Rhinoplasties in reconstructive surgery Personal experience Docteur Ahcene Madjoudj
Docteur Ahcene Madjoudj Plastic Surgeon. I practice in the liberal sector in Algiers (Algeria). I also collaborate with neuro-surgery departments of CHU Blida and Bab-El-Oued mainly in spina-bifida and Cranio- facial surgery. I am a member of the Canadian Society for Aesthetic Plastic Surgery (csaps).
Definition Rhinoplasty is surgery of the nose shape which aims is to harmonize it with the rest of the face. In this presentation we address more specifically the reconstructive rhinoplasty, secondary to traumas or deformities.
Issue Unlike cosmetic rhinoplasty, the reconstructive one, is not codified. This surgery require technical gestures that will be described on some clinical cases in this presentation.
Injuries are mostly caused by: Traffic accidents , violence. Mutilation. • Burns. • After Surgery for cancer. • •
Preoperative The consultation: the patient must not wear nothing that could hide parts of his face (glasses,cap..) Close attention will be paid to the patients expectations, explaining clearly the intervention outcomes and limits . Radiological exams are demanded if needed.The nose exam will determine : Lesions on the nasal pyramidal structure ( bone, cartilage) The impact on the nasal respiratory . Speculum nasal exam must be conducted to look for possible septal and endo-nasal bones lesions We will evaluate the associated lesions of the face.
General Approach During the intervention both aspects, the aesthetical and functional ,should be considered equally. Both aspects should be treated in the same operatory time when it is posssible.
General considerations Will use the hump to fill the isolated cartilaginous dorsum saddles .(personal technique) the bone grafts are taken from the iliac crest or from the skull(clavarial) In saddles ,Grafts are not always necessary.
The saddles They may concern the cartilage dorsum only or the whole dorsum (bone and cartilage).
Post-traumatic saddle: case I Unilateral intercartilaginous incision. minimal dissection of skin and subperiostal dorsum . Removal of the hump with lateral osteotomies . Iliac bone graft is slept into the saddle .
Post-traumatic saddle:case II No bone graft. Hump removed , lateral osteotomies and bones drawn together Hump reinclusion on the cartilaginous saddle.
Post-traumatic: case III Saddle dorsum osteocartilaginous from childhood. Intercatilaginous incision with a minima subcutaneous dissection . Setting up of two two iliac bone grafts. No columellar strut .
Post-traumatic: case IV Post traumatic saddle No bone graft. No reinclusion paramedian osteotomies Lateral osteotomies draw together the bones on the median line .
Post-traumatic: case V Cartilaginous saddle post surgery lateral and paramedian osteotomies. auricular cartilage graft affixed on the saddle.
General considerations Isolated nose burn is rare. Often burn spreads all over the face. The forehead flap reparation is often indicated when lesions occur on the nose tip. The inflammatory and scarring processes make the surgical repair very challenging.
Patient Case I Sequels of burns of the face with loss of the nasal tip. Tissues retraction on the nose and the upper lip. Short forehead . To bring the forehead flap to the nasal tip, we performed : Rhinoplasty with resection of the osteocartilaginous dorsum to lower it. Lateral osteotomies Placed the forehead flap with some difficulties due to scarring problems. 4 surgeries revisions were needed .
General considerations We use the forehead flap technique when the amputation is not important, otherwise we use the forearm to make a composite free flap .
Patient case I Nose tip cancer. Wide resection with satisfactory extemporaneous pathological examination. Placing the forehead flap weaned at day 21. sample’s pathological exam satisfactory.
Patient case II:Sclero-dermiforme epithelioma case Recurrences are frequent despite pathological findings oncologically satisfactory. sclero-dermiform ephitelioma recurence occurred each and every time after surgery. After the third operation, the patient underwent a radiotherapy which helped stop the cancerous process.
General considerations Lefort II is the best solution in malocclusions. In other cases , results are very gratifying by just using bone grafts (nasal, maxillar and malar ).
Patient case I• Minor case• Bone graft apposition on the dorsum was enough.
Patient case II significant retrusion of nasomaxillary area without occlusion problem . Open rhinoplasty. Taking of Iliac bone grafts. Thin and large bone graft is inserted between the septal mucosas. Next we put a large bone graft to rebuild the dorsum.
Patient case III affixing of iliac bone grafts on malars, maxillary and the nose
General considerations Those cases are very common and the surgery is very challenging .
Patient case I lip alignment surgical revision .For the nose: Open rhinoplasty , alar cartilages dissection Setting up of a columellar strut. suture both alar domes to create the nose tip.
Patient case II Open rhinoplasty No struts , just alars dissection . Suture of the hypoplasic alar to the septum and homolateral triangular cartilage. suture both alar domes to create the nose tip.
Patient case III Setting up of a columellar strut. Suture of the hypoplasic alar to the septum and to the homolateral triangular cartilage. suture both alar domes to create the nose tip.
ConclusionAlthough the surgery greatly improves the patients appearance ,results are often far below their expectations.It is important to provide them with a rigorous and objectiveinformation about the surgery limits to avoid futuredisappointments.
Thank you.The slides are available on :www.chirurgieesthetiquealgerie.com