Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_951_Библиотеки_им_академика_М_И_Перельмана
.pdf
43 Part V: Clinical Case 4 255
https://t.me/medicina_free
Direct Dorsal
Overhead
Preoperative
Postoperative
Direct Dorsal
Smiling
Preoperative
Postoperative
Steeper
Backward Tilting Backward Tilting
Basal
Basal
Smiling
256 43 Part V: Clinical Case 4
https://t.me/medicina_free
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
43 Part V: Clinical Case 4 257
https://t.me/medicina_free
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
258 43 Part V: Clinical Case 4
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
44
Preoperative Assessment
1. Frontolateral walls
a. Flat, small but bulky and ill defined nasal tip over-
shadowing the alae nasi (Front al, Direct Dorsal and
Overhead Views).
b. The nasal tip is ill defined due to the flat middle
crurae.
2. Media Wall
a. Acute nasolabial angle (Lateral Views).
b. Mobile tip (Lateral Smiling Views).
c. Severe internal right residual septal deviation.
3. Boney pyramid
a. Wide base of the bony pyramid (Direct Dorsal and
Backward Tilting Views).
b. Supra tip saddle deformity, as well as collapse of the
lower 2/3rds of the nose secondary to previous surgery (Oblique and Lateral Views).
c. The bony pyramid deviated and oblique to the right
(deviation seen in the Overhead, Direct Dorsal and
Frontal Views, Obliquity is seen in the Backward
Tilting Views). There is bilateral maxillary asymmetry—the left cheek is high and narrow while the
right cheek is low and wide (Backward Tilting
Views).
d. The dorsal light reflex is distorted (preopera-
tive Direct Dorsal Views).
4. Alar base
a. Wide nasal apertures with transverse long axes. This
is secondary to the collapse of the lower third (Basal
Views).
Aims of Surgery
1. Reduce the bulk and size of the nasal tip to match the
new reduced size of the bony pyramid.
2. Elevation of the nasal tip.
3. Abolish mobility of nasal tip.
4. Elevating the saddle deformity and the collapsed lawer
2/3rds of the nose.
5. Reduce the size of the bony pyramid and correct its
deviation and obliquity.
Surgical Plan
1. Frontolateral walls
DDD not including the weak triangle to reduce the bulk
of nasal tip only.
2. Media Wall
a. Septoplasty.
b. Division of the Depressor Septi muscles.
c. Trim of the caudal end of the membranous septum.
3. Boney pyramid
a. Reduction of the height of the bony pyramid.
b. Osteotomies as well as Kassanjian maneuver to the
left i.e. cross fracture of the bony pyramid after
osteotomies (Refer to Surgery of the Bony Pyramid).
4. Alar base
Nil of note.
Surgical Procedure
a. As per Surgical Plan.
b. Cephalic trim of the lateral crurae, before defatting,
in order to salvage some needed supratip cartilaginous
grafts.
c. The supra tip depression was filled in with the trimmings
of the lateral crurae including their overlying fatty tissues.
Post-Operative Analysis
1. Frontolateral Wall
a. Tip definition: nasal tip is slimmer with thinner over-
lying skin, more prominent and well identified from
the alae nasi on both sides. The alae nasi become
clearly visible and share in nasal aesthetics (Frontal,
© 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/10.1007/978-3-031-07504-9_44
259
260 44 Part V: Clinical Case 5
https://t.me/medicina_free
Direct Dorsal, Overhead, Backward Tilt ing 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
(Anterior 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 (postoperative 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 (Backward Tilting and Basal Views).
c. Alae nasi aesthetics improved. They are pulled
medially become better seen, smaller and share in
nasal aesthetics (Oblique and Lateral Views).
d. Nasal aperture aesthetics improved by defatting:
i. The sizes of nasal apertures became smaller.
ii. The shape of nasal apertures became 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. There was extensive removal of septal cartilage in the
primary surgery. The supra tip depression was mild at
first, then became steadily worse for almost two years
after the surgery so that the depression extended to
affect the lower 2/3rds of the nose.
b. The saddle deformity was automatically corrected after
rasping the hump, osteotomies and medialization of the
sidewalls of the bony pyram id. He only needed minimal
supportive graft.
c. Having a better nasal respiration as well as appearance,
his general attitude, behavior and mood had greatly
improved. He regained his normal natural bubbling
personality.
Frontal
Frontal
Smiling
Frontal
Middle Third
44 Part V: Clinical Case 5 261
https://t.me/medicina_free
Direct Dorsal
Direct Dorsal
Smiling
Overhead
Overhead
Smiling
Basal
Basal
Smiling
262 44 Part V: Clinical Case 5
https://t.me/medicina_free
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
44 Part V: Clinical Case 5 263
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 6
https://t.me/medicina_free
45
Preoperative Assessment
1. Frontolateral walls
a. A medium sized bulky frontolateral walls that over-
shadows the alae nasi, predominantly the left one
(Frontal and Direct Dorsal Views).
b. Asymmetrical smile, the left cheek ball is smaller than
the right (Frontal and Lateral Smiling Views). There
is bilateral maxillary asymmetry.
2. Medial Wall
Right caudal septal deviation. The right medial crus is
pushed literally encroaching upon the right nasal aperture
that consequently looks smaller than the left (Basal
Backward Tilting and Nasal Aperture Views). The right
nasal sill band is pushed inferiorly (Frontal and Backward Tilting Views).
3. Bony pyramid
a. Osteocartilaginous hump that is only oblique to the
left side due to bilateral maxillary symmetry. The
right cheek is wide and low while the left cheek is
narrow and high (Backward Tilting Views) The
nose is not deviated (Frontal, Direct Dorsal And
Overhead Views).
b. Wide base of bony pyramid (Direct Dorsal and
Backward Tilting Views).
c. The dorsal light reflex is irregular and distorted
(preoperative Directed Dorsal Views).
4. Alar base
Apparent asymmetrical nasal opening due to right caudal
septal deviation. The right nasal apert ure looked smaller
(preoperative Backward Tilting, Basal and Nasal Aperture Views).
Aims of Surgery
1. Reduce the size and the bulk of the frontolateral walls.
2. Correct the deviation in the caudal septum to improve
aesthetics of the columella.
3. To reduce the size and correct the obliquity of the bony
pyramid.
Surgical Plan
1. Frontolateral walls
a. DDD including the weak triangle to reduce the
bulk and size of the nasal tip and supratip area.
b. Cephalic trim of the lateral crurae to reduce the size of
the frontolateral walls.
2. Medial Wall
Septoplasty and trim the distal 2 mm of the caudal septum to improve the aesthetics of the columella.
3. Bony pyramid
a. Excision of the osteocartilaginous hump down to
the level of the anterior septal angle.
b. Osteotomies and Kassanjean maneuver to the right
i.e. cross fracture of the bony pyramid after osteotomies (see Surgery of the Bony Pyramid).
4. Alar base
Nil of Note.
Surgical Procedure
As per surgical plan.
© 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/10.1007/978-3-031-07504-9_45
265
Соседние файлы в папке Библиотека им академика М.И. Перельмана