Our Personal Approach and Philosophy


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Erdem T.

Revision Rhinoplasty, Daniel G Becker,Stephen S. Park, Editör, Thieme (U.S) , New-York, ss.224-245, 2008

  • Basım Tarihi: 2008
  • Yayınevi: Thieme (U.S)
  • Basıldığı Şehir: New-York
  • Sayfa Sayıları: ss.224-245
  • Editörler: Daniel G Becker,Stephen S. Park, Editör

Özet

Aesthetic and functional surgery of the nose presents a variety of complex challenges. These are even more profound in revision rhinoplasty when the surgeon is attempting to correct deformities in which loss of tissue, scar contracture, and lack of autogenous grafting material make optimal results more difficult. Over the years, we have used multiple techniques to address specific situations that arise during both primary and revision rhinoplasty. It is important to learn from others and remain current by techniques described in the literature. Understanding these techniques, modifying them to meet your needs, and perhaps, most importantly, knowing when to use them, must be a continual process to improve outcomes. We have chosen to discuss cases performed within the last 6 months (except Case 5) to provide an overview of our current rhinoplasty practice and the latest techniques we use to address difficult problems in revision rhinoplasty. The first step in evaluating a patient considering rhinoplasty is nasal analysis. Nasal analysis in revision cases should include palpation of the nose to assess the tissues remaining such as septal cartilage, bony pyramid, thickness of the overlying subcutaneous tissue, bossae formation and other tip symmetries, and middle vault contour. Also important is intranasal examination for synechiae, turbinate hypertrophy, persistent septal deviation or perforation, and evidence of valve collapse. Because these patients have not had satisfactory initial results, they can be more demanding. Realistic expectations and goals should be discussed with the patient beforehand. Depending on the anatomic problem, an appropriate incidence of further revisions is provided to the patient. For all but minor revisions, we estimate a 1:15 rate for further revisions. Photographic documentation is critical. In some cases, overresection of tissue or scar contracture severely limits the ability to address cosmetic concerns and thus functional improvement should be considered the primary goal; however, both can often be achieved with careful planning and execution. Camouflage grafts can help improve cosmetic appearance when rearrangement of the primary structures is not possible. Generally, for small contour deformities, cartilage grafts are placed in precise pockets endonasally. More major revision of the tip and middle vault are usually performed through an external approach. Timing of surgery is important as well; major revisions should be approached when an adequate amount of time has allowed for scar maturation, whereas minor revisions may be approached with some flexibility. We describe techniques we routinely use in revision rhinoplasty cases to address specific problems in the middle vault and tip. These are discussed in a case format for graphical clarity. All but Case 5 were performed in the last 6 months to give a true “snapshot” of our current preferences. This, of course, limits our ability to provide longterm follow-up and photographs for this group of patients. Selected cases involved middle vault and tip deformities, but many revisions involve the bony pyramid. Minor irregularities of the dorsum are treated with a rasp or camouflage with autogenous cartilage—frequently lightly morselized cartilage. Osteotomies are usually performed with a perforating technique: external to move the nasal bones medially and internal to move them laterall