/ 3D Rhinoplasty
3D Rhinologic: Virtual planning for Rhinoplasty
As “3D modeling” is allowing the physicians to approach patients with personalized surgery preparation “three-dimensional” technology has proven to provide a strong toolbox for challenging head & neck surgical procedures.
Prior to surgery
Facts about nose surgery
- Patients willing to have a nose surgery almost always experience a frustration & stress about their appearance after the surgery.
- The most important issue that affects the success of the surgery is the proper surgical planning determined by the facial measurements defined by the surgeon.
- Facial measurements provide a quantitative assessment pre-operatively and such information is numerically recorded.
- Measurements are in the form of length & angles, for which each defines the relationship of the nose with the face as well as the sub-structural components of the nose with each other.
A real 3D scanned model (In STL format), created by LASER scanner
Is there a way to standardize a nose surgery with objective measurements?
/ What is 3D Virtual Surgical Planning For Nose Surgery?
It is utilizing of medical 3D facial scanning images validated in true measurements to accurately plan surgery in a digital environment and afterwards simulating the present scanned data by performing “virtual rhinoplasty” applied through “haptic technology” operated by the surgeon. Hence the surgeons apply his/her surgical knowledge virtually to obtain the recommended measurements. Afterwards, these measurements are transferred to 3D software. According to these measurements, patient-specific disposable instruments are manufactured using 3D printing and are used as measurement tools during the actual surgery in return.
/ Haptic Technology
Dr. Karaaltin utilizes the “haptic stylus” to perform digital rhinoplasty on the 3D clay. The device puts the digital content in the surgeon’s hand, allowing him to actually feel models on the screen. Designed for intuitive 3D sculpting, also it eliminates the intimidation of traditional 3D modeling.
/ Creating True Measurements On The Virtual Clay
Nasal analysis in rhinoplasty and revision rhinoplasty is the process by which a plastic surgeon evaluates the nose for possible cosmetic reshaping. In order to properly analyze the nose for rhinoplasty surgery, you must take into consideration how the nose appears in context of the surrounding facial features. You can then look more closely at the nose itself to determine what changes might need to be made to maintain proper balance with the remaining face. The following are the parameters that are involved to determine the ideal anatomical nose shape:
1. The Nose In Context Relation With The Facial Structures
When analyzing the nose as it sits in context of the face, surgeons often first assess the overall facial height. This is done by Looking at what is called the horizontal thirds of the face.
As noted in the above figure, the horizontal thirds refer to the three vertical divisions of the face when seen from the front. The top one-third extends from the anterior hairline down to the glabella (the area of the forehead in between the brows). The middle one-third extends from the glabella to the subnasale, which is where the bottom of the nose junctions with the upper lip. The lower one-third extends from the subnasale down to the lower border of the chin (called the menton). Ideally, each of the facial thirds is equal in vertical height and the nose should be completely contained within the middle one-third. An example of a nose that would appear too large for the central one-third of the face is one that hangs down too low. In this instance, the nasal tip would droop down over the top lip making the middle one-third of the face appear excessively large for the face.
Plastic surgeons also assess what is called the vertical fifths of the face to determine if the nose is properly positioned in context of facial width. The vertical fifths refer to the five vertically oriented divisions that can be seen on frontal view of the face. This concept is demonstrated in the above 3D figure. The two outside fifths are measured from the outer border of the ear to the outer corner of the eye. The next fifth extends from the outer corner of the eye to the inner corner. The central fifth is comprised of the area in between the inner corner of the eyes. Ideally, the vertical fifths are relatively equal in width. As you can see, the width of the nose (as measured by the width of the bottom, or base) should be contained completely within the central one-fifth of the face. Exceptions to this rule include the many different types of ethnic noses, which can be wider than then central one-fifth and still appear aesthetically balanced.
2. Brow - Tip Aesthetic Line
The brow tip aesthetic line is used to assess the frontal appearance of the nose. This is shown in the below photo diagram, which happens to be a past rhinoplasty patient of Dr.Karaaltın. As you can see, an imaginary, uninterrupted, curvilinear line is drawn starting in the brow region. This then transitions along the side of the nasal bridge and middle vault. As it approaches the nasal tip there should be a slight divergence as it curves gently outward. This type of brow tip line is considered ideal for an aesthetically pleasing nose as seen from the front. Both sides of the nose should have relatively symmetric brow tip aesthetic lines. In noses with abnormal contour along this region, the brow tip aesthetic line is disrupted on one side or another because of abnormal shadowing in a certain area. These types of abnormal contours and shadows are precisely what de tracts from an, otherwise, ideal appearing nose when seen on the frontal view.
3. The Nasofrontal Angle
The nasofrontal angle of the nose is evaluated when looking at the profile, or side view. This represents the angulation that is formed between tangential lines drawn along the nasal dorsum and glabella (forehead). In the ideal nose the nasofrontal angle measures 120-130 degrees in males and 115-125 degrees in females. Nasofrontal angles that measure less than this in male and female rhinoplasty patients can create an excessively deep looking radix. This can also contribute to the nasal profile appearing too short for the face. Conversely, when the nasofrontal angle is greater than the measurements noted above, the nasal profile can appear too long in some instances. Some plastic surgeons refer to the nasofrontal angle as the nasal starting point given the fact it appears to be where the forehead ends and the nose begins.
4. Nasolabial Angle
The nasolabial angle is also assessed when looking at the nasal profile view. This measurement represents the angle that is formed by the columella and the upper lip. Many rhinoplasty surgeons use the nasolabial angle to assess nasal tip rotation, however, this is not entirely accurate. Nasal tip rotation refers to the angulation of the nose as it relates to the surrounding facial features, such as the upper lip. You can see this in the below photo diagram as indicated by the dashed curved line. Ideally, the nasolabial angle in male rhinoplasty patients is between 90-95 degrees. In female rhinoplasty patients, the nasolabial angle should be between 100-105 degrees. Rhinoplasty patients with nasolabial angles that measure outside of these numbers are considered to be either over-rotated (greater than normal nasolabial angle) or under-rotated (less than normal nasolabial angle). Nasal tips that are considered over-rotated are commonly referred to as ‘pig noses’ since this translates into more nostril visibility as seen on the front view. Nasal tips that are under-rotated are referred to as being ‘ptotic’ – meaning they appear to hang down over the upper lip.
5. Tip Rotation & Frankfort Plane
Nasal tip rotation is more accurately measured using an alternative technique that involves assessment based on what is called the Frankfort plane. This concept is shown in the below figure. The Frankfort plane is a horizontal line that is drawn through the lower rim of the orbital bone (eye socket) extending back to the level of the ear canal. Another line is then drawn that runs parallel to the columella of the nose. The angle created where these two lines intersect is considered a more reliable measurement for nasal tip rotation since it does not take into consideration variations that might exist in the upper lip angulation. The average range for a male is 0-15 degrees whereas a female should be between 15-30 degrees to be considered as having ideal nasal tip rotation.
6. Nasal Tip Projection
Nasal tip projection is a measurement of how far the nose points out (or projects) from the face. There are actually a variety of methods to measure nasal tip projection and your rhinoplasty surgeon may have their preference of which one to use. In my experience, the method described by Dr. Richard Goode, called the Goode method, has been fairly reliable in assessing tip projection. This concept is shown in the below figure where, first, the alar line is established. The alar line refers to a vertical line drawn through the point where the alar base attaches to the cheek. This essentially establishes the plane of the face as seen on profile view. Another line is then drawn going from the alar line straight out to the nasal tip (“A” in the diagram). A third line is then drawn extending from the nasal tip to the nasal starting point (“B” in the diagram). The ratio of “A” to “B” is then measured and used to assess the nasal tip projection. A normal range for this ratio is 0.55-0.60 in most rhinoplasty patients. If this ratio is greater than the normal range, the nasal tip is considered to be over-projected, meaning it sticks out too far from the face. If the ratio is less than the normal range, the nasal tip is said to be under-projected, meaning it does not stick out as much as it should.
7. Columellar Show
Columellar show refers to the amount of columella that can be visualized when looking at the nose from the side view. This is shown in the photo below as indicated by the two parallel red lines. In between these lines is the visible portion of the sides of the columella. As you can see, this is based on the position of the nostril, or alar, rim as it relates to the undersurface of the columella. Normally there is approximately 2-4 millimeters of columellar show in the average nose. If the columella is in range lesser than the normal measurements it is called “retracted columella”.If it is beyond the 4 millimeters range it is called “hanging columella”.
8. Nasal Tip & Nasal Base
The ideal nasal tip is one that simply does not draw unwanted attention to it. This usually translates into a tip that has an overall soft appearance without any harsh angulations or contours. When looking at the nasal tip on frontal view of the nose, it should appear slightly convex without looking too rounded. In certain light, you can see two light reflexes in the center of the tip that represent the two domes that are part of the underlying nasal tip cartilage. These two ‘domal highlights’ as they are called should be fairly symmetric and are what provides the visible definition of the nasal tip. From the domal region, the tip should transition out to the side in a gentle curvature around the nostril rim. In a similar manner, the tip should transition into the nasal bridge (through what is called the supratip region) in a smooth, uninterrupted fashion. From the frontal view, you should also be able to see at least some nostril shadowing.
From the base view of the nose, the nasal tip should appear as a soft triangle – meaning an overall triangular shape but without the sharp angles. This is visually demonstrated in the adjacent photo diagram. As you can see, the overall outline and shape of the nasal base is that of a triangle, only with gentle rounding of the corners. The blue lines indicate the sides of the columella, which should ideally be situated in the center. Looking at the width of the nasal base, you can appreciate how this particular nose fits within the central one-fifth of the face (between the inner corners of the eyes). Noses that are excessively flared or wide can be seen to extend beyond this distance, which is easily seen from this base view.
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