Dr. Mohamed Ahmed Sayed Mostafa El-Rouby Professor of Plastic and Reconstructive Surgery, Maxillofacial Surgery and Burn management - Faculty of Medicine - Ain Shams University Nationality: Egyptian Location: Cairo - EGYPT. Address: Heliopolis, Cairo, Egypt. Language: Arabic, mother language and English. Telephone: +2-01001556023 or +2-01226531265 Fax: (+2)(02)(27716563) Clinic Address: 107 El Hegaz Street, Heliopolis, Cairo, EGYPT E-mail: DR.MOHAMED_ELROUBY@MED.ASU.EDU.EG ELROUBYEGYPT@ELROYBYEGYPT.COM Website: www.elrouby-clinic.com

1. Dr. Mohamed A. El-Rouby
Rhinoplasty
Mohamed A. S. M. El Rouby, MD
Faculty of Medicine - Plastic, Reconstruction, Burn and Maxillofacial Surgery Department
Ain Shams University

2. Dr. Mohamed A. El-Rouby
Overview
• Point out surgical anatomy of the nose.
• Define the recent advances in rhino and septorhinoplasty.
• Illustrate pitfalls in rhinoplasty.
• Complication versus mistake or malpractice.
• Easiest and safest timeline to get best results.

3. Dr. Mohamed A. El-Rouby
Terminology
&
Surgical Anatomy

4. Dr. Mohamed A. El-Rouby
Terminology

5. Dr. Mohamed A. El-Rouby
Terminology

6. Dr. Mohamed A. El-Rouby
Terminology

7. Dr. Mohamed A. El-Rouby
Surgical Anatomy

8. Dr. Mohamed A. El-Rouby
Surgical Anatomy (osteo-cartilagenous skeleton)

9. Dr. Mohamed A. El-Rouby
Surgical Anatomy (Lower Lateral Cartilage “LLC”)

10. Dr. Mohamed A. El-Rouby
Surgical Anatomy (Lower Lateral Cartilage “LLC”)

11. Dr. Mohamed A. El-Rouby
Surgical Anatomy
• Nasal tip support system:
• Majors
1. LLC and attachment to the piriform
aperture
2. Domal suspensory ligament
3. Fibrous inter-cartilaginous connections
between ULC and LLC
4. Medial crural ligaments
5. Anterior septal angle
• Minors

12. Dr. Mohamed A. El-Rouby
Nasal Septum

13. Dr. Mohamed A. El-Rouby
Surgical Anatomy (valves)

14. Dr. Mohamed A. El-Rouby
Surgical Anatomy (blood vessels)

15. Dr. Mohamed A. El-Rouby
Surgical Anatomy (Nasal SMAS)

16. Dr. Mohamed A. El-Rouby
Surgical Anatomy (muscles and ligaments)

17. Dr. Mohamed A. El-Rouby
Surgical Anatomy (nerves )

18. Dr. Mohamed A. El-Rouby
Aesthetic Units of the Nose

19. Dr. Mohamed A. El-Rouby
Mediterranean Nose Aesthetics

20. Dr. Mohamed A. El-Rouby
Aging changes

21. Dr. Mohamed A. El-Rouby
Philosophy of rhinoplasty or septorhinoplasty
Shape + Function + Psychology
• Reshaping of osteocartilagenous skeleton to mimic the standards.
• Get harmony with other features.
• Get natural dynamic nose.
• Keep or improve nasal function.
• Improve patients self-confidence

22. Dr. Mohamed A. El-Rouby
Religious aspect
•‫ك‬ ‫طبيبين‬ ‫استشارة‬ ‫بعد‬ ،‫لآلخرين‬ ‫السخيفة‬ ‫والتعليقات‬ ‫والعين‬ ‫والفم‬ ‫الوجه‬ ‫حجم‬ ‫لصغر‬ ‫نتيجة‬ ‫نفسية‬ ‫مشكلة‬ ‫لي‬ ‫يسبب‬ ‫كبير‬ ‫أنفي‬‫حجم‬ ‫إن‬ ‫الرأي‬ ‫ان‬‫طبيعي‬ ‫األنف‬
‫بنحت‬ ‫المشكلة‬ ‫عالج‬ ‫ويمكن‬ ‫الجانبين‬ ‫في‬ ‫انتفاخ‬ ‫شكل‬ ‫يعطي‬ ‫مما‬ ‫ألعلى‬ ‫محدب‬ ‫الجانبي‬ ‫الغضروف‬ ‫لكن‬‫العضروف‬‫أل‬ ‫التحديب‬ ‫يكون‬ ‫بحيث‬‫هل‬ ،‫كالمعتاد‬ ‫سفل‬
‫بها‬ ‫المصرح‬ ‫العمليات‬ ‫ضمن‬ ‫العملية‬ ‫تدخل‬.‫الـجـــواب‬:‫بعمليات‬ ‫يقصد‬ ‫الفتوى‬ ‫أمانة‬ ‫فتاوى‬
•‫التجميل‬:‫ذلك‬ ‫ونحو‬ ‫بحروق‬ ‫أصيب‬ ‫كمن‬ ،‫عليه‬ ‫طارئ‬ ‫أو‬ ،‫موجود‬ ‫عيب‬ ‫إصالح‬ ‫أو‬ ،‫الجسد‬ ‫أعضاء‬ ‫أحد‬ ‫لتجميل‬ ‫الجراحي‬ ‫التدخل‬.
•‫ي‬ ‫وأن‬ ،‫العيب‬ ‫هذا‬ ‫له‬ ‫هللا‬ ‫يصلح‬ ‫أن‬ ‫في‬ ‫يرغب‬ ‫أن‬ ‫جسده‬ ‫في‬ ‫منفر‬ ‫عيب‬ ‫به‬ ‫كان‬ ‫إن‬ ‫للمسلم‬ ‫يجوز‬ ‫حيث‬ ،‫جائز‬ ‫العيب‬ ‫إلصالح‬ ‫العمليات‬ ‫هذه‬ ‫وإجراء‬‫سعى‬‫لذلك‬
‫هريرة‬ ‫أبي‬ ‫فعن‬ ،‫والتداوي‬ ‫كالدعاء‬ ‫الشرعية‬ ‫باألسباب‬-‫عنه‬ ‫هللا‬ ‫رضي‬-ِ َّ‫اَّلل‬ َ‫ل‬‫و‬ُ‫س‬َ‫ر‬ َ‫ع‬ِ‫م‬َ‫س‬ ُ‫ه‬َّ‫ن‬َ‫أ‬-َ‫و‬ ِ‫ه‬ْ‫ي‬َ‫ل‬َ‫ع‬ ُ‫هللا‬ ‫ى‬َّ‫ل‬َ‫ص‬َ‫م‬َّ‫ل‬َ‫س‬-ُ‫ل‬‫و‬ُ‫ق‬َ‫ي‬(( :ِ‫ئ‬‫ا‬َ‫ْر‬‫س‬ِ‫إ‬ ‫ي‬ِ‫ن‬َ‫ب‬ ‫ي‬ِ‫ف‬ ً‫ة‬َ‫ث‬َ‫ال‬َ‫ث‬ َّ‫ن‬ِ‫إ‬َ‫ل‬‫ي‬:َ‫ص‬َ‫ْر‬‫ب‬َ‫أ‬
َ‫أل‬‫ا‬ ‫ى‬َ‫ت‬َ‫أ‬َ‫ف‬ ،‫ا‬ً‫ك‬َ‫ل‬َ‫م‬ ْ‫م‬ِ‫ه‬ْ‫ي‬َ‫ل‬ِ‫إ‬ َ‫ث‬َ‫ع‬َ‫ب‬َ‫ف‬ ،ْ‫م‬ُ‫ه‬َ‫ي‬ِ‫ل‬َ‫ت‬ْ‫ب‬َ‫ي‬ ْ‫ن‬َ‫أ‬ َّ‫ل‬َ‫ج‬ َ‫و‬ َّ‫ز‬َ‫ع‬ ِ َّ ِ‫َّلل‬ ‫ا‬َ‫د‬َ‫ب‬ ،‫ى‬َ‫م‬ْ‫ع‬َ‫أ‬ َ‫و‬ َ‫ع‬َ‫ر‬ْ‫ق‬َ‫أ‬ َ‫و‬َ‫ل‬‫ا‬َ‫ق‬َ‫ف‬ ، َ‫ص‬َ‫ْر‬‫ب‬:َ‫ل‬‫ا‬َ‫ق‬ ‫؟‬َ‫ْك‬‫ي‬َ‫ل‬ِ‫إ‬ ُّ‫ب‬َ‫ح‬َ‫أ‬ ٍ‫ء‬ْ‫ي‬َ‫ش‬ ُّ‫ي‬َ‫أ‬:ٌ‫د‬ْ‫ل‬ ِ‫ج‬ َ‫و‬ ،ٌ‫ن‬َ‫س‬َ‫ح‬ ٌ‫ن‬ ْ‫و‬َ‫ل‬َ‫ل‬‫ا‬َ‫ق‬ ، ُ‫اس‬َّ‫ن‬‫ال‬ ‫ي‬ِ‫ن‬ َ‫ِر‬‫ذ‬َ‫ق‬ ْ‫د‬َ‫ق‬ ،ٌ‫ن‬َ‫س‬َ‫ح‬:
‫ا‬ً‫ن‬َ‫س‬َ‫ح‬ ‫ًا‬‫د‬ْ‫ل‬ ِ‫ج‬ َ‫و‬ ،‫ا‬ً‫ن‬َ‫س‬َ‫ح‬ ‫ا‬ً‫ن‬ ْ‫و‬َ‫ل‬ َ‫ي‬ِ‫ْط‬‫ع‬ُ‫أ‬َ‫ف‬ ،ُ‫ه‬ْ‫ن‬َ‫ع‬ َ‫َب‬‫ه‬َ‫ذ‬َ‫ف‬ ُ‫ه‬َ‫ح‬َ‫س‬َ‫م‬َ‫ف‬.......َ‫ل‬‫ا‬َ‫ق‬َ‫ف‬ َ‫ع‬َ‫ر‬ْ‫ق‬َ‫أل‬‫ا‬ ‫ى‬َ‫ت‬َ‫أ‬ َ‫و‬:ُّ‫ي‬َ‫أ‬َ‫ق‬ ،‫ا‬َ‫ذ‬َ‫ه‬ ‫ي‬ِ‫ن‬َ‫ع‬ ُ‫َب‬‫ه‬ْ‫ذ‬َ‫ي‬ َ‫و‬ ،ٌ‫ن‬َ‫س‬َ‫ح‬ ٌ‫ر‬َ‫ع‬َ‫ش‬ َ‫ل‬‫ا‬َ‫ق‬ ‫؟‬َ‫ْك‬‫ي‬َ‫ل‬ِ‫إ‬ ُّ‫ب‬َ‫ح‬َ‫أ‬ ٍ‫ء‬ْ‫ي‬َ‫ش‬َ‫ل‬‫ا‬َ‫ق‬ ، ُ‫اس‬َّ‫ن‬‫ال‬ ‫ي‬ِ‫ن‬ َ‫ِر‬‫ذ‬َ‫ق‬ ْ‫د‬:
‫ا‬ً‫ن‬َ‫س‬َ‫ح‬ ‫ا‬ً‫ر‬َ‫ع‬َ‫ش‬ َ‫ي‬ِ‫ْط‬‫ع‬ُ‫أ‬ َ‫و‬ َ‫َب‬‫ه‬َ‫ذ‬َ‫ف‬ ُ‫ه‬َ‫ح‬َ‫س‬َ‫م‬َ‫ف‬))......‫م‬ ‫طلبوا‬ ‫الثالثة‬ ‫أن‬ ‫والشاهد‬ ،‫صحيحهما‬ ‫في‬ ‫ومسلم‬ ‫البخاري‬ ‫أخرجه‬ ‫الحديث‬‫ينكر‬ ‫ولم‬ ‫العيب‬ ‫عنهم‬ ‫يزيل‬ ‫أن‬ ‫ك‬َ‫ل‬‫الم‬ ‫ن‬
‫النبي‬ ‫حكى‬ ‫وقد‬ ،‫ذلك‬ ‫لهم‬ ‫حقق‬ ‫بل‬ ،‫ذلك‬ ‫ك‬َ‫ل‬‫الم‬ ‫عليهم‬-‫عليه‬ ‫هللا‬ ‫صلى‬‫وآله‬‫وسلم‬-‫ال‬ ‫اتخاذ‬ ‫جواز‬ ‫إلى‬ ‫الفقهاء‬ ‫جمهور‬ ‫ذهب‬ ‫وقد‬ ،‫نكير‬ ‫غير‬ ‫من‬ ‫ذلك‬‫الذهب‬ ‫من‬ ‫سن‬
‫قال‬ ‫أسعد‬ ‫بن‬ ‫عرفجة‬ ‫فعن‬ ،‫تعددت‬ ‫وإن‬ ،‫الفضة‬ ‫وكذلك‬ ‫للرجل‬ ‫حتى‬" :‫عل‬ ‫فأنتن‬ ،‫ورق‬ ‫من‬ ‫أنفا‬ ‫فاتخذت‬ ،‫الجاهلية‬ ‫في‬ ‫الكالب‬ ‫يوم‬ ‫أنفي‬ ‫أصيب‬‫هللا‬ ‫رسول‬ ‫فأمرني‬ ‫ي‬
-‫وسلم‬ ‫عليه‬ ‫هللا‬ ‫صلى‬-‫ذهب‬ ‫من‬ ‫أنفا‬ ‫أتخذ‬ ‫أن‬"‫وقال‬ ،‫سننه‬ ‫في‬ ‫الترمذي‬ ‫أخرجه‬[ :،‫حسن‬ ‫حديث‬ ‫هذا‬...‫أسنا‬ ‫شدوا‬ ‫أنهم‬ ‫العلم‬ ‫أهل‬ ‫من‬ ‫واحد‬ ‫غير‬ ‫روى‬ ‫وقد‬‫نهم‬
‫لهم‬ ‫حجة‬ ‫الحديث‬ ‫هذا‬ ‫وفي‬ ،‫بالذهب‬.]
•‫لتغ‬ ‫كانت‬ ‫وإن‬ ،‫ومباحة‬ ‫جائزة‬ ‫فهي‬ ‫العيب‬ ‫وإصالح‬ ‫للتداوي‬ ‫كانت‬ ‫إن‬ ‫التجميل‬ ‫فعمليات‬ ‫سبق‬ ‫ما‬ ‫وعلى‬‫الخلقة‬ ‫يير‬
‫وأعلم‬ ‫أعلى‬ ‫تعالى‬ ‫وهللا‬ ،‫عنه‬ ‫المنهي‬ ‫التغيير‬ ‫من‬ ‫فهذا‬ ‫آخرين‬ ‫لمشابهة‬ ،‫بها‬ ‫عيب‬ ‫ال‬ ‫التي‬.

23. Dr. Mohamed A. El-Rouby
Patient Interview and
Consultation
Psychological & Physical assessments

24. Dr. Mohamed A. El-Rouby
Scully says, ‘The patients will know if you care, well
before they care if you know.’
• Aim:
effective communication  the trust of the patient  the required information.
• The patient should be sitting comfortably at your eye level.
• Your approach should be courteous and professional, but not over familiar.
• The interview should be a well-organized, structured conversation and free
from interruption.
You direct the interview but allow the patient to explain their feelings and needs.
The patient’s Aesthetic and/or Functional concerns and Psychosocial History.

25. Dr. Mohamed A. El-Rouby
Patient Selection
• The surgeon minimizes complications by:
• carefully selecting patients (medical and psychosocial deficiencies),
• thorough understanding of deformities and correction techniques,
• developing a sense of empathy, and by recognizing his own limitations.
• Patients must be informed of all possible complications.
• They can make the decision to undergo surgery after carefully
considering all risks involved.
• Even so, selection mistakes may be made, and the temperaments of
the surgeon and staff may be tested.

26. Dr. Mohamed A. El-Rouby
Clinical Examination (Static and Dynamic)

27. Dr. Mohamed A. El-Rouby
Photo Analysis (Front View: Ratios)

28. Dr. Mohamed A. El-Rouby
Photo Analysis (Lateral View: Lengths and Angles)

29. Dr. Mohamed A. El-Rouby
Tip projection and rotation assessment

30. Dr. Mohamed A. El-Rouby
Photo Analysis (Base View: Shapes and Dimensions)

31. Dr. Mohamed A. El-Rouby
Types of Nose

32. Dr. Mohamed A. El-Rouby
Best candidates for Rhinoplasty

33. Dr. Mohamed A. El-Rouby
Your Plan

34. Dr. Mohamed A. El-Rouby
Techniques of Rhinoplasty
Open / Closed
Structural / Reduction / Augmentation /Functional
Surgical – Non-surgical

35. Dr. Mohamed A. El-Rouby
Your Plan
• Revise Patient’s needs
• Reassessment
• Anesthesia ?
• Positioning
• Instruments
• Steps

36. Dr. Mohamed A. El-Rouby
Instruments

37. Dr. Mohamed A. El-Rouby
Incision

38. Dr. Mohamed A. El-Rouby
Incision

39. Dr. Mohamed A. El-Rouby
Other Incisions could be needed

40. Dr. Mohamed A. El-Rouby
Skeletonizing the Osteo-cartilaginous framework

41. Dr. Mohamed A. El-Rouby
Humpectomy and Rasping

42. Dr. Mohamed A. El-Rouby
Septoplasty or Septal graft harvesting
1 2

43. Dr. Mohamed A. El-Rouby
Septal Deformities

44. Dr. Mohamed A. El-Rouby
Septoplasty
Recurrent
Avoid

45. Dr. Mohamed A. El-Rouby
Osteotomy
- Internal
- Transnasal
- External
- Continuous
- Micro-perforation
- Green Stick fracture
Elevation of periosteum

46. Dr. Mohamed A. El-Rouby
Cephalic Trim of LLC

47. Dr. Mohamed A. El-Rouby
Tip
Traditional

48. Dr. Mohamed A. El-Rouby
Graft Donors

49. Dr. Mohamed A. El-Rouby
Grafts (Shape)

50. Dr. Mohamed A. El-Rouby
Grafts (Functional rhinoplasty)
Internal and external nasal valves

51. Dr. Mohamed A. El-Rouby
Turbnectomy (Functional rhinoplasty)
- ENT
- Radiofrequency
- Avoid crushing
- Avoid cauterization

52. Dr. Mohamed A. El-Rouby
Structural Rhinoplasty Concept (Gunter Diagram)

53. Dr. Mohamed A. El-Rouby
Closure = Results
• Meticulous closure to avoid any late deformities
• Avoid suturing against Soft triangle
• Absorbable versus Non- Absorbable sutures
• Septal stent  Taping  Packing  Cast
• Anesthesia Recovery (FATAL)

54. Dr. Mohamed A. El-Rouby
Postoperative

55. Dr. Mohamed A. El-Rouby
Early postoperative
• Expected: Facial edema, bruising lower lids, Lid edema
• Removing:
• Pack  2 days
• Cast  7 -10 days
• Septal stent  10 days
• Tap  15 days up to one month
• Nasal obstruction could be relived by VC
• The patient and the relatives will need Reassurance that is not the
final result till one year

56. Dr. Mohamed A. El-Rouby
Late postoperative
• Follow up visit each month till one year
• Massage:

57. Dr. Mohamed A. El-Rouby
Non-Surgical Rhinoplasty
• Injection:
• Filler (for hump and tip)
• Botox (for wide alae)
• Thread lift (for tip, alar base)
• Ultrasonic (for bone reshaping) ?!

58. Dr. Mohamed A. El-Rouby
Complications of Rhinoplasty

59. Dr. Mohamed A. El-Rouby
Intraoperative complications
• Excessive bleeding
• Tears of mucoperichondrial flaps
• Buttonholing of skin
• Cautery burns
• Collapse of bony pyramid
• Disarticulation of upper lateral cartilage
• Osteotomy complications
• "Rocker" deformity
• "Open roof" deformity
• "Step" deformity
• Perinasal trauma

60. Dr. Mohamed A. El-Rouby
Immediate postoperative complications
• Airway obstruction: (FATAL)
• Anaphylaxis
• Visual impairment

61. Dr. Mohamed A. El-Rouby
Early postoperative complications
• Hemorrhage
• Septal hematoma and perforation
• Infection: Wound infection, Septicemia, Toxic shock syndrome,
• Dehiscence of incisions
• Persistent edema
• Skin necrosis (Metal cast edges)
• Sequestra formation

62. Dr. Mohamed A. El-Rouby
Continue Early postoperative complications
• Cardiovascular insufficiency: In the elderly and those with cardiac
disease, nasal packing can lead to hypoxia and associated
problems.
• Cerebrospinal fluid rhinorrhea
• Contact dermatitis
• Nasal blockage
• Numbness and pain
• Olfactory disturbances
• Early psychological complications: Transient episodes of anxiety or
depression and may last up to 6 weeks after the operation.

63. Dr. Mohamed A. El-Rouby
Late postoperative complications
• Scar hypertrophy
• Polly beak nasal deformity
• Synechiae formation
• Septal perforation
• Nasal valve collapse
• Nasal stenosis
• Dorsal cyst
• Aesthetic surgical misjudgments: Undercorrection or
overcorrection.

64. Dr. Mohamed A. El-Rouby
Upper third deformities
• Nasofrontal angle: Deep / Shallow
• widening
• convexity
• overreduction
• asymmetry

65. Dr. Mohamed A. El-Rouby
Middle third deformities
• Widening,
• Convexity,
• Saddling,
• Asymmetry,
• Inverted-V deformity.

66. Dr. Mohamed A. El-Rouby
Lower third deformities
• Tip:
• widening or boxy tip,
• narrowing or pinched tip
• asymmetry
• projection deformities:
• columella:
• Wide
• Hanging columella or "columella show"
• Alae:
• "Hanging" or "veiled" alae
• Alar notching
• Alar collapse
• Nostril asymmetry
• nasolabial angle: Retracted or Protracted.

67. Dr. Mohamed A. El-Rouby
Other
• Graft/implant migration, infection, extrusion
• The disproportionate nose
• Lacrimal fistula
• Underlying maxillofacial deformity
• Persistent psychological complications
• Patient dissatisfaction

68. Dr. Mohamed A. El-Rouby
You botched
my Nose !!!
Unhappy patient
Rhinoplasty is regarded to be associated with many risks as the expectations of
patient and physician are not always corresponding.

69. Dr. Mohamed A. El-Rouby
Aesthetic surgery has 4 possible outcomes:

70. Dr. Mohamed A. El-Rouby
Pitfalls in Rhinoplasty
• Patient Causes
• Rhinoplasty in men
• Ethnic rhinoplasty
• Cleft lip nasal deformity
• Older patients
• Rhinophyma
• Doctor Causes
• Say “No” to a potential patient
• Procedure Causes
• Structural Rhinoplasty /
Reduction / Augmentation
• Open / Closed
• Non-surgical

71. Dr. Mohamed A. El-Rouby
PITFALLS LEAD TO:
• Postoperative deformities 40% (15% for revision rhinoplasty)
• function complications 60%
• Re-operation 35% (15% deformed and 20% unhappy)
• Medico-Legal problems 12%

72. Dr. Mohamed A. El-Rouby
Is this is a complication or a mistake??!!
• An unfavorable result of rhinoplasty may be visible even with
most expert surgeon.
Unfavorable results:
• The patient often blames the surgeon for this result (mistake)
• while the surgeon tends to call it a complication (complication).

73. Dr. Mohamed A. El-Rouby
How to Avoid

74. Dr. Mohamed A. El-Rouby
How to improve your outcomes
• No surgeon has all the answers and many mysteries still
remain.
• Most of patients trust the medical profession. Yet, there’s no
law against poor artistic judgment or malpractice, and
thousands of patients have learned this lesson the hard way.
• However, by an honest evaluation of each surgical outcome,
and by continually refining your technique to accommodate
newly acquired insights, you have substantially improve the
rhinoplasty results.

75. Dr. Mohamed A. El-Rouby
Rhinoplasty is regarded as the most difficult of all
cosmetic procedures
• Mastering the rhinoplasty requires
• a sophisticated understanding of nasal anatomy
• precise surgical technique
• familiarity with the myriad pitfalls that can lead to potential complications.
• In fact, surgical findings at the time of revision rhinoplasty suggest
that fundamental surgical errors, not unfavorable tissue
characteristics, are the most common cause of the failed
rhinoplasty.

76. Dr. Mohamed A. El-Rouby
Preoperative
• Remember that nose is the center of face
• Patient selection
• Learn to say “No” for potential unstable patients
• Tell the patient real expectations (No Guarantee)
• Do only what is the patient need
• Re-consultation
• Photography (pre and post)
• Take your time to planning
• Try to refer the your complicated cases to your friend

77. Dr. Mohamed A. El-Rouby
Intraoperative
• Minimize hemostatic injection of adrenaline and haemostasis by
cautery.
• Take your time in skeletonization and closure.
• Avoid blind dissection.
• Avoid thinning of the skin and try to keep SMAS
• Avoid Reduction Rhinoplasty (use Structural Rhinoplasty)
• Do external osteotomy after elevation of periosteum.
• Do only what is the patient need within your experience
• Do not try to uniform the technique
• Discuss the result with others (Anesthesiologists, Nurses, porters)

78. Dr. Mohamed A. El-Rouby
Postoperative
• Reassurance and Close follow-up for 1 or 2 years
• Take care of metal cast
• Use Micropore plaster for Reshaping
• Tap may be reused for a month
• Postoperative massage for 3 months
• If there is a deformity: mistake or complication
• Revision may be needed (you or your friend)
• Do not push the patient by ignorance to medicolegal way especially if
there is a complication.
• Second surgery by others may be the only solution to avoid medicolegal
problems
• Costs?!!

79. Dr. Mohamed A. El-Rouby
Thank You!