This document discusses external rhinoplasty techniques presented by Dr. Abhineet. It covers indications for external rhinoplasty including reduction/augmentation and trauma/deformities. Pre-op assessment involves standardized photographs. Key anatomical points are defined. Ideal measurements and angles are provided. Techniques for hump reduction, tip work, grafts, and modifications to narrow the base are outlined. Potential complications like hemorrhage, infection and deformities are reviewed. The presentation compares open vs closed approaches and emphasizes achieving symmetry and natural appearance tailored to each patient.

1. External Rhinoplasty
assesment and techniques
Presenter- Dr. Abhineet
Moderator- Dr. R.R. Barle

2. Indications-
 Elaborate reduction & augmentation.
 Severe nasal trauma.
 Extensive revisions.
 Congenital deformities.

3. Pre op aesthetic assesment-
 Standard 35 mm photographs taken in
frontal, full lateral, basal and left & right
three qtr. Lateral view as gold standard
for pre op. evaluation.
 5 mega pixel camera with independent
flash lights.

5. Aesthetic terminology-
 Nasion-deepest point of NFA.
I. ideal location is set between lash and crease
line of upper lid.
II. Nasion height is measured from vertical
tangent to glabella.
 Dorsum-( on anterior view.)
I. Intercanthal width(EN-EN)
II. Parallel dorsal lines
III.Base bony width(X-X)
IV.Tip defining points / philtrum.
V. Alar width(AC-AC)
VI.Alar flatre(AL-AL)

6. Cont..
 On lateral view-
I. NFA -36* male/34* female measured from
ideal nasion(Ni) to ideal tip(Ti).
II. Ni to Ti i.e. length of nose is 2/3rd
of mid
facial height.
III. Ti- ideal tip projection(AC-Ti) is 2/3rd
of
length of nose.
IV. Final aesthetic line- concave for female/
flat for male. If a hump is present, the line is
drawn through it.

7. Radix And Dorsum Aesthetics

8. Dorsum And Tip Assesment

9. Tip aesthetic assesement-
 Intrinsic criterias- alar cartilage config’n.
I. Volume-size & shape of lateral crura.
II. Definition-convex domal & concave lateral
crura.
III.Width-interdomal distance between Ti.
 additional criterias-abutting structures.
I. Projection-intinsic & extrinsic.
II. Rotation- tip angle-105*
female/100*male.has inrinsic and extrinsic
factors.
III.Position- location of tip along the dorsal line.

12. Base aesthetic assesment-
1. Columella base.
2. Pillar.
3. Infralobule triangle.
4. Soft triangle.
5. Lateral wall.
6. Alar base.
7. Nostrill base.
8. Nostril.

13. Cont..
 Aesthetics of 4 components assesed-
I. Alar flare/width.
II. Columella.
III.CLA.
IV.Nostril.

21. ALWAYS
Make the tip fit the ideal dorsum

22. Operative sequence-
 General anaesthesia & local
anaesthetic injection
 Open approach incision
 Elevation of skin envelope.
 Septal exposure via transfixion incision.
 Creation of symmetrical alar rim strip.
 Incremental hump reduction.
 Caudal septum & ANS excision.
 Septoplasty.
 Osteotomies.

23.  Graft preparation
 Spreader grafts
 Columellar strut & sutures
 Tip sutures
 Closure
 Alar base modification
 Alar rim support grafts
 Doyle splint & external & nasal block.

25. Transcollumellar
 External approach
 Crosses collumella just above flared ends of
the medial crura
 If too close to the lip, “dip” deformity
– No cartilage support to counteract tension
generated by the healing skin
 Notching at the midline – “aggie mark”,
Improved scar camouflage

27. Radix reduction-
 Intervening soft tissue excise under skin flap
at level of radix & glabella.
 Bony reduction-
I. Separate radix from bony dorsum by a line at
level of lateral canthus.
II. Define ideal nasion/NFA/new dorsal line.
III.Dorsum is lowered 1st
followed by radix up to
NFsuture line.
 NEVER try to do an en bloc reduction as you
will remove too much dorsum & too little
radix.

28. Radix augmentation-
 As a balancing procedure to minimize
hump reduction thus maintaining both
dorsal height and more natural looking
nose.
 Use of fascia grafts/DC-F/DC+F grafts.
 Most pt. can accept under but not over
correction.

29. Dorsal reduction
 Incremental approach is followed.
 Bony rasping in subperiosteal tunnel is used
in midline & then progressively on sides. It
continues till height of dorsum as it relates to
nasion has been achieved.
 Cartilaginous vault reduction by-
I. Split hump technique.
II. Transverse en bloc.
 Excision of septum lowers dorsal height while
that of ULC narrows width.
 Once osteotomies completed additional
rasping & excision may be needed.

31. Osteotomies-
 Lateral osreotomies- to achieve movement
of lateral wall to narrow bony width.
 It should go beneath the widest point of
base bony width.
I. Low to high
II. Low to low
 Routes may be intrasal, intraoral,and
percutaneous.
 Intraoral approach to be too low and
inflexible while percutaneous one leads to
too many segmental bony bridges and
mucosal perforations.

32.  Medial oblique osteotomy- coupled with
low to low ,to narrow broad bony dorsum.
 Double level osteotomy- coupled with low
to low, along inferior border of nasal bone
and parallel to it. Goal is to reduce convexity
of lateral wall.
 Paramedian osteotomy-straight ones
parallel to midline with out changing height.
 Micro osteotomies- to correct intrinsic
bone irregularities.

36. Spreader grafts
 An integral part of rhinoplasty both for
functional and aesthetic reasons.
 They prevent internal nasal valve collapse &
inverted v deformity of dorsum.
 15-20mm long 3mm high, placed in
extramucosal tunnel with cephalic portion
under bony vault.
 ULC,spreader graft & septum sutured
together.

38. Dorsal augmentation
 Fascia graft-deep temporal fascia as single
or folded sheet is guided into pocket up to
radix & sutured in supratip area to
cartilaginous vault.
 DC-F Grafts-diced cartilage placed in fascia
pocket.
 Rib grafts-usually 7th
/ 9th
rib crtilage.it provide
excellent structural support with little risk of
warping.
 Septal cartilage- prone to visible edges
under thin skin and difficult to obtain in
secondary cases.

39. Biomaterials for augmentation.
 Silicone rubber
 PTFE
 High density polyethylene
 Polyester and polyamide mesh
 Titanium
 Ceramic & non ceramic hydroxyapatite.

40. Nasal Tip
 Dome: formed by the junction of the medial
and lateral crura
– Two point tip: aesthetically pleasing
– Tent deformity: Single point tip
• Overtight suture or poorly placed tip graft
 Sesamoid Cartilage
– Accessory cartilage between lateral crura and
piriform aperture
 Cephalic border of the lower lateral cartilage
forms hinge with upper lateral cartilage

42. Tip shapes-
Broad tip Ball tip

43. Bulbous tip

44. Tip Support
 Anderson: nasal tip similar to a Tripod
– Conjoined medial crura and two lateral crura
represent the three legs of the tripod
 Major support
– Size, shape, resilience of medial and lateral crura
– Fibrous attachment of the medial crura feet to the
caudal septum
– Fibrous attachment of the caudal margin of the
ULC to the cephalic margin of the LLC

45. Tip Support
 Minor Support
– Ligamentous sling between the alar cartilages
– Cartilaginous septal dorsum
– Sesamoid complex – extending the support of the
lateral crura to the piriform aperture
– Attachment of the alar cartilages to overlying skin
and musculature
– Nasal spine
– Membranous septum

46. Symmetrical rim strips-
 Cephalic portion excised in all cases to
reduce volume of tip,to increase
malleability.
 Lateral crura is not excised when
major convcavities of lateral crura exist.
 Actual excision begins at domal notch
the progress laterally,preserving 6mm
strip retaining sufficient to support
nostril rim & preventing alar retraction.

47. Columellar strut & suture-
 It serves three purpose: tip stability,tip
projection & columellar shape.
 It creates a unified tip complex and
symmetry.
 Create a true pocket between middle
and medial drura while preserving
intercrural fibrous connection.

49. Domal creation suture-
 To create ideal aesthetic tip anatomy
by creating a convex domal segment
next to a concave lateral crura.
 Too tight- sharp point under thin skin.
 Too loose- failure of tip definition.
 Too medial- snubs off tip .
 Too lateral- lengthen infralobule.

51. Interdomal suture-
 Controls tip width.
 Too tight creates single pointed tip
while too loose causes a wide tip so
keep in mind “ tip diamond” concept to
preserve normal angle of domal
divergence 30*

53. Domal equalization suture-
 To insure symmetry of tip.
 It is probably the easiest to insert and
most difficult to do wrong.

55. Lateral crural mattress suture-
 Widely used in treatment of wide/broad/
boxy/ ball tips.
 It is a better alternative to segmental
excisions that ultimately led to bossa
formation or lat. Crura collapse.
 A simple transverse mattress is placed
at point of max. convexity on lateral
crura.

57. Tip position suture-
 Achieves tip rotation & tip projection to
create “ supra tip break”.
 It is not done till ideal intrisic tip has
been achieved.
 Most powerful of all tip sutures &
must never be tied too tight …
 No need to include columellar strut.

59. Add on grafts-
 Once suturing is complete ,to add
refinements as enhancement.
 Excised alar cartilage is preferred over
rigid septal / conchal cartilage .
 Accentuate dome defining points and
tip diamond feature.
 5 types-
domal/shield/diamond/folded/combinati
on.

61. Alar rim grafts-
 To correct alar rim retraction &depression as
subtle effect of tip suturing.
 Grafts 8-12 mm long 2-3 mm wide with
tapering cephalically both in width and
thickness.
 2 types-
 ARG -placed subcut.parallel to rim and 2-
3mm back.
 ARS- sutured to true marginal rim incision .it
is useful in ext. nasal valve collapse.

63. Base modifications(narrowing)
 Nostril sill excision-to reduce”nostril show”. It is a
vertical trapezoidal wedge excision.
 Alar wedge excision- to reduce alarflare.it is an
elliptical excision wit inferior border placed in alar
crease, down to mid muscle level without penetrating
vestibular skin.
 Combined sill/base excision- to narrow alar base
maximally while reducing alar flare at the same time.

65. Columellar Labial Angle--
 Surgical modification consists of
preservation,resection,augmentation of either the
columellar/ANS.
 Columella-Vast majority of the problems are due to
caudal septal deviations that needs correction.
 Most common is hanging columella due to
prominent caudal septum that needs resecting lower
half of caudal septum or straight excision of entire
caudal septum to shorten nose.
 Retraction of columella is corrected by long wide
columellar strut.

66.  ANS- if prominent either shortened or
its underlying bony webb depened.
 Retracted ANS can be isolated or part
of hypoplastic maxilla. It needs a large
columella strut and small cartilage graft
placed subcutaneously in columella
base.
 Need of prepyriform augmentation in
hypoplastic maxilla using diced
cartilage or hydroxyapp. granules

71. Post op dressing-

74. Open verses Closed ???
 Open
– Much better exposure of structures
– More accurate placement of grafts
– More accurate structural diagnosis
– Teaching value
 Closed
– Possibly faster than open
– No external scar
– Avoids tip edema
– No loss of tip support

75. Complications
 Hemorrhage
 Wound infection
 TSS
 Septal haematoma.
 Septal abscess.
 Septal perforation
 Nasal obstruction
 Nasal deformity.

76. Hemorrhage -
 Intraoperative bleeding- major bleed
follows medial osteotomies or
turbinectomies.
 Controlled by packing by epinephrine
soaked gauze or cauterization.
 Postop. Bleed can be well controlled
with nasal tampoons.

77. Infection-
 Require aggressive treatment as I&D, gauze packing,
high dose broad spectrum i.v. antibiotics.
 TSS- symptoms
I. Fever/hypotension/ GI symptoms/errythematous
macular rash with desquamation.
II. Admitted to hospital,nasal packs removed and
cleansed.
 scarring,skin necrosis,horrendous appearance are
complications.
 Avoided by at least 5 days of post op. period.

78. Septal complications-
 Septal hematomas- a unilateral inferior
incision with b/l silastic splints.
 Septal abscess- incision followed by
penrose drain sutured in place for 4
days, along with appropiate antibiotics.
 Septal perforation- poor technique
when perichondrium was removed with
septum on one side / associated friable
mucosa.

79. Nasal obstruction-
 In early period- mucosal oedema, nasal
crust formation.
I. Judicious use of nasal saline spray and
nasal decongestant.
 In late period- septal deviation,nasal
valve narrowing, vestibular scarring,alar
collapse, overcrowding of intranasal
structures.

80. Nasal deformity-
 Narrow dorsum.
 Saddle nose.
 Pollybeak tip/ pointed tip.
 Drooping of tip.
 Thick columella.
 Caudal septal deviation.
 Uneven dorsum with show of underlying graft
material.

81. Thank youThank you