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224 38 Part V: Clinical Case 6
https://t.me/medicina_free
Preoperative
Postoperative
Steeper
Backward Tilting Backward Tilting
Right Nasal
Aperture
Basal
Basal
Smiling
Left Nasal
Aperture
Preoperative
Po&operative
38 Part V: Clinical Case 6 225
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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
226 38 Part V: Clinical Case 6
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Preoperative
Postoperative
Right Lateral
Left Lateral
Right Lateral
Smiling
Left Lateral
Smiling
Preoperative
Postoperative
Right Lateral
Middle Third
Left Lateral
Middle Third
Part VI
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al ConditionsSpecial Clinic
Part VI: Clinical Case 1
https://t.me/medicina_free
39
Preoperative Assessment
1. Frontolateral walls
Nil of note.
2. Medial wall
Left caudal septal deviation. (Basal Views).
3. Bony pyramid
Wide base of bony pyramid.
4. Alar base
a. Wide alar flare on smiling due to long inferior seg-
ments of the rim-still folds.
b. Asymmetrical smile. The left ala nasi and left naso-
labial fold was at higher level and more lateralized on
smiling. The left cheek ball is different in size and
shape from the right cheek ball (Frontal Smiling
Views).
c. Asymmetrical sizes of nasal openings due to right
caudal septal deviation that encroach upon the right
nasal aperture.
Aims of Surgery
The main target in of surgery not only to reduce the width of
the alar base, on smiling, but also to reduce the size of the
lower third of the nose that became wide on smiling.
Surgical Plan
1. Frontolateral walls
Nil of note.
2. Medial wall
Septoplasty to overcome asymmetrical sizes of the nasal
apertures after reduction of alar base.
3. Bony pyramid
Bilateral osteotomies. The side walls of the bony pyramid
had to be medialised to match the medialization of the
alae nasi after alar base reduction.
4. Alar base
a. Bilateral resection of the inferior segments of the
rim-still folds.
lar floors up to the mucocutaneous junction.
Surgical Procedure
As per surgical plan.
Post-operative Analysis and Commentary
a. The request of the patient was quite simple, and the the
surgical solution apparently looked equally simple i.e. no
more than excision of the rim-still folds. But in fact there
was some other considerations that the surgeon had to
deal with:
i. Septoplasty was a must otherwise nasal apertures
would become unequal. Although asymmetrical
smile continued postoperatively yet it was less noticeable.
ii. Osteotomies were necessary to avoid a barrel shaped
appearance of the nose as the bony sidewalls will
appear wider than the alar base.
b. Widening of nasal apertures on smiling is usually due to
the stretch of the inferior segments of the rim-sill folds.
In the case of this lady smiling produced widening of the
whole lower third of the nose as well as the nasal apertures. It was necessary to resect the rim-sill folds as well
as segments from the loose skin of the vestibular floors
i.e. 2–3 mm just medial to the posterior alar margins up
to the level of the mucocutaneous junction.
c. Post-operatively alar flare continued to be reduced even
ten years after surgery. She enjoyed taking photog raphs
in her naturally active social life.
© 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_39
229
230 39 Part VI: Clinical Case 1
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Frontal
Frontal
Preoperative
Postoperative
Smiling
10 years postoperatively, maintaining a pleasant smile,
ala nasi are not embarrassingly wide.
39 Part VI: Clinical Case 1 231
https://t.me/medicina_free
Preoperative
Postoperative
Steeper
Backward Tilting Backward Tilting
Right Nasal
Aperture
Rim Sill Test
Basal
Left Nasal
Aperture
Rim Sill Test
Basal
Smiling
Preoperative
Postoperative
232 39 Part VI: Clinical Case 1
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Preoperative
Postoperative
Right Oblique
Cheek Margin
Full Face
Left Oblique
Cheek Margin
Full Face
Right Lateral
Left Lateral
Part VI: Clinical Case 2
https://t.me/medicina_free
40
Preoperative Assessment
1. Frontolateral walls
a. Plunging tip i.e. drooping inferiorly with acute
nasolabial angle (Lateral Smiling Views)
b. Bulbous tip overshadowing the alae nasi (Frontal and
Direct Dorsal Views)
2. Medial Wall
Hanging collumela (Frontal, Lateral and Oblique Views)
3. Bony pyramid
a. Osteocartilagenous hump (Backward Tilting, Lateral
and Oblique Views)
b. Wide base of the bony pyramid (Direct Dorsal and
Backward Tilting Views)
4. Alar base
Nil of note.
Aims of Surgery
1. Correction of the plunging nasal tip (drooping nose).
2. Correction of the hanging collumela.
3. Reduction of the boney hump.
Surgical Plan
1. Frontolateral walls
a. DDD including the weak triangle.
2. Medial Wall
a. Reduction of the membranous septum
b. Direct reduction of the size of medial crurae.
c. Division of depressor septi muscles.
3. Bony pyramid
a. Excision of the osteo-cartilaginous hump.
b. Osteotomies and medialization of the lateral bony
walls.
4. Alar base
Nil of note.
Surgical Procedure
a. As per Surgical Plan.
b. Trim of 2 mm of the caudal cartilaginous septum.
c. Partial trim of the anterior nasal spine.
d. Direct reduction of the medial crural size. An inferior
marginal incision is made on each medial crus at the
junction of the adherent and non-adherent loose external
skin. The inferior margin of the cartilaginous crus was
gradually removed until the collumela became at an
aesthetically acceptable level with the alar margin.
Post-operative Analysis
1. Antrolateral Walls
a. Tip definition: nasal tip is slimmer, more prominent
and well identified from the alae nasi on both sides.
The alae nasi 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
Hanging columella and mobile tip have been rectified. The naso-labial angle is aesthetically attractive.
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 a straight line (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_40
233
234 40 Part VI: Clinical Case 2
https://t.me/medicina_free
b. The posterior alar groove aesthetics improved after
defatting (Backward tilting, Basal, Nasal Aperture,
Oblique and Lateral View).
c. Aesthetics of the alae nasi are better. They moved
medially after defatting and are better seen Nasal
Aperture and Oblique Views).
d. Nasal aperture aesthetics: the shapes of nasal aper-
tures improved by defatting. The lateral angulations
of alae nasi were straightened after defatting with
better oval shaped apertures.
e. Marginal light reflexes are clearly seen at:
i. Inferior alar margins (Nasal Aperture Views).
Frontal
ii. Nasal sill bands (Oblique Views).
iii. Lateral crural prominences (Lateral Views).
Commentary
a. The amount of tissues to be removed from the areas of
the caudal cartilaginous septum, membranous septum,
anterior nasal spine and the medial crural cartilages are
variable according to the size of the nose and the extent
of the deviation of each of these structures from the
acceptable aesthetic relationships. This has to be judged
by the surgeon in each individual nose.
Frontal
Smiling
Frontal
Middle Third
Postoperative
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