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Rhinoplasty

Prepared and Edited by:Mark Arjan R.Fernandez MD,FPSOHNS Levi John G. Lansangan MD,FPSOHNS,FPAAS, Shimmian Manila
The facial proportions are an important factor to be considered during planning of the septorhinoplasty. The nose should not be too large or dominant; neither should it be too small or doll-like. The art of aesthetic surgery lies in the creation of natural proportions. To achieve this goal, it is useful to divide the face into zones; for this purpose there are three horizontal zones and five vertical zones.Figure 1

Figure 1

Suture material (4/0 PDS, 4/0 Prolene, 6/0 Nylon/Prolene, Vicryl 4/0) Scandicaine 0.5% with epinephrine (mepivacaine/lidocaine hydrochloride) 1:200,000 Saline 0.9% Xylometazoline hydrochloride solution Compresses (10 10 cm) Nasal packing Swabs Brown steristrips Leukosilk adhesive tape (w = 1.25 cm) Aquaplast/Plaster of Paris Skin cleaning kit

Instruments and Medication 1 Nasal speculum (short) 2 Bayonet-shaped forceps 3 Tweezers Adson-Brown 4 Delicate surgical tweezers 5 Columella clamp 6 Scalpel handle 7 Turned nose scissors for suture material 8 Dissecting scissors Wullstein 9 Bone rongeur Luer 10 Nasal scissors Heymann 11 Raspatory sharp Dieter 12 sharp/blunt Freer 13 Raspatory McKenty 14 Delicate long singlepronged wound retractor 15 Fine long two-pronged wound retractor 16 Retractor blunt 17 Fine wound retractor sharp 18 Mallet Cottle 19 Chisel 4 mm 20 Chisel 10 mm 21 Large bone file 22 Aspirator 23 Rongeur-BlakesleyElevator 24 Needle holder small 25 Dissecting mosquito forcep

ESSENTIALS OF RHINOPLASTY
Modern primary rhinoplasty is more complicated than the standard reduction rhinoplasties of the past. Each case is tailored to achieve the goals of rhinoplasty that reflect current trends including a natural, nonoperated look, a well-balanced nose and face, a stable and permanent result, and a functional nose. The same surgical

maneuvers may result in different results in different noses. Facial analysis and an awareness of a variety of surgical techniques and their potential outcomes are critical to success. This individualized approach to modern rhinoplasty calls for a variety of specialized techniques. Nevertheless, certain techniques are used commonly for typical problems in patients seeking primary rhinoplasty. Most patients desire After tip-plasty, nasal dorsum work, and establishment of reduction of a nasal hump and tip refinement. Minor changes in tip rotation and the radix, the nasal valves are carefully examined. The projection may also be needed. Despite these seemingly simple goals, the preoperative nasal valves are often narrowed excessively due to analysis may uncover subtle problems that require techniques often considered medialization of the upper lateral cartilages. Insertion of to be advanced, such as grafting or suture modification of the lower lateral spreader grafts can reverse this phenomenon by splinting cartilages. open the nasal valves. A secondary effect of spreader Surgical access is also an important consideration. Although a typical primary grafting is slight widening of the middle third of the nose rhinoplasty can be done through a closed approach, many surgeons prefer an open (middle vault). This can bring the middle and upper thirds approach for wide access and teaching. Therefore, familiarity with a variety of of the nose into better balance while preventing approaches and access incisions is required in basic rhinoplasty. After exposure of the operated look of an inverted V deformity. the dorsum and tip is accomplished, the first decision with regard to surgical corrections is whether to begin with the dorsum or the nasal tip. Traditional reduction rhinoplasty involved correcting the dorsum first with subsequent matching of the nasal tip. This done routinely will result in an overly reduced nasal tip in many patients. In general, it is better to begin with the more complex nasal tip and project it appropriately before altering the nasal dorsum. Surgical correction of the nasal tip (tip-plasty) calls for a variety of techniques that are generally cartilage-sparing. Interrupted cartilage techniques, including dome division, are usually avoided. Although increasing nasal projection may be a part of the preoperative plan, it is accomplished by redistribution of cartilage within the nasal framework, not by the use of cartilage grafts or radical cartilage techniques. Nevertheless, some cartilage grafting may be used to improve tip definition (shield grafts), improve tip stability and projection (columellar strut grafts), and to counteract Figure 4:The Gunter Chart the effects of nasal osteotomy and cartilage excision on the nasal valves (spreader grafts). Prior to working on the nasal dorsum, the projection of the nasal tip and position of the radix must be established. If the radix and nasal tip are appropriately projected and positioned preoperatively, and only tip refinement is planned, it makes no difference whether the dorsum is treated (e.g., removal of the nasal hump) before or after the nasal tip. Cosmetic improvement of the nasal dorsum generally entails reducing the width of the upper and middle cartilaginous vaults and correcting contour irregularities of the dorsum (e.g., eliminating a nasal hump). Altering the projection and vertical position of the nasofrontal angle is also considered. Reducing the widths of the upper and middle nasal vaults is accomplished by osteotomies within the upper third of the nose (bony vault).

The firm attachments of the cephalic upper lateral cartilages to the caudal nasal bones ensure that medial movement of the nasal bones will also result in medial movement (narrowing) of the upper lateral cartilages and middle nasal vault. Multiple osteotomies may be required to accomplish the desired effect. The most common osteotomies that simply narrow the nasal bones include the medial osteotomy and the lateral osteotomy. If a dorsal hump has been removed, a so-called open roof deformity is created and medial osteotomies are not required because the medial aspects of the nasal bones are already released. Hence, in the typical primary rhinoplasty only lateral osteotomies are required.

Primary augmentation rhinoplasty would consist of the following steps


(Figure 5 A,B,C,D) 1. Establish goals with the preoperative nasal analysis. 2. Perform open rhinoplasty to facilitate graft placement. 3. Assess anatomy and symmetry of the lower lateral cartilages. 4. Set tip projection using cartilage modification, suture, and grafting techniques. 5. Correct asymmetries of the nasal bones and set the radix using osteotomies, rasping, and onlay grafts. 6. Reconstitute the middle third and nasal valves using spreader grafts and sutures. 7. Set dorsal projection in the middle and upper thirds using grafts and selective sculpting.

C
8. Reassess tip and establish tip-defining points, if necessary, using shield grafts and suture techniques. 9. Redrape skin envelope and carefully remove subcutaneous scar tissue as necessary to increase tip definition and eliminate soft tissue pollybeak. Familiarity with anatomy and nasal analysis grafts and implants, the open approach, and a variety of procedures directed at correcting common specific aesthetic and functional nasal abnormalities is essential.

Anatomy

Anatomical Overview (Fig. 6) 1. Cartilage of nasal septum 2. Lateral nasal cartilages 3. Lateral crus of greater alar cartilage 4. Medial crus of greater alar cartilage 5. Vestibule of nose 6. Cartilage of nasal septum 7. Anterior nasal spine 8. Dilator muscle of naris 9. Upper lip 10. Depressor muscle of nasal septum 11. Infraorbital nerve 12. Piriform aperture 13. Levator muscle of upper lip and ala of nose 14. Angular artery 15. Compressor muscle of naris 16. Accessory nasal cartilages 17. Nasomaxillary suture 18. Supratrochlear nerve 19. Infratrochlear nerve 20. Nasal bones 21. Frontonasal suture 22. External nasal branches of anterior ethmoidal nerve 23. Procerus muscle

Figure 7 A , 7B: Nasal Subunits

Planes of Dissection and the SSTE

Figure 9 The skin thickness varies.the skin is thicker over the nasion,supratip,and premaxilla and thinner over the rhinion the domes . Planes of dissection (Figure 8 ) 1.Soft tissue envelope 2.Vascular Musculoaponeurotic layer 3.Osteocartilaginous framework
Maintenance of a convex osseocartilaginous dorsum is required to achieve the appearance of a straight dorsum due to the differing skin thicknesses along the nasal dorsum. Note that the skin over the mid-dorsum is quite thin. To achieve an apparently straight dorsum, the underlying bone must kept slightly convex after removal of a nasal hump. Figure 10 Cross-sectional view through the upper and lower Cartilages. The junction is shown between the upper and lower cartilages( insert)

Incisions and Approaches

1 Vestibular border incision 2 Intracartilaginous incision 3 Intercartilaginous incision

Figure 11

Incision for External Approach Sercers Goodmans Stair step Jugos Padovans

Figure 12

Nasal Blood Supply

Arterial Network of the Nose


1. 2. 3. 4. 5. 6. 7. Facial A. Superior labial A. Angular A. Artery of the nasal alae Columellar A. Dorsal Nasal A. Lateral Nasal A.

Blood Supply to the Nasal Tip


Figure 13 Projected structure,Cartilage at the back(no perforators) LNA,DNA: Major blood supply Columellar A.:Minor LNA,DNA:SMAS, Superficial and deep fatty layer

Figure 14

Osteotomy

INDICATIONS 1. WIDE FLAT NASAL DORSUM 2. CLOSE ON OPEN ROOF DEFORMITY 3. CORRECT NASAL DEVIATION 4. REDUCTION RHINOPLASTY

Figure 15

Figure 16: Types of lateral Osteotomy

Figure 18

COMPONENTS(Figure 15) 1. LATERAL 2. MEDIAL APPROACH 1. ENDONASAL(Figure 17,18) Figure 17 Internal Lateral Osteotomy Figure 19:Landmarks to avoid in Lateral external osteotomy 2. EXTERNAL (Figure 19) 3.

Septoplasty and Septal Cartilage Graft harvest

Figure 20 The Nasal Septum

Figure 21:Cartilage Graft Harvest ,Relevant Anatomy

ANATOMY and DISSECTION of the FACE for FACELIFT


Prepared and Edited by:JomarTinaza, MD,FPSOHNS
1. Superficial temporal artery and vein, frontal branch 2. Epicranial muscle, occipitofrontal muscle, highest nuchal line of occipital bone 3. Supraorbital artery 4. Superciliary depressor muscle 5. Supratrochlear artery 6. Aponeurotic structure of the scalp 7. Procerus muscle 8. Supratrochlear nerve 9. Superciliary corrugator muscle 10. Supraorbital nerve, medial and lateral branches 11. Nasal bone 12. Zygomaticofacial nerve 13. Zygomatic bone 14. Zygomatic branches of facial nerve 15. Infraorbital nerve 16. Parotid gland 17. Infraorbital nerve (anastomosis with facial nerve) 18. Levator muscle of angle of mouth 19. Masseter muscle, zygomatic process of maxilla and lower border of zygomatic arch 20. Buccinator muscle 21. Buccal branch of facial nerve 22. Orbicular muscle of mouth 23. Marginalmandibular branch of facial nerve 24. External jugular vein 25. Sternocleidomastoid muscle 26. Thyrohyoid membrane 27. Transverse nerve of neck 28. Thyroid gland 29. Cricoid cartilage 30. Thyroid cartilage 31. Median thyrohyoid ligament 32. Platysma 33. Mentalis muscle 34. Depressor muscle of lower lip 35. Mental branch of inferior alveolar artery 36. Depressor muscle of angle of mouth 37. Risorius muscle 38. Depressor muscle of septum 39. Levator muscle of angle of mouth 40. Levator muscle of upper lip and ala of nose 41. Greater zygomatic muscle 42. Lesser zygomatic muscle 43. Levator muscle of upper lip 44. Facial artery and vein, lateral nasal branch 45. Nasal muscle 46. Facial artery and vein 47. Medial palpebral ligament 48. Superior palpebral sulcus 49. Orbicular muscle of eye, lateral canthus 50. Angular artery and vein 51. Orbicular muscle of eye, medial margin of orbit 52. Superficial temporal artery and vein, parietal branch 53. Temporal muscle

Anatomical Overview 1. Superficial temporal artery and vein (frontal branch) 2. Masseter muscle, lower border and medial surface of zygomatic arch 3. Supraorbital nerve 4. Supraorbital nerve (lateral branch) 5. Temporal branch of facial nerve 6. Orbicular muscle of eye 7. Malar ligament (McGregors patch) 8. Angular artery and vein 9. Zygomatic ligament 10. Greater zygomatic muscle 11. Masseter muscle, zygomatic process of maxilla and lower border of zygomatic arch 12. Buccal branches of facial nerve 13. Lesser zygomatic muscle 14. Buccinator muscle 15. Distal zygomatic ligament 16. Orbicular muscle of mouth 17. Risorius muscle 18. Masseteric ligament 19. Parotid ligament 20. Depressor muscle of angle of mouth 21. Mandibular ligament 22. Facial artery and vein

23. Submental ligament 24. Marginalmandibular branch of facial nerve 25. Thyrohyoid membrane 26. Internal jugular vein 27. Cervical branch of facial nerve 28. Thyroid cartilage 29. Retromandibular vein 30. External jugular vein 31. Platysma 32. Transverse nerve of neck 33. Great auricular nerve 34. Parotid gland 35. Transverse facial artery 36. Lesser occipital nerve 37. Articular capsule, lateral ligament 38. Sternocleidomastoid muscle 39. Zygomatic branches of facial nerve 40. Superficial temporal artery and vein 41. Temporal muscle 42. Auriculotemporal nerve

Instruments and Medication 1 Tumescence pump syringe 2 Liposuction handle 3 Special small liposuction canula 4 Comb (aluminium) 5 Scalpel handle 6 Dissecting scissors Wullstein 7 Sharp two-pronged roller hook Mang 8 Large retractor 9 Large surgical tweezers 10 Dissecting scissors Mang 11 Tweezers Adson-Brown 12 Needle holder small 13 Needle holder medium 14 Sharp clamp Backhaus 16 Dissecting and ligature forcep (mosquito forcep) 2 Redon drains 8 Ch Sterile marking pen Electrocoagulation forceps Suturematerial (3/0 Resolon, 5/0 and 6/0 Prolene, 3/0 Vicryl, 4/0 Monocryl) Triamincinolene hydrochloride 4:1ml dissolved in 20 ml 0.9% saline Arnica Solution 1:5 diluted with NaCl 0.9% 500 ml 0.9% saline 20ml Scandicainewith epinephrine (mepivacaine hydrochloride) 1:200 000 20 ml/50 ml Xylonest 1% 2 sterile 6 cm 5 cm elastic bandages Mesh stocking

Anatomy of the facial soft tissues


Five layers of critical anatomy: 1. Skin 2. Subcutaneous fat 3. Superficial Musculoaponeurotic system (SMAS)/ muscle layer. 4. Deep Fascia 5. Facial n.

Subcutaneous Soft Tissue Homogenous fascial fatty layer.

Malar Fat Pad: Triangular in shape Beneath is the SMAS. SMAS - Superficial musculoaponeurotic system A tissue plane that is composed of fibrous or muscular tissue, lies in direct continuity with the platysma, and lacks direct bone insertion.

SMAS
History Henry Gray, 1859 Skoog, 1974- Plication and flap suspension in facelift. Mitz and Peyronie, 1976- Detailed anatomic description of the SMAS in the parotid and cheek area : 1.The SMAS was continuous with the frontalis m. 2. Continuous with the platysma m. inferiorly. 3. Motor n. run deep to the SMAS. 4. Sensory n. are superficial.

Jost and Levet, 1984remnant of the primitive platysma muscle; true platysma, risorius, triangularis, auricular posterior. The SMAS over the parotid forms the parotid fascia.

A second layer of facial muscles located deep to the SMAS , oriented vertically and attached to the skull and facial bones; The sphincter colliprofundus: frontalis, periorbital, zygomaticus, and quadratus labiiinferioris.

Parotid region
Mitz and Peyronie, 1976: The SMAS anterior to the tragus is particularlydense. Jost and Levet, 1984: Impossible to separate the SMAS from the deepparotid fascia.

Zygomatic and Temporal regions


Mitz and Peyronie, 1976: The SMAS tightlyadhered to the zygoma. The fascial layer in the temple, thetemporoparietalis fascia, is continuous with theposterior portion of the frontalis m. Jost and Levet, 1984: The SMAS ends at the levelof the zygoma, and does not join the frontalis m Stuzin: Three fascial layers in the temporalarea: Temporoparietal fascia, Superficial layer of deep temporal fascia, and the deep layer of of the DTF.

Nasolabial fold
Mitz and Peyronie, 1976: The NLF as a cutaneousdepression where the SMAS ends. Pensler, 1985: The superficial fascia in the upperlip is continuous with the cheek SMAS through the NLF. Barton, 1992: The SMAS in the anterior cheek isthe nesting fascia for the muscles of the upper lip;Lateral traction on the SMAS would have little effect on the medial cheek skin. Yousif, 1994: Traction on the SMASdeepens the NLF; traction on the fascial fatty layer lessens the fold.

SMAS
S.Aston: It is fibrous, muscular, or fatty,depending on the location in the face: A single, heterogenous layer: Galea Frontalis- Temporoparital fascia SMASOrbicularisoculi- Orbicularis oris-Platysma.

Retaining ligaments of the Cheek


Furnas: Described 4 ls., that support the soft tissue of the face: Zygomatic (McGregors patch), Mandibularretaining ligaments in the cheek: from the periosteum to affix the skin. Anterior Platyma- cutaneous l., Platysma- Auricular l. Stuzin: 2 types of retaining ll: 1. Osteocutaneousll.:Zyg, Man. l.l. 2. Fascial connections: Parotid- cut.l, Massetericcut The zygomaticll ., Stuzin: Fixate the malarpad to the underlying zygomatic eminence in the youthful face. Masseteric Cutaneous ls.,Stuzin, Baker,and Gordon: Fibroelasticsepti that extends between thesuperficial and deep facial fascia along theanterior margin of the masseter m. Provides support to the SMAS- platysma inthe midface.

The platysma muscle


Size: 8*12 cm Origin: Fascia over the upper parts of thepectoralis major and deltoid. Insertion: Skin and subcutaneous tissue of thelower face. Has no bony insertions! Pattern of circulation: type II: Dominant pedicle: submental a. Minor a: suprasternal a. Nerve supply: Motor: cervical branch, VII. Sensory: transverse cervical n.

Vistnes and Souther, 1979: 61%- Decussated from the level of thehyoid 39%- No decussation- Turketglobblerdeformity.

Cardoso de Castro, 1980: Three differentconformations:

Facial Nerve danger zones

Facial danger zone 1


Greater auricular n.-Mckinney andKatrana: 6.5 cm below external auditorymeatus Posterior to SMAS

Facial danger zone 2


Frontal branch of VII A line from 0.5 cm below the tragus to 1.5 above the lateral end of eyebrow.

Facial danger zone 3


marginalmandibularbranch Dingman and Grabb: The mandibular n.passes above the mandibular border81%-posterior to the facial a.

Facial danger zone 4


Zygomatic and BuccalBrancHes

Facial danger zone 5


Supraorbital and Supratrochlearnn.

Facial danger zone 6


Infraorbital n

Facial danger zone 7


Mental n.

The standard facelift procedure


_ Following tumescence and undermining with 1- to 2-mm facial cannulas, disinfection, and suction, a metal comb is used to comb and part the patients hair in preparation for the incision . No hair must be shaved or cut off.

Incision Lines
_ These are first drawn with a sterile marking pen. An important point to bear in mind is that the incision line can and, in fact, must vary, depending on the patients individual hairline. We show here the incision lines made on a patient with a normal Using a number 15 blade, the surgeon starts the incision in the preauricular region.While he pulls the patients ear in a dorsal fashion, the assisting surgeon stretches the patients facial skin slightly. Now the incision is continued temporally to the upper curve of the S in the hair Tumescence region; the assisting surgeon gently pulls up the hair lying in front of and suction the incision. The incision is then continued around the auricular lobule margin Preparation about 2 mm above the retroauricular fold cranially; from here it proceeds margin above the mastoid into the hair-covered portion of the neck in a Incision line zigzag pattern. The assisting surgeon now inserts the long two-pronged hook in the retroauricular incision and pulls the auricle slightly to the front. Using the number 15 blade and then the surgical tweezers, the surgeon can now detach the skin flap over the mastoid. The tendon of the posterior auricular muscle and the insertion of the sternocleidomastoid muscle are exposed. Dissection is continued caudally along this important anatomical line until the great auricular nerve is reached. Dissection must always be carried out under tension. Dissection of the Cheeks and Neck _ Afterwards, further dissection is carried out in the cheek region with theMang dissecting scissors. _ For this purpose, the surgeon inserts the roller hook in the lipocutaneous flap and pulls it up vertically with his or her thumb. The surgeon now has a good view of the dissecting layer. The parotid capsule serves as a guide structure. Following the perforations created by the tumescence dissection, the surgeon detaches the thick lipocutaneous flap. During the dissection in the direction of the orbit, a hard resilient cord is encountered. This is the ligament of the orbicularis oculi muscle. It is exposed and transected. Creating constant tension by pulling upwards with his or her left thumb in the roller hook, the surgeon continues dissection up to the nasolabial fold. This fold constitutes the medial dissection boundary. _ For the dissection of deeper lying areas, the roller hook is replaced by Langenbeck forceps. In place of the Mang scissors, a swab or a saline compress placed over the index finger can be very useful as a blunt dissection instrument. To ensure optimal lighting conditions, the novice is advised to use a forehead lamp.

Deep Dissection and Exposure of the Platysma _ Theplatysma is identified following the complete exposure of the sternocleidomastoid muscle. _ Subsequently, the lipocutaneous flap is detached above the platysma up to the lower edge of the thyroid cartilage. Ideally, this flap should be detached by blunt dissection with the swab. To provide a better view of the surgical area, Langenbeck forceps are used. At this location, as well, it is easy to push back the entire submental region, thanks to the tumescence procedure. Owing to the intact vascular structure, the surgical site now resembles a spiders web. The infrastructural supportive tissue is easily exposed; it can be removed or coagulated if necessary. The risk of injury to the facial nerve is virtually ruled out with this dissection method, since blunt dissection methods are used in critical areas such as the mandibular angle, the lateral orbital region, and the nasolabial area. Wound Trimming andWound Sealing with Fibrin Adhesive _ After the left side has been dissected, precise hemostasis is performed again on the right side under controlled hypotension. The head is lowered to identify any sources of bleeding. Hemostasis is carried out with the following technique: with the aid of a battery-powered headlamp, the surgeon places the Langenbeck forceps in the lipocutaneous flap with his or her left hand and pulls it upwards at a 90angle. Holding the electrocoagulation forceps in his or her right hand, the surgeon coagulates the blood source; a moist flattened saline compress is used as a pad. _ Larger blood vessels can be ligated at this time if necessary. A large number of anatomical structures can now be identified in the surgical area that has been exposed underneath the lipocutaneous flap. These include: the temporal muscle, the capsule of the parotid gland, the orbicular muscle of the eye, the orbicular muscle of the mouth, the platysma, the sternocleidomastoid muscle, the thyroid cartilage, the great auricular nerve, the external jugular vein, and the upper pole of the thyroid gland capsule. _ Finally, the wound area is flushed several times with triamincinolene hydrochloride 40 and then dried with a saline compress.

Postoperative Care and Precautions _ Antibiotic protection was already instituted during the operation and is continued orally for 7 days postoperatively, starting in the evening of the day of surgery. In addition, we administer nonsteroidantiphlogistic agents to minimize swelling and inflammation. _ The surgical wound should be cooled intermittently during the first 3 days postoperatively. _ The patient is given strict instructions to restrict his or her activities drastically for 8 days. He or she is advised to sleep on his or her back, not to laugh or grimace, and to avoid strenuous activities. _ The bandage and Redon drains are removed after 24 h. The patient can subsequently be discharged if arrangements have been made for aftercare at an outpatient facility. _ The wounds are examined and cleaned daily by a physician. Using a cotton swab, the patient applies a thin layer of healing ointment to the sutured areas three times a day. In addition, he or she should wear a loosely wound silk scarf during the day to protect the wound against dirt and dust. At night the patient shouldwear a protective bandage to prevent injuries to the ear region. These precautions are to be followed for around 10 days. The patient is allowed to wash his or her hair under supervision on the third day after the operation.We also recommend that lymph drainage, electrotherapy, and professional cosmetic treatments be instituted on this day to promote wound healing. The patients should avoid exposure to solar radiation. Spectacle frames should not be place directly on the ear in order to prevent infection and pressure points. The sutures may be removed between day 7 and day 10. Sauna visits, sports, exposure to solar radiation, and hair dying should be avoided for 4 weeks. The patient will be able to return to work after 2 weeks. The patient should be advised that the results of aesthetic surgery are not visible for several weeks after the operation. Moreover, scars, swelling, and a loss of sensation around the ears can last for months. Finally, the patient should be advised that aesthetic surgery is not a solution to emotional problems.

Rejuvenation of the Brow

Ideal brow position with the apex of the brow above the lateral limbus.row extends well above this, with its highest point not

vectors of pull.

Central pocket incisions.

(A)Release at the arcus marginalis reveals the retro-orbicularis oculus fat (ROOF). (B) Complete release of the periosteum at the arcus marginalis bilaterally is essential

Blepharoplasty
Overview (Please refer to Figure 1) The eyelid is a bilamellar structure comprising of an anterior and a posterior lamella. The anterior lamella consists of skin and orbicularis oculi muscle. The posterior lamella includes the tarsoligamentous sling (which is comprised of the tarsal plate, medial, and lateral canthal tendon) along with the capsulopalpebral fascia and conjunctiva. The orbital septum, which originates at the arcus marginalis along the orbital rim, separates the two lamella. The tarsal plates constitute the connective tissue framework of both the upper and lower eyelid.

Figure 1. The Multiple Layers of the Eyelid

The Upper Eyelid


7 distinct layers in the upper eyelid: 1. Skin 2. Orbicularis oculi muscle 3. Orbital septum 4. Preaponeurotic fat pads 5. Levator aponeurosis or Levator muscle 6. Muellers muscle 7. Conjunctiva Figure 2. Upper eyelid anatomy. The Orbicularis oculi o This is located beneath the skin and subcutaneous tissue with the following functions: lacrimal pump for tear drainage, protects the globe with forced eyelid closure as well as medial brow depression, voluntary and involuntary blinking. o This is divided into an outer orbital portion and an inner palpebral portion. o The palpebral portion is further subdivided into a preseptal and pretarsal parts. o Beneath the orbital and preseptal portions of the orbicularis oculi is the preseptal fat known as the retroorbicularis oculi fat (ROOF). This fat pad lies over the orbital rim extending outward toward the tail of the eyebrow. Resection of the ROOF decreases the heaviness of the lateral brow and upper eyelid.

The Orbital septum o This separates the anterior and posterior lamella. o It is firmly attached to the superior orbital rim at the arcus marginalis. (Note: Pulling and palpating this structure differentiates it from the levator muscle which is not attached. Inadvertent suspension of the eyelid from the orbital septum will prevent eye closure). o It hangs from the superior orbital rim and joins the levator aponeurosis at the superior border of the tarsal plate.

Figure 3. The Preaponeurotic fat pads

The Preaponeurotic fat pads o These are always anterior to the levator aponeurosis and deep to the orbital septum. o This is composed of two fat pads: medial and central (the lateral space is occupied by the lacrimal gland). o The medial fat pad is yellow and relatively avascular and must be distinguished from the lacrimal gland which is pink to white and bleeds profusely when incised. o The central fat pad contains more fibrous tissue rendering its whiter color than the other fat pads and is surrounded by larger blood vessels making careless removal of this fat pad bloody. In addition, the superior oblique tendon and trochlea lie deep in this fat pad and may be damaged if you happen to get to deep in the orbit resulting to diplopia.

The Levator Muscle o This is the primary lid elevator (opens the upper eyelid). o It originates in the apex of the orbit, just superior to the superior rectus and is supported by the Whitnalls ligament at the orbital aperture. o This muscle becomes aponeurotic as it passes the Whitnalls ligament. o The anterior interdigitation of this aponeurosis with the orbicularis muscle fibers leads to the formation of the supratarsal fold. The Muellers Muscle o This muscle also contributes to eyelid opening and is sympathetically innervated. o This originates from the posterior aspect of the levator aponeurosis and travels inferiorly, closely adherent to the conjunctiva, to insert on the superior border of the tarsus. The Conjunctiva o The innermost layer of the upper lid.

The Lower Eyelid

The anterior lamella consists of the following: 1. Skin 2. Orbicularis oculi (orbital, preseptal, and pretarsal) muscle 3. Preseptal suborbicularis oculi fat (SOOF)

Figure 5.

The orbital septum. o o The orbital septum is a continuation of the orbital periosteum that extends from the inferior orbital rim (arcus marginalis) to the inferior border of the tarsus. The orbital septum fuses with the capsulopalpebral fascia just below the tarsal plate. (Note that in the upper eyelid, the orbital septum fuses with the levator aponeurosis at approximately 2 to 3mm above the tarsal plate). o The orbital septum provides the anterior border of the 3 fats pads found in the lower eyelid: medial, middle, and lateral. o Note that the inferior oblique (which is most commonly injured during blepharoplasty) separates the medial and the middle fat pad. Whereas, the arcuate expanse divides the middle from the lateral fat pad. o The medial fat pad is whiter than the middle and lateral fat pads. The posterior lamella is composed of the following: 1. Tarsus 2. Lower lid retractors 3. Conjunctiva
Figure 6. The Lower Eyelid Anatomy

LANDMARKS FOR ANALYSIS

Upper Blepharoplasty Preliminary markings should be made in the preoperative area to ensure that the scar will be in a crows foot with the patient smiling in the vertical position, and completed on the operating room table following the induction of anesthesia. This is done with the use of calipers to ensure symmetry of markings on both eyelids. First, the upper eyelid crease is marked at the level of the midpupillary line. (Remember that the upper eyelid crease is formed by the levator aponeurosis insertion into the dermis after traversing the orbicularis oculi. This fold is formed by excess skin and muscle that overhang the crease. In Caucasians, the crease is approximately 7mm above the lash margin at the midpupillary line in men and 10 mm in women. Whereas in Asians if the crease is present, this is approximately 4 to 6mm above the lash margin. This low crease is due to the low insertion of the orbital septum and levator apneurosis, allowing preaponeurotic fat to descend into the pretarsal space.)

Figure 7. a. The patient is looking at the root of the surgeons nose. The overlapping skin has been marked. b. Closed eyes. c. Semilunar excision area completed markings. d. Skin excisions and e. Pull out running intradermal sutures.

Figure 8. Upper blepharoplasty and surgical objectives

Lower Blepharoplasty Outline a subciliary incision just below the lash line and extend it about 1 to 2 cm lateral to the lateral canthus more or less depending on the amount of skin that needs to be removed.

Figure 9. Lower blepharoplasty and surgical objective

TIPS AND PEARLS Remember to perform a thorough assessment of the patient. Specific questions as to the presence of dry eyes, diplopia, and use of contact lenses must be asked. Examination of the eyelids should include position of the eyebrow, any obvious eyelid pathology, amount of excess eyelid tissue, position and relative excess of fat pads, presence of lagopthalmos (inability to close the eyelids), and degree of eyelid laxity. Once you incise and penetrate the orbital septum in either the upper or lower eyelid, you are now performing orbital surgery with all of its potential complications like blindness, diplopia, hemorrhage, etc. Treat the orbital fat and deeper orbital structures with respect, avoid and manage bleeding. Make sure that bleeding is controlled before closure. o The central fat pad bulges in the medial upper eyelid if not removed during upper eyelid surgery. It is often not removed for fear of bleeding because it is surrounded by larger blood vessels and contains more fibrous tissue rendering its whiter color than the other fat pads. This can be safely removed by remembering to: 1. Only clamp, cauterize, and remove the medial fat pad that egress from the capsule and 2. Blepahroplasty is integrated with correction of the brow position and correction of midfacial descent. In the upper eyelid, the goals include preservation of upper orbital fullness and a defined upper lid crease. In the lower eyelid, the goasl include smooth transition between the cheek and lid while restoring youthful eye shape. These ideals may require canthal anchoring, periorbitak fat preservation if repositioning, and careful anatomical manipulation of brow and cheek.

Figure 10. Blepharoplasty instruments

SURGICAL TECHNIQUES Upper Blepharoplasty The patient is placed in supine position with their head up. The lower border of the skin excision is defined. The upper border of the skin excision is assessed by gently pinching the eyelid skin between the blades of a pair of blunt forceps. The upper border of the skin excision is defined at multiple points across the upper eyelid. A strip of skin and the underlying orbicularis muscle is then removed from the upper and lower borders of the skin excision. The fat pads are accessed through small incisions in the orbital septum. A clip is placed across the base of the fat pads and they are transected. Light diathermy is applied to the transected base of the fat pad. Variation of the surgical technique Upper eyelid skin invaginating procedures The upper eyelid fold can be reconstructed during blepharoplasty. This is performed by tacking the superficial layers of the upper eyelid to the deeper structures.

Blepharoplasty
Prepared and Edited by:Julie Ann Uy-Regalado MD,FPSOHNS

Blepharoplasty
Prepared and Edited by:Julie Ann Uy-Regalado MD,FPSOHNS

Anatomical Overview (Fig. 5.1) 1. Eyebrow 2. Supraorbital incisure 3. Supraorbital nerve (medial branches) 4. Supraorbital margin of frontal bone 5. Supraorbital nerve (lateral branches) 6. Adipose body of orbit 7. Bulbar conjunctiva 8. Tarsal cartilages 9. Supratrochlear nerve 10. Upper lacrimal duct 11. Fornix of lacrimal sac 12. Medial palpebral ligament 13. Medial angle of eye 14. Upper lacrimal point 15. Upper eyelid 16. Lateral angle of eye 17. Lacrimal nerve (palpebral branches) 18. Orbicular muscle of the eye (palpebral part) 19. Palpebral lacrimal gland 20. Orbital lacrimal gland 21. Levator muscle of upper eyelid 22. Tarsal membrane 23. Supraorbital nerve (lateral branches)

Anatomical Overview (Fig. 5.19) 1. Semilunar fold of conjunctiva 2. Lower lacrimal point 3. Lacrimal caruncle 4. Medial angle of the eye 5. Superior lacrimal canal 6. Fornix of lacrimal sac 7. Medial palpebral ligament 8. Inferior lacrimal canal 9. Lacrimal sac 10. Angular artery 11. Adipose body of orbit 12. Nasolacrimal duct 13. Orbital septum 14. Frontal process of maxilla 15. Supraorbital margin 16. Zygomatic bone 17. Inferior palpebral branches of infraorbital nerve 18. Infraorbital nerve 19. Orbicular muscle of the eye 20. Lower tarsal cartilage 21. Lower eyelid 22. Eyelid edges 23. Inferior conjunctival fornix 24. Lateral angle of the eye 5 Eyelid Surgery Blepharoplasty

Lower Blepharoplasty An incision is made just below the lash margin and is extended laterally along a natural skin crease. The lower eyelid skin can be elevated alone or with a strip of the underlying orbicularis oculi muscle. The three lower eyelid fat pads are accessed through small incisions in the orbital septum. The lower eyelid skin is then redraped and the amount of excess tissue is assessed. The excess skin is excise and the wound is closed with fine sutures. Variation on the traditional technique 1. Fat repositioning procedure to correct tear trough deformity and avoid sunken appearance of the lower eyelid. 2. Lower eyelid transconjunctival blepharoplasty is a procedure wherein the fat pads are accessed through

Otoplasty
Prepared and edited by:Pio V.Nebres M.D.FPSO-HNS Eduardo Yap M.D.,FPSOHNS

Anatomical Overview
1. Temporoparietal muscle 2. Crura of anthelix 3. Greater muscle of helix 4. Cymba 5. Anterior incisure of the ear 6. Lesser muscle of helix 7. Crus of helix 8. Bony external acoustic meatus 9. Muscle of tragus 10. Tragus 11. Antitragus 12. Intertragic incisure 13. Antitragohelicine fissure 14. Auricular lobe 15. Helix 16. Antitragus muscle 17. Cavity of concha 18. Posterior auricular muscle 19. Concha of auricle 20. Auricular tubercle 21. Anthelix 22. Scapha 23. Triangular fossa

(A) Landmarks of the normal auricle. (B) Four components of the auricle

Mattress Suture Technique (Correction of Prominent or Deformed Ears) (Lore after Mustarde, 1963)

A The cartilage anatomy composing a normal ear is shown. B Deformity is absence of antihelix. The ear is folded back to form the new antihelix. This is now marked on the skin with a sterile solution of methylene blue dye. Following this curved line, both medially and laterally, being at least 7 mm from the curved line, through-and-through punctures are made by a hypodermic needle stained with a similar dye. These marks indicate the placement of the mattress sutures. C An ellipse of skin 0.5 to 1.5 cm wide is excised on the posterior aspect of the auricle. Skin and subcutaneous flaps are elevated to expose the dye marks through the perichondrium. Mattress sutures of 4-0 white silk are now placed along the dye marks. These sutures pass through both posterior and anterior layers of perichondrium as well as cartilage but, of course, not through the skin. A non-cutting edge needle is best used to avoid slashing the cartilage. As each suture is placed, it is temporarily snugged down and the effect on the antihelixes surveyed to be sure the result is pleasing without any folds between the helix and antihelix. If not correct, the suture is removed and replaced. Spacing should not exceed 4.0 mm. The number, position, and tension vary depending on the deformity and the desired result. It is not necessary to firmly approximate the posterior layers of the perichondrium. (Fig. 12-2 F and G)

D A variation of the staining technique is depicted. The puncture marks are made along the new antihelix. E Similar mattress sutures are placed paralleling the dye marks. The same precautions, trials, and placements are performed as under C. F Coronal section depicts the placement of sutures through both layers of perichondrium and cartilage but not the skin. G Coronal section depicts the sutures are tied. It is not necessary to approximate the posterior layer of perichondrium. Tension depends on the desired results.

H The completed mattress suture line. If the concha is too cup-shaped, it is sutured to the periosteum of the mastoid bone (Fig. 12-2 O). I If the superior portion of the helix has a tendency to fold out, a tacking suture is placed through the perichondrium and cartilage into the periosteum of the adjacent temporal bone as depicted. J By the same token, if the lobule protrudes, a similar type of suture is placed inferiorly. K Prominence of the ear may be due to a deeply cupped concha. Depicted is a relatively normal antihelix with a deep concha.

L Mustarde corrects this by repositioning the antihelix with mattress sutures. Coronal section depicts the deformity. The arrow indicates the existing antihelix. The suture is placed so that the concha cupping is reduced and the antihelix repositioned medially. M The completed correction in coronal section. Again, the arrow depicts the original antihelix with the new antihelix depicted by X. N Furnas (1968) corrects this deeply cupped concha with a normal antihelix by transecting the posterior auricular muscle and then placing mattress sutures through the auricular cartilage secured to the exposed periosteum and fascia overlying the mastoid bone. Two mattress-type sutures are used. Exact positioning of these sutures may require trial-and-error.

O Care must be used in the placement of these postauricular sutures to avoid pulling the concha forward. Depicted is the correct placement. P Placement of sutures is incorrect, pulling the concha forward and thus narrowing the external auditory canal orifice.

References:
1. Werner L. Mang Manual of Aesthetic Surgery second Edition Springer 2010
2. Dean M. Toriumi MD,Daniel G.Becker MD Rhinoplasty Dissection Manual,Lippincott Williams & Wilkins 1999

3. Grabb Smith Plastic Surgery ^th edition 2007 4. Dimitrije E. Panfilov Aesthetic Surgery of the Facial Mosaic Springer 2007 5. Baileys Atlas of Otolaryngology 6. Charles W. Cummings Otolaryngology 3th Ed 1998 7. Thomas C. Spoor Atlas of Oculoplastic and Orbital Surgery 2010 8.Jack P.Gunter Dallas Rhinoplasty Second Edition Vol 1,2007 9. Calvin M. Johnson,Open Structure Rhinoplasty Saunders 1990 10. Jung I.Park,Asian Facial Cosmetic Surgery,Saunders 2007 11.Robert W. Dolan Facial Plastic Reconstructive and Trauma Surgery,MarcelDekker Inc 2007 12.Ira D. Papel, Facial Plastic and reconstructive Surgery,Thieme 2002

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