Surgical Assessment in Rhinoplasty - Advanced Rhinoplasty - Dirk Jan Menger - the Netherlands

1. Surgical Assessment in
Rhinoplasty
DJ Menger
International Course in Advanced Rhinoplasty Techniques
The Netherlands
www.AdvancedRhinoplasty.nl

2. Dear colleague,
This presentation outlines the importance of adequate surgical assessment. Pre-operative pictures
together with clinical information will be shown, based on this an assessment of the surgical plan will be
presented. Training of surgical assessment is an important teaching tool and a unique opportunity to gain
knowledge of the surgical anatomy and to study the postoperative outcome of the applied surgical
techniques. Note, there is never just one solution, modifications- or other surgical techniques might
always be an option.
CAUTION: The lecture can contain pictures taken during surgery, which might be shocking. The lecture is
intended for colleagues and is part of the "International Course in Advanced Rhinoplasty Techniques".
Dirk Jan Menger, MD
Course Director
The Netherlands
www.AdvancedRhinoplasty.nl

3. Preoperative evaluation.
This patient had a long nasal dorsum with a short upper-lip.
www.AdvancedRhinoplasty.nl

4. Surgical Assessment
•
limited hump removal
•
osteotomies (lateral/oblique)
•
septal correction
•
reduction of the caudal septum, upper laterals and nasal spine
•
thin spreader grafts
•
upward rotation of the tip using the "tongue in groove technique"
www.AdvancedRhinoplasty.nl

5. Pre- and postoperative frontal view.
www.AdvancedRhinoplasty.nl

6. Pre- and postoperative lateral view.
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7. Pre- and postoperative basal view.
www.AdvancedRhinoplasty.nl

8. Preoperative evaluation.
This patient had a slight deviation of the cartilaginous dorsum to the left side, over-projection of the nasal tip
and dorsum, a short and "crowded" upper-lip and malocclusion.
www.AdvancedRhinoplasty.nl

9. Assessment
•
external approach rhinoplasty
•
limited hump removal
•
osteotomies; lateral / oblique
•
septal correction, harvesting cartilage
•
spreader grafts
•
tip:
– medial crural overlay
– lateral crural overlay
– suturing
•
augmentation of the naso-frontal angle and reduction of the nasal spine
www.AdvancedRhinoplasty.nl

10. Pre- and postoperative lateral view.
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11. Pre- and postoperative frontal view.
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12. Pre- and postoperative basal view.
www.AdvancedRhinoplasty.nl

13. Preoperative condition.
This patient had a collapse of the external nose due to destruction of the cartilaginous nasal septum, as a result
a saddle nose deformity and columellar retraction.
www.AdvancedRhinoplasty.nl

14. Assessment
•
external approach
•
irradiated homologous costal cartilage
– dorsal onlay graft
– septal reconstruction
– columellar strut graft
•
osteotomies, medial- and oblique
www.AdvancedRhinoplasty.nl

15. Pre- and postoperative frontal view.
www.AdvancedRhinoplasty.nl

16. Pre- and postoperative lateral view.
www.AdvancedRhinoplasty.nl

17. Preoperative condition.
This patient had a severe deviation of the cartilaginous- and bony dorsum.
www.AdvancedRhinoplasty.nl

18. Assessment
•
external approach rhinoplasty
•
mild hump resection
•
osteotomies; lateral / oblique and intermediate on the left side
•
septoplasty
•
spreader/splint graft on the left side
•
medial- and lateral crural overlay
•
reduction of the nasal spine
www.AdvancedRhinoplasty.nl

19. Pre- and postoperative lateral view.
www.AdvancedRhinoplasty.nl

20. Preoperative evaluation.
This patient had a hump deformation, over-projection and under-rotation of the nasal tip and too much
columellar show.
www.AdvancedRhinoplasty.nl

21. Assessment
•
hump reduction
•
osteotomies; lateral / oblique
•
spreader grafts
•
septal correction
•
reduction caudal septum and upper laterals
•
tip:
–
–
–
–
•
medial- and lateral crural overlay technique
tongue in groove technique
cephalic resections
trans- and interdomal sutures
wedge resection inner-lining “mucosa” (not skin)
www.AdvancedRhinoplasty.nl

22. Pre- and postoperative lateral view.
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23. Pre- and postoperative basal view.
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24. Preoperative condition.
This patient had a pseudo hump deformation, a saddle nose deformity and columellar retraction which was
caused by destruction of the cartilaginous nasal septum.
www.AdvancedRhinoplasty.nl

25. Assessment
•
external approach rhinoplasty
•
mild hump resection
•
osteotomies; lateral / oblique
•
dorsal onlay graft
•
caudal septal extension graft (auricular)
www.AdvancedRhinoplasty.nl

26. Pre- and postoperative lateral view.
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27. Pre- and postoperative frontal view.
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28. Preoperative condition.
This patient had a very thin skin in combination with bulbous/broad lower lateral cartilages and bony dorsum.
www.AdvancedRhinoplasty.nl

29. Assessment
•
mild hump resection
•
osteotomies; lateral / oblique
•
cephalic reduction of the LC
•
dome creation sutures and limited medial crural overlay
www.AdvancedRhinoplasty.nl

30. Pre- and postoperative frontal view.
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31. Pre- and postoperative lateral view.
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32. Pre- and postoperative helicopter view.
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33. Preoperative evaluation.
This patient had a bulbous, drooping tip and a hump of the cartilaginous/bony dorsum.
www.AdvancedRhinoplasty.nl

34. Assessment
•
external approach rhinoplasty
•
mild hump resection
•
osteotomies; lateral / oblique
•
sepal correction and harvesting cartilage
•
columellar strut graft
•
cephalic trim of the LC
•
tip sutures; inter- and transdomal
www.AdvancedRhinoplasty.nl

35. Pre- and postoperative oblique view.
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36. Preoperative evaluation.
This patient had very prominent domes of the lower lateral cartilages, over-projection of the nasal tip and some
columellar retraction
www.AdvancedRhinoplasty.nl

37. Assessment
•
external approach rhinoplasty
•
limited lateral- and medial crural overlay
•
columellar strut graft
www.AdvancedRhinoplasty.nl

38. Pre- and postoperative oblique view.
www.AdvancedRhinoplasty.nl

39. Preoperative evaluation.
This patient had a broad nasal dorsum after septoplasty, insufficient support of the upper lateral cartilages.
www.AdvancedRhinoplasty.nl

40. Assessment
•
external approach rhinoplasty
•
reconstruction of the L-strut of the nasal septum
•
lateral and oblique osteotomies, infraction of the bony pyramid
•
small dorsal onlay graft (auricular or rib)
www.AdvancedRhinoplasty.nl

41. Pre- and postoperative frontal view.
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42. Preoperative evaluation.
This patient had a very broad nasal dorsum and breathing problems due to a severe septal deviation.
www.AdvancedRhinoplasty.nl

43. Assessment
•
septoplasty
•
osteotomies, medial-, lateral- and oblique
•
limited strip of the upper laterals (caudal to cephalic orientation)
www.AdvancedRhinoplasty.nl

44. Pre- and postoperative frontal view.
www.AdvancedRhinoplasty.nl

45. Preoperative evaluation.
This patient a mild hump deformation, over-projection of the nasal tip with mild under-rotation.
www.AdvancedRhinoplasty.nl

46. Assessment
•
external approach rhinoplasty
•
mild hump resection
•
osteotomies; lateral / oblique
•
cephalic strip of the lateral crura
•
lateral crural steal, suture technique
•
medial crural overlay
•
columellar strut graft
www.AdvancedRhinoplasty.nl

47. Pre- and postoperative lateral view.
www.AdvancedRhinoplasty.nl

48. Preoperative evaluation.
This patient had collapse of the cartilaginous nasal skeleton due to over-resection of the nasal septum.
www.AdvancedRhinoplasty.nl

49. Assessment
•
external approach rhinoplasty
•
septal reconstrucution of the L-strut
•
osteotomies, lateral- and oblique; infraction of the pyramid
•
dorsal onlay graft (auricular or rib)
•
columellar strut graft
www.AdvancedRhinoplasty.nl

50. Pre- and postoperative lateral view.
www.AdvancedRhinoplasty.nl

51. Pre- and postoperative frontal view.
www.AdvancedRhinoplasty.nl

52. Pre-operative condition.
This patient a mild hump deformation and over-projection of the nasal tip.
www.AdvancedRhinoplasty.nl

53. Assessment
•
external approach rhinoplasty
•
mild hump resection
•
osteotomies; lateral / oblique
•
spreader grafts
•
limited medial- and lateral crural overlay
www.AdvancedRhinoplasty.nl

54. Pre- and postoperative lateral view.
www.AdvancedRhinoplasty.nl

55. Preoperative condition.
This patient had a deviation of the nasal dorsum to the right side.
www.AdvancedRhinoplasty.nl

56. Assessment
•
external approach rhinoplasty
•
mild hump resection
•
osteotomies; lateral / oblique and intermediate on the left side (long nasal bone)
•
septoplasty
•
spreader/splint on the left side
•
limited cephalic resection of the lateral crus
•
tip sutures; inter- and transdomal
www.AdvancedRhinoplasty.nl

57. Pre- and postoperative lateral view.
www.AdvancedRhinoplasty.nl

58. Preoperative evaluation.
This patient had a deviation of the nasal dorsum to the left side in combination with over-projection of the
nasal tip.
www.AdvancedRhinoplasty.nl

59. Pre-operative condition.
The caudal part of the nasal septum was deviated to the left side.
www.AdvancedRhinoplasty.nl

60. Assessment
•
external approach rhinoplasty
•
septal correction
– Fixation of the caudal border to the anterior nasal spine
– "splinting" technique
•
reduction of the cartilaginous septum
•
osteotomies, lateral and oblique
•
spreader grafts
•
tip: inter- and transdomal sutures, limited cephalic strip of the LC’s
www.AdvancedRhinoplasty.nl

61. Pre- and postoperative frontal view.
www.AdvancedRhinoplasty.nl

62. Pre- and postoperative lateral view.
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63. Pre- and postoperative basal view.
www.AdvancedRhinoplasty.nl

64. Preoperative condition.
This patient a deviation of the cartilaginous and bony dorsum to the right side.
www.AdvancedRhinoplasty.nl

65. Assessment
•
external approach rhinoplasty
•
mild hump resection
•
osteotomies; lateral / oblique and intermediate on the left side (long nasal bone)
•
septoplasty
•
spreader/splint on the left side
•
limited cephalic resection of the lateral crus
•
tip sutures; inter- and transdomal
www.AdvancedRhinoplasty.nl

66. Pre- and postoperative lateral view.
www.AdvancedRhinoplasty.nl

67. Preoperative condition.
This patient had a hump deformation and too much columellar show due to a combination of a long caudal
septum / nasal spine and mild retraction of the ala.
www.AdvancedRhinoplasty.nl

68. Assessment
•
external approach rhinoplasty
•
hump resection
•
osteotomies; lateral / oblique
•
thin spreader grafts
•
reduction of the anterior nasal spine and caudal septum
•
composite graft alongside the lateral crus (reduce alar retraction)
•
columellar strut graft
•
trans- interdomal suture techniques
www.AdvancedRhinoplasty.nl

69. Pre- and postoperative lateral view.
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70. Preoperative evaluation.
This patient had a deviation of the very narrow cartilaginous dorsum to the right side.
www.AdvancedRhinoplasty.nl

71. Assessment
•
external approach rhinoplasty
•
septoplasty
•
osteotomies: lateral / oblique
•
spreader / splint grafts
•
small alar batten grafts
www.AdvancedRhinoplasty.nl

72. Pre- and postoperative lateral view.
www.AdvancedRhinoplasty.nl

73. Preoperative evaluation.
This patient had underdevelopment of the nasal dorsum and a deviation of the nasal septum.
www.AdvancedRhinoplasty.nl

74. Assessment
•
external approach rhinoplasty
•
osteotomies; lateral / oblique
•
dorsal onlay graft
•
septoplasty and caudal septal extension graft
www.AdvancedRhinoplasty.nl

75. Pre- and postoperative lateral view.
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76. Pre- and postoperative basal view.
www.AdvancedRhinoplasty.nl

77. Preoperative condition.
This patient had a mild concavity on the left side of the cartilaginous- and bony nasal dorsum.
www.AdvancedRhinoplasty.nl

78. Assessment
•
external approach rhinoplasty
•
osteotomies; lateral / oblique
•
spreader graft on the left side
•
tip; inter- and transdomal sutures
www.AdvancedRhinoplasty.nl

79. Pre- and postoperative frontal view.
www.AdvancedRhinoplasty.nl

80. Preoperative evaluation
This patient had over-projection of the nasal dorsum and tip, with a crowded upper-lip.
www.AdvancedRhinoplasty.nl

81. Assessment
•
external approach rhinoplasty
•
mild hump resection
•
osteotomies; lateral / oblique
•
spreader grafts
•
cephalic trim of the lateral crura
•
columellar strut graft
•
trans- and interdomal sutures
•
augmentation of the naso-frontal angle
www.AdvancedRhinoplasty.nl

82. Pre- and postoperative lateral view.
www.AdvancedRhinoplasty.nl

83. Preoperative condition.
This patient had complaints of an irregular and over-projected nasal dorsum and tip. There was a concavity in
the mid nasal third on the right side and breathing problems due to a strong deviation of caudal nasal septum.
www.AdvancedRhinoplasty.nl

84. Assessment
•
external approach rhinoplasty
•
reduction of the cartilaginous- and bony dorsum
•
osteotomies: lateral and oblique
•
septoplasty, including splinting of the caudal septum
•
spreader graft on the right side
•
medial- and lateral crural overlay technique
•
columellar strut graft
•
trans- and interdomal sutures
www.AdvancedRhinoplasty.nl

85. Pre- and postoperative lateral view.
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86. Pre- and postoperative frontal view.
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87. Pre- and postoperative basal view.
www.AdvancedRhinoplasty.nl

88. Preoperative condition.
This patient had a mild deviation of the cartilaginous and bony nasal dorsum to the left side.
www.AdvancedRhinoplasty.nl

89. Assessment
•
external approach rhinoplasty
•
osteotomies; lateral / oblique and intermediate on the right side
•
septoplasty
•
spreader / splint graft on the right side
www.AdvancedRhinoplasty.nl

90. Pre- and postoperative frontal view.
www.AdvancedRhinoplasty.nl

91. Pre- and postoperative helicopter view.
www.AdvancedRhinoplasty.nl

92. Preoperative condition.
This patient had a severe saddle nose deformity
www.AdvancedRhinoplasty.nl

93. Assessment
•
external approach rhinoplasty
•
mild hump resection
•
osteotomies; lateral / oblique
•
dorsal onlay graft
•
caudal septal extension graft (auricular)
www.AdvancedRhinoplasty.nl

94. Pre- and postoperative frontal view.
www.AdvancedRhinoplasty.nl

95. Pre- and postoperative lateral view.
www.AdvancedRhinoplasty.nl

96. Preoperative evaluation.
This patient had a deviation of the nasal tip to the left side due to an under-development of the ala on the left
side. In the lateral view a hump deformation, drooping tip with very acute naso-labial angle and a deep nasofrontal angle.
www.AdvancedRhinoplasty.nl

97. Assessment
•
external approach rhinoplasty
•
mild hump resection
•
osteotomies; lateral / oblique
•
septoplasty
•
spreader grafts
•
augmentation of the naso-frontal angle
•
reconstruction of the lateral crus on the left side and Z-plasty of the ala
•
lateral crural overlay of the right LC
•
tongue in groove technique
•
trans- and interdomal suture techniques
www.AdvancedRhinoplasty.nl

98. Pre- and postoperative frontal view.
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99. Pre- and postoperative lateral view.
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100. Preoperative condition.
This patient had a thick soft-tissue envelope, a hump deformation and under-projection of the nasal tip.
www.AdvancedRhinoplasty.nl

101. Assessment
•
external approach rhinoplasty
•
mild hump resection
•
osteotomies; lateral / oblique
•
columellar strut graft
•
shield graft
•
alar rim grafts
www.AdvancedRhinoplasty.nl

102. Pre- and postoperative lateral view.
www.AdvancedRhinoplasty.nl

103. Preoperative evaluation.
This patient had nasal trauma in the past, complete destruction of the nasal septum in childhood. The nasal
skeleton is underdeveloped.
www.AdvancedRhinoplasty.nl

104. Assessment
•
external approach rhinoplasty
•
osteotomies; lateral / oblique
•
dorsal onlay graft (rib cartilage)
•
caudal septal extension graft (auricular cartilage)
•
Columellar strut graft
•
Tip sutures, inter- and transdomal
www.AdvancedRhinoplasty.nl

105. Pre- and postoperative oblique view.
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106. Pre- and postoperative lateral view.
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107. Pre- and postoperative frontal view.
www.AdvancedRhinoplasty.nl

108. Preoperative condition.
This patient had a hump deformation and deviation of the nasal dorsum to the right side, a bulbous- and
drooping nasal tip.
www.AdvancedRhinoplasty.nl

109. Assessment
•
external approach rhinoplasty
•
mild hump resection
•
osteotomies; lateral / oblique
•
septoplasty
•
columellar strut graft
•
cephalic trim of the lower laterals
•
trans- and interdomal suturing
www.AdvancedRhinoplasty.nl

110. Pre- and postoperative frontal view.
www.AdvancedRhinoplasty.nl

111. Pre- and postoperative lateral view.
www.AdvancedRhinoplasty.nl

112. Preoperative condition.
This patient had a mild hump deformation and over-projection of the nasal tip.
www.AdvancedRhinoplasty.nl

113. Assessment
•
external approach rhinoplasty
•
mild hump resection
•
osteotomies; lateral / oblique
•
thin spreader grafts
•
lateral- and medial crural overlay
•
columellar strut graft
www.AdvancedRhinoplasty.nl

114. Pre- and postoperative lateral view.
www.AdvancedRhinoplasty.nl

115. Preoperative evaluation.
This patient had a saddle nose deformity due to destruction of septal cartilage after septoplasty performed
elswhere. Note the columellar retraction and the relative long upper-lip due to absence of the caudal part of
the septum.
www.AdvancedRhinoplasty.nl

116. Assessment
•
external approach rhinoplasty
•
mild hump resection
•
osteotomies; lateral / oblique
•
dorsal onlay graft (rib / auricular)
•
reconstruction of the L-strut / septal replacement graft (auricular)
www.AdvancedRhinoplasty.nl

117. Pre- and postoperative lateral view.
www.AdvancedRhinoplasty.nl

118. Pre- and postoperative frontal view.
www.AdvancedRhinoplasty.nl

119. Preoperative evaluation.
This patient had a concavity of the bony- and cartilaginous dorsum on the left side.
www.AdvancedRhinoplasty.nl

120. Assessment
•
external approach rhinoplasty
•
septoplasty
•
osteotomies; lateral and oblique, out-fracture on the left side
•
spreader graft on the left side
•
limited cephalic resection of the LC's
•
trans- and interdomal suturing
www.AdvancedRhinoplasty.nl

121. Pre- and postoperative frontal view.
www.AdvancedRhinoplasty.nl

122. Pre- and postoperative helicopter view.
www.AdvancedRhinoplasty.nl

123. Preoperative condition.
This patient had severe retraction of the ala on the left side with too much columellar show.
www.AdvancedRhinoplasty.nl

124. Assessment
•
Auricular composite graft alongside the lateral crus on the left side.
•
Shortening the caudal septum
www.AdvancedRhinoplasty.nl

125. Pre- and postoperative lateral view.
www.AdvancedRhinoplasty.nl

126. Preoperative condition.
This patient had a saddle nose deformity due to displacement of the nasal septum after trauma, insufficient
support of the nasal dorsum.
www.AdvancedRhinoplasty.nl

127. Assessment
•
external approach rhinoplasty
•
mild hump reduction
•
osteotomies: lateral and oblique
•
septoplasty
•
dorsal onlay graft (auricular)
•
trans- and interdomal suturing
www.AdvancedRhinoplasty.nl

128. Pre- and postoperative lateral view.
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129. Pre- and postoperative frontal view.
www.AdvancedRhinoplasty.nl

130. Preoperative evaluation.
This patient had a concavity on the right side of the nasal dorsum and a bony- and cartilaginous hump.
www.AdvancedRhinoplasty.nl

131. Assessment
•
external approach rhinoplasty
•
hump reduction
•
osteotomies: lateral and oblique
•
spreader graft on the right side
•
augmentation of the naso-frontal angle
•
cephalic reduction of the LC's
•
columellar strut graft
•
trans- and interdomal suturing
www.AdvancedRhinoplasty.nl

132. Pre- and postoperative frontal view.
www.AdvancedRhinoplasty.nl

133. Pre- and postoperative lateral view.
www.AdvancedRhinoplasty.nl

134. Preoperative condition.
This patient had insufficient support of the cartilaginous dorsum and nasal tip.
www.AdvancedRhinoplasty.nl

135. Assessment
•
external approach rhinoplasty
•
bony hump reduction
•
lateral- and oblique osteotomies
•
reconstruction of the L-stut of the nasal septum (rib grafts)
•
lateral crural steal suture technique
•
columellar strut graft
•
spreader grafts
www.AdvancedRhinoplasty.nl

136. Pre- and postoperative lateral view.
www.AdvancedRhinoplasty.nl

137. Preoperative condition.
This patient had under-rotation of the nasal tip, a mild hump and deviation of the dorsum to the left side.
www.AdvancedRhinoplasty.nl

138. Assessment
•
external approach rhinoplasty
•
limited hump removal
•
osteotomies; lateral- and oblique
•
septoplasty
•
reduction of the anterior nasal spine and caudal septum
•
lateral crural steal suture technique
•
columellar strut graft
www.AdvancedRhinoplasty.nl

139. Pre- and postoperative frontal view.
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140. Pre- and postoperative lateral view.
www.AdvancedRhinoplasty.nl

141. Preoperative evaluation.
This patient had over-projection and too much upward rotation of the nasal tip.
www.AdvancedRhinoplasty.nl

142. Assessment
•
external approach
•
reduction of the cartilaginous dorsum
•
septoplasty and caudal septal extension of the dorsal part
•
medial crural overlay
•
reduction of the anterior nasal spine
•
columellar strut
www.AdvancedRhinoplasty.nl

143. Pre- and postoperative lateral view.
www.AdvancedRhinoplasty.nl

144. Preoperative condition.
This patient had a hump deformation, over-projection and downward rotation of the nasal tip and a "crowded
upper-lip"
www.AdvancedRhinoplasty.nl

145. Assessment
•
external approach rhinoplasty
•
hump reduction
•
osteotomies; lateral and oblique
•
thin spreader grafts
•
medial crural overlay
•
reduction of the anterior nasal spine and caudal septum
•
columellar strut graft
www.AdvancedRhinoplasty.nl

146. Pre- and postoperative lateral view.
www.AdvancedRhinoplasty.nl

147. Preoperative evaluation.
This patient had a deviation of the bony- and cartilaginous dorsum to the right side.
www.AdvancedRhinoplasty.nl

148. Assessment
•
external approach rhinoplasty
•
osteotomies; lateral and oblique and intermediate on the left side
•
septoplasty
•
spreader / splint on the left side
•
trans- and interdomal tip sutures
www.AdvancedRhinoplasty.nl

149. Pre- and postoperative frontal view.
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150. Pre- and postoperative helicopter view.
www.AdvancedRhinoplasty.nl

151. Preoperative condition.
This patient had a hump deformation, over-projection and under-rotation of the nasal tip.
www.AdvancedRhinoplasty.nl

152. Assessment
•
external approach rhinoplasty
•
hump resection
•
osteotomies; lateral and oblique
•
spreader grafts
•
medial- and lateral crural overlay technique
•
reduction of the anterior nasal spine and caudal septum
•
columellar strut graft
www.AdvancedRhinoplasty.nl

153. Pre- and postoperative lateral view.
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154. www.AdvancedRhinoplasty.nl
www.AdvancedRhinoplasty.nl