Rhinoplasty (2) /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078

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Rhinoplasty (2) /certified fixed orthodontic courses by Indian dental academy

  1. 1. RHINOPLASTY THE ART AND SCIENCE INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. PATIENT SELECTION AND EVALUATION • The decision to perform a rhinoplasty carries great responsibility. GOALS:1) TO achieve an aesthetic result 2) to have a satisfied patient www.indiandentalacademy.com
  3. 3. EXAMINATION AND AESTHETIC EVALUATION • • THIS must begin with an evaluation of the complete face before focus on the nose. The face must be examined both at rest and in motion. FULL FACE VIEW • • • An imaginary vertical line is traced from the hair line to the menton dividing the face into two halves. the horizontal line is traced at the level of medial canthus. these to lines constitute the axis of the face and are called the midface vertical and horizontal lines. www.indiandentalacademy.com
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  5. 5. • Four horizontal lines are traced 1. 2. 3. 4. at the hair line at the supra orbital notch at the base of the nose at the tip of the menton An extra line is traced at this stomion to divide the lower third. www.indiandentalacademy.com
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  7. 7. Lateral examination • An imaganary horizontal line corresponding to the frankfort horizontal plane is traced. • this line extends from the centre of the external auditory channel to the inferior orbital rim, or from the lower limit of the tragus to the junction of the lower lid and the cheek • A vertical line perpendicular to the frankfort plane, is traced from the supra orbital notch • In a well proportioned face, these lines cross the upper lip at the level of the columellar base • The horizontal lines crossing the glabella and the sub nasale are traced to present a lateral view of the three thirds of the face. www.indiandentalacademy.com
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  9. 9. NASAL AESTHETICS • The nose must be examined in full face view and basal view and from the two profiles. • On the full face view, the nasal bridge is seen as two paralell straight or slightly concave lines extending from the brows to the tip of the nose • The width of the bridge is roughly similar to the distance between the tip highlights. • The symetry of the dorsum is evaluated, as is the junction of the nasal walls and the cheek. • If the distance between the two junctions of the nose and cheek is 80% or more of the width of the alar base, the nasal pyramid must be narrowed. www.indiandentalacademy.com
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  11. 11. • • • • On the full face view a small portion of the columella must be visible at the center. An exaggerated caudal projection of the columella must be noted, if it is not visible, the columella is retruded. The width of the alar base is assessed by drawing two vertical lines from the medial canthus on each side. The ala cheek junctions should be located 1 or 2 mm inside the canthal line. BASAL VIEW • • • • From this viewpoint it should look like an eqilateral triangle. The length and the width of columella are noted. In the vertical axis of the triangle, two thirds correspond to the columella and one third corresponds to the tip lobule. The lower third of the columella should be wider, if it flares too much the foot plates need defatting. www.indiandentalacademy.com
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  13. 13. • now the nose is examined in profile. • The frontonasal groove is examined, this depression of 4 to 6 mm, called the nasion, is located at a point between the upper border of the tarsal plate and the upper lid margin. • If a straight line is drawn from the nasion to the most prominent point of the nasal tip, the dorsum should be about 2mm behind the line, this difference correspons to the tip prominence and supratip break. • The nasal length is measured from the nasion to the tip prominence, and the nasal projection is measured from ala cheek junction to the tip. • As a general rule, a 1 to 0.6 ratio between the length and anterior projection is adequete. www.indiandentalacademy.com
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  15. 15. • Tip projection is assessed by drawing a vertical line that passes in front of the upper lip and crosses the alar tip line. • The projection is exaggerated when 60% or more of the tip is in front of the vertical line and viceversa. • On the profile view, the columella should be about 4mm lower than the alar margin. • The nasolabial angle is then evaluated to determine the need for tip rotation. • Tracing a line that follows the lower alar margin, the nasolabial angle is measured at its intersection with a vertical axis. • An aperture of 95o to 105o is adequate for females it should around 90o for males www.indiandentalacademy.com
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  18. 18. SURGICAL ANATOMY • Bony framework • The bone is skeletal framework if the nose is composed of paired nasal bones and ascending (frontal) process maxilla. • The joint nasal bones are thick cephalomedially but are extremely thin has the extend Infero laterally. • The cephallic portion articulates with the frontal bones at the nasao frontal suture and laterally with the maxilla at the naso maxillary suture. www.indiandentalacademy.com
  19. 19. • Lateral osteotomies to naro the nose may be un necessary and even contra indicated. • If the lateral osteotomies are deemed necessary, the must be executed as low as possible on the ascending process of maxilla to avoid narrrowing of the nose. • • There is a wide range of normal variation in the height, length and width of the • nasal bones www.indiandentalacademy.com
  20. 20. • The lacrimal sac and associated drainage apparatus are in close proximity so care should be taken during lateral osteotomies. • Inferiorly the skeletal frame work overlap the cephallic edges of the upper lateral cartilages. • Maintenance of the anatomical bony – cartilaginous attachment is critical, the inadverant dislocation or avulsion of the upper lateral cartilage from the bones during the dissection inevitably lead to depression of the nasal side wall. www.indiandentalacademy.com
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  22. 22. CARTILAGINOUS FRAME WORK Upper lateral cartilages • The upper lateral cartilages form an angle of 10o - 15o with the anterior septal edge. • This angle constitute the nasal valve, which widens and narrows under influence of respiration. • Usually, the cephallic edge of the alar cartilage overlaps the lower edge of the upper lateral cartilage by 1 to 3 mm. • Between the cartilages there is a fibro aponeurotic connective tissue that represents one of the support for projection of tip, this weakens with edge leading to dropping of the tip. www.indiandentalacademy.com
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  24. 24. ALAR CARTILAGES • There is infinite variety of combinations in the shape and size of the alar cartilages. • The alar cartilages have an arch form that is made of 3 sections. 1. Medial crus 2. Middle crus 3. Lateral crus • The transition between the medial and lateral crura is called the dome and is the site of highest projection of the teeth. • The two arches formed by the alar cartilages are attached to each other at the level of medial crura and separate at the level of domes. • The divergence at this level is responsible for the width of the tip if it is more bifidity of the tip occurs. www.indiandentalacademy.com
  25. 25. • The medial crus extends anteriorly and superiorly toward the dome area. • Inferiorly foot plates face outward and flare laterally to your variable extent as they embrace the caudal septum. • At the collumella, the medial crus lies intimately subadjacent to the skin, and loose areolar tissue provides an inter crural attachment. • The lateral crus extend obliquely and posteirorly towards the piriform apperature, it is firmly attached to the accessory cartilages by a fibrous ligament, forming an arch that follows the lateral wall of the nostril. www.indiandentalacademy.com
  26. 26. • The shape of the lateral crus is more significant than its size, the resection of its cephalic edge reduces the lateral bulge, producing a narrower and more refined tip, it also allows cephalad rotation. www.indiandentalacademy.com
  27. 27. Nasal septum • • • • The septum is a vertical structure made of thin bone and cartilage the devides the nose into two separate cavities. The anatomical components of the septum include the nasal spine of the frontal bone, the perpandicular plate of ethmoid, a portion of medial segments of the nasal bones, vomer, a nasal crest of the palatine bone, nasal crest of maxilla, pre-maxilla, and nasal spine, the septal cartilage. All these septal components are paired except vomer which may be bilaminar because of its dual embryonic origin. Significant deviation in the ethmoid bone produces posterior airway obstruction. www.indiandentalacademy.com
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  29. 29. • the vomer is the basis of the bony septum, articulating with the nasal crest of the maxilla and palatine bone below, with the crest of the sphenoid bone behind, and with the septal cartilage in front. • The septal cartilage the most important component of the nasal septum. • The most caudal portion of the septal cartilage, along with the flared wings of the upper lateral cartilages that firmly attached to it and give form and support to the middle third of the nose. • Caudally the anterior septal angle can be identified and palpated by depressing the nasal tip. www.indiandentalacademy.com
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  31. 31. Skin of the nose 1. 2. 3. 4. 5. Skin Superficial fatty layer Fibro muscular layer with superficial and deep facsia. Deep fatty layer Longitudinal fibrous sheet with periostium, perichondrium and ligaments of nose. www.indiandentalacademy.com
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  33. 33. Muscles 1. Levators, which shorten the nose and dilate the nostrils, musculus process, musculus levator labil superioris alaeque nasi, and musculus anomalus nasi. 2. Depressors, which lengthen the nose and dilate the nostrils, alar nasalis and musculus depressor septi nasi. 3. Compressors, which lengthen the nose and narrow the nostrils, transverse nasalis and musculus compressor naris minor. 4. Minor dilator, musculus dilator naris anterior www.indiandentalacademy.com
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  35. 35. Vascular supply • The Blood supply is from branches of external carotid ophthalmic and infra orbital artries. • The branches of facial artery vary widely, such as angular artery (60%), superior labial artery (18%), inferior labial artery (22%) • The main arteries and nerves of the external nose lie beneath the fibromuscular layer • The venous network ; the frontomedian region of the face belongs to the facial vein and orbitopalpebral area belongs to the opthalmic veins • www.indiandentalacademy.com Lymphatic drainage into the sup-mandibular notes.
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  38. 38. Nerve supply • The skin of the nose is innervated by the branches of trigeminal nerve, the root and dorsum by the opthalmic division and nasal ala by the maxillary division 1. 2. 3. 4. Infra orbital nerve Anterior ethmoidal nerve The infratrochler nerve The inner vault by the nasocilary and spheno palatine ganglion. www.indiandentalacademy.com
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  40. 40. OSTEOTOMIES • For laterla osteotomies use of the percutanious route is indicated. • A 2 mm chisel is introduced through the skin about 3 to 4 mm below and medial to the canthus • Maintaining the osteotome perpandicular to the bone, a high to low osteotomy is made, cutting 5 to 6 separate point beginning at the lateral edge of the nasal bone and following thorugh the ascending process of maxilla to the piriform edge. • This maneuver is performed with care so that chisel barely cuts through the full thickness of the bone, www.indiandentalacademy.com reserving the integrity of the nasal mucosa.
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  42. 42. • Moderate continuous pressure is then applied with the thumb, forcing the nasal skeleton medially until the bones are slowly displaced to the mid line. • With this maneuver a green stick fracture is produced. • There is no need to suture this small 2 mm incision cast is given. • Usually cast is changed on fifth post operative day. www.indiandentalacademy.com
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  44. 44. Case • This 20 year old women presented with a moderatly vide and slightly deviated nasal pyramid, a slight dorsal convexity, and some bulging of the ala cartilages. Surgical Plan 1. Septoplasty to correct the nasal deviation 2. Minimal dorsal resection 3. Trimming of the cephallic edge of the ala cartilages 4. Lateral osteotomies and infracture www.indiandentalacademy.com
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  49. 49. AUGMENTATION TECHNIQUE • All types of materials such as metals, mineral oils, plastics and homo and hetero grafts are used but are discarded due to intolerence and resorption and erosion through skin. • Preferred donar tissues are cartilages and bones. 1. Nasal Septum 2. Ear concha 3. Costal grafts 4. Parital bone 5. Temporalil muscle facia www.indiandentalacademy.com
  50. 50. Nasal Septum • A mucosal incision parallel to the caudian edge is made an one side. The mucoperichondrium is carefully dissected on both sides of the cartilage. • The vertical incision is then made on the cartilage parallel to the caudal edge and 6 to 8 mm posterior to it. The incision in the cartilage begins inferiorly at the junction with the nasal spine and stops superiorly 6 to 8 mm from the anterior edge so that L shaped portion of septum always remains intake. • To obtain a larger graft the septal discetion must be extended posteriorly to the vomer and 2 cuts made parallel using mayo scissors. • www.indiandentalacademy.com This contains bone and cartilage also.
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  53. 53. Ear Concha • To harvest this graft we use a posterior incision near the auriculomastoid fold. • The skin is reflected, exposing the convex aspect of the concha. • The cartilage is then dissected from the conchal skin with fine blunt scissors. • The skin is then sutured and is packed with wet cotton for 3 days. • To avoid injuring the external skin, the left index finger of the free hand is held on the concha while the knife cuts from the posterior www.indiandentalacademy.com aspect.
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  56. 56. Costal grafts • A five cm sub mamarry skin incision is use to harvest the rib cartilage in females, the incision is lower on the thoracic wall in males. • A full thickness section of the fifth costal cartilage is dissected including a portion of the rib 5 to 6 cm in length reserving the condrocostal joint. • The periostium is always preserved on the convex (External) side of the bone, this is achieved by making two parallel incision on the periostium at the superior and inferior borders of the rib. • Any remaining cartilages used can be packed in the same incision and closed, these can be used for secondary www.indiandentalacademy.com corrections.
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  58. 58. Parietal Bone • This membranous bone similar in origin to the facial skeleton would undergo less resorption as a graft. • Satisfactory long term results may be related more to the fixation methods that use metallic screws. • To obtain this graft 8 cm scalp incision is made on the parietal area 1 to 4 cm lateral to the vertex. • For safety reasons it is better to stay 2 to 3 cm lateral to the sagital suture to avoid perforating the vessels. • The periosteum is elevated then usually 1.5 x 5 cm bone is drilled with air driven bur, until cancellors bone is reached • www.indiandentalacademy.com Then short curved osteotome is used to separate the 2 cortical
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  60. 60. Temporal muscle facia • A 4 cm vertical incision is made on the scalp of the temporal area. • Then exposing the aponeurosis of the temporalis muscle, to parallel incision are made on the fascia and a segment of 12 mm x 5cm long is dissected. www.indiandentalacademy.com
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  62. 62. THE TIP The Projection • The anterior of projection of the nasal tip is determined primarily by the size of the alar cartilages. • 1st Chapter Over Projection • The tip can be considered as a structure formed by 2 arches. Each arches supported by 2 pillars – the medial and lateral crus. • The lateral crus as fibrous and perichondrial attachments with the sesmoid cartilages, which extend laterally in to the piriform fossa. • This ring works as a unit providing support to the tip. www.indiandentalacademy.com Contd..
  63. 63. • If one of the pillars is shortened the height of the arch is decreased without disturbing the architecture of the dome, sometimes both the pillars can be shortened. • The two medial crura are attached to each other in the columella and function as a unit, so tripod concept can be applied to the tip. • Dorsal augmentation may be indicated, and in some cases it will be sufficient to solve the problem. Dorsal over resection will automatically exaggerate the deformity. www.indiandentalacademy.com
  64. 64. 1. An intracartilaginous incision is made, including only mucosa and perichondrium. Cephalad flap dissection and trimming the upper edge of the alar cartilage is followed by wide retrograde skin undermining. This eliminates the “Splinting effect” of the skin and allows draping of the cutanious cover. by this the tip projection is slightly decreased, and the restraining effect of the intercartilagenous ligament is eliminated using the resection of the cephallic edge. 2. The intracartilagenous incisions are extended along the caudal edge of the septum, completing the transfixion. The liberated medial crus automatically moves posteriorly as a result of the severance of its soft union with the septum. www.indiandentalacademy.com
  65. 65. 3. The vestibular incision is extended a few mm laterally, and the lateral crus is exposed in continuity with the accessory cartilages. a 4 mm section is resected at the junction of the alar and accessory cartilages. 4. If more correction is necessary, a section of medial crus is resected at the base of the columella and alternating in complete cross cutting of the alar cartilages at the dome is done to prevent the widening of the tip resulting from lateral displacement of the doms. www.indiandentalacademy.com
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  68. 68. Case • • • This patient requested nasal reduction. She had a straight dorsum with over projecting tip covered by thin skin. Wide lateral crura produced tip fulness. Nasal labial angle was 80 ˚ Surgical plan 1. 2. 3. 4. 5. Intra cartilagenous and trans fixing incision Minimal dorsal reduction 6mm resection of the upper edge of the lateral crura 5 mm resection at the juction of lateral crura and accessory cartilagenous. Medical and lateral osteotomies. www.indiandentalacademy.com
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  72. 72. Broad tip • The fullness is determined by the shape and size of alar cartilages and skin thickness. • It is preferred to preserve the intergritive of the arch shape by multiple, alternative in complete cross cuts of the ala at the level of the dome. • The cartilages are exposed through an infra cartilagenous incision following the caudal edge of the ala cartilage. • Full thickness cuts are made across the width of the cartilage without competing the transition this will cause elasticity of the door. • Splint is the must www.indiandentalacademy.com
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  74. 74. Case • • This patients notes is a typical example of a bulbous boxy tip produced by strong convex lateral crura and flaring, widely seperated domes. The pyramid, the skin, and the alar bases are adequate. Surgical Plan 1. 2. 3. Intra cartilagenous incision and exposure of the domes Trimming the cephalic edge Alternating in complete cross cuts of the alar dome withour resection. www.indiandentalacademy.com
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  76. 76. Plunging Tip • Trimming the cephalic edge of the lateral crura automatically severs intercartilagenous ligament and allows the narrowed alar cartilage to rotate superiorly and overlap with the upper lateral cartilage. • When the lower lateral cartilages are obliquely located, pointing downwards, a very considerable cephalad rotation is required. • The arch formed by lateral crura attached to the accessory cartilages that extend to the piriform fossa and the floor is functional unit. • Unless this arch is transected its memory will tend to rotate the tip caudally. www.indiandentalacademy.com
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  78. 78. THE NASOLABIAL ANGLE • The angle formed by the columella and the upper lip is a key point in nasal aesthetics, for females 95 to 105 and for males 90 to 95. • The nasolabial angle is formed by a labial plane and a columella plane that meet at the bace of the collumella. • On the nasal side, the angle is formed primorely by the position of the medial crura. • Short medial crura decrease the anterior prominance of the tip and allow the tip to rotate inferiorly, closing the angle. www.indiandentalacademy.com
  79. 79. • The aperture of the nasiolabial angle is also influenced by the position of the nasal spine and caudal edge of the septum. • A projecting nasal spine increases the aperture and a retrusive spine results in acute angle. • The second vector of angle is formed by the upper lip • Its position and inclination are determined by volume and position of the maxillary alveolar ridge and soft tissues supported by the bone. • Most of the surgical procedures used to modify nasiolabial angle are therefore directed towards the changing the position and inclination of the columella plane. www.indiandentalacademy.com
  80. 80. Case • This young female had a narrow, fine nasal pyramid with prominent alar domes, a short columella, a protruding upper lip and a nasiolabial angle of 65˚ Surgical plane 1. 2. 6 mm of laterla crura were trimmed to allow tip rotation Collumelar and tip septal grafts. www.indiandentalacademy.com
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  83. 83. HUMP REMOVAL www.indiandentalacademy.com
  84. 84. • One of the first tasks during a rhinoplasty is to remove the hump if one is present. • The hump is made of bone and cartilage, and both components must be carved down in order to eliminate the nasal hump. • The squiggly red line on the nose shows the border between the bony part and the cartilaginous part of the nose. • The first task in removing the hump was accomplished by exposing the cartilage and bone of the nose by making the incisions and lifting the skin. The process of making the incisions and elevating the skin is called "skeletonizing . www.indiandentalacademy.com
  85. 85. The tip of the scissors is pointing to the right lower lateral cartilage, and the cartilage hump is colored in blue in the diagram www.indiandentalacademy.com
  86. 86. • We make a cut in the cartilage hump with a scalpel. In the diagram the location of the cut is indicated in red, and the cartilage that comprises the hump, which will be removed from the nose, is colored blue. www.indiandentalacademy.com
  87. 87. • It's not possible to estimate exactly how much hump needs to be removed and make the cut precisely in that location. • In practice, start out by removing less hump than is necessary. Then, as the operation proceeds, look carefully at the nose and remove small additional pieces of the hump until you get it just right. That piecemeal approach avoids the problem of removing too much hump initially. • When we lift up the piece of cartilaginous hump that we have incised, we see the white edges of some cartilages that we have cut. That hump is shaded blue and highlighted in white the edges of the cartilages that we seem to have cut into when we incised the hump. www.indiandentalacademy.com
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  89. 89. • note that once the hump is removed, when we look at the nose, we should be able to see the top cut edge of the septum all along the dorsum of the nose (green arrow), as well as the top cut edges of the right and left upper lateral cartilages along the dorsum of the nose (black arrows). www.indiandentalacademy.com
  90. 90. • we can see the top cut edge of the septum (pink above right), and the cut edges of the upper lateral cartilages (blue). • www.indiandentalacademy.com
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  93. 93. • next task is to remove the portion of the hump that is made out of bone, the part colored pink in the diagram. • These pictures show you where the bony hump resides. The red in the diagram above colors the bone that will be removed to take down the bony hump. www.indiandentalacademy.com
  94. 94. In the nose above, the cartilaginous hump has already been removed, and is in the process of removing the bony hump with a chisel. In the diagram, the chisel is colored blue, and the bone that will be removed is pink. www.indiandentalacademy.com
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  97. 97. LONG NOSE www.indiandentalacademy.com
  98. 98. • noses can be shortened by addressing the length of the septum. • The triangular portion of the septum shaded light blue will be excised during surgery, That is the portion of the septum that was resisting the upward push of your finger when you pushed up to shorten your nose. • After that piece of septum is removed, the septum will be shorter. Note that the longer black arrow indicates the length of the septum before the excision, and the shorter white arrow indicates the length of the septum after removing the light blue piece. Because the septum is now shorter, the tip of the nose rotates up (blue arrow), shortening the nose. www.indiandentalacademy.com
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  100. 100. • why we usually can't count on shortening the septum alone to decrease the length of a nose? • If, during surgery, you were to push on the base of the nose in the direction of the reduced septum, the tip would not elevate; you would feel resistance to its motion. What's going on here? • Inside the nose, there are many factors which influence the nose's length. Possibly the most important factor is the length and strength of the lower lateral cartilages . • The right lower lateral cartilage is outlined in blue, with a black arrow following down the middle of the cartilage. The prodigious length of that cartilage is forcing the tip down, making the nose appear long. www.indiandentalacademy.com
  101. 101. • The length and strength of that lower lateral cartilage is straight-arming the tip of the nose down toward the lip,creating a long nose. • We shorten the lower lateral cartilage by cutting it midway along its lateral arm and allowing the two sections to overlap each other. • The upper image in the diagram above is of the intact lower lateral cartilage, and the lower image shows the cartilage after it is cut and the two halves are allowed to overlap, to slide across each other. The blue arrows demonstrate the resulting length of the cartilage in each www.indiandentalacademy.com case
  102. 102. • The length and strength of the lower lateral cartilage, represented by the black arrow, holds the tip down in the image above center. After the cartilage is cut and overlapped, it no longer has the power and length to hold the tip down, and the natural elasticity of the skin allows the tip of the nose to rise. www.indiandentalacademy.com
  103. 103. • using a concept called the "tripod model." In the image above left, we see two solid beams, one blue and one green. The beams are joined to each other at the red dot. The black dots show where they are affixed to the ground. • Now, we have cut the green beam, overlapped the pieces, and welded the pieces back together. Since the beams are still attached to the ground (black dots) and to each other (red dot), the blue beam rotates up as the green beams are overlapped. www.indiandentalacademy.com
  104. 104. CLEFTS COMMON FEATURES • • • • • • • • • SHORT HEMI COLUMELLA COLUMELLAR BASE DEVIATED TO UNAFFECTED SIDE DECREASED PROJECTION AND LATERAL DISPL OF THE ALAR DOME NO NASAL FLOOR OPEN ARCH OF NOSTRIL ALAR BASE DISPLACED LATERALLY AFFECTED ALAR CARTILAGE CAUDALLY DISPL DECREASED OR NO OVERLAPPING BETWEEN UPPER AND LOWER LATERAL CARTILAGES ABNORMAL RELATIONSHIPS AMONG THE SKIN, CARTILAGE, AND THE MUCOSAL LAYERS OF THE ALA. www.indiandentalacademy.com
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  106. 106. UNILATERAL CLEFTS • Nasal correction is performed at 2 months of age in conjunction with lip closure. • The lip is repaired with the rotation advancement tech, which keeps the surgical scar at limit between the aesthetic units of the lip and facilitates the repair of the muscle layer, this is imp for the future shape of the nose cos the normally aligned muscle fibres at the level of the nasal spine model the skeletal position. • Elongation of the hemicolumella is also obtained, and incisions provide good access for the alar dissection. www.indiandentalacademy.com
  107. 107. • Once the lip incisions are made, the nasal dissection begins on the medial side. • With fine iris scissors entering at the base of the columella, the two medial crura are separated from each other. • This undermining is extended to the dome superiorly and under the mucosa posterior to the columella. • Entering through the lateral lip incision, the base of the ala is freed from the maxilla. • The dissection then proceeds subcutaneously to the nasal bones and medially to the alar dome on the opposite side. • Inf the alar cartilage is freed from the skin, extending the undermining around the alar rim from the base of the ala to the medial crus and continuing inside the nostril to the caudal edge of the alar cartilage. • At this point, the cart remains attached to the nasal mucosa only www.indiandentalacademy.com and can be easily mobilized to a normal position
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  109. 109. • The tip of the flap made by alar base is sutured to the lip and the columellar skin ant and to the nasal mucosa posteriorly. • To maintain the position of the cartilage 3 or 4 pull-out sutures are used.( mc coomb) • Using 5-0 monofilament nylon, a straight needle enters the skin at the upper level of the undermined area, passes through the cephallic edge of the alar cartilage, and comes out again near the entry point around the glabella. • Three sutures are necessary- at the vertex of the dome, at the midsection of the ala, and at the tip of the lateral crus • Pulling gently at the sutures, the ala is mobilized to normal position. • The sutures are fixed to the skin with tape and are removed in 3 days. • The medial rotation of the alar base and a 3 layered lip closure www.indiandentalacademy.com
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  111. 111. SECONDARY CORRECTION OF UNILATERAL CLEFTS • DECESENDED ALAR CARTILAGES • DECREASED PROJECTION AND LATERALIZATION OF THE ALAR DOME • NOTCHING OF THE ALAR RIM • ASYMMETRICAL NOSTRIL BASE • SEVERE SEPTAL DEVIATION THAT INCLUDES ALL SEGMENTS • DEVIATION OF THE NASAL PYRAMID www.indiandentalacademy.com
  112. 112. • Views of the patient showing nostril assymetry, the dome is less projected laterally, and the wide nostril sill is on the cleft side. • Infracartilagenous incision starting at the columella and following the caudal edge of the alar cartilage www.indiandentalacademy.com
  113. 113. • The alar cartilage is seperated from the skin • The skin undermining extends to the bones, to the contralateral alar dome, and to the columella www.indiandentalacademy.com
  114. 114. • The second incission is made along the cephalic edge of the alar cartilage, forming a composite flap made of mucosa and cartilage with a median pedicle. • The flap is elevated and rotated medially. A small rim incission is made on the normal side to facilitate suturing of the dome www.indiandentalacademy.com
  115. 115. • The domes are sutured to eachother to achieve projection and symmetry. The nasal mucosa is closed in v-y fashion • 2 or 3 pull-out sutures are placed on the cephallic edge of the lateral cartilage to raise it to its normal overlapping with the upper lateral www.indiandentalacademy.com cartilage
  116. 116. • The alar base is rotated medially. The de-epitheliazed distal end is introduced at the base of the columella • This procedure included osteotomies and costal cartilage grafts to the columella, tip, and piriform areas to camouflage midfacial retrusion. www.indiandentalacademy.com
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  118. 118. PARANASAL AREA • THE nose is supported on the face by the frontal bone superiorly and by the maxilla laterally and caudally. • The anterior projection of the nose is influenced to some extent by the projection of its maxillary base, the convexity of the area around the piriform fossae is important. • The most common problem is flattening of the paranasal area that is produced by the concave surface of the maxilla around the piriform aperture. • The lateral insertion of the alae, supported by the anterior aspect of the maxilla, takes a more post position when the bone is less prominent www.indiandentalacademy.com
  119. 119. SURGICAL TECHNIQUES • Several materials such as silicone, polypropylene(marlex), polymerized tetrafluorocarbon(proplast), and other alloplastic materials have been used succesfully. • Autogenous materials such as cranial, illiac, and rib bone grafts are also used. • The early result with onlay bone grafts is satisfactory, but the rsorption of the bone graft is unpredictable. • Prefer to use autogenous cartilage grafts, large pieces of costal cartilage can be harvested through a small submammary incission. these cartilages maintain their volume perm and can be carved easily. • The cartilage is carved in the form of a crescent 6 to 10mm thick at the concave edge and tapering to the opposite convex edge. • The length varies from 15 to 25mm in height and 10 to 20mm in www.indiandentalacademy.com width.
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  121. 121. • The graft is placed subperiosteally in the piriform area, its concave edge paralell and very near the edge of the nasal cavity. • The pocket may be desected through a small vestibular incission or on the lateral side of the nasal vestibule. • The pocket should only be large enough to accommodate the graft in the proper position. If the pocket is made too large, it is convinent to introduce a pull-out non-resorbable suture through the cheek skin and then through the graft, coming out again at the cheek. • This fixation is maintained for 2 to 3days with a tape, this prevents the displacement of the cartilage. • The inferior edge of the piriform aperture and the nasal spine may also be retrusive, affecting the position of the nostril sill and the upper part of the lip. www.indiandentalacademy.com
  122. 122. • • It is then convenient to introduce another graft that is carved as a curved bar 3 to 4mm thick and inserted subperiosteally across the base of the nose in front of the nasal spine. The curvature of this bar should correspond to the curve of the anterior aspect of the premaxilla. Another indication of augumentation of the piriform area is to camouflage the protrution of the alveolar arches CASE:SURGICAL PLAN • INTRACARTILAGENOUS INCISION • 4MM RESECTION OF CEPHALIC BORDER OF ALAR CART • HARVESTING OF COASTAL CARTILAGE GRAFT • CRESCENT SHAPED GRAFTS INSERTED INTO PIRIFORM AREA • CART BAR INSERTED TRANSVERSLY INFRONT OF NASAL SPINE • CART GRAFT TO COLUMELLA www.indiandentalacademy.com • CART GRAFT TO TIP
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  126. 126. SPLINT • profile line is ever so slightly concave, without looking scooped-out (red line). • The tip of her nose is strong, and it projects out a little bit beyond the line of the dorsum (blue arrow). • The nose is adequately short (length of the arrowed white line), • an angle between the upper lip and the bottom of the nose that is greater than a 90-degree right angle (green lines). The medial osteotomy was placed along the purple line and the lateral osteotomy www.indiandentalacademy.com was made along the brown line. •
  127. 127. • The first task in applying the dressing is to place tape tightly against the nose. The skin had been elevated from the nose during surgery so that we could see and alter the bones and cartilages, and we tape the skin tightly back down to help the skin adhere to the new framework. • The tape also keeps fluid from collecting in a pool between the skin and the underlying cartilages. The body might replace a fluid collection with scar tissue, degrading the quality of the final www.indiandentalacademy.com result.
  128. 128. • Now the metal splint is placed. • The underside is lined with a white cloth tape that helps to cushion the nose from the metal of the splint. • The lowest edge of the splint (blue line and arrow in the diagram above right) is above the location where the nasal bone was cut (red line and arrow). Stated differently, the splint isn't so big that it comes down to cover that red line of the bone cut on the side of the nose. Very important www.indiandentalacademy.com
  129. 129. • Now that the bones have been moved, • the splint, in red, is in place, and you can see that the splint does not extend down to the level of the osteotomy, the bone cuts, at the green arrow. • the splint hugs the moved bones, and will hold them in their exact position as the nose heals during the week after surgery. • If the splint too long, and the bottom edge of the splint drapes over the non-moved parts of the bone, the upper portions of the splint are not hugging the nasal bones as closely, and the bones won't stay where they were placed. www.indiandentalacademy.com
  130. 130. FAILURES • SCAR TISSUE:-Every nose responds to surgery by making a layer of scar tissue underneath the skin, but with proper technique the scar tissue doesn't interfere with the appearance of the nose and doesn't stand in the way of achieving the desired results • operation will be to attempt to meticulously carve away the scar tissue and find the lower lateral cartilages underneath. This task is not easy. The scar tissue hugs the underlying cartilages tightly. It doesn't just peel off. It is possible to tear the cartilages in the process of finding them in this mass of scar, or to fail to find them entirely. www.indiandentalacademy.com
  131. 131. • :- over-resection of tip cartilage When the tip cartilages have been more severely over-resected, we must use the strut and grafting techniques on tip support to help with the reconstruction. www.indiandentalacademy.com
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  133. 133. LOST SURGEON SYNDROME:• It looks as though the surgeon was lost inside the nose, and was just cutting and removing pieces atrandom. Think this stuff doesn't happen? • Above and below we see noses for which our working diagnosis is lost surgeon syndrome. The lower lateral cartilages were modified haphazardly. www.indiandentalacademy.com
  134. 134. SYNECHIUM • patient has a bridge of scar tissue that stretches from the area of the columella to the side wall of the inside of the nose. An unwanted bridge of scar tissue like that is called a synechium, • a synechium is relatively easy to excise, opening the nostril up again. www.indiandentalacademy.com
  135. 135. ABNORMAL PROJECTIONS • previous surgeon had placed a cartilage strut in the nose, but he placed it in an abnormal position, not in the columella as would be routine. • This strut was placed below the arch of the dome of the lower lateral cartilage, and the strut eroded through the cartilage to poke out above it and deform the tip of the nose. • The strut is shaded blue in the diagrams. www.indiandentalacademy.com
  136. 136. Even a "simple" hump removal won't go well in untrained or inexperienced hands • previous surgeon wasn't even able to carve down the cartilage and bone of her hump smoothly www.indiandentalacademy.com
  137. 137. INCISSION MARKS www.indiandentalacademy.com
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