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     Rhinoplasty
                                                   Rhinoplasty

                                  • Bone,cartilage,soft tissue of nose
         ,   ., .                 • Osteotomy,tip plasty,alar plasty
                                  • grafting




     Rhinoplasty
                                                   Asian Nose
    in ASIAN nose
                                  •   Asian Nose
                                  •   Broad low dorsum
                                  •   Decreased tip projection
                                  •   Thick lobular skin
• Augmentation > Reduction
                                  •   Wide lobule
                                  •   Abundant subcutaneous fatty tissue
                                  •   Alar flaring
                                  •   Retracted columella
                                  •   Small osteocartilagenous framework




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    Augmentation rhinoplasty
                                                              Implant materials
                                                       Ideal characteristics
                                                                   nonimmunogenic
• Augmentation of nasal bone,upper-lower
  cartilage using various grafting materials                           Durable
                                                               Capable of being scalpted
                                                                 Resistant to infection
                                                                     Long lasting




                   Options                                          Biological graft


               • Biological graft
                                                                         • Autograft
                                                                   bone: calvarium/hip/leg
                • Synthetic graft
                                                                  cartilage: septum,ear,rib




         Autologous cartilage                                         Homograft


   – Short supply                                                          Alloderm
   – Donor site morbidity                                          Irradiated Rib Cartilage
   – Quality of available graft may preclude use




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                         Alloderm                      Irradiated Homograft Rib Cartilage
• Acellular human dermis
  obtained from donated human                         • Appears to be stable
  skin                                                  over time
• Provides soft tissue
  augmentation that is stable                         • Risk of warping
  after an early period of                              decreased if carved
  resorption (6 months); must
  overcorrect                                           from core
• Can be used to camouflage
  contour irregularities created
                                                      • Easy to carve and
  by alloplastic or autoimplants                        stabilize with sutures
  in nasal reconstruction




                        Alloplasts                           Liquid silicone injection
• liquid :
  liquid silicone (polydimethylsiloxane)
• semisolid : polyacrylamide (aquamid)
• solid

   – Silicone rubber
   – Porous High Density Polyethylene (Medpor)
   – Extended PTFE (Gore-Tex)




  Solid Silicone Rubber [Silastic]                               Silicone Implants
• Solid, non-porous implant
  which is not incorporated into
  surrounding tissues                                     • Solid Silicone has been used as a
• Fibrous capsule-forming
• Elicits minimal inflammation                            material for facial implants since about
• ?Tendency to extrude/migrate                            1956. The silicone facial implants are
• Cannot be used in thin-skinned
  areas                                                 solid, yet flexible. They are manufactured
• Used as L or I-shaped implant
  or the “bird”
                                                         in different durometers (strengths) to be
• Easily be carved,removed                                            soft or quite hard
• Popular in Asian countries




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                                                              Tissue Engineered Human
           Silicone Implants
                                                                    Chondrocytes
 • Bad thing about silicone implants. or                • Methods of culturing
                                                          human chondrocytes
   implants in general, is that in some thin-             is active area of
   skinned patients or after aging, the implant           research
   itself can become palpable (easily seen              • Recently the
   and felt) - especially if they are not placed          engineering of human
   or sized correctly. There is also an                   nasal septal
                                                          neocartilage
   possibility of infection even years after              described without use
   implantation.                                          of biodegradable
                                                          scaffold




In cartilage tissue engineer lab                                     Biological graft
                                                        • Advantages



                                                                            No rejection
                                                                            Long lasting
                                                                         Less complications




              Biological graft                                       Synthetic graft
 • Disadvantages                                                         • Advantages

                                                                       No donor site morbidity
                Donor site morbidity                               Higt quality of graft (cosmetics)
         Limited quality of graft (cosmetics)                             Less expensive
                    Expensive




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                 Synthetic graft                                      Conclusion

                      • Disadvantages             • Silicone elastomer and new inert biomaterials still
                                                    have place in asian rhinoplasty.
                        More rejection
                         Long lasting?
                                                  • Autogenous cartilage fabrication in the form of nasal
                                                    prosthesis will replace and use more and more
                       More complications           especially in complicated,secondary rhinoplasty

                                                  • Cartilage tissue engineering in the form of nasal
                                                    prostheses will be used in the future.




                      Rhinoplasty                                          Silicone Prosthesis
                     in Asian nose
•   Silicone augmentation – most popular
•   Affordable
•   Readily available
•   Easily fashioned
• No donor site morbidity
• Easy,short time operation




                                 Silicone
                                    “L”-shape


         Bird shape




         “I” shape




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 Approaches


• Closed technique
    (endonasal)
 • Open technique




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                Open technique




            pocket          Prosthesis
• Superficial




• Submucular
•   Supra-periostium
•   Sub-periostium

• Mixed plane




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             Closed technique                                Patient evaluation


                                                                  • Motivations
                  Mostly used
                                                                 • Expectations
                   technique
                                                                   • Concerns
                                                         • Explannation/communication
                                                              • Pre-op. evaluation
                                                                 • Photography




                     History                                    Examination
•   nasal trauma                                 •   External nasal deformity
•   nasal obstruction                            •   Internal nasal anatomy
•   nasal obstruction                            •   Tip ptosis
•   allergic disorders                           •   Septal deviation
•   comorbid conditions                          •   Existence of any purulence in the middle
•   medications                                      meatus
    – aspirin, anticoagulants, and herbal
      supplements




                                                       Preoperative photographs
                                                                  • frontal view
                                                                  • lateral view
                                                              – Frankfort horizontal plane
                                                                   • basal view
                                                                  • oblique view




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                                                                       INDICATIONS


              • Informed consent
                                                                • Functional and/or aesthetic
                  • questions
                                                          • Nasal obstruction secondary to anatomic
                   • concerns                                              deformities




                Indications                                        Contraindications
• Contours the nose and makes it proportionate            • Augmentation rhinoplasty has relatively
  with the rest of the face
• Augments flat nose (Low nasal profiles)                   few contraindications. Any medical
• Narrows nostrils that flares                              condition that inhibits patient safety during
• Corrects droopy nasal tips, bumps or                      the procedure is a contraindication.
  irregularities
• Defines and sharpens the nasal tip
• Corrects a deviated or crooked nose Makes long
  and wide noses smaller and thinner
• Corrects nasal length (if too long or too short)
• Improves breathing




                                                                         Photography

• Patients should not be taking any
  anticoagulants (eg, enoxaparin [Lovenox],
  warfarin [Coumadin], heparin [Hep-Lock]),
  aspirin, or nonsteroidal anti-inflammatory
  drugs before the surgical procedure




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                Instrumentations




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         COMPLICATIONS
• As is true in other surgical procedures,
  occasional postoperative complications
  should be expected in rhinoplasty.
  Fortunately, most complications are minor.
  In general, approximately 5-15% of
  patients require a revision rhinoplasty




       Serious complications

• less than 3% of patients and consist of
  – Infection
  – rejection
  – extrusion
  – unfavorable scarring
  – anesthesia-related problems




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                        Prosthesis




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     Prosthesis




                                       Prosthesis
  Deviation




                                       Prosthesis
Depressed scar




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                   Prosthesis

        • Prosthesis

        •




                                                          ,          ,
•          Dorsal Root , dorsum
    Stability   Prosthesis
•
•       Silicone     Curve




      prosthesis




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stability   prosthesis




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         Factors for success in rhinoplasty
     •   Anatomy
     •   Structure-tissue evaluations
     •   Sterile technique
     •   Graft charactor-tissue response,selection
     •   Skills - experiences
     •   Art
     •   Patient doctor-relationship
     •   patience




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