Rhinoplasty is a surgical procedure to improve the appearance and function of the nose. It requires a systematic approach including thorough analysis of the nose and entire face. Key aspects of the nose such as tip shape, rotation, and dorsal profile are evaluated. Patient motivations and expectations must also be understood. The surgery can be performed through an external or endonasal approach depending on the degree of change needed. Key steps involve refinement of soft tissue and manipulation of nasal cartilage and bone. Proper osteotomies, grafting, and suture techniques are used to achieve the desired nasal shape. While rhinoplasty can enhance appearance, consistent excellent results require technical skill and managing patient expectations.

1. RHINOPLASTY
Dr. Raju Kafle
3rd Year Resident ,
ORL-HNS Dept, NMCTH
1

2. Introduction
• Rhinoplasty : surgical procedure in order to improve the function and appearance of human
nose
• Nose reshaping or nose job
• One of most challenging facial plastic surgery
• Technically difficult to achieve consistently excellent results
• Compared to other cosmetic procedures, rhinoplasty has a relatively low patient satisfaction
rate
2

3. History
• Nose reconstruction surgery dates as far back as the 6th century BC
• Indian physician Sushruta outlined the forehead flap method for rebuilding nose in patients who’d
lost their noses as a form of criminal punishment
• At 16th century in Europe was mass outbreak of syphilis that left hordes of sufferers with rotting
and disfigured noses.
• Reconstructive nose jobs were performed for correction of these deformities
• American otolaryngologist John Orlando, considered the father of modern rhinoplasty using
endonasal techniques (1887)
3

4. Patient
(Motivations,
Anxiety, and
Expectations)
Analysis
of face
Analysis
of nose
Examinations Photography
Assessment : Systematic approach
4

5. • History including past history
• Identification of any structural, congenital, traumatic, cosmetic and /or functional issues
• It is critical to understand the patient’s motivations, anxieties and expectations
• Aims: to identify the high risk patients ( inappropriate for rhinoplasty )
Patient
(Motivations,
Anxiety, and
Expectations)
5

6. High-risk patients
High risk patients
• Potentially problematic patients
• Body dysmorphic disorder (BDD)
 Acronyms : SIMON
• Single
• Inmmature
• Male
• Obessive/ overtly expectant
• Narcissistics
Ideal patients
Acronym: SYLVIA
 Secure
 Young
 Listens
 Verbal
 Intelligent
 Attractive
6
• 33%--44% of patients seeking rhinoplasty had
moderate symptoms of BDD

7. 7

8. Further evaluation and treatment
• Poor results are often based on emotional dissatisfaction rather
than technical failure.
• It is therefore important to ask:
1. What are your outcome expectations?
2. How do you anticipate your life will be different following
treatment?
3. What if your expectations are not met?
• Rhinoplasty improvement scale
8

9. • Entire facial aesthetics not only nose
• Asymmetrical face : post op dissatisfaction
• Leonardo da vinci originally described:
• Rule of 3rd (horizontal )
• Rule of 5th (transverse)
Analysis
of face
9

10. Terminology of facial landmark
10

11. • Frankfurt line : defined by a plane oriented parallel to the floor connecting the superior aspect of
the external auditory canal to the infraorbital rim.
• It defines the patient position in which all-facial analysis and photography should occurs.
11

12. Ideal angles : Powell and Humphrey
12

13. • Fitzpatrick skin typing helps to predict the possible sun damage in a person and the risk
of skin cancer.
• It can also be used to evaluate the response of different skin types to commonly used facial
asthetic procedures
13

14. Skin quality :
• Thin skin: minor irregularities are easily detectable
• Thick skin : refining and narrowing the nasal tip is
challenging
Deviations
Analysis
of nose Inspection of external nose
14

15. Length of the nose
15
Tip projection
=0.55-0.60

16. Lip–chin relationship
.
? Over projected
nose
? Under projected
nose
16

17. Dorsum
• Inspected from both frontal and lateral views.
• Tracing the lateral aesthetic lines (brow–tip line)
• Smooth curvilinear line
• In the lateral view, the height of dorsum is assessed;
• Men : straight line
• Women : gently curves with a supratip break
• Wide variation in different ethnicities
17

18. Tip configuration
Four tip-defining points
• areas that project the most , looks white in photographs by light reflection.
• These represent the domes, the supratip and the infratip.
• commonly encountered selection of tip appearances: normal, boxy, bifid, bulbous and
amorphous
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19. Bifid tip : where a groove is
present in the midline.
19
Boxy tip: excessive separation of the lower lateral
cartilages or excessively wide lower lateral cartilages
Bulbous tip : when the tip of the nose is enlarged
and rounded in appearance
Amorphous tip : a nasal tip with a
wide, dome-like arch of the lower
lateral cartilage

20. Tip rotation
• This describes the position of the tip
along an arc with its radius centred on
the nasolabial angle.
20
Columellar show

21. Basal view
• Upper 1/3rd : lobule
• Lower 2/3rd : columella
• A line that transects the columella at the area of medial
crural footplate diversion divides the base into two
halves
• Looks as isosceles triangle with pear-shaped nostrils
lying 45 ° to vertical.
• Multiple ethnic variations
21

22. Inspection of Internal nose
• Anterior rhinoscopy and nasal endoscopy
• Septum inspection
• Inspection of lateral wall and turbinates
• Nasal valve assessment : cottle’s manoeuvres
• Endoscopy
22

23. Palpation
• Skin: texture and elasticity
• Underlying irregularities
• Nasal bones size and position
• Alar cartridges: Palpate for thickness, strength and shape.
• Tip recoil
23

24. Studies of nasal function
• Not performed routinely in rhinoplasty assessment and are mainly
confined to the research environment.
Objective tests : Nasal inspiratory peak flow, acoustic rhinometry and
rhinomanometry
24

25. • Standard 35mm size
• For detail evaluation and medicolegal purpose
• Compare post operatively about 4 months (by the time
most edema subsided)
• Further change after 6 months and slight change a years
afterwards
Photography
25

26. Applied anatomy : anatomical subunits of nose
26

27. Osteocartilageneous vault
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Bony pyramid

28. Key stone area and scroll region
28
Key stone area : confluence of bone and cartilage at the
junction of the upper and middle thirds of the nose.
• Provides stability
• poor surgical handling of this area : post op deformity
Scroll area :the interval structure between the upper and
lower lateral cartilages—contains fibrous tissues
• provides rigidity to the area of the internal nasal
valve.
• It also provides tip support

29. Tip support
29
• Tardy ( 3 major and 6 minor )
Importance
• If disrupted during rhinoplasty
leads to tip ptosis

30. Anderson Tripod theory
• 2 long legs of lateral crura ( red)
• 1 short leg of medial crura , joined to each other (yellow )
Importance
• Manipulation of any of the three legs will cause varying
degrees of change in the projection and rotation of the
nasal tip.
30

31. Rhinoplasty
Rhinoplasty
External / open Endonasal Fillers technique septorhinoplasty
Revision
rhinoplasty
31

32. 32

33. Approach for rhinoplasty
33
Approach
for
rhinoplasty
Delivery
Non delivery
External
Endonasal approach

34. Incision in endonasal approach
34

35. Non delivery approach
Appropriate for
• Small volume reduction of the lateral crus
• Slight cephalic rotation of the tip
Incision : transcartilageneous
35

36. • Vestibular skin : 5/0 absorbable
suture material.
• This simple tip refinement procedure
gives
• minimal surgical trauma
• integrity of the lower lateral
intact
• ensuring the best chances for
uncomplicated healing process
36

37. Delivery approach
Although more traumatic, is indicated when the planned
changes to the nasal tip are more voluminous.
With this approach, it is possible to modify the alar cartilages
under direct vision up to the dome and interdomal area.
The indications for this approach are:
• Asymmetry
• Bifidity
• Extra cephalic tip rotation
• Diminishing of the tip projection
37

38. 38

39. 39

40. Delivery approach is also appropriate bifidity of the nasal tip
• Horizontal mattress suture technique can be performed to advance the domes with a non-
absorbable or slow absorbable (PDS) suture
40

41. Endonasal approach : overall
41
Advantages
• Leaves no external scar
• Limits dissection to area needing
modification
• Permits healing by maintaining vascular
bridges
• Minimal post surgical edema
• Reduces operating time
• Grafting in alar region is easy
Disadvantages
• Does not allow direct vision to normal nasal
anatomy
• Requires more surgical experience
• Not good teaching and learning technique

42. External Approach Rhinoplasty : principle
• conservation of the structural support of the nose by full exposure of the underlying
structures -- allowing open access for corrective surgical manoeuvres.
• It promotes emphasis on augmentation and reorientation of the supportive structures
rather than reduction and resection
• Full anatomical exposure, the ability to bimanually manipulate and handle underlying
tissues gives a major advantage to endonasal technique
• particularly in more complex surgery, revision and post-traumatic deformity.
• It facilitates accurate resection and modelling of underlying bony and cartilaginous
components and enables straightforward placement and suturing of graft material.
42

43. Benefits of external rhinoplasty
• Provides very extensive exposure for both septal and rhinoplasty surgery
• Binocular vision
• Use of both hands
• Control of bleeding with diathermy
• Precise placement and suturing of struts and shield grafts
• Very useful teaching tools
• As intercartilageneous incision are not used , the valve area is preserved.
43

44. Disadvantages of external approach
• Loss of some of minor tip support mechanisms resulting in tip ptosis
• External nasal scar
• Oedema of nasal tip (esp if thick skin )
• Increase operative time
• Columellar incision separation
• Delayed wound healing
44

45. Indications
1. Congenital deformities ( cleft lip nose)
2. Extensive revision surgery
3. Severe nasal trauma
4. Elaborate reduction and augmentation procedures
5. Marked tip deformities
6. Need for extra tip rotation
7. Correction of extreme over-projection
8. Situations where assessment of the exact pathology is difficult
9. Nasal septal perforation repair
10. Access to nasal dorsum for nasal dermoid
11. As an approach for hypophysectomy
45

46. Infiltration techniques
• 8 to 10ml of lidocaine at 1% with epinephrine at 1: 100 000 in 6 key points:
• Then cottonwoods pledges soaked in phenylephrine or cocaine ointment at 10%, are placed in both nasal cavities
• To reduce nasal mucosa congestion , improve exposure and minimize blood loss,
• It takes 15 in for full effect of vasoconstriction
46

47. Surgery of soft tissue envelope
47

48. Incisions
• broken line transcolumellar incision -- less visible scar
and less prone to contraction.
• Usually in upper two-thirds at its narrowest point, to
protect medial crural footplates (ensure adequate support )
• Commonly used incision variations include the step,
gullwing and inverted V-type ( most preferred)
• In cleft-lip rhinoplasty, a V incision made at the base of
the columella to perform a V–Y lengthening procedure
may be indicated
48

49. Incision
49
Using 11 no blade , columellar incision continues laterally with the marginal incisions made on the vestibular
skin caudal to the lower border of the medial and intermediated crura, just 2mm behind the leading edge of the
columella

50. Dissection with Iris and Converse scissor
• Converse scissor is used to dissect under the (SMAS) muscle-aponeurotic plane and dissect
superficial to the caudal margin of the LLCs and tunneling through until reaching the contralateral
marginal incision
50

51. Completing the incision while protecting the medial crura
• These blades of the scissors can then be used as a guard upon which the columella
incision is completed
51

52. Exposure of the medial crurae with development of the columella
skin flap
52

53. • Dissection over the nasal domes with
converse scissors.
• Exposure of the caudal septal cartilage by
dissection between medial crurae
53

54. /*
• Columella strut placed between medial
crurae
• Closure of incision after correction of
asymmetric bulbous tip .
• 2 layers closing to prevent cutaneous tension
• Inner : PDS ( 5-0)
• Skin : 6-0 ethilon or vicryl (upto 5-9 sutures)
• Vertical incisions : single suture or stitch
normally suffices.
54

55. • Lateral crural steal technique
55
• Undermining vestibular skin at dome area and
placement of suture
• Medial advancement of the lateral crura onto
medial crura
• Aim : To Create tip projection and rotation
Rotation and projection deformities
• Lateral crural flap/ overlay technique
• Lateral crus is transected
• The cut end then is overlapped
• The overlapped lateral crura sutured with
horizontal matress suture
• Aim : to create deprojection and rotation

56. Tip refinement
56
• Interdomal sutures approximate
the medial crura
• Transdomal sutures are
mattress-type sutures
placed across the dome
of the middle crura
• onlay tip graft is usually
placed over the dome of the
middle crura.
• infratip lobular graft
overlies the dome and
extends inferiorly a
variable distance.

57.  Assess to nasal septum
• Can be accessed by division of soft tissue between medial crura of LLC by dividing
membranous septal area
• This will disrupt one of the minor tip support mechanisms so may be best avoided (unless
cartilage graft available , to maintain post op tip projection)
• Prevent by : alternative exposure by traditional separate hemitransfixion or Killian’s
incision.
57

58.  Surgery of the bony vault
• With tip-supratip relation ship satisfactorily established, the
exact degree of bony hump is readily apparent
• Endonasal or external approach
Bony hump
• Only enough periosteum to allow removal of bony hump is
elevated over the bony dorsum
• Preserving periosteum and soft tissue attachment overlying
nasal bones and maxillary process laterally reduces trauma and
bleeding , stabilize the bony side walls
58

59. • The osteotome (Rubin / anderson) is seated at the
caudal end of the bony hump
• Then it is aligned and positioned to remove only that
amount of bone desired
• The detached fragments then removed and then
inspect for asymmetries
• If irregularities persist : smoothing the bone , shaving
with sharp osteotome, trimmed under direct vision
59

60. Osteotomy
Corner stone step for closing an open roof deformity after dorsal hump surgery
Other indications
1. To straighten deviated nasal bones
2. To narrow broad nasal dorsum
3. To reduce dorsal height
4. To out fracture or widen previously narrowed nasal bones
60

61. Medial oblique osteotomy
• A 2- to 3-mm delicate, sharp micro-osteotome is seated at the
superior extent of the bony hump removal on either side of the
bony septum
• It is then advanced cephalically and obliquely at an angle of 15
to 20 degrees outward
• Medial oblique osteotomy helps to create significant and
atraumatic narrowing and straightening of the bony pyramid,
• particularly in patients with heavy or previously fractured
nasal bones.
61

62. Intermediate osteotomy
62
• Vertical cuts made between the medial and
lateral osteotomies
• Following medial and prior lateral
osteotomy

63. Lateral osteotomy
• Lateral osteotomies are reserved for last in
rhinoplasty because it may be more traumatic .
• Additional tip refinement, septal reconstruction, or
alar base reduction surgery is completed before the
lateral osteotomies are initiated.
• If 2- or 3-mm micro-osteotomes are used : less
trauma
63

64. The position of the osteotomy described by starting
and ending points along the piriform aperture and
relative to the midline.
• A low osteotomy is positioned further off the
midline
• A High osteotomy is positioned more medially, or
higher on the lateral nasal wall.
Most preferred and recent : high - low - high
technique
• slight medial at pyriform aperture (high) ---
maxillary grove (low) --- curving superiorly and
anteriorly nasofrontal sutire line (high)
64

65. Advantage
• Starting high on the piriform aperture -- preservation of a
small triangle of maxillary bone extending medially and
anteriorly, termed “Webster's triangle
• Supports lateral nasal cartilage and prevent nasal valve
collapse
Older technique low-to-low” lateral osteotomy :
postoperative complications : midvault collapse
65

66. 66
After intersection of the low lateral osteotomy with the cephalic extent of the medial oblique
osteotomy, infraction and narrowing of the bony pyramid is ordinarily accomplished easily with
gentle medial finger pressure

67. Double level lateral osteotomy
• double-level lateral osteotomy is indicated in cases
• where there is an excessive lateral wall
convexity that could not be corrected by
standard single-level lateral osteotomy
• The more medial of the two lateral osteotomies is
first created along the nasomaxillary suture line.
•
• The more lateral of the two is then created in
standard low-to-low fashion
67

68. 68

69.  The middle nasal vault
• The ‘nasal valve area’ is the smallest cross-sectional area in the nasal airway.
• Rhinoplasty can compromise the nasal valve
• particularly in patients with short nasal bones, a high bony– cartilaginous
hump and weak upper lateral cartilages.
• Additional corresonding aesthetic defect of a ‘sunken’ or ‘pinched-in middle
third.
• There may be associated internal nasal valve collapse giving rise to nasal
obstruction
• Treated with Auto spreader graft
69

70. Spreader Grafts
• can be used
• to help stent open the internal valve
• to stabilize the septum
• and to preserve or enhance the dorsal aesthetic lines
• usually obtained from septal cartilage, measure
approximately 25-30 mm * 3 mm.
• lengthening the nose : if positioned more anterior to
anterior septal angle
• stronger dorsal aesthetic lines : if positioned more
anteriorly along the septum
• The grafts are secured with 5-0 PDS in a horizontal
mattress fashion
70

71. Augmentation rhinoplasty
• depressed nasal dorsum was commonly the result of
luetic destruction of the bony and cartilaginous
support in lower 2/3rd of nasal dorsum
• Management of the saddle nose deformity generally
involves implantation of additional material to
augment the depressed area.
71

72. Saddle nose
• Abnormal concave dorsum of the nose with
projection of nasal tip
• Can be bony, cartilageneous or both
72

73. 73

74. Implant materials
74
Implant
Natural Synthetic
1. Autograft
2. Homograft
1. Xenograft
Alloplastic materials
• Silicone rubber (silastic)
• Polytetrafluroethylene (Teflon , proplast )
• High density polyethylene
• Polyster and polyamide mesh
• Calcium phosphate based materials ( ceramic
and non ceramic based hydroxyapatite)

75. Autografts - cartilage, bone, fascia, dermis
• Advantage - no biocompatibility problems
• Disadvantage - limited quantity
- morbidity of donor site
Septal cartilage
- excellent graft for tip support
- More rigid than ear cartilage- easy to carve and shape
75

76. Pinna
- Upto 3.5cm can be excised from concha without
change in shape (keeping antihelix intact)
- Composite ear cartilage graft including skin
Costal cartilage
- Sufficient amount of cartilage
- ribs- 5 & 6, 7 & 8
- Carving technique- create boat-like technique
76

77. Bone
- Membranous bone (split calvarium) less likely to absorb than endochondral bone (iliac crest)
- Split calvarium- same operative field as rhinoplasty- incision placed 2 cm off the midline to
avoid sagittal sinus
Disadvantages
Donor site morbidity
Unnatural feeling in soft part of nose( lower 1/3rd)
77

78. 2) Homografts/ Allografts - preserved, irradiated or lyophilized cartilage and bone
Disadvantage
• long term not stable
• transmission of slow virus
3) Xenografts- processed to some degree hence semisynthetic- bovine/ porcine
collagen
Disadvantage-
• Gets resorbed and replaced by host fibrous tissue
78

79. • Carved or crushed cartilage used as graft during
rhinoplasty has some disadvantages
• Mainly that it may be perceptible through the
nasal skin after tissue resolution is complete.
• To overcome these problems and to obtain a
smoother surface Turkish delight flap is used
79
Turkish delight graft
• Wrapped piece of cartilage pieces in
fascia lata

80. Crooked nose
• It is the condition involving deviation of the nasal pyramid from the median line
• Trauma with nasal bone fracture is the most common cause
80

81. Management
1. Correction of septal deformity and spreader or auto spreader grafts
2. Osteotomy techniques
3. Extrcorporeal cartilage reshaping and repositioning techniques
81
• The Gubisch technique of extracorporeal
reshaping of the nasal septum
• C-shaped deviation of the dorsal septum and its
correction using a spreader graft on the concave side

82. Revision rhinoplasty
• revision rate between 5 and 10 percent
• The common deformities that can occur following rhinoplasty are listed below in
order of frequency of occurrence ( scott brown 7th edition)
• Pollybeaks- most common (40% )
• Dropping/ under projected tips (4%)
• uncorrected broad/ amorphous nasal tips(8%)
• irregularities on nasal dorsum (16%)
82

83. Pollybeak deformity
• defined by the typical appearance of a dorsal nasal
convexity resembling a parrot's beak.
• This dosal hump is located in the supra-tip region of the
nose which then "pushes" the tip downward causing under-
rotation
• Most commonly seen after dorsal hump reduction surgery
• The majority of pollybeak deformities are caused by two
effects.
• dropping of the nasal tip (loss of tip projection), and
• an absolute or relative high septal angle
83

84. • The most reliable technique to increase tip projection and protection is a columella
cartilage strut with fixation of the medial crura using an external approach
• If the nasal tip is still in a reasonable position after primary surgery, further reduction of
the cartilaginous dorsum may be sufficient.
• In severe cases, both structures must be addressed.
• In principle, the dorsum must be adapted to the definite position of the nasal tip.
84

85. • Directed towards patients comfort , reduction of swelling and edema, patency of nasal
airway, splint compression and stabilization of nose
• Propped up position
• Ice cold compression
• Soft diet for 2-3 days
• I.V steroid and antibiotics
• Anti-inflammatory, analgesics, sedatives
85
Post surgical consideration

86. • Nasal pack change after 48hrs in rhinoplasty and 72 hrs in SRP
• External splint removed between 5-7 days
• Important considerations
• Gentle removal of the tape and bluntly dissecting the nasal skin from overlying splint with
dull instrument
• This should be done without disrupting or tenting up the healing skin
• Failure to do so : disturbances in newly formed subcutaneous fibroblastic layer over the
nasal dorsum—leading to unwanted scarring and abrupt hematoma
• Avoid trauma, strenuous activities and excessive sunlight for few weeks
• Arrange visit 1, 3, 6 ,9, 12, 18 and 24 months to observe subtle change and educational
purpose –helps in refining the surgical techniques of surgeon
86

87. According to Robbs smith
• Immediate postoperative complications of rhinoplasty are very uncommon
• Epistaxis in absence of associated septal surgery is rare
• Lateral osteotomy causes periorbital edema and hematoma
• Oedema settles within 3-4 days
• Subconjunctival hemorrhage and bruising may take 2 weeks to resolve
87
Complications

88. According to corrective rhinoplasty by V.P sood , 2nd edition
• Hemorrhage
• Wound infection –TSS , periostitis , graft infection
• Septal complications : hematoma /abscess/ perforation
• Nasal obstruction
• Post operative retention cysts
• Necrosis of skin
• Rejection / absorption of implant or graft
• Nasal deformities : saddle nose, pollybeak deformities , pointed tip , drooping of tip ,thick
columella , caudal septal deviations, uneven dorsum
88

89. Source : Cummings Otorhinolaryngology, Head and Neck surgery, 6th
Edition
89

90. References
1. scott brown 7th and 8th edition
2. Cummings 6th and 7th edition
3. Corrective rhinoplasty by V P sood, 2nd edition
4. Open Access Atlas of Otolaryngology, Head & Neck Operative Surgery
5. Rhinoplasty archives for open approach rhinoplasty, Alwyn d’soza 2011
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