education

1. CLOSED
RHINOPLASTY

2. OUT LINE
 Anatomy
 History and Physical examination
 Basic Nasal Aesthetics
 INCISIONAL APPROACHES
 Parameters of Rhinoplasty Planning
 Preoperative evaluation
 Procedure
 Post op and complication

3. SKIN
 Upper 2/3 of the skin envelope is thinner and
more mobile than the lower third

4. NASAL
 The outer layer
 like a soft, elastic sleeve, slides over
the inner, fixed, semi rigid layer
 The inner layer
 everything else (the bony and
upper cartilaginous vaults, the
nasal septum, and their associated
linings.)

5. MUSCLES
 Levator labii superioris alaeque nasi
 Dilate nostril
 Assists in patency of external nasal valve
 Nasalis
 Elevate corner of nostril, depress tip of
nose
 Assists in nasal airway patency
 Depressor septi
 Depression nasal septum
 When hyperactive, may shorten the
upper lip and decrease tip projection

6. BLOOD SUPPLY
 superficial to the nasal
musculature in the subcutaneous
plane.
1. Ophthalmic artery
 Supplies the superior portion of
nasal envelope
1. Facial artery
 Supplies most of nasal envelope
and responsible for nasal tip
blood supply

7. INNERVATION
 Maxillary and ophthalmic branches of CN V
 provide sensation to nose.
 Supraorbital and supratrochlear branches of
ophthalmic nerve
 supply cephalic portion.
 External nasal branch of anterior ethmoid
 innervates middle vault and nasal tip.

8. UPPER VAULTS
 formed by paired nasal bones and ascending frontal processes
of maxilla.
 Nasal bones have greater thickness and density above the
medial canthus
 gradually become thinner toward the tip.
 area of the internal nasal valves
 Brace in position of the middle vault roof

9. MIDDLE VAULT (CARTILAGINOUS)
 paired upper lateral cartilages (ULCs),
 dorsal septum
 soft tissue attachments.
 ULCs join the septum medially to form a “T” in cross-section
 creating the internal nasal valve
 Scroll area describes the region of abutment
 between the ULCs and LLCs

10.  the “watershed” area
 the internal and external nasal valves
 The point of intersection of the upper and lower lateral cartilages creates
 aggressive surgery in this area
 also affects external valvular competence
 Keystone area describes the region
 where the bony upper vault meets the cartilaginous middle vault.
 It is commonly the widest portion of the dorsum

11. RESECTION OF THE MIDDLE VAULT ROOF DURING
HUMP REDUCTION
 Middle vault collapse
 "inverted V" deformity
 narrowing at the internal valves
 Middle vault collapse

12. LOWER VAULT (CARTILAGINOUS)
 Composed of the lower lateral cartilages (LLCs).
 Each LLC may be divided into three crura:
 medial
 middle
 lateral

13. LOWER VAULT (CARTILAGINOUS)
 The lateral crus shares
 a common perichondrium
with the accessory cartilage.
 Lateral crus and accessory
cartilage
 function as a single unit
called lateral crura complex.
 LLCs are related
 tip projection, rotation, and
definition.

14. • THE LATERAL CRURAL COMPLEX IS SUPPORTED
BY THREE STRUCTURES:
 Suspensory ligaments of the
tip
 Fibrous connections to the
ULC
 Abutment with the piriform
aperture

15. DORSUM AND TIP
 Support and projection of the
nasal tip are provided by the
following:
1. LLC and attachment to the piriform
aperture
2. Domal suspensory ligament
3. Fibrous intercartilaginous
connections between ULC and LLC
4. Medial crural ligaments
5. Anterior septal angle

16. INTERNAL NASAL VALVE
 Created by junction of caudal border of the ULC and nasal septum.
 Normal angle is 10-15 degrees, with a more acute angle leading to
nasal obstruction.
 Narrowest portion of the nasal airway thus regulating airflow
resistance.

17. COTTLE MANEUVER

18. EXTERNAL NASAL VALVE
 Created primarily by caudal edge of lateral crus and nasal septum.
 Contributions from soft tissue of ala and nasal sill.
 The nasal ala is void of cartilage.
 External valve collapse may be seen with nostril collapse on
inspiration.
 Assess alar rims for notching or eversion on inspiration, which
may be a compensatory response for external valve collapse.

19. SEPTUM
 Composed
 septal cartilage and bone of ethmoid and vomer
 Variations in anatomy of the osteocartilaginous
junction are common
 Evaluate septum
 deviation, perforation,or bone spurs.
 Fractures from prior trauma occur in patterns based
on underlying biomechanics

20. TURBINATES
 Paired bony structures regulate and humidify
inspired air.
 Superior, middle, and inferior turbinates are extensions of
the lateral nasal wall.
 Complete removal of the inferior turbinate may cause
nasal obstruction with empty nose syndrome.

24. DIFFERENCES IN PRIMARY AND SECONDARY
CANDIDATES
 secondary rhinoplasty patient's
 Scar
 contracted soft tissues will not tolerate aggressive
dissection
 multiple incisions
 tight dressings.
 graft donor sites is harvested
 more difficult (distorted septum or concha)
 painful (costal)
 frightening (calvarial) donor sources.
 morale is often more fragile

25. HISTORY AND PHYSICAL
EXAM

26. PATIENT'S HISTORY
 initial interview with the patient alone
 photographs that reflect the preoperative appearance

27. PATIENT'S FUNCTIONAL AND AESTHETIC
COMPLAINTS ?
 PATIENT'S FUNCTIONAL COMPLAINTS
 Ask about periodic or cyclic airway obstruction
 seasonal allergies that obstruct the airway
 sinusitis requiring antibiotics
 snoring, epistaxis, and sinus headache
 history of nasal trauma
 secondary rhinoplasty
 self-medicate with steroid or vasoconstrictive sprays
 history of tobacco ,cocaine or alcohol consumption
 which may cause nasal congestion

28. THE PREOPERATIVE EXAMINATION
 INTRANASAL EXAMINATION
 patients who breathe poorly may be unaware of their
obstructions
 Nasal Valves
 Nasal Septum
 Turbinates

29. NASAL VALVES
EXAMINATION
 asking the patient to breathe deeply and observing
areas
 collapse or asymmetry nasal sidewalls
 inspiration at one or both of the nasal valves is
surprisingly common
 compare flow through the unobstructed airway
 cotton-tipped applicator
 high septal deviations
 distortion of the columella
 protrusion of the caudal septum
 alar rim collapse

30. NASAL SEPTUM
EXAMINATION
 palpation for substance, contour, and mucosal cover
 septal deviation exists; because hump removal can
unmask a high septal curvature,

31. TURBINATES
EXAMINATION
 evere septal deflection
 in which the turbinate contralateral to the septal
deviation hypertrophies
 plan conservative or resections ?

32. THE EXTERNAL EXAMINATION
 cartilaginous size and substance
 bony vault length
 nasal sidewall stiffness
 (another assessment of valvular support)
 soft tissue thickness.
 Tip lobular contour
 balance between nasal base size and bridge height

33. BASIC NASAL
AESTHETICS

34. ON FRONTAL VIEW
 Assess overall facial proportions and their relationship to
the nose.
 Determine thickness and quality of nasal skin envelope.
 Determine if nose is straight or crooked
 Analyze the dorsal aesthetic lines.
 Evaluate width of upper vault.
 Evaluate middle vault.
 Evaluate width of alar base
 Assess nasal tip definition.

35. LATERAL VIEW
 Evaluate nasal dorsum and tip.
 Assess nasal tip projection.
 Assess nasal tip rotation.
 Evaluate nasal ala.
 Assess infratip lobule.

36. BASAL VIEW
 alar rims and nasal tip should form an equilateral
triangle
 Nasal tip/columella (nostril) ratio should be 1:2.
 The nostril should have a slight teardrop shape with
the apex slightly medial to the base.

38. PARAMETERS OF
RHINOPLASTY
PLANNING

39. (1) SKIN THICKNESS AND
DISTRIBUTION
 large nasal baselarge nasal base does not contract into a small nasal
base
 Thicker skin requires more skeletal support and
contracts less
 Thinner skin allows greater reductions but requires
softer grafts to avoid surface distortions

40. TIP LOBULAR CONTOUR
 soft tissues are always thicker in the caudal than in
the cephalic nose
 surgeon should select first those maneuvers that
provide the best nasal base contours.

41. IDEAL TIP AESTHETICS
 Well defined
 greatest projection
 flat supratip
 tip lobular mass that
falls below the point of
greatest projection
 poorly defined
 low point of greatest tip
projection
 a convex supratip
 a tip lobular mass that lies
cephalad to the point of
greatest projection

42. BALANCE BETWEEN NASAL BASE SIZE AND
BRIDGE HEIGHT
 This powerful illusion has its most important
practical application

43. 1. nasal base size is excessive
 aesthetic goal may best be reached by a change in balance
instead of only size
1. patients whose soft tissues are thick
 who therefore may be more successfully treated by the
combination of reduction and augmentation

44. KEY FEATURES OF MALE NOSES
(COMPARED WITH FEMALE NOSES)
1. • Dorsum tends to be straighter and wider with decreased
concavity at the superciliary ridges
2. • Nasal dorsal profile (a line drawn from the radix to the tip
defining points) should approach 1 mm or less, instead of
falling 2 mm behind and parallel to this line in women
3. • No supratip break
4. • Tip rotation slightly less (95-100° vs 103-105° in
females)because less nostril show secondary to a longer nasal
dorsum

45. KEY FEATURES OF MALE NOSES
(COMPARED WITH FEMALE NOSES)
5. • Stronger chin abutting the plumb line drawn
tangential to the upper lip (vs 2-3 mm posterior to
this line in women)
6. • Broader, more bulbous, nasal tip, in general
7. • Skin is usually thicker, making the amount of
change that can be perceived

46. 4 COMMON
ANATOMIC
VARIANTS THAT
PREDISPOSE
TO UNFAVORABLE
RESULTS

47. FOUR COMMON ANATOMIC VARIANTS THAT
PREDISPOSE
TO UNFAVORABLE RESULTS
1. low radix/low dorsum
2. narrow middle vault
3. inadequate tip projection
4. alar cartilage malposition

48. LOW RADIX OR LOW DORSUM
 When the radix begins lower than the upper lash
margin
 dorsal length is therefore shorter and so nasal base
size appears larger

49. OFTEN COMPLAINT:
“THE TIP OF MY NOSE STICKS OUT TOO FA
 If the surgeon reduces the nasal dorsum
 Skeltal and skin sleeve maldistribution will worsen
 the lower nose will appear even larger
 choices
 limit tip reduction or raise the dorsum segmentally or
entirely to balance the nasal base

50. NARROW MIDDLE VAULT
 upper cartilaginous vault that is at least 25%
narrower than the upper or lower nasal third
 link between resection of the cartilaginous roof and
postoperative internal valvular collapse
 surgical avulsion of the upper lateral cartilages from the
nasal bones
 Rhinomanometric studies
 indicate that valvular obstruction

51. INADEQUATE TIP PROJECTION
 tip that does not project to the level of the anterior septal angle
 assess tip projection by
 measuring the distance of the most projecting point of the tip
from a facial parameter
 nasal base segments anterior and posterior to the upper lip
 the relative lengths of the nasal base and upper lip

52. ALAR CARTILAGE MALPOSITION
 cephalically-rotated lateral crura
 whose long axes run on an axis toward the medial canthi instead of toward the lateral
canthi, the position of orthotopic lateral crura
 cause
 First
 the abnormal cephalic position of the lateral crura places
 risk if an intercartilaginous incision
 Secondary,
 Resected or whole, lateral crura
 leading cause of external valvular incompetence
 The treatment
 cephalic rotation of the lateral crura requires resection
 replacement of these structures relocation of the lateral crura to
support the external valves

54. THE MOST COMMON GROUPING OF THE FOUR
ANATOMIC VARIANTS THAT PREDISPOSE TO
UNFAVOURABLE RESULTS;
LOW RADIX, NARROW MIDDLE VAULT, AND INADEQUATE TIP PROJECTION
dorsal reduction; conservative reductions of the lateral
crura and caudal upper lateral cartilages; maxillary
augmentation; and radix, spreader, and tip
grafts with left unilateral osteotomy.

55. MANAGEMENT

56. ROUTINE ORDER OF SURGICAL STEPS
 reverse Trendelenburg position
 minimize bleeding
 nose is blocked(anterior ethmoidal,infraorbital, infratrochlear)
 1% lidocaine with epinephrine 1 : 100 000 (20 mL of
1% lidocaine plus 0.2 mL of epinephrine 1 : 1000)
 nose is cleansed: povidone iodine

57. INCISION-ENDONASAL APPROACH
 Nondelivery: cartilage-splitting (transcartilaginous) incision
 transcartilaginous (cartilage splitting) incision or a
retrograde or eversion incision.
 several millimeters cephalad to the caudal margin of the lateral
crura
 preserves a rim strip to support the ala
 delivery :
 cephalic-most margin of the LLC
 maintains the caudal alar margins
 prevents potential scar contracture deformities in this area.
 used in cases where moderately complex tip modifications (tip
bifidity.)

59. SKIN ENVELOPE DISSECTION
 exposure of the nasal framework
 not to injure the cartilages
 on the surface of the tip cartilage. until the bony
pyramid
 avoid disruption of all of the periosteal attachments
 assure that the ULCs are not detached from the nasal
bones

60. AUGMENTING THE MOST COMMON NASAL
AREAS:
RADIX, SPREADER, AND TIP GRAFTS
 Dorsum and radix
 Spreader grafts
 Lateral wall and columellar grafts
 Tip grafting

61. DORSUM AND RADIX
 The key principle in all augmentation
 His or her aesthetic goals.
 match the graft material to the patient’s soft tissue
characteristics
thinner skin
 requires softer, well contoured grafts that will not show
excessively
Thicker skin
 needs more augmentation to provide a given result but
will hide more underlying flaws

62. TECHNICAL DETAILS
 lightly crushed grafts to fit the defect:
 longer graft that extends from the radix toward the
mid-dorsum,
 shorter graft fixed to its cephalic end at the deepest
part of the defect
 Most grafts are not sutured into position but only
fixed with the tape dressing

63. SPREADER GRAFTS
 septal cartilage provides the ideal spreader graft
 span middle vault length from the bony arch almost
to the septal angle
 After spreader grafts are placed
 caudal slippage can be avoided by a single 4-0 plain
catgut transfixing
 suture placed at the septal angle

65. LATERAL WALL AND COLUMELLAR GRAFTS
 Cartilage provides the ideal lateral wall graft, split
tangentially or crushed to fit the defect
 correct asymmetries in the deviated nose, or mask
the edges of a dorsal graft
 “filler grafts” to correct columellar notching from
prior open rhinoplasty scars or retraction after
trauma or surgery

67. TIP GRAFTING
 concept of grafting the primary tip or correcting
supratip deformity by augmentation
 early appearance as an augmentation method
 The two most common graft designs
 Shield graft
 cephalic transverse onlay graft,

69. POSTOPERATIVE CARE
 bed elevated at an angle of 45º
 Cool compresses are used periorbitally
 NSS solution for postoperative nasal congestion
 ATB 3 day
 Pain killer drug
 imperative to keep the nasal splint dry,

70. POSTOPERATIVE CARE
 5–7 days postoperatively, at which time the sutures and nasal
splints are removed
 Any manipulation of the nose for the first 3 weeks
 The patient cannot let anything,
 including eyeglasses, rest on the nose for at least 4 weeks.
 normal sensation returning within 3–6 months

71. PROBLEMS IN THE POSTOPERATIVE COURSE
 Iatrogenic airway obstruction(More common)
 internal valvular incompetence
 from resection of the middle vault roof
 external valvular incompetence
 alar cartilage resection
 Soft tissue problems
quality determines : graft quality, soft tissue
 Skeletal problems
 Irregularities or asymmetries

72. PROBLEMS IN THE POSTOPERATIVE COURSE
 Hemorrhage
 moderate bleeding for the first 48–72 h postop
 Rx: Placed packs, suction the airway
 reinsertion of an absorbent pack soaked in phenylephrine
hydrochloride
 epinephrine-soaked cotton does not promptly stop the
bleed

73. PROBLEMS IN THE POSTOPERATIVE COURSE
 Septal perforation
difficult septoplasties
 curious whistling;
larger ones cause crusting, epistaxis, and rhinitis
the turbulent airflow spins through the
perforated mucosa
 The repair of
 septal perforations is difficult; recurrence after local
or even distant (labial mucosal) flaps in the largest
series approaches 50%. In symptomatic
perforations,

74. PROBLEMS IN THE POSTOPERATIVE COURSE
 Circulatory problems
 Infection
 methicillin-resistant staphylococcal aureus as a
community-acquired pathogen
 Toxic shock syndrome, cavernous sinus and nasofrontal
 abscess, and even endocarditis are extremely

75. PROBLEMS IN THE POSTOPERATIVE COURSE
 Septal collapse
 Loss of cartilaginous support
 required reconstruction is therefore predictably complex
 Red nose“post-rhinoplasty red nose”
 facial telangiectases develop red noses
 discoloration, usually manifested as a “blush” in the nasal
tip during the early postoperative period
 Non tender
 most improve spontaneously
 laser treatment

76. TAKE HOME

79. THANK YOU