Rhinogrid™: Precision Instrument in Rhinoplasty

Abstract

Rhinoplasty is a surgery where the result depends on precision in assessment, shaping and placing grafts. The grafts should be accurately measured with the help of precise measuring instruments. There is a need of instruments which allow precise slicing, measuring and re-sizing of the grafts. Other than depending on multiple instruments for slicing and measuring, we need a single instrument with multiple functions. We have developed a simple tool for measurements in Rhinoplasty incorporating both measurement grid and costal cartilage slicer into one device.

Brief Communication

The prose “Beauty Lies in the Eyes of the Beholder” by Greek Philosopher Plato, was expressed by an Irish novelist in the nineteenth century. The concept of beauty has always been a very debatable topic. Whenever there is cosmetic correction for beautifying, there is a very important role of understanding the concept of beauty and aesthetics. And both beauty and aesthetics have a very close association with the knowledge of anthropometry and precision measurements [1].

Beauty can be enhanced by correcting the nasal parameters. Rhinoplasty surgeons are the creators or purveyors of beauty. Rhinoplasty is one of the most challenging surgical procedures aimed to beautify the face by reconfiguring the external and internal anatomy of nose. It aims to establish specific aesthetic results along with preservation of functions of nose. As aesthetic sense is variable across different races and places, most of the work of Rhinoplasty is based on approximate measurements depending on judgment and expertise of the surgeon. Any slight anatomical deflection may result in disturbance of nasal harmony leading to cosmetic deformity as well as functional issues breathing difficulty, nasal discharge and epistaxis [2]. In cases of depressed and saddle noses, elevation of the nasal dorsum by way of augmentation with precise measured grafts not only beautifies the face but also boosts the confidence levels.

Augmentation rhinoplasty is one of the most important aspect of reconstruction of the nose. Amongst the various grafts used for dorsal augmentation, cartilage is the preferred one. Commonly used cartilages in rhinoplasty are conchal cartilage, septal cartilage or costal cartilage. Each of these cartilages have their own advantages. The costal cartilage provides abundance of the graft material which can be sliced, diced, layered, crushed and fashioned for not only dorsal augmentation, but also for alar, baten, spreader, onlay, shield, collumellar strut, septal extension, rim grafts etc. Arbitrary and random slicing of the costal cartilage may not only give uneven non- precise slicing but also may waste the graft. Experienced surgeons have developed precision about the sizes of the grafts to be used. But precision and accuracy should not be limited only to the experienced surgeons. Even a budding rhinoplasty surgeon too should be able to give satisfactory and pleasing results due to accurate and precise size grafts. We have developed a measurement grid and a slicing tool of coastal cartilage for use in rhinoplasty so that accuracy and precision should not be limited to a few surgeon. Our instrument combines both the rib cartilage slicer and measurement grid in one device. We have named it as Rhinogrid™. The aim of this paper is to describe the design and to elaborate its uses and advantages.

Description of the Rhinogrid™

It is a metallic, square-shaped block measuring 16 × 16 cm and 5 mm in thickness with two surfaces. One side has a measurement grid of 12 × 12 cm in dimension and the other side has peripheral 4 hemicylindrical slots measuring 8 × 2 cm with depths of 1 mm, 1.5 mm, 2 mm and 3 mm respectively on the 4 sides (Fig. 1). In the central part lies a square well/ indentation measuring 9 cm × 9 cm × 0.5 cm. The measurement grid helps in measuring the sizes of the various grafts in rhinoplasty or any other surgery which involves grafts and measurements. The measurement grid has the impression of graph paper (Fig. 2). Graph paper is a writing paper that is printed with fine lines at 1 mm distance making up for a regular grid of 1 cm square. We use the grid consisting of 10 small squares per centimeter (similar to the millimeter paper used in algebra). The one centimeter lines are darker compared to the 1 mm fines lines so as to be easy guide for the measurements. The measurement grid is printed on the metallic plate of 3 mm thickness with laser markings. The metallic plate is made of surgical stainless steel SAE 316.

Fig. 1.

Rhinogrid (side with slots for slicing costal cartilage)

Fig. 2.

Rhinogrid (side with measurement grid)

This concept of such a measurement grid was conceived in the year 2010, when we first used the laminated sterilized graph paper as a measurement grid after sterilization [3].

1.2 Sterilization

• 1. Autoclave.

• 2. ETO.

• 3. Cidex Sterilisation.

Discussion

Rhinoplasty is a surgery where the result depends on accurate assessment precision of reshaping using accurately measured grafts [4]. Cartilaginous grafts are harvested are from septal cartilage, concha and rib cartilage. Grafts used at different sites and for different functions have different measurements. Alar grafts are usually 15–25 mm long and 2–3 mm wide [5]. It’s not only the length of the graft, but also its thickness which makes a difference in the final result of rhinoplasty. When septal and conchal cartilages are used to fashion the grafts (rim, alar, onlay etc.), the thickness of these cartilages are adequate to maintain structural support. However the problem arises when the rib cartilage is used as it has to be adequately sliced to appropriate thickness. Different costal cartilages can be used in rhinoplasty from fifth to tenth. The fifth costal cartilage offers the smallest measurements in terms of area and length (Mean ± SD) for both females (1119 ± 248.8 mm² and 69.48 ± 10.29 mm) and males (1525 ± 353.1 mm² and 79.67 ± 14.62 mm) [6]. The seventh costal cartilage offers the largest surface area and total length measurements among both sexes (Females: 1836 ± 271.1 mm² and 123.4 ± 14.62 mm; Males: 2390 ± 409.3 mm² and 137.5 ± 20.49 mm, respectively) [6]. While using rib cartilage for fashioning various grafts in rhinoplasty, thickness also plays an important role. It should not be too thin to be ineffective support nor too thick and uneven to be cosmetically unacceptable. So appropriate sized slices are to be created for effective strength to the reconstructed nose. In case of septal extension grafts, if the graft slices are too thin then it may result in curling of graft compromising the final result. This is usually in cases of nasal extension grafts which are usually carved in sizes of 15 × 4 × 1 to 25 × 8 × 1.5 mm [7]. Less thickness of these graft may lead to un-stabilized nasal pyramid support. RhinoGrid has deep slots of depth of 1 mm, 1.5 mm, 2 mm and 3 mm (Figs. 3, 4) on one side which help to chip off and carve the graft of respective thickness according to requirement ranging from 1 to 3 mm. A number of grafts have been used of specific measurements including shield graft ( 8–15 × 8–12 × 1–3 mm), Onlay tip graft ( 18–25 × 7–13 mm), Spreader graft ( 6–18 × 3–5 × 2–4 mm), Strut graft (5–12 × 3–6 × 1–3 mm) [8]. Our Rhinogrid helps to achieve precise grafts (onlay, collumellar strur, rim, alar) both in terms of thickness as well as lenghts. Both the functions of slicing the costal cartilage graft to a particular thickness as well as obtaining specific desired lenghts and breadths can be achieved from one single instrument.

Fig. 3.

Rhinogrid for graft preparation

Fig. 4.

Rhinogrid for the slicing the costal cartilage

The advantages and applications of our RhinoGrid can be summarized as:

• A.Advantages of the Grid:
• 1.For creating precise measurement grafts in Rhinoplasty: Spreader grafts, rim grafts, shield graft, collumellar strut, septal extension, batten grafts
• 2.For dicing of the cartilage for Diced Cartilage Fascia preparation.
• 3.As a plate for Collection and placements of the grafts after preparation (in Rhinoplasty, tympanoplasty etc.)
• 4.For preparation of the grafts during septoplasty
• 5.For measurements and preparation of the grafts as in Tympanoplasty and ossiculoplasty
• 6.As a block for spreading and dehydrating (drying) fascia grafts
• 7.For measuring and preparing silastic implant in Medialisation thyroplasty
• 8.As a plate for cutting the silastic sheet during tympanoplasty
• 9.For post excision measurements of the specimens as in head and neck surgeries: thyroidectomies and parotidectomies.

• B.Of the Slicer part of RhinoGrid:

1. Creation of precision slices from costal cartilage of predefined desired thickness of 1 mm, 2 mm and 3 mm thickness for Spreader grafts, rim grafts, shield graft, collumellar strut, septal extension, batten grafts etc.

• C.The central square well/ indentation

1. can be used for dicing the cartilage graft

2. Also for placing of the various designed grafts.

Peculiarities of Our Measurement Grid

1. First instrument incorporating both the slicer of the costal cartilage and a measurement grid in a single device

2. Economical as no need to buy two different instruments

Disadvantages of Rhinogrid

1. Weight

Funding

This study was not financially supported from external sources.

Compliance with Ethical Standards

Conflict of interest

Rhinogrid is the trademark registered under the name of Dr. Mubarak M. Khan.