Dr. Nachbar on 3-D Printed Surgical Guides for Rhinoplasty

One of the newest innovations in plastic surgery is 3-D printing.  For the past 40+ years, surgeons and doctors have had to make do with the use of 2-D imaging when consulting with their patients.  2-D images have always been a great reference in terms of planning out a surgery.  Some surgeons, including myself, still do standard 2-D photos, which are easier to modify.  Then, the patient and I would use those to get the first-pass appearance that the patient would like.  Typically, we do that at the first consultation. 

Many years ago, I started using the very first 3-D surgical simulation camera in Arizona. That system has been replaced twice, so I am currently on my third generation 3-D surgical simulation camera. We had mostly used it for 3-D breast surgery simulation, to be able to simulate the appearance that a patient will get with breast augmentation of a specific size and type of breast implant. I have a number of examples on my website showing the breast surgical simulation compared to the final post-surgical appearance. 

Now, it is possible to use that same high-resolution 3-D camera to take a 3-D picture of the face. The system has six high-definition cameras that instantly and simultaneously capture the face from different angles. The software then churns through those images, matching up all the little spots and pores in your skin, and producing a 3-D computer model of your face. The system also includes software that allows me to make changes to the 3-D picture. Once I have a pretty good idea of the patient’s goal from the 2-D image we have worked on together, I can work on adjusting the 3-D picture to try to match the goal. 

Then, we send the original and modified 3-D pictures to a company that uses a 3-D printer to produce models of both the before and after 3-D pictures. Even better, the 3-D printer can print a plastic 3-D template showing the planned result. The template is sterilized, and then is used to guide the surgery, improving the ability to match the surgical result to the planned result.

Like any surgical simulation, this does not guarantee a specific result, but it is incredibly helpful both for the patient to communicate the goal and for me to understand what the patient wants, and also for me to be able to place it on the nose during surgery and see what still needs to be done. That is why I was so excited to be able to use 3-D printing to guide Rhinoplasty. 

The modern Open Rhinoplasty gives us a lot of control over the shape of the nose, but one of the most difficult parts is getting the tip of the nose to match the goal. While I have used photographic surgical simulation for decades so that I could look at an image of our goal during surgery, it is still a challenge to compare the patient’s nose to the image. Rhinoplasty is a very precise surgery, and often the modifications we make during a Rhinoplasty are smaller than a millimeter, and changes that are smaller than a millimeter can often be seen in the nose.

While there are a lot of potential steps during Rhinoplasty, and no two Rhinoplasties are the same, the overall process of the Open Rhinoplasty is to make a tiny incision in the columella, which is the small fleshy part of the nose between the nostrils. Then, I carefully separate the skin and underlying tissue from the cartilages of the nose, to get access to those cartilages. The cartilage is basically the “skeleton” of the nose. By modifying that skeleton, I am able to change the external appearance of the nose once the skin has been draped back over the nasal skeleton.

After the cartilages and skeleton of the nose have been exposed, I can adjust the individual pieces separately. There are a whole range of possible modifications, and no Rhinoplasty could use all of them, but some of the most popular modifications are removing some of the bone that causes the “dorsal bump,” narrowing the bone at the upper part of the nose, narrowing the cartilages that form the tip in order to narrow the tip itself, and placing a cartilage support graft to hold the tip in a stable position. When the patient wants the nose to be less projecting, I can also remove part of the cartilage that holds up the tip, using the cartilage support graft to keep the tip where I put it. But, how can I exactly match the tip position in the simulated surgery to the actual nose on the operating table? That was always the hardest part of a precise Rhinoplasty.

I began using this system a few months ago, and now I would not want to do a Rhinoplasty without it. While the 3-D models are nice, the surgical template is the most useful part of the system.

If you want to see our 3-D camera in action and how we can simulate nose surgery, go to https://nach.bar/appt to set up an appointment, or call 480-289-5300.