This document provides an overview of the basic principles of rhinoplasty surgery. It discusses nasal anatomy including landmarks like the radix, rhinion, septal angle, and lower lateral cartilages. It covers surgical techniques for both endonasal and external rhinoplasty approaches. Key steps for various nasal deformity corrections are outlined such as hump removal, dorsal augmentation, and tip work. The document also lists common instruments used in rhinoplasty surgery.
2. Anatomy
Radix (nasion)
●Junction of frontal bones and
dorsum of the nose.
●Ideally projects 15mm anterior to
medial canthus, 11mm to corneal
surface. Or at the level of tarsal
edge / upper lid crease.
Rhinion:
●Junction of bony and cartilaginous
dorsum.
6. Surgical implications
●At the rhinion upper lateral
cartilages joins the septum to form
a single piece of cartilage.
●The attachment between ULC and
septum is fibrous near the septal
angle.
●Dividing this attachment during
rhinoplasty helps in straightening
incase of crooked nose deformity.
7. Nasal valve:
●Angle between the septum and
Lower border of upper alar
cartilage is called nasal valve.
●Even minimal Constriction at this
point can cause substantial
airflow obstruction.
●Ostiotomies for removal of hump
deformity can narrows nasal
valve.
●Preferring spreader graft over
ostiotomies can prevent this
complication.
8. ANALYSIS OF THE FACE
●Symmetry is assessed using midline facial landmarks: a line running through
the mid-philtrum of the upper lip, the midpoint of the glabella and the
midpoint of the chin indicates a symmetrical face.
●Analysis of facial proportions is performed using the ‘rule of thirds’ and the
‘rule of fifths’ to assess the face from a frontal view.
●Rule of thirds: landmarks defining each third are the trichion to glabella,
glabella to sub nasale and the subnasale to soft-tissue menton.
●The rule of fifths : ideal transverse proportions of the face vertically divided
into equal fifths, each fifth approximately equal to the width of one eye; the
alar base is equal to the intercanthal distance.
9. ●The nose ideally occupies one-third
of the length of the face and one-
fifth of its width
12. Analysis of the Nose
●Skin quality: thick / sebaceous /thin.
●Thin skin- minor irregularities are
easily detectable.
●Thick skin- refining and narrowing the
nasal tip can be challenging.
Length of the nose: nasion to nasal tip.
13. Tip projection:
●Measure of how far the nasal tip lies anterior to the face.
●Goode’s ratio : NA/NT = 0.55 to 0.60
●N= nasion
●A= Alar-facial groove.
●T= Tip
●< 0.55 = underprojection, >0.60 overprojuction.
14. Lip–chin relationship:
●The anterior surface of the upper and lower lips rest
on the nasomental line in an aesthetic face .
●When the chin lies posterior to this line-retrognathic.
●when it lies anterior to this line - prognathic.
●Retrognathic and prognathic chins gives illution of
over and under projected nose respectively.
15. ●Dorsum:
●Front view: Lateral esthetic lines / brow tip
line.
●smooth curvilinear line connecting the
eyebrow superiorly to the nasal tip inferiorly.
●any irregularities in this smooth curve
highlights sources of nasal deformity.
● lateral view : height of the dorsum is
assessed;
● men-straight line
● women- gently curves with a supratip break
delineating the dorsum from the nasal tip.
16. Top configuration:
●four tip-defining points identified by light reflection.
●These represents
1. Right and left domes.
2. supratip
3. infratip.
●Normally encounterd tip deformities: Boxy, bifid, bulbous and
amorphous.
18. ●Tip rotation: This
describes the position of
the tip along an arc with its
radius centred on the
nasolabial angle.
●The ideal dimension of the
nasolabial angle in men is
90–95°and in women is
95–105°.
19. ●Columellar show:
●The amount of visible caudal septum is
ideally limited to 3–5mm.
●This is the distance between
●two parallel lines drawn from the most
anterior and the most posterior parts of
the nasal vestibule.
●Greater columellar show may be due to
either
1. a hanging columella
2. Abnormalities in the alar margins such
notching or retraction
20. ●Basal view:
●The width of the alar base approximates to the intercanthal distance.
● The ratio of the width of the dorsum of the nose relative to the alar base
should be equal to 80%.
●The overall basal view outline conforms to an isosceles triangle with pear-
shaped nostrils lying at an angle of 45 ° to the vertical.
21. Inspection of internal nose
●Septum and lateral wall should be examined for any abnormalities and
assesment of donar cartilage sites.
●Assesment of external and internal nasal valves should be done.
FUNCTIONAL ASSESMENT OF NOSE:
●Nasal inspiratory peak flow, acoustic rhinometry and rhinomanometry can
be used as objective tests of nasal function and to quantify surgical results.
22. ●Septorhinoplasty can be performed under local or general anaesthesia.
●Local anaesthesia:
●Mixture of oxymetazoline and 4% lignocane is spary – nostrils before
entering OT.
●Sub mucosal injection of 1% lidocaine + 1:100000 epinephrine.
Anaesthesia
23. Infra orbital nerve block
●O.5ml LA injected through
vestibular puncture.
●This facilitates subsequent passage
of needle between the ingraorbital
foramen and medial canthus.
24.
25. ●Injecting at base helps to
anasthetise the tip before going to
give injections at alar margin.
26. ●Should inject at 4 points of alar
margin as shown in the figure.
●Judicious injection while directing
the Needle over the cartilage
Maximizes vasoconstriction and
minimizes deformity of alar
cartilages.
27.
28. Trans oral pterygopalatine nerve blocking
●Done through The greater palatine
foramen.
●Identified by dimple medial to the
3rd molar.
●Needle should not be inserted more
than 2.5cm in to the foramen – can
affect ON.
29. ●Most commonly under anaesthetized areas are
1. Posterior septum
2. High on the perpendicular plate
3. Underneath the nasal bones.
33. Hemitransfixation incision and
harvestation of graft
●Hemi transfixiation incision – through the one side of mucosa of caudal
septum.
●Provides access for septoplasty.
●Indicated in dislodged causal septum over Pre maxillary spine.
35. ●6mm dorsal strut and 1mm caudal
strut are preserved To support
external nose , when septal
cartilage is used in rhinoplasty.
36. Other Donar sites of cartilage harvestation
1. Ear( conchal cartilage)
2. Calvarial bone
3. Costal bone and cartilage
harvestation
4. Iliac crest bone
37. Intercartilagenous incisions
●Bilateral inter cartilaginous
incisions were made between the
upper lateral cartilages and alar
cartilage.
●Ideally 1mm above the Caudal
margin of upper lateral cartilage.
●Extends medially on to the nasal
valve area of septum to meet the
hemi/full transfixiation incision.
39. Complete exposure of dorsum
●Mckantey elevator is used to
elevate Periostium over nasal
bones.
●Small midline raphe of the
periostium at rhinion is divided with
scissors to place the alfricht
retractor.
●With the retractor in place the
entire dorsum can be exposed.
40. ●After complete exposure of dorsum
to tip, now surgeon can deal with
correction of
1. Hump Deformity
2. Radix reduction / augmentation.
3. Tip deformities
4. Ostiotomies and width
manipulation ( medial f/b lateral)
for Broad and crooked nose.
5. Dorsal augmentation
41. Advantages
●No external scar
●Limits dissection to areas of
interest
●Permits creation of precise pocket,
so that graft can be fits exactly
without need for fixation.
●pramotes healing by vascular
bridges
●Encourages accurate pre op
diagnosis and planning.
●Minimal postoperative edema
●Reduced operating time
●fast patient recovery
●Intact tip
●Allows composite grafting to alar
rims
Disadvantages
●Requires experience
●Prohibits simultaneous visualization
of operating field By teaching
surgeon and students.
●Does not allow direct visualise the
nasal anatomy.
●Difficulty in dissection of alar
cartilages.
43. ● External or open approach is firmly established and important
technique in rhinoplasty.
● Key advantage over endonasal approach is ability to access
anatomical deformities by direct inspection of nasal cartilages and
bony frame work.
● Allows bimanual sculpturing of skeletal components and applying
sutures and placements of grafts under direct vision.
● Historical aspects:
● First description about external incisions and open approach for
rhinoplasty is believed to have stemmed from India in 600BC.
● First external rhinoplasty via transcolumellar incision was done by
Reti in 1934.
● Goodman first advocated butterfly incision- a modified
transcolumellar Incision.
44. Indications of external rhinoplasty
• congenital deformities such as the cleft lip nose
• extensive revision surgery
• severe nasal trauma
• marked tip deformities including significant rotation
and projection issues
• significant septal deviations, especially where high dor-
sal deviations are present
• situations where assessment of the exact underlying
pathology is difficult.
45. Principles
●External rhinoplasty starts with bilateral incisions starting just anterior to
medial crura And extending from dome to the mid columellar region.
●Dissection in the subperichondrial and subperiosteal plane leaves as much
soft tissue as possible on the skin flap.
●Preserves skin flap viability.
●lower and upper lateral cartilages together with the bony dorsum can be
exposed to the nasofrontal angle in their undisturbed positions.
46. ●Division of the medial intercrural tissue offers access to the caudal septum
and premaxillary spine.
●By dividing the upper laterals from the quadrilateral cartilage,
●the whole of the septum is accessible from the cephalic as well as the caudal
aspect
● allows the treatment of nasal valve problems, dorsal septal deviations and
septal perforation repair.
47. ●As intercartilaginous incisions are not used,
the valve area is preserved and the scroll
area is not disrupted which is a major
mechanism for tip support.
●But the division of soft tissue over lateral
cartilages and disruption of medial
Intercrural ligaments may leads to loss of
minor supports of tip, Therefore some tip
ptosis should be anticipated in all surgeries.
The junction between the upper
lateral and alar cartilages is often a
continuous roll of cartilage – the scroll
58. Advantages
●Its unparalleled exposure and the ability to bimanually manipulate and
handle underlying tissues gives a major advantage to endonasal techniques,
particularly in more complex surgery, revision and post-traumatic deformity.
●It facilitates accurate resection and modelling of underlying bony and
cartilaginous components
● enables straightforward placement and suturing of graft material.
