial contour: narrow ing genioplast y to achieve a fem inine and slim lower face. Plast Reconstr Surg 2008;122(1):261–268 13. Lee TS, Kim HY, Kim T, Lee JH, Park S. Im p or tan ce of th e ch in in ach ieving a fem in in e low er face: n arrow ing th e ch in by th e “m in i V-lin e” su rger y. J Cran iofac Su rg 2014;25(6):2180–2183 14. Lee TS, Kim HY, Kim TH, Lee JH, Park S. Con tou ring of th e low er face by a n ovel m eth od of n arrow ing an d length en ing gen iop last y. Plast Recon st r Surg 2014;133(3): 274e–282e 15. Park S. Classi cat ion of ch in in term s of con tou r an d w idth an d preferen ce in Korean . Paper presen ted at: 61st An n ual Meet ing of Korean Societ y of Plast ic Su rger y; 2007:355 16. Neligan PC. Prin cip les. In : Neligan PC, ed . Plast ic Su rger y. Vol. 1, 3rd ed. Seat tle, WA: Elesevier Saun ders; 2012:179–183 17. Morris DE, Moaven i Z, Lo LJ. Aesth et ic facial skelet al con touring in th e Asian pat ien t . Clin Plast Surg 2007;34(3):547–556 18. Lo LJ, Wong FH, Ch en YR. Th e p osit ion of th e in ferior alveolar n er ve at th e m an dibu lar angle: an an atom ic con sid erat ion for aesth et ic m an d ibu lar angle redu ct ion . An n Plast Surg 2004;53(1):50–55 19. Hw ang K, Han JY, Kil MS, Lee SI. Treat m en t of con dyle fract ure caused by m an dibular angle ostectom y. J Cran iofac Surg 2002;13(5):709–712 20. Jin H, Park SH, Kim BH. Sagit t al split ram u s osteotom y w ith m an dible redu ct ion . Plast Recon st r Su rg 2007;119(2): 662–669 21. Hsu YC, Li J, Hu J, Luo E, Hsu MS, Zhu S. Correction of square jaw w ith low angles using m andibular “V-line” ostectomy com bined w ith outer cortex ostectomy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109(2):197–202

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Seong Yik Han and Kar Su Tan

Pearls • Orth ogn ath ic su rger y is a du al-p ronged op erat ion

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•

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th at ful lls both fun ct ion al an d aesth et ic goals th rough reposit ion ing of th e m a xilla an d/or m an dible via orth odon t ic an d su rgical m an ip u lat ion . Fu n ct ion al restorat ion sh ould take preceden ce over aesth et ic con siderat ion s. Th e psych ological im pact of orth ogn ath ic surger y sh ou ld be em p h asized in th e preoperat ive evalu at ion . It is recom m en ded th at sign i can t oth ers at ten d th e p reoperat ive discussion w ith th e p at ien t . Un derstan ding of m alocclusion is im port an t for proper fun ct ion al reh abilit at ion . How ever, restoring n orm al occlu sion does n ot n ecessarily en sure a good aesth et ic ou tcom e. Pure or th odon t ic com pen sat ion t reat m en t is som et im es abou t m oving th e teeth in th e opp osite direct ion to th e surgical m ovem en t . Hen ce, it is im port an t for th e orth odon t ist to be able to recogn ize w h ich pat ien ts w ill even t ually require

■ Introduction “Orth ogn ath ic su rger y” literally m ean s “correctly (or th o-) posit ion ed jaw (gn ath ic).” It refers to th e surgical correct ion of abn orm al m an dible, m axilla, or both . Abn orm al den tofacial developm en t or asym m et r y m ay n ot on ly result in an u n aesth et ic face an d fun ct ion al deteriorat ion , but also can lead to psych osocial problem s. Th us th e object ive of th is su rger y is to restore both fun ct ion an d aesth et ics. Fu n ct ion al restorat ion refers to rein st at ing th e fu n ct ion s of occlu sion , m ast icat ion , sw allow ing, tem porom an dibu lar join t (TMJ) fu n ct ion , sp eech , an d p h on at ion . Aesth et ic im p rovem en t involves th e re-establish m en t of facial sym m et r y an d h arm ony. Th e form er sh ou ld alw ays be priorit ized over th e lat ter. Ult im ately, it is h oped th at th e fu n ct ion al an d aesth et ic im p rovem en t w ill en cou rage th e resolut ion of any psych osocial issu es. In th e au th ors’ decades of experien ce w ith m ore th an 3600 orthognathic surgical cases, 96%percen t of th e patients reported th at they overcam e their inferiorit y com plex follow ing orthognathic surger y. Their new -found con den ce could be seen on th eir faces a m on th after surger y. Recen tly,

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su rger y, an d th u s avoid a p ain fu l detou r to a t rial of or th odon t ics th at produ ce n o ben e t . Tem porom an dibular join t posit ion ing sh ould be assessed rst as th e con dylar posit ion is th e key referen ce poin t of th e m an dible. Mast icator y m uscle fu n ct ion an d facial n er ve fu n ct ion sh ou ld also be ch ecked before t reat m en t . High sagit t al su praforam in al osteotom y is su perior to sagit t al sp lit ram u s osteotom y n ot on ly becau se it requ ires a sh or ter operat ing t im e, h as less bleeding ten den cy, an d is less invasive, but also because it h as th e low est risk of in ferior alveolar n er ve injur y. Adequ ate soft t issu e p rotect ion , m et icu lou s h em ostasis, rigid xat ion , prop er preoperat ive plan n ing, an d good su rgical skills are th e key ten ets for a successful facial bon e surger y. “Aged appearance” can result from the relaxed m idfacial soft tissue follow ing LeFort I or bim axillary surgery, and m ay require additional aesthetic procedures.

there has been an em erging trend of perform ing a t w o-jaw su rger y (m axillar y Le Fort I operation w ith m an dibu lar setback) on patien ts w ith n orm al occlu sion for purely cosm etic reason s. In th e auth ors’ opin ion th is is un acceptable. Su rgeon s m ust be w ar y of th e com m ercialization of m edicin e and of th e ne line bet w een ethics and econom ics, and n ever lose sigh t of th e sacred nat ure of their job. Du ring or th ogn ath ic su rger y’s h istor y of m ore th an 170 years, m any surgeon s h ave t ried to set th e con cept of operat ion to ach ieve th ese purposes.1,2 Tech n ically, th e site an d design of osteotom y, th e ap p roach for th e osteotom y (ext raoral or in t raoral), th e m eth od for xat ion (w ith w ire or w ith plates an d screw s), an d th e em ergen ce of th e bon e exp an sion an d dist ract ion osteogen esis tech n iqu es are am ong th e in n ovat ion s (Fig. 21.1).3,4,5 Sin ce 1960 or th ogn ath ic su rger y h as m ade rap id p rogress alongside th e advan cem en t s in tech n ology su ch as th e xat ion p late an d screw system for rigid xat ion . In form at ion tech n ology (IT) d evelopm en t w ith soft w are an d 3D con e beam com p uted tom ography (CT) an d prin t ing tech n ology also h ave con t ributed to th e im provem en t of an alysis an d diagn osis. To approach or th ogn ath ic surger y, an un derst an ding of th e basic con cept of occlusion is cru cial sin ce restorat ion

21

Blair (1907)

Perthes (1924) Schlössm ann (1922)

Schuchardt (1954)

Aesthetic Orthognathic Surgery

Trauner & Obwegeser (1975)

Obwegeser & Dal Pont (1958)

Fig. 21.1 The development of the mandibular ramus osteotomy technique. Blair, Schlössmann, and Perthes perform ed osteotomy via the external oral approach, Schuchardt and Obwegeser used the intraoral approach, and Perthes (1924) is known to be the rst to perform a sagit tal osteotomy on the ascending ramus. The intraoral sagit tal spit ramus osteotomy was rst performed by Obwegeser (1953), and Dal Pont modi ed Obwegeser’s procedure to enlarge the contacting surfaces.

to n orm al occlusion is th e overriding priorit y of all or th ogn ath ic su rgeries. It is th erefore of u t m ost im p or tan ce th at th e su rgeon rst be w ell in form ed on w h at con st it u tes n orm al occlu sion . In n orm al occlu sion , th e m esiobu ccal cu sp of th e upper rst m olar is received in th e groove bet w een th e m esial an d dist al buccal cusps of th e low er rst m olar. An teriorly, th e upper can in e sh ould occlu de bet w een th e low er can in e an d rst prem olar. Angle classi ed th e m alocclusion in to th ree classes w ith respect to th e den tal align m en t an d in terrelat ion sh ip of m axillar y an d m an dibu lar arch es an d bon es (den to-skelet al) (Fig. 21.2).4 Class I m alocclusion is de n ed as h aving a n orm al m olar occlusion bet w een th e upper rst an d low er rst m olars but prob lem s w ith th e oth er teeth , su ch as rot at ion or m alp osit ion ing. Class II m alocclu sion involves cases w h ere th e low er rst m olar is occlu ded dist al to th e u pp er rst m olar. Th is is su bdivided in to t w o division s: Division 1 is w h ere th e u pp er in cisors are proclin ed, in creasing th e overjet; division 2 is for cases w ith ret roclin ed in cisors, w ith redu ced overjet . Class III m alocclu sion describes th e low er rst m olar as being occlu ded m esial to th e u p p er rst m olar. Accord ing to Angle’s classi cat ion , it w as fou n d th at class I is th e m ost com m on occlu sion pat tern across all races. How ever, Japan ese p erson s w ere fou n d to h ave a sign i can tly greater percen t age of class II relat ionsh ips (15%), w h ile class III relat ion sh ips are h igh est am ong th e Ch in ese p opu lat ion (34%).6

Th e m odern in terpret at ion of Angle’s classi cat ion is con n ed m ain ly to th e an terior-posterior relat ion s (on th e sagit t al plan e), om it t ing in form at ion on th e ver t ical an d t ransverse plan es. In pract ice, th e ideal occlu sion can be described as h aving (1) class I m olar an d can in e relat ion sh ip; (2) n o crow ding, n o sp acing, n o rotat ion ; (3) overjet ~ 2 to 4 m m ; (4) correct crow n angu lat ion an d in clin at ion ; (5) at an d sligh t upw ard cu r ve of Spee; an d (6) upper an d low er m idlin es th at are in align m en t . Malocclu sion sh ould be an alyzed w ith respect to in t ra-arch an d in ter-arch problem s. In t ra-arch problem s are related to in dividual teeth—sagit t ally an d vert ically rot ated, or t ran sposit ion ed. In ter-arch p roblem s are related to th e in term axillar y p rob lem s, w h ich occur on th ree plan es: (1) class II or III m alocclusion s in th e sagit t al plan e; (2) cross-bite, scissor bite, or m idlin e sh ift in th e t ran sverse plan e; an d (3) deep bite or open bite in th e vert ical plan e.

■ Patient Evaluation The goal of consultation is to determ ine w hat a patient wants (chief com plaints) an d h is or her concerns regarding function and aesthetics. Past m edical and dental history (especially orthodontic treatm ent) is particularly im portant. The psychological state of the patient should also be evaluated during the inter view. If the patient appears to have

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a

b

c

Fig. 21.2 Angle’s classi cation of malocclusion. (a) Class I malocclusion. (b) Class II malocclusion. Mandible is in a retruded position compared with the maxilla. (c) Class III malocclusion. Protrusion of the mandible with mesial occlusion of the lower teeth is observed.

obsessive-com pulsive tendencies, extra care should be taken before the surgery. The psychological im pact of orthognathic surgery should be discussed w ith the patient before surger y. It is recom m en ded that signi cant others, including fam ily m em bers, also at ten d the preoperative discussion . In bim axillary protrusion patients, w ho have the greatest risk of postoperative “aged face,” it is w ise to w arn them about the possibilit y of additional aesthetic procedures because of the increased skin redundancy after surgery. Docu m en t at ion of any tem p orom an d ibu lar join t (TMJ) sym ptom s su ch as clickin g, deviat ion on m ou t h op en ing, an d associated h eadach es sh ou ld be record ed . In p ar t icu lar, p re-exist in g TMJ dysfu n ct ion p r ior to su rger y sh ou ld be ad d ressed before or t h od on t ic t reat m en t , as t h e con dylar p osit ion is t h e key referen ce p oin t of t h e m an d ible. Th e range of m ot ion an d any d eviat ion on m ou t h op en in g sh ou ld be carefu lly d ocu m en ted . Mast icator y m u scle fu n ct ion an d facial n er ve fu n ct ion sh ou ld also be ch ecked before t reat m en t . Harm ony an d sym m et r y are th e key factors determ in ing facial aesth et ics, even th ough it sh ou ld be recogn ized th at w h at de n es a beaut iful face can di er according to sociocu lt u ral factors. In th e fron tal view, th e face can be d ivid ed equ ally in to th e up per th ird (t rich ion to glabella), m iddle th ird (glabella to su bn asale), an d low er th ird (su b n asale to m en ton ) (Fig. 21.3a). Ver t ically th e fron t al p lan e is com posed of equal fth s (rule of fth s) (Fig. 21.3b). Th e cen t ral fth is th e dist an ce bet w een th e m edial can th i (w h ich is equivalen t to th e alar base w idth ). Th e outer t w o- fth s is th e dist an ce bet w een th e outer can th i an d th e ou term ost p oin t of th e ear. A vert ical lin e from eith er ou ter can th u s in d icates th e ideal vert ical p osit ion of th e gon ion (m an dibu lar angle) on both sides. Th e facial h eigh t-to-w id th rat io (facial in dex) is opt im al w h en it app roach es 1.35:1 for m ales an d 1.3:1 for fem ales. Th e

facial h eigh t is th e dist an ce bet w een th e soft t issu e n asion an d m en ton . Th e facial w idth is de n ed by th e bizygom at ic w idth —th e distan ce bet w een th e outerm ost poin t s of th e soft t issu e zygom at ic arch . Th e bitem poral w idth an d bigon ial w idth sh ou ld ap proxim ate 80 to 85% an d 70 to 75% of th e bizygom at ic w idth , respect ively (refer to Fig. 19.4). Lip p roject ion is also a d eterm in ing factor of facial aesth et ics. Asian s usu ally h ave dist in ct ive ch aracterist ics of th e lip due to a com bin at ion of th ickn ess, bim axillar y prot rusion , an d labioversion of th e upper an d low er in cisors. Th e ideal upper lip sh ould be balan ced w ith th e n ose an d ch eek, an d th e low er lip sh ould be sligh tly posterior to th e u pp er lip. Th e am oun t of teeth exp osu re depen ds on th e ver t ical h eigh t of th e m axilla. W h en both lip s are in repose, th e verm illion of th e low er lip sh ould be ~ 25 to 30% m ore exp osed com p ared w ith th e u p p er lip. Th is is esp ecially im port an t for or th ogn ath ic surger y for a cleft lip -palate pat ien t . W h en sm iling, th e in cisors sh ould be at least th reequar ters exposed yet n ot exceed 2 m m of gingival sh ow. A gu m m y sm ile, or excessive gingival sh ow du ring sm iling, is n ot a reliable in dicator of th e adequ acy of m axillar y h eigh t . Fin ally, facial sym m et r y can be assessed based on several relat ion sh ips, involving th e m idsagit t al plan e th rough th e n asal t ip, m idlin e of th e u pper an d low er in cisors, m idlin e of th e sym physis of th e ch in , an d th e gon ion posit ion of eith er sid e. Dyn am ic sym m et r y can be assessed by obser ving th e level of th e oral com m issures an d teeth exposure on sm iling. Occlusal plan e can t ing sh ould also be assessed. Cephalom et ric analysis is crucial for ident ifying the patient’s skeletal and den tal problem s for correct ive surgical planning and postoperative assessm en t. Standard reference points on a cephalom et ric X-ray im age and basic proportion s are show n in Fig. 21.4 and Fig. 21.5. Ceph alom etric data an alysis reveals that there exists som e disparit y in certain param et ric values bet w een Asian s and Caucasians

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Aesthetic Orthognathic Surgery

Tr 1/3

G' 1/3

Sn

1/3 1/3 2/3

Me'

a

b

1/5

1/5

1/5

1/5

1/5

Fig. 21.3 Aesthetic facial division on frontal view. (a) The face can be divided equally into the upper third (trichion to glabella), middle third (glabella to subnasale), and lower third (subnasale to menton). (b) Vertically, the face is divided into equal fths (rule of fths).

G' N S

N'

Por

Or Pr

Ar UIA

PNS

ANS A Sn A' Ls

LIE UIE

Go LIA Me a Fig. 21.4

B

Li

B' Pog Gn Pg' M'

b

(a,b) The skeletal, dental, and soft tissue reference points in cephalometry (see Table 21.1 for key).

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N

N S

ANS

A

E line B

a

Me

b

G

1/2

Sn 1/3

St

1/2 1/2

Li 2/3

c

Me'

1/2

Fig. 21.5 Basic proportions, angles, and lines in cephalom etric analysis of the face. (a) The nasion (N)–anterior nasal spine (ANS)/anterior nasal spine (ANS)–menton (Me) ratio is the most frequently used parameter to assess the adequacy of the vertical height of the chin. (b) The “esthetic line” (E-line, Ricket t s line) is drawn from the nasal tip (pronasale) to the soft tissue pogonion (Pog′) to evaluate lip position. (c) The ideal ratio of the distances Sn–St:St–Me′ is 1:2 and that of the distances Sn–Li:Li–Me′ is 1:1. S, sella; Me′, soft tissue menton; St, stomion; A, A point, subspinale; B, B point, submentale; G, glabella; Sn, subnasale; and Li, Labrale inferior.

(Fig. 21.6).6,7,8 Th ese di eren ces accoun t for th e ch aracteristics feat ures in facial m orphology obser ved in these eth nic groups. Im portan t obser vat ion s in Asian s in clude (1) m ore vert ical grow th ten den cy (dow nw ard grow th ); (2) upper an d low er in cisors th at are are m ore labially in clin ed, giving the lip a m ore prot rusive appearance; (3) facial pro les th at are m ore convex, especially in th e m iddle th ird of th e face (bet w een points A and B); (4) m ore acute nasolabial angle; (5) signi can tly sh orter distance bet w een the upper lip and E-lin e (UL–EL) an d low er lip an d E-lin e (LL–EL). No stat istically signi cant di erence w as obser ved in reference angles like sella-nasion -A point angle (SNA), sella-n asion -B point angle (SNB), A poin t-n asion -B poin t angle (ANB), an d m en tolabial angle across all th e eth n ic grou ps (Fig. 21.6). With th e adven t of n ew tech n ology su ch as con e beam com puted tom ography (CBCT) an d 3D processing soft w are, w e are cu rren tly on th e verge of t ran sit ion ing from th e 2D era in to 3D. Bu t cep h alom et ric an alysis is st ill u sefu l today an d form s th e fou n dat ion of ou r u n derst an d ing of th e facial m et rics. A den t al m odel is also im p or t an t in p roviding in form at ion on th e arch form (arch w idth an d arch length ), teeth posit ion, upper an d low er m olar relat ion , an d teeth in clin at ion . It also gives a rough sim ulat ion of p ostoperat ive u pp er an d low er jaw relat ion sh ips.

Fig. 21.6 Disparit y of parametric values of cephalometry among Asians and Caucasians.8 Asians (dotted line) show a higher vertical growth tendency and a more convex pro le compared with Caucasians (solid line). The nasolabial angle is more acute in Asians and the upper incisors are more labially inclined, giving the upper lip a m ore protrusive appearance. The lower anterior teeth are also labially inclined to the mandibular plane in Asians.

21 Table 21.1

Aesthetic Orthognathic Surgery

Reference point s in cephalometry

Skeletal reference points N

Nasion

Most anterior point of nasofrontal suture

S

Sella

Center of sella turcica

Or

Orbitale

Most inferior point on orbital m argin

A

A point, subspinale

Deepest point of anterior border of m axilla

B

B point, subm entale

Deepest point of anterior border of m entum

Pog

Pogonion

Most anterior point of mentum

Gn

Gnathion

Midpoint bet ween Me and Pog

Me

Menton

The lowest point of symphysis

ANS

Anterior nasal spine

Most anterior point of nasal oor

PNS

Posteror nasal spine

Most posterior point on hard palate contour

Ar

Articulare

Intersection of sphenoidal basis and condylar posterior border

Go

Gonion

Most inferior, posterior point on mandibular angle

Por

Porion

Upperm ost point on bony external auditory m eatus

Dental reference points UIE

Upper incisor edge

Incisal point of upper incisor

UIA

Upper incisor apex

End point of root of incisor

LIE

Lower incisor edge

Incisal point of lower incisor

LIA

Lower incisor apex

End point of root of lower incisor

Soft tissue reference points Tr

Trichion

Hairline at the forehead m iddle line

G′

Soft tissue glabella

Median point bet ween eyebrows (most anterior point of forehead)

N′

Soft tissue nasion

Deepest point on skin at root of nose

Pr

Pronasale

Most anterior point of tip of nose

Sn

Subnasale

Transitional point of nasal septum and upper lip

A′

Soft tissue A point

Deepest point bet ween subnasale and upper lip

Ls (UL)

Labialis superior (upper lip)

Most anterior point of upper lip

St

Stomion

Middle point bet ween upper and lower lips

Li (LL)

Labialis inferior (lower lip)

Most anterior point of lower lip

B′

Soft tissue B point

Deepest point bet ween lower lip and chin

Pog′

Soft tissue pogonion

Most prom inent point of soft tissue chin

Me′

Soft tissue menton

Most inferior point of chin

273

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IV Facial Bone Surgery

■ Surgical Techniques In p at ien t s w ith sligh t m alocclu sion an d n o cosm et ic con cern s, it is reason able n ot to o er any t reat m en t . But in cases of skelet al discrepan cy of th e facial bon es, surger y m igh t be th e m ost u sefu l m odalit y of t reat m en t . For Asian pat ien t s, th e auth ors prefer Le For t I osteotom y, h igh sagittal su praforam in al osteotom y (HSSO), an terior segm en tal osteotom y (ASO), an d gen ioplast y. Table 21.2 su m m arizes th e appropriate operat ion s for th e respect ive diagn oses. Typically, th e orth ogn ath ic su rger y is perform ed un der gen eral an esth esia w ith n asot rach eal in t u bat ion . In ten t ion al hypoten sion an d perioperat ive an t ibiot ic coverage in m ost cases is m an dator y.

Surgery of the Mandible Sagittal Split Ramus Osteotomy (SSRO) Am ong the various techniques of m andibular osteotom y proposed so far, sagittal split ram us osteotom y (SSRO), after the Obwegeser–Dal Pont m ethod, is the m ost w idely adopted technique. It is generally indicated in horizontal m andibular excess or de ciency, or cases of m andibular asym m etry.9 First , m ark th e m idlin e th at run s from th e glabella along th e n asal dorsu m , d ow n th e ph ilt ru m an d th e m idlin e of th e up p er lip an d up per in cisors, th rough th e m idlin e of th e low er in cisors to th e m idlin e of th e sym physis. Th is lin e is h elpful as a referen ce during an d after surger y. Mu cosal in cision st ar ts from th e bu ccal vest ibu le of th e low er rst m olar an d con t in u es along th e an terior m argin of the ascen ding ram us laterally (Fig. 21.7a). Met icu lou s soft t issu e d issect ion to th e periosteu m w ith p roper h em ostasis w ill gu aran tee safe bon e su rger y. Th e bu ccal fat p ad

Table 21.2

located at th e u pp er part of th e ascen ding ram us sh ou ld be kept u n less it w ill con st an tly sp ill in to th e su rgical eld for th e rest of th e su rger y. Th e periosteu m is in cised w ith diath erm y an d elevated o th e ascen ding ram us, ret rom olar area, an d rst m olar region laterally an d buccally. Elevat ion of th e periosteu m is also don e m edially bet w een th e sigm oid n otch an d lin gu la arou n d th e m an dibu lar foram en . Periosteal elevat ion sh ou ld exten d u p to th e p osterior m argin to allow in st ru m en t s to be in serted an d to p rotect th e soft t issu e at th e posterior m argin during osteotom y. Prior to elevat ion of th e lingual periosteum of th e ascen ding ram us, in lt rat ion of epin eph rin e an d lidocain e is h elpful to avoid acciden t al ru pt u re of n u t rien t vessels em erging from th e bony foram en . After soft t issu e p rotect ion is en su red, bon e cu t t ing begin s w ith a 3.1- or 4-m m roun d bur at th e an terior border of th e ascen ding ram u s. Th e cor tex at th e an terior border is rem oved carefully u p to th e rst m arrow bleeding poin t . At th is poin t , in lt rat ion of epin eph rin e/lidocain e is perform ed again before con t in uing th e n ext step. Lingu al cor tex osteotom y is d on e w ith a 2.7-m m rou n d bur. Soft t issue protect ion is en sured w ith a n arrow ch an n el ret ractor or broad cur ved periosteal elevator. Special care sh ould be t aken n ot to injure th e in ferior alveolar n er ve an d vessels. Th e au th ors usu ally keep th e dissect ion area n arrow to avoid dam age to th e vessel an d n er ve at th e m an dibu lar foram en . Th e lingu al cortex osteotom y is carried to th e posterior border of th e ascen ding ram u s. Bu ccal cortex osteotom y sh ou ld be d esign ed d ep en ding on w h eth er th e object ive is to ach ieve setback, advan cem en t , or t ran sverse rot at ion of th e m an dible. Th is can range from a vert ical osteotom y n ear th e rst m olar area to an obliqu e lin e ru n n ing from th e secon d m olar to th e m an dibu lar angle. On ce again , adequ ate p rotect ion is n ecessar y to avoid inju r y to th e facial arter y an d th e m argin al m an dibu lar bran ch of th e facial n er ve.

Categorization of orthognathic surgery by diagnosis

Diagnosis

Appropriate operation

Mandibular protrusion

Mandibular setback (SSRO or BVSRO) + genioplast y

Maxillary protrusion

Le Fort I

Mandibular vertical excess

Genioplast y

Maxillary vertical excess

Double jaw surgery

Mandibular retrusion

SSRO

Mandibular vertical de ciency

SSRO + genioplast y

Open bite

Double jaw surgery or Le Fort I only

Bimaxillary protrusion

ASO + genioplast y or upper ASO and lower SSRO + genioplast y

Abbreviations: ASO, anterior segmental osteotomy; BVSRO, bilateral vertical sagittal ramus osteotomy; SSRO, sagittal split ramus osteotomy.

21 After th e cortex of th e an terior ram u s border h as been rem oved as described earlier, th e au th ors create several gu ide h oles in th e m edu lla (Fig. 21.7b) dow n to th e posterior border w ith a 1.8-m m rou n d bu r. Care is taken to avoid th e in ferior alveolar n er ve an d vessels by st aying close to th e buccal cor tex, especially at the m an dibular body an d angle area. Ram u s sp lit t ing is com p leted by join ing th ese gu ide ch an n els w ith a 2-m m ch isel (Fig. 21.7c). Th e separat ion sh ould be perform ed gen tly an d precisely, t aking care n ot to cau se u nw an ted fract u re of any segm en t . The tooth-bearing segm ent is referred to as the distal segm ent w h ile th e segm en t bearing th e con dylar head is the proxim al segm ent. Once the proxim al and distal segm ents are separated, th e m andibular body can m ove freely. With the prefabricated occlusal splint w ired to the upper teeth, the free-m oving m andibular distal segm ent can be easily adapted to the upper teeth and splint. Interm axillary xation (IMF) is then perform ed w ith the m axillary and m andibular teeth occluded in this new position. The auth ors generally prefer elastic rubber bands over w ires for this purpose. Th e n ew m an d ib le p osit ion is ch e cke d w it h t h e m id lin e d raw n p re op e rat ively t o e n su re fa cia l sym m e -

Aesthetic Orthognathic Surgery

t r y. Th e con d ylar h ea d is ch e cke d t o m a ke su re it is in a good an d st a b le p osit ion in t h e gle n oid fossa . On ce eve r yt h in g is con fir m e d t o b e in p osit ion , ost e osyn t h e sis is p e r for m e d . Th e re are t w o m et h od s of ost e osyn t h esis a ccord in g t o t h e level of fixat ion . Th e fir st , r igid fixat ion w it h u t ilizat ion of t it an iu m p lat es an d screw s or lag screw s, resu lt s in a bsolu t e st a b ilizat ion of t h e t w o b on e se gm e n t s. Th e re is n o m ovab le gap a n d p r im ar y b on e h ea lin g occu rs w it h m in im a l callu s for m at ion . Th e se con d , n on r igid fixat ion w it h w ires, p e r m it s in t e rse gm e n t a l m ob ilit y. Th e w ire ’s m ain act ion is t o lim it d ist ra ct ion of t h e t w o se gm e n t s w h ile se con d a r y bon e h e alin g t akes p la ce. Desp it e b e in g n on r igid , t h is for m of fixat ion is a cce p t e d a s b e in g fu n ct ion ally st ab le. Th e au t h or s’ p refe re n ce is t h e r igid fixat ion t e ch n iqu e be ca u se it is less p ain fu l a n d sh or t e n s h ea lin g t im e. In ad d it ion , r igid fixat ion can sh or t e n t h e IMF t im e. On ce ost e osyn t h esis is d on e, t h e IMF is rele ase d t o ch e ck for n or m al occlu sion as p lan n e d . Th e w ou n d is t h e n ir r igat e d w it h n or m a l salin e, an d a fin a l ch e ck for h e m o st asis is d on e before closu re w it h 4 – 0 silk. A 4 - t o 5- cm sila st ic d rain is a n ch ore d on ea ch sid e.

Fig. 21.7 Sagit tal split ramus osteotomy (SSRO). (a) Mucosal incision line. (b) Osteotomy is done following the guide holes created in the medulla down to the posterior border. (c) Ramus split ting and repositioning to the proper new occlusion.

a

c

b

275

276

IV Facial Bone Surgery

High Sagittal Supraforaminal Osteotomy (HSSO)

Intraoral Vertical Ramus Osteotomy (IVRO)

High sagit tal su p raforam in al osteotom y (HSSO), also referred to as supraforam in al h orizon t al oblique osteotom y (SHOO),10 w as origin ally design ed by W J Höltje,11 an d it d erived from Sch u ch ardt (Fig. 21.1). HSSO is an esoteric yet m ore clin ically at t ract ive m eth od th an t radit ion al SSRO11 because of its sh orter operat ing t im e; lesser bleeding ten den cy an d invasiven ess; low er risk of in ferior alveolar n er ve inju r y; an d faster recover y. HSSO begin s w it h a m u cosal in cision st ar t in g at t h e low est p oin t of t h e asce n d in g ram u s an d p roce e d in g lat e rally u p t h e an te r ior b ord e r of t h e ram u s. A 25- t o 30-m m in cision is u su ally su cie n t (Fig. 21 .8a). Th e p e r ioste u m is elevate d o t h e lat e ral su r face of t h e asce n d in g ram u s u p to it s p ost e r ior b ord e r. Th e au t h ors u se a sim p le late ral ret ractor (w id t h 2 0 m m ) to p rote ct t h e late ral an d p ost e r ior su r face d u r in g t h e ost e ot om y. Me d ial su r face p e r iosteal elevat ion is d on e b et w e e n t h e sigm oid n otch an d t h e foram in a above t h e m an d ibu lar foram e n . As t h is area is h igh ly vascu lar ize d , it t e n d s to ble e d from t h e m u scu lar an d n u t r ie n t vascu lar bran ch es. A 5- to 15-m m n ar row t u n n el is u su ally su cie n t to p e rfor m t h e m e d ial ost e otom y. Th e elevat ion is con t in u e d u n t il t h e late ral ret ractor from t h e lat e ral sid e is e n cou n te re d at t h e p oste r ior bord e r. Th e oste otom y on t h e lat e ral cor t ical su r face is 10 to 15 m m low e r t h an t h e m e d ial oste otom y on t h e asce n d in g ram u s (Fig. 21.8b). Afte r t h e m e d ial an d late ral ost e otom ies are com p let e d , sp lit t in g is p e r for m e d . Fixat ion is d on e u sin g a m a xip late w it h fou r screw s on each sid e for ost e osyn t h esis (Fig. 21 .8 c). An alt e r n at ive is to u se t w o fou r-h ole m in ip lates w it h e igh t screw s on each ram u s.

a

b

Th is m eth od is relat ively sim ple an d par t icularly useful for asym m et ric cases requ iring m an dibular m obilizat ion (Fig. 21.9). After elevat ing th e lateral periosteu m o th e ram us from th e sigm oid n otch to th e in ferior border of th e m an dible (gon ial angle), th e osteotom y is m ade from th e sigm oid n otch to th e m an dibu lar foram en p osteriorly w ith an oscillat ing saw. Great care sh ou ld be t aken n ear th e m an dibular foram en n ot to dam age th e vascular bun dle, w h ich can poten t ially cause m assive bleeding. Occasion ally, th e an t ilingu la on th e lateral su rface can be u sed as a referen ce to ap proxim ate th e lingu la on th e m edial su rface. After com plet ing th e vert ical osteotom y, th e prepared splin t is u sed to guide th e dist al segm en t to n orm al occlusion . Th e dist al segm en t sh ould be located on th e m edial surface of th e proxim al segm en t . Osteosyn th esis w ith a m in iplate is n ot obligator y in th is case, an d in term axillar y xat ion alon e w ith or w ith ou t in terosseou s w iring n orm ally su fces. Th is in term axillar y xat ion is kept for 6 to 8 w eeks.

Surgery of the Maxilla Th e m ost w idely perform ed m axillar y orth ogn ath ic su rger y is th e Le For t I osteotom y w ith dow n fract u re.12 Th is operat ion is relat ively sim ple, but if n ot perform ed correctly, it can h ave dire con sequen ces such as severe h em orrh age, lar yngeal edem a, an d respirator y failure. Lidocain e an d ep in ep h rin e (1:100,000) is injected in to th e labial an d bu ccal vest ibu le in clu d ing th e su bp eriosteal area. Th is hydrodissect ion w ill m ake raising th e m ucoperiosteal ap easier, as w ell as decrease th e am ou n t of bleeding du ring th e surger y. Th e m idpoin t is m arked w ith a 6–0 nylon

c

Fig. 21.8 High sagit tal supraforaminal osteotomy (HSSO). (a) The incision line is 25 to 30 mm long and follows the anterior border of the ramus. A simple lateral retractor (width 20 mm) is applied to protect the lateral and posterior surface during the osteotomy. (b) The osteotomy on the lateral cortical surface is ~ 10 to 15 mm lower than the medial osteotomy on the ascending ramus. (c) Osteosynthesis is performed using a maxiplate with four screws on each plate.

21

Fig. 21.9 Intraoral vertical ramus osteotomy (IVRO). Vertical ramus osteotomy is useful in case of mandibular asymmetry or prognathism. The segments are xed with interosseous wiring or miniplates and screws. The position of the TMJ can be passively adapted. This m ethod is simple but requires a long period of intermaxillary wiring (more than 6 weeks).

su t u re for referen ce later. A m u cosal in cision is m ade 5 to 8 m m above th e m u cogingival ju n ct ion , from th e dist al rst m olar of on e side to th e oth er. Th e au th ors t yp ically u se a th in n eedle elect rocauter y for th is pu rpose. Hem ostasis is p erform ed m et icu lously as th e in cision is deepen ed in layers. At th e en d, a 5-m m u p -cu t is d on e to p reven t m u cosal tearing du ring dissect ion of th e pter ygoid process. Once the bone is reached, periosteal dissection is perform ed from the piriform aperture (not entered at this point) to the zygom atic crest. Dissection should be done carefully to avoid entering the buccal fat pad. The anterior dissection extends from the anterior nasal spine up to the infraorbital foram en. Great care should be taken w hile elevating the nasal m ucosa from the nasal septum , hard palate, and lateral nasal wall. A nasal m ucosal tear (especially at the nasal oor) results in an annoying hem orrhage that can be a challenge to control. After lifting th e periosteum , th e plan n ed osteotom y lin es are draw n on th e bone w ith a pencil. Using a diam ond bur, 5-m m h oles are m ade on the anterior m axillar y w all. The sinus m ucosa is then lifted o the anterior m axillar y w all. Using a reciprocating saw, a h orizon tal tran sverse osteotom y is m ade start ing at the lateral w all of the piriform fossa an d en ding at th e m axillar y t uberosit y (Fig. 21.10a). W hen m aking the cut over the anterior m axillar y sinus w all, th e sin u s m u cosa can be protected w ith a exible periosteal elevator. Once this horizon tal osteotom y is perform ed on both sides, the low er part of the nasal septal cartilage an d vom er is detach ed from th e m axilla an d palat in e bon e u sing a n asal sept u m osteotom e (Fig. 21.10b).

Aesthetic Orthognathic Surgery

Th e soft palate at th e posterior en d can be protected w ith a nger during th e separat ion . Next , th e pter ygoid plate is separated from th e m axilla w ith a cur ved pter ygoid osteotom e. Th e operator’s nger sh ould be placed on th e pter ygoid h am ulu s during th e osteotom y at th e pter ygom a xillar y ju n ct ion to preven t inju r y to th e m axillar y ar ter y an d pter ygoid p lexu s (Fig. 21.10c). On ce det ach m en t of th e n asal sept um , an terior m axillar y sin us w all, m axillar y t uberosit y, an d pter ygoid process is com p leted, th e m a xilla is ready to be dow n -fract u red (Fig. 21.10d). Th is can be don e w ith Row e disim pact ion forceps or m an ually. With th e Row e forcep s, th e blad e w ith th e large cu r vat u re protect s th e an terior upper teeth an d th e oth er, sh orter blade h olds th e n asal oor. Perform th e dow n -fract ure in a deliberate an d at raum at ic m an n er to preven t un con t rolled fract u re lin es an d bleed ing. On ce th e d ow n -fract u re is com pleted, th e segm en t is h eld dow n w ith a bon e h ook w h ile bony irregularit ies are sm ooth ed w ith diam on d bu rs or th e ult rason ic bon e cu t ter. In m axillar y setbacks or u pw ard displacem en t s, th e posterior sin us w all sh ould also be t rim m ed to create space for th e desired posterior or superior m ovem en ts. Avoid inju ring th e descen ding p alat in e arter y du ring bon e rongeu ring at th e posterior sin u s w all, as th is can p oten t ially cau se a cat ast roph ic h em orrh age. On ce th e posterior sin u s w all h as been p repared, th e m a xilla is m oved in to th e n ew p lan n ed p osit ion u sing th e prefabricated splin t as a guide. With th is n ew occlusion , IMF is ap plied u sing in t raoral elast ic ban ds on th e bracket s. Measu rem en ts can th en be taken of th e length of th e st itch at the m edial can th us to th e bracket of th e cen t ral in cisors to con rm th at th e correct ion as p reop erat ively plan n ed h as been ach ieved. Fou r L-sh aped, fou r-h ole m in ip lates are used for osteosyn th esis. On e is placed on each side of th e piriform rim , an d on e on each of th e lateral bu t t resses (Fig. 21.10e ). A cin ch su t u re is app lied at th e alar base before w oun d closu re to preven t splaying of th e alar base (Fig. 21.10f). For closu re, th e au th ors st ar t by p u t t ing on e st itch on th e prem arked nylon su t u re in th e m idlin e w ith 4–0 or 3–0 silk (in cisor area). Th e w oun d is th en closed start ing from th e lateral-m ost edge ( rst m olar area) an d w orking m edially. At th e m id lin e, a V-Y closu re is fash ion ed to restore th e n orm al ap pearan ce of th e u pp er lip ; oth erw ise it m ay look at an d elongated. Fin ally, t w o passive silast ic drain s are in serted, on e on each side, an d an ch ored.

Bimaxillary Surgery Anterior Segmental Osteotomy for Bimaxillary Protrusion Bim axillar y prot ru sion is m ost prevalen t in Sou th east an d East Asia. Th e t ypical ch aracterist ics of bim axillar y prot rusion are p rot ru ded m axilla an d m an dible, ret ru ded sm all ch in , acu te n asolabial angle w ith /w ith out open bite, an d a

277

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IV Facial Bone Surgery

b a c

d

e

f

Fig. 21.10 Le Fort I osteotomy. (a) Osteotomy starts at the lateral wall of the piriform fossa and ends at the maxillary tuberosit y (red line). (b) The lower part of the nasal septal cartilage and vomer is detached from the maxilla and palatine bone using an osteotome. (c) The pterygoid plate is separated from the maxilla with a curved pterygoid osteotome. (d) The m axilla is down-fractured. (e) Four L-shaped, four-hole miniplates are applied on each side of the piriform rim and lateral but tress. (f) A cinch suture is applied at the alar base before wound closure to prevent splaying of the alar base.

sm all in terin cisal angle. In dicat ion s for an terior segm en tal osteotom y (ASO) for pat ien ts w ith bim axillar y prot rusion in clude 1. Prot rusion of m axillar y teeth an d bon e, causing sign i can t facial deform it y 2. Orth odon t ically un t reat able prot ru sion , such as an kylosed teeth , root resorpt ion , or im m ovable/ slow -m oving tooth d u e to th ick bon e stock 3. An terior open bite n ot t reatable w ith orth odon t ic t reat m en t alon e 4. Un aesth et ic sm all ch in w ith lip excess First , segm en t al osteotom y of th e m axilla is perform ed. On th e labial side, th e m argin al gingival in cision ru n s from th e secon d prem olar of on e side to th at of th e oth er side. Th e palat al m argin al gingival in cision is sh or ter, from th e can in e to th e rst prem olar on each side (Fig. 21.11a). Th is in cision can p reser ve th e vascular su pply to th e bon e sin ce th ere are n o m ucosal in cision s. On ce th e in cision is m ade, th e periosteum is elevated to th e an terior n asal spin e on

th e labial side an d to th e coron al m idlin e of th e h ard palate on th e palat al surface. Ext ract ion of both upper an d low er rst p rem olars follow s (Fig. 21.11b). Th e prem olar socket m arks th e osteotom y lin e an d th e am oun t of posterior setback of th e an terior segm en t . Th e bon e spicu les at th e edges are sm ooth ed to allow for proper bon e con tact during osteosyn th esis later. Care m ust be taken n ot to injure th e can in e an d secon d prem olar by keep ing th e in ter ven ing socket w all in t act . Th e osteotom y lin es are m arked on th is prem olar socket w ith a pen cil, keep ing a distan ce of at least 5 m m p osteriorly an d 3 to 4 m m in feriorly from th e an terior teeth root s, an d ru n parallel to th e n asal oor. Th e bu ccal an d p alatal bony w all at th e ext racted socket is rem oved prim arily w ith a bon e rongeur. Using a sm all roun d bu r, th e au th ors u sually m ake sm all port s along th e p lan n ed osteotom y lin e an d in lt rate ep in ep h rin e an d lidocain e in to th e m arrow p rior to perform ing th e osteotom y. Th e au th ors start by deepen ing a groove along th e p lan n ed osteotom y lin e w ith a 3.8-m m roun d bur (Fig. 21.11c). Th e diam eter of th e bu r is determ in ed by th e am ou n t of sh orten ing requ ired. Altern at ively,

21

Aesthetic Orthognathic Surgery

Fig. 21.11 Anterior segmental osteotomy (ASO). (a) The palatal marginal gingival incision is made from the canine to the rst premolar on each side of the maxilla and m andible. (b) Extraction of both upper and lower rst premolars follows. (c) Osteotomy is performed by burring out a groove along the planned osteotomy line. (d) The segment is mobilized and a splint fabricated preoperatively is used as a guide to achieve the desired occlusion.

a

b

c

a recip rocat ing saw can be u sed. Bleed ing from th e in cisive foram en d u ring drilling is con t rolled by bon e w ax easily. Th e m axillar y sin u s can be en coun tered as th e groove is d eep en ed . Th e sin us m ucosa is kept in t act an d lifted o th e bon e in stead of being cut th rough . On ce th e osteotom y is com pleted, th e segm en t is m obilized an d th e preoperat ively fabricated splin t is used as a gu ide to ach ieve th e d esired occlu sion (Fig. 21.11d). Th e can in e an d secon d prem olar teeth are ligated w ith w ires on both sides an d IMF is don e. Th e occlusion is ch ecked before osteosyn th esis w ith four-h ole, L-sh aped m in iplates an d screw s. After rigid xat ion is ach ieved, th e sp lin t is rem oved an d th e m argin al gingival in cision is closed w ith in terden tal su t u res. Segm en tal osteotom y of th e m an d ible is ver y sim ilar to th at of th e m axilla. A m argin al gingival in cision is m ade from th e secon d p rem olar of on e side to th at of th e oth er side (Fig. 21.11a). Su bperiosteal dissect ion p roceed s along th e ch in an d body of th e m an dible. Th e osteotom y lin e is m arked an d th e rst p rem olars are ext racted on both sides. Th e bon e is cut in a sim ilar m an n er as described per viously to create th e an terior segm en t (Fig. 21.11c). Th e splin t is ap plied n ext to get th e desired align m en t an d occlu sion . IMF w ith orth odon t ic ru bber elast ics is don e, follow ed by osteosyn th esis w ith 4-h ole st raigh t plates ben t for proper t an d adapt at ion . In terru pted in terden t al p ap illar y su t u res are u sed to close th e in cision an d a silast ic d rain is in serted . For ASO, th e p refabricated occlusion splin t s are used p u rely to gu ide th e plan n ed an terior occlusion an d th en rem oved p rior to ext ubat ion . Postoperat ive IMF is n ot requ ired, an d th e p at ien t is allow ed to open h is or her m ou th im m ediately.

d

Double Jaw Surgery Dou ble jaw su rger y is also called t w o-jaw su rger y or bim axillar y surger y. Dou ble jaw surgeries sh ould be lim ited to pat ien t s in w h om (1) th e am oun t of m an dibu lar setback requ ired is m ore th an 14 m m (in th ese cases, m an dibular osteotom y alon e is in su cien t to ach ieve n orm al occlusion , an d w ill likely h ave a h igh relap se or com p licat ion rate), (2) sign i can t open bite or seriou s bim axillar y p rot ru sion in class III m alocclu sion is presen t , or (3) h orizon tal occlusal can t ing can n ot be adequately corrected or th odon t ically. Th e m axilla an d m an dible are osteotom ized an d m obilized as described previously in th e sam e set t ing. Operat ion begin s w ith a Le Fort I m axillar y osteotom y an d th e m a xilla is d ow n -fract u red . Next th e m axilla is align ed w ith th e h elp of a prefabricated splin t an d xed w ith m in iplates an d screw s. Man dibu lar osteotom y w ith SSRO or HSSO is perform ed n ext an d align ed an d xed in a sim ilar m an ner. Th e n ew occlu sion is plan n ed p reoperat ively an d t w o splin t s are n ecessar y: On e is u sed as an in term ed iate sp lin t after m a xillar y osteotom y to t th e m ovable m axilla to th e un t reated m an dible, an d th e oth er is for after th e m an dibu lar osteotom y, to be u sed as th e n al splin t .

■ Postoperative Care Day surger y is possible after postoperat ive m on itoring for ~ 4 to 5 h ou rs. Th e n ext visit is on p ostop erat ive day 3, for rem oving th e silast ic drain an d dressing th e w ou n d. On postoperat ive day 4 or 5, IMF is released an d t w o m iddle

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IV Facial Bone Surgery ring elast ics are u sed on each sid e to en able th e pat ien t to start early m obilizat ion of th e TMJ w ith sligh t m ou th op en ing. On p ostoperat ive day 7 or 8, th e splin t is rem oved an d th e orth odon t ist begin s postoperat ive or th odon t ic t reatm en t . Th e su t u res are u su ally rem oved on postoperat ive day 10. An t ibiot ics an d an algesics are prescribed in liquid form . Th e pat ien t is advised to alw ays carr y arou n d a p air of sm all scissors to cut o th e ru bber elast ics in case of an em ergen cy.

■ Key Technical Points 1. Prior to elevat ing th e lingual periosteu m of th e ascen d ing ram u s, in lt rat ion of epin eph rin e an d lidocain e is h elpful to avoid acciden t al ru pt ure of n u t rien t vessels em erging from th e bony foram en . 2. During periosteal elevat ion for lingu al cortex osteotom y, keep th e dissect ion area n arrow to avoid dam age to th e vessel an d n er ve from th e m an dibular foram en . 3. For accurate ram us split t ing, create several guide h oles in th e m edu lla, dow n to th e posterior border w ith a 1.8-m m roun d bur. Ram u s split t ing is com pleted by join ing th ese guide ch an n els w ith a 2-m m ch isel. 4. Rigid xat ion after p recise redu ct ion is key to sh orten IMF an d bon e h ealing t im e, an d pain less h ealing. 5. Th e operator’s nger sh ould be placed on th e pter ygoid ham ulu s during th e osteotom y at th e pter ygom axillar y jun ct ion to preven t injur y to th e m a xillar y arter y an d pter ygoid plexu s. 6. After m axillar y bon e su rger y, a cin ch sut ure is ap plied at th e alar base before w ou n d closu re to p reven t splaying of th e alar base. 7. During ASO, care sh ould be t aken n ot to injure th e can in e an d secon d prem olar by keeping th e in ter ven ing socket w all in t act after ext ract ion of th e u pp er rst p rem olars. Th e bon e sp icu les at th e edges are sm ooth ed to allow p rop er bony con t act du ring osteosyn th esis. 8. Th e osteotom y lin es sh ould be kept at least 5 m m aw ay from th e an terior teeth root s so as n ot to d isru pt th e vascular su pply to th e tooth .

■ Complications and Their Management

Common Complications Follow ing Facial Bone Surgery Bleeding du ring SSRO occurs m ain ly from th e bon e m arrow of th e ram us an d body of th e m an dible. Nut rien t ar teries from adjacen t soft t issu e also con t ribu te to th e bleeding. Th ese are m ostly self-lim it ing an d n on -life-th reaten ing. Severe bleed ing, h ow ever, can resu lt from inju r y to th e in ferior alveolar ar ter y du ring elevat ion of th e periosteu m o th e lingual cor tex. Hen ce, th e ut m ost care sh ould alw ays be taken w h en dissect ing n ear th e lingual cor tex, an d proper soft t issu e p rotect ion w ith broad elevators sh ou ld alw ays be em ployed to avoid such m ish aps. If severe bleeding is en cou n tered, p acking th e lingu al t u n n el w ith ep in ep h rin esoaked gau ze an d app lying direct digit al pressu re over th e m an dibu lar foram en rem ain s th e m ost reliable w ay to slow th e bleeding. Th e pressure sh ould be sust ain ed for ~ 5 to 10 m in u tes. After th e bleeding h as ceased, th e packing is kept in sit u w h ile th e oth er side is prepared. Th e osteotom ies m ay p roceed as per u su al if th ere is n o rebleeding. Su rgicel or brin glue can be applied to th e bleeding area after lin gu al cor t ical osteotom ies. If m assive bleed ing resu lts from facial ar ter y inju r y during SSRO, th e bleeding site sh ould be packed w ith epin eph rin e gau ze w ith digital com p ression . A 2–0 or 3–0 h em ostat ic su t u re can be app lied over th e bleeding area. During Le Fort I osteotom ies, the vessels at risk are th e descending palatine arter y, the m axillar y artery, and the pterygoid plexus.13,14 The descending palatine artery in the retrom axillar y region is particularly vulnerable during separation of the m axilla from the pterygoid process or dow nfract uring of the m axillary segm ent because th is process is not visualized directly. Thus, placem ent of the osteotom e at its inferior aspect by palpation is critical to avoid vessel injury w ithin the pterygopalatine fossa.14,15 Som etim es delayed secondary h em orrhage (days 1–2 or 7–9) can arise from th e t uberosit y area. Although the am ount of bleeding is m oderate, it should be m anaged prom ptly as it can poten tially develop into airw ay obstruction. Bleeding from the nasal oor an d sin us m ucosa can be con trolled spontaneously. Infection is uncom m on follow ing orthognathic surgery; the reported incidence is less than 1%.16,17 Nonetheless, if infection occurs, it is usually associated w ith the m andibular osteotom y. Follow ing SSRO procedures, m assive irrigation to rem ove bony dust and chips is required.14 Em pirical antibiotics are routinely prescribed for 7 days after surgery. If localized infection occurs around the screws, then it is recom m ended that they be rem oved. Postoperative pain is usually m inim al and is easily controlled w ith analgesics such as acetam inophen. Severe TMJ pain can occur on the third or fourth postoperative day and m ay require loosening of the IMF.

21

Complications Speci c to Maxillary and Mandibular Orthognathic Surgery Nerve Injury Th e in fraorbit al n er ve can be dam aged during m axillar y su rgeries an d cau se n u m bn ess of th e u p p er lip w ith or w ith out involvem en t of th e m axillar y teeth , gingiva, an d alveolar bon e. Gen erally, sen sor y loss in th e in fraorbit al n er ve dist ribu t ion is tem porar y an d resolves gradually over a 12- to 18-m on th p eriod.14 Rarely, it develop s in to in fraorbital n euralgia in severe cases. In con t rast to m a xillar y orth ogn ath ic su rger y, m an d ibu lar su rger y h as a h igh er rate of tem porar y (60–70%) or perm an en t (20–30%) n er ve injur y.18,19 Presu m ably, th e inju r y is su stain ed du ring osteotom y of th e low er lateral en d of th e body of th e m an dible, or d uring m an dibu lar split t ing sin ce it often requ ires cu t t ing n ear th e n er ve, an d som et im es even crossing th e m an d ibu lar can al. Th is is on e of th e reason s th e au th ors prefer HSSO. Th e low in ciden ce of n er ve inju r y can be at t ributed to th e fact th at th e areas of osteotom y an d split t ing are far aw ay from the n er ve du ring HSSO. An oth er danger site is n ear th e m olar or prem olar areas d u ring th e lateral cort ical osteotom y, w h ere th e ner ve can cou rse laterally n ear th e osteotom y lin es. Th e pat ien t w h o experien ces such a violat ion w ill com plain of nu m bn ess over th e corn er of th e m ou th .

Functional Relapse On e of t h e m ain factors in creasin g t h e r isk of relap se after or t h ogn at h ic su rger y is an occlu sal d iscre p an cy t h at in d u ces t h e m an d ible to m ove in an abn or m al d irect ion . Th is occu rs u su ally w it h in a m on t h . Th erefore, it is ad visable to se n d t h e p at ien t to an or t h od on t ist 5 to 7 d ays after su rger y. An ot h e r con cer n is t h e TMJ factor. An u n st able TMJ w ill resu lt in an u n st able occlu sion , an d t h is eve n t u ally lead s to relap se an d recu r re n ce of m alocclu sion after su rger y. Th e au t h ors p refe r to get t h e TMJ in a good con d yle-fossa t before align in g t h e d ist al segm en t . Abn or m al m u scu lar t ract ion also can lead to fu n ct ion al relap se. Soft t issu e h as a ten d en cy to ret u r n to it s p reop erat ive p osit ion after su rger y. For exam p le, if t h e p oster ior facial h e igh t is lon ger t h an before, t h e m u scles are st retch ed e ccen t r ically an d ten d to re coil back to t h eir old p osit ion s. Th is cau ses m an d ibu lar in st abilit y, w it h t h e m an d ible m ovin g in a rot ator y d irect ion , or back to it s p reviou s p osit ion . Th e p ter ygom asseter ic m u scle is su sp ecte d to be a m ajor con t r ibu tor to t h is p h en om en on . As a resu lt , t h e p at ien t w ill h ave a relap se of an op en bite or class III m alocclu sion . Ot h er t h an t h e pter ygom asseter ic m u scles, t h e ton gu e, lip s, ch eek, an d su p rahyoid m u scles are also involved in su ch a relap se. On e w ay to cou n teract t h is is to u se a r igid xat ion . Tech n ically, in com p lete

Aesthetic Orthognathic Surgery

osteotom ies h in d e r t h e segm en t s from m ovin g freely to t h e n ew p lan n ed p osit ion . As a resu lt , t h e segm e n t s are in stead brough t in to occlu sion by force, w h ich in evit ably lead s to relap se. In com p lete osteotom y m ost com m on ly occu rs at t h e p oster ior ram u s of t h e m an d ible, w h ile t h e m a xillar y t u berosit y an d p ter ygoid p late are t h e m ost com m on sites in t h e m a xilla.

Unfavorable Osteotomies Du ring m a xillar y su rger y, u n con t rolled fract u ring m ay occur w h en a dow n -fract ure is at tem pted despite in com plete osteotom y. To iden t ify th e resist an ce, th e m axillar y dow n -fract u re sh ou ld be perform ed w ith digit al pressure on ly, an d Row e disim pact ion forceps sh ould be used on ly for m obilizat ion after separat ion . Un favorable fract u re sites during m an dibular surger y are th e con dylar n eck, lingual plate, an d buccal plate, an d th e in ciden ce rate ranges from 3 to 23%.20,21 If in adverten t fract u re occu rs du ring su rger y, prom pt m anagem en t for th e fract ure sh ould be un dert aken , depending on it s pat tern an d on w h eth er th e dist al segm en t advan ces or set s back. A prolonged postoperat ive m a xillar y-m an d ibu lar xat ion is also h elp fu l.14

Condylar Resorption Con dylar resorpt ion is a late com plicat ion th at usually occurs 7 to 12 m on th s after th e surger y.14 Th e et iology is n ot kn ow n yet , bu t cau t ion sh ou ld be paid to pat ien t s h aving class II m alocclu sion , sm all or abn orm al sh ape of th e con dyle.14,22 Progressive con dyle resorpt ion m ay lead to open bite an d loss of posterior facial h eigh t . Th e surgeon m u st w ait at least 6 m on th s u n t il th e resorpt ion is com pleted. Th ere is n o e cien t t reat m en t , but in cases of severe resorpt ion , tot al join t recon st ruct ion m ay be required.

Partial Necrosis of Bone Segment and Mucosa Vascular isch em ia an d t issue n ecrosis are caused by un favorable soft t issu e in cision , excessive st retch ing of th e palat al soft t issue pedicle, m in u te segm en talizat ion of th e m a xilla, exten sive hyp oten sion , severan ce of feeding vessels, an d gen eral con dit ion s th at in du ce t ran sien t vascu lar isch em ia. Usually, vascular com prom ise is t ran sien t but it can result in devit alizat ion of th e teeth , periodon t al defect s, an d segm en t al bon e loss. For preven t ion , excessive p eriosteal st ripping sh ould be avoided an d osteotom y sh ould be m ade 5 to 6 m m dist an t from teeth root s.23 W h en t issu e n ecrosis occu rs, u se of recom bin an t bon e m orph ogen et ic protein 2 (r-BMP2) an d platelet-rich plasm a (PRP) w eekly for a m on th can be at tem pted. In som e cases, en dodon t ic t reat m en t is n eeded (Fig. 21.12).

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IV Facial Bone Surgery a

b

Fig. 21.12 Partial necrosis of bone segment. (a) The X-ray shows that partial necrosis of the bone segment developed 10 days after surgery. (b) The anterior maxillary bone was recovered, but root resorption rem ained.

■ Case Studies Case 1: Mandibular Prognathism w ith Long Face A you n g m ale p at ie n t visite d for h abit u al lu xat ion of TMJ accom p anyin g ch ew in g d i cu lt y (Fig. 2 1.1 3). He

a

h ad lon g face w it h a h igh ly con cave facial p ro le an d a p rot r u sive ch in t h at h e fou n d aest h et ically u n p leasin g. He w as classi e d as class III m alocclu sion . Afte r a 9-m on t h p re op e rat ive or t h od on t ic t reat m e n t , HSSO an d ge n iop last y w e re p e r for m e d . Re d u ct ion in t h e am ou n t of t h e ge n iop last y w as 12 m m , an d t h e am ou n t of set back w as 13.4 m m . Ove r-cor re ct ion w as m an d ator y t o p reve n t relap se (Fig. 21 .1 4).

b

c

Fig. 21.13 Case 1. Mandibular prognathism with long face. (a,b) Preoperative photographs. (c,d) Preoperative cephalometry and panoram ic view.

d

21 a

Aesthetic Orthognathic Surgery

b

c

Fig. 21.14 Case 1. (a,b) Two years postoperative photographs. (c,d) Two years postoperative cephalometry and panoramic view.

Case 2: Mandibular Prognathism w ith Long Face A you ng m ale pat ien t visited for relat ive ret ru sion of th e u pp er jaw an d p rot ru sive low er jaw (Fig. 21.15). He sh ow ed an excessive low er facial th ird , a h igh ly con cave facial p role, a long an d p rot ru sive ch in , an d a long face w ith ou t a labiom en tal fold. In fun ct ion al assessm en t , h e w as design ated as a classi cat ion of class III m alocclu sion skelet al t yp e w ith accom p anying m ast icator y di cu lt y an d TMJ fu n ct ion al derangem en t . Preop erat ive orth od on t ic t reatm en t w as adm in istered for in t ru sion of m axillar y p osterior m olars, arrangem en t of m axillar y an d m an dibu lar den t al arch discrep an cy w ith p alatal exp an sion , decom p en sat ion of upper an d low er teeth (adjust m en t of teeth in clin a-

d

t ion ), leveling of upper an d low er teeth , tooth align m en t to restore th e rotat ion s, an d crow ding teeth . Becau se t h e p at ien t refu sed d ou ble jaw su rger y, HSSO an d gen iop last y w ere t h e on ly opt ion s at t h e t im e of t reat m en t p lan n ing. Sin ce t h e ver t ical im p act ion of t h e u p p er p oster ior teet h w as n ot p ossible w it h or t h od on t ic t reat m en t on ly, en dodon t ic p roced u res on t h e u p p er m olars on each sid e, follow in g p rost h od on t ic t reat m en t , w as ad opted ad d it ion ally. On gen iop last y, t h e am ou n t of ch in red u ct ion w as 13.5 m m , an d t h e d ist al segm en t w as m oved 3.5 m m backw ard . Con sid erin g t h e p ostop erat ive relap se, m an d ibu lar set back w as over cor rected 3 m m . After 3 years, t h e occlu sion w as n or m alized, bu t 1 m m an ter ior d isp lacem en t of t h e m an d ible w as n oted (Fig. 21.16).

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b

c

Fig. 21.15 Case 2. Mandibular prognathism with long face. (a,b) Preoperative photographs. (c,d) Preoperative cephalometry and panoram ic view.

a

d

b

c

Fig. 21.16 Case 2. (a,b) Three years postoperative photographs. (c,d) Three years postoperative cephalometry and panoram ic view.

d

21

References

Aesthetic Orthognathic Surgery

13. Bell W H. Le Forte I osteotom y for correct ion of m axillar y deform it ies. J Oral Su rg 1975;33(6):412–426

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16. Ruggles JE, Han n JR. An t ibiot ic p rop hylaxis in in t raoral orth ogn ath ic surger y. J Oral Maxillofac Surg 1984; 42(12):797–801

5. Blair VP. Operat ion s on th e jaw -bone an d face. Surg Gyn ecol Obstet 1907;4:67–78

17. Gallagher DM, Epker BN. Infection follow ing intraoral surgical correction of dentofacial deform ities: a review of 140 con secutive cases. J Oral Surg 1980;38(2):117–120

6. Ow en s EG, Goodacre CJ, Loh PL, et al. A m ult icen ter in terracial st u dy of facial ap p earan ce. Part 2: A com parison of in t raoral param eters. In t J Prosth odon t 2002;15(3): 283–288

18. Posn ick JC, Al-Qat t an MM, Step n er NM. Alterat ion in facial sen sibilit y in adolescen t s follow ing sagit t al split an d ch in osteotom ies of th e m an dible. Plast Recon st r Su rg 1996;97(5):920–927

7. Ow en s EG, Goodacre CJ, Loh PL, et al. A m ult icen ter in terracial st u dy of facial ap p earan ce. Part 1: A com parison of ext raoral param eters. In t J Prosth odon t 2002;15(3): 273–282

19. Lindquist CC, Obeid G. Com plications of genioplast y done alone or in com bination w ith sagittal split-ram us osteotom y. Oral Surg Oral Med Oral Pathol 1988;66(1):13–16

8. Ah n SN. Keph alom et risch e Vergleich st udie von skelet t alen u n d Weich teil Param etern zw eier eth nisch er Gruppen . Doctoral dissert at ion . Kieferor th op aedie, ZMK Klin ik, Un iversit at Ham bu rg; 1995 9. Obw egeser HL, ed. Man dibular Grow th An om alies. Berlin , Heidelberg, Germ any: Sp ringer-Verlag; 2001 10. Kadu k W M, Podm elle F, Lou is PJ. Revisit ing th e su p raforam in al h orizon t al obliqu e osteotom y of th e m an dible. J Oral Maxillofac Su rg 2012;70(2):421–428 11. Scheuer HA, Höltje WJ. [Stability of the m andible after high sagittal supraforam inal osteotomy. Roentgen cephalom etric study.] Mund Kiefer Gesichtschir 2001;5(5):283–292 12. LeFort R. Et u de experim en tale su r les fract u res d e la m ach oire su p erieu re. Rev Ch ir 1901;23:208–227

20. Van d e Perre JP, Stoelinga PJ, Blijdorp PA, Brou n s JJ, Hop pen reijs TJ. Perioperat ive m orbidit y in m axillofacial orthopaedic surger y: a ret rospect ive st u dy. J Cran iom axillofac Surg 1996;24(5):263–270 21. van Merkesteyn JPR, Groot RH, van Leeuw aard en R, Kroon FH. In t ra-operat ive com plicat ion s in sagit t al an d vert ical ram u s osteotom ies. In t J Oral Maxillofac Su rg 1987;16(6):665–670 22. Merkx MA, Van Dam m e PA. Con dylar resorpt ion after orth ogn ath ic su rger y. Evalu at ion of t reat m en t in 8 p at ien t s. J Cran iom axillofac Su rg 1994;22(1):53–58 23. Bell W H, Fon seca RJ, Ken n eky JW, Levy BM. Bon e h ealing an d revascu larizat ion after tot al m axillar y osteotom y. J Oral Su rg 1975;33(4):253–260

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22

Genioplasty

Seong Yik Han and Kar Su Tan

Pearls • Gen ioplast y has n o e ect on occlusion an d can thus

•

•

•

be considered a w holly aesthet ic procedure aim ed at m odifying the form and appearance of th e bony m en t um . Gen iop last y is m ost com m on ly don e as an adju n ct ive p rocedu re of an terior segm en tal osteotom y, angle redu ct ion surger y, m an dibular sh aving, zygom at ic su rger y, an d rh in oplast y to yield syn ergist ic e ects in m aking an aesth et ically pleasing face. Proper evaluat ion an d docum en tat ion in th e form of facial ph otography, sim ulat ion m odeling, an d radiograp h ic invest igat ion s (pan oram ic view, lateral an d p osterior-an terior [PA] cep h alogram , an d/or 3D com puted tom ography [CT] scan ) are im perat ive prior to surger y. Th e object ive is to ach ieve facial h arm ony th rough su rgically m odifying th e m en t u m an d m an dibu lar sym p hyseal areas, recreat ing ap p ropriate facial propor t ion s an d sym m et r y of th e low er th ird of th e face.

■ Introduction Th e ch in is vital in creat ing a sen se of sym m et r y an d proport ion of th e face. Th e feat ures of im por tan ce in th e ch in in clu de (1) th e cur vat u re from th e in ferior verm illion to th e ch in t ip, (2) th e volum e of th e ch in bon e, an d (3) th e posit ion of th e ch in t ip. In terest ingly, th e ch in h as a sign i can t im pact on th e p at ien t socially. Many p at ien t s w ith m icrogn ath ia or m an dibu lar hyp op lasia reveal a lack of con den ce, in t roversion , an d an in feriorit y com plex. In th is sen se, th e role of aesth et ic su rgeon s exten d s beyon d sim ple aesth et ic en h an cem en t s an d augm en tat ion s. Th e con cept of beaut y borrow s h eavily on th e in dividu al’s cu lt u ral backgrou n d an d exp osu re. In East Asian t radit ion s, a roun d an d volum in ous ch in w as preferred as th e ideal. Now adays, h ow ever, m any fem ale pat ien t s w an t a sm all face w ith a V-sh ap ed ch in in stead of th e big U-sh aped ch in of previous t im es. Most m ale pat ien ts also prefer a n arrow er, sligh tly longer an d m oderately p rom in en t ch in . We

286

• Th e ideal ch in posit ion varies am ong in dividuals,

•

•

•

an d is determ in ed by taking in to con siderat ion both th e h ard an d soft t issue ceph alom et r y referen ce poin t s. Gen ioplast y can be perform ed in t w o w ays: (1) osseou s gen ioplast y an d (2) augm en tat ion gen iop last y u sing im p lan ts. Th e au th ors p refer osseous gen ioplast y because it provides a m ore reliable outcom e. Osseou s gen iop last y is don e in t raorally u n der gen eral an esth esia. Horizon t al bon e cu t s are m ade bicort ically w ith an oscillat ing saw, t aking care n ot to injure th e m en tal n er ve, an d th e m obilized segm en t is xed w ith pre-ben t m in iplates. Alth ough gen iop last y is a relat ively safe operat ion w ith ver y low com plicat ion rates, m en t al n er ve inju r y, m alun ion /n on u n ion , irregularit y of bon e su rface, lip droop ing or skin dim p ling, ch in ptosis, an d asym m et r y m ay develop .

can safely assum e th at th is t ren d w ill con t in ue to evolve, an d su rgeon s w ill h ave to st ay cu rren t w ith th e t im es an d m odify th eir tech n iqu es to su it th e requ irem en t s of th e con tem porar y aesth et ic preferen ce. Gen iop last y, w h ile seem ingly a relat ively st raigh tforw ard procedu re, h as a sign i can t im pact on overall facial h arm ony an d at t ract iven ess. Th is surger y is gen erally con sidered an adjuvan t su rger y, p erform ed to en h an ce an d com plem en t oth er facial bon e surgeries such as sagittal split ram us osteotom y (SSRO), anterior segm ental osteotom y (ASO), m andibular angle reduct ion surgery, an d m alarplast y. The m ost com m on indications for genioplast y are (1) sm all chin w ith class II m alocclusions (w ith or w ithout open bite or bim axillary protrusion) and (2) big chin w ith class III m alocclusion and an excessively long face. These problem s are often a result of congenital syndrom es (e.g., Treacher-Collins syndrom e) or hereditary m alocclusion, chin hypoplasia secondary to childhood osteom yelitis, chin deviation due to soft tissue contractures (e.g., burns), and anterior chin or tem porom andibular joint grow th center disruptions from traum a.

22

■ Historic Background of Genioplasty

Historically, gen ioplast y is p erform ed in on e of t w o w ays: th e use of on lay augm en tat ion over th e m en t um surface, an d th e rep osit ion ing of th e ch in via osteotom ies. G. Au frich t in 1934 described th e u se of th e excised n asal h u m p as an au tograft m aterial “recycled” from rh in oplast y.1 In 1948, K. H. Th om a described th e use of t it an ium m esh for gen iop last y. Nu m erou s m aterials h ad been experim en ted w ith th rough ou t h istor y w ith var ying success, but as im p lan t tech n ologies advan ced, so did th e ou tcom es. Som e exam p les of th ese in clu d e acr ylic, w ax, silast ic ch in im plan t (Brow n et al 1953), expan ded polytet ra uoroeth ylen e (e-PTFE, or Gore-Tex [W. L. Gore]) syn th et ic im p lan t s, ceram ics an d hydroxyapat ite, an d dem in eralized gran u lated tooth (Auto BT) w ith BMP. Th e con cept of osseous gen ioplast y w as rst presen ted by O. Hofer in 1942. He ut ilized a th ree-step tech n ique: segm en tal osteotom y, relocat ion , an d xat ion of th e ch in bon e to th e n ew posit ion .2 Hofer d escribed rst creat ing a h orizon tal osteotom y of th e an terior p ar t (m en t u m ) of th e m an dible via an ext raoral subm en t al in cision to correct p rogn ath ism an d m icrogn ath ia (Fig. 22.1a). H. Obw egeser (1957) later described advan cem en t sliding gen ioplast y via an in t raoral approach to avoid visible ch in scars (Fig. 22.1b).3 After osteotom izing th e low er port ion of th e an terior m an dible, th is segm en t w as p u lled for w ard, p edicled on th e gen iohyoid m u scle. He xed th e segm en t u sing p erim an dibular Supram id (S. Jackson ) th read over th e acr ylic splin t . Later Obw egeser sw itch ed to direct bon e w iring. He also described m odi cat ion s of h is tech n ique for asym m et ric ch ins, by m odifying th e arc of th e segm en t . With th e excep -

a

Genioplast y

t ion of th e xat ion m eth od, th is tech n ique is st ill w idely used today. Fur th er advan ces in th e osteotom y design s in th e h orizon t al, ver t ical, an d sagit t al p lan es resulted in greater con t rol over th e n al ap pearan ce of th e ch in .

■ Essential Cephalometric Data for Genioplasty

Th e im por t an t n orm s for ch in posit ion in ceph alom et ric an alysis are su m m arized in Table 22.1. Th e di eren ces in ceph alom et ric n orm s am ong various eth n ic groups h ave been w ell docum en ted th rough various com parat ive st udies.4,5,6 Th e m ajor di eren ce in ch in ceph alom et ric param eters is th e length of th e low er face. In Korean s, Sp ′–Gn (m m ) is longer th an it is, for exam ple, in Germ an s (65.91 m m versu s 63.27 m m , respect ively). Th u s, th e rat io N–ANS/ ANS–Me (79.5%) is low er in Korean s. Th is valu e is a u sefu l gu ide for th e calcu lat ion of th e ideal ver t ical length of th e ch in . Oth er variables also sh ow ed sign i can t di eren ces (see Chapter 21, Fig. 21.4 an d Fig. 21.5).

■ Patient Evaluation Patient Consultation It is im p ort an t to in qu ire abou t th e p at ien t’s m edical an d fam ily h istor y. Som et im es pat ien t s m ay w ith h old sign i can t det ails, such as previou s ller inject ion or ch in im plan t su rger y, on ly to be revealed du ring rou t in e p reop erat ive radiologic exam in at ion s. Th is h igh ligh t s th e im port an ce of a com plete preoperat ive assessm en t in clu ding X-rays. It is also im port an t to listen at ten t ively an d t ake n ote of th e

b

Fig. 22.1 Early genioplast y techniques. (a) Anterior sliding advancement genioplast y was rst described by O. Hofer in 1942. It was performed via an extraoral submental approach. (b) Genioplast y surgery described by Obwegeser. This sliding advancement genioplast y was performed intraorally, xed with perimandibular Supramid thread on each side over an acrylic dental splint.

287

288

IV Facial Bone Surgery Table 22.1

Important norms of chin position by cephalometric analysis (adapted from Dr. SN Ahn 4)

Variables a

Norms (Asian)

Norms (Caucasian)

N–Me (mm )

118.8 ±4.5

115.7 ±4.5

N–ANS (mm)

52.9 ±2.7 (45% from N–Me)

52.4 ±3.0 (45% from N–Me)

ANS–Me (mm )

65.9 ±4.5 (55–56% from N–Me)

63.3 ±5.5 (54–55% from N–Me)

N–ANS/ANS–Me (%)

80.5 ±5.7

83.2 ±6.2

S–N–A (°)

82.0 ±3.9

81.1 ±4.1

S–N–B (°)

79.4 ±3.5

79.0 ±3.5

G–Sn:Sn–Me′

1:1

Sn–St:St–Me′

1:2

a

See Chapter 21, Table 21.1 for a guide to variables.

p at ien t’s desires an d exp ect at ion s. Th e param eters discussed usually in clude (1) th e volu m e an d sh ape of th e ch in (sm all/large, broad/n arrow, sh arp/oval), (2) posit ion ing of th e ch in t ip on th e sagit t al plan e (prot rusion or ret ru sion ), (3) vert ical h eigh t of th e ch in (length ening/sh or ten ing), an d (4) sym m et r y (in all th ree plan es). Occasion ally, th e su rgeon m ay en cou n ter a pat ien t h aving good ch in sh ape, p osit ion , h eigh t , an d sym m et r y but w h o requests su rger y. In th is sit u at ion , th e surgeon n eeds to con sider th e p at ien t ju diciou sly. Th e pat ien t’s occlusion is also exam in ed during th e con su ltat ion . Th is is especially crucial in pat ien t s w h o h ave h ad p reviou s orth odon t ic t reat m en t or jaw surgeries. Gen erally, sim ple gen iop last y alon e is su cien t for a pat ien t w ith n orm al class I occlusion . How ever, it w ill n ot su ce for p rop er aesth et ic correct ion for pat ien t s w ith class II or III occlu sion s. In th is case, orth odon t ic t reat m en t or su rger y (su ch as an terior segm en t al osteotom y or sagit tal split ram u s osteotom y) sh ould precede gen ioplast y to correct m alocclu sion .

■ Patient Assessment For preoperat ive assessm en t , an alysis of facial ph otograph s, in clu ding fron tal, 45 degrees obliqu e, lateral, basal, an d h elicopter view s, an d sm iling an d pou t ing view s, is th e rst step . It is cru cial to obt ain sm iling an d pou t ing p h otograph s sin ce som e problem s, su ch as skin dim p ling, m ay ap pear on ly du ring p ou t ing or sm iling. To determ in e th e ideal soft t issue vert ical dim en sion of th e low er th ird of th e face, various referen ces m ay be used, su ch as (1) th e Ricket ts lin e (E-lin e), (2) th e ru le of th irds, (3) soft t issue division s from th e su bn asale (Sn ) to th e soft t issue m en ton (Me′) an d from th e glabella to th e soft t issu e

m en ton (see Ch apter 21, Fig. 21.5), an d (4) th e con cept of th e “zero-m eridian ” (Gon zalez-Uloa, 1962). Th e “esth et ic” lin e, or E-lin e, can be draw n from th e n asal t ip (pron asale) to th e soft t issue pogon ion (Pog′) to evalu ate lip p osit ion (Fig. 22.2). Th e m ean dist an ce of th e upper lip to th e E-lin e is 0.41 m m in Asian s an d 4.72 m m in Cau casian s; w h ile th e m ean d ist an ces for th e low er lip are 1.27 m m an d 3.14 m m for Asian s an d Caucasian s, resp ect ively.4 Using th ese m easu rem en t s, th e p osit ion of th e pogon ion can be ext rapolated. On e pitfall to n ote is th at th is m eth od relies h eavily on th e pat ien t’s h aving a n orm ally p rojected pron asale (n asal t ip ). Usu ally th e pron asale is in adequately projected in Asian s; th u s, u sing th is poin t as a referen ce in su ch p at ien ts can lead to an erron eou s con clusion in iden t ifying a ret ruded pogon ion posit ion . Th e rule of th irds is also applied in th e an alysis of facial p ropor t ion s. Th e face is divided in to th ree equ al vert ical sect ion s: Th e p ort ion from th e t rich ion (Tr) to th e glabella form s th e u pper th ird, from th e glabella to th e su bn asale th e m iddle third, an d from th e su bn asale to th e m en ton th e low er th ird (see Ch apter 21, Fig. 21.3a). Asian s are kn ow n to h ave a longer low er th ird th an Caucasian s by ~ 2 to 3%. Th is m eth od of propor t ion al an alysis m ay be used to determ in e th e ideal p osit ion of th e soft t issu e m en ton (Me′) (Fig. 22.3a). In addit ion , fu rth er an alysis of th e low er th ird can be m ade by st udying th e posit ion s of th e subn asale (Sn ), stom ion (St), low er lip (LL), an d soft t issue m en ton . Th e rat io of th e dist an ces Sn –St:St–Me′ is 1:2, an d th at of th e dist an ces Sn –LL:LL–Me′ is 1:1 (Fig. 22.3b). In p at ien t s w ith sm all chin s, th e Sn –LL:LL–Me′ rat io w ill be m ore th an 1. Using th ese rat ios of th e low er facial th ird, th e opt im al p osit ion of the soft t issue m en ton can be calculated. Th e con cept of zero-m eridian w as described by Gon zalez-Ulloa in 1962.8 From th e soft t issue N poin t , a lin e p erp en dicu lar to th e Fran kfort h orizon t al lin e (FH lin e), th e

22 Fig. 22.2 Esthetic line (E-line, Ricket ts’ line). The “esthetic” line, or “E-line,” is drawn from the nasal tip (pronasale, Pn) to the soft tissue pogonion (Pog′) to evaluate lip position.

Pn

UL to E line LL to E line

Pog'

Genioplast y

lin e from th e upper rim of th e extern al auditor y can al to th e low er rim of th e orbit , is draw n . Th is is kn ow n as th e zero-m eridian . Th e soft t issu e pogon ion is located along th e zero-m eridian (Fig. 22.3c). Im aging an alysis in clu ding X-ray (p an oram ic view, Ceph alo PA, Ceph alo Lat) or 3D CT scan is also a n ecessit y. In th e p lan n ing of th e ideal p osit ion of th e ch in t ip (Me or Pog), it is u sefu l to bear in m in d th at p roport ion is m ore im port an t th an th e act ual length . Lateral cep h alom et r y is perh aps th e single m ost in form at ive tool in assessing an d d eterm in ing th e posit ion of th e ch in . Th e an teriorposterior ch in project ion (Pog) is determ in ed on th e sagit tal plan e by locat ing it bet w een th e SNA an d SNB lin es. Th e n asion (N)–an terior n asal spin e (ANS)/an terior n asal spin e (ANS)–m en ton (Me) rat io is th e m ost frequ en tly u sed param eter to assess th e adequacy of th e ver t ical h eigh t of th e ch in (Fig. 22.4). Th ese p aram eters are th e n orm s for referen ce; h ow ever, depen ding on th e pat ien t’s preferen ce, th e n al ch in posit ion m ay be adjusted to w ith in 6% of th is referen ce gure safely.

a

G

1/2 N

Sn

Frankfort line

1/3

St

1/2 1/2

Li 2/3

1/2 Pg

b

Me'

c 0-Meridian

Fig. 22.3 Proportional analysis by facial thirds to determine the vertical dimension of the chin. (a) Normal vertical dimension (left); vertical de ciency of lower third (middle); vertical excess of lower third (right). (b) Distance ratio Sn– St:St–Me′ is 1:2, and the distance ratio Sn–LL:LL–Me′ is 1:1. (c) Zero-meridian line: from N′ (soft tissue nasion) perpendicular to the Frankfort horizontal line (upper rim of the external auditory canal to lower rim of the orbit). Pog′ (soft tissue pogonion) should be located along this line. Otherwise the chin is retruded or protruded.

289

290

IV Facial Bone Surgery

S

N

NSL

N-ANS ANS NL

Go

ANS-Me

2. Su bp eriosteal in lt rat ion of local an esth esia w ith 1:100,000 epin eph rin e from th e rst prem olar to th e con t ralateral side w ill n ot on ly provide h em ost asis but also ease hydrodissect ion for periosteal elevat ion over th e ch in . In lt rat ion in to th e labial m u cosa is also h elpfu l in redu cing m u cosal bleeding. 3. Th e in t raoral approach is preferred, especially in Asian s, sin ce th e in cision al scar on the skin ten ds to be m ore prom in en t th an in Caucasian s. Th ere are t w o w ays of m aking th e in t raoral in cision , via eith er a labial m u cosal in cision or a m argin al gingival in cision (Fig. 22.6). a.

Me

ML

Fig. 22.4 Cephalometric analysis of chin position. The ratio N– ANS/ANS–Me is the best parameter for determining the ideal vertical chin length. The N–ANS/ANS–Me index is 80% ± 6 in Asians as opposed to 83% ± 6 in Caucasians. The N–ANS length averages 51 to 53 mm in every ethnic group. However, the ANS–Me length is signi cantly di erent, averaging 66 mm in Asians and 63 mm in Caucasians. ANS, anterior nasal spine; S, sella; N, nasion; NSL, nasion-sella line; NL, nasal line; Go, gonion; Me, menton; ML, mandibular line. (See Fig. 21.4 and Table 21.1 for the de nition of reference points.)

In pract ice, it is im p ort an t to rem em ber th at th e soft t issue does n ot m ove at th e sam e m agn it u de as its un derlying rep osit ion ed bon e. For exam ple, a 5-m m advan cem en t of th e ch in bon e usually result s in soft t issue advan cem en t of ~ 75% of th at . In vert ical length en ing an d sh or ten ing of th e ch in , h ow ever, soft t issue follow s bon e m ore closely, on th e order of ~ 90%.

■ Surgical Techniques Th ere are essen t ially ve kin ds of gen ioplast y, depen ding on th e direct ion of ch in m obilizat ion : (1) sagit tal augm en tat ion , (2) sagit tal reduct ion , (3) vert ical augm en t at ion , (4) ver t ical redu ct ion , an d (5) t ran sverse correct ion (Fig. 22.5). Alth ough osseou s gen ioplast y is a relat ively sim ple operat ion , it is bet ter to perform it using gen eral an esth esia as th e n oise an d vibrat ion of th e bony w ork can be u n settling an d dist ressing to th e pat ien t . Nasal in t ubat ion is th e m eth od of ch oice for secu ring th e air w ay. Th is also allow s th e ch in sh ape an d posit ion to be ch ecked in closed occlusion du ring su rger y. Recen tly, osseou s gen ioplast y u sing an u lt rason ic bon e cu t ter h as becom e feasible w ith local an esth esia un der IV sedat ion (Fig. 22.8). 1. Th e m idlin e of th e face (run n ing th rough th e dorsum of th e n ose an d ph ilt rum , bet w een th e t w o m edial in cisors to th e m idpoin t of th e ch in ) is draw n w ith a m arking p en preoperat ively. Th is ser ves as an in t raop erat ive gu ide.

Labial m ucosal incision: Th e m id lin e is h atch ed w ith a scalpel for referen ce. Th en a labial in cision is m ade 5 m m aw ay from th e labiogingival groove, leaving an edge for easier sut uring during closure. It exten ds from th e rst prem olar of on e side to th at of th e oth er. From th e su p er cial m u cosa, th e in cision is m ade to th e periosteu m w ith diath erm y. Take n ote to avoid excessive disru pt ion of th e m en talis m u scle bers to p reven t ch in ptosis.

b. Marginal gingival incision: An in cision is m ade along th e gingival m argin from th e secon d prem olar of on e side to th at of th e con t ralateral side w ith a n o. 12 or n o. 15 scalpel dow n to th e bony alveolar crest . Next th e periosteum is directly lifted an d th e m ucogingival ap is developed to expose th e bony surface of th e ch in . Th e advan t ages of th is in cision in clude sparing of th e m en talis m uscle an d th e absen ce of a m u cosal scar. 4. Th e dissect ion sh ou ld exten d to th e in ferior m argin of th e m an dible on th e labial m an dibular surface, an d sh ou ld be w ide en ough for th e osteotom y. Un n ecessarily w ide dissect ion aroun d th e sym physis area sh ou ld be avoided. Th e ap sh ou ld n ot exten d to th e lingual su rface; this is n ecessar y to preven t ch in ptosis, dim pling, an d un easin ess of low er lip m ovem en t after su rger y. Bleeding from n u t rien t vessels en cou n tered du ring d issect ion m ay be easily con t rolled w ith bon e w ax. Iden t ifying th e m en t al n er ve is n ot m an dator y, bu t it w ill be safer. If gen iop last y is to be com bin ed w ith m an dibu lar sh aving or angle redu ct ion su rger y, it is m ore conven ien t to skeleton ize th e m en tal n er ve to allow m ore sp ace for op erat ion . 5. Th e m idlin e of th e ch in is m arked w ith a sm all rou n d bu r, n orm ally from th e lin e bet w een th e low er cen t ral in cisors to th e m idlin e of th e ch in t ip. Th is m arking is u sed for app roxim at ion of th e m idlin e of th e ch in segm en t later. Th e h orizon tal cut t ing lin e is m arked as design ed (Fig. 22.7). With a m icrom otor d rill, t w o or th ree ver y sm all h oles are m ade along th e p lan n ed osteotom y lin e,

22

a a

Genioplast y

b

Fig. 22.6 Operative incisions for osseous genioplast y. (a) Labial mucosal incision. (b) Marginal gingival incision.

b

c

d

e Fig. 22.5 Five t ypes of genioplast y. (a) Sagit tal augmentation (anterior advancement). (b) Sagit tal reduction (posterior reduction). (c) Vertical augmentation with bone graft. (d) Vertical reduction. (e) Transverse correction in facial asymmetry.

Fig. 22.7 Bony marking for genioplast y. The midline of the chin is marked with a small round bur or saw. Marking the horizontal cut ting line is done with a pencil or marking pen as designed. A long groove is created at the t wo ends of the planned osteotomy to prevent slippage during sawing.

an d local an esth et ic w ith ep in ep h rin e is in lt rated in to th e m edulla via th ese por ts to redu ce bleeding during th e m en t al osteotom y. A 5-m m -long groove is created at th e t w o en ds of th e plan n ed osteotom y w ith a 1.8-m m bur, to create a leading groove for th e saw blade to preven t slippage during saw ing. Th e osteotom y lin e sh ould be at least 5 m m aw ay from th e m en tal foram in a in feriorly. A recip rocat ing saw w ith a rou n d-t ip blade is u sed to m ake th e h orizon tal osteotom y. Th e rst cut is from on e lateral edge to th e m idlin e, an d th is is repeated on th e con t ralateral side. During th e osteotom y, th e m en tal n er ves sh ould alw ays be protected w ith in st ru m en t s to p reven t in adver ten t inju ries to th e n er ves. Bear in m in d th at it is often easier to create a m ore n at u rallooking m an dibular lin e w h en th e osteotom y lin e start s m ore p osteriorly. Th e progress of th e cu t t ing can be felt as th e saw cut s th rough th e ou ter cortex an d m edulla to engage th e in n er lingual cor tex. On ce both cort ices h ave been engaged, it m ay be m ore expedit ious to cut bicort ically. Perisym physeal bleeding can be reduced if prior in t ram edu llar y in lt rat ion w as p erform ed as described earlier. Du e to it s at rau m at ic n at u re,

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IV Facial Bone Surgery th e ult rason ic bon e cu t ter reduces t raum a to th e t issue, bony h em orrh age, an d postoperat ive sw elling (Fig. 22.8). How ever, it exten ds th e operat ion t im e by 30 to 40%. Th is tech n ique is part icularly useful w h en em ployed n ear th e m en t al n er ve or facial arter y. 6. On ce th e osteotom y is com pleted an d h em ost asis secu red , th e distal osteotom ized m en t u m segm en t is m obilized . Th e an terior belly of th e digast ric m u scle is at tach ed to th e d igast ric fossa on th e lingual su rface of th is segm en t , an d it is n ot n ecessar y to det ach th is st ruct ure. How ever, in cases of vert ical redu ct ion , th e m u scle at tach m en t to th e reducing bon e sh ould be rem oved w ith an elect ric cauter y. 7. Th e m obilized segm en t is th en xed in th e n ew posit ion according to preoperat ive plan s w ith t w o pieces of t w o- or th ree-h ole m in iplate an d screw s. Pre-ben t p rot ru sion /ret ru sion m in ip lates are available (Fig. 22.9). Du ring xat ion , alw ays refer to th e m arked m idlin e to en sure th e cen t ral posit ion of th e ch in . In vert ical sh orten ing of th e ch in , a bony step is form ed at each en d of th e ch in segm en t w h ere th e origin al m an dibu lar lin e h as been disrupted. Ut m ost care sh ould be taken w h en t rim m ing th e step to restore a sm ooth m an dibular lin e, as th e m en tal n er ve is often in close proxim it y. 8. Th e m ucosa is th en closed w ith in terrupted 4–0 Vicr yl (Eth icon ) or silk. Th e m idlin e is rst iden t i ed an d op posed u sing th e p reviou sly h atch ed m u cosal poin t s, an d th e rest of th e in cision is closed from lateral to m edial. Th e im p or t an ce of prop er closu re can n ot be overem ph asized sin ce poorly m atch ed closu re can result in facial asym m et r y, discom for t , an d fu n ct ion al dist u rban ce p ostop erat ively, desp ite perfect bony align m en t an d xat ion . For th is reason , m argin al gingival in cision is m ore conven ien t , as it can be ret u rn ed to it s origin al posit ion w ith out m ucosal or m uscu lar m ism atch . Closing of th e m argin al gingival in cision can be don e w ith in terden t al papillar y m at t ress su t u res. Silast ic drain s 3 to 4 cm in length are in serted prior to put t ing in th e n al st itch es on both sides.

a

b Fig. 22.8 The ultrasonic bone cut ter is e ective for sensitive areas. (a) Equipment. (b) Bone cut ting with ultrasonic bone cut ter during genioplast y.

9. After n ish ing th e sut ures, com pressive dressing is ap plied w ith elast ic t aping to th e ch in , giving it a m ild lift . Gen iop last y is alw ays d on e as a day su rger y, an d h osp it alizat ion is n ot n ecessar y in m ost cases. Pat ien t s are p rescribed an t ibiot ics an d an algesics.

Fig. 22.9 The mobilized segment is xed in the new position according to preoperative plans with pre-bent four-hole miniplate and screws.

22

■ Key Technical Points 1. A preoperat ively draw n m idlin e of th e face from th e d orsu m of th e n ose to th e m idp oin t of th e ch in w ill ser ve as a ver y u sefu l in t raop erat ive gu ide. 2. In lt rat ion of su bperiosteal local an esth esia from th e rst prem olar to th e con t ralateral side provides hydrodissect ion as w ell as h em ostasis to ease lift ing of th e periosteum over th e ch in later. 3. An in t raoral in cision is preferred over th e extern al ap proach in Asian s sin ce th e in cision al scar on th e skin ten d s to be easily n ot iceable com p ared w ith Cau casian . 4. A labial in cision is m ade 5 m m aw ay from th e labiogingival groove, leaving an edge for sut u ring d u ring closure. Margin al gingival in cision h as th e advan t ages of sp aring th e m en talis m u scle an d th e absen ce of a m u cosal scar. 5. W h ile m aking an in cision , care sh ould be t aken to avoid detach m en t of m en t alis m uscle bers, w h ich can lead to ch in ptosis. 6. Th e exten t of subperiosteal ap dissect ion sh ou ld be lim ited to th e in ferior m argin of th e m an dible on th e labial m an dibular su rface sin ce u n n ecessarily w ide d issect ion aroun d th e sym physis area can result in in adver ten t ch in ptosis or dim pling an d u n easin ess of low er lip m ovem en t after surger y. 7. Iden t ifying th e m en tal n er ve is n ot alw ays n ecessar y, but it is m ore conven ien t to skeleton ize it w h en gen iop last y is to be com bin ed w ith m an d ibu lar sh aving or angle redu ct ion su rger y. 8. With a m icrom otor drill, t w o or th ree ver y sm all h oles are m ade along th e lin e of th e p lan n ed osteotom y to in lt rate epin eph rin e in to th e m edulla, w h ich can h elp reduce bleeding during th e m en t al osteotom y. 9. Osteotom y cut s are m ade from lateral to m idlin e. Grooves m ay be m ade on th e bon e w ith a sm all bur to preven t saw slippage w h en perform ing th e osteotom y. 10. It is bet ter to m ake a h orizon tal osteotom y lin e m ore p osteriorly to create a m ore n at u ral-looking m an dibu lar lin e.

Genioplast y

■ Complications and Their Management

General Complications Gen ioplast y is a relat ively safe operat ion w ith ver y low com plicat ion rates. Gen eral com plicat ion s in clude h em orrh age, in fect ion , sw elling, an d pain . Most of th e postoperat ive bleeding is from th e m arrow of th e osteotom ized bon e an d can be con t rolled in t raop erat ively w ith h em ostat ic product s such as h em ostat ic collagen (CollaTape, Zim m er Den t al, or Helist at , Moore Medical), gelat in agen t s (Gelfoam , P zer), bon e w ax, or cellu lose m aterials (Surgicel, Eth icon ). Mu cosal bleed ing can be con t rolled w ith an elect ric cauter y. In fect ion risks are m it igated w ith judicious in t ra- an d postoperat ive an t ibiot ic use, en suring sterile operat ive procedures an d environ m en t an d m et iculous hem ostasis. For t un ately, in fect ion rates in gen ioplast y are ver y low. Postoperat ive edem a is th ough t to be related to th e degree of surgical t rau m a sust ain ed in t raoperat ively. Th e at rau m at ic n at ure of th e ult rason ic bon e cut ter h as redu ced postoperat ive sw elling sign i can tly. Edem a usu ally p eaks on p ostop erat ive days 3 an d 4 before su bsiding. Gen ioplast y is a relat ively pain less su rger y. Postoperat ive pain can usually be easily con t rolled w ith acet am in oph en .

Mental Nerve Injury Inju r y to th e m en t al n er ve p resen t s w ith low er lip paresth esia, especially at th e corn ers of th e m outh . Th is is preven ted w ith carefu l p rotect ion of th e n er ve du ring su rger y. In cases w h ere a w ide operat ive eld is requ ired , th e n er ve sh ou ld be dissected an d m obilized to avoid excessive t ract ion on it . If th e n er ve is severed during surger y, re-an astom osis sh ou ld be at tem pted w ith a 9–0 or 10–0 su t u re. Th e n er ve fun ct ion can be assessed postoperat ively w ith a pin ch test at th e corn er of th e m outh . Tract ion injuries on th e n er ve often recover w ith in 1 to 3 w eeks. Sm all bran ch es m ay be cu t d u ring labial m u cosa in cision . Th e loss of lip sen sat ion is m ore p rom in en t at th e m edian area rath er th an th e corn ers of th e m outh . In such cases, sen sat ion usually ret u rn s w ith in a m on th .

Bony Malunion or Nonunion Th e risk of m al- or n on un ion is h igh er w ith w ire xat ion . Th e developm en t of th e m in iplate osteosyn th esis system en abled rigid xat ion of th e segm en ts. Malu n ion or n on un ion is ver y rare in gen ioplast y as long as th ere is con tact bet w een th e bon e segm en ts. Tw o m in iplates w ith four screw s are often su cien t to obt ain rigid xat ion in th e sym p hyseal region .

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Irregularity of Bone Surface Irregu larit y of th e in ferior border of th e m an dible is a com m on com plicat ion , par t icu larly in vert ical ch in h eigh t redu ct ion surgeries. After m aking parallel h orizon t al osteotom ies, th e m iddle segm en t is rem oved; th e cau dal segm en t is th en p laced to th e m ain m an dibu lar body. At th e lateral en ds of th e bon e edges, a t riangular bony prot u beran ce w ill be p rod u ced du e to th e m isalign ed m an dibu lar lin e (Fig. 22.10). If th is p rot u beran ce is n ot sh aved o du ring th e su rger y, pat ien t s w ill com plain of irregu larit y an d som et im es pain at th e m an dibular border. It m ay also be seen in aggressive n arrow ing of th e ch in t ip. In th is case u sing ar t i cial bon e w ith BMP can h elp sm ooth out th e steps.

Lip Drooping, Chin Ptosis, and Skin Dimpling Ch in ptosis is de n ed as th e drooping of ch in soft t issue over th e in ferior border of th e m an dible. Lip droop ing is de n ed as low er-posit ion ed lip w ith dim pled skin during lip closure. Ch in ptosis an d lip droop ing are due to prob lem s w ith th e m en talis an d depressor m u scles of th e low er lip. Th e m en talis m uscle origin ates from th e in cisive fossa of th e m an dible an d in sert s in to th e derm is of th e ch in skin . It h as t w o fu n ct ion s: (1) to su pp ort , elevate, an d prot ru de th e low er lip; an d (2) elevat ion an d w rin kling of th e skin of th e ch in . Failure to re-at tach th e m en t alis m uscle after division an d m uscular brosis after in fect ion or rem oval of a large im p lan t are kn ow n to be th e m ain cau ses of th is ph en om en on .9 Pat ien t s h aving a h istor y of ch in im plan t su rger y h ave a h igh er risk of exacerbat ion of ch in ptosis after revision osseou s gen iop last y for th is reason . Th u s, it is im port an t to obt ain preoperat ive ph otograph s for docum en t at ion . To preven t th e aesth et ic an d fu n ct ion al com plicat ion s m en t ion ed previously, preser vat ion of th e m en t alis

a

an d it s p rop er re-at t ach m en t d u ring su rger y are essen t ial. W h en it is u sed, revision surger y is aim ed at re-an ch oring th e m en t alis m uscle to th e in cisive fossa, an d to repose th e dragged periosteum an d ch in pad superiorly.

Asymmetry Asym m et r y m ost frequ en tly results from errors in plan n ing an d/or surgical execu t ion . Correct ive gen ioplast y for asym m et ric ch in s sh ou ld be p lan n ed m et icu lou sly. Failu re to m ark th e m idlin e p rior to perform ing th e osteotom y w ill lead to asym m et r y. Also, it m ust be kept in m in d th at th e m agn it u de of soft t issu e m ovem en t correspon ds to on ly 75 to 90% of th e m agn it u de of bony t ran slat ion s. For exam p le, if th e bon e segm en t is m oved 5 m m t ran sversely, th e corresp on ding soft t issu e posit ion w ill on ly m ove bet w een 3.75 an d 4.75 m m . Th erefore, in correct ion of th e asym m et ric ch in , over-correct ion of th e bon e is often requ ired to ach ieve soft t issu e sym m et r y. On ce it is establish ed th at th ere is postoperat ive asym m et r y as a resu lt of m alposit ion ing, revision is advised w ith in 2 w eeks.

Allograft-Related Complications: Chin Drooping, Distortion, Irregular Skin Ch in drooping an d distort ion occu r after im plan tat ion of an allograft su ch as silicon e or Gore-Tex. Th ere is invariably erosion of th e cort ical ch in bon e by in ser ted im p lan ts, an d in som e p at ien t s th is is cou p led w ith an osteop hyt ic react ion along th e p erim eter of th e im plan t , creat ing a crater-like bony defect (Fig. 22.11). Occasion ally th is erosion can exten d th rough th e an terior alveolar bon e to reach th e root s of th e fron t al teeth . A peau d’orange appearan ce of th e ch in is an oth er frequ en tly en cou n tered p roblem follow ing ch in im p lan ts,

b

Fig. 22.10 (a,b) Treatment of bony irregularit y after osseous genioplast y. Triangular bony irregularities at both lateral ends following vertical or sagit tal reduction genioplast y. This bony edge needs to be removed to prevent postoperative inconvenience. It is usually located near the mental foramen, and thus extra caution should be taken during the removal.

22

a

Genioplast y

b

Fig. 22.11 Osteolytic crater on chin bone by alloplastic chin implant. (a) Identi cation of previously inserted Gore-Tex chin implant. (b) Crater-like erosion of the chin bone near the root of anterior teeth is observed during removal of the chin implant.

esp ecially Gore-Tex. Th is m ay be du e to disru pted m u scle bers failing to re-align an d re-at t ach to th e cort ical bon e su rface du e to th e presen ce of th e in terp osit ion ed im plan t . An oth er possibilit y m ay be im plan t m igrat ion . Th ese allop last ic im plan t s h ave also been fou n d to adh ere to overlying m u scle bers an d derm is, result ing in skin th in n ing over t im e. Care sh ou ld be t aken in perform ing revision su rger y in su ch cases, as p erforat ion of th e skin can occu r d u ring im plan t rem oval.

■ Case Studies

f.

Low er an d u p p er lip p rot ru sion : u p per lip to E-lin e, 3.7 m m (m ean –1.02); low er lip to E-lin e, 7.2 m m (m ean 2.03)

Treatment Plan 1. Con ser vat ive tem porom an dibular join t (TMJ) t reat m en t w ith an occlusal stabilizing applian ce. Th e aim is to set up th e opt im al an d stable con dylar posit ion

Case 1

2. Orth odon t ic t reat m en t: teeth align m en t for an terior crow ding, leveling of den tal arch es, in t rusion of u pp er posterior m olars.

A 23-year-old wom an presents w ith a bim axillary protrusion and a severely retruded sm all chin (Fig. 22.12 and Fig. 22.13).

3. Operat ion : an terior segm en tal osteotom y (ASO) of m a xilla, sagit t al sp lit ram u s osteotom y (SSRO) of m an dible, gen iop last y.

Problem List 1. Aesth et ic: un favorable facial aesth et ics, h igh ly convex facial pro le, ret ruded ch in , beak-like lip sh ape, fu lln ess of m ou th w ith gu m m y sm ile 2. Fun ct ion al: in tern al TMJ derangem en t , m u scle st rain arou n d lip s, crow ding of low er an terior teeth 3. Ceph alom et ric an alysis: a.

Severe proclin at ion of low er an terior teeth (L1 in clin at ion ): 37.3 degrees (m ean 25 degrees ± 2)

b. Ext rem ely sm all in terin cisal angle: 99.8 degrees (m ean 124.0 degrees ± 8.3) c.

Position of Pog too posterior from N-perpendicular (Pog to N-perp): –12.5 m m (m ean, –5 m m ± 1)

d. High degree of facial convexit y: 16.5 degrees (m ean 3.6 degrees ± 4.6) e.

Sh or t m an dibu lar body length : 66.7 m m (m ean 78 m m ± 4.3)

Notes 1. Th e rst aim of th is operat ion w as TMJ st abilizat ion an d th en n orm alizat ion of th e occlu sion . 2. For aesth et ic im provem en t , advan cing gen ioplast y alon e cou ld n ot fu l ll th ese goals; th erefore, m a xillar y an terior segm en t al osteotom y (ASO) w as ap plied in com bin at ion . 3. After su rger y, upper an d low er an terior teeth in clin at ion , th e zero-m eridian an d Pog′ relat ion sh ip , an d th e E-lin e to u pp er an d low er lip dist an ces w ere n orm alized. Lip m u scle st rain an d gu m m y sm ile w ere also im proved. 4. Most im p or tan t , th e p at ien t’s con den ce an d sm ile w ere restored, an d sh e recovered from th e in feriorit y com plex an d depression sh e h ad experien ced before t reat m en t .

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b

c

d

Fig. 22.12 Case 1. Pre- and postoperative photos. Frontal and lateral views showing improvement of chin projection. (a,b) Before the surgery; (c,d) After the surgery.

22

Genioplast y

Fig. 22.13 Case 1. Cephalogram. (a) Measurements of angles and lengths were marked on the cephalogram and lateral photograph. (b) Measurement drawings overlapped on lateral photograph. (c) Postoperative cephalogram showing bone cuts and miniplates.

a

b

c

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Case 2

– LIE to facial plan e: 12.6 m m (m ean , 4.6 m m ± 1.7)

A 26-year-old w om an presen ted w ith t yp ical bim axillar y prot rusion an d a ret ruded ch in (Fig. 22.14).

– FMIA (angle FH lin e): 32.1 degrees (m ean , 59.8 degrees ± 6.4) e.

Problem List 1. Aesth et ic: un sat isfactor y facial con tour, convex facial p ro le, u pper lip prot ru sion w ith excessive up per an terior teeth labioversion , sm all ch in , n on ideal cer vical cu r vat ure 2. Fun ct ion al: m uscle st rain surroun ding lips, hyperton ic m en t alis m uscle, lip incom peten ce

Sh or ter m an dibu lar body length : 65.7 m m (m ean , 78.0 m m ± 4.3)

Treatment Plan 1. Orth odon t ic t reat m en t: teeth align m en t for an terior crow ding, leveling of den tal arch es. 2. Operat ion : (1) an terior segm en t al osteotom y (ASO) of m axilla an d m an dible; (2) gen ioplast y.

3. Ceph alom et ric an alysis: a.

Bim axillar y p rot ru sion (Angle’s class I occlu sion )

b. Ch in ret rusion : – Pog to N-p erp : –40.9 m m (m ean , –5 m m ± 1) – SNB: 69.4 degrees (m ean , 79.1 degrees ± 3) – Y-axis to SN (angle N–S–Gn ): 80.2 degrees (m ean 70.3 degrees ± 2.4) – Pog′ to A′B′: –6.91 m m (m ean 3.0 m m ± 2.0) c.

Proclin at ion of upper an d low er lips: – Nasolabial angle: 89.9 degrees (m ean , 100 degrees ± 2) – Up per lip to E-lin e: 3.7 m m (m ean , –1.0 m m ± 2.0) – Low er lip to E-lin e: 7.17 m m (m ean , 2.0 m m ± 3.0)

Notes 1. Th e m ain object ives of th e surger y w ere (1) to correct th e proclin at ion of th e upper an d low er an terior teeth , an d (2) to restore th e p osit ion of th e ch in an d soft t issue pogon ion . 2. Th e correct ion of u pper an d low er an terior teeth proclin at ion can be easily ach ieved. But for m ore aesth et ically pleasing resu lt s, th e osteotom ized m a xillar y segm en t is m obilized u pw ard an d th e m an dibu lar segm en t dow nw ard. Oth er w ise th e orth odon t ist m ay h ave di cult ies postoperat ively t r ying to ach ieve adequ ate im pact ion of th e an terior teeth .

– In ter-in cisal angle: 110.4 degrees (m ean , 124.0 degrees ± 8.3)

3. Gen erally, th e m an dibular body can be length en ed via body osteotom y in class II p at ien t s. In th is case, th e pat ien t h ad class I occlu sion ; h en ce, advan cem en t of th e ch in w ith sliding gen iop last y alon e w as su cien t .

– UIE to facial plan e: 16.61 m m (m ean , 6.0 m m ± 1.5)

4. All surgeries w ere perform ed in a single stage as a day surger y.

d. Prot ru sion an d proclin at ion of upper an d low er an terior teeth :

22 a

Genioplast y

b c

d

e f

Fig. 22.14 Case 2. Pre- and postoperative photos and cephalogram. (a,b) Preoperative facial photographs show slightly protruding lips with retruded chin. (d,e) Postoperative photographs show increased chin projection and improved lip position. (c,f) Pre- and postoperative lateral cephalograms.

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References 1. Aufrich t G. Com bin ed n asal plast ic an d ch in plast ic: correct ion of m icrogen ia by osteocart ilagin ou s t ran sp lan t from large h u m p n ose. Am J Su rg 1934;25:292 2. Hofer O. Operat ion del Progn ath ie un d Microgen ie: Die Op erat ive Beh an d lu ng d er alveolaren Ret rakt ion des Un terkiefers u n d ih re Anw en du ngsm oglich keit fu r Progn ath ie un d Mikrgen ie. Dt sch Zah n Mun d Kieferh eilk 1942;9:121–132 3. Obw egeser H. Surgical procedures to correct m an dibular p rogn ath ism an d resh ap ing of th e ch in . In : Trau n er R, Obw egeser H, eds. Th e su rgical correct ion of m an dibu lar p rogn ath ism an d ret rogn ath ia w ith con siderat ion of gen iop last y. Oral Su rg Oral Med Oral Path ol 1957;10:677–689 4. Ah n SN. Keph alom et risch e Vergleich st udie von skelet t alen u n d Weich teil Param etern zw eier eth nisch er Gruppen . Doctoral Dissert at ion . Kieferorth op aedie, ZMK Klin ik, Un iversit at Ham bu rg; 1995

5. Hw ang HS, Kim WS, McNam ara JA Jr. Ethn ic di eren ces in th e soft t issu e pro le of Korean an d Eu rop ean -Am erican adult s w ith n orm al occlusions an d w ell-balan ced faces. Angle Orth od 2002;72(1):72–80 6. Ioi H, Nakat a S, Nakasim a A, Coun t s AL. Com parison of ceph alom et ric n orm s bet w een Jap an ese an d Cau casian adult s in antero-posterior an d vert ical dim en sion . Eur J Or th od 2007;29(5):493–499 7. Ricket t s RM. Esth et ics, environ m en t , an d th e law of lip relat ion . Am J Orth od 1968;54(4):272–289 8. Gon zalez-Ulloa M. Quan t it at ive prin ciples in cosm et ic surger y of th e face (pro leplast y). Plast Reconst r Surg Tran splan t Bu ll 1962;29:186–198 9. Zide BM, McCarthy J. Th e m en talis m uscle: an essen t ial com p on en t of ch in an d low er lip posit ion . Plast Recon st r Surg 1989;83(3):413–420

V Facial Skin and Hair Rejuvenation

23

Management Strategies for the Aging Asian Face : Philosophy and Evolution

Samuel M. Lam

Pearls • Th e prin cipal m an ifestat ion of aging for m ost

•

•

East Asian s (an d all oth er peoples for th at m at ter) is volum e loss. Ju diciou s volu m izat ion u sing fat graft ing an d/or llers can p rovide w on derfu l rejuven at ion th at is n at ural an d im pactful. Hair restorat ion can be a vit al com p on en t to global facial rejuven at ion an d can p rovide an im p or tan t fram e to th e u p per face to m ake it ap p ear m ore you th fu l an d at t ract ive. Th e aging Asian eyelid is a com plicated su bject . Th e t reat m en t algorith m is based on w h ich t ype of eyelid a pat ien t possesses: a n at u ral eyelid crease, an eyelid w ith ou t a crease, or an eyelid w ith a previously surgically created crease.

• Typically, low er facial rejuven at ion for th e East

•

Asian is n ot n ecessar y un t il m uch later in life w h en com pared w ith the Caucasian . Neurom odulators can be used in th e plat ysm a to reverse early aging an d to delay th e n eed for a facelift . A ch in im p lan t can be an im port an t adjun ct to im prove th e sh ape of th e Asian face as w ell as to en h an ce a facelift result . Lipocon touring of th e n eck sh ou ld be don e sh arply w ith scissors in a con ser vat ive fash ion un der direct vision rath er th an w ith a su ct ion can n u la. Man agem en t of th e skin sh ou ld be an in tegral part of ever y con sult at ion an d st rategy for global rejuven at ion . How ever, it is advisable to alw ays be m ore con ser vat ive w h en it com es to ablat ive tech n iqu es ow ing to th e in creased risk an d t im e of convalescen ce for th e Asian pat ien t .

■ Introduction

■ Patient Assessment and

Th e aging East Asian face bears rem arkable sim ilarit ies to th e aging faces of oth er peoples, but also h as dist in ct at t ributes th at separate it from th e rest of th e w orld. Th is ch ap ter w ill explain both th e sim ilarit ies an d di eren ces of th e Asian face regarding th e aging process an d h ow to approach it in a cu lt u rally sen sit ive, e ect ive, an d safe m an n er. Th e focu s of th e ch apter w ill be h eavily biased th rough th e ltered len s of m y w orldview, w h ich I h ope w ill in crease th e pragm at ism of th e con ten t rath er th an be con sidered overly sim p list ic or p reju diced .1,2,3 Th e m ajor topics th at w ill be covered in clude h air restorat ion , facial volum izat ion , Asian bleph aroplast y,4 an d facelift ing. To cover each of th ese top ics su rgically w ou ld t ake a textbook to do th e subject m atter just ice. In stead, th is ch apter w ill focus on th e relevan t aging process of th e Asian face on a global scale an d tou ch on th e ph ilosophy of w h at ages th e Asian face an d h ow in gen eral term s to m an age th is problem . I believe th at th is ch apter w ill be helpful both for th e surgeon w h o is n ew to w orking w ith th e East Asian face an d for th e su rgeon w h o h as great exp erien ce in th is eld.

Th e Asian face h as been con sidered relat ively resistan t to th e aging process, at least com pared w ith th e fairer races, w h o are m ore subject to th e w eath ering e ect s of solar exp osu re. Th e u n iqu e n at u re of th e Asian’s skin st an ds as a barrier to th e det rim en tal e ect s of solar rays an d h elps keep th e face from th e accelerated aging th at is a com m on an d early feat u re of m any Cau casian faces.5 Never th eless, aging does occur both subtly an d profoun dly but perh aps n ot so aggressively as in th e Cau casian . Part of th is p rot racted youth fuln ess in th e Asian can be at t ributed to th e cult ural proclivit y to avoid th e sun for t w o prin cipal reason s. First , su n spots an d freckles th at m ay be con sidered ch arm ing in th e Occiden t are often deem ed un at t ract ive in Asia. Secon d, th e darker skin th at an Asian bears m ay relegate th e in dividual to a lesser societ al stat u s, w h eth er overtly or su bcon sciou sly. Th is bias tow ard fairer com plexion reign s in m any cult ures th rough ou t Eu rope, Africa, an d m any oth er sectors of th e w orld. I believe th at su n exp o-

Philosophy of Aging

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V Facial Skin and Hair Rejuvenation su re can act u ally be w orse for aging th an sm oking or oth er n icot in e u se, an d th at su n an d n icot in e togeth er can be n egat ively syn ergist ic. Fu rth er, Asian s w h o rem ain in Asia t yp ically h ave h ealth ier diets th an th ose Asian s w h o m igrate to th e West , w h ich can fur th er m ain tain th eir youth fu l m ien . All bet s are o w h en th e Asian decides to t ravel to th e West to set tle an d th en adopts Western h abits of sun bath ing an d con su m pt ion of processed an d h eavily adip ose-laden foods. Never th eless, th e gen et ic n at u re of th e Asian skin t yp e can p rovide relat ive protect ion again st aging d esp ite th e adopt ion of such adverse lifest yle ch anges.

■ Volume Loss and Volume Restoration

Even th ough Asian s age relat ively less th an th eir fairerskin n ed coun terparts, th ere are still un m istakable sign s of aging in the Asian face. It w ould be quite rare to look at a 70-year-old Asian and unw it t ingly assum e that she is on ly 30 years old. If her skin (like that of m any of m y octogen arian aun ts) is relat ively w h ite, u n blem ish ed, an d alm ost w rin kle free, w hy is it so obvious th at sh e is in deed m uch older? To m e, th e an sw er is readily apparen t . It is th e u n iversal sign of volum e loss that a ects all races in relat ive degrees but is the predom inan t feat ure of the aging Asian face.6 Volu m e loss is obser ved as a lin ear loss of fat from birth u n t il death . A 1-year-old h as con siderably m ore facial fat th an a 5-year-old. Sim ilarly, a 5-year-old’s face h as m ore fat th an a 10-year-old’s. In an adu lt if body w eigh t is h eld th e sam e, ever y 5 years represen t s in elu ctable, progressive volum e loss an d skeleton izat ion of th e face. Accordingly, th e sen escen t sh adow s th at develop across th e face an d th e loss of glorious, youth fu l h igh ligh t s sh ould be th e prin cipal target s in revolum izing th e face. Furth er, th ere is an im m ediate “blin k” e ect: We pret t y m uch kn ow w h o is you ng an d w h o is old in a n an osecon d, based on facial sh ap e. A you ng face is ver y rou n d, w h ich w e h ave a special term for: baby fat . Baby fat is n oth ing special. It just represen ts th e exu beran t fat of you th th at grad u ally d issip ates. As you th regresses, th e sh ape of th e face becom es a m ore angelic oval by 30 years of age, w h ich is ch erish ed by m any w om en w h o fear looking fat as th e ideal age of beaut y. By 40 years of age, as th e fat con t in ues to skeleton ize an d th e m alar bon es begin to be part ially exposed, th e face becom es squared o in appearan ce. Fur th er volum e loss an d possibly som e w eigh t gain con t ribu te to an inversion of th e facial feat u res, w h ere th e low er face in creasingly becom es th e dom in an t at t ribu te. Accordingly, a prim ar y focu s for th e aging Asian face is to restore balan ce an d sh ape to th e face to m ake it look m ore you th ful. I believe th at lling th e tem ple, periorbital region , m alar area, an d perioral area can be as h elpful for th e Asian face as it is for oth er eth n ic an d n on eth n ic faces, w ith a few caveat s. First , Asian faces in gen eral ten d to be fu ller to begin w ith th an m any w h ite faces. Th erefore, it is im port an t

w h en lling an Asian face n ot to do so as robustly in m any cases as for th e ver y gaun t faces th at are often seen in oth er races. In fact , lling areas aroun d th e periorbital an d ch in region s can m ake a face act u ally appear slim m er if don e in a ju diciou s fash ion (Fig. 23.1). A fu r th er w ord of cau t ion is th at in m any Korean faces, lling th e m alar region can be deem ed m asculin izing sin ce it can squ are o a w ide face; in fact , m any Korean s pay to h ave th eir m alar bon es surgically redu ced an d collap sed inw ard. Th is cu lt u ral sen sit ivit y sh ould be verbally addressed an d h eeded to avoid a m iscalcu lated ou tcom e. Th ere are t w o prin cipal m ech an ism s for volu m izing a face, fat graft ing (a su rgical m odalit y) an d inject able llers (an in -o ce procedu re). Fat graft ing is ver y e ect ive as a d u rable, long-last ing resu lt bu t su ers from a few draw backs. First , absorpt ion is relat ively u npredictable. Th ere can be variable loss of th e t ran splan ted fat , th ough in gen eral th ere sh ould be a large percen t age th at rem ain s. Accord ingly, I do n ot like to u se fat graft ing to t r y to x on e area of th e face sin ce th e absorpt ion rate m ay com p rom ise th e in ten ded ou tcom e. Conversely, if th e en t ire face is t reated, su cien t fat graft ing can sur vive so th at th e en t ire face ap p ears bet ter. Su ch an in st an ce, w h en en ough of th e t ran splan ted fat is left to con t ribute to an im proved look of th e face, m ay be called an im provem en t in on e’s “blin k”; th at is on e looks bet ter in th e blin k of an eye to an on looker even th ough th e m in ut iae of th e face m ay n ot be en t irely corrected in ever y w ay. I use llers to touch up alm ost any fat graft to ach ieve im p roved ou tcom es.

a

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Fig. 23.1 A Chinese patient who underwent single facial fat grafting procedure along with a conservative skin-only upper blepharoplast y. (a) Before the procedure. (b) One year after the surgery. The patient’s face appears narrower by selective targeting of the periorbital and perioral regions for volumization and by avoiding the buccal area. The upper blepharoplast y was helpful since the eyelid skin had de ated near the ciliary margin. However, the principal method of rejuvenation of the eyelid was facial fat grafting.

23 Managem ent   Strategies  for  the  Aging  Asian  Face:  Philosophy  and  Evolution If llers can be so accu rate in rejuven at ing th e face, w hy is th is m eth od n ot preferred over fat graft ing? Th e sim ple reason is cost . Fat is free; it can be h ar vested w ith ou t paying for each syringe except for th e labor th at is involved . Fillers, especially d u rable llers like p oly m ethyl m eth acr ylate, can be costly w h en m ult iple syringes are used to con tour ever y detail of th e face. Today, w ith th e adven t of disposable m icrocan n u las, I h ave h ad an exp on en t ial in crease in th e use of llers because m any pat ien t s do n ot prefer th e up -fron t cost , th e n at ure an d t im e of th e recover y process, an d th e variable absorpt ion of fat graft ing. W h en ap proach ing a face w ith eith er llers or fat graft ing, I prefer to t arget a lit tle bit of ller or fat at alm ost ever y sm all area of th e face, in clu ding th e tem ple, brow /u pp er eyelid, low er eyelid, n asojugal groove, an terior ch eek, lateral ch eek, su bzygom at ic recess, bu ccal area (as deem ed ap p ropriate), can in e fossa an d n asolabial groove, p rejow l su lcu s, an terior ch in , an d lateral m an dible (as deem ed ap prop riate). By lling all of th ese areas, th e face appears balan ced an d rejuven ated. Th e degree an d dist ribut ion of th e ller are based on artist r y, ju dgm en t , an d exp erien ce an d lie beyon d th e scope of th is ph ilosoph ically based ch apter.

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Fig. 23.2 A Chinese patient who underwent hair restoration. (a) Before the procedure. (b) After the procedure. Hair restoration provides a stronger frame to his face.

■ Hair Loss and Hair Restoration Hair restorat ion occu p ies a large p ar t of m y clin ical p ract ice, an d I h ave exten sive experien ce w orking w ith th e Asian pat ien t . I w ill speak h ere again in term s th at are speci c to th e Asian , an d also presen t som e un iversal con cept s th at can be h elpful for anyon e w h o is con tem plat ing en tering th e eld of h air t ran splan t surger y. Fu rth er, to elaborate on ever y tech n ical aspect of h ow to perform h air restorat ion w ould be n early im possible in a span of a few pages, an d any cu rsor y t reat m en t of th e p rocedu re w ou ld n ot do it ju st ice. Never th eless, th e ar t ist ic an d ph ilosoph ical poin ts are w ell w orth exp loring even in th e form at of th is ch apter. First of all, w h at is th e en d object ive of p erform ing h air t ran splan t surger y? I w ould like to st ate th at goal at th e out set , w h ich is to provide a st rong aesth et ic fram e to th e u pp er face. Sim ilarly, fat graft ing aroun d th e eyes can h elp w ith providing an eye fram e, lling th e tem ple an d outer ch eek can provide an outer facial fram e, an d facelift ing/ ch in im plan t s/volu m izat ion can provide a low er face fram e. W h en th e h airlin e h as been re-est ablish ed for eith er a m an or a w om an , th e face looks m ore at t ract ive an d youth ful in st an tly. Th e fram e of th e u pper face is com p rised of t w o com pon en t s: th e cen t ral h airlin e an d th e tem ple h airlin e. Not ever y p erson n eeds both h orizon t al (cen t ral) an d vert ical (tem ple) h airlin es im proved, but it is w orth w h ile for th e reader to u n derst an d th e im por t an ce of con sidering th ese opt ion s (Fig. 23.2). Oth er exam p les of facial fram ing w ith h air restorat ion in clu de an eyebrow h air t ran splan t (Fig. 23.3) th at w ill fram e th e eye, an d a crow n h air t ran splan t (Fig. 23.4) th at

w ill fram e th e back of th e h ead. All of th ese elem en t s can provide im provem en t for th e Asian pat ien t . Even w om en lose th eir facial fram e an d can ben e t from h air restorat ion as part of a global st rategy of rejuven at ion (Fig. 23.5). Today, h air t ran splan t su rger y can produce results as in credibly n at ural as any oth er t ype of facial procedure. Many su rgeon s st ill recall th e u n n at u ral ap p earan ce of plug

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Fig. 23.3 An Indian patient who underwent eyebrow hair transplant. (a) Before the procedure. (b) After the procedure. An eyebrow hair transplant brightens the eyes and provides an improved frame to the eyes.

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Fig. 23.4 A Vietnamese patient who underwent crown hair transplant. (a) Before the procedure. (b) After the procedure. Fig. 23.5 A Filipina patient who underwent hair transplant. (a) Before the procedure. (b) After the procedure. A hair transplant improves the frontal fram e to her face.

graft s th at t ran sform ed a pat ien t in to a doll’s h ead. How ever, n o longer is th at th e case. Using n at u rally occu rring clusters of h air kn ow n as follicular un its, t ran splan ts can be perform ed an d bring in credible n at u raln ess. W h at gives m e absolu te pleasu re in w orking w ith h air t ran splan t at ion is th e art ist r y th at can be exercised during any procedure, from design ing a h airlin e or eyebrow to allocat ing grafts w ith th e den sit y gradien t th at is opt im al for a part icular p at ien t . Th e tediu m th at m any surgeon s associate w ith th e surgical procedure lies in th eir ign oran ce of h ow m uch enjoym en t can be h ad w h en perform ing it . Th e Asian pat ien t h as a few ver y salien t di eren ces from oth er races th at sh ou ld be con sidered before p erform ing a procedu re on h im or h er. First , th e h airs t ypically are ver y dark, ver y coarse, an d ver y st raigh t an d are set again st a p aler to m oderately dark skin . Th is is perh ap s th e w orst com bin at ion of ch aracterist ics to h ave w h en on e w an t s to ach ieve n at uraln ess. Th e darker, coarser, an d st raigh ter h air, esp ecially w h en set again st a scalp th at is fairer in com plexion , can m ake a graft look un n at ural if n ot perfectly execu ted . It is, h ow ever, ext rem ely easy for th e tech n ician team to dissect an d t ran sp lan t th ese graft s becau se th ey are so dark, coarse, an d st raigh t . Th e surgical team m u st t ake steps to en su re th at th e resu lt ap pears absolu tely n at u ral in ever y w ay. To en su re th is ou tcom e, I alm ost alw ays p erform an in creased n u m ber of single-h air grafts along th e fron tal h airlin e so th at th e h airlin e looks n at u ral. For exam p le, I m ay use on ly 150 to 200 single-h air graft s in a ligh t-skin n ed, ligh t-colored, n e- an d cu rly-h aired in dividual. In con t rast , I m ay use t w ice th at n um ber of singleh air grafts for an Asian p at ien t before I even con tem plate start ing w ith t w o-h air grafts becau se I w an t th e h airlin e to ap pear ver y soft in n at u re. Th e recip ien t sites th at are m ad e to accom m odate th ese graft s form w h at is kn ow n as th e “m icro” h airlin e. Th e “m acro” h airlin e refers to th e act u al in it ial lin e draw n on th e scalp in to w h ich th ese recipien t sites w ill be p laced . Th e m acro h airlin e draw n on th e t yp ical Asian also can look quite di eren t from th at in th e Caucasian pat ien t . Th e m acro h airlin e is t ypically rou n der in sh ap e w ith less su p pression or con cavit y along th e lateral exten t of th e h airlin e, w h ich m atch es th e rou n der sh ap e of

m any Asian faces. A ver y n arrow h airlin e often w ill n ot look quite righ t on an Asian pat ien t because th e h airlin e sh ape w ill n ot m atch th e face or w ill n ot m atch a h airlin e th at exist s in th is race. St u dying n at u ral, n on balding h airlin es in Asian s can be a good guide to t rain ing on e’s aesth et ic eye w ith real-w orld exam ples before begin n ing to operate on th ese in dividuals. Th ere are t w o t ypes of don or h ar vest ing th at are cu rren tly o ered. Th e t radit ion al m eth od of graft h ar vest ing is kn ow n as follicular un it t ran splan t , or FUT, w h ich involves a lin ear st rip from th e back of th e h ead. Th e n ew er m eth od, w h ich involves sm all pun ch es an d avoids th e lin ear in cision , is kn ow n as follicu lar u n it ext ract ion , or FUE. FUT st ill plays a ver y sign i can t role for m any of m y pat ien t s for several reason s. First , graft s th at are taken th rough a lin ear h ar vest an d th en dissected are u n qu est ion ably h ealth ier an d th ereby h ave an in creased su r vival rate after t ran sp lan tat ion . Even th e ver y best FUE grafts are m ore fragile an d, even w ith th e m ost assid uou s h an dling an d t ran splan t at ion of th em , are st ill less viable relat ive to FUT. Secon d, FUE m ay n ot be th e best w ay to opt im ize th e u se of th e don or h air region , in th at grafts m ust be t aken ver y broadly across th e en t ire expan se of th e back of th e h ead, an d th at m ay cause several problem s. First , th ere can be don or deplet ion if you t ake m ore th an 20% of th e graft s, leading to a m oth -eaten ap p earan ce or dim in ish ed d en sit y in th e don or area. Secon d, FUE is n ot a scarless procedu re an d can lead to pu n ctate w h ite d ot s correlat ing w ith w h ere th e p u n ch es h ave taken th e graft s. Th ird, because h ar vest ing m ust occu r in a w ide expan se, th e h ar vest can approach or exceed th e de n ed safe don or area; th at is, fut u re h air loss can progress in to th e areas w here h ar vest ing occu rred, leading to loss of t ran splan ted grafts in a h aph azard fash ion . FUE scars are m ore visible as w ell in p at ien t s w ith greater p igm en t at ion sin ce th e scars are t yp ically hypopigm en ted in n at ure. FUT, h ow ever, is n ot w ith out risk eith er, p ar t icularly in th e Asian . Becau se Asian s ten d to create m ore exuberan t

23 Managem ent   Strategies  for  the  Aging  Asian  Face:  Philosophy  and  Evolution scar form at ion th an Cau casian s, at t im es a th icker scar m ay d evelop in th e don or area. Fu rth er, because th e don or h air is ver y dark black an d ver y st raigh t , th e w h ite lin e of a scar can be m ore visible th an in m any oth er races. Th ese con siderat ion s are m ean t to ser ve on ly as gu idelin es for a p hysician w h o is in terested in perform ing a h air t ran splan t in an Asian pat ien t , an d are n ot in ten ded to frigh ten or m islead eith er a prosp ect ive su rgeon or p at ien t . Recen tly, th ere h as been a rise in th e use of regen erat ive m edicin e tech n iqu es th at I like to refer to as “fert ilizers” sin ce th ese adju n ct ive m easu res h elp t ran sp lan ted h airs grow m uch bet ter, faster, an d m ore con sisten tly. Th e don or scar can be h elp ed w ith th ese p rodu ct s as w ell. Th e th ree m ajor p rodu ct s th at w e u se are Mat riStem (ACell), p lateletrich p lasm a (PRP), an d aden osin e t rip h osp h ate (ATP). It lies beyon d th e scope of th is ch apter to discuss h ow an d w hy each of th ese p rodu ct s is u sed . Su ce it to say th at I believe th ese produ cts are in dispen sable for ever y h air t ran splan t p rocedu re th at I p erform an d can be ver y h elpfu l to ach ieve bet ter outcom es w h eth er th e pat ien t is Asian or n ot .

■ Aging Asian Eyelids and

Brow s, and Eyelid Rejuvenation

I h ave w rit ten abou t th is topic before in oth er textbooks, an d I believe I h ave com e to a good u n derstan ding of h ow to h elp a su rgeon t r ying to m an age th e com plex top ic of th e aging Asian eyelid. I h ave divided th e aging Asian eyelid in to th ree categories: Asian s born w ith a n at u ral supratarsal eyelid crease, Asian s w h o do n ot h ave a crease, an d Asian s w h o h ave h ad a previou sly surgically created crease. By ap proach ing an Asian p at ien t in th is fash ion , th e su rgeon sh ou ld be able to n avigate th is issu e safely to develop th e best outcom es for a part icular in dividu al. Let u s begin w ith Asian s w h o are born w ith a n at u ral eyelid crease. Th ese in dividu als are perh ap s th e easiest categor y to m an age. Becau se of th e crease, th eir eyelid beh aves alm ost iden t ically to a Caucasian on e, an d accordingly th e sam e opt ion s are available. If th e eyelid skin h angs over th e ciliar y m argin , I recom m en d a con ser vat ive u p p er bleph aroplast y, rem oving skin on ly. I alm ost alw ays recom m en d ad ding som e kin d of volu m e to th e u p per eyelid an d brow sim ult an eously or in a st aged procedure. As I h ave th orough ly discu ssed, de at ion of th e brow an d upper eyelid is th e p rin cipal m ech an ism by w h ich aging occurs in all races. Th erefore, I believe th at eyelid skin rem oval is on ly a su pp ort to re-in at ion of th e eyelid an d brow. Fu r th er, I believe th at brow lift ing is u n n ecessar y an d det rim en tal. On e caveat is w orth issuing h ere: I rem ove skin on ly w h en it appears to be h anging at or over th e ciliar y m argin . If th ere is st ill a ver y visible dist an ce of 1 to 3 m m of exp osed su p ratarsal crease w h en th e p at ien t h as h is or h er eyes op en on for w ard gaze, th en I do n ot recom m en d any addit ion al skin rem oval becau se su ch rem oval w ou ld cau se

th e crease to be too h igh an d th ereby ren der th e appearan ce u n n at u ral in m y op in ion . Sim ilarly, brow lift ing can m ake a su prat arsal crease too h igh in an Asian , esp ecially if p erform ed in conju n ct ion w ith eyelid skin rem oval. Con versely, fat graft ing an d llers m ain tain or low er th e eyelid crease. Accordingly, if skin is rem oved or a brow lift perform ed, I alm ost alw ays use som e level of lling to bring th e eyelid crease h eigh t back dow n as n eeded (Fig. 23.6). On e oth er p oin t th at sh ou ld be st ressed is th at an eyelid crease, un fort un ately, is not an all-or-n on e proposit ion . Th ere are par t ial creases, an d a pat ien t can h ave a fu ll crease on on e side an d a part ial crease on th e oth er side. Typically, th e side w ith th e par t ial crease h as a n arrow er palpebral apert ure th at resem bles t rue ptosis. W h en I speak of an Asian born w ith an eyelid crease, I am speaking on ly of Asian s w h o h ave 100%com plete full creases bilaterally. Part ial creases of any degree really beh ave abou t th e sam e as n o creases at all an d sh ou ld be p laced in to th at categor y, w h ich I w ill discu ss n ext . Th e tem ptat ion w ith th e Asian w h o is born w ith out a crease is sim ply to perform a st an dard bleph aroplast y in w h ich eyelid skin is rem oved an d n o xat ion is perform ed to create a crease. Sin ce th ere is n o crease, w h ere does th e su rgeon m ake th e in cision ? Th ere is n o good an sw er. I h ave not iced th at w h en on e sim ply rem oves th e skin in th ese pat ien t s, th ere is n o discern ible result , th at is, n o im provem en t . In stead, a visible scar m ay becom e ap p aren t sin ce th e skin can n ot fold over a crease th at doesn’t exist . If th e su rgeon con cu rren tly t ries to rem ove fat from th e p ost sep -

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Fig. 23.6 A Chinese patient who has ptosis on her right side and what appears to be too high a supratarsal crease even though she has never had a previous eyelid surgery. The height of her crease is high most likely from volume loss as well as acquired ptosis. She had full facial fat grafting that improved her eyelid position and contour, thereby rejuvenating her upper eyelid. She also underwent a transconjunctival blepharoplast y. (a) Before the surgery. (b) After the surgery.

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V Facial Skin and Hair Rejuvenation t al t issue w ith out crease xat ion sut u res, th en th e eyelid apert u re u n fort u n ately st ill looks n arrow, w ith ou t su bst an t ive ch ange. Even w orse, th ere can be variable xat ion in w h ich creases are on ly par t ially xed but n ot u n iform ly or even ly so. In m y opin ion it is in advisable in an Asian p at ien t w h o does n ot h ave a crease (or w h o h as a part ial crease) to sim ply rem ove skin . It w ill n ot w ork an d w ill lead to poor outcom es. So, th en , w h at can be don e for an Asian w ith ou t a crease? In m y opin ion , th ere are t w o opt ion s: create a crease an d/or use llers or fat graft ing in th e upper-eyelid/ brow region (Fig. 23.7 an d Fig. 23.8). To create a su prat arsal crease is an ap p aren tly st raigh tfor w ard p rocess bu t carries w ith it som e im por t an t lim itat ion s th at sh ould be conveyed to th e pat ien t before surger y is con tem plated. First , a crease does ch ange th e look of an in divid ual, m aking th e eyelid sh ape roun der an d m ore op en . Th is is usually n ot a big issu e for a teen ager or you ng adu lt w h o com es to th e physician for th e express purpose of creat ing a crease. How ever, it can be m ore of an issu e for som eon e w h o h as lived , say, 50 or 60 years an d n ow w ou ld like to h ave a rejuven at ive p rocedu re. Th is p oin t sh ou ld be com m u n icated to a prospect ive pat ien t expressly an d clearly. Furth er, th e m eth od th at I p refer to u se to create a crease is th e fu ll-in cision m eth od th at I learn ed from m y late m en tor, Dr. Joh n A. McCu rdy. Th e tech n ique o ers th e m ost durable results but su ers from a prot racted recover y t im e. Th e crease can look ver y abn orm al at a w eek an d can appear sligh tly u n n at u ral even for a few m on th s follow ing th e procedure. Th is is m uch m ore di cu lt for m en because th ey can n ot w ear cam ou aging eye m akeu p an d can th erefore look m ore u n n at u ral w ith a h igh er crease th an w om en do. Th is h igh er crease w ill even t u ally becom e sm aller an d sm aller u n t il it becom es com p letely n at ural in app earan ce several m on th s to a year dow n th e road. I also recom m en d th e u se of th icker-fram ed rect angular glasses th at can rest approxim ately at th e su prat arsal crease or sligh tly above to dist ract an on looker’s eyes from th e tem p orarily elevated crease h eigh t . If th e in dividu al does n ot w ear glasses n orm ally, I recom m en d th at h e or sh e start w earing su ch glasses before th e surger y to h abit uate on lookers to th e presen ce of eyeglasses on th e face. For th e in dividu al w ith ou t a n at ural crease, th e oth er suggested altern at ive is lling th e u p p er-eyelid/brow com p lex w ith llers or fat graft ing. Alth ough th is tech n ique m ay ap pear n ot to m ake m u ch sen se sin ce th e brow often already looks too fu ll, recall th at in fact th e eyelid is de ated an d on ly app ears to be dep en den t an d h anging. If th ere is any qu est ion as to th e pat ien t’s persp ect ive on w h eth er th is w ould be a suitable opt ion , I recom m en d a test using a tem p orar y, reversible p roced u re like adm in ist rat ion of hyaluron ic acid to determ in e if th e aesth et ic is in align m en t w ith th e p at ien t’s goals. If so, th en a m ore p erm an en t opt ion can be un der taken . Also, recall th at if th e person h as

a

b

Fig. 23.7 This 53-year-old Korean man wanted eyelid rejuvenation and he is shown in the “before” photograph without a true supratarsal crease. He underwent a formal Asian blepharoplast y to create a supratarsal crease and seems more rejuvenated in his appearance. (a) Before the procedure. (b) After the procedure.

a p art ial crease, th at crease sh ou ld be con sid ered n on existen t an d t reated accordingly. A great opt ion is to perform both a supratarsal crease an d volu m izat ion of th e brow. How ever, I t yp ically do n ot like perform ing both p rocedures at th e sam e t im e, as I am alw ays con cern ed th at th e fat w ill disru pt th e secu rit y of th e crease xat ion . Also, I gen erally do n ot like to do th e fat graft rst an d later th e crease xat ion becau se th is m ay in terfere w ith th e crease xat ion at a later date. Accordingly, if I w ere to perform both procedu res, in an ideal w orld I w ou ld p erform th e su prat arsal crease xat ion rst follow ed 4 to 6 m on th s later w ith fat graft ing or llers.

a

b Fig. 23.8 A Vietnamese wom an who had fat grafting to her eyelids and face. She has a partial eyelid crease and accordingly has t wo options only: create a supratarsal crease and/or volumize the brow. I performed only a single session of fat grafting to her eyelids. (a) Before the procedure. (b) One year after the procedure. The de ated brow appears lifted only because it has been lled out.

23 Managem ent   Strategies  for  the  Aging  Asian  Face:  Philosophy  and  Evolution The nal categor y is the Asian patient w ho has had a previously surgically created crease. You could potentially treat this patient just like an individual born w ith a natural crease. However, the reason this is a separate category has a lot to do w ith how high the previous crease w as m ade and how long ago. Back in the 1980s, a procedure know n as Western ization w as in vogue, in w hich a lot of skin and fat w as rem oved and a high crease created. Over tim e, as the patient ages, the skin around the crease continues to de ate, m aking the crease look m uch sm aller than it w as originally. How ever, this low er crease cannot be treated as a norm ally low crease. The reason for this is that if skin is further rem oved from this patient, the previously abn orm ally high crease w ill ret urn and the patient m ay experience lagophthalm os. The way th at the physician can determ ine if th e crease w as m ade too high is sim ply to lift up th e eyelid skin and look at w h ere the crease w as fashioned. Just by doing this sim ple m aneuver during the consultation, the surgeon can easily determ ine if th e crease w as m ade very h igh and the eyelid tissue excavated (i.e., already excessively rem oved). Another option is just to look at the patient. With previous surgery the eyelid w ill look som ew hat unnatural but it m ay not be apparent w hy to the surgeon since the crease height can be relatively low. The reason for this is that the crease prim arily consists of thick brow skin that has been folded over, m aking the eyelid look deep set and bizarre. I believe that the only w ay to im prove this situation is w ith volum ization using either fat grafting or llers. I w ould contend that any oth er m eth od would com prom ise the desired outcom e by return ing the patient to the m ore unnat ural state of m any years ago.

■ Low er Facial Aging and Rejuvenation

Fort u n ately, for m any Asian s th e low er face does n ot age as m u ch as in Cau casian s. Th eir th icker an d solar-resist an t skin h elps th em to keep th eir n eck posit ion bet ter for a m u ch longer p eriod th an for Cau casian s. How ever, aging st ill w ill sh ow u p in th e Asian , even th ough it m ay do so a decade or t w o later th an in oth er races. A preven t at ive m an euver th at I u se in all races to delay th e n eed for a facelift is rout in e applicat ion of n eu rotoxin to th e p lat ysm al bands (using ~ 10 to 15 un it s of bot ulin um toxin ). Pat rick Trevidic, from Paris, Fran ce, h as presen ted convin cing eviden ce th at in dividuals w h o h ad st rokes m any years prior su er n o n eck aging on th e a ected/st roked side. I h ave seen clin ical evid en ce of ongoing im p rovem en t in th e n eck w ith con t in uous n eurotoxin used to ret urn th e n eck to a m ore you th fu l st ate. Obviou sly, if th e n eck h as already con siderably advan ced in aging, it w ill be di cult to elevate th e n eck t issu e w ith ou t a form al rhyt idectom y. Even in th ese cases, I like o ering n eurom odu lator t reat m en t s

as a preven t ive m easu re again st recu rren ce an d as a rst at tem pt to see h ow m uch im provem en t can be h ad sh or t of surger y. Th ere really is n o di eren ce in m y facelift tech niqu es for an Asian n eck an d a Caucasian n eck. I t ypically use sh or t in cision s th at on ly circum scribe th e ears an d do not exten d in to th e h air-bearing area, along w ith an in cision in th e su bm en t al region , w h ich I believe can be u n iversally accept able n o m at ter th e race. Becau se th e Asian skin is th icker an d m ore elast ic th an th at of m any fairer-skin n ed races, often I do n ot rem ove a lot of skin during th e su rger y, but th at is n ot th e poin t of a facelift anyw ay. An oth er procedu re th at can be ver y h elpful for m any Asian s, w h eth er a facelift is perform ed or n ot , is an alloplast ic ch in im plan t . (I use th e exten ded an atom ic Con form im plan t m an ufact u red by Im plan tech .) Many Asian s have a ret ruded ch in along th e in ferior border as w ell as prem axillar y de cien cy. Adding a ch in im plan t can provide im proved skelet al project ion an d ren der th e face less fu ll an d rou n d in asp ect . In add it ion , I believe a ch in im plan t in an Asian can be h elpful in im proving a facelift resu lt for th ree reason s. First , th e n eck length is in creased, m aking th e n eck appear im proved w ith out th e n eed to perform a lift ing procedure in m any cases of early t issue descen t . Secon d, th e ch in im plan t can provide a fulcrum aroun d w h ich th e lift ing of th e t issues is im proved, as w ou ld be th e case in any in dividual w ith w eaker skeletal support . Fin ally, th e ch in im plan t can disrupt th e m an dibular ligam en t , a retain ing st ruct u re th at lim it s th e abilit y to lift th e t issues e ect ively. William Bin der, w h o lect ures on th e subject , believes th at th e perm an en t in terposit ion of th e ch in im plan t w ill bet ter m ain tain th e posit ion of th e jaw lin e sin ce th e m an dibular ligam en t n ever re-adh eres. As far as neck adiposit y is con cerned, for the younger or older pat ient I prefer to open the neck t issues sharply w ith scissors an d th en select ively rem ove ju st th e righ t am ou n t of adipose tissue, taking care to leave en ough fat on top of th e plat ysm a that plat ysm al dehiscen ce does not show up afterw ard if a facelift is n ot being sim u ltan eously perform ed. I believe that judicious an d selective rem oval of pre-plat ysm al adipose tissue w ith ou t a con curren t rhyt idectom y can be undertaken in som e Asian s even into their 50s, unlike in fair-skin n ed in dividuals, in w h om I gen erally am con cern ed about doing so after ~ 40 to 45 years of age for fear th at th e plat ysm al bands w ill becom e m ore eviden t if no con curren t tighten ing procedure is undertaken. I alm ost never perform liposuction using a cannula anym ore because I believe that it overskeletonizes a neck that can already be skeletonized in appearance from aging. Accordingly, m y liposuct ion m ach in e gen erally sits in th e corn er of m y operat ing room collect ing dust. A com bin at ion of judicious lipocon touring, ch in augm en tation , an d rhyt idectom y often can provide far bet ter results th an any one procedure alone, but obviously m ust be un dertaken in th e righ t can didate w h o w ould ben e t from all th ree of th ese treat m en t st rategies.

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■ Skin Aging and

Rejuvenation Methods

I am con den t th at Asian skin th erapy is far bet ter t reated elsew h ere in th e book th an I h ave don e h ere. I h ave a great reluct an ce to perform ablat ive resurfacing, w h eth er fract ion al or oth er w ise, in an Asian due to th e pigm en t ar y risks—both hyper- an d hyp opigm en t at ion —an d th e p rolonged recover y t im es th at en su e. Accordingly, I p refer to u se top ical th erap ies su ch as grow th factors, an t i-oxidan ts, an d brigh ten ers to h elp p at ien t s, an d lim ited n on ablat ive ph ototh erapies like erbium an d ph otofacial t reat m en t s to im p rove skin qu alit y. I kn ow th at m y m ore exp erien ced colleagu es ach ieve excellen t ou tcom es by m ean s of aggressive skin resu rfacing w ith lim ited m orbidit y, so I h u m bly defer a m ore com preh en sive discu ssion of th e su bject to th em .

■ Conclusion Th e aging process in th e Asian , albeit delayed an d less profoun dly eviden t th an in th e fairer-skin n ed races, n ever th eless does occu r an d m u st be t reated for opt im al ou tcom es. For m e, th e prin cipal approach to h elp rejuven ate m ost Asian s lies in u n derstan ding volu m e restorat ion . For Asian s w ith lim ited volum e loss, I prefer in -o ce inject able llers becau se th ey do n ot n eed ver y m u ch volu m e an d allow m ore accu racy in accom p lish ing th e righ t level of volum izat ion . Fat graft ing st ill h as a sign i can t role in m y p ract ice tow ard ach ieving th ese goals, bu t I reser ve th is in ter ven t ion for som eon e w h o h as a greater degree of volu m e loss du e to m ore advan ced aging. I believe th at h air restorat ion can be a ver y im p ort an t asp ect to rejuven at ion for both th e Asian m ale an d fem ale pat ien t but is overlooked because m any surgeon s do n ot perform th is procedure. W h en an in dividual h as a w eak h airlin e bu t h as been rejuven ated th rough ou t th e rest of th e face an d n eck area, I con ten d th at th e overall result is com prom ised an d th e pat ien t sh ould con sider h aving h air restorat ion if it is applicable to an d ben e cial for h im or h er. Even if su rger y is n ot an opt ion for w h atever reason , th ere are m any poten t and e ect ive m edical solut ion s such as n asteride, m in oxidil, an d low -level laser th erapy th at can part ially coun teract early to m oderate h air loss. Even top ical cam ou aging p rodu ct s can be u sed to tem p orarily restore th e h air for social even ts or even on a daily basis if th e in dividual forgoes a surgical opt ion .

I perform far few er low er facial rejuven at ion s in Asian s th an I do in Caucasian s, even th ough for th e m id- an d upper face I p erform alm ost th e sam e frequ en cies of in ter ven t ion . I believe th at Asian s sim p ly d o n ot su er as m u ch from low er facial descen t an d sh ould n ot be n eedlessly su bjected to rejuven at ion in th is area. As st ressed earlier in th e ch ap ter, I believe th at n eurom odulators an d ch in im plan ts are ver y e ect ive adju n ct s to m an agem en t of th e low er face, particularly in th e Asian pat ien t w h o m ay ben e t from th ese in ter ven t ion s. Th e com plicated subject of th e aging Asian eyelid is presen ted in an algorith m ic fash ion th at I believe can h elp alm ost any p hysician steer clear of p roblem s, esp ecially th e surgeon w h o h as lim ited experien ce w orking w ith th e Asian pat ien t or w h o does n ot perform Asian eyelid surger y in gen eral. Breaking dow n pat ien t s in to th e broad categories of th ose born w ith a n at u ral crease, th ose w h o do not h ave a crease, an d th ose w h o h ave previou sly h ad a su rgically created crease can be ver y h elp fu l in design ing a proper t reat m en t plan th at is both e ect ive and safe. Alth ough I h ave on ly brie y m en t ion ed th e m an agem en t of th e Asian skin an d th e fact th at I do n ot often p erform aggressive skin th erapy, I believe th at in m ost Asian s skin th erapy can be h igh ly e ect ive as part of a global st rategy. I h ave alm ost ever y aging Asian p at ien t on n eu rom odulator th erapy an d on a com preh en sive topical skin regim en . Helping th e skin look m ore polished can m ake anyon e look bet ter an d sh ou ld n ot be overlooked in any in dividual of any race.

References 1. Lam SM, Glasgold MJ, Glasgold RA, eds. Com plem en t ar y Fat Graft ing. Ph iladelph ia, PA: Lippin cot t , William s & Wilkin s; 2006 2. Glasgold MJ, Glasgold RA, Lam SM. Volum e restorat ion an d facial aesth et ics. Facial Plast Surg Clin North Am 2008;16(4):435–442, vi 3. Lam SM, Glasgold RA, Glasgold MJ. Lim it at ion s, com plicat ion s, an d long-term sequ elae of fat t ran sfer. Facial Plast Surg Clin North Am 2008;16(4):391–399, v 4. Karam AM, Lam SM. Managem ent of the Asian upper eyelid. Facial Plast Surg Clin North Am 2010;18(3):419–426 5. McCurdy JA Jr, Lam SM, eds. Cosm et ic Su rger y of th e Asian Face. New York, NY: Th iem e Medical Pu blish ers; 2005 6. Lam SM. A n ew paradigm for th e aging face. Facial Plast Surg Clin North Am 2010;18(1):1–6

24

Facial Fat Grafting

Kyoung-Jin (Saf ) Kang

Pearls • Reducing th e in it ial excessive expect at ion s of th e •

• • •

•

pat ien t by adequate coun seling is im port an t . Th e st ruct u ral an d fun ct ion al relat ion sh ip of th e aging an d soft t issue fou n dat ion s un der th e in u en ce of gravit y sh ould be con sidered to avoid an u n n at u ral facial con tou r after fat graft ing. Fat graft ing ach ieves volum et ric lift ing by st rength en ing soft t issu e fou n dat ion s an d restoring volu m e de cien cy. Com m on fat h ar vest ing sites are th e abdom en an d lateral th igh , follow ed by th e m edial th igh an d an k. Fat graft ing of th e face sh ould be perform ed sequ en t ially from th e p ostero-su p erior to th e an tero-in ferior area an d from th e deep layer to th e su p er cial layer. Pressing or m assaging after fat inject ion m ust be avoided sin ce it can dam age m at ure adipocytes.

■ Introduction Au tologou s fat t ran sfer h as been w idely u sed to im p rove w rin kles, folds, an d depression s caused by aging an d to t reat part ial congen ital facial hypoplasia. In 2000, Fourn ier in t rodu ced a lipo- lling tech n ique as a good solut ion for reversing th e aging process via volum e surger y. Also, h e w as th e rst u ser of th e syringe-n eedle u n it or syringe-can n u la un it to com p letely block con t act w ith air.1 Sin ce th en , com plem en tar y fat graft ing h as been frequently used as an adju n ct ive t reat m en t to restore volu m e de cien cy th at can n ot be im proved by conven t ion al rhyt idectom y.2 At p resen t , fat graft ing is don e n ot on ly for volu m e recover y, bu t for facial con tou r im provem en t as w ell. Despite th e su rgeon’s at tem pt s to ach ieve su ccessfu l fat graft ing, an u n n at u ral facial con tou r su ch as a at , broad, an d sagged app earan ce can occu r w h en th e fat is injected on ly for th e correct ion of volu m e deplet ion , w ith n o con siderat ion of th e st ru ct u ral an d fu n ct ion al relat ion sh ip of th e aging an d soft t issue foun dat ion s.3 Sp ecial st ru ct u res th at m ain t ain soft t issu e con tours by rest rict ing or xing th e m ovem en t of facial soft t issue are classi ed according to th ree m orp h ologic form s: ret ain ing ligam en t , sept u m , an d adh esion . How ever, w ith aging as w ell as after years of m u scular act ivit ies and th e pu ll of gravit y, th e ligam en tou s xat ion s becom e disten ded, elongated, an d th in n ed due to th e decrease of collagen ber an d loss of in t ra- an d

• Using an ideal grip tech n iqu e is im port an t in • •

•

in creasing sur vival an d redu cing th e com plicat ion s of fat graft ing. Fat inject ion s m ust alw ays be perform ed as th e syringe or can n u la is being d raw n back to p reven t vascu lar occlu sion . W h en inject ing fat in to th e foreh ead area, th e su rgeon is st rongly recom m en d ed to inject bot ulin um toxin before th e procedu re for bet ter fat su r vival, w ith th e except ion of pat ien t s w h o h ave eyelid ptosis. Fat inject ion is n ot a procedure w ith ou t com plicat ion s. Serious com plicat ion s such as in fect ion an d vascular occlu sion alw ays n eed both th e surgeon’s an d th e pat ien t’s at ten t ion .

peri-ligam en t al fat . Even t u ally, th e soft t issue fou n dat ion s becom e w eak an d laxit y of face en sues. Autologous fat can be injected in to th e in t ra- an d peri-ligam en t al space, th ereby st rength en ing th e at ten uated ligam en tou s xat ion to p rovide solid soft t issu e fou n dat ion s. Th us, to ach ieve a successful outcom e in fat inject ion , a system at ic ap proach con sid ering th e roles of variou s st ru ct u res related to facial con tou r, th e st ru ct u ral ch anges im posed by th e aging process, an d th e in uen ce of gravit y is n ecessar y. Con sidering all th ese factors, th e w h ole face is divided in to several zon es, an d th e autologous fat is grafted according to a sp eci c sequ en ce of inject ion s.

■ Patient Evaluation Th e physician sh ould evaluate th e facial proport ion s, degree of aging, an d th e facial sh ape of th e pat ien t (oval, roun d, h ear t , square, rect angle, inverted t riangle, t riangle, an d d iam on d sh ap es). According to th e facial sh ap e an d degree of aging, th e physician can recom m en d th e best ap proach for fat graft ing th at can m ake th e p at ien t’s face look younger, sm aller, an d m ore beaut iful. For exam ple, fat graft ing for an terior p roject ion is recom m en ded in a broad an d at face. Volu m et ric lift ing u sing fat graft ing is recom m en ded in a sagged, t riangular, or rect angular face. An asym m et ric face or facial exp ression sh ou ld be evalu ated

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V Facial Skin and Hair Rejuvenation p rior to th e procedu re. According to th e degree of asym m et r y, th e am oun t of fat an d level of placem en t sh ould di er. To predict th e tot al am oun t of fat to be injected, it is n ecessar y to id en t ify th e areas w h ere th e p at ien t w an ts graft ing, an d to con rm oth er areas n ecessar y to create n at u ral con tou r w ith ou t sagging, even if th e p at ien t does n ot w an t to p erform fat graft ing in th ose areas. Addit ion ally, th e th ickn ess an d elast icit y of th e skin an d su bcu t an eous t issue sh ou ld be ch ecked to adjust th e am ou n t of fat an d level of p lacem en t . Du ring th e con su ltat ion , th e im p or tan ce of environ m en t al factors th at can decrease th e su r vival rate an d lon gevit y of grafted fat sh ou ld be exp lain ed to th e p at ien t . Th e physician m ust precisely ch eck th e pat ien t’s surgical h istor y, in clu ding all facelift ing procedu res, previous fat graft ing, allograft im p lan tat ion , an d any inject ion s of art icial llers in clu ding foreign bodies (silicon e or p ara n ). Oth er ch ecking poin t s in clu de th e h em orrh agic ten den cies of curren tly taken drugs, h ealth foods, an d n ut rit ion al su p p lem en t s, su ch as asp irin , ibu profen , deer an tler, red gin seng, licorice, ep h edra, garlic, on ion liqu id , vit am in E (α -tocoph erol), an d om ega-3 fat t y acids. Sm oking an d d rin king sh ou ld be stopped 1 or 2 w eeks prior to th e p roced u re an d at least 2 w eeks to a m axim u m of 3 m on th s after th e procedure because th ey in crease th e in ciden ce of h em orrh age, edem a, in am m at ion , an d delayed w oun d h ealing. Gen erally, th e t u rn over of grafted fat occu rs w ith in 2 to 3 m on th s after th e p rocedu re du e to t ran sien t reperfu sion isch em ia, bu t it can occu r after u p to 6 m on th s.4 Th erefore, it w ould be good to m ain tain th e pat ien t’s body w eigh t u n t il 6 m on th s after th e procedu re. It is advisable to in form th e pat ien t in advan ce th at if th ere is a n eed for addit ion al fat graft ing, it sh ou ld be don e w ith in 3 m on th s after th e rst p rocedu re, as su ch t im ing is safer an d is associated w ith bet ter e ects. W h en th e pat ien t h as asym m et ric facial m ovem en t , bot u lin u m toxin can be injec