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RAMA RAJU
INCISIONS
 MAIN INCISIONS
1. Caudal septal incision (hemitransfixion)
2. Intercartilaginous incision
3. Vestibular incisi...
CAUDAL SEPTAL INCISION
 Aka hemitransfixion
 Made 2 mm above and
parallel to the caudal
margin of cartilaginous
septum
...
Intercartilaginous incision
 Is a cut made in the
vestibular skin just
cranial to the caudal
end of triangular
cartilage
...
Vestibular incisions
 Vestibular incision is a
slightly curved cut
made in the vestibular
skin just lateral to the
margin...
Infracartilaginous incision
 It is an incision at
the caudal margin of
the lateral crus
,dome and medial
crus of the lobu...
Transcolumellar inverted-v-
incision:
 It is a horizontal
reversed-v- shaped
incision of the columella
at about one-third...
SPECIAL INCISIONS
 EXTERNAL
1. Labiogingival incision
2. Sublabial incision
3. Paranasal incision
4. Lateral columellar
5...
Pyramid surgery
One of basic procedures in functional
reconstructive nasal surgery
It involves
 Mobilizing the bony pyram...
steps for mobilizing the bony
pyramid
1. Mobilizing and correcting the septum
2. Outlining the osteotomies
3. Undermining ...
Types of osteotomy
1. Paramedian
osteotomy
2. Lateral osteotomy
3. Transverse
osteotomy
4. Intermediate
osteotomy
5. Obliq...
Paramedian osteotomies:
 It separates the nasal
bone from each other
as well as from
septum ,they are
made on both sides
...
Paramedian osteotomy
intraseptal approach technique
Lateral osteotomy
 It separates the
lateral bony wall of
pyramid from nasal
process of maxilla.
 A cut is made into
the ...
Lateral osteotomy through
endonasal-subperiosteal
technique
Transverse osteotomy
 A transverse
osteotomy
separates the bony
pyramid from the
frontal bone and the
nasal spine of the
...
Transverse osteotomy through
endonasal – subperiosteal
approach
Repositioning the bony pyramid
 After mobilizing, bony pyramid is
repositioned using maneuvers like
1. Bilateral infractu...
Bilateral infracture
 Both lateral walls of
the bony pyramid are
moved inwards
(medially).
 This requires
paramedian , l...
Bilateral outfracture
 Lateral walls of the
bony pyramid are
moved outward
(laterally), thus
widening the
pyramid and val...
Rotation by u/l infracture and
outfracture on opposite side
 Long ,shallow side is
infractured
 Short steep is
outfractu...
Rotation by u/l wedge rotation
 A wedge of bone is
resected at the base
of long side of
pyramid
 Used in patients with
s...
Push down with b/l infracture
 The bony pyramid is
pushed down and b/l
infractured
 Projection is reduced
and pyramid is...
Let down following b/l wedge
resection
 Bony pyramid is let
down after performing
osteotomies and b/l
wedge resection
 T...
HUMP REMOVAL
 TYPES OF HUMP
1. Bony hump
2. Bony and cartilaginous hump
3. Cartilaginous hump
Surgical techniques:
1. Reduction by rasp and file
2. Resection
3. Push-down with infracture of pyramid
4. Let down of pyr...
Correcting bony hump with rasp
and file
 Is performed
through
intercartilaginous
incision
 Only bony bumps
can be correc...
Resection of bony and/or
cartilaginous hump
 Most common way to correct bony and/or
cartilaginous hump
 Had several draw...
Resecting bony hump
 The hump to be
resected is outlined
on the skin
 The dorsum is
approached by
combining the right
in...
 The skin over the
bony and
cartilaginous dorsum
is undermined
subperichondrially
and subperiosteally
 Resection is done...
Resecting a cartilaginous hump
 The triangular
cartilages are
separated
intraseptally from
septal cartilage
using no.64 b...
 The cartilaginous hump
is resected stepwise ,
the height of the
cartilaginous pyramid is
adjusted to the height of
the m...
saddle nose correction
 Types of saddling
1. bony and cartilaginous saddle nose
2. Low , wide pyramid syndrome
3. Bony sa...
Bony and cartilaginous saddle
nose
 both bony and
cartilage pyramid
severely depressed.
 Corrected by
reconstruction of
...
Low wide pyramid syndrome
 both bony and cartilaginous
pyramid are severely
depressed and lobule is wide
and low
 Valve ...
Bony saddle
 Dorsum is severely
depressed, while
cartilaginous pyramid
and cartilaginous
septum are normal
 Corrected by...
Cartilaginous saddling
 Cartilaginous pyramid is
severely or moderately
depressed and
broadened .
 There may be atropy o...
Surgical techniques
 Repositioning and reconstruction of
anterior septum
 Narrowing and push up of bony pyramid
followin...
Repositioning and
reconstruction the septum
 Done through CSI incision
 Through antero-superior
tunnel and inferior tunn...
Augmentation by dorsal implant
 Limited degree of
cartilage sagging is
corrected by
inserting crushed
sepatal cartilage
t...
 Autografts such as
conchal cartilage , rib
cartilage can be used for
augmentation.
 Inserted through IC
incision
 Unde...
Tip surgery
“The one who masters tip masters nose”
 tip surgery is never related to
improvement of function ,but is alway...
Characteristics of tip
 most prominent point or area of external
nasal pyramid
 Built by:
1. Two lobular cartilages
2. I...
Projection of tip
 Aka tip prominence
 Too high- narrow pyramid
syndrome
 Too low-wide pyramid syndrome
(saddle nose)
...
Position of tip
 Position of tip in vertical and horizontal
axis of face is determined by above
mentioned factors.
 Upwa...
Tip abnormalities
1. Broad ,bullous,square,ball tip
2. Bifid tip
3. Asymmetrical tip
4. Underprojected tip
5. Overprojecte...
Broad,bullous,square,ball tip
 Broad tip- domes apart
 Bullous-domes are wide and
massive
 Square tip-domes are not
arc...
Bifid tip
 Tip is duplicated due
to an abnormally large
distance between the
two domes with an
excessive amount of
interd...
Asymmetrical tip
 Domes are
asymmetrical .
 It is isolated variety
or in combination
with bifidity
Underprojected tip
 The projection of the tip
is abnormally low
compared with that of
bony and cartilaginous
pyramid
 Re...
Overprojected tip
 it is abnormally
prominent when
compared to projection
of cartilaginous and
bony dorsum
 Requires com...
Upwardly rotated tip
 Tip is more cranial
than normal
 Upwardly rotated tip
is usually
overprojected
 Nasolabial angle ...
Hanging tip
 Tip is more caudal
than normal and
underprojected at
the same time .
 The nasolabial
angle is abnormally
sm...
Surgical technique
1. Narrowing tip and supratip area
2. Increasing tip projection
3. Reducing tip projection
4. Upward po...
Narrowing tip and supratip area
 it is narrowed by
1. Resecting a strip or wedge of cartilage
from the cranial margin of ...
Resecting a strip or wedge of
cartilage
 Done by
intercatilaginous
incision and using
retrograde
technique
 The cranial ...
Suturing the domes together
 Done by external
approach
 If required
resections or
incisions are made
to break the spring...
Redraping the lobular cartilage
 Done using external
approach
 The lateral crus and dome
are dissected from
underlying v...
Reducing tip projection
 Reduced by various ways
1. Let down of pyramid and lobule
2. Lowering domes by dome resection
an...
Let down of pyramid and lobule
 when overprojected
tip is part of narrow
pyramid syndrome
 Removing of
horizontal and ve...
Dome resection and
reconstruction technique
 Delivery approach is
required
 Tip projection is
decreased by resecting
sma...
Resecting strips of medial crura
 External approach is
mandatory
 Tip projection is
decreased by resecting
nonopposing s...
Upward positioning of tip
1. Resecting a triangle of cartilage from
the caudal septal end,with or without
resecting a tria...
Upward rotation and
shortening of
nasal length by
resections from
1. Caudal end of septum
2. The caudal margin of
lateral ...
 Upward rotation of
the tip and
shortening of nasal
length by resecting
a ventrally based
triangle of cartilage
from the ...
A triangle of
vestibular skin
resected from
membranous
septum
The medial part of
cranial margin of the
lateral crus is resected
together with triangle
of vestibular skin
A triangle of ...
Increasing tip projection
1. a columellar strut (in combination with
anterior septal reconstruction)
2. A tip graft (a shi...
Columellar strut
 External or endonasal
approach
 Anterior septum
reconstructed
 A strut with 3mm width
and 20-25mm len...
Tip graft or shield graft
 Placed by either
external approach or
CSI
 Sculpted according
to requirement
 Sutured to dom...
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Rhinoplasty raju ppt full

  1. 1. RAMA RAJU
  2. 2. INCISIONS  MAIN INCISIONS 1. Caudal septal incision (hemitransfixion) 2. Intercartilaginous incision 3. Vestibular incision 4. Infracartilaginous incision 5. Transcolumellar inverted-V-incision
  3. 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. 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. 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. 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. 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. 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. 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. 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
  11. 11. Types of osteotomy 1. Paramedian osteotomy 2. Lateral osteotomy 3. Transverse osteotomy 4. Intermediate osteotomy 5. Oblique osteotomy
  12. 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
  13. 13. Paramedian osteotomy intraseptal approach technique
  14. 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
  15. 15. Lateral osteotomy through endonasal-subperiosteal technique
  16. 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
  17. 17. Transverse osteotomy through endonasal – subperiosteal approach
  18. 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. 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. 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. 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. 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. 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. 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. 25. HUMP REMOVAL  TYPES OF HUMP 1. Bony hump 2. Bony and cartilaginous hump 3. Cartilaginous hump
  26. 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. 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. 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. 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. 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. 31. Resecting a cartilaginous hump  The triangular cartilages are separated intraseptally from septal cartilage using no.64 beaver knife
  32. 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. 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. 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. 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. 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. 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. 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. 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. 40. Augmentation by dorsal implant  Limited degree of cartilage sagging is corrected by inserting crushed sepatal cartilage through intercartilaginous or caudal septal incision.
  41. 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. 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. 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. 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. 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. 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. 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. 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. 49. Asymmetrical tip  Domes are asymmetrical .  It is isolated variety or in combination with bifidity
  50. 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. 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. 52. Upwardly rotated tip  Tip is more cranial than normal  Upwardly rotated tip is usually overprojected  Nasolabial angle is large
  53. 53. Hanging tip  Tip is more caudal than normal and underprojected at the same time .  The nasolabial angle is abnormally smaill
  54. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 65.  Upward rotation of the tip and shortening of nasal length by resecting a ventrally based triangle of cartilage from the caudal septal margin
  66. 66. A triangle of vestibular skin resected from membranous septum
  67. 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. 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. 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. 70. Tip graft or shield graft  Placed by either external approach or CSI  Sculpted according to requirement  Sutured to domes with resorbable sutures
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this ppt is in detail about the basic rhinoplasty procedures .

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