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Daly City, California OPERATIVE/PROCEDURE REPORT |
| Patient: | CARNEY, STEPHEN | Med Rec #: | 48-74-02 |
| Dictator: | JAMES J. ROMANO, M.D. | Date of Surg: | 12/18/2001 |
PREOPERATIVE DIAGNOSIS: Nasal deformity.
POSTOPERATIVE DIAGNOSIS: Nasal deformity.
OPERATION: Rhinoplasty.
ASSISTANT: None.
ANESTHESIA: General endotracheal, Dr. Michael Hulton.
ESTIMATED BLOOD LOSS: Less than 10 cc.
FLUIDS ADMINISTERED. Approximately 2500 cc crystalloid
SPECIMENS: None.
DRAINS: None.
BRIEF CLINICAL HISTORY:
This 43-year-old gentleman has been seen in the office on several
occasions to discuss his nasal features and nasal anatomy. He has a large
dorsal hump and a tension nose with some crowding of his upper, wide
nasal bones, and would like these features improved. We have discussed
his anatomy and the alternatives for surgery including to do nothing. We
have discussed the different techniques and procedures and operative
approaches and I have diagramed this for him on a worksheet in the of office.
We have agreed upon an open rhinoplasty with reduction of his dorsal nasal
hump and narrowing of his nose, refinement of the tip, and the treatment of the
crowding of his upper lip. I have discussed with the patient on several
occasions and reviewed the potential risks and complications and signed
informed consent had previously been obtained. I reminded the patient
that in situations where there is a large dorsal nasal hump that the skin
will contract down around his reduced framework and this may be difficult
to control. I have also discussed that although his nose looks relatively
straight or only mildly deviated removal of the dorsal hump may reveal a
straight or curved part of the septum and we will deal with this
appropriately. O have also stated that in patients with large noses that
there is a tendency for prolonged postoperative edema and persistence of
some asymmetries and deviations. I reminded the patient that despite our
best efforts the he may still end up with a poor, unsatisfactory, or
disappointing cosmetic result requiring revision or reoperation at a later
date and at added expense to the patient and he understands and accepts.
In the preoperative area in the sitting upright position, I again examined the patient and noted his dorsal hump, the the tethering of his upper lip and discussed these features as well as his asymmetric nasal bones and deviation and he understands. We reviewed the operative plan and he agreed
PROCEDURE:
The patient was taken to the operating room and placed on the
operating table. All pressure points were padded. He was placed in the
lawn chair position with the head up and the knees flexed. He was induced
with a satisfactory level off general endotracheal anesthesia. Intravenous
antibiotics, antinausea medications and Decadron wrench administered. A
Foley catheter and lower extremity pumps were placed. A generous amount
of ointment was placed in the eyes place and the lids shut tight. The
endotracheal tube was sutured in place in the midline and a throat pack
was placed. I then performed a very thorough Betadine scrub and then pain
preparation of the entire face, intranasal area, and intraoral region and
he was draped in the usual sterile fashion. Preparation was begun and I
infiltrated approximately 5 cc of a mixture of Marcaine and lidocaine
with epinephrine intranasally and extranasally. I placed four cocaine
soaked pledgets, two on either side of the septum.
Using a headlight a throughout, I began by trimming the vibrissa. I then made a V-incision in the columella at its narrowest point, approximately one-third of the distance from the tip. This was extended into bilateral rim incisions which followed the caudal edge of his alar cartilages. I undermined a thick nasal flap above his alar and then upper lateral cartilages and then over the bony dorsum. The radix was in the normal position and did not need to be raised or lowered. I then performed a complete transfixion incision from the intercartilaginous space and tightly against the caudal edge of the septum down to the nasal spine. There was quite a prominent posterior septal angle that was adjacent to a prominent anterior nasal spine. The nasalis muscle was cleaned thoroughly off of this area and I used the double rat-tooth rongeurs to reduce the anterior nasal spine bone. I removed approximately 3 mm of the posterior septal angle. I did not violate the anterior septal angle as the rotation of his nose was satisfactory.
I then used a rasp to take down the bony dorsum and this was done sequentially with me observing and palpating frequently during this maneuver. I separated the upper lateral cartilages from the alar cartilages and retracted the tip complex to gain exposure to the septum. I took down the mucosa between the upper lateral cartilages and the septum to preserve this as a natural spreader graft. I then took down the cartilaginous septum sequentially with a fraction of a millimeter at a time using the 15 blade and did this individually with he septum and the upper lateral cartilages. I observed the nose on profile until the dorsum was straight. This flowed nicely into the tip without a supertip take off. The tip had adequate projection and did not need to undergo a strut or any control sutures. I was very happy with the profile.
The nose was quite wide and the nasal bones were deviated in their natural state. Therefore, decided that he would need a complete bilateral osteotomy to mobilize these and equalize them as much as possible. The perpendicular plate of the ethmoid was deviated also. I made three separate osteotomies using a 2 mm osteotome and through a percutaneous incision applied the osteotome along the medial canthus from the upper to the lower aspect of the sidewall of the nose.
I then intranasally performed an osteotomy between the nasal bones and the perpendicular plate of the ethmoid. A small stab incision was made in the vestibule above the inferior turbinate and this was spread down to the piriform aperture at which point I used the elevator to remove the soft tissues off of the nasal maxillary junction up to the medial canthus. I used a guarded osteotome to make this osteotomy from low to low and with only gentle pressure both nasal bones were mobilized. The bones were naturally curved and somewhat asymmetric but once they were medialized, this was much better than his previous condition. I examined the perpendicular plate and this was deviated slightly and I used a large flat duckbill forceps to fracture and move this more to the middle.
At this point, the septum was completely exposed and I examined this from the septal angle to the perpendicular plate of the ethmoid and this was unquestionably straight without any curvatures or deviations. His nasal base was wide and the internal nasal valve was wide and open and therefore, I decided that he did not need any spreader grafts. The upper lateral cartilages were slightly asymmetric. I decided that he did not need a septoplasty. I sewed the upper lateral cartilages gently to each other over the top of the cartilaginous dorsum using several interruptions 4-0 Vicryl. I then redraped the nasal flap and sewed this in place with a temporary suture of 5-0 chromic.
I examined the nasal width and the dorsum, the base, and the tip and there was excellent improvement in symmetry. The radix was in normal position. The dorsum was straight. There was excellent nasolabial angle. The upper lip was no longer tethered to the lower aspect of the columella. There was a nice columellar lobular angle. I did not resect any alar cartilages and the tip size and dimensions fit perfectly with the rest of his nose. The nose was nearly perfectly straight exception for some slight fullness along the right mid portion which was due to the upper lateral cartilages and treated with suture from the upper lateral cartilage to the septum.
I felt the bony dorsum in this was perfectly straight except for one small area over the right nasal bone tip or the caudal edge of the right nasal bone. I used a piece of crushed cartilage in this region to fill in. I examined for hemostasis one more time and this was excellent. I did not need to place a stitch from the upper lip to the columella as the tissues re-draped here nicely. I did not remove any of his membraneous septum. The projection was excellent. The dorsum was lowered and in perfect proportion to his tip projection and tip size. The width had been nicely reduced. I therefore closed all incisions using interrupted 5-0 chromic suture. Several interrupted chromic mattress sutures were placed on the caudal septum where I had undermined this slightly to resect the posterior angle and determine straightness. The transcolumellar incision was closed with several interrupted 7-0 nylon. Steri-Strips, benzoin, and cloth tape and a six plaster cast were gently applied over the nose. A drip pad was placed. The throat pack was removed. The nasal vestibule and posterior pharynx were suctioned. He was awakened from anesthesia without difficulty. He was extubated in the operating room and sent to the recovery room in stable condition. All sponge, needle and instrument counts were reported as correct and there were no complications.
| JR: | YOG/02869219/rel | JOB#: | 44511 |
| DD: | 12/18/2001 13:12 | DT: | 12/19/2001 14:21 |
Copyright © James J. Romano, M.D. – used with permission. This information may not be copied, duplicated or posted without expressed permission from the author.
