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22 Part III: Clinical Case 10 137
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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
Preoperative
Postoperative
Right Lateral
Left Lateral
Right Lateral
Smiling
Left Lateral
Smiling
138 22 Part III: Clinical Case 10
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Preoperative
Postoperative
Right Lateral
Middle Third
Left Lateral
Middle Third
Part III: Clinical Case 11
https://t.me/medicina_free
23
Preoperative Assessment
1. Frontolateral walls
Large and bulky tip overshadowing the alae nasi (Frontal
Views).
2. Nasal Septum
Protruding columella (lateral and oblique views).
3. Bony pyramid
a. Wide base of the bony pyramid (Backward Tilting
Views).
b. Small osteocartilagenous hump (Oblique and Lateral
Views).
4. Alar base
a. Wide alar base due to long inferior segments of
rim-sill folds (Backward Tilting and Basal Views).
b. Long and thick inferior segments of the rim sill folds
have given the nasal apertures quadrangular shapes
(Basal Views).
Aims of Surgery
1. Reduction of the tip size and bulk.
2. Reduction of the protruding columella.
3. Reduction of the size of the boney pyramid and excision
of the hump.
4. Improve aesthetics of the alar base.
Surgical Plan
1. Frontolateral walls
DDD including the weak triangle.
2. Nasal Septum
Septoplasty and trim of the caudal 2mm of the cartilagenous septum.
3. Bony pyramid
a. Excisionof the osteocartilaginous hump.
b. Osteotomies and medialization of the lateral bony
walls.
4. Alar base
Bilateral resection of the inferior segments of the rim sill
folds.
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 View).
2. Medial Wall
Collumelar protrusion is corrected. The alae nasi have
excellent aesthetic relations with the columella (Lateral
and Oblique Views).
3. Bony Pyramid
Bony pyramid aesthetics improved: the nasal dorsum is
straight and the sidewalls are smooth and narrow (all
views except the Basal 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 defatting
as well as excising the inferior segments of the
rim-sill folds. The flat tire appearance of the alae
nasi on the upper lip is no longer present i.e. the
© 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_23
139
140 23 Part III: Clinical Case 11
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posterior alar groove angle is wider (Backward Tilting, Basal 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:
i. The size of the nasal openings are reduced by
defatting as well as excising the inferior segments of the rim-sill folds. (Backward Tilting,
Basal and Nasal Aperture views).
ii. The shapes of nasal openings improves by
defatting and excision of the rim-sill folds
transforming the nasal apertures from thick
Preoperative
heavy wide and quadrangular opening to thin
delicate small oval openings with anterior long
axes (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).
iii. Lateral crural prominences (Lateral Views).
Commentary
All of the four areas of Rhinoplasty are minimally addressed
in this finesse case viz the nasal tip, bony pyramid, the nasal
septum and alar base.
Frontal
Postoperative
23 Part III: Clinical Case 11 141
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Preoperative
Postoperative
Right Oblique
Cheek Margin
Middle Third
Left Oblique
Cheek Margin
Middle Third
142 23 Part III: Clinical Case 11
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Preoperative
Postoperative
Right Lateral
Left Lateral
Part III: Clinical Case 12
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24
Preoperative Assessment
1. Frontolateral walls
Slightly bulbous frontolateral walls overshadowing both
ali nasi predominantly the right side (Frontal, Overhead
and Direct Dorsal Views).
2. Medial Wall
a. Left caudal septal deviation and dislocation. The left
medial crus is pushed laterally and the left nasal sill
band is displaced inferiorly (frontal, backward tilting,
Basal and Left Nasal aperture views).
b. Protruding columella. The lateral surfaces of the
medial crurae are exposed. It is not quite a hanging
columella (lateral and oblique views).
3. Bony pyramid
a. Osteocartilagenous hump, predominantly carti lagi-
nous. The hump is oblique to the left due to minor
bilateral maxillary asymmetry. The right cheek is
wide and low while the left cheek is narrow and high
(backward tilting view).
b. Wide base of bony pyramid (Direct Dorsal, Overhead
and Backward Tilting View).
c. The nose is long. It looks as if pulled forward with
dissociation between the upper third and lower two
thirds.
4. Alar base
The left nasal aperture is encroached upon by the left
caudally deviated cartilaginous septum (Basal and Left
Nasal Aperture Views).
Aims of Surgery
1. Reduce the bulk of the frontolateral walls.
2. Correction of the columellar protrusion.
3. Reduction of the size of the bony Paremyd and
mid-vault.
Surgical Plan
1. Frontolateral walls
DDD including the weak triangle to reduce the bulk.
2. Medial Wall
Septoplasty and trim of few millimeters from the caudal
septum. Trim of the anterior septal margin to reduce the
nasal height.
3. Bony pyramid
a. Excision of the osteocartilagenous hump, as well as
trim of few millimeters off the dorsal septum down to
the anterior septal angle.
b. Osteotomies and medialization of lateral bony walls.
4. Alar base
Nil of Note.
Surgical Procedure
As per surgical plan.
Post-operative Analysis
1. Frontolateral Wall
a. Tip definition: the 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).
© 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_24
143
144 24 Part III: Clinical Case 12
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2. Medial Wall
a. Correction of caudal deviation.
b. Protruding columella disappeared.
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 (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 defatting
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. (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 after defatting and
correction of caudal septal deviation:
i. The size of the two nasal openings became equal.
ii. The shapes are 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
a. Three of the four Rhinoplasty areas were addressed i.e.
the front olateral walls, medial wall and the bony pyramid.
b. There was minimal fat over the middle and lateral crurae,
yet defatting had positive aesthetic effects.
c. Maintaining her original image i.e. “nasal print“, the
patient is more attractive with positive psychological
impact. Friends and relatives did not notice the changes
in her nose and face. They thought she was on a diet or
changed her makeup.
d. The dissociation between the upper third and the lower
two thirds of the nose disappeared. The nose is now one
unit, smaller than before.
24 Part III: Clinical Case 12 145
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146 24 Part III: Clinical Case 12
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Basal
Basal
Preoperative
Postoperative
Smiling
Preoperative
Po&operative
Right Nasal
Aperture
Right Nasal
Aperture
Rim Sill Test
Left Nasal
Aperture
Rim Sill Test
Left Nasal
Aperture
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