ARtiCLe | RHINOPLASTY |
are in no way concurrent with surgery. Rhinoplasty remains foremost a highly surgical
procedure (Figure 6 — overleaf), but the use of fillers and botulinum toxins compel us to apprehend the indications for treatment and the advice we give to patients in a different way6, 7
. The objectives of treatment
arise from an artistic analysis of the nose and its relationship to the rest of the face. The author will often attempt to modify: ■ The nose in its own unit and its volumes, which corresponds to nasal volumetry ■ The nose within the face, with regard to the total harmony of the face (in particular contact angles to the face and with the upper lip). Contemporary treatment of the lip and chin with
dermal fillers will also create a medical ‘profiloplasty’ (i.e. a full harmonisation of the face).
The anatomical basics Knowledge of the basic anatomy of the face and nose is essential to understand the aims of treatment and to understand the possible risks related to the injections8
. In
fact, there are no high vascular or neurologic risks, other than if the physician mistakenly injects the angular vessels. It is also important to remain cautious and avoid injections of high pressure at the tip of the nose (to avoid skin necrosis). Occupying approximately one third of the face, the
nose is a hollow triangular pyramid of osteocartilaginous structure, with the top corresponding to the root of the nose and a base where the nostrils open. On this osteocartilaginous frame (Figure 7 — overleaf), lies an envelope comprising perichondrium and periosteum. These fibres are inter-connected and between them, form the nasal pyramid. The structure of the nose confers to each individual an anatomical feature determining the beauty and harmony of the face. In this way, the following aspects can be seen: ■ A fixed portion (formed by the frontal notch), the rising branches of the jawbones, the clean bones, the higher side cartilages (triangular), and the septum ■ A mobile portion, essentially corresponding to the lower side cartilages (wing), but also to the higher side cartilages (lower portion), which play a vital role in the nasal valve. The relationship between the fixed and mobile
elements of the nose is fundamental in the aesthetic analysis and the medico–surgical undertaking of rhinoplasty. The applications of surgery rely on an understanding
of dynamic and static correlations between the nose and its structures; this is therefore a fundamental aspect that the physician should fully understand before carrying out a treatment of medical rhinoplasty using fillers. The skin, which is very rich in sebaceous glands
compared with the cartilaginous framework of the nose, significantly varies in thickness according to area. Indeed, very fine on top, it thickens in an important way toward the point compared with the weak triangle of
40 ❚ September 2011 |
prime-journal.com
Figure 4 Lateral osteotomy
Figure 5 Excellent outcomes can be achieved using the mini-rhinoplasty approach. (A) before and (B) after treatment
Converse. Mobility in the segment becomes adherent with the subjacent planes in the portion corresponding to the cartilage. This adherence is especially intimate on the lobule, the wings, and superficial partition. The cellular fabric is under-cutaneous, little developed and low in grease, and forms a rather clear layer only on the level of the mobile nose. The muscles (Figure 8 — overleaf), innervated by the
facial nerve, are connected by the superficial muscular aponeurotic system (SMAS). It is possible to see the
Knowledge of the basic
anatomy of the face and nose is essential to understand the aims of treatment and to understand the possible risks related to the injections.
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76