Corrective surgery of nose

1. Corrective Surgery of
Nose
Presented by
Dr Kamini Dadsena
Department of Oral and Maxillofacial Surgery
New Horizon Dental College And Research Institute, Bilaspur, Chhattisgarh

2. Outline
• Introduction
• History
• Anatomy
• Clinical examination
• Different procedure in Rhinoplasty
• Conclusion
• References

3. Introduction
• The word rhinoplasty is derived from 2 Greek words,
rhino, meaning nose, and plasikos, meaning to shape or
mold.
• Cosmetic surgery of the nose is often considered one of
the most difficult esthetic operations. This is partly
because the nose holds a prominent position on the face
and irregularities or asymmetries cannot be easily
camouflaged.

4. HISTORY
• Description of nasal reconstruction in Susruta samhita
(600 B.C.)
• 1887 - John Orlando Roe performed first intranasal
rhinoplasty.
• Jacques joseph – father of modern facial plastic surgery –
published his Treatise on rhinoplasty.

5. Nasaldeformities
• Tip
• Bulbous
• Bifid
• Overprojected
• Underprojected
• Tip ptosis

6. Nasaldeformities
• Columella
• Retracted
• Deviated

7. • Alar cartilage
• Pinching/flaring
• Osseocartilagenous vault
• Deviated
• Bony/cartilagenous/both
• Saddle
• Bony/cartilagenous/both
• Hump
• Bony/cartilagenous/both

8. ANATOMY

9. • 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.

10. Anatomy

11. Anatomy

13. Basal view

14. scroll

15. Nasal Musculatures

16. Blood supply of External nose

17. Blood supply of lateral wall of
nose

18. Blood supply of nasal septum

20. Sensory supply of nose

21. ClinicalAssessment
• Routine investigation
• Clinical assessment
Assess external nasal deformity
Quality of skin
Facial analysis
• Photographic documents

22. Basic principles to be takencare……
• Be conservative
• Should know where to stop
• Never promise miraculous results after surgery
• Beware of psychotic patients
• Consent

23. Clinical photographs

24. Clinical examination
Upper Nose and Dorsum
Front view
gross asymmetry
lateral bony irregularities
deviation of the dorsum
width of the upper nose

25. Upper Nose and Dorsum
Profile view
position of Radix
nasal length
depth of the nasofrontal depression
nasofrontal angle

26. Nasal tip
Shape
bulbous
boxy,
Pinched
twisted, or
Asymmetric
Nasal projection

27. Alar-columellar relationship

28. Skin Thickness
• A patient with thin nasal skin will show dramatic
changes with alteration of the underlying bone and
cartilage, and this limits room for error because
little is camouflaged by the thickness of the skin.
• On the other hand, thick-skinned individuals
require more aggressive sculpting of the nasal
skeleton in order to see significant change

29. Incisions for Rhinoplasty
Marginal and rim (infracartilaginous) incisions

30. Incisions for Rhinoplasty

31. The intercartilaginous and
intracartilaginous incisions

32. The Killian incision

33. Tip Plasty
Tip
Projection
Tip
Rotation
Tip Shape

34. Tip Projection

35. Tip Projection

36. Tip Projection
Lateral crural steal

37. Tip Projection
The shield graft

38. Decreasing the Tip projection
• Simply skeletonizing the nose will decrease the
projection slightly.
• If aggressive deprojection is required, the medial
crura can be transected horizontally, overlapped, and
sutured with horizontal mattress sutures.
• The same can be done to the lateral crura if the tip
needs increased rotation as well.

39. Alar base resection

40. Tip Rotation
Increasing tip rotation
• Simply reducing the dorsal hump of the nose
• Removing a cephalic strip of cartilage from the
lower lateral cartilages
• An intercartilaginous incision
• Resecting a small triangular piece of caudal septum
• Transecting, overlapping, and resuturing the lateral
crura with 6-0 Prolene
• Cartilage grafts, such as the shield graft

41. Tip Rotation
The cephalic strip.

42. Tip Derotation
• Trimming the caudal septum near the anterior
nasal spine
• Augmenting the nasal dorsum

43. Nasal Tip
1. The complete strip technique
2. The weakened complete strip technique
3. The interrupted strip technique/ Goldman
tip

44. Tip Shape
The Goldman tip

45. Surgical Steps
1. Columellar incision
2. Bilateral marginal incisions
3. exposure of the bone and cartilage
4. Dorsal reduction
5. Dome division if access is needed to the septum for septoplasty or
graft harvest
6. Septoplasty if required
7. Lateral nasal osteotomies (micropuncture technique)
8. Tip plasty
9. Alar base modification
10. Closure, taping, and splinting

46. Anesthesia
• General anesthesia.
• Local anesthesia
• Excess nasal hair should be trim
• 0.05% oxymetazoline-soaked cottonoids can be
placed along the septum, middle turbinate, and
superior nasal vault.

47. Incisions for Rhinoplasty
V inverted V stairstep

48. Incisions for Rhinoplasty
Marginal and rim (infracartilaginous) incisions

49. • With a 7-mm double skin hook placed at the
nostril apex, the ala is retracted superiorly
and the caudal edge of the lower lateral
cartilage is usually easily visualized.
• The incision should be made just caudal to
the cartilage beginning laterally and
extending medially to the apex of the nose

50. • The incision is extended along the very thin
mucosa overlying the medial crus
approximately 1 mm posterior to the skin of
the columella.
• The incision should join up with the previously
made transcolumellar incision.
• After that dissection is carried out
submucoperichondrium

51. Dorsal reduction

52. Lateral nasal osteotomies

53. The medial osteotomy

54. Dorsal augmentation
Autogenous materials
septal, auricular, and rib cartilage;
cranial bone; or iliac crest.
Alloplastic materials
silicone and ePTFE implants.

55. Septoplasty
• The cartilage can be easily obtained by
separating the upper lateral cartilages at the
anterior septal angle.
• A portion of the nasal septum can be resected
and used for cartilage grafting techniques.
• It is important to preserve approximately 1 cm
of cartilage dorsally and caudally to prevent a
saddle-nose deformity

56. Harvesting nasal septum

57. • The surgeon can now perform the tip plasty
• columellar strut/ graft for tip support
• Closer
• Skin – 6-0 prolene
• Mucosal – 5-0 lain gut
• Septoplasty- 4-0

58. Alar base modification

59. Dressings and Splinting

60. Follow-up Care
• The patient is seen at 24 hours and again in 1
week
• Not to blow the nose
• Oxymetazoline nasal spray to improve
breathing.
• Saline spray

61. Complication
• Nasal bleeding
• 0.05% oxymetazoline nasal spray
• cauterize the bleeding points
• nasal packing
• Infection
• Hematoma formation
Septal hematomas in particular can result in cartilage
necrosis, septal perforation, and saddle-nose deformity if
not recognized and drained. Septal mattress suturing is a
good preventive measure.
• Scar
• Overcorrection

62. Conclusion
• Cosmetic surgery of the nose is often
considered one of the most difficult esthetic
operations because the nose holds a prominent
position on the face and irregularities or
asymmetries cannot be easily camouflaged.

63. Conclusion
• Taking time to listen to the patient’s concerns
and desires is critical to help formulate the
surgical goals and determine if the patient is
suitable for surgery and has realistic
expectations.

64. Conclusion
• Once the patient decides to proceed with
surgery, the surgeon must perform a
comprehensive examination, taking into
consideration the dynamic influence of the
skin type, bone and cartilage structure, and
anatomic limitations.

65. Conclusion
• Creating a detailed three-dimensional plan
with a structured sequence will help the
surgeon achieve more predictable results.

66. THANK YOU……