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Rhinoplasty
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- 2. Introduction ⦿ Challenging procedurein facial plastic surgery
- 3. Historical aspects ⦿ Firstin India 600 b.C external and open approaches ⦿ 1887 - John orlando roe performed first intranasal rhinoplasty. ⦿ Rethi and sercer in 1934 developed transcolumellar inscisions
- 4. ANATOMY • Upper third •Middle third • Lower third
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- 9. Preoperative assessment ⦿ Considerfacial aesthetics ⦿ nasal function ⦿ Consideration of the patient’s motivations, anxieties and expectations ⦿ Analysis of the face ⦿ Analysis of the nose ⦿ Examination ⦿ Photography.
- 10. Patient ⦿ History ⦿ Expectations ⦿Body dysmorphic disorder ⦿ High risk patient SIMON ⦿ Ideal patient SLYVIA ⦿ Second opinion from psychiatrist
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- 12. • nasofrontal angle115–135 ° • nasofacial angle 30–40 ° • nasomental angle 120–132 ° • mentocervical angle 80–95 °
- 13. Analysis of nose ⦿Inspection of external nose ⦿ Inspection of internal nose ⦿ Palpation
- 14. ⦿Skin quality: ⦿ Thickand sebaceous--- refining and narrowing the nasal tip can be challenging ⦿ Thin skin--- minor irregularities are easily detectable
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- 16. ⦿ Saddle nosehump nose
- 17. ⦿Length of thenose:
- 18. ⦿ Ideal projectionis determined using Goode’s ratio, where a line drawn from the alar– facial groove to the nasal tip measures 0.55–0.60 of the distance from the nasion to the nasal tip. ⦿ A ratio less than this equates to an underprojected nose and greater than this corresponds to overprojection Tip projection:
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- 21. Tip abnormalities BROAD ,BULLOUS,SQUAREBALL TIP BIFID TIP UPWARDLY ROTATED TIP ASYMMETRIC TIP
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- 24. ⦿ Tip rotationColumellar show
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- 27. Aetiology ⦿ Nasal fractures– 40% of facial fractures ⦿ Injury – functional aesthetic problems ⦿ Chilhood/ adult fractures ⦿ Growth in facial skeleton more often asymmetric leading to appearance of a damaged nose without any prior history of trauma.
- 28. Types of nasalfractures
- 29. Stranc and Robertsonclassification
- 30. ⦿Lateral blows: ⦿ Simpledepressed nasal bone ⦿ Displacement of bony cartilage ⦿ Deviation of nasal axis in lower 2/3rd due to vertical fracture of septum. ⦿Frontal blows: ⦿ Fracture of tip of nasal bone ⦿ Injury to cartilagenous vault ---widening of bridge ⦿ Horizontal fracture of septum--- loss of height in middle third leading to saddle nose deformity.
- 32. Closed reduction within2-3 weeks
- 33. Types of rhinoplasty ⦿External --- open approach ⦿ Endonasal--- closed approach ⦿ Advantages of external rhinoplasty ⦿ Extensive exposure ⦿ Binocular vision ⦿ Use of both hands ⦿ Control of bleeding and diathermy ⦿ Precise placement of struts and grafts ⦿ Valve area preserved
- 34. ⦿ Indications ⦿ Extensiverevision surgery ⦿ Severe nasal trauma ⦿ Congenital deformities: cleft lip nose ⦿ Marked tip deformities ⦿ Elaborate reduction and augmentation procedures ⦿ Correction of extreme overprojection
- 36. Surgical technique ⦿Inscision: ⦿ Brokenline transcolumellar inscision --- less visible scar ⦿ Step, gullwing , inverted v type ⦿ In upper 2/3rd at narrowest point ⦿ In lower1/3rd least support ⦿ Joined to marginal inscions along the lateral crus
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- 38. Dissection of softtissue envelope ⦿ In subperichondrial and subperiosteal planes to ensure minimal bleeding ⦿ Expose medial and lateral crura ⦿ Cephalic dissection towards nasal bones ⦿ Potential complication – supratip odema ⦿ Soft tissue pollybeak -- if done in wrong planes disturbs the integrity of transverse nasalis muscle.
- 39. Access to nasalseptum ⦿ Division of soft tissue between medial crura of LLC ⦿ Alternative – killians inscision ⦿ Columellar strut placement ⦿ Between medial crura with matress sutures ⦿ To correct buckled medial crura ⦿ To strengthen weak MC ⦿ Correct tip asymmetry ⦿ Provide base for tip grafts
- 40. Closure ⦿ With 6-0vicryl or with tissue glue.
- 42. Specific applications ⦿ Bonypyramid in external rhinoplasty ⦿ Allows use of burr or reduction of the soft tissue envelope at nasion to deepen the nasofrontal angle ⦿ Application of soft tissue onlay grafts ⦿ Bony dehumping together with lateral, medial, and intermediate osteotomies
- 43. ⦿ The middlenasal vault ⦿ Placement of cartilaginous strips or spreader grafts to open up the nasal valve area and angles ⦿ Auto spreader grafts infolded ULC ⦿ Reconstuction of dorsal nasal roof ⦿ Straightening of high dorsal deviated septum ⦿ Recreation of dorsal aesthetic lines
- 45. Nasal tip surgery ⦿Tripod theory ⦿ Structural framework of nasal tip ⦿ Deprojected – medial and lateral crura decreased length ⦿ Projected – medial and lateral crura increased length ⦿ Rotation shortening of lateral crura and lengthening of medial crura.
- 46. ⦿ Treatment ⦿ LLCdivided laterally and overlapped to deprojected tip and create tip rotation. ⦿ Lateral crural steal ⦿ Tongue in groove technique of septocolumellar suturing
- 50. Augumentation rhinoplasty ⦿ Saddlenose --- Pug nose or boxer nose ⦿ Aetiology 1. Trauma 2. Nasal surgery 3. Familial/ethnic 4. Infections 5. Chronic Inflammatory conditions 6. tumour
- 51. Daniel and BrennerClassification for saddle nose Type 0 pseudosaddle ⦿ Relative depression of cartilaginous dorsum relative to bony septum
- 52. Type 1 minorcosmetic concealment ⦿ Minor decrease in septal support supratip depression and columella retraction ⦿ Correction with diced cartilage grafts / columellar strut
- 53. Type 2 moderatecartilage vault restoration ⦿ Cartilaginous vault collapse, ⦿ Columellar retraction ⦿ Loss of tip support ⦿ Correction combination of extended vault grafts and columellar strut.
- 54. Type III major–composite reconstruction ⦿Total absence of septal support for the cartilaginous vault, columella, nasal tip,and external valves. ⦿ Foundation layer extended spreader and septal strut grafts. ⦿ Esthetic layer columellar strut and diced cartilage in fascia for dorsal contour.
- 55. Type IV severe–structuralreconstruction ⦿ End stage of septal collapse. ⦿ Bony vault disruption ⦿ Severe contracture of the nasal lining, often associated with major septal perforations ⦿ Composite reconstruction costal cartilage graft placed in the dorsum ⦿ Crural strut with tip graft
- 56. Type V catastrophic–nasalreconstruction ⦿ Esthetic reconstruction of the nose and its adjacent tissues. ⦿ Extensive bone grafting or plating
- 57. Properties of implantmaterials ⦿ Noncarcinogenic and nonimmunogenic ⦿ Not toxic ⦿ Nondestructive , should not impede healing ⦿ Physical properties match the local tissues ⦿ Nonresorbable ⦿ Easily available ⦿ Cost effective easy to sterilize
- 58. Graft Materials ⦿ Autografts- cartilage, bone, dermis and fascia ⦿ Homografts - Irradiated rib, pooled acellular dermis ⦿ Xenografts - Leather, duck's sternum, bovine cartilage ⦿ Precious metals - Titanium, gold, silver, metal alloys ⦿ Synthetic biomaterials • Silicone • Teflon • Proplast • Gore-tex
- 59. Type of autografts ⦿Septal cartilage ⦿ Auricular cartilage ⦿ Costal cartilage ⦿ Bone graft
- 60. REDUCTION RHINOPLASTY ⦿ Indications ⦿Patients with ideal height and position of the nasion associated with excess dorsal convexity ⦿ Oversized alar cartilages producing increase tip and lobule volume Dorsal hump
- 61. Osteotomies ⦿ Medial osteotomy ⦿Lateral osteotomy • Low to high • Low to low ⦿ Transverse osteotomy ⦿ Intermediate osteotomy
- 62. Medial osteotomy ⦿ Itseperates the nasal bone from the septum ⦿ Made on both side ⦿ Nasal bone seperated at intranasal suture ⦿ Outer peritosteun is pushed to the side ⦿ Osteotome is placed at about 2mm paramedially • Osteotome is worked through the bone slightly below the level of frontal bone
- 63. Lateral osteotomy ⦿ Itseperates the lateral bony wall of pyramid from nasal process of maxilla ⦿ Short lateral incision is given ⦿ Medial to lateral subperiosteal tunnel is formed upto level of medial canthus ⦿ Osteotome placed across frontal process of maxilla ⦿ Lateral osteotomy done upto the level of frontal bone
- 64. Tranverse osteotomy ⦿ Seperatesthe bony pyramid from frontal bone and nasal spine of frontal bone ⦿ Osteotomy made at a level just below nasion
- 66. Complications ⦿ Bossae formation ⦿Knuckling of LLC in domal area ⦿ Triad of---thin skin ⦿ strong alar cartilages ⦿ bifidity of tip ⦿ Treatment trimming/ reection of knuckled areas ⦿ Suture reconstruction ⦿ Covering with caumoflaage grafts in minor deformities
- 67. ⦿ Alar retraction ⦿Over zealous cephalic strip resection ⦿ Absolute minimum of 6 mm cartilage should be preserved. ⦿ Hanging columella ⦿ Over resection of caudal septum ⦿ Tongue in groove suturing / strut placement
- 68. Revision rhinoplasty ⦿ 5– 10% require revision ⦿ Unpredictable healing beyond surgeons control ⦿ Inadequate primary procedure ⦿ Safian 3 basic rules to prevent revision ⦿ Never change normal basic anatomy/relationships and never totally remove a component ⦿ Never allow skin and lining membrane to meet or left in contact ⦿ Never destroy nasal cartilage
- 69. Pollybeak deformity ⦿ Droppingof nasal tip and loss of projection
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- 71. References ⦿ Daniel, R.K., & Brenner, K. A. (2006). Saddle Nose Deformity: A New Classification and Treatment. Facial Plastic Surgery Clinics of North America, 14(4), 301–312. doi:10.1016/j.fsc.2006.06.008 ⦿ Scott brown 8th edition ⦿ Cummings 6th edition