2017-18 HSC Section 4 Green Book

Special Topic Reprinted by permission of Plast Reconstr Surg. 2017; 139(3):604-612.

The Importance of the Anterior Septal Angle in the Open Dorsal Approach to Rhinoplasty

Rod J. Rohrich, M.D. Phillip B. Dauwe, M.D. Benson J. Pulikkottil, M.D. Ronnie A. Pezeshk, M.D. Dallas, Texas

Summary: Functional and aesthetic manipulation of the nose relies on a de- tailed understanding of nasal anatomy and a meticulous dissection. Maneu- vers are performed in four regions of the nose: nasal tip, dorsum, posterior septum, and caudal septum. Positioned at the cornerstone of these regions, the anterior septal angle acts as a point of reference, especially in secondary rhinoplasty. Identification of the anterior septal angle early in the nasal dissec- tion aids in reliable exposure, either wide or limited, and facilitates desired ma- neuvers. In addition, alteration of the position of the anterior septal angle can affect nasal tip projection, especially in cases such as the tension tip deformity. The authors emphasize the importance of the anterior septal angle in their simplified methodology for the open dorsal approach in rhinoplasty. ( Plast. Reconstr. Surg. 139: 604, 2017.)

T he role and importance of the anterior sep- tal angle in open rhinoplasty is well known by rhinoplasty experts, but is not so clear to the majority of rhinoplasty surgeons. This Special Topic article delineates, in detail, how and why it is so critical to demarcate the anterior septal angle first after opening the nose, as this will assist the surgeon in successfully and reproducibly deliver- ing multiple maneuvers in both primary and sec- ondary rhinoplasty. In primary open rhinoplasty, the anterior septal angle defines the gateway to how one can safely and reliably approach the dorsum, the tip, and the septum in a graduated and precise manner. In secondary rhinoplasty, it is even more vital, as often the anterior septal angle is one of the few landmarks that is pre- served and can be identified after prior dissec- tions that have produced significant scarring in the tip and supratip region. Safe exposure of the anterior septal angle allows the surgeon full access to the septum, dorsum, and tip (for harvesting of cartilage), and allows restoration of the dorsum and the internal nasal valves and reshaping the tip—all three of the components necessary to restore a nose in secondary rhino- plasty (Fig. 1). From the Department of Plastic Surgery, University of Texas Southwestern Medical Center. Received for publication May 12, 2015; accepted June 21, 2016. Copyright © 2017 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000003123

UNDERSTANDING THE ANATOMY The anterior septal angle is a fundamental component of a successful rhinoplasty. A complete understanding of how the septum relates to the osseocartilaginous framework and function of the nasal airway is essential for the rhinoplasty surgeon to obtain reproducible results in a consistent man- ner. The anterior septal angle represents the cor- nerstone on which the open dorsal approach to rhinoplasty has been developed, and knowledge of its anatomical relationships to the cartilaginous framework allows open access to critical functional and aesthetic manipulation of the nose. The quadrangular cartilaginous septum is pri- marily supported on its posterior and inferior mar- gins by the nasal bones, perpendicular plate of the ethmoid, vomer, and maxillary nasal crest. The Disclosure: The authors have no financial interests in this research project or in any of the techniques or equipment used in this study. Dr. Rohrich receives instrument royalties from Eriem Surgical, Inc., and book royalties from Taylor and Francis Publishing. No funding was received for this article. Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal ’s website (www. PRSJournal.com).

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