3. CAUDAL SEPTAL INCISION
Aka hemitransfixion
Made 2 mm above and
parallel to the caudal
margin of cartilaginous
septum
Incision provides access
to;
1. Septum
2. Premaxilla and anterior
nasal spine
3. Nasal dorsum
4. Columella
5. Floor of nasal cavity
4. Intercartilaginous incision
Is a cut made in the
vestibular skin just
cranial to the caudal
end of triangular
cartilage
Incision starts halfway
along the lower end of
cartilage and continues
past .
Provides access to :
1. Nasal
dorsum(cartlaginous
and bony vault)
2. Valve
3. lobule
5. Vestibular incisions
Vestibular incision is a
slightly curved cut
made in the vestibular
skin just lateral to the
margin of pyriform
aperture.
It is used to access:
1. Paranasal area
2. Pyriform aperture
3. Lateral wall of nasal
cavity
6. Infracartilaginous incision
It is an incision at
the caudal margin of
the lateral crus
,dome and medial
crus of the lobular
cartilage
It gives access to :
1. Lobular cartilages
2. Cartilaginous vault
7. Transcolumellar inverted-v-
incision:
It is a horizontal
reversed-v- shaped
incision of the columella
at about one-third of the
distance from its base ,
it is made in
combination with
infracartilaginous
incision on both sides in
the external approach
Access to
1. Lobular cartilages
2. Cartilaginous dorsum
3. Anterior septum
8. SPECIAL INCISIONS
EXTERNAL
1. Labiogingival incision
2. Sublabial incision
3. Paranasal incision
4. Lateral columellar
5. Rim incision
6. Alarfacial incision
7. ‘v’ incision of
columellar base
8. Dorsal incisions
INTERNAL
1. Transfixion incision
2. Transcartilaginous
incision
3. Incisios in the
turbinate mucosa
4. Incisions in the septal
mucosa
9. Pyramid surgery
One of basic procedures in functional
reconstructive nasal surgery
It involves
Mobilizing the bony pyramid
Repositioning and fixation of bony
pyramid
10. steps for mobilizing the bony
pyramid
1. Mobilizing and correcting the septum
2. Outlining the osteotomies
3. Undermining the skin over the pyramid
4. Bilateral paramedian osteotomies
5. Bilateral lateral osteotomies
6. Bilateral transverse osteotomies
7. Mobilizing the bony pyramid
12. Paramedian osteotomies:
It separates the nasal
bone from each other
as well as from
septum ,they are
made on both sides
The nasal bones are
separated at
intranasal suture.
Mostly done through
intraseptal approach
14. Lateral osteotomy
It separates the
lateral bony wall of
pyramid from nasal
process of maxilla.
A cut is made into
the bone above and
more or less parallel
to NBL
16. Transverse osteotomy
A transverse
osteotomy
separates the bony
pyramid from the
frontal bone and the
nasal spine of the
frontal bone.
This osteotomy is
usually made at a
level just below the
nasion
18. Repositioning the bony pyramid
After mobilizing, bony pyramid is
repositioned using maneuvers like
1. Bilateral infracture
2. Bilateral outfracture
3. Rotation by unilateral infracture and
outfracture on opposite side
4. Rotation following u/l wedge resection
5. Push down with bilateral infracture
6. Letdown following b/l wedge resection
7. Push up
19. Bilateral infracture
Both lateral walls of
the bony pyramid are
moved inwards
(medially).
This requires
paramedian , lateral
and transverse
osteotomies on both
sides.
20. Bilateral outfracture
Lateral walls of the
bony pyramid are
moved outward
(laterally), thus
widening the
pyramid and valve
area
Requires
paramedian , lateral
and transverse
osteotomies.
21. Rotation by u/l infracture and
outfracture on opposite side
Long ,shallow side is
infractured
Short steep is
outfractured
Lateral osteotomy on
the longer side is
performed somewhat
higher than on short
side so that distance
b/w osteotomies and
dorsum become
symmetrical
22. Rotation by u/l wedge rotation
A wedge of bone is
resected at the base
of long side of
pyramid
Used in patients with
severely deviated
bony pyramid
23. Push down with b/l infracture
The bony pyramid is
pushed down and b/l
infractured
Projection is reduced
and pyramid is
narrowed
Requires resection of
basal horizontal and
posterior vertical strip
from septum in
combination with
osteotomies
24. Let down following b/l wedge
resection
Bony pyramid is let
down after performing
osteotomies and b/l
wedge resection
This technique allows
lowering of the bony
pyramid without
concominant
narrowing.
25. HUMP REMOVAL
TYPES OF HUMP
1. Bony hump
2. Bony and cartilaginous hump
3. Cartilaginous hump
26. Surgical techniques:
1. Reduction by rasp and file
2. Resection
3. Push-down with infracture of pyramid
4. Let down of pyramid following bilateral
wedge resection
27. Correcting bony hump with rasp
and file
Is performed
through
intercartilaginous
incision
Only bony bumps
can be corrected
with this .
Not effective on
cartilage
28. Resection of bony and/or
cartilaginous hump
Most common way to correct bony and/or
cartilaginous hump
Had several drawbacks
We resect the bony part of hump first and
f/b cartilaginous part
The bony part is resected with chisel ,f/b
smoothing the defect with rasp
The cartilaginous hump is then resected by
using straight or angled scissors
29. Resecting bony hump
The hump to be
resected is outlined
on the skin
The dorsum is
approached by
combining the right
intercartilaginous with
the CSI. This is f/b
wide undermining of
the dorsal skin
30. The skin over the
bony and
cartilaginous dorsum
is undermined
subperichondrially
and subperiosteally
Resection is done
with chisel
Bevel up –first part
Bevel down-upper
part
31. Resecting a cartilaginous hump
The triangular
cartilages are
separated
intraseptally from
septal cartilage
using no.64 beaver
knife
32. The cartilaginous hump
is resected stepwise ,
the height of the
cartilaginous pyramid is
adjusted to the height of
the modified bony
pyramid
The triangular cartilages
are sutured to the septal
cartilage to close the
cartilaginous pyramid
33. saddle nose correction
Types of saddling
1. bony and cartilaginous saddle nose
2. Low , wide pyramid syndrome
3. Bony saddle
4. Cartilaginous saddling
34. Bony and cartilaginous saddle
nose
both bony and
cartilage pyramid
severely depressed.
Corrected by
reconstruction of
septum ,narrowing
and push up of bony
pyramid following
osteotomies and
dorsal transplant.
35. Low wide pyramid syndrome
both bony and cartilaginous
pyramid are severely
depressed and lobule is wide
and low
Valve area is lowered and
widened ,valve angle is
increased (>90 degress)
Is corrected the same way as
for bony and cartilaginous
saddle nose
36. Bony saddle
Dorsum is severely
depressed, while
cartilaginous pyramid
and cartilaginous
septum are normal
Corrected by
narrowing and push
up of the bony
pyramid following
osteotomies and
insertion of a dorsal
transplant.
37. Cartilaginous saddling
Cartilaginous pyramid is
severely or moderately
depressed and
broadened .
There may be atropy or
balloning of triangular
cartilages
Most common cause is
killian-freer submucous
septal resection
This is corrected by
anterior rotation of
septal cartilage.
38. Surgical techniques
Repositioning and reconstruction of
anterior septum
Narrowing and push up of bony pyramid
following osteotomies
Augmentation of pyramid by inserting a
dorsal implant
Increasing lobular projection and narrowing
lobular width
Lengthening and lowering the columella
39. Repositioning and
reconstruction the septum
Done through CSI incision
Through antero-superior
tunnel and inferior tunnel
,premaxilla and anterior
nasal spine is exposed
Anterior septum is detached
from base and bony septum
Guide wires are fixed to
caudal end of septum at its
ventrocaudal angle and its
base
40. Augmentation by dorsal implant
Limited degree of
cartilage sagging is
corrected by
inserting crushed
sepatal cartilage
through
intercartilaginous or
caudal septal
incision.
41. Autografts such as
conchal cartilage , rib
cartilage can be used for
augmentation.
Inserted through IC
incision
Undermining of dorsal
skin
Pocked created between
two domes to accomdate
caudal end of transplant
Held in place by external
stenting
42. Tip surgery
“The one who masters tip masters nose”
tip surgery is never related to
improvement of function ,but is always
done for aesthetic reasons.
43. Characteristics of tip
most prominent point or area of external
nasal pyramid
Built by:
1. Two lobular cartilages
2. Inter-domal soft tissue
3. Overlying skin
Tip is defined by two domes ,should be visible
as separate structures.
44. Projection of tip
Aka tip prominence
Too high- narrow pyramid
syndrome
Too low-wide pyramid syndrome
(saddle nose)
Projection related to :
1. Lobular base line
2. Nasal base line
3. Prominence of bony
cartilaginous pyramid
4. Nasal lenghth
45. Position of tip
Position of tip in vertical and horizontal
axis of face is determined by above
mentioned factors.
Upwardly rotated tip
Pendant or drooping tip
46. Tip abnormalities
1. Broad ,bullous,square,ball tip
2. Bifid tip
3. Asymmetrical tip
4. Underprojected tip
5. Overprojected tip
6. Upwardly rotated tip
7. Hanging (pendant ,drooping )tip
47. Broad,bullous,square,ball tip
Broad tip- domes apart
Bullous-domes are wide and
massive
Square tip-domes are not
arched but rectangular
Ball tip-domes rounded
Is due thickness of both
cartilage , lobular skin and
subcutaneous tissue
Requires narrowing procedure
without compromising function.
48. Bifid tip
Tip is duplicated due
to an abnormally large
distance between the
two domes with an
excessive amount of
interdomal connective
tissue.
Requires dissection
and repositioning of
the lobular cartilage
49. Asymmetrical tip
Domes are
asymmetrical .
It is isolated variety
or in combination
with bifidity
50. Underprojected tip
The projection of the tip
is abnormally low
compared with that of
bony and cartilaginous
pyramid
Requires complete
septorhinoplasty
Projection of domes
may be increased by
redraping the lobular
cartilage ,columellat
strut ,or by applying tip
graft
51. Overprojected tip
it is abnormally
prominent when
compared to projection
of cartilaginous and
bony dorsum
Requires complete
suptorhinoplasty
Projection of domes
dimnished by redraping
of lobular cartilages or
by minor resections
52. Upwardly rotated tip
Tip is more cranial
than normal
Upwardly rotated tip
is usually
overprojected
Nasolabial angle is
large
53. Hanging tip
Tip is more caudal
than normal and
underprojected at
the same time .
The nasolabial
angle is abnormally
smaill
54. Surgical technique
1. Narrowing tip and supratip area
2. Increasing tip projection
3. Reducing tip projection
4. Upward positioning (rotation) of tip
5. Downward positioning of tip
55. Narrowing tip and supratip area
it is narrowed by
1. Resecting a strip or wedge of cartilage
from the cranial margin of lateral crus
2. Suturing the domes together
3. Redraping the lobular cartilage
56. Resecting a strip or wedge of
cartilage
Done by
intercatilaginous
incision and using
retrograde
technique
The cranial margin
of the lateral crus is
inverted by hook
and the vestibular
skin and the cranial
part of the lateral
crus is cut
57. Suturing the domes together
Done by external
approach
If required
resections or
incisions are made
to break the spring
Both domes are
brought together by
suturing
58. Redraping the lobular cartilage
Done using external
approach
The lateral crus and dome
are dissected from
underlying vestibular skin
leaving the medial crura
The lateral crura are
moved in ventral direction
making the domes more
projecting
Now transcrural and
transdomal sutures applied
59. Reducing tip projection
Reduced by various ways
1. Let down of pyramid and lobule
2. Lowering domes by dome resection
and reconstruction technique
3. Resecting strips from medial crura
60. Let down of pyramid and lobule
when overprojected
tip is part of narrow
pyramid syndrome
Removing of
horizontal and vertical
strip of septal cartilage
along with bilateral
wedge resection
Procedure will
broaden lobule and
reduces tip
61. Dome resection and
reconstruction technique
Delivery approach is
required
Tip projection is
decreased by resecting
small strips from the
lateral and medial crus
just lateral and medial
to domes , the strips
are removed and
domes are repositioned
The domes are sutured
to medial and lateral
crura
62. Resecting strips of medial crura
External approach is
mandatory
Tip projection is
decreased by resecting
nonopposing strips
from the medial crura
The lateral ends of
lateral crura is
somewhat shortened to
allow reduction of
lateral leg of tripod
63. Upward positioning of tip
1. Resecting a triangle of cartilage from
the caudal septal end,with or without
resecting a triangle of skin from the
membranous septum
2. Trimming the cranial margin of the
lateral crus with resection of a triangle
of vestibular skin
3. Resecting a triangle of cartilage,skin
and mucosa from the lower margin of
triangular cartilage
64. Upward rotation and
shortening of
nasal length by
resections from
1. Caudal end of septum
2. The caudal margin of
lateral crura
3. The caudal margin of
triangular cartilage
65. Upward rotation of
the tip and
shortening of nasal
length by resecting
a ventrally based
triangle of cartilage
from the caudal
septal margin
67. The medial part of
cranial margin of the
lateral crus is resected
together with triangle
of vestibular skin
A triangle of cartilage
is resected from the
lower margin of the
triangular cartilage
68. Increasing tip projection
1. a columellar strut (in combination with
anterior septal reconstruction)
2. A tip graft (a shield graft)
3. Redraping of the lateral crura and
domes with lateral crural steal
69. Columellar strut
External or endonasal
approach
Anterior septum
reconstructed
A strut with 3mm width
and 20-25mm length
is positioned on the
anterior nasal spine
between the medial
crura
Strut is fixed 2 or 3
transverse sutures
70. Tip graft or shield graft
Placed by either
external approach or
CSI
Sculpted according
to requirement
Sutured to domes
with resorbable
sutures