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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4525_Библиотеки_им_академика_М_И_Перельмана
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18 Part III: Clinical Case 3 109
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Preoperative
Postoperative
Direct Dorsal
Direct Dorsal
Backward Tilting Backward Tilting
Smiling
Steeper
Overhead
Basal
Overhead
Smiling
Basal
Smiling
Preoperative
Postoperative
Note: The change in the shapes of the nasal tip and nasal openings
after defatting process.
110 18 Part III: 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
18 Part III: Clinical Case 3 111
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Preoperative
Postoperative
Right Oblique
Cheek Margin
Full Face
Right Lateral
Left Oblique Right Oblique
Cheek Margin Cheek Margin
Full Face Middle Third
Right Lateral
Left Lateral
Smiling
Left Oblique
Cheek Margin
Middle Third
Left Lateral
Smiling
Preoperative
Postoperative
112 18 Part III: Clinical Case 3
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Preoperative
Postoperative
Right Lateral
Middle Third
Left Lateral
Middle Third
Part III: Clinical Case 4
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19
Preoperative Assessment
1. Frontolateral walls
a. Homogenously large and bulky frontolateral walls
(Frontal, Direct Dorsal and Overhead Views).
b. Excess fat at the lower end of the nasal tip
(Direct Dorsal and Backward Tilting Views).
c. Dissociation between the bulky lower third and upper
two thirds (Backward Tilting Views).
d. The alae nasi are over shadowed by the bulbous
tip. They are almost not seen. The right ala nasi is
naturally larger than the left (Frontal and Direct
Dorsal Views).
2. Medial Wall
Mobile tip (Lateral Smiling Views).
3. Bony pyramid
a. Wide base of the boney pyramid (Direct Dorsal and
Backward Tilting Views).
b. Small osteocartilaginous hump caused by the natural
concovoconvex anatomy of the nasal bones from
above downwards (See Anatomy Section).
4. Alar base
Thick and Wide alar base due to thick posterior and long
inferior segments of the rim sill folds successively
(Backward Tilting, Basal and Nasal Aperture Views).
Aims of Surgery
1. Reduction of the nasal bulk.
2. Abolishing the mobile tip.
3. Reduction of the size of the boney pyramid.
4. Reduction of the bulk and size of the alar base.
Surgical Plan
1. Frontolateral walls
a. DDD including the weak triangle to reduce the bulk
and size of the nasal tip and midvault.
b. Cephalic tri m of lateral crurae to reduce the size of
the frontolateral walls.
2. Medial Wall
Division of the Depressor Septi muscle.
3. Bony pyramid
a. Excision of the osteocartilaginous hump.
b. Osteotomies and medialization of the lateral bony
walls to reduce the size of the bony pyramid.
4. Alar base
Resection of the inferior and posterior segments of the
rim sill folds.
Surgical Procedure
As per Surgical Plan.
Post-Operative Analysis
1. Frontolateral Wall
a. A Tip definition improved. The nasal tip is slimmer.
The alae nasi came into view to share in nasal aesthetics (Frontal, Direct Dorsal, Overhead and Backward Tilting Views). The superior alar grooves are
clearer and longer (Oblique and Frontal Views).
b. Incomplete defatting of the nasal tip have led to less
favorable tip projection (post operative Lateral and
Oblique 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/10.1007/978-3-031-07504-9_19
113
114 19 Part III: Clinical Case 4
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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 an uninterrupted line off
the nasal dorsum (Direct Dorsal Views).
4. Alar Base
a. The superior alar grooves now clear off fat, become
deeper, longer and visible (Direct Dorsal, Oblique and
Lateral Views).
b. Posterior alar groove aesthetics improved. The angle
of the alae nasi with the upper lip is wider. Aesthetics
of the alae nasi is better.
c. On reducing the alar base, removal of the posterior
segments of the rim sill folds was omitted.
d. Removing the inferior segments alone and approxi-
mating the alar margins to the nasal sills have resulted in unpleasant, laterally angulated nasal
apertures and residual bulky alar base (see illustrations in the pre and post operative Left Nasal Aperture Views). Surprisingly most patients do not show
displeasure of this deformity. Very few patients tend
to look at their nose from below i.e. basal view.
e. Marginal light reflexes were only seen at the inferior
alar margins (Nasal Aperture Views).
Commentary
a. Generally, the patient was happy with the overall out-
come, as the main issue in her mind was the bulky nose.
b. The nasal air flow is not compromised by the reduced
size of the alar base.
c. Defatting of the frontolateral walls resulted in the full
integration of the lower third with the upper two thirds of
the nose.
d. Although the main objective of the surgery was achieved
i.e. patient satisfaction by the overall reduction of the bulk
and size of the nose, yet two misjudgments took place;
the incomplete defatting of nasal tip and omitting resection of the posterior segments of the rim sill folds.
Preoperative
Postoperative
Frontal
Frontal
Smiling
Frontal
Middle Third
19 Part III: Clinical Case 4 115
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Preoperative
Postoperative
Direct Dorsal
Direct Dorsal
Smiling
Overhead
Overhead
Smiling
Preoperative
Postoperative
Steeper
Backward Tilting Backward Tilting
Basal
Basal
Smiling
116 19 Part III: Clinical Case 4
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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
19 Part III: Clinical Case 4 117
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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
118 19 Part III: Clinical Case 4
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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
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