Rhinoplasty.pptx

Rhinoplasty
Dr.G.Kathirvel
PG OMFS

Contents:
• Introduction
• Surgical anatomy of the nose
• Preoperative assessment
• Techniques
• Post operative care
• Complications

Rhinoplasty:
• Defined by the American Academy of Otolaryngology (AAO) as “a surgical
procedure that alters the shape or appearance of the nose with functional
rhinoplasty specifically aimed at enhancing the nasal airway.”
• 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

Surface anatomy
• The descriptors used to describe relative spatial
relationships include the standard anatomic
terms
• Assist the surgeon in defining problem areas of
the nose and facilitate treatment planning

NASAL VAULTS
• Bony vault
• Upper cartilaginous vault
• Lower cartilaginous vault
Bony Vault
• This is comprised of paired nasal bones as well as
the ascending frontal process of the maxilla
• The bones are narrowest above the intercanthal
level but have increased thickness in that area
becoming progressively thinner toward the
keystone area
Kenyon G. Nasal Anatomy and Analysis. Int J Otorhinolaryngol Clin 2013;5(1):34-42.

Upper Cartilaginous Vault:
The upper lateral cartilages underlay the nasal bones
for 6 to 8 mm and their junction form a tight
synchondrosis.
The keystone area - formed by the junction of the
upper lateral with the nasal bones and the dorsal
septum.
Internally this forms a T-shaped structure.
They extend down to the scroll area - junction
between the upper and lower lateral cartilages.

Lower Cartilaginous Vault
• The lowest vault is comprised of the medial, intermediate and
lateral crura of the lower lateral cartilages.
• These structures are important in normal tip projection and in
maintenance of a normal nasal airway. They are supported by:
1. The length and strength of the lower lateral cartilages.
2. The suspensory ligament of the tip.
3. The fibrous connections between the lateral crura and the
caudal border of the upper lateral cartilages.
4. The abutment with the bony pyriform aperture.
5. The anterior septal angle.
The angle of divergence of the lower lateral occurs at the middle
crus and is an important factor in determining tip type

MUSCULAR SYSTEM
Nasal muscles can be divided into four groups:
• Elevator muscles
• Depressor muscles
• Compressor muscles
• Minor dilator muscle
All of them are innervated by temporal, zygomatic
and buccal branch of facial nerve.
Taek Kyun Kim, Jae Yong Jeong; Surgical anatomy for Asian rhinoplasty; Arch Craniofac Surg Vol.20 No.3, 147-157

Elevator muscles:
They shorten nasal length and dilate nostril.
Procerus muscle:
Origin : From the periosteum of the nasal bones and the
aponeurosis of the transverse nasalis
Insertion : Into the glabellar skin.
Levator labii superioris alaeque nasi muscle:
Origin: From the periosteum of the frontal process of the
maxilla medial to the orbicularis oris
Insertion: At muscle and skin of nasolabial fold, nasal alae
and upper lip.

Depressor muscles
They lengthen nasal length and dilate nostril.
Dilator naris posterior muscle:
Origin: From the periosteum of the maxilla above the
canine tooth
Insertion: Into the alar base.
Depressor septi nasi muscle:
Origin: From the periosteum of the maxilla above the
canine tooth
Insertion: Onto the footplates of the medial crura with
attaching tightly to the anterior nasal spine and mucosa,
perichondrium and membranous septum.

Compressor muscles
Transverse nasalis muscle :
Origin: From the periosteum of the maxilla above and lateral to the
incisor fossa.
It interdigitates on the nasal dorsum with its counterpart from the
opposite side and the procerus muscle to form a sling.
Compressor narium minor muscle:
Origin: From the tail of the lateral crura and the accessory cartilages
Insertion: Into the deep dermal surface of the alar groove.
Minor dilator muscle
Dilator naris anterior muscle:
Origin: from the surface of the lateral crus
Insertion: into the nostril rim.

Vascular supply:
External nose:
The internal carotid artery supplies via the dorsal nasal
artery (a branch of the ophthalmic artery) and the external
nasal artery (a branch of the anterior ethmoid artery).
The external carotid artery provides blood supply via
the facial artery branches (angular artery, lateral nasal
artery, alar artery, septal artery, and superior labial artery)

Internal nose : both internal and external carotid branches .
Internal carotid - the ophthalmic artery branches into the
anterior and posterior ethmoidal arteries.
The anterior ethmoidal artery - the anterosuperior part of the
septum and the lateral nasal wall.
The posterior ethmoid artery - the septum, lateral nasal wall,
and superior turbinate.
External carotid - the internal maxillary artery branches that supply the internal nose include
the sphenopalatine artery and the greater palatine artery.
The sphenopalatine artery - most of the posterior part of the nasal septum, lateral wall of the
nose, roof, and part of the nasal floor.
The greater palatine artery - a portion of the anterior and inferior portion of the nasal septum.

Little’s area: (APPLIED ASPECT)
• A common site of epistaxis is known as Kiesselbach’s
plexus
• This area is located in the anteroinferior part of the nasal
septum
Represents the anastomosis of the sphenopalatine, greater
palatine, superior labial artery, and anterior ethmoid arteries.
The venous drainage of the nose is primarily from the
facial and ophthalmic veins.

Nerve Supply
The sensory nerve supply to the skin of the external nose is
supplied by the ophthalmic and maxillary divisions of the
trigeminal nerve.
Branches of the supratrochlear and infratrochlear nerves
supply the skin in the region of the radix and rhinion.
The lower half of the nose is supplied by the infraorbital nerve
and the external nasal branch of the anterior ethmoidal nerve
The main sensory nerve supply to the nasal septum comes
from the internal nasal nerve (a branch of the anterior
ethmoidal nerve) and the nasopalatine nerve.
The lateral nasal wall sensation is supplied by the anterior
ethmoidal nerve, branches of the pterygopalatine ganglion,
branches of the greater palatine nerve, the infraorbital nerve,
and the anterior superior alveolar nerve.

Symmetry of Nose
Degree of deviation:
Looking at the frontal view a line drawn from
the midglabellar region to the menton should
bisect the nasal bridge, nasal tip and the Cupid’s
bow
Kenyon G. Nasal Anatomy and
Analysis. Int J Otorhinolaryngol Clin 2013;5(1):34-42.

Width of the body and tip of the nose:
The base width should equal to the intercanthal distance or one eyes
width.
If it is wider than this, alar base resection should be considered
The bony base should be 80% of the alar base width
If wider than this, consideration should be given to
narrowing this at the time of osteotomy.

Basal view:
• An equilateral triangle should be visualized.
• The ratio of the columella to the lobular part of the nose
should be 2:1
• The nostrils should be teardrop shaped with the long
axis from the apex to the base orientated in a slightly
lateral direction.

Radix:
• Should be located vertically between the superior palpebral margin
and the upper eyelid margin.
• If the radix is low, the patient will have the appearance of a short nose
• If it is high, the patient will have the appearance of a long nose.
• The depth of the nasofrontal depression should be approximately 4 to
9 mm anterior to the corneal plane.
• The depth of the radix can greatly affect the nasofrontal angle.
• The ideal nasofrontal angle is between 115 and 130 degrees.
• The nasofrontal angle tends to be more acute in men and more obtuse
in women.

Tip projection:
The most commonly quoted method is Goode’s method.
This definition states that the ideal tip projection is 0.55 to 0.6 RT,
where RT is the distance between radix and pronasale

Nasal tip projection:
• 50 to 60% of the tip should lie anterior to a vertical line
drawn adjacent to the most projected portion of the upper
lip.
• If over 60% lies anterior to this line, the tip is likely to be
overprojected.
• If nasal length is correct then the ratio of nasal length to tip
projection should be 1:0.67.

Degree of tip rotation
• If a straight line is drawn through the most anterior and
posterior parts of the nostrils the angle is determined by
measurement against a plumb line from the nasofrontal
angle.
• The angle should be 90 to 95° in men and more than this is
women (95-100°).
Columella-lobular angle:
• This should be approximately 45°
In a profile view a woman’s chin should be on or slightly behind
an imaginary vertical line from the subnasale perpendicular, and in
men it should be on or slightly in front of this line.

Nasal Function:
• The airflow through the nose is regulated by the internal and
external nasal valves.
• The external nasal valve is formed by the lower lateral cartilage. In
severe cases, collapse of the external nasal valve can be seen when
the nares become occluded on even gentle inspiration.
• This problem is more common in patients with narrow nostrils,
overly projected nasal tip, and thin alar sidewalls.
• The external nasal valve collapse can be corrected by deprojecting an overprojected nose,
realigning the lateral crura into a more caudal orientation, and placing alar batten grafts to
provide structural support and prevent collapse.
• The internal nasal valve is formed by the junction of the septum and the upper lateral cartilages.
The angle formed should be a minimum of 10 to 15 degrees to maintain patency

TIMING OF RHINOPLASTY
Divided based on surgical timing: primary, intermediate, and secondary.
Primary rhinoplasty:
Performed at the time of cleft lip repair. The typical age of cleft lip repair is 2–3 months old
Intermediate rhinoplasty:
Performed at age 5–11 years old, typically between 4 and 6 years old before patients attend school.
Secondary or definitive rhinoplasty:
Generally undergone after completion of facial growth, which differs based on gender.
For females it is usually 14–16 years of age, while males it is later at 16–18 years of age

Armamentarium
retractors
osteotome
scissors
rasp

Surgical Management of Basic Nasal Deformities

Surgical Techniques involve correction of :
• Nasal Septum deviation
• Dorsal hump deformity
• Nasal tip
• Wide Alar base

EXTERNAL (OPEN) RHINOPLASTY APPROACH
• The external rhinoplasty approach to the nose provides maximal exposure of the lower
lateral cartilages, upper lateral cartilages, middle nasal vault and bony nasal vault.
• The increased exposure facilitates accurate suture placement and fixation of cartilage
grafts.
• The external rhinoplasty approach also facilitates diagnostic capability and is a
tremendous aid in teaching rhinoplasty.

Open structure rhinoplasty
The open approach involves the use of a marginal and mid-columellar
incision
Marginal incision
• The incision is placed along the caudal margins of the LLC, starting
at the caudal margin of the medial crus, running along the entire dome
and extended laterally along the caudal margin of the lateral crus.
Columellar incision
• This is a transverse mid-columellar incision extending across to
connect the marginal incisions on either side.
Nasir A. Nasser; Chapter 28-Rhinoplasty; Oral and Maxillofacial Surgery for the Clinician; Springer

Modifications of the columellar incision
– Rethi transcolumellar incision 1931
(across the apex of the nostril aperture)
– Sercer “nasal decortication” approach 1957
– Goodman modifcation mid columellar ‘V’ facing upwards 1952
– Johnson & Toriumi inverted ‘V’ midcolumellar incision
– Stair-step mid columellar incision (Bahman Guyuron)

Open rhinoplasty
Dean M Torium, Daniel G Becker; Rhinoplasty dissection manual; 1999

Closed technique:
• The main advantage of this technique is the lack of any external scars.
• The surgeon should be experienced in rhinoplasty surgery if any significant tip plasty is
required.
• It is much more difficult to do cartilage grafting and suture techniques precisely with this
approach.

Incisions for the endonasal / closed approach
• Intercartilaginous (limen-vestibular) incision
• Intracartilaginous (trans-cartilaginous/cartilage splitting)
• Infracartilaginous (alar marginal) incision
• Septal transfixion incision - partial/full
• Pyriform rim incisions for access to the lateral nasal wall

Closed rhinoplasty:

Closed Rhinoplasty Open Rhinoplasty
1. Partial transfixion incision
2. Intercartilaginous incision
3. Septoplasty if required
4. Turbinate modification if required
5. Dorsal reduction
6. Lateral nasal osteotomies
7. Marginal incision
8. Delivery of lower lateral cartilages
9. Tip plasty
10. Alar base modification
11. Closure, taping, and splinting
1. Columellar incision
2. Bilateral marginal incisions
3. Skeletonization and 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. Turbinate modification if required
8. Lateral nasal osteotomies (micropuncture technique)
9. Tip plasty
10. Alar base modification
11. Closure, taping, and splinting
SEQUENCING IN CLOSED VS OPEN RHINOPLASTY

Nasal Septum
• The nasal septum is formed by both bone and cartilage.
• The ethmoid and vomer provide bony support posteriorly.
• The quadrangular cartilage provides support anteriorly
Deformities of Nasal Septum
Septal deformities depend on alterations in the growth and direction of growth of the septal cartilage

Classification of septal deformites :
Congenital:
Acquired:
• Developmental: midline dermoid cyst, short nose/long nose
• Post traumatic: bent nose/crooked nose
• Iatrogenic
Incorrect or aggressive rhino/septal surgery
• Lefort I maxillary impaction with inadequate trimming of septum
Cocaine misuse: Destruction of cartilage and bony septum

Deformities of the nasal septum may present clinically
1. Dorsal excess may present as a tension nose.
2. Dorsal deficiency causes concave or Saddle nose.
3. Caudal excess causes increased columellar show.
4. Caudal deficiency leads to columellar retraction.
5. Lateral angulation of the septum is seen as a bent nose.
6. Both lateral & AP curvatures give a twisted nose/
crooked nose.
7. Septal perforations and collapse may lead to a variety of
deformities.

Surgical Approaches
Septoplasty may be performed in conjunction with a formal rhinoplasty using an open or closed
approach.
Closed approaches for septoplasty include;
1. Endonasal caudal vestibular access via a right or a left hemi-transfxion incision
2. Bilateral septal transfxion incision

SEPTOPLASTY WITH CARTILAGE HARVEST
• Make a hemitransfixion incision along the caudal
border of the cartilaginous septum with a no. 15 blade
to gain access to the caudal septum.
• With a no. 15 blade, small, sharp -pointed scissors, or
other suitable instrument, incise the perichondrium of
the septum adjacent to the caudal septum on one side .
• Perform a subperichondrial dissection along the lower
half of the septum to allow harvesting of septal
cartilage.

• If the septum needs any shortening, now may be a
good time to perform selective excision of the caudal
aspect of the septum
• If rotation of the nasal tip is necessary, a superiorly
based triangle of caudal septum can be excised.
• For an obtuse nasolabial angle, the posterior septal
angle can be trimmed .
• For a tension nose deformity or hanging-columella
deformity, the entire caudal septum may need to be
trimmed.

Dorsal Hump Deformity
Most common problem
Based on the anatomical units involved
1. Osseous/bony hump - the bony vault,
2. Cartilaginous hump - cartilaginous middle vault with septal and upper
lateral cartilages
3. The osseocartilagenous hump - combination of the two.

Types:
True humps - may occur isolated or may occur in conjunction with other nasal
deformities.
Pseudohump - relative appearance of a dorsal hump, the appearance may be due to
a high anterior septal angle, supratip prominence or tip ptosis.
Dorsal Hump Reduction (Profle Lowering)
The procedure for dorsal hump reduction (profle lowering) is facilitated by two
important steps, namely,
(1) Bony hump removal and
(2) Cartilaginous hump removal.

Bony hump removal
• Expose the cartilaginous dorsum with a Converse retractor
• Next, beginning at the osseocartilaginous junction and proceeding caudally, incise the
cartilaginous dorsum at the planned level of initial excision
• Under direct vision, place an osteotome against the bony hump at the osseocartilaginous junction
• Controlled two-tap technique, incise the bony hump with the osteotome

• Remove the hump with a hemostat or similar instrument
• When executing hump excision, preserve the underlying nasal mucoperichondrium.
• The nasal mucoperichondrium provides support to the upper lateral cartilages and helps decrease
the risk of inferomedial collapse of the upper lateral cartilages after hump excision
• The bony margins should now be smoothed with a rasp by using few but firm strokes. An
alternative to the manual rasp is a powered reciprocating rasp or sheathed burr

Tip Plasty
• The nasal tip is the centre of focus for both nasal anatomy and aesthetics.
• It is a very important anatomical subunit and can be most challenging to refne surgically.
• Nasal tip deformities may show varied morphology and diverse clinical presentations.
Types of tip deformities
• Wide
• Bulbous
• Over projected
• Under projected
• Over-rotated (piggy nose/toffee nose)
• Under-rotated (ptotic tip)
• Asymmetric

Placement of Columellar Strut
• The placement of a rectangular cartilage strut between the medial crura can improve tip
support and augment tip projection.
• A columellar strut also can be used to correct buckled medial or intermediate crura or to
increase columellar show.
Placement of Columellar Strut via an External Rhinoplasty
Approach
• The area between the medial crura is dissected to create a
pocket to place the strut. The rectangular cartilage strut
typically measures 8 mm to 12 rnm in length, 3 mm to 4 mm
in width, and 1 mm to 2 mm in thickness.
• The strut is most typically fashioned from harvested septal
cartilage, but also, when necessary, from auricular cartilage,
and at times from rib cartilage.
• The strut is positioned so that it sits above (without extending
to) the nasal spine

• It is preferable to leave a small soft-tissue pad between the strut and the nasal spine.
• The strut should not extend above the intermediate crura.
• It is secured to the medial crura with several absorbable mattress sutures (e.g., 4-0 plain gut, Keith
needle) placed through the vestibular skin.
• Asymmetries of the lower lateral cartilage (LLC) may be improved with placement of the strut.

Managing the Wide Ala
The normal width of the ala falls within or just beyond an imaginary vertical line dropped from the
medial canthus to the upper lip.
Causes:
It may also be wide in patients with congenital anomalies like cleft lip and palate.
Wide alar base may also be due to iatrogenic causes like
1. After a Le Fort 1 maxillary advancement or impaction surgery
2. Injudicious rhinoplasty with loss of tip projection due to loss of septal support
Clinical Features
• Patients with a wide alar base exhibit a nose that looks fat and broad
• Alar columellar line may be straight and
• An associated wide nasal tip.
• In the basal view, the nose presents with reduced tip projection and short or distorted columella.
• The alar side walls show increased bulk and increased fare and the alar insertion into the
nasolabial area may be horizontal or oblique.

INTERNAL NOSTRIL FLOOR REDUCTION
• In patients requiring minimal alar reduction, excision
of a wedge of epithelium and soft tissue from the
nostril floor only is done.
• No medial repositioning of the alar-facial junction is
effected.
• The scar is effectively hidden within the nostril floor
WEDGE EXCISION OF NOSTRIL FLOOR AND SILL
• Further reduction of alar flare is accomplished by
carrying the incision across the sill into the alar- facial
junction 1 mm to 2 mm above the alar-facial crease.
• Reduction of flare as well as slight reduction of the alar
bulk is effected

ALAR WEDGE EXCISION
• If the alar development is excessive and bulbous ,
excision of a wedge of ala at the alar-facial junction 1
mm to 2 mm above the alar-facial crease
• Reduction of the overall length of the alar sidewalls
occurs
• Ideal in the reduction of the alar flare created when
correcting the overprojecting tip.
SLIDING ALAR FLAP
• More substantial alar reduction with medial
repositioning is effected with a generous incision above
the alar- facial junction with various degrees of alar
excision.
• A backcut placed 2 mm above the alar-facial junction
allows the alar flap to slide medially, narrowing the alar
base significantly.

• During the first 48 to 72 hours, the patient is instructed to keep the head of bed elevated at 45
degrees and use a chilled gel eye mask to help minimize postoperative swelling.
• The drip pad under the nose is changed as often as necessary until the drainage stops, at which
time it can be discontinued. Intranasal splints are removed in 2 - 4 days.
• Any manipulation of the nose, including rubbing, blotting, or blowing, is discouraged for the
first 3 weeks postoperatively. Sneezing should be done through the mouth during this time.
• The sutures and external nasal splints are removed at the initial visit on postoperative day 5 to 7.

• The patient is encouraged to breathe through the mouth if there is
difficulty with air passage through the intranasal splints.
• During the first 2 weeks postoperatively nasal congestion should be
treated with the use of normal saline nasal spray and over-the-
counter oxymetazoline nasal sprays.
• The patient is instructed to avoid letting anything, including
eyeglasses, rest on the nose for at least 4 weeks.
• Any contact sports or activities that may cause direct trauma to the
nose are prohibited for at least 4 to 6 weeks after surgery.

Complications
Divided into early, late, and technical complications.
Early Complications
These complications tend to present within the first week after surgery.
Postoperative hemorrhage/hematoma
• Bleeding-related complications such as epistaxis or hematoma are the most
common complications encountered following rhinoplasty, with incidence
reported to be 0.2% to 6.7%.
• Bleeding is most commonly from traumatized nasal mucosa and incision sites
and typically responds well to head elevation, topical decongestants such as
oxymetazoline, and nasal pressure to the anterior septum as needed.

• Packing with absorbable (Surgicel, Gelfoam, NasoPore) or nonabsorbable (Rhinorocket,
Merocel) options can be used and removed in 2 to 4 days if necessary.
• If bleeding persists despite this, trauma to a branch of the sphenopalatine artery must be
considered.
• Such serious bleeding is uncommon and occurs in less than 1% of patients.
• In recent years, there has been growing interest in the use of tranexamic acid, an
antifibrinolytic agent, to reduce bleeding in a variety of surgical procedures.
• Hematomas of the nasal soft tissues or the septum following rhinoplasty must be drained,
which can typically be done in the office.
• If located in the septal mucosal pocket, hematomas can lead to cartilage necrosis, loss of
dorsal support, and a saddle nose deformity.

Infection
• Infection following rhinoplasty can range from a mild soft tissue cellulitis to an
abscess, or ultimately to a severe complication such as brain abscess or
meningitis, although exceedingly rare
• Cellulitis can be adequately treated with oral antibiotics and observation,
whereas suspected abscesses of the soft tissue envelope or septum require
drainage and potentially intravenous antibiotics.
• The use of perioperative antibiotics in rhinoplasty has continued to be a source
of variability among surgeons. Although many rhinoplasty surgeons use
antibiotics in the perioperative setting, the details of duration and benefits are
not clearly known.

Complications associated with rib cartilage use
• Complications with autologous rib cartilage use are related to both donor site issues and more
often recipient site issues.
• The most serious complication at the donor site is pneumothorax (0.1%), whereas pleural tears
and breeches without pneumothorax are more frequently reported (0.6%).
• The most common long-term donor site complication was scarring, reported in 2.9%.
• To minimize the impact of any scarring, using a limited incision length or selecting an
inframammary incision can be beneficial, particularly in female patients.

Soft tissue complications
• Contact dermatitis related to adhesives used for nasal taping and
dressing applications can be observed, and all patients should be
queried for any known adhesive allergies before surgery.
• If encountered, this can typically be managed with topical cortisone
and gentle cleansing.
• The blood supply is found in the deep fat layer above the nasal
superficial musculoaponeurotic system, and thus dissection must
occur below this layer to maintain safe perfusion of the soft tissue.

• Vascular compromise can also occur without sacrifice of the vessels
directly, but by either excessive internal or external compression.
• Internal compression can be seen with significant dorsal augmentation
approaches, with rare cases reported. Alternatively, external compression
from tight nasal taping and splinting, most frequently with metal splints,
has been associated with nasal skin necrosis as well.
• It has thus been suggested that the more malleable thermoplastic splints
with pores in it can better accommodate postoperative edema and prevent
excessive compression.

Late Complications
• Late complications tend to occur in the weeks to months following surgery, and oftentimes
even years later.
• These complications are often more gradual in onset and present in continued followup with
patients.
Unfavorable scarring
• Unfavorable scarring includes hypertrophic scarring and keloids, hyperpigmentation, or
notching irregularities.
• Certain patients are predisposed to hypertrophic scarring, especially those with darker skin
pigmentation or a personal or family history of scarring. Closure must be meticulous and
tension free to minimize this complication.
• If keloids do occur, they can be treated as they would at other locations with intralesional
steroid and/or 5-fluorouracil injections.

Technical complications
Septal perforation
• The reported incidence rates of septal perforation in the
literature vary from 0% to 2.9%.4,5
• This complication typically results from opposing mucosal
tears obtained during cartilage harvest.
• Prudent dissection of the mucoperichondrial flap to avoid
unnecessary tears, as well as closure of at least one side in the
case of any opposing tears, will help to prevent this
complication.

Saddle nose deformity
• The saddle nose deformity is a known
manifestation of middle vault collapse
• This deformity is commonly due to loss of middle
vault support following overly aggressives
rhinoplasty, or septal perforation resulting from
iatrogenic, neoplastic, infectious, or
granulomatous etiologies.
• Correction and prevention require restoration of
the dorsalcaudal support using grafting materials,
frequently from costal cartilage or other sources.

Open roof deformity
• In an open roof deformity, following resection of the bony
dorsum, the nasal bridge appears flat and wide, in a trapezoidal
shape.
• This appearance is a result of gaps remaining between the
septum and each nasal bone.
• To correct this, lateral osteotomies must be performed and
adequate medialization of the nasal bones must be ensured.
• Incomplete osteotomies that do not allow for full mobilization
of the bones will lead to persistent open roof and unsatisfactory
outcomes.

Inverted V deformity
• Aggressive resection can lead to dissociation of the upper lateral
cartilages from the caudal margin of the nasal bones, which then
creates the shadow effect for which the deformity is named.
• To maintain the natural brow-tip esthetic line, spreader grafts
and suture resuspension of the upper lateral cartilages to the
septum are important
• This will help prevent the inferomedial migration of the upper
lateral cartilages and avoid development of the inverted V.

Pollybeak deformity
• This deformity is caused by the relative underprojection of the
nasal tip compared with the projection of the dorsum
• Most frequently, insufficient lowering of the cartilaginous
dorsum, particularly at the anterior septal angle failure to
restore adequate tip support can lead to eventual tip ptosis
• Development of scar tissue in the supratip region following
dorsal reduction
• This can often be addressed with localized steroid injections in
the office, thereby avoiding the need for revision rhinoplasty

Rocker deformity:
• The rocker deformity is a complication following
osteotomies in which the nasal bone inferior to
the osteotomy sinks relative to the bone superior
to the cut.
• This deformity may occur when osteotomies are
carried out superior to the medial canthus.
• In these cases, steps must be taken to camouflage
the often visible bony step off or replace the bone
and wait until the bone healsbefore attempting
further osteotomy

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