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40 Part VI: Clinical Case 2 235
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Direct Dorsal
Direct Dorsal
Preoperative
Postoperative
Smiling
Preoperative
Postoperative
Basal
Basal
Smiling
236 40 Part VI: Clinical Case 2
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Preoperative
Postoperative
Right Nasal
Ape rt ur e
Right Oblique
Mid Cheek
Full Face
Left Obliq u e
Mid Cheek
Full Face
Right Oblique
Mid Cheek
Middle Third
Left Nasal
Ape rt ur e
Left Obliq u e
Mid Cheek
Middle Third
Preoperative
Post operat ive
40 Part VI: Clinical Case 2 237
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Preoperative
Post operat ive
Right Oblique
Cheek Margin
Full Face
Right Lateral
Left Oblique Right Oblique
Cheek Margin Cheek Margin
Full Face Middle Third
Right Latera l
Left Lateral
Smiling
Left Oblique
Cheek Margin
Middle Third
Left Later al
Smiling
Preoperative
Post operat ive
238 40 Part VI: Clinical Case 2
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Preoperative
Post operat ive
Right Lateral
Middle Third
Left Latera l
Middle Third
Part VI: Clinical Case 3
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41
Preoperative Assessment
1. Frontolateral walls
a. Large, bulky tip. Slightly ill defined tip despite of
good projection.
b. Mobile tip (Lateral Smiling Views).
c. Supra-tip congenital fistula that communicates with
the nasal cavity (Frontal Views).
2. Nasal Septum
a. Deeply grooved columella (Backward Tilting and
Basal Views).
b. Mobile tip i.e. the nasal tip moves inferiorly on
smiling.
3. Bony pyramid
a. Small bony hump that is more prominent on the
patient’s left side due to bilateral maxillary asym-
metry. The right cheek is wide and low while the left
cheek is high and narrow (Backward Tilting Views).
b. Very wide base of the bony pyramid. This lady have
mild hypertelorism i.e. excessive width between the
two eyes (Frontal, Direct Dorsal, Overhead and
Backward Tilting Views).
c. Irregular dorsal light reflexes (Direct Dorsal Views).
4. Alar base
Wide alar base mainly due to long inferior segments and
slightly thick posterior segments of the rim-sill folds
(Backward Tilting, Basal and Nasal Aperture Views).
Aims of Surgery
1. To produce a slimmer nose including the dorsum, tip and
alar base.
2. Closure of the supra-tip congenital fistula.
3. Abolishing the mobility of the tip.
Surgical Plan
1. Frontolateral walls
a. DDD excluding the weak triangle.
b. Closure of the supra-tip congenital fistula.
2. Nasal Septum
Division of the depressor septi muscles.
3. Bony pyramid
a. Excision of the osteocartilagenous hump.
b. Osteotomies and medialization of the lateral bony
walls to reduce the width of the bony pyramid.
4. Alar base
Resection of the posterior and inferior segments of the
rim-sill folds.
Surgical Procedure
a. As per Surgical Plan.
b. Insertion of a supratip cartilage graft.
Post-operative Analysis
1. Frontolateral 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 (Frontal and
Backward Tilting Views).
d. The supratip fistula is closed.
© 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_41
239
240 41 Part VI: Clinical Case 3
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2. Medial Wall
Grooving of the columellar disappeared by defatting.
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 appears as uninterrupted line of
light (Direct Dorsal Views).
4. Alar Base
a. Superior alar groove aesthetics improved by defatting.
The grooves became longer and deeper (Oblique,
Lateral and Direct Dorsal grooves).
b. Posterior alar groove aesthetics improved: by defat-
ting as well as excising the rim-sill folds. (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.
d. Nasal apertures aesthetics improved by defatting and
excision of the rim-sill folds:
i. Nasal apertures are smaller.
Frontal
ii. The shapes of nasal aperture become 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. Removing the fistula has taken away some of the sub-
cutaneous fat and tissues that needed to be replaced by
supratip cartilage graft. The graft mitigates the risk of the
fistula reopening.
b. Although the distance between the eyes is the same, yet
post operatively the visual impact of her hypertelorism is
reduced and was more aesthetically attractive. The slim
high nasal dorsum was visually better than the broad one.
c. Post-operative photographs were taken only few weeks
after surgery. Slimming of the tip with better tip definition as well as bony pyramidal aesthetics will continue to
improve by time.
Frontal
Smiling
Frontal
Middle Third
Postoperative
41 Part VI: Clinical Case 3 241
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Direct Dorsal
Overhead
Preoperative
Postoperative
Direct Dorsal
Smiling
Preoperative
Postoperative
Steeper
Backward Tilting Backward Tilting
Basal
Basal
Smiling
242 41 Part VI: Clinical Case 3
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Preoperative
Postoperative
Right Nasal
Aperture
Right Oblique
Mid Cheek
Full Face
Right Nasal
Aperture
Rim Sill Test
Left Oblique
Mid Cheek
Full Face
Left Nasal
Aperture
Rim Sill Test
Right Oblique
Mid Cheek
Middle Third
Left Nasal
Aperture
Left Oblique
Mid Cheek
Middle Third
Preoperative
Postoperative
41 Part VI: Clinical Case 3 243
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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
244 41 Part VI: Clinical Case 3
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Preoperative
Postoperative
Right Lateral
Middle Third
Left Lateral
Middle Third
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