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15 Part III: Clinical Case 3 93
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Preoperative
Postoperative
Direct Dorsal
Direct Dorsal
Smiling
Steeper
Backward Tilting Backward Tilting
Overhead
Basal
Overhead
Smiling
Basal
Smiling
Preoperative
Postoperative
Preoperative
Right Nasal
Aperture
Right Nasal
Aperture
Rim Sill Test
Left Nasal
Aperture
Rim Sill Test
Left Nasal
Aperture
Postoperative
94 15 Part III: Clinical Case 3
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Preoperative
Postoperative
Right Oblique
Mid Cheek
Full Face
Right Oblique
Cheek Margin
Full Face
Left Oblique
Mid Cheek
Full Face
Right Oblique
Mid Cheek
Middle Third
Left Oblique Right Oblique
Cheek Margin Cheek Margin
Full Face Middle Third
Left Oblique
Mid Cheek
Middle Third
Left Oblique
Cheek Margin
Middle Third
Preoperative
Postoperative
15 Part III: Clinical Case 3 95
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Preoperative
Postoperative
Right Lateral
Left Lateral
Right Lateral
Middle Third
Right Lateral
Smiling
Left Lateral
Middle Third
Left Lateral
Smiling
Preoperative
Postoperative
Part III: Clinical Case 4
https://t.me/medicina_free
16
Preoperative Assessment
1. Frontolateral walls
Small but bulky bulbous tip, overshadowing the appearance of the alae nasi (Frontal, Direct Dorsal and Overhead
views).
2. Medial Wall
Nil of note.
3. Bony pyramid
Wide base of the bony pyramid (Frontal, Direct Dorsal,
Overhead and Backward Tilting views).
4. Alar base
Nil of note.
Aims of Surgery
1. Reduce the size and bulk of the nasal tip.
2. Reduce the width of the base of the bony pyramid.
Surgical Plan
1. Frontolateral walls
DDD not including the weak triangle to reduce the bulk.
2. Medial Wall
Nil of note.
3. Bony pyramid
Osteotomies and medialization of the lateral bony walls.
4. Alar base
Nil of note.
Surgical Procedure
As per Surgical Plan.
Post-operative Analysis
1. Frontolateral Wall
a. Tip Definition: nasal tip is smaller with thinner and
smoother overlying skin. It is more prominent and
well identified from the alae nasi on both sides. The
alae nasi come into view to become clearly visible
and share in nasal aesthetics (Frontal, Direct Dorsal,
Overhead, Backward Tilting and Basal Views).
b. Tip projection: The nasal tip at the same level of the
nasal dorsum with good aesthetic angle. This is
coupled with good aesthetic nasolabial angle (lateral
and oblique views).
c. Tip light reflex is seen as one spot off the nasal tip
(Frontal and Backward Tilting Views).
2. Medial Wall
Nil of Note.
3. Bony Pyramid
a. Bony pyramid aesthetics: the nasal dorsum is straight
and the sidewalls are smooth and narrow (all views
except the Basal Views).
b. Dorsal light reflex is seen as an uninterrupted line off
the nasal dorsum (Direct Dorsal Views).
4. Alar Base
a. Superior alar groove aesthetics improved by defatting.
The grooves become longer and deeper (Oblique,
Lateral and Direct Dorsal grooves).
b. Posterior alar groove aesthetics improved by Defat-
ting alone. The defatted crurae are pulled medially as
they become semidetached from the alae nasi, by the
defatted superior alar grooves. The angles of the
posterior alar grooves with the upper lip become
wider. Aesthetics of the alae nasi improved (Backward Tilting and Nasal Aperture Views).
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty,
https://doi.org/10.1007/978-3-031-12271-2_16
97
98 16 Part III: Clinical Case 4
https://t.me/medicina_free
c. Alae nasi aesthetics improved. They are pulled medially
become better seen, smaller and share in nasal aesthetics
(Nasal Aperture, Oblique and Lateral Views).
d. Nasal aperture aesthetics improved by defatting:
i. The size of the nasal openings are reduced.
ii. The shape of nasal openings become more ele-
gantly oval on shape with thinner walls (Backward Tilting, Basal and Nasal Aperture views).
e. Marginal light reflexes are clearly seen at:
i. Inferior alar margins (Nasal Aperture Views).
ii. Nasal sill bands (Oblique Views).
Frontal
Preoperative
iii. Lateral crural prominences (Lateral Views).
Commentary
Only two areas of Rhinoplasty needed to be addressed in
these types of Finesse Rhinoplasty i.e. the nasal tip and the
bony pyramid. Debulking of the first and reducing the size of
the latter have given the nose the extra sharp and defined
appearance with no change in the nasal image and nasal
print. The nose looked more neat and attractive in an originally attractive nose and face.
Frontal
Smiling
Frontal
Middle Third
Postoperative
Preoperative
Postoperative
Direct Dorsal
Direct Dorsal
Smiling
Overhead
16 Part III: Clinical Case 4 99
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Preoperative
Preoperative
Postoperative
Right Nasal
Aperture
Backward Tilting Backward Tilting
Steeper
Right Nasal
Left Nasal
Aperture
Rim Sill Test
Rim Sill Test
Aperture
Basal
Left Nasal
Aperture
Postoperative
Preoperative
Postoperative
Right Oblique
Mid Cheek
Full Face
Left Oblique
Mid Cheek
Full Face
Right Oblique
Mid Cheek
Middle Third
Left Oblique
Mid Cheek
Middle Third
100 16 Part III: Clinical Case 4
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Preoperative
Postoperative
Right Oblique
Cheek Margin
Full Face
Right Lateral
Left Oblique Right Oblique
Cheek Margin Cheek Margin
Full Face Middle Third
Right Lateral
Left Lateral
Smiling
Left Oblique
Cheek Margin
Middle Third
Left Lateral
Smiling
Preoperative
Postoperative
16 Part III: Clinical Case 4 101
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Preoperative
Postoperative
Right Lateral
Middle Third
Left Lateral
Middle Third
Part III: Clinical Case 5
https://t.me/medicina_free
1. Frontolateral walls
a. Large bulbous and bulky tip which semi-separated
from the upper two thirds of the nose (Frontal Views).
b. The Bulky tip completely overshadowed the alae
nasi on both sides (Frontal and Direct Dorsal Views).
2. Medial Wall
Slight columellar protrusion (Lateral Views).
3. Bony pyramid
a. Wide base of the bony pyramid (Frontal, Direct
Dorsal and Backward Tilting Views).
b. Small osteocartilagenous hump (Oblique and Lateral
Views). This is the natural concavoconvex anatomy
of the nasal bones from above downwards (see
Anatomy Section in the Text).
4. Alar base
The nasal opening were unpleasantly thick walled and
rounded in shape (Backward Tilting, Basal and Nasal
Aperture Views).
1. Reducing the bulk of the frontolateral walls.
2. Overall reduction of the nasal size.
3. Reduction of the nasal hump.
1. Frontolateral walls
a. DDD including the weak triangle to reduce the bulk.
b. Cephalic trim of lateral crurae to reduce the size.
2. Medial Wall
Nil of note.
3. Bony pyramid
a. Excision of the osteocartilaginous hump.
b. Osteotomies and medialization of the lateral bony
walls.
17
4. Alar base
Nil of note.
As per Surgical Plan.
1. Frontolateral Wall
a. Tip Definition: nasal tip is smaller with thinner and
smoother overlying skin. It is more prominent and
well identified from the alae nasi on both sides. The
alae nasi come into view to become clearly visible
and share in nasal aesthetics (Frontal, Direct Dorsal,
Overhead, Backward Tilting and Basal Views).
b. Tip projection: The nasal tip at the same level of the
nasal dorsum with good aesthetic angle. This is
coupled with good aesthetic nasolabial angle (lateral
and oblique views).
c. The nasal tip is integrated with the upper two thirds of
the nose. The dissociation between the two components disappeared.
d. Tip light reflex is clear as one spot off the nasal tip
(Frontal and Backward Tilting View).
2. Medial Wall
Columellar protrusion was reduced.
3. Bony Pyramid
a. Bony pyramid aesthetics: the nasal dorsum is straight
and the sidewalls are smooth and narrow (all views
except the Basal Views).
b. Dorsal light reflex is seen as an uninterrupted line off
the nasal dorsum (Direct Dorsal Views).
4. Alar Base
a. Superior alar groove aesthetics improved by defatting.
The grooves become longer and deeper (Oblique,
Lateral and Direct Dorsal grooves).
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty,
https://doi.org/10.1007/978-3-031-12271-2_17
103
104 17 Part III: Clinical Case 5
https://t.me/medicina_free
b. Posterior alar groove aesthetics improved by Defat-
ting alone. The defatted crurae are pulled medially as
they become semidetached from the alae nasi, by the
defatted superior alar grooves. The angles of the
posterior alar grooves with the upper lip become
wider. Aesthetics of the alae nasi improved (Backward Tilting and Nasal Aperture Views).
c. Alae nasi aesthetics improved. They are pulled medially
become better seen, smaller and share in nasal aesthetics
(Nasal Aperture, Oblique and Lateral Views).
d. Nasal aperture aesthetics improved by defatting:
i. The sizes of the nasal openings are reduced.
ii. The shape of nasal openings become more ele-
gantly oval on shape. (Backward Tilting, Basal
and Nasal Aperture views).
Frontal
e. Marginal light reflexes are clearly seen at:
i. Inferior alar margins (Nasal Aperture Views).
ii. Nasal sill bands (Oblique Views).
iii. Lateral crural prominences (Lateral Views).
Defatting the middle and lateral crurae have released the
frontolateral skin from the binding subdermal bands that
connect the dermis to the envelops of fatty capsules of the
crurae. (See Anatomy of the Skin).
The skin becomes softer, thinner, smoother and continuous with the upper lateral skin. The demarcation and dissociation between the lower third and upper two third thus
naturally overcome (see Anatomy of Nasal Skin in Text).
Frontal
Smiling
Frontal
Middle Third
Postoperative
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