Basic Open Rhinoplasty. Principles and Practical Steps for Surgeons in Training

Expressly designed for surgeons in training who are new to nasal rhinoplasty, this textbook is written in a simple didactic style. A century after the first open rhinoplasty was performed by Dr. Aurel Rethi in Hungary, open rhinoplasty is now the most commonly used approach to aesthetic and reconstructive nasal surgery; the author's decades of experience will safely guide the reader through her/his journey from the first contact with new patients to the postoperative analysis of clinical results.

Instead of the usual classification of surgical techniques and anatomical regions, here the learning process is based on a sequence of steps, each of which addresses the most frequent problems that surgeons are likely to encounter in everyday clinical practice. In addition, the most relevant surgical instruments and electromedical devices are presented, together with their specific features and techniques, such as inclination and positioning during the procedure. Each step is richly illustrated and supported by a suggested reading list, as well as content on ethical and general principles. A specific chapter on radiological pre-evaluation assessment makes this book unique. Given its clear structure, its appealing didactic style and wealth of figures, Basic Open Rhinoplasty offers a much-valued step-by-step companion for postgraduate students, surgeons in training, and medical practitioners who deal with rhinoplasty in their clinical practice.

Dr. Fabio Meneghini earned his MD in Medicine and Surgery and specialized with honors in Maxillofacial Surgery from the University of Padua and Ferrara, Italy. He additionally gained a Master's Degree in Plastic and Aesthetic Surgery with a dissertation on open rhinoplasty at the University of Padua, where he was soon nominated Adjunct Professor at the School of Specialization in Maxillofacial Surgery. He has been teaching Facial Aesthetic Surgery, later lecturing for the Postgraduate course in Aesthetic Medicine and Surgery, and teaching clinical facial studies and facial aesthetic surgery at the University of Padua, and at the International Academy of Aesthetic Medicine in Parma. His areas of expertise in facial surgery cover: aesthetic, reconstructive and functional nasal surgery (rhinoplasty, septoplasty, inferior turbinate surgery), profiloplasty and aesthetic surgery of the chin (mentoplasty, submental liposuction), corrective surgery of jaw deformities (orthognathic) and otoplasty (correction of protruding ears, earlobe reconstruction). Dr Meneghini patented three surgical instruments dedicated to open rhinoplasty, two tools for facelift and a tool for eyebrow lifting. On top of his 30 years of clinical activity and teaching, he has also published in peer-reviewed journals as Aesthetic Plastic Surgery, Journal of Cranio-Maxillo-Facial Surgery, Journal of Craniofacial Surgery and authored the well-received Springer title Clinical Facial Analysis, now in its second edition.

Preface.- 1 Introduction.- 2 Guiding principles and steps approach to nasal surgery.- 3 Rationale for Open Primary Rhinoplasty.- 4 Rationale for Closed Secondary Rhinoplasty.- 5 David Sarver's paradox.- 6 Maxillofacial deformities and nasal deformities (anterior maxilla deficiency).- 7 The power of saying "No".- 8 Before the in-office visit (how new patients may find you).- 9 Start with a gift: book for patient information.- 10 How to conduct the first visit prefer fixed steps initially to approach a new patient.-11 Two preoperative long visits: a concept (and, eventually, other short preoperative meetings).-12 Your first minutes with a new patient.- 13 Endonasal analysis.-14 External nasal analysis.- 15 The hourglass example (how to explain nasal function to patients).- 16 Realize a complete photographic facial documentation & standard nasal photographic set.- 17 State of the art lighting equipment and alternatives.- 18 Preoperative CT scan and Cone Beam CT scan.- 19 State of the art lighting equipment and alternatives.- 20 Standard nasal photographic set.- 21 Nasal and whole facial profile analysis.- 22 Prepare for the second visit.- How to conduct the second visit.- 24 Informed consent.- 25 Preoperative standard exams list.- 26 Preoperative list for the day of surgery.- 27 Preoperative written aesthetic, functional and reconstructive surgical plan.- 28 Ideal surgical plan and anatomical limiting factors.- 29 The main phases of every Open Primary Rhinoplasty: explorative phase, conservative correction phase, reconstructive final phase.- 30 Patient preparation for general anaesthesia.- 31 Oro tracheal tube positioning and fixation.- 32 Protection of laryngeal part of pharynx.- 33 Skin, endonasal and oral disinfection, sterile draping, eye protection.- 34 Patient positioning for surgery.- 35 Local anaesthesia principles: safe, limited, three times.- 36 Stair step or inverted "V" columellar incision?.- 37 Incisions: inverted "V": marginal right and marginal left.- 38 One surgical blade.- 39 Skeletonization (tip, skin flap control, conservative defatting of the tip and supratip under surface).- 40 Skeletonization: dorsum (laterally limited).- 41 Hold the skin flap with Meneghini self-retained nasal retractor.- 42 Skeletonization: septal cartilage.- 43 Create a small bilateral tunnel of elevated mucosa under the junction between the Upper Lateral Cartilages and the dorsal margin of the cartilaginous septum (Preserving nasal mucosa).- 44 Separation of the Upper Lateral Cartilages from the Septum (with 15c blade) maintain intact the underling nasal mucosa.- 45 First review of the surgical treatment plan based on bony and cartilaginous deformities.- 46 Depressor septi muscle work utilizing a fine needle tip electro cautery (nasal versus intraoral approach).- 47 Septal work, first part: submucous resection of the deviated posterior (septal spur) and inferior (overlapping redundant maxillary portion of the septal cartilage) components.- 48 Obtaining of a 'swinging door' type free movement of the cartilage respect to the nasal crest of maxilla.- 49 Removing septal bony spur and maxillary crest deviation with Piezosurgery.- 50 Conservative inferior turbinate works - anterior third.- 51 Anterior Nasal Spine work: midline reposition with osteotomy, reduction by remodelling or resection with Piezosurgery.- 52 Dorsal Work part one: conservative cut of cartilaginous septum.- 53 Alternative Dorsal Work with Piezosurgery.- 54 Radix deepening and nasal bone final shaping with electric burr and Modified Maliniac Meneghini nasal retractor.- 55 Septal work, second part: harvesting cartilage for grafting maintain a L shaped strut for dorsal and columellar support.- 56 Straightening the dorsal septum with unilateral or bilateral Spreader Graft.- 57 Suture fixation of the cartilaginous septum to Anterior Nasal Spine.- 58 Caudal septal elongation with septal extension graft.- 59 Quilting suture of the Septal mucosa with Vicryl Rapid 4/0 - Avoid tension surgical principle.- 60 Temporary bilateral anterior nasal packing with Merocel soaked with Ugurol.- 61 Reduction of transverse dimension of large bony vault with Piezosurgery.- 62 Dorsal Work part two: reconstruction of cartilaginous dorsum.- 63 Piezosurgery for osteotomy and modelling nasal bones.- 64 Medial crura reconstructive work: caudal profile alignment utilizing a long columellar strut sutured with almost three stiches of Monocril 5/0 adsorbable sutures.- 65 Methods for medial crura lengthening.- 66 Methods for medial crura shortening.- 67 Tongue in Groove technique for tip control.- 68 Lateral crura work, first part: conservative cephalic excision.- 69 Alternative to conservative cephalic excision of LLC.- 70 Grafting technique to shaping and supporting LLC.- 71 Methods for lateral crura lengthening.- 72 Methods for lateral crura shortening (lateral crura overlapping).- 73 Middle crura work, first part: tip sutures (interdomal, transdomal suture) utilizing Monocril 5/0.- 74 Nasal osteotomies: medial endonasal, basal percutaneous.- 75 Lateral crura work, second part: lateral crura Spanning suture.- 76 Alar batten graft.- 77 Middle crura work, second part: visible graft (onlay tip graft, long shield graft) sutured with Monocril 5/0 with final "in place" refinements.- 78 Dorsal Work, third part: onlay grafting, autologous temporal fascia grafts.- 79 Radix graft.- 80 Open up an acute nasolabial angle with plumping graft.- 81 Tip camouflage with Gel Cartilage graft.- 82 Final review of the surgical treatment plan and finesse.- 83 Closure of the skin incisions.- 84 Footplates work: excision and/or sutured together.- 85 Alar base work.- 86 Removal of bilateral packing - rationale for anterior nasal packing in the postoperative phase.- 87 Taping and splinting.- 88 Disposable materials.- 89 Diced cartilage grafts.- 90 Crushed and morselized cartilage grafts.- 91 Temporal fascia graft harvesting.- 92 Ear cartilage graft harvesting.- 93 Rib cartilage graft harvesting.- 94 Chin surgery.-95 Sutured in place and non-sutured in place grafts.-96 Modified Gunter postoperative record sheet.-97 Early postoperative care and rules.-98 First postoperative visit.-99 Late postoperative care: manage postoperative supratip fullness with Kenalog.-100 One year postoperative documentation and analysis: the importance of thinking over results.-101 How an old happy patient can help you.-102 The 20 marketing commandments by Rod Rohrich.-103 When the "Close Approach" help you.- 104 Final comments.