This document discusses various incisions and techniques used in rhinoplasty surgery. It describes the main incisions used including caudal septal, intercartilaginous, vestibular, infracartilaginous, and transcolumellar incisions. It then discusses techniques for accessing and mobilizing the bony nasal pyramid including different types of osteotomies. Other topics covered include hump removal, saddle nose correction, tip surgery, and correcting various tip abnormalities.

1. RAMA RAJU

2. INCISIONS
 MAIN INCISIONS
1. Caudal septal incision (hemitransfixion)
2. Intercartilaginous incision
3. Vestibular incision
4. Infracartilaginous incision
5. Transcolumellar inverted-V-incision

3. CAUDAL SEPTAL INCISION
 Aka hemitransfixion
 Made 2 mm above and
parallel to the caudal
margin of cartilaginous
septum
 Incision provides access
to;
1. Septum
2. Premaxilla and anterior
nasal spine
3. Nasal dorsum
4. Columella
5. Floor of nasal cavity

4. Intercartilaginous incision
 Is a cut made in the
vestibular skin just
cranial to the caudal
end of triangular
cartilage
 Incision starts halfway
along the lower end of
cartilage and continues
past .
 Provides access to :
1. Nasal
dorsum(cartlaginous
and bony vault)
2. Valve
3. lobule

5. Vestibular incisions
 Vestibular incision is a
slightly curved cut
made in the vestibular
skin just lateral to the
margin of pyriform
aperture.
 It is used to access:
1. Paranasal area
2. Pyriform aperture
3. Lateral wall of nasal
cavity

6. Infracartilaginous incision
 It is an incision at
the caudal margin of
the lateral crus
,dome and medial
crus of the lobular
cartilage
 It gives access to :
1. Lobular cartilages
2. Cartilaginous vault

7. Transcolumellar inverted-v-
incision:
 It is a horizontal
reversed-v- shaped
incision of the columella
at about one-third of the
distance from its base ,
it is made in
combination with
infracartilaginous
incision on both sides in
the external approach
 Access to
1. Lobular cartilages
2. Cartilaginous dorsum
3. Anterior septum

8. SPECIAL INCISIONS
 EXTERNAL
1. Labiogingival incision
2. Sublabial incision
3. Paranasal incision
4. Lateral columellar
5. Rim incision
6. Alarfacial incision
7. ‘v’ incision of
columellar base
8. Dorsal incisions
 INTERNAL
1. Transfixion incision
2. Transcartilaginous
incision
3. Incisios in the
turbinate mucosa
4. Incisions in the septal
mucosa

9. Pyramid surgery
One of basic procedures in functional
reconstructive nasal surgery
It involves
 Mobilizing the bony pyramid
 Repositioning and fixation of bony
pyramid

10. steps for mobilizing the bony
pyramid
1. Mobilizing and correcting the septum
2. Outlining the osteotomies
3. Undermining the skin over the pyramid
4. Bilateral paramedian osteotomies
5. Bilateral lateral osteotomies
6. Bilateral transverse osteotomies
7. Mobilizing the bony pyramid

11. Types of osteotomy
1. Paramedian
osteotomy
2. Lateral osteotomy
3. Transverse
osteotomy
4. Intermediate
osteotomy
5. Oblique osteotomy

12. Paramedian osteotomies:
 It separates the nasal
bone from each other
as well as from
septum ,they are
made on both sides
 The nasal bones are
separated at
intranasal suture.
 Mostly done through
intraseptal approach

13. Paramedian osteotomy
intraseptal approach technique

14. Lateral osteotomy
 It separates the
lateral bony wall of
pyramid from nasal
process of maxilla.
 A cut is made into
the bone above and
more or less parallel
to NBL

15. Lateral osteotomy through
endonasal-subperiosteal
technique

16. Transverse osteotomy
 A transverse
osteotomy
separates the bony
pyramid from the
frontal bone and the
nasal spine of the
frontal bone.
 This osteotomy is
usually made at a
level just below the
nasion

17. Transverse osteotomy through
endonasal – subperiosteal
approach

18. Repositioning the bony pyramid
 After mobilizing, bony pyramid is
repositioned using maneuvers like
1. Bilateral infracture
2. Bilateral outfracture
3. Rotation by unilateral infracture and
outfracture on opposite side
4. Rotation following u/l wedge resection
5. Push down with bilateral infracture
6. Letdown following b/l wedge resection
7. Push up

19. Bilateral infracture
 Both lateral walls of
the bony pyramid are
moved inwards
(medially).
 This requires
paramedian , lateral
and transverse
osteotomies on both
sides.

20. Bilateral outfracture
 Lateral walls of the
bony pyramid are
moved outward
(laterally), thus
widening the
pyramid and valve
area
 Requires
paramedian , lateral
and transverse
osteotomies.

21. Rotation by u/l infracture and
outfracture on opposite side
 Long ,shallow side is
infractured
 Short steep is
outfractured
 Lateral osteotomy on
the longer side is
performed somewhat
higher than on short
side so that distance
b/w osteotomies and
dorsum become
symmetrical

22. Rotation by u/l wedge rotation
 A wedge of bone is
resected at the base
of long side of
pyramid
 Used in patients with
severely deviated
bony pyramid

23. Push down with b/l infracture
 The bony pyramid is
pushed down and b/l
infractured
 Projection is reduced
and pyramid is
narrowed
 Requires resection of
basal horizontal and
posterior vertical strip
from septum in
combination with
osteotomies

24. Let down following b/l wedge
resection
 Bony pyramid is let
down after performing
osteotomies and b/l
wedge resection
 This technique allows
lowering of the bony
pyramid without
concominant
narrowing.

25. HUMP REMOVAL
 TYPES OF HUMP
1. Bony hump
2. Bony and cartilaginous hump
3. Cartilaginous hump

26. Surgical techniques:
1. Reduction by rasp and file
2. Resection
3. Push-down with infracture of pyramid
4. Let down of pyramid following bilateral
wedge resection

27. Correcting bony hump with rasp
and file
 Is performed
through
intercartilaginous
incision
 Only bony bumps
can be corrected
with this .
 Not effective on
cartilage

28. Resection of bony and/or
cartilaginous hump
 Most common way to correct bony and/or
cartilaginous hump
 Had several drawbacks
 We resect the bony part of hump first and
f/b cartilaginous part
 The bony part is resected with chisel ,f/b
smoothing the defect with rasp
 The cartilaginous hump is then resected by
using straight or angled scissors

29. Resecting bony hump
 The hump to be
resected is outlined
on the skin
 The dorsum is
approached by
combining the right
intercartilaginous with
the CSI. This is f/b
wide undermining of
the dorsal skin

30.  The skin over the
bony and
cartilaginous dorsum
is undermined
subperichondrially
and subperiosteally
 Resection is done
with chisel
 Bevel up –first part
 Bevel down-upper
part

31. Resecting a cartilaginous hump
 The triangular
cartilages are
separated
intraseptally from
septal cartilage
using no.64 beaver
knife

32.  The cartilaginous hump
is resected stepwise ,
the height of the
cartilaginous pyramid is
adjusted to the height of
the modified bony
pyramid
 The triangular cartilages
are sutured to the septal
cartilage to close the
cartilaginous pyramid

33. saddle nose correction
 Types of saddling
1. bony and cartilaginous saddle nose
2. Low , wide pyramid syndrome
3. Bony saddle
4. Cartilaginous saddling

34. Bony and cartilaginous saddle
nose
 both bony and
cartilage pyramid
severely depressed.
 Corrected by
reconstruction of
septum ,narrowing
and push up of bony
pyramid following
osteotomies and
dorsal transplant.

35. Low wide pyramid syndrome
 both bony and cartilaginous
pyramid are severely
depressed and lobule is wide
and low
 Valve area is lowered and
widened ,valve angle is
increased (>90 degress)
 Is corrected the same way as
for bony and cartilaginous
saddle nose

36. Bony saddle
 Dorsum is severely
depressed, while
cartilaginous pyramid
and cartilaginous
septum are normal
 Corrected by
narrowing and push
up of the bony
pyramid following
osteotomies and
insertion of a dorsal
transplant.

37. Cartilaginous saddling
 Cartilaginous pyramid is
severely or moderately
depressed and
broadened .
 There may be atropy or
balloning of triangular
cartilages
 Most common cause is
killian-freer submucous
septal resection
 This is corrected by
anterior rotation of
septal cartilage.

38. Surgical techniques
 Repositioning and reconstruction of
anterior septum
 Narrowing and push up of bony pyramid
following osteotomies
 Augmentation of pyramid by inserting a
dorsal implant
 Increasing lobular projection and narrowing
lobular width
 Lengthening and lowering the columella

39. Repositioning and
reconstruction the septum
 Done through CSI incision
 Through antero-superior
tunnel and inferior tunnel
,premaxilla and anterior
nasal spine is exposed
 Anterior septum is detached
from base and bony septum
 Guide wires are fixed to
caudal end of septum at its
ventrocaudal angle and its
base

40. Augmentation by dorsal implant
 Limited degree of
cartilage sagging is
corrected by
inserting crushed
sepatal cartilage
through
intercartilaginous or
caudal septal
incision.

41.  Autografts such as
conchal cartilage , rib
cartilage can be used for
augmentation.
 Inserted through IC
incision
 Undermining of dorsal
skin
 Pocked created between
two domes to accomdate
caudal end of transplant
 Held in place by external
stenting

42. Tip surgery
“The one who masters tip masters nose”
 tip surgery is never related to
improvement of function ,but is always
done for aesthetic reasons.

43. Characteristics of tip
 most prominent point or area of external
nasal pyramid
 Built by:
1. Two lobular cartilages
2. Inter-domal soft tissue
3. Overlying skin
Tip is defined by two domes ,should be visible
as separate structures.

44. Projection of tip
 Aka tip prominence
 Too high- narrow pyramid
syndrome
 Too low-wide pyramid syndrome
(saddle nose)
 Projection related to :
1. Lobular base line
2. Nasal base line
3. Prominence of bony
cartilaginous pyramid
4. Nasal lenghth

45. Position of tip
 Position of tip in vertical and horizontal
axis of face is determined by above
mentioned factors.
 Upwardly rotated tip
 Pendant or drooping tip

46. Tip abnormalities
1. Broad ,bullous,square,ball tip
2. Bifid tip
3. Asymmetrical tip
4. Underprojected tip
5. Overprojected tip
6. Upwardly rotated tip
7. Hanging (pendant ,drooping )tip

47. Broad,bullous,square,ball tip
 Broad tip- domes apart
 Bullous-domes are wide and
massive
 Square tip-domes are not
arched but rectangular
 Ball tip-domes rounded
Is due thickness of both
cartilage , lobular skin and
subcutaneous tissue
 Requires narrowing procedure
without compromising function.

48. Bifid tip
 Tip is duplicated due
to an abnormally large
distance between the
two domes with an
excessive amount of
interdomal connective
tissue.
 Requires dissection
and repositioning of
the lobular cartilage

49. Asymmetrical tip
 Domes are
asymmetrical .
 It is isolated variety
or in combination
with bifidity

50. Underprojected tip
 The projection of the tip
is abnormally low
compared with that of
bony and cartilaginous
pyramid
 Requires complete
septorhinoplasty
 Projection of domes
may be increased by
redraping the lobular
cartilage ,columellat
strut ,or by applying tip
graft

51. Overprojected tip
 it is abnormally
prominent when
compared to projection
of cartilaginous and
bony dorsum
 Requires complete
suptorhinoplasty
 Projection of domes
dimnished by redraping
of lobular cartilages or
by minor resections

52. Upwardly rotated tip
 Tip is more cranial
than normal
 Upwardly rotated tip
is usually
overprojected
 Nasolabial angle is
large

53. Hanging tip
 Tip is more caudal
than normal and
underprojected at
the same time .
 The nasolabial
angle is abnormally
smaill

54. Surgical technique
1. Narrowing tip and supratip area
2. Increasing tip projection
3. Reducing tip projection
4. Upward positioning (rotation) of tip
5. Downward positioning of tip

55. Narrowing tip and supratip area
 it is narrowed by
1. Resecting a strip or wedge of cartilage
from the cranial margin of lateral crus
2. Suturing the domes together
3. Redraping the lobular cartilage

56. Resecting a strip or wedge of
cartilage
 Done by
intercatilaginous
incision and using
retrograde
technique
 The cranial margin
of the lateral crus is
inverted by hook
and the vestibular
skin and the cranial
part of the lateral
crus is cut

57. Suturing the domes together
 Done by external
approach
 If required
resections or
incisions are made
to break the spring
 Both domes are
brought together by
suturing

58. Redraping the lobular cartilage
 Done using external
approach
 The lateral crus and dome
are dissected from
underlying vestibular skin
leaving the medial crura
 The lateral crura are
moved in ventral direction
making the domes more
projecting
 Now transcrural and
transdomal sutures applied

59. Reducing tip projection
 Reduced by various ways
1. Let down of pyramid and lobule
2. Lowering domes by dome resection
and reconstruction technique
3. Resecting strips from medial crura

60. Let down of pyramid and lobule
 when overprojected
tip is part of narrow
pyramid syndrome
 Removing of
horizontal and vertical
strip of septal cartilage
along with bilateral
wedge resection
 Procedure will
broaden lobule and
reduces tip

61. Dome resection and
reconstruction technique
 Delivery approach is
required
 Tip projection is
decreased by resecting
small strips from the
lateral and medial crus
just lateral and medial
to domes , the strips
are removed and
domes are repositioned
 The domes are sutured
to medial and lateral
crura

62. Resecting strips of medial crura
 External approach is
mandatory
 Tip projection is
decreased by resecting
nonopposing strips
from the medial crura
 The lateral ends of
lateral crura is
somewhat shortened to
allow reduction of
lateral leg of tripod

63. Upward positioning of tip
1. Resecting a triangle of cartilage from
the caudal septal end,with or without
resecting a triangle of skin from the
membranous septum
2. Trimming the cranial margin of the
lateral crus with resection of a triangle
of vestibular skin
3. Resecting a triangle of cartilage,skin
and mucosa from the lower margin of
triangular cartilage

64. Upward rotation and
shortening of
nasal length by
resections from
1. Caudal end of septum
2. The caudal margin of
lateral crura
3. The caudal margin of
triangular cartilage

65.  Upward rotation of
the tip and
shortening of nasal
length by resecting
a ventrally based
triangle of cartilage
from the caudal
septal margin

66. A triangle of
vestibular skin
resected from
membranous
septum

67. The medial part of
cranial margin of the
lateral crus is resected
together with triangle
of vestibular skin
A triangle of cartilage
is resected from the
lower margin of the
triangular cartilage

68. Increasing tip projection
1. a columellar strut (in combination with
anterior septal reconstruction)
2. A tip graft (a shield graft)
3. Redraping of the lateral crura and
domes with lateral crural steal

69. Columellar strut
 External or endonasal
approach
 Anterior septum
reconstructed
 A strut with 3mm width
and 20-25mm length
is positioned on the
anterior nasal spine
between the medial
crura
 Strut is fixed 2 or 3
transverse sutures

70. Tip graft or shield graft
 Placed by either
external approach or
CSI
 Sculpted according
to requirement
 Sutured to domes
with resorbable
sutures