Rhinoplasty

The nose is a primary factor in determining facial aesthetics. The central location combined with the visual prominence on the sagittal, coronal, and transverse planes supports this observation. Rhinoplasty is an aesthetic procedure requiring great precession. Rhinoplasty is divided into two main procedures, closed or open. The main difference between closed and open rhinoplasty is the incision used and the exposure of the nasal framework. ⁽¹⁾ The closed technique is a fast and efficient method for addressing certain anatomic nasal deformities, specifically those requiring reduction procedures. ⁽¹⁾ The open technique offers advantages in terms of direct visualization and control. These advantages make the open technique superior for the correction of tip under projection and severely deviated noses. ⁽¹⁾

The surgeon will give a thorough physical evaluation, which facilitates surgical planning. Key steps in this evaluation are evaluating the entire face for shape, size, symmetry, and proportion. The nasal tip will be evaluated for size, shape, position of the tip defining points, skin quality, and skin thickness. The septum, turbinates, internal and external valves will be examined. The surgeon will use diagnostic and analytical techniques including anatomic, functional, photographic, and computer imaging. ⁽¹⁾ Standard photographic procedure is to take a front view, worms eye (inferior aspect ⁽²⁾), three-quarter (right and left) views, and a profile view (in repose and smiling).

Figure 1. Face Profile - sagittal plane

Tip projection is defined as the distance from the tip of the nose to the most posterior point of the nose-cheek junction. ⁽¹⁾

Figure 2. Nose profile - sagittal plane

The preoperative exam should include a thorough evaluation of the shape, size, location and inherent strength of the medial, middle and lateral crura of the alar cartilages. ⁽¹⁾

Figure 3. Anterior aspect nose, coronal plane

The arterial supply of the nose comes from two sources: 1. dorsal nasal artery (anterior ethmoidal), which is a branch of the ophthalmic artery and supplies the proximal nose and subdermal plexus of the tip; 2. two branches of the facial artery, the angular artery and superior labial artery, both of which supply the nasal tip area.

Figure 4. Gray’s Anatomy Figure 514 ⁽³⁾

Figure 5. Grey’s Anatomy Figure 508 ⁽³⁾

A cold compress should be applied for 48 hours postoperatively, to minimize bruising and swelling. The head should remain elevated while resting and during sleep. The patient should sleep on their back. Heavy exercise and sexual intercourse should not be performed for three weeks postoperatively. Alcohol, and consumption of NSAIDs (non-steroidal anti-inflammatory), vitamin E, is prohibited for one week. Pain medication is usual prescribed for a transient period.

Figure 6. Projecting tip reduced, dorsal lowering

Figure 7. Dorsal lowering, reduced tip projection, shortening of the caudal septum, correction of cranial, lateral asymmetry

Figure 8. Dorsal lowering, removal of a dorsal hump

References

1. Aston, Sherrell J, Steinbrech, Douglas S and Walden, Jennifer L. Aesthetic Plastic Surgery. s.l. : Elsevier Limited, 2009. ISBN: 978-0-7020-3168-7.

2. Standring, Susan. Gray’s Anatomy The Anatomical Basis of Clinical Practice. 40. s.l. : Churchill Livingstone ELSEVIER, 2008. p. xxiii. 978-0-443-06684-9.

3. Gray, Henry. Gray’s Anatomy. 15th Edition. New York : Barns & Novle Books, 1901, 1995.

Posted in General, Rhinoplasty
Tags: cosmetic surgery, nose job, Nose Surgery, Rhinoplasty

Liposuction Surgery

Liposuction surgery (lipoplasty), is performed to remove unwanted localized fat deposits. The ideal candidates for this procedure are patients with localized fat accumulation who have been unable to reduce these areas through diet and exercise. The reduction of adipocyte (fat cell) volume can be accomplished by diet (energy intake restriction) and exercise (directly - through work performed, indirectly - through increased BMR). These methods work by inducing a prolonged catabolic state that promotes lipolosis, and gluconeogenesis. One can lose a significant amount of body fat, through mobilizing the 9 kcal/g energy store in adipose tissue but still have a significant local accumulation specific to a body part or area. Contrary to the common misconception, exercises targeted to a specific muscle group or body area will not reduce the body fat local to the specific area. Lipoplasty removes adipose cells present as opposed to reducing individual cell volume, like is seen with a negative energy balance. It is for this reason, lipoplasty applied specific adipose stores may offer aesthetically pleasing results.

Lipoplasty procedures including LVL (large volume lipoplasty), are not substitutes for diet and exercise, as research and primary literature have shown that lipoplasty does not reduce the metabolic risk factors for coronary heart disease, or improve insulin sensitivity.

Fat excess or deficiency can have adverse effects on endocrine function. Since significant adipose tissue removal can be achieved through lipoplasty, the procedure should be taken seriously. Adipose tissue is integrally involved in coordinating a variety of biological processes including energy metabolism, neuroendocrine function, and immune function. Adipose tissue is a major site for metabolism of sex steroids and is active in both efferent and afferent signaling. Two major efferent signals produced by adipose tissue are adipsin, and leptin (endocrine factors). Adipose tissue is known to express and secrete a variety of bioactive peptides (adipokines), which act at both the local (autocrine/paracrine) and systemic (endocrine) level. Adipose tissue expresses numerous receptors that allow it to respond to afferent signals from traditional hormone systems as well as the (CNS).

Tumescent liposuction consists of injection of fluid into a specific area as preparation for liposuction surgery. This procedure sometimes helps to reduce the bleeding and facilitate the liposuction surgery. A common method of preparing tumescent solution involves the use of a 3 L bag of lactated Ringer’s solution to which 2% lidocaine 75 ml is added yielding a concentration of 0.05% lidocaine. Next, 1:1000 epinephrine 3 mL is added, resulting in a 1:1,000,000 concentration of epinephrine. The Ringer’s lactate contains 28 mEq/L of bicarbonate ion and has a resultant pH of approximately 6.5. The system is pressurized to approximately 200mm Hg. A suction tube is inserted through a small incision. The surgeon minimizes the incision scar visibility, whenever possible, by placing the incision within and parallel to skin creases on the body.

Multiple modalities for the removal of adipose tissue exist in lipoplasty. SL (syringe lipoplasty), SAL (suction assisted lipoplasty), PAL (power assisted lipoplasty), and UAL (ultrasound assisted lipoplasty), are such modalities. Limitations of traditional lipoplasty (SL / SAL), when performed on fibrotic areas, such as the back, flanks, and gynecomastia, or in secondary or LVL procedures, encouraged the development of energy-efficient devices that allow greater precision and require less physical effort to use. The introduction of UAL, PAL, VAL (Vaser-assisted lipoplasty) resulted in less trauma to the patient, as evidenced by decreased ecchymoses. The surgeon will select the appropriate method, or combination thereof, as appropriate for the anatomy of the area and the tissue removal quantity required.

Areas where the liposuction procedure can be beneficial are the neck, arms, abdomen, waist, back, thighs and knees.

Figure. Lipoplasty preformed on the waist and thighs. This patient is an example of an ideal candidate, in whom, diet and exercise were not adequate to markedly reduce the size of the adipose tissue, heavily distributed in the waist and thighs.

Figure. Lipoplasty of the waist and back. A significant reduction in waist size was achieved by removing adipocyte stores in the waist and lower back. The “love handles” as patients sometimes refer to the adipose tissue located superficial to the external abdominal oblique, internal abdominal oblique, gluteus medius, and tensor fasciae latae muscles.

Figure. A Profile view of a young female, with an adipose tissue store located superficial to the digastric, mylohyoid, and stylohyoid muscles. The postoperative view taken at 1-years time, displays a feminine neck contour, with no skin redundancy. The patients skin elasticity was excellent, which enabled the skin to adjust to the new neck contour after the appropriate volume of adipose tissue was removed.

Posted in Abdomen Waist and Thighs, Arm Reduction, Back & Waist, General, Liposuction, Neck
Tags: abdomen, arms, back, Lipoplasty, Liposculpture, Liposuction surgery, Neck, waist