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Microscopically-Assisted Open Structure Rhinoplasty

Ahmed El-Guindy, MDORL-HNS Department, Tanta University, Tanta, Egypt

INTRODUCTION

CONCLUSION

SUBJECTS AND METHODS (cont’d)

Figure 1: Accurate Dissection. Figure 2. Preservation of structures.

ABSTRACT

Objective: To evaluate the use of the operating microscope during open approach rhinoplasty for achievement of preoperative goals precisely and accurately.Study Design: A prospective cohort study.Setting: A tertiary care center.Subjects and Methods: In 72 patients undergoing open structure rhinoplasty for cosmetic demand with or without functional request, the operative microscope was used throughout whole procedure. Surgical field was observed for dissection and preservation, surgical steps for accuracy and precision, and operative view for illumination, magnification and depth perception. Surgical results were checked against patient’s expectations and satisfaction, and against conformance to aesthetic and functional standards.Results: Dissection preserved delicate tissues. Surgical steps were accurate and precise. The microscope afforded better illumination, magnification and depth perception, but found unfeasible during lateral osteotomy. 90.6% of surgeries met patient’s expectations while 92.2% fulfilled patient’s satisfaction. 85.9% of cases conformed to aesthetic measures while 93.7% to functional parameters.Conclusion: The use of the operative microscope during open structure rhinoplasty afforded a better illumination especially in the depth, stereoscopic vision and magnification that allowed better preservation of delicate structures and accurate dissection in targeted planes. As an extra advantage over endoscopy, both hands were free. It is user friendly for ENT surgeons. It is superb in photo-documentation and unprecedented in training courses as it offers to trainees an image identical to what the surgeon sees. The introduction of the operating microscope is a value-add to doing a safe rhinoplasty precisely and accurately that ends with achieving preset goals effectively and efficiently.

ROE scale3. Conformance to standards was evaluated for nasal form and function through measuring facial symmetry4 and nasal tip projection and rotation angles, and assessing the nasal septum position (on a four point scale5) and nasal valve (by digital imaging analysis of video-endoscopy6). Data from preoperative and postoperative evaluations were then analyzed to evaluate responsiveness to change. A paired Student’s t test was used to compare preoperative and postoperative scores. A p value of less than 0.001 was considered statistically significant.

Rhinoplasty is a pursuit for perfection, and every aesthetic surgeon strives for excellence. In order to continuously improve outcomes of surgery, each surgical step must be ACCURATE to effectively produce the desired change (validity) and PRECISE to predictably control the desired change (reliability). The operative microscope was used in all the study population during incision, dissection, septum reconstruction, hump removal, medial osteotomies, upper lateral cartilages techniques and alar cartilages remodeling. The introduction of the operative microscope during rhinoplasty offered to us many advantages; the better illumination especially in the depth allowed us to precisely elevate the periostium off the nasal dorsum bones and to effect hump removal and medial osteomtomies under vision. The 3D stereoscopic vision allowed a better depth perception. The magnification afforded by the operative microscope ensured dissection in the proper sub-SMAS level with better preservation of blood vessels and nerves which was reflected by reduced bleeding during surgery and decreased postoperative pain, hematoma and edema. Moreover, the magnification helped us preserve the delicate alar cartilages during elevation of the skin-soft tissue envelop in the proper subperichondrial plane and effect the desired tip remodeling by suture technique predictably in a controllable manner. In addition, it helped accurate cooptation of incision margins with improved healing results. As an extra advantage over endoscopy10, both hands were free. It was found user friendly as ENT surgeons are skilled in microsurgery. It was superb in photo-documentaion and unprecedented in training courses as it offered to trainees an image identical to what the surgeon sees.

This study was performed on a consecutive series of 72 patients undergoing open structure rhinoplasty at Otolaryngology-Head and Neck Surgery Department, Tanta University Hospitals, in the period from February 2008 to June 2009. The indications were cosmetic demand with or without associated functional request. The operation was done under general anesthesia. The operative microscope was used throughout the whole procedure. During the operation, the surgical field was observed for dissection accuracy, preservation of delicate structures and amount of bleeding, the surgical steps for accuracy of the desired change and precision and control over the technique, the operative view for illumination, magnification and depth perception, and the use of the operating microscope for ergonomics and mastery learning. Any emerging difficulty or complication was recorded. The immediate postoperative period was observed for pain, edema and hematoma. Follow up visits were arranged every week in the first two months and then every month for one year. Patient’s expectation was measured by comparing preoperative virtual image with the postoperative real one on a scale2. Patient’s satisfaction was measured by preoperative and postoperative evaluation with

The introduction of the operating microscope in rhinoplasty is a value-add to doing a safe surgery precisely and accurately that ends with achieving preset goals effectively and efficiently with better patient’s QOL.

Rhinoplasty is a pursuit for perfection, and every aesthetic surgeon strives for excellence. In order to continuously improve outcomes of surgery (quality improvement), new armamentaria have been added to increase precision and accuracy in the surgical steps. Power drills to sculpture nasal dorsum, endoscopes to effect internal osteotomies, the 2 mm percutaneous osteotomes to reduce dorsum width precisely and accurately, and non-destructive suture techniques1 to reversibly alter nasal tip position and shape are examples. As he has used the operative microscope for long periods during his training fellowship and practice in middle ear surgeries, extratemporal facial nerve dissection during parotidectomies and phonosurgeries, the author felt that adopting and adapting the microsurgical principles in his open structure rhinoplasties might help achievement of preoperative goals in a predictable and precise manner and improve the quality of life (QOL) of his patients.This study is a prospective cohort study to evaluate the use of the operating microscope during open approach rhinoplasty for achievement of preoperative goals precisely and accurately.

SUBJECTS AND METHODS

1. Tebbetts JB. Primary rhinoplasty: Redefining the logic and techniques Mosby, Elsevier.2008..

2. Mühlbauer W, Holm C. Computer imaging and surgical reality in aesthetic rhinoplasty. Plast Reconstr Surg. 2005;115: 2098-104.

3. Alsarraf R, Murakami CS, Larrabee WF, Johnson CM. Measuring cosmetic facial plastic surgery outcomes: a pilot study. Arch Facial Plast Surg 2001;3:198–201.

4. Orten S, Hilger PA. Facial analysis of the rhinoplasty patient. In Papel ID. Facial plastic and reconstructive surgery. Thieme, NewYork,2002: 361-8.

5. Boyce JM, Eccles R. Assessment of subjective scales for selection of patients for nasal septal surgery. Clin Otolaryngol 2006;31:297–302.

6. Keck T et al. Video-endoscopy and digital image analysis of the nasal valve area. Eur Arch Otorhinolaryngol 2006;263:675–9.

REFERENCES

Ahmed El-Guindy, MD.ENT Department, Tanta University, Tanta, EgyptEmail: aelguindy@yahoo.comPhone: +20184988000Website: www.tanta.edu.eg

CONTACT

RESULTS

72 patients met the inclusion and exclusion criteria, 64 of them completed the follow-up period. During the operation, dissection was found more accurate in the proper sub-SMAS level with noticeably reduced bleeding (Fig. 1), and delicate structures as alar cartilages were remarkably preserved (Fig. 2). The operative view was optimized by better illumination, magnification and depth perception. During execution of the surgical steps, the desired change was accurately effected and predictably controlled (Fig. 3-5). The surgeon being an ENT consultant found the operating microscope user friendly and the operation time decreased remarkably with ascent of the learning curve. The use of the microscope was found unfeasible during lateral osteotomy as it needs a wider view. Patients’recovery was uncomplicated with lesser pain, edema and hematoma and unremarkable scar.90.6% of surgeries met patient’s expectations while 92.2% fulfilled patient’s satisfaction. 85.9% of cases conformed to aesthetic measures (Fig. 6) while 93.7% to functional parameters.

DISCUSSION

Figure 3. Asymmetry of crura. Figure 4. Columellar strut in place.

Figure 5. Power burr hump reduction. Figure 6. Pre and Postop views.