External Incisions in Rhinoplasty a Historical Review
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FA2E 1553 2D E5-8A External incisions in rhinoplasty a historical review T.D. ZIJLKER, M.D.*, H. VUYK, M.D., Ph. D.**, P.A. ADAMSON F.R.C.S.C., F.A.C.S.*** * Department of Otorhinolaryngology and Head & Neck Surgery, University Hospital Maastricht, P O Box 5800, 6202 A) Maastricht, The Netherlands * * Department of Otorhinolaryngology and Facial Plastic Surgery, ,ooi- Noord Hospital, .i/ksstraat0eg l, 1261 AN Blaricum, The Netherlands * * * Department of Otorhinolaryngology and Facial Plastic Surgery, University of Toronto, Toronto, 2anada Summary Extern l incisions in rhinoplasty h ve long tr dition, from the ncient cultures until present. The n ture nd loc liz tion of the n s l bnorm lities h s determined the 0 y of exposure. Ho 0ever, lthough rhinoplasty st rted by me ns of n extern l incision through s1in nd c rtilage, during the 20th century it developed into sophistic ted techni4ue m inly executed 0ith n endon s l or 5closed5 ppro ch. More recently, the concept of n extern l ppro ch of the n s l s1eleton, 0hich h s ppe led to f cial plastic surgeons in se rch for improved exposure, encountered rene0ed ppreciation. Initi lly dvoc ted in the 17809s by Rethi, nd later improved by Sercer, P dov n, nd :oodm n, the extern l ppro ch using columellar s1in incision h s evolved to its present st tus in 0hich it enjoys gro0ing interest nd pprov l for v riety of indic tions. A historic l revie0 of the extern l s1in incisions used for rhinoplasty is presented. Keyvoords: incision, extern l rhinoplasty, history Introduction The history of rhinoplasty goes b c1 to the e rli- Exposure is b sic principle in surgery. In recon- est ye rs of the ncient cultures in India, Egypt, structive nd esthetic n s l surgery, both endon s l :reece nd It ly B1-2C. Until 0ell into the 17th cen- nd extern l incisions re used. The n ture nd tury, n s l surgery 0 s confined to the immediate loc liz tion of the n s l p thology by nd large de- c re of cute injuries nd to flap reconstruction of termines, 0hich incision is the most prefer ble nd p rts cut off or destroyed by dise se. The e rliest the le st tr um tic. rhinoplasties 0ere reduction procedures, executed 0ith extern l s1in incisions of m ny v rieties, fol- 2orrespondence to3 T. D. Zijl1er M.D., Dep rtment of lo0ed by v rious 0edge resections of s1in, c rtil ge Otorhinol ryngology nd He d & Nec1 Surgery, University Hospit l M stricht, P.O. Box 5800, A202 AZ M stricht, The Netherl nds. nd soft tissue. Tod y the endon s l or closed p- pro ch for rhinopl sty is f vored 0orld0ide. 75 76 T.D. ZIJLKERETAL However, renewed interest is growing for alterna- E F In the same year, h7 described the use of intranasal tive a roaches. incisions for rhino lasty in a ati<nt with a straight, The external incisions for different nasal areas will but over roBected nose. However, as a sort of adden- be resented here and discussed. Then modern de- dum to the mentioned a er, Ceir also described this velo ments are highlighted as well as the surgeons, o eration as not so successful, because after four sur- who have made significant contributions to the field gical rocedures, using lateral skin wedge resections of rhino lasty. /8Ceirs83 for alar base narrowing, the final result was unsatisfactory and Gualified as a 8dece tion8 ,7.. In 1191, Monks of 6oston ,1., later also Cooghlin External approach for rhinoplasty: ,52. used an a roach for corrective rhino lasty, in history which the alar bases were cut loose and the columella was se arated from the u er li . The nose was com letely elevated for better ex osure and correc- 1845-1955 tion. This techniGue is considered to have layed a In the 19th century lastic surgery of the nose was role in delayed acceptance of rhino lasty in gener- rimarily confined to those atients suffering from al, because of the resulting scars. extraordinary disfigurements, with concurrent mental The revious mentioned ublications fo Dieffen- de ression. The indication for surgery was es e- bach were unknown to these American surgeons and cially acce ted in those atients with a rofession of the reverse counted for the few Euro ean rhino lasty high social ex osure, such as actors, singers, oliti- surgeons. 5rofessor Dr. JacGues Jose h /1165-19323, cians and teachers, women in articular* an Ortho edie surgeon from 6erlin, ublished in The first two referrals for a reduction rhino lasty 1191 a a er entitled 8Surgical Correction of the were made by Johann Friedrich Dieffenbach ,3. Nose8 ,9.. He executed a reduction rhino lasty /1790-11273, a 4eneral 5racticioner from 6erlin, /8Rhinomio lastik83, on a male ati<nt with a large when h7 re- ublished his 8O erative surgery8 in nose suffering from de ression, excising a D-sha ed 1125, in which h7 described the use of external inci- segment along the nasal dorsum, evidently through sions or wedge resections containing dorsal skin, car- skin, bone, cartilage and lining, and also took a tilage, and soft tissue. The first atiënt was treated wedge off the bottom of the se tum and anterior for a defect of the ala and a large nose, the second nasal s ine /Figure la, Ib, and Ie3. Rosenstirn, a sur- seemed to have a 8normal8, but too large nose. He geon from San Francisco, as a guest of Rudolf Dir- used a 8cross sha ed8 skin incision to reduce skin chow /1101-19003, chairman of 8The Medical and cartilage. Society8 in 6erlin, informed Jose h about the ubli- An im ortant milestone in the develo ment of cations in the american literature ,6-7., after a slide- rhino lasty was the lecture in 1117 by John Orlan-do resentation of his first reduction rhino lasty, even Roe ,2, 5. /1125-19153, an American Otolaryngol-ogist though all American medical re orts were ublished from Rochester, New York, before the State in the Index Medicus* Medical Society of New York entitled 8The defor- In 1902, Jose h ublished 8Intranasal hum mity termed ug nose8, and its correction by a sim- removal8, based on forty-three cases ,10.. He then le o eration. He is regarded the first surgeon to was using an endonasal a roach for the nasal dor- introducA endonasal subcutaneous rhino lasty in sum. Rhino lasty was executed more as a tactile America. This first atiënt had a 8fairly large nose, rocedureJ it was said to be 8as if the skin became with a slight concave nasal dorsal rofile and an over- trans arent8. In 1907 the state of the art on closed rojected nasal ti 8. rhino lasty was ublished in 8Korrektive Nasen- und In 1190 Robert F. Ceir ,6. /1131-19073 of New York Ohren lastik8 in Katz and 6lumenfeld ,11., showing ublished a a er entitled 8On restoring sunken excellent clinical results /Figure 0a and b3. In 1931 noses8. Ceir used an inverted D-sha ed incision on the monumental monogra h 8Nasen lastiek und the dorsum of a saddle nose to gain access to the nose sonstigen 4esichts lastiek nebst Mam-mo lastiek8 for augmentation with the breast bone of a young ap eared ,10.. Through his work and ublications duck* However, after the seventh osto erative week Jose h layed an uniGue role in the develo ment of an abscess destroyed the 8fine aesthetic result". facial lastic surgery. His systematic EXTERNAL RHINOPLASTY : HISTORY 77 Figure l Schematic drawings of different techni ues in a reduction rhinoplasty according to %oseph. a A wedge resection of dorsal skin, upper lateral cartilage and nasal septum shortens the nose. b A wedge resection of dorsal skin, lower lateral cartilage and upper lateral cartilage. c Two triangular resections of cartilaginous nasal septum and an- terior nasal spine. Figures 2a, b b Pre- and postoperative lateral views after a closed reduction rhinoplasty e,ecuted by %. %oseph. 78 T.D. ZIJLKERETAL scientific approach lead to ingeniously de ised me- ans and Instruments for surgical correction of the nose. In 1889 Friedrich Trendelenburg '13) (1844-1924- from .erlin was one of the first 0lastic 1urgeons with a clear concept for treatment of a croo2ed nose, us-ing subcutaneous low lateral osteotomies and a horizontal external s2in incision in the nasofrontal area to mobilize the nasal bones (Figure 3-. Figure 4a Reduction of the nasal dorsum by way of an hori4ontal incision through s2in and periosteum. The hump is remo ed with an Luer forceps. Figure 3 Rhinoplasty according to Trendelenburg for correction of a croo2ed nose. The nasal bony sidewalls are mobili4ed with lateral osteoto- mies, which begins at the piriform aperture to the direction of the ; orbital rim. An e5ternal incision is used for the trans erse os- teotomies. Figure 4b Insertion of a bone graft in a saddle nose deformity ia an external incision. A hori4ontal s2in incision was ad ocated for a reduction rhinoplasty of a nose with a large bony- tion, for reduction of a nasal hump (Figure 5-. As this cartilaginous hump. This approach allo wed the sur- incision lies perpendicular to the R1TL, the scar will geon to operate under aseptic conditions with direct be ob7ectionable. isual control, which is an ad antage in augmenta- After the first 8orld 8ar the lac2 of e5posure of tion procedures with grafts.