Sách phẫu thuật thẩm mỹ mũi (Tiếng anh) Aesthetic rhinoplasty

Aesthetic
Septorhinoplasty

Barış Çakır

123


Aesthetic Septorhinoplasty



Barış Çakır

Aesthetic
Septorhinoplasty


Barış Çakır
Private Practice Fulya Teras
Istanbul
Turkey

English translation by Ali Rıza Öreroğlu
ISBN 978-3-319-16126-6
ISBN 978-3-319-16127-3
DOI 10.1007/978-3-319-16127-3

(eBook)

Library of Congress Control Number: 2015949109

Springer Cham Heidelberg New York Dordrecht London
© Springer International Publishing Switzerland 2016
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Printed on acid-free paper
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In memory of my dear father Kemal Çakir
who passed away in 2012



Foreword

Dr. Baris Çakır has written a worthy successor to Jack Sheen’s monumental
text Aesthetic Rhinoplasty. As a resident, I remember reading Sheen’s textbook and suddenly seeing rhinoplasty in a fundamentally new way. Sheen set
specific aesthetic goals and achieved them with a range of new techniques
which he had developed.

For the next 30 years, I learned a great deal in the operating room and from
lectures by my colleagues. However, I had not had that feeling of excitement
of witnessing a new era in rhinoplasty surgery until I attended the Combined
Rhinoplasty Meeting of the Turkish and American Rhinoplasty Societies held
in Istanbul in 2011. As usual, I was taking notes and trying to stay awake late
in the afternoon during the 5 min presentations. Suddenly, I became aware
that something dramatic was happening. A speaker was talking about new
concepts for tip aesthetics (polygons), bony vault remodeling (bony sculpting), and nostril sill excision. When the session was over, I went up to
Dr. Çakır and asked him if he would present the talk again for me the next
morning. He did and I had him repeat it three times. I was totally amazed at
his concepts, but wondered if he could really do in the operating room what
he was presenting. Therefore, I asked him if he could do a case for me. The
conversation went as follows: “I’d like to see you do a case.” “When?”
“Tomorrow.” “Okay.” The next day, Dr. Çakır did a rhinoplasty employing a
wide range of techniques which he had developed and achieved a superb
result. Later that day at lunch, my head was still reeling from trying to understand the nasal polygons, his advanced tip suture techniques, and repair of
numerous ligaments that I had routinely cut. I reasoned that the only way I
could understand his concepts was to help Dr. Çakır write up his techniques
which he had thus far been unable to publish. Subsequently, he came to me
and said he had more ideas for journal articles. I told him that he would
always have too many ideas and too little time. I advised him to go ahead and
write a book as it would clarify his thinking and allow others to build on his
concepts. Naively, I thought he would be preoccupied for a couple of years.
Six months later, he sent me the manuscript and 3 months after that the
Turkish Edition was published to be followed by the English Edition.
In reading Dr. Çakır’s masterpiece, I am struck anew by how original and
advanced his concepts truly are. Something as mundane as nasal photography
and analysis suddenly becomes an art form and the use of preoperative
“shadow photographs” a brilliant break through. Some of his polygon
concepts require multiple readings before one fully understands them. For

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Foreword

viii

example, the concept of a “resting angle” between the lower lateral and upper
lateral crura is totally new. At first one may think it is of little importance, but
when linked to the long lateral crus and herniation of the lateral crus into the
vestibule its relevance becomes obvious. One suddenly has an answer for a
previously inexplicable problem as well as a method of treatment and more
importantly a method of prevention. The discussion of multiple tip points and
definition of the soft tissue facets as well as their relation to specific tip
sutures is crucial information. In the surgical technique chapter, the importance of the continuous subperichondrial-subperiosteal dissection plane
becomes apparent. The novice surgeon should remember that many of his
techniques were perfected through the open approach before Dr. Çakır progressed to the closed approach. There are certain ideas with which I disagree,
including scoring of the septum, leaving a 2 mm gap between the septal base
and the anterior nasal spine, and resection of the membranous septum. I also
recognize that the book may prove daunting to some given the plethora of
new concepts and the quality of the English translation.
Yet, this is a book to be savored and read multiple times before returning
to specific chapters for greater insight into the challenges of rhinoplasty surgery. For the younger surgeon, the book provides in-depth discussion of how
to analyze and photograph the patient while formulating an individualized
patient-specific operative plan. The linkage of surface aesthetics to nasal
anatomy to surgical techniques is the foundation of this text. For the experienced surgeon, the book will be a revelation of how to set and achieve higher
aesthetic standards using the described methods. For the master surgeon, Dr.
Çakır challenges many of our accepted principles and techniques ranging
from the aesthetic dorsal lines to the need for lateral crural transposition.
Every surgeon performing nasal surgery should purchase a copy of Aesthetic

Septorhinoplasty as Dr. Çakır’s concepts, principles, and techniques represent the future of rhinoplasty surgery.
Newport Beach, CA, USA

Rollin K. Daniel, MD


Preface to the Turkish Edition

Who is Barış Çakır?
After graduating from the Electronics Department of the Çukurova Technical
High School, I studied at the Faculty of Medicine upon my parent’s wish, and
during the fifth year of my studies I had to undergo rhinoplasty, followed by
revision surgery six months later. Within my own medical career in plastic
surgery, I focused on microsurgery and performed many such operations, but
my strongest interest has been in nose surgery because it requires both technical skill and aesthetic understanding. Even for someone like me who has both
undergone and then continually performed nose surgery, this specialization
continues to present interesting challenges because it is constantly developing. Several years of drawing and sculpting courses have contributed to my
own professional development, and in my own practice of eight years—
ninety percent of which consists of rhinoplasty—I have made changes to
almost half of all the techniques I learned in medical school. For instance, I
began nose remodeling surgery with the open technique, but since 2008
turned to closed technique instead—a rather unusual turn, as most surgeons
move in the opposite direction. Today, I am performing approximately 200 to
300 closed-technique rhinoplasties per year.
In 2012, at the ASAPS Congress, Dr. Rollin Daniel encouraged me to
write this book in the format of an instruction manual, so as to allow others to
benefit from my experiences with rhinoplasty as well as visual documentation surrounding this type of surgery, since in the framework of this book, I
have defined proper standards for surgical photography and technical drawings. It is my hope that readers will find the present work most useful for their
own practice.

What Kind of Book is this?
This book describes closed rhinoplasty in which open rhinoplasty techniques
are used. In order to make the information presented here quickly and easily
accessible, the writing style has deliberately been kept simple and more
emphasis is put on the images, so that the book reads like detailed surgery
notes. No extensive explanation accompanies the photographs, but text, photographs, and drawings complement each other and the images illustrate the

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Preface to the Turkish Edition

preceding text. Photographs of those patients who gave permission of use are
in standard format, while the photographs of those who refused permission
were cropped to make their faces unrecognizable. Since I wanted to illustrate
the effects of closed rhinoplasty, dissection and ostectomy techniques on
healing rates, I have also included images with early results.

Acknowledgments
Special thanks are due to Tayfun Aköz, MD, and Mithat Akan, MD, who
taught me about nose surgery; Ali Teoman Tellioğlu, MD, and Mithat Akan,
MD, who undertook the scientific revision of the book; my wife Çiğdem
Çakır; Metin Bahçivan for editing the Turkish text; and Nina Ergin for proofreading the English translation.
Barış Çakır, MD
www.bariscakir.com
Inquiries, comments and suggestions to the author can be sent to:

Preface to the English Edition

Aesthetic Septorhinoplasty: The English Edition
The English edition of this book was planned while the author was still writing the Turkish original text. As with the original, the intent was to offer the
reader an introduction of aesthetic rhinoplasty similar to an instruction manual, with abundant images but much less text. My task as translator was to
convey the original content of aesthetic concepts and surgical techniques,
while at the same time choosing plain language, keeping in mind that the
reader may be a junior plastic surgeon who is not a native speaker of English.
Being familiar with all the concepts and surgical techniques, I attempted to
make the instructions understandable, yet simple and practical. I hope that I
have achieved this goal and that the English edition will serve its purpose.
Ali Rıza Öreroğlu, MD

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Contents

1

Preoperative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1 Patient Photographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.1 The Photography System . . . . . . . . . . . . . . . . . . . . . . . .
1.2
Preoperative Photographs . . . . . . . . . . . . . . . . . . . . . . .
1.3
Light Cheats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.4

Fish-Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.5
Shooting with a Smartphone . . . . . . . . . . . . . . . . . . . . .
1.6
Camera Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.7
Paraflash Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.8
Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.9
Shadowing the Images . . . . . . . . . . . . . . . . . . . . . . . . . .
2 Surgery Notes and Archiving . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1 Photography Archive . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2
Backup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3 Skin Care and Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1
Oral Vitamin A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4 Menstruation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5 Forehead Fat Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.1
Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6 Jaw and Cheek . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.1
Importance of the Cheek . . . . . . . . . . . . . . . . . . . . . . . .
7 The Rhinoplasty Instrument Set . . . . . . . . . . . . . . . . . . . . . . . .
7.1
Dorsum Retractor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.2
Small Retractor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7.3
Forceps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.4
Needleholder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.5
Scissors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.6
Bone Scissors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.7
Rasp and Saw . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.8
Osteotomes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.9
Elevators. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.10 Hook. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.11 Osteoectomy Chisels . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.12 Lateral Osteotomes . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.13 Arkansas Stone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.14 Sutures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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2

How to Draw a Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.1
Sketch from the Front . . . . . . . . . . . . . . . . . . . . . . . . .
1.2
Sketch from the Side . . . . . . . . . . . . . . . . . . . . . . . . . .
1.3
Sketch from Above and Below . . . . . . . . . . . . . . . . . .
2
Analysis of Patient Photographs . . . . . . . . . . . . . . . . . . . . . . .

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39
40
42
44
48

3

Nasal Polygons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
Infratip Triangle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2
Tip Defining Point . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
What Is a Facet? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
The Non-Mobile Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
The Mobile Tip Area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.1
Mass Polygons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.2
Space Polygons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
Tip Breakpoints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
Dome Triangles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
Interdomal Triangle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.1
Dome Divergence. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
Infralobular Polygon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10 Columellar Polygon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11 Footplate Polygons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12 Facet Polygons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12.1 Relation of the Facet and Dome Polygons . . . . . . . . . .
13 Lateral Crus Polygons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14 Resting Angle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14.1 Vertical Compression Test . . . . . . . . . . . . . . . . . . . . . .
14.2 Incorrect Resting Angle and its Effect on the Ala . . . .

14.3 Wide Lateral Crura. . . . . . . . . . . . . . . . . . . . . . . . . . . .
14.4 Long Lateral Crura. . . . . . . . . . . . . . . . . . . . . . . . . . . .
14.5 Convex Lateral Crura . . . . . . . . . . . . . . . . . . . . . . . . . .
14.6 Cephalic Malpositioning . . . . . . . . . . . . . . . . . . . . . . .
15 Scroll Facet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
16 Scroll Line. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
17 Dorsal Cartilage Polygon . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18 Dorsal Bone Polygon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19 Upper Lateral Cartilage Polygons. . . . . . . . . . . . . . . . . . . . . .
20 Lateral Bone Polygons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
21 Dorsal Aesthetic Lines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
21.1 Summary: Dorsal Aesthetic Lines . . . . . . . . . . . . . . . .
22 Lateral Aesthetic Lines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23 The Polygon Model. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Contents

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4

Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1

Patient Position and Tracheal Intubation . . . . . . . . . . . . . . . .
2
Local Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
Head Lamp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
Cleaning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
Lighting in the Operating Room . . . . . . . . . . . . . . . . . . . . . . .
6
Drawings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
Basic Surgical Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
Concha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.1
Concha SMR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
Nasal Dorsum Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9.1
Transfixion Incision . . . . . . . . . . . . . . . . . . . . . . . . . . .
9.2
Intercartilaginous Incision . . . . . . . . . . . . . . . . . . . . . .
9.3
Entering the Nasal Dorsum from the Septal Angle . . .
9.4
Subperichondrial Dissection in the Open Approach . .
9.5
Periosteum Dissection . . . . . . . . . . . . . . . . . . . . . . . . .
9.6 Why the Subperichondrial Dissection? . . . . . . . . . . . .

9.7
Upper Lateral Cartilage Mucosa Dissection . . . . . . . .
9.8
Dorsal Cartilage Resection . . . . . . . . . . . . . . . . . . . . .
9.9
Dorsal Bone Resection. . . . . . . . . . . . . . . . . . . . . . . . .
9.10 Nasal Radix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10 Septum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10.1 Dissection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10.2 Removing the Septum . . . . . . . . . . . . . . . . . . . . . . . . .
10.3 The “Gummy Smile” . . . . . . . . . . . . . . . . . . . . . . . . . .
10.4 When there is Extreme “Gummy Smile” . . . . . . . . . . .
11 The Footplates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11.1 Narrowing of the Footplate Polygon . . . . . . . . . . . . . .
12 Tip Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12.1 Incision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12.2 Autorim Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12.3 Lateral Crus Subperichondrial Dissection . . . . . . . . . .
12.4 Delivering the Domes . . . . . . . . . . . . . . . . . . . . . . . . .
12.5 Marking and Resections. . . . . . . . . . . . . . . . . . . . . . . .
12.6 How Did the Nose Break Down? . . . . . . . . . . . . . . . . .
12.7 Observation and Theory . . . . . . . . . . . . . . . . . . . . . . . .
13 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13.2 How to Perform the Footplate Setback . . . . . . . . . . . .
13.3 Lateral Crus Steal Procedure . . . . . . . . . . . . . . . . . . . .
13.4 Dome Symmetry Test . . . . . . . . . . . . . . . . . . . . . . . . .
13.5 Cephalic Dome Suture . . . . . . . . . . . . . . . . . . . . . . . . .
13.6 Control 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13.7 Control 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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14

15
16
17
18
19
20

21

22

23

24
25

13.8 Medial Crus Overlap . . . . . . . . . . . . . . . . . . . . . . . . . .
13.9 Suturing the Domes . . . . . . . . . . . . . . . . . . . . . . . . . . .
13.10 Columellar Strut Graft . . . . . . . . . . . . . . . . . . . . . . . . .
13.11 Infralobular Caudal Contour Graft. . . . . . . . . . . . . . . .
13.12 Columellar Polygon Stabilization . . . . . . . . . . . . . . . .
13.13 Closure of Tip Incisions . . . . . . . . . . . . . . . . . . . . . . . .
13.14 Tip Asymmetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13.15 Cephalic Malpositioning . . . . . . . . . . . . . . . . . . . . . . .
13.16 Interdomal Graft. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Nasal Dorsum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14.1 Setting the Dorsum Height. . . . . . . . . . . . . . . . . . . . . .
14.2 Osteotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14.3 Osteoectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14.4 Osteoectomy Technique . . . . . . . . . . . . . . . . . . . . . . . .
14.5 Bone Dust and Cartilage Paste . . . . . . . . . . . . . . . . . . .
14.6 Short Nasal Bones . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14.7 Dorsal Reconstruction in Men . . . . . . . . . . . . . . . . . . .
14.8 Stabilization of the Nasal Tip. . . . . . . . . . . . . . . . . . . .
14.9 Reconstruction of the Scroll Line . . . . . . . . . . . . . . . .
Internal Splints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Internal Valve Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Drains . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Pitanguy Ligament . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Superficial SMAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Internal Taping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
20.1 The New SMAS Anatomy . . . . . . . . . . . . . . . . . . . . . .
20.2 Importance of the Pitanguy Ligament
in the Supratip Region . . . . . . . . . . . . . . . . . . . . . . . . .
Redrape . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
21.1 Dissection Borders . . . . . . . . . . . . . . . . . . . . . . . . . . . .
21.2 How to Use the Ligaments for Redraping . . . . . . . . . .
21.3 Why Internal Taping?. . . . . . . . . . . . . . . . . . . . . . . . . .
21.4 Camouflage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Additional Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
22.1 Extra Columellar Strut . . . . . . . . . . . . . . . . . . . . . . . . .
22.2 Rim Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Nostril Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23.1 Problems and Solutions . . . . . . . . . . . . . . . . . . . . . . . .
23.2 Thick Alar Base: Simple Elliptic Resection . . . . . . . .
23.3 Big Nostrils: Avulsion Advancement Flap . . . . . . . . .
23.4 Big Nostril and Thick Alar Base:
Combination of Avulsion Advancement Flap
and Elliptic Resection . . . . . . . . . . . . . . . . . . . . . . . . .
23.5 Hanging Alae: Alar Rim Excision . . . . . . . . . . . . . . . .
Taping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

205
211
213
222

229
231
232
238
251
252
252
252
254
256
276
278
280
281
283
288
288
288
289
290
291
291
292
295
295
296
296
297
297
297

298
299
299
299
302

307
311
317
318


Contents

xvii

26

How to Correct the Deviated Nose . . . . . . . . . . . . . . . . . . . . .
26.1 How Did the Nose Deviate?. . . . . . . . . . . . . . . . . . . . .
26.2 Reference Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26.3 Nasal Dorsum Resection . . . . . . . . . . . . . . . . . . . . . . .
26.4 Septoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26.5 Tip Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cartilage Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27.1 Septal Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27.2 Rib Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Columellar Show. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
28.1 Hanging Columella . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

320
320
321
323
324
325
334
334
335
339
341
349

Patient Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
Case Analysis: A Common Patient . . . . . . . . . . . . . . . . . . . . .
2
Case Analysis: Thick Skin . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
Case Analysis: Thick and Oily Skin . . . . . . . . . . . . . . . . . . . .
4
Case Analysis: Revision of My Own Case . . . . . . . . . . . . . . .
5
Case Analysis: Thick Skin and Large Hump . . . . . . . . . . . . .
6
Case Analysis: Closed Approach Healing Rate . . . . . . . . . . .
7
Case Analysis: Supratip Healing Period . . . . . . . . . . . . . . . . .
8

Case Analysis: Wide Dorsum, Wide Radix,
Bulbous Overprojected Tip . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.1
First Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.2
Second-Year Revision . . . . . . . . . . . . . . . . . . . . . . . . .
9
Case Analysis: Fractured Nose, Operated Twice . . . . . . . . . .
9.1
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10 Case Analysis: Long Nose . . . . . . . . . . . . . . . . . . . . . . . . . . .
11 Case Analysis: Cephalic Malpositioning . . . . . . . . . . . . . . . .
11.1 Surgery Photos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12 Case Analysis: Closed Approach Revision. . . . . . . . . . . . . . .
12.1 Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12.2 Surgery Photographs . . . . . . . . . . . . . . . . . . . . . . . . . .
13 Case Analysis: Overrotated Saddle Nose . . . . . . . . . . . . . . . .
13.1 First Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13.2 Second Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13.3 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14 Case Analysis: Thin Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15 Case Analysis: Thin Skin, Deviated Nose,
Tip Asymmetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
16 Case Analysis: Tip Asymmetry . . . . . . . . . . . . . . . . . . . . . . .
17 Case Analysis: Thick Skin, Low Radix
and Cephalic Malpositioning . . . . . . . . . . . . . . . . . . . . . . . . .
17.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18 Case Analysis: Saddle Nose, Notched Nostril . . . . . . . . . . . .
18.1 Surgery Photographs . . . . . . . . . . . . . . . . . . . . . . . . . .

351
351
355
357
359
362
364
366

27

28
29
5

368
369
370
372
374
374
376
376
378
380
380
381
382
383
383

386
388
389
390
391
391
393


Contents

xviii

19

20
21
22
23
24
25
26
27
28
29
30
31

32
33

34
Index

Case Analysis: Very Short Infralobule,
Very Narrow Facet Polygon . . . . . . . . . . . . . . . . . . . . . . . . . .
19.1 Surgery Photographs . . . . . . . . . . . . . . . . . . . . . . . . . .
19.2 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Case Analysis: Saddle Nose, Hanging Nostril . . . . . . . . . . . .
Patient Example: Bulbous Tip . . . . . . . . . . . . . . . . . . . . . . . .
Patient Example: Thin Skin, Big Nose . . . . . . . . . . . . . . . . . .
Patient Example: Thin Skin, Pseudocephalic
Malpositioning and Tip Asymmetry . . . . . . . . . . . . . . . . . . . .
Case Analysis: Tension Nose . . . . . . . . . . . . . . . . . . . . . . . . .
24.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Case Analysis: Thin Skin, Tension Nose . . . . . . . . . . . . . . . .
Case Analysis: Ideal Patient for the Closed Approach . . . . . .
26.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Case Analysis: Learning from a Patient . . . . . . . . . . . . . . . . .
Case Analysis: Bulbous Tip . . . . . . . . . . . . . . . . . . . . . . . . . .
Case Analysis: Thin Skin, Axis Deviation
and Breathing Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Case Analysis: Thick Skin, Bulbous Tip
and Deviated Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Case Analysis: Medium-Thick Skin . . . . . . . . . . . . . . . . . . . .
31.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
31.2 Surgery Photographs . . . . . . . . . . . . . . . . . . . . . . . . . .
Case Analysis: Revision for Droopy Tip . . . . . . . . . . . . . . . .
32.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
What Not to Eat Before Surgery . . . . . . . . . . . . . . . . . . . . . . .
After Surgery: A Few Notes . . . . . . . . . . . . . . . . . . . . . . . . . .

394
395
395
395
396
397
398
399
400
400
401
402
402
403
404
406
407
407
408
411
412
413
414

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415


1

Preoperative

1

Patient Photographs

My interview starts with taking photographs. I
designed one of the rooms in my office as a photography studio. I archive the photographs with
patient names. In addition to that I have a
“beautiful Nose” folder. I take photos of people
with beautiful noses. I ask my patients’ relatives
and my friends who have good-looking noses and
take their photo. I collect the photographs that
patients bring to me. Sometimes I look at them. I
suggest that you also do this. You can see a
female and a male nose that I consider beautiful
below. You can return to these photos for the aesthetic details to be explained further.

© Springer International Publishing Switzerland 2016
B. Çakır, Aesthetic Septorhinoplasty,
DOI 10.1007/978-3-319-16127-3_1

1


2

1 Preoperative

1 Patient Photographs

3


4

1 Preoperative


1 Patient Photographs

5

You should employ a photographic standard.
The more importance you give to patient photography, the more you will develop your own standards and make your patient feel valued. Do not
take photos just before surgery. Be done with
your photography and design work during patient
consultation.

1.1

The Photography System

Obtain an intermediate-level SLR camera. A
proper lens (e.g. macro) is more important than
the camera itself. I use a 100 mm macro lens.
Standard shots cannot be taken with zoom lenses.
If you use a zoom lens, try to take photos adjusting the zoom to 100 mm. You should have a standard background. It’s better to select the correct
background color in advance, because you cannot change it later. The best choices in my opinion are black, grey, blue and dark blue. Black will

appear more artistic, but blue is a better choice
for scientific purposes.
Shadows will not occur if there is at least 1 m
distance between the patient and the background.
If you have a studio with paraflash system you
should be able to take good photos.
Take vertical (portrait) photos. Archiving and
photo merging will be much easier. If you take
horizontal (landscape) photos, you will be creating extra work for yourself later on.
Remember that, if you do not allow a distance
between you and your patient during photographing, you cannot take good photos. If you use a
macro lens, you should have at least a 2 m distance between you and your patient in order to
capture your patient’s face in the correct
quadrage. Another important issue is the position
of the patient in relation to light sources.


1 Preoperative

6

single flash for the preoperative photo and
paraflashs for the postoperative one is a common
cheat. A single flash exaggerates any deformity.
Half of the surgery can therefore be done by
light changes alone. For instance, no surgery is
documented in the photographs below. Both
photos were taken with a 10 s interval. The photograph on the left was taken with a single top
flash, and the photograph on the right using
paraflashs.

The location and intensity of light reflections
change as the patient changes positions. Because
of that, the location of the lights and patient position must remain stable. In our photography studio there is a circle on the ground, guiding the
patient position. You can use self-adhesive footprints for this purpose.

1.2

Preoperative Photographs

For years I have been taking photos of the cartilage structure during the operation, before and
after the surgery. Evaluating your first-year
results with preop photographs will accelerate
your development. In my practice, I use an SLR
camera with 100 mm macro lens for preoperative
surgical photographs in the operating room as
well.

1.3

Light Cheats

The lights, the patient and your position should
never change. Sometimes I look at patient eyes
in photographs presented at congresses. Using a

The same cheat occurred with these photographs
as well.