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36 Part V: Clinical Case 4 213
https://t.me/medicina_free
Preoperative
Postoperative
Right Lateral
Left Lateral
Right Lateral
Smiling
Left Lateral
Smiling
Preoperative
Postoperative
Right Lateral
Middle Third
Left Lateral
Middle Third
Part V: Clinical Case 5
https://t.me/medicina_free
37
Preoperative Assessment
1. Frontolateral walls
a. Bulbous tip overshadowing the alae nasi (frontal and
direct dorsal views).
2. Medial wall
Nil of note.
3. Bony pyramid
Wide base of the bony pyramid (Frontal, Direct Dorsal
Views).
4. Alar base
a. The nasal openings are irregular and dissimilar in
shape, yet they are similar in size.
b. The right nasal opening is triangular in shape, while
the left nasal opening is pear shaped (Basal Views).
c. The posterior alar margin is attached to the upper lip at
the lower level than the columella.
Aims of Surgery
1. Reduction of the size and bulk of the bulbous tip.
2. Creating better tip definition and better tip projection.
3. Narrowing the side walls of the bony pyramid and elevation of nasal dorsum.
4. Reduction of the size of the alar base.
Surgical Plan
1. Frontolateral walls
a. DDD including the weak triangle.
b. Cephalic trim of the lateral crurae.
2. Media wall
Nil of note.
3. Bony pyramid
Osteotomies and medialization of the lateral bony walls.
4. Alar base
Resection of the inferior segments of the rim sill folds.
Surgical Procedure
a. As per Surgical Plan.
b. Crushed cartilage tip graft was necessary.
Post-operative Analysis
1. Frontolateral wall
a. Tip definition: There is better definition of 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).
2. Medial wall
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 a regular one 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
and excision of the inferior segments of the rim-sill
© 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_37
215
216 37 Part V: Clinical Case 5
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folds. 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. Excision of the inferior segments of the rim sill folds
has elevated the alar margins to the same level as the
columella. The lateral columellar margin is seen
post-operatively in the Oblique views.
d. Alae nasi aesthetics improved. They are pulled
medially become better seen, smaller in size and
share in nasal aesthetics. (Nasal Aperture, Oblique
and Lateral Views).
e. Nasal aperture aesthetics improved: The nasal open-
ings are smaller in size, yet the shapes remain
as different as before. If the sizes of the two nasal
openings were widely different, they appear strikingly
unaesthetic whether they are the same shape or not.
They do not appear unaesthetic if they have the same
size and different shapes.
f. 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 has mixed Asian and African facial features.
The forehead and cheeks are large and wide as commonly seen in Asians. The mouth is large with thick lips
as commonly seen in Africans. The nose is mixed small
Asian type and thick skinned bulky Africa type.
b. The shortcomings of the primary surgery: i. The nasal tip
was not touched and remained bulky and bulbous
looking. ii. No attempt was made to reduce the width and
increase the height of the bony pyramid. iii. The size of
the alar base was not sufficiently reduced.
c. The middle third photography is important in this lady as
the nose is comparatively small to the surrounding large
cheeks and forehead.
d. Changes in the small nose may seem unimpressive but if
the large forehead and cheeks are excluded then these
changes are quite noticeable and aesthetically pleasing, especially to the patient who is quite consci ous of.
Preoperative
Postoperative
Frontal
Frontal
Smiling
Frontal
Middle Third
37 Part V: Clinical Case 5 217
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Direct Dorsal
Direct Dorsal
Preoperative
Smiling
Preoperative
Postoperative
Steeper
Backward Tilting Backward Tilting
Basal
Basal
Smiling
Postoperative
218 37 Part V: Clinical Case 5
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Preoperative
Postoperative
Right Nasal
Aperture
Right Nasal
Aperture
Rim Sill Test
Left Nasal
Aperture
Rim Sill Test
Left Nasal
Aperture
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
37 Part V: Clinical Case 5 219
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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
220 37 Part V: Clinical Case 5
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Preoperative
Postoperative
Right Lateral
Middle Third
Left Lateral
Middle Third
Part V: Clinical Case 6
https://t.me/medicina_free
38
Preoperative Assessment
1. Frontolateral walls
a. Bulbous tip, partially overshadowing the alae nasi
predominantly the left side. (Frontal and Direct Dorsal Views).
2. Medial wall
a. Right caudal septal deviation (Backward Tilting and
Right Nasal Aperture Views). The medial crus is
pushed laterally i.e. lateral crural prominence (Basal
Views).
b. Slightly mobile tip (Lateral Smiling Views).
3. Bony pyramid
a. Wide base of bony pyramid (Frontal, Direct Dorsal
and Backward Tilting Views).
b. Osteocartilaginous hump deviated to the left due to
bilateral maxillary asymmetry. The right cheek is
wide and low, the left cheek is high and narrow
(backward tilting views).
c. Deep nasofrontal angle (Lateral, Oblique, Backward
Tilting and Frontal Views).
4. Alar base
a. Asymmetrical smile. On smiling, the right cheek is
larger in size and different in shape than the left cheek
and the right ala nasi is larger and more prominent
than the left. (preoperative Smiling Frontal view).
b. Nasal apertures are thick walled and encroached upon
by lateral crural prominences of the medial crurae.
There was apparent asymmetrical sizes of the two
nasal openings due to protrusion of the right caudal
cartilaginous septum into the right nasal aperture
(Backward Tilting, Basal and Nasal Aperture Views).
Aims of Surgery
1. Reduction of thickness frontolateral walls.
2. Reduction of the height and size of the bony pyramid.
Adjusting the obliquity of the pyramid.
3. Providing extra length to the nose i.e. giving the nose its
normal natural length by leveling the nasofrontal
depression with the nasal dorsum.
Surgical Plan
1. Frontolateral walls
D. D. D. including the weak triangle to reduce the bulk of
nasal tip.
2. Medial wall
a. Septoplasty to correct the right septal caudal
deviation.
b. Division of depressor septi muscles.
3. Bony pyramid
a. Excision of osteocartilaginous hump.
b. Osteotomies and Kassanjean maneu ver to the right
i.e. cross fracture of the bony pyramid after osteotomies (see Surgery of the Bony Pyramid in the text).
c. Filling the nasofrontal angle using a septal graft.
4. Alar base
Transcrural stitch to medialize the lateral crural
prominences.
Surgical Procedure
a. As per surgical plan.
b. An accurately measured cartilaginous septal graft was
used to fill the nasofrontal depression. Deep longitudinal
scoring were made on one side to give the graft the same
external rounded surface as the nasal dorsum. Further
height was provided to the graft by inserting more graft
material on the concave side.
c. The transcrural stitch: a no. 3/0 nylon transfixing stitch
on a straight needle is passed across the two medial
crurae, going superior and then coming back inferior to
the inferior vestibular bands on both sides (see Surgery
of Columella in the text). The stitch is remove in
4–6 weeks.
© 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_38
221
222 38 Part V: Clinical Case 6
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Post-operative Analysis
1. Frontolateral walls
a. Tip definition, the nasal tip lost its bulk and became
nice and slim with thinner skin, matching with her
facial features. (Frontal, Direct Dorsal, Backward
Tilting and Basal Views). The alae nasi came into
view to share in nasal aesthetics. They became of
almost equal sizes.
b. Tip projection. The tip is at the same height as the
nasal dorsum with good angle. This is coupled with
excellent nasolabial angle. (Lateral and the Oblique
views).
c. Tip light reflex is seen as one spot off the nasal
tip. (Frontal and Backward Tilting Views).
2. Medial wall
a. The lateral crural prominences disappeared especially
on the right side after septoplasty and the trans-crural
stitch (Backward Tilting, Basal and Right Nasal Aperture Views).
b. Caudal deviation of the septum.
3. Bony pyramid
a. Bony pyramid aesthetics improved: the nasal dorsum
is straight and the sidewalls are smoo th and narrow.
Filling the deep naso-frontal angle have added an
extra length to nasal dorsum. The long nose matches
better with the tall stature of the patient (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. There are wider posterior groove angles. (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 improved by defatting only
of the frontolateral walls. The aperture look more
elegantly oval in shape. The nasal apertures became
similar in size after reducing the caudal septal deviation and the lateral crural prominences.
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
1. Post-operative photographs were taken five years after
surgery.
2. All goals of surgery were achieved so that:
a. She has a high dorsum, long nose, the size and length
of which matches perfectly with size and length of her
face and body.
b. The body of the left ala nasi become clearer and
bigger after defatting the frontolateral walls. The two
alae are closer in size to each other than before
surgery.
c. There was visual improvement of the epicanthi
especially to left one.
38 Part V: Clinical Case 6 223
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Preoperative
Postoperative
Frontal
Frontal
Smiling
Frontal
Middle Third
Preoperative
Postoperative
Direct Dorsal
Direct Dorsal
Smiling
Overhead
Overhead
Smiling
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