primary rhinoplasty

dr sumer yadav, mch plastic and reconstructive surgery,

smeryadav2004@gmail.com

The nose is the central & most prominent feature of the face; & on its shape, size, & appearance, to a greater degree, depends the relative facial beauty of the person

A skillful dissembler may disguise, in a degree, the expression of the mouth; the hat may be slouched over the eyes; the chin may be hidden in an impenetrable thicket of beard; but the nose will stand out and `make its sign’ inspite of all precautions

Functions of the nose◦ Regulation of nasal airflow

◦ Filtration

◦ Defense against infection

aesthetics

Nasal landmarks

aesthetics

aestheticsTip define

aestheticsNaso-facial

Esthetics

Naso-labial (columellar-labial) angle

L.A◦ I.V. Sedation

◦ Topical & Infiltrative Anesthesia

G.A. with endotracheal intubation

Topical & Infiltrative Anesthesia

Volume (1%lidocaine + 1:1ooooo epinephrine)

Vestibule,aperture – 2mlDorsum – 1ml

Lateral walls – 2mlTip, columella – 2mlDistal septum – 2ml

Closed Technique

An order of procedure: six stages

Two main objectives◦ To resect the excess cartilage & thus reduce the

size of the nasal tip & permit its reshaping

◦ To weaken the cartilage between the lateral & medial crura in order that the lateral crus may lie down assume a position in harmony with the new profile of the nose

Three precautions in performing surgical modifications of the shape of the alar cartilages◦ Avoid raw areas resulting from the removal of

vestibular lining

◦ Avoid excessive removal of the cartilage to avoid a pinched deformity

◦ Avoid sharp angles & protuberances

Open techniqueBasic differences

Indications◦ Sculpting the tip cartilages

◦ Proper placement of grafts

◦ Difficult septum

◦ Straighten a crooked nose

Contraindications◦ Who have not stopped smoking 7-10 days prior to

surgery

◦ External nasal scar

◦ Thick skinned noses requiring reduction

Dorsal humps are managed acc. to their size ◦ < 5mm – rasp

◦ > 5mm – osteotome

Nasal tip surgery◦ Columellar struts(intercrural)

◦ Suture techniques

◦ Tip grafts

Five basic types of tip sutures◦ Transdomal suture

◦ Interdomal suture

◦ Lateral crural mattress suture

◦ Intercrural suture &

◦ Columellar-septal suture

Transdomal sutureFirst suture

Domal creation suture of Daniel

Dome spanning suture of Tebbetts

Dome suture

Interdomal sutureDomal equalization suture of Daniel

Medial fixation suture of tebetts

Intercrural suture

Flare control suture

Columellar-septal sutureOrthopedic suture

Projection control suture

Tip rotation suture

OsteotomiesMedial oblique osteotomy

Indications◦ The secondary rhinoplasty deformity with loss of

alar cartilage◦ The secondary `polly tip’ deformity with loss of

definition of the profile line◦ The hypo plastic tip◦ The tethered lip◦ Congenital deformities `cleft lip nasal deformity’◦ The plunging tip with caudal angulations of alar

cartilage◦ the thick skinned tip with loss of anatomic

definition

Adjunctive techniques

Indications◦ To reduce the size of the nostrils

◦ To aid in recessing the tip &

◦ To reduce the flaring

It is designed to safe guard the integrity & preserve the physiologic mechanism of the nasal valve

It also provides an excellent exposure of the septal framework when correction of a septal deviation is required during the rhinoplasty

Contraindicated in very large nose because of the excess of mucous membrane that remains after the reduction of the nose

Tip exposure techniqueHockey stick incision

Popularized by Brown & McDowell (1951)

Tip exposure Retrograde technique

Tip exposureEversion technique

Projecting tip◦ Excessively projecting tip, `the Pinocchio nose’

require shortening & recession

◦ Whether tip is projecting or is the dorsum recessed

◦ If dorsum is recessed , the dorsal profile elevated by the cartilagenous graft with minimal tip surgery

Condition that become more accentuated with the aging

Anatomic basis of this deformity can vary◦ The septum is long, invading the lip & the

ligamentus attachments of the alar cartilages to the septal angle are adequate or

◦ 2nd type shows, on digital distraction, a lack of continuity between the tip of the nose & the septal angle

Extensive submucus resection rarely required

Conservative measures◦ Resection of bony spur /obstructive portion of

septum

◦ By incising the base of the septum, replacing it into the vomer groove

◦ Shaving areas of thickened septal cartilage

◦ Straightening a curved dorsal border of septum

◦ Straightening the dislocated caudal portion of septum

Saddle noseDepression of the dorsum of the nose

may occur in the bony or cartilagenous portion; when both are

affected termed saddle nose

Hemorrhage Infection Mucus cyst Necrosis Functional Iatrogenic◦ Tip ptosis◦ Alar retraction◦ Pollybeak◦ Nasofrontal angle◦ Saddle nose

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