Facial Plastics and Rhinoplasty Assessment

FACIAL PLASTICS AND
RHINOPLASTY
ASSESSMENT
Bhaskar Ram
Aberdeen Royal Infirmary
Dundee FRCSENT VIVA course
www.frcsentvivacourse.co.uk
Aesthetic Principles
• Ensure Complete Excision
•
Consider Moh’s surgery
•
Replace tissue with like tissue
▫
Replace all missing components
• Restore units and aesthetics
• Evaluate tissue surrounding donor and recipient
sites
Nasal Reconstruction
•
What does the patient want?
Expectations
REMEMBER KIS
• Patient Factors
Health of patient, health of skin,
smoker
• Diagnose the nasal defect
Subunits, tissue layer, internal structures
• Evaluate donor materials for missing surface
and tissue layers
FACIAL REGIONS
NASAL SUBUNITS
Restore units and
aesthetics
• If greater than 50%, then best
to excise and recon entire
subunit.
• Match color and texture.
Replace tissue with like tissue
• Cutaneous cover
Full thickness skin graft
Local or regional flaps
Structural support
Septal cartilage
Auricular or rib cartilage
Calvarial bone
• Lining flaps
▫
Septal mucoperichondrial flaps
Vestibular or turbinate mucosal flaps
HOW TO RECONSTRUCT
• START from the THE BASE
• BUILD the SUPPORT next
• COMPLETE with COVERING the defect with the skin
NASAL LINING FLAPS
• Bipedicled
vestibular flap
(Aka bucket handle flap)
(must be defect <1.5cm in
vertical height)
▫ Make intercartilagenous incision
between upper and lower lats
Elevate the flap, sufficiently to mobilize
• Auricular cartilage can serve as
framework to attach to.
Lining Flaps
• Unilateral Septal
Mucopericondrial hinge flap
(Can measure up to 4-4.5cm
in length and 2.5 – 3 cm in
Width)
▫ Sub-perichondrial dissection
is completed from above
downward towards the floor
and from anteriorly to
Posteriorly
▫ Turn flap laterally as a hinge
Framework
Framework
• Cephalic Dorsum – cranial bone.
▫
These are secured to frontal bone with miniplates.
• Caudal Dorsum – septal or auricular cartilage.
• Lateral Sidewall – may be replaced with bone or
cartilage.
• Alar defects – cartilage (usually contralateral
concha cymba).
Nasal Reconstruction – CUTANEOUS DEFECTSLadder
• Primary closure
• Healing by secondary intention
• Dermabrasion
• Full thickness skin grafts (FTSG)
• Composite grafts
• Random Flaps
• Pedicled Flaps
Secondary Intention
Typically for medial canthal
defects
• Results in contraction
and distortion of nose
• Poor aesthetic
outcomes on most
defects of nose
Primary closure
• Little
redundant skin on
nose
▫ Easier on elderly patients
• Defect usually < 1cm
▫
Dorsum or sidewall
• May produce alar or tip
distortions
(rotation of tip).
Full Thickness Skin Graft
• Used instead of STSG to avoid contraction
• Need intact framework to support
• Use like tissue
• Best on younger patients with thin skin
• Best for nasal sidewal unit defects
Local Flaps
LOCAL FLAPS
Types of Flaps: Defined by direction of
tissue movement
• Advancement flaps: Linear movement
▫
Y-V advancement
• Rotational Flaps: Radial movement
• Transposition Flaps: Raised from donor sites
and rotated over to defect
Interpolated Flaps: Flap passed over or under
bridge of skin separating site : Island flap, Paramedian forehead flap.
from defect:
▫ Important to recognize vectors of pull and force
▫ Especially when pulling from structures with low
tensile strength such as the eyelid.
What flap to use and
Where
Nasal Dorsum – Cutaneous cover
Glabellar Flap
Forehead flap
Primary closure
FTSG
Nasal Sidewall- Cutaneous Cover
FTSG
Transposition Flap
Bilobed Flap
Forehead Flap
Nasal Tip Lobule – Cutaneous cover
•
Bilobe flap
• Forehead flap
• FTSG
Tip Lobule – Bilobe Flap
• Original design by Esser (1918)
Total transposition of ‹100°
• Ideal for defects:
1.5 - 2.0cm
▫ Best of ›5mm from margin of
nostril
Preferably laterally based
Most common nasal local flap
Double transposition flap
Little distortion of alar rim
Paramedian Forehead flap
Based off supratrochlear
Artery
1.7 – 2.2cm lateral to midline
Performed on same side of
majority of defect
Pedicle can be as narrow as
1.2cm
▫ Allows for greater arch of
Rotation
▫ Minimizes standing
deformity
Columella – Cutaneous cover
FTSG (superficial)
Composite graft (<1.5cm)
Melolabial flap
Forehead flap
Alar rim – Cutaneous cover
• Melolabial flap
• Forehead flap
• Composite graft
Melolabial
•Melolabial Interpolation Flap
• Preserves
alar-facial sulcus
▫ Pedicle crosses sulcus and is
taken down at 3 weeks
• Three types:
▫ Superiorly Based
Lateral nasal wall, nasal ala
Single stage
▫ Inferiorly Based
Nasal sill and columella
▫ Island Pedicled flap
Indicated for whole subunit
alar surface replacement
TEMPLE AND FOREHEAD
DEFECTS
CHEEK DEFECTS
Take home points
Mohs Surgery – Principles
Reconstruction of Mohs Defects
Cosmetic Principles
Healing by Secondary Intent
Skin Graft
Primary closure
Flap Reconstruction
Reconstruction of specific locations
FACIAL ANALYSIS OF THE
RHINOPLASTY PATIENT
Bhaskar Ram
Consultant Otolaryngologist
The standard attractive face
Symmetry
Proportions
Angles
Relationships
Correction of what is askew determines the surgical plan
Primary points of
interest
Trichion
Glabella
Nasion
Supratip
Tip
Subnasale
Stomion
Menton
Zimbler, Marc Ham, Jongwook. Aesthetic Facial Analysis,
Cummings: Otolaryngology: Head and Neck Surgery, 4th ed
2010
•Trichion: Anterior hairline in the midline
•Glabella: Most prominent midline point of
forehead, well appreciated on lateral view
•Nasion: Most posterior midline point of forehead,
typically corresponds to nasofrontal suture
•Rhinion: Soft-tissue correlate of
osseocartilaginous junction of nasal dorsum
• Supratip: Point cephalic to the tip
Tip: Ideally,
• Subnasale:
Junction of columella and upper
lip
•Menton: Most inferior point on chin
•Pogonion: Most anterior midline soft-tissue
Nasal aesthetic subunits
Zimbler, Marc Ham, Jongwook. Aesthetic Facial Analysis,
Cummings: Otolaryngology: Head and Neck Surgery, 4th ed
Tip Support
•Major
•LLC size and shape
•LLC attachment to
ULC
•LLC attachment to
caudal spine
•Minor
•Interdomal ligament
•Soft tissue envelope
•Cartilagenous
dorsum
membranous
septum
•Nasal spine
Rhinoplasty consultation
• First Consultation
• Understand patients wants
• Are they genuine, realistic
• Understand what you can realistically achieve
•
• Will the pt be happy with the outcome
•
BEWARE
• Intranasal substance abuse (eg, cocaine)
• Psychological or psychiatric instability
• SIMON (single, immature, male, overly expectant, narcissistic)
personality traits
• Patient refusal of external scar
• Very thick nasal skin
STANDARD FACIAL
PHOTOGRAPHS
Facial Analysis
 Horizontal 1/3s
 Trichion glabella
 Glabella subnasale
 Subnasalementon
 Lower 1/3 may be
subdivided
 Upper lip 1/3
 Lower lip + chin 2/3
Orten, Steven and Hilger, Peter. Facial Analysis of the Rhinoplasty Patient.
Papel: Facial and Plastic ReconstructiveSurgery, 2002.
Facial Analysis
• Vertical 1/5s- intercanthal distance
Orten, Steven and Hilger, Peter. Facial Analysis of the
Rhinoplasty Patient. Papel: Facial and Plastic
ReconstructiveSurgery, 2002.
Frontal View
• Twisted
• Dorsal width
• Alar base
• Tip defining
points
• Asymmetry of
domes
Rhinoplasty DominicMCastellanoM.D. Castellano&HowardSpecialtyCenter Tampa,Fl , Osler Review Course
Frontal view
• A curved, unbroken line should sweep from the medial brow to
the tip defining point
Orten, Steven and Hilger, Peter. Facial Analysis of
the Rhinoplasty Patient. Papel: Facial and Plastic
ReconstructiveSurgery, 2002.
Disruption of brow-tip esthetic line
Abnormal contour involving the middle vault of the nose
http://www.drhilinski.com/rhinoplasty-tutorial/spreadergrafting/
Frontal View- Symmetry
• A line from midglabella to the menton should bisect the nasal
bridge and tip symmetrically
Deviated Nose
/
http://www.drlamperti.com/blog/post/how-to-fix-a-crookednose-with-rhinoplasty
Frontal View- Nasal Dorsum and Alar base
• The width of the alar base = intercanthal distance
Alar base Reduction
http://www.plasticsurgerypractice.com/issues/articles/2011-01_02.asp
Frontal View
•The width of the bony
sidewall of the nose
should be 75-80% of the
normal alar base.
WIDE BONY SIDEWALL
Surgically corrected with lateral osteotomy
http://www.noses.co.nz/Photo%20Gallery?Service=Show&Image=4
Frontal View- Tip Defining Points
• Represent light reflection from the skin overlying the domes of lower
lateral cartilages
Tip- Angle of Divergence
•Angle of divergence
•Lateral angulation from
midline 50-60°
•Variations
• Narrow
• Elongated tip
• Wide (Bulbous)
• “Box and ball”
Rhinoplasty DominicMCastellanoM.D.
Castellano&HowardSpecialtyCenter Tampa,Fl , Osler
Review Course
Angle of DivergenceWide vs Narrow
Wide angle of divergence = BOX
Narrow angle
Rhinoplasty DominicMCastellanoM.D. Castellano&HowardSpecialtyCenter Tampa,Fl ,
Osler Review Course
Frontal View- Columella
 Columella should hang
just inferior to alar rims
 Infratip lobule should be a
gentle “gull in flight”
 Too much-reduction
 Retracted-augmentation
Orten, Steven and Hilger, Peter. Facial Analysis of the
Rhinoplasty Patient. Papel: Facial and Plastic
ReconstructiveSurgery, 2002
.
Lateral View
•Dorsal hump
•Projection
•Rotation
•Nasofrontal
Angle
•Columella
Rhinoplasty DominicMCastellanoM.D.
Castellano&HowardSpecialtyCenter Tampa,Fl , Osler
Review Course
Profile- Nasofrontal angle
 Connects the brow with the
nasal dorsum
 GlabellaNasion
 NasionNasal tip
 Nasion (deepest point) should
lie at supratarsal crease
 Angle is usually 115-130
degrees
 No well established
parameters, use judgement to
determine what is too shallow
and too deep.
Orten, Steven and Hilger, Peter. Facial Analysis of the Rhinoplasty Patient.
Papel: Facial and Plastic ReconstructiveSurgery, 2002.
Tip Projection- 60% Goode method
•Line from alar crease
 tip
•Nasiontip
•Ratio should be 0.550.60 (alar) to 1.0
(nasion)
www.rhinoplastyspecialistsurgeon.com/
Tip Projection- relation to lip
• Nasal tip projection may also
be measured in relation to
the upper lip
• 50-60% of the horizontal
projection of the nose lies
anterior to upper lip
• >60% is over projected
• <50% is under projected
Orten, Steven and Hilger, Peter. Facial Analysis of
the Rhinoplasty Patient. Papel: Facial and Plastic
ReconstructiveSurgery, 2002
.
Lateral View- Dorsum
 Line from Nasion to
desired tip projection
 Nasal dorsum should lie
at or slightly (1-2mm)
posterior and parallel to
this line
 Slight supratip break of
dorsum gives definition
and helps distinguish
dorsum from tip
NasoFacial Angle
•The incline of the
nasal dorsum in
relation to the facial
plane.
•Ideally 36 degrees
(varies 30 to 40)
Zimbler, Marc Ham, Jongwook. Aesthetic Facial Analysis, Cummings:
Otolaryngology: Head and Neck Surgery, 4th ed
Tip rotation- Nasolabial Angle
• Line anterior to posterior
point of nostril
• Vertical line perpendicular
to Frankfurt plane,
dropped along upper lip
• Men 90-95
• Women 95-115
Tripod theory
• First proposed by Anderson JR (1969)
• Tripod
• Lateral cruras= two posterior legs
• Conjoined medial cruras = anterior third
leg
• Helps predict the tip rotation
• Tilt in the direction of the shorter leg
• Cephalic rotation
• Shortening of the lateral cruras
• Lengthening medial cruras
Tripod Theory
Alar -Columellar Relationship
• 2-4 mm columella should be
visible below alar margin on
profile
• >4 mm is excessive
• Retracted alar lobule
• Hanging caudal septum
Orten, Steven and Hilger, Peter. Facial Analysis
of the Rhinoplasty Patient. Papel: Facial and
Plastic ReconstructiveSurgery, 2002.
Columella- double break
• Columella is seen to have a
double break
• 1st-tip of the nose turns
posterior-inferior to infratip
lobule
• 2nd- mid columella , where takes
a horizontal course to subnasale
Base View
Size
Shape
Orientation
Width and length
of columella
Height of Lobule
Rhinoplasty DominicMCastellanoM.D.
Castellano&HowardSpecialtyCenter Tampa,Fl ,
Osler Review Course
http://noserevisionsurgeryandsurgeons.blogspot.com
/
Base View
•Isosceles Triangle
•Lobule 1/3
•Columella 2/3
•Nostrils
•Symmetric
•Pear shaped
•Columella flare at
base and at infratip
lobule
Chin Position
• Gonzales-Uloa
• Line from nasion perpendicular to Frankfort planechin should
approximate this line
Orten, Steven and Hilger, Peter. Facial Analysis
of the Rhinoplasty Patient. Papel: Facial and
Plastic ReconstructiveSurgery, 2002
.
Inadequate Chin
 Microgenia
 Underdeveloped mental portion of mandible
 Micrognathia
 Underdeveloped mandible with class II occlusion
 Retrognathia
 Mandible is normal in size but retruded with class II occlusion
 Micrognathia or retrognathia= orthognathic surgery
 Microgenia or doesn’t desire orthognathic surgery=augmentation
mentoplasty
Nasal –Forehead
A forehead that
slopes posteriorly from the
brow to the hairline tends to
exaggerate
the appearance of nasal
length and projection.
A flat, vertically oriented, or
protruding forehead
diminishes
the appearance of nasal
length.
Orten, Steven and Hilger, Peter. Facial Analysis of the
Rhinoplasty Patient. Papel: Facial and Plastic
ReconstructiveSurgery, 2002.
Summary- Frontal View
 Frontal View
 Divide the face
▪ Horizontal 1/3
▪ Vertical 1/5
 Look for asymmetry
 Dorsal width
▪ 75% of alar base
 Alar width
▪ Intercanthal distance
 Shape and asymmetry of tip
 Note abnormalities in the dental occlusal relations
Summary-Lateral View
• Nasal length
• Tip projection
• Goode 1: 0.6 ratio
• Crumley 3,4,5
• Tip Rotation
• Nasolabial angle 90-95 men
• 950-115 in women
Nasal Relation
• All analysis of lips should include assessment of forehead, brow,
lips, chin, dentition.
• Forehead- Nasofrontal angle
• Chin- Vermillion borders to chin (should be within 2-3 mm)
THE END
Now that I have your attention, let’s practice!
LIP DEFECTS
Lip defects
<1/2 – primary closure, w plasty
1/2-2/3- lip switch (abbe if away from commissure, estlander +
commissureplasty if near commissure) flap width ½ defect width, kerapanzic
>2/3- bernard webster bipedicled advancement flap, melolabial transposition,
temporal forehead flap, free flap
Abbe
W plasty
Karapanzic
Bernard burrows
Estlander
Estlander Flap
Abbe fLAP