Dr. Rahul VC Tiwari - Fellowship In Orthognathic Surgery - Jubilee Mission Medical College Hospital and Research Center, Thrissur, Kerala - Rhinoplasty

RHINOPLASTY
THE ART AND SCIENCE
11/06/17 06:33 PM rahul tiwari / rhinoplasty / 140 1

PATIENT SELECTION AND EVALUATION
• The decision to perform a rhinoplasty carries great
responsibility.
GOALS:-
1) TO achieve an aesthetic result
2) to have a satisfied patient

EXAMINATION AND AESTHETIC
EVALUATION
• THIS must begin with an evaluation of the complete face before
focus on the nose.
• The face must be examined both at rest and in motion.
FULL FACE VIEW
• An imaginary vertical line is traced from the hair line to the
menton dividing the face into two halves.
• the horizontal line is traced at the level of medial canthus.
• these to lines constitute the axis of the face and are called the
midface vertical and horizontal lines.

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• Four horizontal lines are traced
1. at the hair line
2. at the supra orbital notch
3. at the base of the nose
4. at the tip of the menton
An extra line is traced at this stomion to divide the lower
third.

Lateral examination
• An imaganary horizontal line corresponding to the frankfort horizontal
plane is traced.
• this line extends from the centre of the external auditory channel
to the inferior orbital rim, or from the lower limit of the tragus to the
junction of the lower lid and the cheek
• A vertical line perpendicular to the frankfort plane, is traced from the
supra orbital notch
• In a well proportioned face, these lines cross the upper lip at the level
of the columellar base
• The horizontal lines crossing the glabella and the sub nasale are
traced to present a lateral view of the three thirds of the face.

NASAL AESTHETICS
• The nose must be examined in full face view and basal view and
from the two profiles.
• On the full face view, the nasal bridge is seen as two paralell straight
or slightly concave lines extending from the brows to the tip of the
nose
• The width of the bridge is roughly similar to the distance between the
tip highlights.
• The symetry of the dorsum is evaluated, as is the junction of the
nasal walls and the cheek.
• If the distance between the two junctions of the nose and cheek is
80% or more of the width of the alar base, the nasal pyramid must be
narrowed.

• On the full face view a small portion of the columella must be visible
at the center.
• An exaggerated caudal projection of the columella must be noted, if
it is not visible, the columella is retruded.
• The width of the alar base is assessed by drawing two vertical lines
from the medial canthus on each side.
• The ala cheek junctions should be located 1 or 2 mm inside the
canthal line.
BASAL VIEW
• From this viewpoint it should look like an eqilateral triangle.
• The length and the width of columella are noted.
• In the vertical axis of the triangle, two thirds correspond to the
columella and one third corresponds to the tip lobule.
• The lower third of the columella should be wider, if it flares too much
the foot plates need defatting.

• now the nose is examined in profile.
• The frontonasal groove is examined, this depression of 4 to 6 mm,
called the nasion, is located at a point between the upper border of
the tarsal plate and the upper lid margin.
• If a straight line is drawn from the nasion to the most prominent
point of the nasal tip, the dorsum should be about 2mm behind the
line, this difference correspons to the tip prominence and supratip
break.
• The nasal length is measured from the nasion to the tip prominence,
and the nasal projection is measured from ala cheek junction to the
tip.
• As a general rule, a 1 to 0.6 ratio between the length and anterior
projection is adequete.

• Tip projection is assessed by drawing a vertical line that passes in
front of the upper lip and crosses the alar tip line.
• The projection is exaggerated when 60% or more of the tip is in front
of the vertical line and viceversa.
• On the profile view, the columella should be about 4mm lower than
the alar margin.
• The nasolabial angle is then evaluated to determine the need for tip
rotation.
• Tracing a line that follows the lower alar margin, the nasolabial
angle is measured at its intersection with a vertical axis.
• An aperture of 95o
to 105o
is adequate for females it should around
90o
for males

SURGICAL ANATOMY
• Bony framework
• The bone is skeletal framework if the nose is composed of paired nasal
bones and ascending (frontal) process maxilla.
• The joint nasal bones are thick cephalomedially but are extremely thin
has the extend Infero laterally.
• The cephallic portion articulates with the frontal bones at the nasao frontal
suture and laterally with the maxilla at the naso maxillary suture.

• Lateral osteotomies to naro the nose may be un necessary and
even contra indicated.
• If the lateral osteotomies are deemed necessary, the must be
executed as low as
• possible on the ascending process of maxilla to avoid narrrowing of
the nose.
• There is a wide range of normal variation in the height, length and
width of the
• nasal bones

• 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.

CARTILAGINOUS FRAME WORK
Upper lateral cartilages
• The upper lateral cartilages form an angle of 10o
- 15o
with
the anterior septal edge.
• This angle constitute the nasal valve, which widens and narrows
under influence of respiration.
• Usually, the cephallic edge of the alar cartilage overlaps the lower
edge of the upper lateral cartilage by 1 to 3 mm.
• Between the cartilages there is a fibro aponeurotic connective tissue
that represents one of the support for projection of tip, this weakens
with edge leading to dropping of the tip.

ALAR CARTILAGES
• There is infinite variety of combinations in the shape and size of
the alar cartilages.
• The alar cartilages have an arch form that is made of 3 sections.
1. Medial crus
2. Middle crus
3. Lateral crus
• The transition between the medial and lateral crura is called the
dome and is the site of highest projection of the teeth.
• The two arches formed by the alar cartilages are attached to each
other at the level of medial crura and separate at the level of
domes.
• The divergence at this level is responsible for the width of the tip if
it is more bifidity of the tip occurs.

• The medial crus extends anteriorly and superiorly
toward the dome area.
• Inferiorly foot plates face outward and flare laterally to
your variable extent as they embrace the caudal
septum.
• At the collumella, the medial crus lies intimately
subadjacent to the skin, and loose areolar tissue
provides an inter crural attachment.
• The lateral crus extend obliquely and posteirorly
towards the piriform apperature, it is firmly attached to
the accessory cartilages by a fibrous ligament, forming
an arch that follows the lateral wall of the nostril.

• The shape of the lateral crus is more significant than
its size, the resection of its cephalic edge reduces the
lateral bulge, producing a narrower and more refined
tip, it also allows cephalad rotation.

Nasal septum
• The septum is a vertical structure made of thin bone
and cartilage the devides the nose into two separate
cavities.
• The anatomical components of the septum include the
nasal spine of the frontal bone, the perpandicular plate
of ethmoid, a portion of medial segments of the nasal
bones, vomer, a nasal crest of the palatine bone, nasal
crest of maxilla, pre-maxilla, and nasal spine, the
septal cartilage.
• All these septal components are paired except vomer
which may be bilaminar because of its dual embryonic
origin.
• Significant deviation in the ethmoid bone produces
posterior airway obstruction.

• the vomer is the basis of the bony septum, articulating
with the nasal crest of the maxilla and palatine bone
below, with the crest of the sphenoid bone behind, and
with the septal cartilage in front.
• The septal cartilage the most important component of
the nasal septum.
• The most caudal portion of the septal cartilage, along
with the flared wings of the upper lateral cartilages that
firmly attached to it and give form and support to the
middle third of the nose.
• Caudally the anterior septal angle can be identified and
palpated by depressing the nasal tip.

Skin of the nose
1. Skin
2. Superficial fatty layer
3. Fibro muscular layer with superficial and deep facsia.
4. Deep fatty layer
5. Longitudinal fibrous sheet with periostium,
perichondrium and ligaments of nose.

Muscles
1. Levators, which shorten the nose and dilate the
nostrils, musculus process, musculus levator labil
superioris alaeque nasi, and musculus anomalus nasi.
2. Depressors, which lengthen the nose and dilate the
nostrils, alar nasalis and musculus depressor septi
nasi.
3. Compressors, which lengthen the nose and narrow the
nostrils, transverse nasalis and musculus compressor
naris minor.
4. Minor dilator, musculus dilator naris anterior

Vascular supply
• The Blood supply is from branches of external carotid
ophthalmic and infra orbital artries.
• The branches of facial artery vary widely, such as
angular artery (60%), superior labial artery (18%),
inferior labial artery (22%)
• The main arteries and nerves of the external nose lie
beneath the fibromuscular layer
• The venous network ; the frontomedian region of the
face belongs to the facial vein and orbitopalpebral area
belongs to the opthalmic veins
• Lymphatic drainage into the sup-mandibular notes.11/06/17 06:33 PM rahul tiwari / rhinoplasty / 140 35

Nerve supply
• The skin of the nose is innervated by the branches of
trigeminal nerve, the root and dorsum by the opthalmic
division and nasal ala by the maxillary division
1. Infra orbital nerve
2. Anterior ethmoidal nerve
3. The infratrochler nerve
4. The inner vault by the nasocilary and spheno palatine
ganglion.

• For laterla osteotomies use of the percutanious route is
indicated.
• A 2 mm chisel is introduced through the skin about 3 to
4 mm below and medial to the canthus
• Maintaining the osteotome perpandicular to the bone, a
high to low osteotomy is made, cutting 5 to 6 separate
point beginning at the lateral edge of the nasal bone
and following thorugh the ascending process of maxilla
to the piriform edge.
• This maneuver is performed with care so that chisel
barely cuts through the full thickness of the bone,
reserving the integrity of the nasal mucosa.
OSTEOTOMIES

• Moderate continuous pressure is then applied with the
thumb, forcing the nasal skeleton medially until the
bones are slowly displaced to the mid line.
• With this maneuver a green stick fracture is produced.
• There is no need to suture this small 2 mm incision cast
is given.
• Usually cast is changed on fifth post operative day.

Case
• This 20 year old women presented with a moderatly
vide and slightly deviated nasal pyramid, a slight dorsal
convexity, and some bulging of the ala cartilages.
Surgical Plan
1. Septoplasty to correct the nasal deviation
2. Minimal dorsal resection
3. Trimming of the cephallic edge of the ala cartilages
4. Lateral osteotomies and infracture

• All types of materials such as metals, mineral oils,
plastics and homo and hetero grafts are used but are
discarded due to intolerence and resorption and erosion
through skin.
• Preferred donar tissues are cartilages and bones.
1. Nasal Septum
2. Ear concha
3. Costal grafts
4. Parital bone
5. Temporalil muscle facia
AUGMENTATION TECHNIQUE

Nasal Septum
• A mucosal incision parallel to the caudian edge is made an
one side. The mucoperichondrium is carefully dissected on
both sides of the cartilage.
• The vertical incision is then made on the cartilage parallel
to the caudal edge and 6 to 8 mm posterior to it. The
incision in the cartilage begins inferiorly at the junction with
the nasal spine and stops superiorly 6 to 8 mm from the
anterior edge so that L shaped portion of septum always
remains intake.
• To obtain a larger graft the septal discetion must be
extended posteriorly to the vomer and 2 cuts made parallel
using mayo scissors.
• This contains bone and cartilage also.

Ear Concha
• To harvest this graft we use a posterior incision near the
auriculomastoid fold.
• The skin is reflected, exposing the convex aspect of the
concha.
• The cartilage is then dissected from the conchal skin with
fine blunt scissors.
• The skin is then sutured and is packed with wet cotton for 3
days.
• To avoid injuring the external skin, the left index finger of
the free hand is held on the concha while the knife cuts
from the posterior aspect.11/06/17 06:33 PM rahul tiwari / rhinoplasty / 140 53

Costal grafts
• A five cm sub mamarry skin incision is use to harvest the
rib cartilage in females, the incision is lower on the thoracic
wall in males.
• A full thickness section of the fifth costal cartilage is
dissected including a portion of the rib 5 to 6 cm in length
reserving the condrocostal joint.
• The periostium is always preserved on the convex
(External) side of the bone, this is achieved by making two
parallel incision on the periostium at the superior and
inferior borders of the rib.
• Any remaining cartilages used can be packed in the same
incision and closed, these can be used for secondary
corrections.

Parietal Bone
• This membranous bone similar in origin to the facial skeleton
would undergo less resorption as a graft.
• Satisfactory long term results may be related more to the fixation
methods that use metallic screws.
• To obtain this graft 8 cm scalp incision is made on the parietal
area 1 to 4 cm lateral to the vertex.
• For safety reasons it is better to stay 2 to 3 cm lateral to the
sagital suture to avoid perforating the vessels.
• The periosteum is elevated then usually 1.5 x 5 cm bone is
drilled with air driven bur, until cancellors bone is reached
• Then short curved osteotome is used to separate the 2 cortical11/06/17 06:33 PM rahul tiwari / rhinoplasty / 140 58

Temporal muscle facia
• A 4 cm vertical incision is made on the scalp of the temporal
area.
• Then exposing the aponeurosis of the temporalis muscle, to
parallel incision are made on the fascia and a segment of 12 mm
x 5cm long is dissected.

The Projection
• The anterior of projection of the nasal tip is determined
primarily by the size of the alar cartilages.
• 1st
Chapter
Over Projection
• The tip can be considered as a structure formed by 2
arches. Each arches supported by 2 pillars – the medial and
lateral crus.
• The lateral crus as fibrous and perichondrial attachments
with the sesmoid cartilages, which extend laterally in to the
piriform fossa.
• This ring works as a unit providing support to the tip.
THE TIP
Contd..

• If one of the pillars is shortened the height of the arch is
decreased without disturbing the architecture of the dome,
sometimes both the pillars can be shortened.
• The two medial crura are attached to each other in the
columella and function as a unit, so tripod concept can be
applied to the tip.
• Dorsal augmentation may be indicated, and in some cases it
will be sufficient to solve the problem. Dorsal over resection
will automatically exaggerate the deformity.

1. An intracartilaginous incision is made, including only
mucosa and perichondrium. Cephalad flap dissection and
trimming the upper edge of the alar cartilage is followed
by wide retrograde skin undermining. This eliminates the
“Splinting effect” of the skin and allows draping of the
cutanious cover. by this the tip projection is slightly
decreased, and the restraining effect of the
intercartilagenous ligament is eliminated using the
resection of the cephallic edge.
2. The intracartilagenous incisions are extended along the
caudal edge of the septum, completing the transfixion.
The liberated medial crus automatically moves posteriorly
as a result of the severance of its soft union with the
septum.

3. The vestibular incision is extended a few mm laterally, and
the lateral crus is exposed in continuity with the
accessory cartilages. a 4 mm section is resected at the
junction of the alar and accessory cartilages.
4. If more correction is necessary, a section of medial crus is
resected at the base of the columella and alternating in
complete cross cutting of the alar cartilages at the dome
is done to prevent the widening of the tip resulting from
lateral displacement of the doms.

Case
• This patient requested nasal reduction. She had a straight
dorsum with over projecting tip covered by thin skin.
• Wide lateral crura produced tip fulness.
• Nasal labial angle was 80 ˚
Surgical plan
1. Intra cartilagenous and trans fixing incision
2. Minimal dorsal reduction
3. 6mm resection of the upper edge of the lateral crura
4. 5 mm resection at the juction of lateral crura and
accessory cartilagenous.
5. Medical and lateral osteotomies.

Broad tip
• The fullness is determined by the shape and size of alar
cartilages and skin thickness.
• It is preferred to preserve the intergritive of the arch
shape by multiple, alternative in complete cross cuts of
the ala at the level of the dome.
• The cartilages are exposed through an infra cartilagenous
incision following the caudal edge of the ala cartilage.
• Full thickness cuts are made across the width of the
cartilage without competing the transition this will cause
elasticity of the door.
• Splint is the must11/06/17 06:33 PM rahul tiwari / rhinoplasty / 140 72

Case
• This patients notes is a typical example of a bulbous boxy
tip produced by strong convex lateral crura and flaring,
widely seperated domes.
• The pyramid, the skin, and the alar bases are adequate.
Surgical Plan
1. Intra cartilagenous incision and exposure of the domes
2. Trimming the cephalic edge
3. Alternating in complete cross cuts of the alar dome
withour resection.

Plunging Tip
• Trimming the cephalic edge of the lateral crura
automatically severs intercartilagenous ligament and
allows the narrowed alar cartilage to rotate superiorly and
overlap with the upper lateral cartilage.
• When the lower lateral cartilages are obliquely located,
pointing downwards, a very considerable cephalad
rotation is required.
• The arch formed by lateral crura attached to the
accessory cartilages that extend to the piriform fossa and
the floor is functional unit.
• Unless this arch is transected its memory will tend to
rotate the tip caudally.

• The angle formed by the columella and the upper lip is
a key point in nasal aesthetics, for females 95 to 105
and for males 90 to 95.
• The nasolabial angle is formed by a labial plane and a
columella plane that meet at the bace of the collumella.
• On the nasal side, the angle is formed primorely by the
position of the medial crura.
• Short medial crura decrease the anterior prominance of
the tip and allow the tip to rotate inferiorly, closing the
angle.
THE NASOLABIAL ANGLE

• The aperture of the nasiolabial angle is also influenced
by the position of the nasal spine and caudal edge of
the septum.
• A projecting nasal spine increases the aperture and a
retrusive spine results in acute angle.
• The second vector of angle is formed by the upper lip
• Its position and inclination are determined by volume
and position of the maxillary alveolar ridge and soft
tissues supported by the bone.
• Most of the surgical procedures used to modify
nasiolabial angle are therefore directed towards the
changing the position and inclination of the columella
plane.

Case
• This young female had a narrow, fine nasal pyramid
with prominent alar domes, a short columella, a
protruding upper lip and a nasiolabial angle of 65˚
Surgical plane
1. 6 mm of laterla crura were trimmed to allow tip rotation
2. Collumelar and tip septal grafts.

HUMP REMOVAL

• One of the first tasks during a rhinoplasty is to remove the hump if
one is present.
• The hump is made of bone and cartilage, and both components
must be carved down in order to eliminate the nasal hump.
• The squiggly red line on the nose shows the border between the
bony part and the cartilaginous part of the nose.
• The first task in removing the hump was accomplished by exposing
the cartilage and bone of the nose by making the incisions and
lifting the skin. The process of making the incisions and elevating
the skin is called "skeletonizing .

The tip of the scissors is pointing to the right lower lateral
cartilage, and the cartilage hump is colored in blue in the
diagram

• We make a cut in the cartilage hump with a scalpel. In
the diagram the location of the cut is indicated in red,
and the cartilage that comprises the hump, which will be
removed from the nose, is colored blue.

• It's not possible to estimate exactly how much hump
needs to be removed and make the cut precisely in that
location.
• In practice, start out by removing less hump than is
necessary. Then, as the operation proceeds, look
carefully at the nose and remove small additional pieces
of the hump until you get it just right. That piecemeal
approach avoids the problem of removing too much
hump initially.
• When we lift up the piece of cartilaginous hump that we
have incised, we see the white edges of some cartilages
that we have cut. That hump is shaded blue and
highlighted in white the edges of the cartilages that we
seem to have cut into when we incised the hump.11/06/17 06:33 PM rahul tiwari / rhinoplasty / 140 87

• note that once the hump is removed, when we look at
the nose, we should be able to see the top cut edge of
the septum all along the dorsum of the nose (green
arrow), as well as the top cut edges of the right and left
upper lateral cartilages along the dorsum of the nose
(black arrows).

• we can see the top cut edge of the septum (pink above
right), and the cut edges of the upper lateral cartilages
(blue).
•

• next task is to remove the portion of the hump that is
made out of bone, the part colored pink in the diagram.
• These pictures show you where the bony hump resides.
The red in the diagram above colors the bone that will be
removed to take down the bony hump.

In the nose above, the cartilaginous hump has already
been removed, and is in the process of removing the bony
hump with a chisel. In the diagram, the chisel is colored
blue, and the bone that will be removed is pink.

LONG NOSE

• noses can be shortened by addressing the length of the
septum.
• The triangular portion of the septum shaded light blue
will be excised during surgery, That is the portion of the
septum that was resisting the upward push of your finger
when you pushed up to shorten your nose.
• After that piece of septum is removed, the septum will be
shorter. Note that the longer black arrow indicates the
length of the septum before the excision, and the shorter
white arrow indicates the length of the septum after
removing the light blue piece. Because the septum is
now shorter, the tip of the nose rotates up (blue arrow),
shortening the nose.11/06/17 06:33 PM rahul tiwari / rhinoplasty / 140 98

• why we usually can't count on shortening the septum
alone to decrease the length of a nose?
• If, during surgery, you were to push on the base of the
nose in the direction of the reduced septum, the tip
would not elevate; you would feel resistance to its
motion. What's going on here?
• Inside the nose, there are many factors which influence
the nose's length. Possibly the most important factor is
the length and strength of the lower lateral cartilages.
• The right lower lateral cartilage is outlined in blue, with a
black arrow following down the middle of the cartilage.
The prodigious length of that cartilage is forcing the tip
down, making the nose appear long.

• The length and strength of that lower lateral cartilage is
straight-arming the tip of the nose down toward the
lip,creating a long nose.
• We shorten the lower lateral cartilage by cutting it
midway along its lateral arm and allowing the two
sections to overlap each other.
• The upper image in the diagram above is of the intact
lower lateral cartilage, and the lower image shows the
cartilage after it is cut and the two halves are allowed to
overlap, to slide across each other. The blue arrows
demonstrate the resulting length of the cartilage in each
case

• The length and strength of the lower lateral
cartilage, represented by the black arrow, holds
the tip down in the image above center. After
the cartilage is cut and overlapped, it no longer
has the power and length to hold the tip down,
and the natural elasticity of the skin allows the
tip of the nose to rise.

• using a concept called the "tripod model." In the image
above left, we see two solid beams, one blue and one
green. The beams are joined to each other at the red
dot. The black dots show where they are affixed to the
ground.
• Now, we have cut the green beam, overlapped the
pieces, and welded the pieces back together. Since the
beams are still attached to the ground (black dots) and to
each other (red dot), the blue beam rotates up as the
green beams are overlapped.

CLEFTS
COMMON FEATURES
• SHORT HEMI COLUMELLA
• COLUMELLAR BASE DEVIATED TO UNAFFECTED SIDE
• DECREASED PROJECTION AND LATERAL DISPL OF THE ALAR
DOME
• NO NASAL FLOOR
• OPEN ARCH OF NOSTRIL
• ALAR BASE DISPLACED LATERALLY
• AFFECTED ALAR CARTILAGE CAUDALLY DISPL
• DECREASED OR NO OVERLAPPING BETWEEN UPPER AND
LOWER LATERAL CARTILAGES
• ABNORMAL RELATIONSHIPS AMONG THE SKIN, CARTILAGE,
AND THE MUCOSAL LAYERS OF THE ALA.

UNILATERAL CLEFTS
• Nasal correction is performed at 2 months of age in
conjunction with lip closure.
• The lip is repaired with the rotation advancement tech, which
keeps the surgical scar at limit between the aesthetic units of
the lip and facilitates the repair of the muscle layer, this is imp
for the future shape of the nose cos the normally aligned
muscle fibres at the level of the nasal spine model the skeletal
position.
• Elongation of the hemicolumella is also obtained, and incisions
provide good access for the alar dissection.

• Once the lip incisions are made, the nasal dissection begins on the
medial side.
• With fine iris scissors entering at the base of the columella, the two
medial crura are separated from each other.
• This undermining is extended to the dome superiorly and under the
mucosa posterior to the columella.
• Entering through the lateral lip incision, the base of the ala is freed
from the maxilla.
• The dissection then proceeds subcutaneously to the nasal bones
and medially to the alar dome on the opposite side.
• Inf the alar cartilage is freed from the skin, extending the
undermining around the alar rim from the base of the ala to the
medial crus and continuing inside the nostril to the caudal edge of
the alar cartilage.
• At this point, the cart remains attached to the nasal mucosa only
and can be easily mobilized to a normal position

• The tip of the flap made by alar base is sutured to the lip and the
columellar skin ant and to the nasal mucosa posteriorly.
• To maintain the position of the cartilage 3 or 4 pull-out sutures are
used.( mc coomb)
• Using 5-0 monofilament nylon, a straight needle enters the skin at
the upper level of the undermined area, passes through the
cephallic edge of the alar cartilage, and comes out again near the
entry point around the glabella.
• Three sutures are necessary- at the vertex of the dome, at the
midsection of the ala, and at the tip of the lateral crus
• Pulling gently at the sutures, the ala is mobilized to normal position.
• The sutures are fixed to the skin with tape and are removed in 3
days.
• The medial rotation of the alar base and a 3 layered lip closure

SECONDARY CORRECTION OF UNILATERAL CLEFTS
• DECESENDED ALAR CARTILAGES
• DECREASED PROJECTION AND LATERALIZATION OF THE
ALAR DOME
• NOTCHING OF THE ALAR RIM
• ASYMMETRICAL NOSTRIL BASE
• SEVERE SEPTAL DEVIATION THAT INCLUDES ALL SEGMENTS
• DEVIATION OF THE NASAL PYRAMID

• Views of the patient showing nostril assymetry, the dome is less projected
laterally, and the wide nostril sill is on the cleft side.
• Infracartilagenous incision starting at the columella and following the caudal
edge of the alar cartilage

• The alar cartilage is seperated from the skin
• The skin undermining extends to the bones, to the contralateral alar
dome, and to the columella

• The second incission is made along the cephalic edge of the alar
cartilage, forming a composite flap made of mucosa and cartilage
with a median pedicle.
• The flap is elevated and rotated medially. A small rim incission is
made on the normal side to facilitate suturing of the dome

• The domes are sutured to eachother to achieve projection and
symmetry. The nasal mucosa is closed in v-y fashion
• 2 or 3 pull-out sutures are placed on the cephallic edge of the lateral
cartilage to raise it to its normal overlapping with the upper lateral
cartilage11/06/17 06:33 PM rahul tiwari / rhinoplasty / 140 115

• The alar base is rotated medially. The de-epitheliazed distal end is
introduced at the base of the columella
• This procedure included osteotomies and costal cartilage grafts to the
columella, tip, and piriform areas to camouflage midfacial retrusion.

PARANASAL AREA
• THE nose is supported on the face by the frontal bone superiorly
and by the maxilla laterally and caudally.
• The anterior projection of the nose is influenced to some extent by
the projection of its maxillary base, the convexity of the area around
the piriform fossae is important.
• The most common problem is flattening of the paranasal area that is
produced by the concave surface of the maxilla around the piriform
aperture.
• The lateral insertion of the alae, supported by the anterior aspect of
the maxilla, takes a more post position when the bone is less
prominent

SURGICAL TECHNIQUES
• Several materials such as silicone, polypropylene(marlex),
polymerized tetrafluorocarbon(proplast), and other alloplastic
materials have been used succesfully.
• Autogenous materials such as cranial, illiac, and rib bone grafts are
also used.
• The early result with onlay bone grafts is satisfactory, but the
rsorption of the bone graft is unpredictable.
• Prefer to use autogenous cartilage grafts, large pieces of costal
cartilage can be harvested through a small submammary incission.
these cartilages maintain their volume perm and can be carved
easily.
• The cartilage is carved in the form of a crescent 6 to 10mm thick at
the concave edge and tapering to the opposite convex edge.
• The length varies from 15 to 25mm in height and 10 to 20mm in
width.11/06/17 06:33 PM rahul tiwari / rhinoplasty / 140 119

• The graft is placed subperiosteally in the piriform area, its concave
edge paralell and very near the edge of the nasal cavity.
• The pocket may be desected through a small vestibular incission or
on the lateral side of the nasal vestibule.
• The pocket should only be large enough to accommodate the graft
in the proper position. If the pocket is made too large, it is convinent
to introduce a pull-out non-resorbable suture through the cheek skin
and then through the graft, coming out again at the cheek.
• This fixation is maintained for 2 to 3days with a tape, this prevents
the displacement of the cartilage.
• The inferior edge of the piriform aperture and the nasal spine may
also be retrusive, affecting the position of the nostril sill and the
upper part of the lip.

• It is then convenient to introduce another graft that is carved as a
curved bar 3 to 4mm thick and inserted subperiosteally across the
base of the nose in front of the nasal spine. The curvature of this bar
should correspond to the curve of the anterior aspect of the
premaxilla.
• Another indication of augumentation of the piriform area is to
camouflage the protrution of the alveolar arches
CASE:-
SURGICAL PLAN
• INTRACARTILAGENOUS INCISION
• 4MM RESECTION OF CEPHALIC BORDER OF ALAR CART
• HARVESTING OF COASTAL CARTILAGE GRAFT
• CRESCENT SHAPED GRAFTS INSERTED INTO PIRIFORM
AREA
• CART BAR INSERTED TRANSVERSLY INFRONT OF NASAL
SPINE
• CART GRAFT TO COLUMELLA
• CART GRAFT TO TIP

SPLINT
• profile line is ever so slightly concave,
without looking scooped-out (red line).
• The tip of her nose is strong, and it
projects out a little bit beyond the line of
the dorsum (blue arrow).
• The nose is adequately short (length of
the arrowed white line),
• an angle between the upper lip and the
bottom of the nose that is greater than a
90-degree right angle (green lines).
• The medial osteotomy was placed along
the purple line and the lateral osteotomy
was made along the brown line.11/06/17 06:33 PM rahul tiwari / rhinoplasty / 140 126

• The first task in applying the
dressing is to place tape tightly
against the nose. The skin had
been elevated from the nose during
surgery so that we could see and
alter the bones and cartilages, and
we tape the skin tightly back down
to help the skin adhere to the new
framework.
• The tape also keeps fluid from
collecting in a pool between the skin
and the underlying cartilages. The
body might replace a fluid collection
with scar tissue, degrading the
quality of the final result.11/06/17 06:33 PM rahul tiwari / rhinoplasty / 140 127

• Now the metal splint is placed.
• The underside is lined with a
white cloth tape that helps to
cushion the nose from the metal
of the splint.
• The lowest edge of the splint
(blue line and arrow in the
diagram above right) is above the
location where the nasal bone
was cut (red line and arrow).
Stated differently, the splint isn't
so big that it comes down to
cover that red line of the bone cut
on the side of the nose. Very
important

• Now that the bones have been moved,
• the splint, in red, is in place, and you can see
that the splint does not extend down to the level
of the osteotomy, the bone cuts, at the green
arrow.
• the splint hugs the moved bones, and will hold
them in their exact position as the nose heals
during the week after surgery.
• If the splint too long, and the bottom edge of the
splint drapes over the non-moved parts of the
bone, the upper portions of the splint are not
hugging the nasal bones as closely, and the
bones won't stay where they were placed.

FAILURES
• SCAR TISSUE:-Every nose responds to
surgery by making a layer of scar tissue
underneath the skin, but with proper
technique the scar tissue doesn't interfere
with the appearance of the nose and
doesn't stand in the way of achieving the
desired results
• operation will be to attempt to meticulously
carve away the scar tissue and find the
lower lateral cartilages underneath. This
task is not easy. The scar tissue hugs the
underlying cartilages tightly. It doesn't just
peel off. It is possible to tear the cartilages
in the process of finding them in this mass
of scar, or to fail to find them entirely.

• over-resection of tip cartilage:-When the tip cartilages have been
more severely over-resected, we must use the strut and grafting
techniques on tip support to help with the reconstruction.

LOST SURGEON
SYNDROME:-
• It looks as though the
surgeon was lost inside
the nose, and was just
cutting and removing
pieces atrandom. Think
this stuff doesn't happen?
• Above and below we see
noses for which our
working diagnosis is lost
surgeon syndrome. The
lower lateral cartilages
were modified
haphazardly.

SYNECHIUM
• patient has a bridge of
scar tissue that stretches
from the area of the
columella to the side wall
of the inside of the nose.
An unwanted bridge of
scar tissue like that is
called a synechium,
• a synechium is relatively
easy to excise, opening
the nostril up again.

ABNORMAL PROJECTIONS
• previous surgeon had placed a
cartilage strut in the nose, but he
placed it in an abnormal position,
not in the columella as would be
routine.
• This strut was placed below the
arch of the dome of the lower
lateral cartilage, and the strut
eroded through the cartilage to
poke out above it and deform the
tip of the nose.
• The strut is shaded blue in the
diagrams.

Even a "simple" hump removal won't go well in untrained or
inexperienced hands
• previous surgeon wasn't even able to carve down the cartilage and
bone of her hump smoothly11/06/17 06:33 PM rahul tiwari / rhinoplasty / 140 136

INCISSION MARKS

Dr. Rahul VC Tiwari - Fellowship In Orthognathic Surgery - Jubilee Mission Medical College Hospital and Research Center, Thrissur, Kerala - Rhinoplasty

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