2. HISTORY
• Began - ancient egypt and India.
• Description of nasal reconstruction in Susruta samhita
(500 B.C.)
• 1887 - John Orlando Roe performed first intranasal
rhinoplasty.
• Jacques joseph – father of modern facial plastic surgery –
published his Treatise on rhinoplasty.
22. Basic principles to be taken care……
• Be conservative
• Should know where to stop
• Never promise miraculous results after surgery
• Beware of psychotic patients
• Consent
26. Tip Recoil
• Tip Recoil is defined as the
inherent strength and support of
the nasal tip.
• It can be evaluated by
depressing the tip towards the
upper lip and watching for the
tip's supportive structure to
spring back into position.
• If the recoil is good, and the tip
cartilages resist the deforming
influence, then tip surgery can
usually be performed without
fear of substantial support loss.
1/27/2017 Prof Sameer ALI Bafaqeeh 26
30. Quality of skin
Thick skin
Masks refinement and
definition
Failure to contract – excess
soft tissue scar
Does not show small
irregularities
Thin skin
• Small irregularities
become visible
• Early healing
• Less oedema
• Ensure that all bony,
cartilageneous grafts or
implants are precisely
positioned and smoothly
contoured.
35. Indications
• Extensive revision surgery
• Severe nasal trauma
• Congenital deformities: cleft lip nose
• Marked tip deformities
• Elaborate reduction and augmentation procedures
• Correction of extreme overprojection
36. Principles of external rhinoplasty
• Incision- mid-columella incision connected to bilateral
marginal incision
• Dissection in subperiosteal and subperichondrial planes
• Division of medial intercrural tissue offers access to
caudal septum and premaxillary spine
• Division of upper lateral cartilages from quadrilateral
cartilage offers acccessability to whole of septum
37. Advantages
• Extensive exposure for both septal and rhinoplasty
surgery
• Binocular vision
• Use of both hands
• Control of bleeding and diathermy
• precise placement and suturing of struts,battens and
shield grafts
• Valve area preserved
39. Surgical technique
• Broken transcolumellar incision
• If columella short in case of cleft lip-V incision
• Mid-columella incision situated above medial crural foot
plates
• Vertical columellar incision made 1.5-2mm inside
vestibule
• Separate lateral incision given which is joined medially
over the domes
40. Surgical technique……
• Dissection carried in midline just cephalic to dome
subperichondrial plane
• Dissection of soft tissue of bony pyramid should start
above caudal end of nasal bone
• Nasal septum- between medial crurae of lower lateral
cartilage or hemitransfixion incision
• Strut used to
correct buckled medial crura
,strengthen weak medial crura
,correct tip asymmetries
,stable base for tip graft
41.
42. Specific applications
The bony pyramid in external rhinoplasty
• Allows use of burr or reduction of the soft tissue envelope
at nasion to deepen the nasofrontal angle
• Application of soft tissue onlay grafts
• Bony dehumping together with lateral, medial, and
intermediate osteotomies
• The middle nasal vault
• Placement of cartilaginous strips or spreader grafts to
open up the nasal valve area and angles
43. • Middle nasal vault
Shaded areas showing placement of
spreader grafts
45. Indications…
• Patients with ideal height and position of the nasion
associated with excess dorsal convexity
• Oversized alar cartilages producing increase tip and
lobule volume
46. Aims
o Aim-strong nasal dorsum in lateral profile-relates to ideal
nasion height
• Tip defining point-projecting just above dorsal line-to
create supratip break. In males may be on a straight line
with dorsum
51. Tip surgery
Cephalic trim for volume reduction of lower lateral
cartilage done
Transcartilagenous incision
5mm of continous
Strip of lateral crus of
Lower lateral cartilage
Is preserved .
for rotation excision
Of caudal end of septum
53. Dehump
• Nasal hump
• Bony
• Cartilagenous
• Both
• Minimal bony hump can be reduced by using endonasal
approach with just rasping
• Small cartilagenous humps only require shaving of
cartilagenous ridges of the septal dorsum
• Dorsal hump which involves both cartilagenous and bony
vault open approach is preferred
54. • Cartilagenous dorsum is reduced first.
• Blade no.15 is held at the key area in horizontal plane to
incise across left upper lateral cartilage, quadrilateral
cartilage and right upper lateral .
• Advanced caudally in the plane of reduction this transects
the upper lateral cartilage and cartilagenous septum.
• Osteotome is then inserted under the cartilagenous
segment removing the osteocartilagenous hump en bloc
57. Medial osteotomy
• It seperates the nasal bone from the septum
• Made on both side
• Nasal bone seperated at intranasal suture
• Short intercartilageneous given
58. • Outer peritosteun is pushed to the side
• Osteotome is placed at about 2mm paramedially
• Osteotome is worked through the bone slightly below the
level of frontal bone
61. • It seperates the lateral bony wall of pyramid from nasal
process of maxilla
• Short lateral incision is given
• Medial to lateral subperiosteal tunnel is formed upto level
of medial canthus
• Osteotome placed across frontal process of maxilla
• Lateral osteotomy done upto the level of frontal bone
62.
63.
64.
65. Tranverse osteotomy
• Seperates the bony pyramid from frontal bone and nasal
spine of frontal bone
• Osteotomy made at a level just below nasion
70. Daniel and Brenner Classification for
saddle nose
• TYPE TERM DESCRIPTION
0 pseudosaddle relative depression of
cartilaginous dorsum relative
to bony septum
71. Type 1 minor minor decrease in septal support
cosmetic supratip depression and columella
concealment retraction
72. • Type 2 moderate cartilage vault collapse, columella
• cartilage retraction,loss of tip support
• vault reduced projection
• restoration
73. • Type3 major obvious depression, flattening of
• composite of middle vault,drop in septal dorsum
• reconstruction and roof. Upward rotation of nasal tip
74. • Type 4 severe large septal deformity involving bony
• structural vault
• reconstrution
75. • Type 5 catastrophic massive defect requiring total
• construction
76. Properties of implant materials
• Noncarcinogenic and nonimmunogenic
• Not toxic
• Nondestructive , should not impede healing
• Physical properties match the local tissues
• Nonresorbable
• Easily available
• Cost effective easy to sterilize
79. Type of autografts
• Septal cartilage
• Auricular cartilage
• Costal cartilage
• Bone graft
80. Septal cartilage graft
• Harvested using hemitransfixion/transfixion/external
approach
• Harvested posterior to an imaginary line drawn from
anterior nasal spine to osteocartilagenous junction
• Septal cartilage is more rigid and easier to carve and
shape
81. Conchal cartilage
• Conchal cartilage of 3.5cm in length ,antihelix fold to be
kept intact
• Can be harvested by anterior or posterior approach
• For anterior approach incision is given just anterior and
deep to antihelical fold
• Skin is elevated from underlying cartilage by blunt
dissection upto the posterior edge of external auditory
meatus
82.
83. Costal cartilage
• Straight rib cartilage harvested from 6th to 8th rib through
3-4cm skin incision
• Rectus muscle is split vertically and retracted
84. Management ..
• Surgical approach
• External approach preferred
Suture fixation
Reduces risk of infection
Preparation of graft and implant
Use template to achieve the exact size
Avoid abrupt edges
Suture fixation in case layered cartilage graft
85. • Preparation of bed
• Level base to avoid rocking
• Rasped to remove irregularities
• Splinting
• Percutaneous securing sutures
• Taping the skin of the nose down
• External nasal splint
88. Principles of surgical correction
• Deviation and a dorsal hump – reduction technique
• Deviated nose without dorsal hump- septal surgery
• Deviation with saddling- augmentation
89.
90. Treatment of upper nasal third
(bony pyramid)
• Medial ,lateral ,transverse percutaneous osteotomies at
the level of medial canthus allow shifting of the pyramid
back to the midline
• Minor deformity treated by unilateral osteotomies
• Disruption of key stone area can lead to notching of
dorsum,saddling.
91. Septal reconstruction
• Bony septum
• Resection of most prominent and curved part
• Cartilagenous septum
• Resection of redundant and displaced cartilage
• Scoring concave surface of carilage
• Correction of subluxated caudal septum
92. Treatment of middle third
• Shaving of the convex part of the septum
• Use of bilateral and unilateral spreader graft
• Staggered cuts to weaken bowed cartilage
93. Treatment of lower third
If nasal spine central –post septal angle should be sutured
with figure of eight
Locking technique- untrimmed displaced caudal septum is
placed on contralateral side of thinned nasal spine
Absent caudal septum with deviated tip will require
replacement with graft.
96. Tip Support Mechanisms
• Major:
• size, shape, and resiliency of the
medial and lateral crura.
• fibrous attachment of the medial
crural footplates to the caudal
septum.
• attachment of the caudal margin of
the upper lateral cartilages to the
cephalic margin of the alar cartilage.
• Minor:
• dorsal cartilaginous septum,
interdomal ligaments, membranous
septum, nasal spine, surrounding
skin and soft tissues, and alar
sidewalls.
98. Surgical approach
• Incisions
• Transcartilaginous
• Intercartilaginous
• Columellar break incision
• Marginal incision
• Approaches
• Delivery of tip cartilages
• Non-delivery of tip cartilages
• Open approach
• Retrograde approach
• Techniques
• Volume reduction with residual complete strip
• Volume reduction with suture reorientation of residual strip
• Interrupted strip
99.
100.
101. Transcartilagenous Incision
• Incise through vestibular skin
• Similar to intercartilaginous, but 3-5mm caudal to the
cephalic end of LLC
• This is caudal to the nasal valve
• Decreases risk of nasal obstruction (avoids scar
contracture of the valve)
102.
103. Transcollumellar and marginal incision
• External approach
• Crosses collumella just above flared ends of the
medial crura
• Vertical columellar incision placed 1-2 mm inside
the vestibule
• Separate lateral incision given along the caudal
margin of lower lateral cartilage joined medially
over the domes.
104.
105. Tip defining procedures
Methods
• Removal of cephalic strip of lower lateral cartilage
• Vertical division with or without strip excision of lower
lateral cartilage
• Tip suturing
• Tip graft
• Approximately 10mm of lower lateral cartilage left intact
• Lateral part of the cartilage left intact
106. Tip suturing technique
• Interdomal suture –to narrrow the nasal cartllage
• Technique for narrowing and rotation of the nasal tip
• Suture contouring of the nasal tip used to support grafts
such as columellar strut to strengthen media; crura and
enable tip projection
107.
108.
109. Underprojected nasal tip
• Cause
• Small alar cartilage
• Middle and upper third disproportionately large
• Maxillary n mandibular abnormality
• Methods of increasing tip projection
• Goldman tip
• Onlay graft
• Lateral crural steal
• Shield graft
110. • goldman tip and crural strut
• Vertical dome division of dome 2mm or lateral to the apex
• cause lengthening of medial crura segment
• Allows increase tip projection
• Cartilage strut 3-4 mm wide placed and sutured between
medial cruras
• Onlay graft
• graft over the alar cartilage
112. • lateral crural steal
• Alar cartilage resected in intermediate crural area
alar cartilage may be delivered
lateral crura advanced to medial crura and
sutured
tip advancement and tip rotation
113. Shield grafts
In 1975 by Sheen
Indication-
Narrow middle nasal
Vault
Underprojected tip
Weak lower lateral
Cartilage
Incision- marginal
Or via external rhinoplasty
115. Overprojecting tip
• Cause
• Overdevelopment of alar cartilage/ nasal spine/caudal
Septum/quadrangular cartilage dorsum
• Elongated columella
• Iatrogenic overprojection
• Methods of reduction
• transfixion excision
• Vertical dome division (goldman)
• Medial and lateral vertical segment excision
116. Vertical dome division –Irwing Goldman in 1957
Tip delivery approach
Vertical division of alar dome 1mm lateral to highest point
of dome
intermediate crura rotated anteriorly
intermediate crura sutured with medial crura
Medial crura stabilized their height trimmed
122. Polybeak deformity
• Causes
• Drooping of nasal tip
• Absolute or relative high septal angle
• Reconstruction
• Increase of tip projection
• Reduction of cartilagenous nasal dorsum
• Combination of both
123.
124. Nasal Dorsal Irregularities
• More prominent in thin skinned patients- tension nose
• Most common site is K area
• Small bony irregularities can be easily rasped
• Cartilagenous are made smooth with knife or scissors
• Autogenous grafts-from radix to septal cartilage
• Crushed septal cartilage strut preferred
125. Columella deformities
• Acute nasolabial angle
• Retraction of columella
• Cause-
• Overresection of caudal septal end
• Resection of anterior nasal spine
• Creation of columella pocket between medial crura
Correction-
Distance between columellar skin and caudal septum by
inserting a cartilage strut
