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Rhinoplasty Techniques

2006; American Medical Association; Volume: 8; Issue: 5 Linguagem: Francês

10.1001/archfaci.8.5.341

1538-3660

Frederick J. Stucker, Alan R. Burningham,

Global Healthcare and Medical Tourism

Archives of Facial Plastic SurgeryVol. 8, No. 5 PerspectivesFree AccessRhinoplasty TechniquesA Historical Perspective and Survey of 8155 Single Surgeon CasesFrederick J. Stucker and Alan R. BurninghamFrederick J. StuckerCorrespondence: Dr Stucker, Department of Otolaryngology–Head and Neck Surgery, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Hwy, Shreveport, LA 71130 E-mail Address: fstuck@lsuhsc.eduSearch for more papers by this author and Alan R. BurninghamSearch for more papers by this authorPublished Online:1 Sep 2006https://doi.org/10.1001/archfaci.8.5.341AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail The teaching of rhinoplasty surgery has evolved over the past 50 years to its present status of measured and systematic techniques routinely taught in our residencies and fellowships. The impact of this is a measurable improvement in the technical expertise of a trained otolaryngologist. There is a profound difference between the level of formal training given today and that of 4 or 5 decades ago. Today, the majority of otolaryngology–head and neck surgery residents and most assuredly those fellowship-trained individuals are remarkably well schooled in nasal surgery. The transition from a few experts of 50 years ago to today's flow of consistently well-trained specialists is a remarkable evolution. This educational advancement demonstrates how markedly different rhinoplasty training was 50 years ago. The difficulties encountered by interested individuals to acquire the necessary skills to present themselves as rhinoplasty surgeons were immense. The obstacles a fledgling rhinoplasty surgeon had to overcome prior to the residency programs accepting the teaching responsibility of their field was daunting and is a testimony to some of the early leaders in the field.AN EVOLUTION IN RHINOPLASTY TEACHINGThose individuals who wished to acquire the skills necessary to perform rhinoplasty surgery in the 1950s and 1960s following their formal training would invariably take a week-long course from one of the leaders or pioneers in the field. Men such as Maurice H. Cottle, MD, Irving B. Goldman, MD, and Ira J. Tresley, MD, routinely conducted such courses. Often these attendees would return to take the course again in ensuing years or perhaps enroll in another of these experts' training formats. These courses were quite diverse, and conflicting opinions and techniques were espoused. Proponents of one or the other technique became dedicated disciples of one technique or another. Since these were very strong willed and talented individuals, their tenets were often standardized and actually became more divergent from one another. Although major contributions evolved by these experts, there was little communication among the various schools. Pettiness and zeal of a religious proportion precluded ecumenical sharing of ideas. Real growth in the field awaited the formation of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS).The AAFPRS was founded because a group of individuals interested in facial plastic surgery appreciated the need for an ecumenical educational venue. This was in sharp contrast to the exclusivity of the previously mentioned schools of thought. These surgeons were more inclusive and less inclined to follow the prejudicial zeal of their predecessors. A less dogmatic approach and a more inclusive attitude lay the ground work for an organization dedicated to educating a new generation of facial plastic surgeons without the constraints and the dogma of their predecessors.It was extremely fortunate that the specialty of otolaryngology–head and neck surgery had a group of very talented individuals with an ecumenical disposition at that time. Another fortuitous occurrence was that the specialty made significant parallel growth and expansion in other subspecialty areas such as head and neck surgery and otology. The global appeal of the specialty broadened and increased. The numbers and the quality of the individuals attracted to otolaryngology increased. Residency quality markedly improved, but the subspecialty of facial plastic surgery was yet to be embraced by the academic community. Fellowship training was a natural evolution of this process but was delayed a decade or two by the reticence of program directors to embrace the subspecialty as a legitimate arm of otolaryngology. The early growth of facial plastic surgery depended primarily on the selfless efforts of academy individuals who organized courses to fill the void left by disinterested academicians. This may be the only instance in our specialty in which the private sector provided the impetus and leadership for core curriculum changes in our academic programs. It provided the format necessary to promote and advance a subspecialty until its eventual incorporation into the structure of the residency programs.Following the founding of the AAFPRS, whose primary purpose is education, its open forums provided the teaching in the budding subspecialty area until it was embraced and imbedded in the residency curriculum as it is today.Figure. Number of procedures performed using the cartilage splitting approach (A), delivery approach (B), and external rhinoplasty approach (C) and the number of all approaches (D).With this backdrop of rhinoplasty education, I (F.J.S.) reviewed my 35-year experience of rhinoplasties and the evolutions of the techniques that I have used. Using a database containing the surgical records from the past 35 years, I reviewed and categorized the techniques based on the rhinoplasty approach used and the indication for each procedure. As of the end of 2005, I had performed 8155 rhinoplasty procedures. The Figure shows the number of procedures performed each year using the cartilage splitting, delivery, open, and all techniques. The indications for each approach are summarized in the Table.RESIDENCY TRAININGIn residency training, 2 of our staff members had taken the previously mentioned 1-week courses. As expected, they advocated their respective experience. One subscribed to the dome division technique, having completed the Goldman course. The other managed the lower lateral cartilages (LLCs) though an intercartilagenous incision and surgically modified the LLC in a retrograde manner. They taught the house officers these techniques. In 1966, Jack R. Anderson, MD, published an article that was lucid and easily understood, and as a result, served as the basis for my early rhinoplasty experience.1 I personally carried out the cartilage splitting technique as described by Dr Anderson in his article on over 80 patients in my chief year of residency.EARLY PRACTICEIn the years following my residency training, I was fortunate to perform a great number of rhinoplasties. The cartilage splitting technique became very familiar to me, and this facile procedure, with immediate surgical gratification, was quite appealing. Long-term results were an anathema to this young surgeon enthralled with some of his seemingly excellent early results. The 4 years following my residency I had the good fortune, or so I thought, of doing over 1000 rhinoplasties, all via a transcartilage approach. Problems were starting to present themselves in spite of a military practice in which longer follow-up was not easily obtained.FELLOWSHIP WITH TARDY AND BEEKHUISIn 1973 I had the opportunity of spending a fellowship year with 2 renowned surgeons who rarely used the technique that was by now a habit for me.My first exposure to the cartilage delivery technique was by observing M. Eugene Tardy, MD, who used this method routinely. It is technically more difficult, but the skill and finesse of Dr Tardy made it appear quite facile. The compulsive examination of his results and the routine scrutinizing of his long-term follow-ups impelled in me a more discriminating review of my results, which has lasted a lifetime. The cosmetic complications that occurred using exclusively the splitting technique were troubling. Dr Tardy convinced me to reflect on my technique. It occurred to me, and Dr Tardy reinforced this observation, that tip problems could result from unidentified anatomy routinely undiagnosed in the blind transcartilage technique. Inherent to the splitting technique is that the surgeon is unaware of potential anatomic problems. In addition, the traction required to evert the LLC pulls it away from the soft tissue rim jacket. This generally results in a more generous resection of cephalic margin of the LLC than intended. The combined effects of a very narrow caudal strip and perhaps unidentified asymmetry make the operated nose subject to the vicissitudes of scar contracture during healing. These combined forces can result in various postoperative deformities. These contractions and abnormal lower lateral cartilage (LLC) deformities yield the various cartilage distortions often seen with this technique. No technique is perfect or without potential problems, but in my experience the transcartilage procedure has potentially more problems compared with techniques that allow visualization and more precise surgery on the LLC. The postoperative deformities are more common and amplified in thin-skinned individuals.Dr Tardy's surgical management of the nasal tip convinced me that the delivery technique had clear advantages in many situations over my favorite procedure. I then had the opportunity to spend a few months of my fellowship with Dr G. J. Beekhuis, MD (many fellowships were split in those days). He was a very versatile surgeon who used several techniques (splitting, delivery, and dome division). He had indications and criteria for each and had personally visited a great number of the accomplished rhinoplasty surgeons in the United States and Europe. He assimilated many tricks and pearls from the numerous sources and was a significant beneficiary of the ecumenical exchange brought about by his efforts and the AAFPRS. He had a thriving practice, and I was afforded the opportunity of observing a large number of rhinoplasties. The fellowship experience made a life-long impact on my career as a rhinoplasty surgeon because of the broad exposure to various techniques and because it instilled a curiosity and a desire to keep looking for new techniques and refinement of my own practice. Both these surgeons followed their cases with a compulsive zeal. Specifically, they followed their result with an unquenching desire to determine the reason for any adverse result or surgical indiscretion.It is my opinion, based on my mentors’ philosophies, that the more familiar we are with the consequences of our previous surgical actions, the more likely we are to increase our experience and skill.POSTFELLOWSHIP PERIODThis started as a confusing period; I was familiar and comfortable with the splitting technique and carried it out with alacrity. Yet intellectually I appreciated its shortcomings and the superior aspects of the delivery technique in many patients. As I became more familiar and comfortable with the delivery approach, within 3 years of my fellowship this technique became the dominant one that I used. The fundamental reason for this change is that delivery of the LLC procedures, for me, had yielded more predictable long-term results. The transcartilage technique described by Anderson1 continues to be a valuable tool because it is the least invasive, but because it is the least versatile, the indications are rather limited.A review of this series of 8155 rhinoplasty cases indicates that the most significant change over 35 years is the replacement of the splitting technique with the delivery approach as the dominant procedure. This evolution occurred over a 4-year period and was a response to the combination of my fellowship experience and a rather significant percentage of tip asymmetries and bossing noted postoperatively with the splitting technique. Often this was observed in a gradual or subtle deterioration following a very acceptable early result. Another noteworthy factor in this evolution was the experience gained from the revision surgery on those with less than ideal results. Managing those presenting for revision surgery through a repeated procedure of the original blind technique proved to be extremely difficult. The delivery technique at revision often revealed previously unrecognized asymmetry and/or excessive resection of the cephalic margin of the LLC at the primary surgery. There was also a significant number of regenerations of the previously resected LLC.2 For these reasons, in 1977, the delivery technique replaced the splitting technique and has continued to be the favored approach in this series of rhinoplasties.EXTERNAL RHINOPLASTYMy first exposure to the external rhinoplasty technique was at a cleft lip and palate course, which I attended in 1975. Janus Bardock, MD, advocated its routine use in managing the nasal deformity in the patient with unilateral cleft lip. For congenital deformities of the LLC, the approach had unquestioned appeal. The ability to directly view and modify the cartilage structures with suture and/or grafts moved this type of surgery exponentially forward. Why I did not immediately use this technique in other challenging rhinoplasty cases probably was because of my reluctance to jump on the popular external rhinoplasty band wagon. The axiom to not be the first nor last to embrace a new wave and my high comfort level with the delivery approach likely influenced my reticence. The popularity of the external rhinoplasty is obvious, and for a majority of residents finishing after 1985, it was the only approach taught and practiced by them. The hesitancy of previous generations of surgeons to routinely commit all rhinoplasty patients to a transcolumellar incision likely dampened the acceptance of this technique (which was not new but only newly revived). The concerns and reluctance of surgeons to embrace this more radical approach were allayed by the promotion of this technique by well-established surgeons, such as Jack Anderson, MD, and Calvin Johnson, MD.3,4 It is ironic that Jack Anderson is most responsible for the acceptance of the cartilage splitting technique and also the individual most responsible for its demise. I can only speculate that his experience of managing thousands of LLCs blindly and then visualizing their entire anatomy and their relationships through the external approach had to be life-altering. Clearly, Dr Anderson had the most influence in popularizing 2 of the most polarizing techniques in rhinoplasty surgery. I was somewhat slow to the table in incorporating the decortication technique in my general rhinoplasty practice, but over the years I have increased my indications and the incidence. Besides cleft lip rhinoplasties, other routine indications for the external approach in my practice include revisions, ethnic noses, and most patients requiring cartilage grafts.THE PAST 15 YEARSFor the past 15 years, the indications and techniques used in my practice have been remarkably steady. The total numbers have fallen, which may be explained by several humbling reasons; I prefer to think that 50% of our city's otolaryngology–head and neck surgery practitioners have trained in our program.Hopefully, experience and maturity explain the stable relationship of the basic techniques. The delivery technique accounted for 53% of cases in the past 15 years. The external approach accounted for 35%, while only 11% were carried out via the transcartilage technique.The cartilage splitting technique is an expedient procedure used when little tip work is indicated, especially in thick-skinned individuals. It is never used in thin-skinned female patients, whatever the presentation, with the direct visualization of the tip cartilages being preferred. A few cases each year present with unusual circumstances lending to the use of external incision. Excessive skin that has no potential to shrink and excision of skin is mandatory, and rhinolifts are the most common presentations.COMMENTThere is little doubt that all surgery is evolutionary when improvements and subtle modifications occur more than quantum changes. Since the introduction of rhinoplasty surgery by Jacque Joseph, MD,5 and John Orlando Roe, MD,3 there has been little change in the procedure and it had not achieved wide acceptance until the 1950s. My experience with 8155 cases reflects this evolution. It is clear that no single technique can address the myriad of anatomical variations and clinical challenges in rhinoplasty. The clinical setting dictates the preferred approach at the discretion of the operating surgeon. The cartilage splitting technique may be used in thick-skinned patients when only a minimal amount of resection is required and tip work is not needed. The delivery approach is suitable for most primary rhinoplasties and is my preferred approach for patients who require tip grafts. Open rhinoplasty is the preferredapproach for most nonwhite patients, complicated revisions, tip grafting, cleft lip or other congenital anomalies, and repair of septal perforations. Fortunately, our training programs have evolved significantly over the years and now incorporate the collective knowledge and experience of those who have dedicated their careers to refining the practice of rhinoplasty.REFERENCES1. Anderson JR. A new approach to rhinoplasty. Trans Am Acad Ophthalmol Otolaryngol. 1966;70:183-192.5913650 Medline, Google Scholar2. Stucker FJ. Cartilage regeneration: a clinical and experimental study. Trans Sect Otolaryngol Am Acad Ophthalmol Otolaryngol. 1977;84(4 Pt 1):ORL-785-790.898528 Medline, Google Scholar3. Cottle MH. John Orlando Roe, pioneer in modern rhinoplasty. Arch Otolaryngol. 1964;80:22-27.14152147 Medline, Google Scholar4. Anderson JR, Johnson CM, Adamson P. Open rhinoplasty, an assessment. Otolaryngol Head Neck Surg. 1982;90:272-274.6810277 Medline, Google Scholar5. Joseph J. The classic reprint: nasal reconstruction. Plast Reconstr Surg. 1971;47:79-83.4921911 Medline, Google ScholarFiguresReferencesRelatedDetailsCited byHas the Pendulum Swung Too Far? Trends in the Teaching of Endonasal Rhinoplasty Steven Dayan and Raj Kanodia2 November 2009 | Archives of Facial Plastic Surgery, Vol. 11, No. 6Measuring Outcomes in Nasal Surgery Realities and Possibilities John S. Rhee2 November 2009 | Archives of Facial Plastic Surgery, Vol. 11, No. 6 Volume 8Issue 5Sep 2006 InformationCopyright 2006 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.To cite this article:Frederick J. Stucker and Alan R. Burningham.Rhinoplasty Techniques.Archives of Facial Plastic Surgery.Sep 2006.341-345.http://doi.org/10.1001/archfaci.8.5.341Published in Volume: 8 Issue 5: September 1, 2006PDF download