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116 19 Part III: Clinical Case 7
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3. Bony pyramid
a. Excision of the osteocartilaginous hump.
b. Osteotomies with Kassanjian maneuver to the left i.e.
cross fracture of the bony pyramid after osteotomies
(see Surgery of the Bony Pyramid in Text).
4. Alar base
a. Bilateral resection of the posterior and inferior seg-
ments of the rim sill folds.
Surgical Procedure
a. As per Surgical Plan.
b. Division of the Depressor Septi muscles was done
intranasally.
Post-operative Analysis
1. Frontolateral Wall
a. Tip definition:
i. The tip is smaller with thinner overlying skin. It
is more prominent and well identified from the
alae nasion both sides. The alae nasi become
clearly visible (Frontal, Direct Dorsal, Overhead,
Backward Tilting and Basal Views).
ii. Defatting of the middle crurae in this case was
sufficient to bring the two domes closer together
overcoming the bifidity. There was no need to
further approximate the domes by stitching.
iii. The supra tip depression disappeared after
removing the prominent margins of the lateral
crurae.
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
a. Medial wall aesthetics improved after septo plasty.
Columella becomes centrally in midline. Nasal apertures are closer in shape to each other.
b. Mobility of the tip was abolished.
3. Bony Pyramid
a. Bony pyramid aesthetics improved: the nasal dorsum
is straight and the sidewalls are smooth and narrow
(all views except the Basal Views).
b. Dorsal light reflex appears as a straight line post-
operatively as compared to the interrupted reflex
pre-operatively (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: the posterior segments of
rim-sill folds were incompletely removed. This
resulted in left sided angulation. Nevertheless the
angle of the alae nasi with the upper lip improved
with better looking alae nasi and improved posterior
alar groove aesthetics.
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: improve alar groove aes-
thetics after defatting and excision of the rim-sill
folds:
i. The sizes of nasal apertures are smaller.
ii. The shapes of nasal apertures became closer to
each other in shapes and more elegantly oval.
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).
Commentary
The post operative nasal aperture view should have clear
arrow and writings on the Photograph and under the photograph. This is not seen in the displayed photograph.
a. All four areas were addressed in this case. The outcome
is a more refined nose that kept its original features and
nasal print.
b. Alar flare was greatly reduced after excision of the
inferior segments of the rim-sill folds.
19 Part III: Clinical Case 7 117
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Postoperative
Frontal
Frontal
Smiling
Frontal
Middle Third
Preoperative
Postoperative
Direct Dorsal
Direct Dorsal
Smiling
Overhead
Overhead
Smiling
118 19 Part III: Clinical Case 7
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Preoperative
Postoperative
Steeper
Backward Tilting Backward Tilting
Right Nasal
Right Nasal
Aperture
Aperture
Rim Sill Test
Basal
Left Nasal
Aperture
Rim Sill Test
Basal
Smiling
Left Nasal
Aperture
Preoperative
Postoperative
Note: The pale area of the
rim sill fold.
19 Part III: Clinical Case 7 119
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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
Preoperative
Postoperative
Right Oblique
Cheek Margin
Full Face
Left Oblique Right Oblique
Cheek Margin Cheek Margin
Full Face Middle Third
Left Oblique
Cheek Margin
Middle Third
120 19 Part III: Clinical Case 7
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Preoperative
Postoperative
Right Lateral
Left Lateral
Right Lateral
Left Lateral
Preoperative
Postoperative
Right Lateral
Middle Third
Left Lateral
Middle Third
Part III: Clinical Case 8
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20
Preoperative Assessment
1. Frontolateral Wall
Nil to note.
2. Medial Wall
Nil to note.
3. Bony Pyramid
a. Low dorsum (Backward Tilting, Oblique and Lateral
Views).
b. Wide base of the bony pyramid (Frontal, Backward
Tilting, Oblique and Lateral Views).
4. Alar base
Wide and thick alar base due to long inferior segments
and thick posterior segments of the rim-sill folds.
Aims of Surgery
1. To elevate and narrow the nasal dorsum.
2. Reduce the alar base width and thickness.
Surgical Plan
1. Frontolateral walls
Nil to note.
2. Nasal septum
Nil to note.
3. Bony pyramid
a. Bilateral osteotomies and medialization of the lateral
bony walls.
b. Dorsal augmentation using a septal graft.
4. Alar base
Bilateral resection of the posterior and inferior segments
of the rim-sill folds.
Surgical Procedure
As per Surgical Plan.
Post-operative Analysis
1. Frontolateral Walls
Nil of Note.
2. Medial Walls
Nil of Note.
3. Bony Pyramid
a. Bony pyramid aesthetics improved: 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 (Frontal Views).
4. Alar Base
a. Posterior alar groove aesthetics improved after exci-
sion of the rim-sill folds. They have wider angels with
the upper lip and the thick posterior segments of the
rim-sill folds are gone.
b. Alae nasi aesthetics improved. They are pulled
medially become better seen, smaller and share in
nasal aesthetics (Nasal Aperture, Oblique and Lateral
Views).
c. Nasal aperture aesthetics improved: the size are
smaller and the shapes are oval.
d. 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).
Commentary
a. This lady needed minimal surgery to only two of the four
areas of Rhinoplasty to achieve the aesthetic goal. These
two areas are:
1. The bony pyramid : osteotomies and dorsal augmentation.
2. The alar base: Resection of the rim-sill folds.
b. The overall aesthetics of the nose improved. It became
slimmer, higher with smaller nasal apertures.
© 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_20
121
122 20 Part III: Clinical Case 8
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Postoperative
Frontal
Frontal
Middle Third
Preoperative
Postoperative
Steeper
Backward Tilting Backward Tilting
g
20 Part III: Clinical Case 8 123
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Preoperative
Postoperative
Right Nasal
Aperture
Right Nasal
Aperture
Rim Sill Test
Right Oblique
Mid Cheek
Full Face
Left Nasal
Aperture
Rim Sill Test
Left Oblique
Mid Cheek
Full Face
Left Nasal
Aperture
POSTERIOR
SEGMENT
SCAR
INFERIOR
SEGMENT
SCAR
The scar of the posterior
segment is above the posterior
roove.
alar
Preoperative
Postoperative
124 20 Part III: Clinical Case 8
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Preoperative
Postoperative
Right Oblique
Cheek Margin
Full Face
Left Oblique Right Oblique
Cheek Margin Cheek Margin
Full Face Middle Third
Right Lateral
Left Lateral
Left Oblique
Cheek Margin
Middle Third
Preoperative
Postoperative
20 Part III: Clinical Case 8 125
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Preoperative
Postoperative
Right Lateral
Middle Third
Left Lateral
Middle Third
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