Rhinoplasty Video Library, Volume II: Structural Grafting for Definitive Management of the Unilateral Cleft Lip Nasal Deformity

Abstract

As a service to our readers, Plastic and Reconstructive Surgery® reviews books, DVDs, practice management software, and electronic media items of educational interest to reconstructive and aesthetic surgeons. All items are copyrighted and available commercially. The Journal actively solicits information in digital format for review. Reviewers are selected on the basis of relevant interest. Reviews are solely the opinion of the reviewer; they are usually published as submitted, with only copy editing. Plastic and Reconstructive Surgery® does not endorse or recommend any review so published. Send books, DVDs, and any other material for consideration to: Arun K. Gosain, M.D., Review Editor, Plastic and Reconstructive Surgery, Brookriver Executive Center, 8150 Brookriver Drive, Suite S-415, Dallas, Texas 75247. Arun K. Gosain, M.D. Review Editor Dr. Toriumi is an internationally recognized name within the field of rhinoplasty who has provided countless classic educational articles on the structural approach to rhinoplasty. As one of the modern pioneers in structural rhinoplasty, he now introduces a clear, concise, and detailed DVD series on the topic. Each video provides a unique perspective on the philosophy of structural rhinoplasty through the eyes of a renowned expert via surgical case examples. Volume II, the subject of this review, guides the viewer through structural grafting of the unilateral cleft lip nasal deformity.The DVD begins with a comprehensive facial analysis in which each patient’s deficiencies are categorized. This transitions into an honest appraisal of potential improvements and limitations using preoperative morphing computer software. This initial evaluation serves as an outline for the upcoming surgery. The first portion of the video concludes with detailed surgical markings to explain the options for rib harvesting along with pertinent anatomy. This will serve as a roadmap for Dr. Toriumi’s short-scar costal cartilage harvesting technique performed later in the surgery. Before surgical incision, an endoscopic nasal examination is performed and the pertinent aspects are discussed as relevant to the upcoming surgery. The objectives of the procedure are explicitly laid out, and the surgery commences with injection of local anesthesia. The direction provided in the video on how to open a cleft nose without violating the underlying asymmetric cartilage is very instructive. After elevation of the nasal flap, key points are provided so as to gently elevate around the nasal floor and bony spurs without perforation. In describing osteotomy techniques, the video explains in detail how to adjust the nasal bones and then realign the lower third of the nose to give the appearance of a straight dorsum on the anterior view. With the foundation of the rhinoplasty set, the operation then moves to cartilage harvesting. One of the prior drawbacks to rib cartilage harvesting was the traditional 3- to 5-cm incision used for access. Dr. Toriumi’s keyhole approach to costal cartilage harvesting with a 1.2-cm incision significantly enhances harvest of rib cartilage. Careful filming of this portion of the surgery provides insight on how the sixth rib is approached, the perichondrium elevated, and the rib safely lifted off the underlying perichondrium then delivered through the incision. The technique for creating cartilage grafts may be the most important aspect of the video. Dr. Toriumi has been using rib cartilage for more than two decades; he imparts key observations on how to recognize the bend of the cartilage and use this bend to facilitate the surgical outcome, as well as techniques to prevent long-term cartilage warping. During this process, the creation of asymmetric spreader grafts, lateral crural strut grafts, and caudal septal extension grafts is demonstrated. The operative technique concludes by focusing on final nasal tip definition. The adage “as the tip goes, then so goes the rhinoplasty” is apparent with the meticulous attention given to this portion of the procedure. The feedback loop of rhinoplasty is also appreciated during execution of the tip work, as each adjustment triggers a repeated evaluation and another adjustment until the tip is ideal. With this and every step of the rhinoplasty, clear explanations are provided and are of value for surgeons irrespective of their past level of experience. This video is an excellent addition to any educational library, and we would recommend it to all surgeons treating cleft nasal deformities.