The successful rhinoplasty surgeon’s operative plan is based on a clear understanding of the patient’s desired changes, a careful and accurate diagnosis of the patient’s anatomy, and a wide armamentarium of surgical techniques. Prior techniques and the surgeon’s personal experiences with the array of surgical techniques are also primary factors in the decision for a particular operative approach. The successful surgeon’s application of surgical techniques is designed to accommodate differences in anatomy and to account for variant anatomy. For example, noses with thin skin and noses with thick skin each present specific problems that must be considered when choosing techniques for altering nasal structure. Also, the effects of scar contracture vary from patient to patient and can significantly affect the ultimate aesthetic and functional outcome. The rhinoplasty surgeon must recognize that the healing process may distort the changes made at the time of surgery, however expertly they were accomplished. The surgeon’s only recourse is to build a structurally sound nasal architecture that can withstand the forces of scar contracture and provide an acceptable success rate.

The importance of experience in rhinoplasty cannot be overemphasized. The experienced rhinoplasty surgeon can anticipate the likelihood of a favorable outcome based on his or her experience using certain techniques with a specific deformity. Selection of the proper technique for each circumstance should provide the opportunity for a high success rate.

The purpose of this dissection manual is to provide practical information about a wide range of surgical techniques in rhinoplasty. The dissection manual guides the reader through a step-by-step dissection. It focuses on the execution of basic and advanced rhinoplasty techniques and seeks to provide practical information that can be readily applied in surgery. The text is intended to be a procedurally oriented dissection manual and is organized to allow easy reference to a wide array of basic and advanced rhinoplasty techniques. Illustrations and intraoperative photographs, along with detailed text, guide the reader through the step-by-step dissection. Important technical and clinical "pearls" are high- lighted in each section. A programmatic cadaver dissection videotape accompanies the text.

Before beginning the nasal dissection, review the chapter on nasal anatomy (Chapter 1) and the chapter on pre-operative rhinoplasty analysis (Chapter 2). Chapter 3 outlines local anesthesia injection techniques, the dissector is instructed to practice the injections prior to commencing the programmatic dissection.

The dissection manual guides you through the following dissections: septoplasty, transcartilaginous or inter-cartilaginous approach, delivery approach and an external rhinoplasty approach. The remainder of the programmatic nasal dissection details a number of rhinoplasty techniques and addresses a number of specific rhinoplasty problems. The manual focuses primarily on the external rhinoplasty approach; however, all approaches are covered and can be performed sequentially, or the dissector may choose to focus on a specific approach. Appropriate targeted references for further reading are also provided.

We recommend that the dissector proceed with Chapters 1-6 with the skin-soft tissue envelope intact. For the remaining chapters, the dissector may wish to split the skin down the midline for better exposure. In this fashion, the dissection can be performed without an assistant, and (except for a complete septoplasty) without it headlight.

The cadaver laboratory is the place to sharpen one’s surgical skills. This manual seeks to provide the dissector with the opportunity to obtain maximum benefit from performing this complex operation on cadaver specimens. The dissection manual was "field-tested" at the University of Pennsylvania Rhinoplasty Course : Aesthetic & Functional Rhinoplasty. Participants, many of whom professed relatively limited rhinoplasty experience, undertook the stepwise, programmatic dissection and worked through the manual (with the exception of riborclavarial bone harvest) in a single five-hour period.

Rhinoplasty is an operation that requires constant thought, assimilation of information, and reaction to unexpected findings. With this in mind, the authors s t r ongly recommend involvement in as many advanced teaching encounters as possible. This may involve reading timely literature, attending advanced rhinoplasty courses. observing other experienced surgeons, or sharpening one’s skills in the cadaver laboratory. We hope that use of this dissection manual will stimulate thought and incite both the enthusiasm of the beginner as well as experienced rhinoplasty surgeons seeking to broaden their surgical armamentarium.

Dean M. Toriumi, M.D. Daniel G. Becker, M.D.