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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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24 4 Part II: Clinical Case 2
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4. Alar Base
a. Superior alar groove aesthetics improved by defatting.
The grooves become longer and deeper (Oblique,
Lateral, Direct Dorsal and Overhead Views).
b. Posterior alar groove aesthetics improved by defatting
as well as excision of the inferior and posterior
segments of the rim-sill folds. The flat tire appearance
is no longer present. (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. (Nasal Aperture, Oblique and Lateral
Views).
d. Nasal Aperture Aesthetics improved:
i. The size of the nasal openings are reduced by
defatting as well as excising the inferior segments
of the rim-sill folds. (Backward Tilting, Basal and
Nasal Aperture views).
ii. The shape of nasal openings improved. Defatting
and excision of the rim-sill folds transformed the
nasal apertures from thick heavy wide and round
openings with transverse long axes to become thin
delicate small oval openings with anterior long
axes. (Backward Tilting, Basal and Nasal Aperture views).
e. Marginal light reflexes are better seen at:
i. The inferior alar and flat triangular margins. The
light reflex is absent from the rim-sill folds. The
latter were accurately excised (Nasal Aperture
Views).
ii. Nasal sill bands (Oblique Views).
iii. Lateral crural prominences (Lateral Views).
Commentary
a. Photographs of the lateral views apparenly show a flat
nasofrontal angle. The oblique views show a well formed
nasofrontal angle. This was confirmed by palpation. The
excess hairs of eyebrows have given the impression of
the flat angle in the lateral view photographs. The surgeon must not rush into reducing the nasofrontal angle
based on the photographic appearance.
b. Photographs were taken 10 days postoperatively (note the
fresh alar scar in the postoperative frontal view). A more
uniform reduction in the size of the bony pyramid, midvault and nasal tip will take place in the long term.
c. The overall size of the nose is smaller and proportion-
ately suites his face better than before surgery. Patient’s
wish was fulfilled. Naso-facial relationships are best seen
in the frontal, oblique and lateral views.
Preoperative
Postoperative
Frontal
Frontal
Smiling
Frontal
Middle Third
4 Part II: Clinical Case 2 25
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Preoperative
Postoperative
Direct Dorsal
Direct Dorsal
Smiling
Steeper
Backward Tilting Backward Tilting
Overhead
Basal
Overhead
Smiling
Basal
Smiling
Preoperative
Postoperative
26 4 Part II: Clinical Case 2
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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
4 Part II: Clinical Case 2 27
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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
28 4 Part II: Clinical Case 2
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Preoperative
Postoperative
Right Lateral
Middle Third
Left Lateral
Middle Third
Part II: Clinical Case 3
https://t.me/medicina_free
5
Preoperative Assessment
1. Frontolateral walls
Large Bulbous tip that overshowed the alae nasi (frontal
and direct dorsal views).
2. Medial Wall
Nil of note.
3. Bony pyramid
a. Wide base of the boney pyramid (Direct Dorsal and
Backward Tilting Views).
b. Small osteocartilagenous hump (Oblique, Lateral,
Backward Tilting and Nasal Aperture Views).
c. The dorsal light reflex was defused (pre-operative
Direct Dorsal Views).
4. Alar base
Bilateral high alar arches (Lateral and Oblique Views).
Aims of Surgery
1. Smaller nasal tip.
2. Reduction of the size of the bony pyramid.
3. Lowering the alar margins.
Surgical Plan
1. Frontolateral walls
a. DDD including the weak triangle to reduce the size
and bulk of the nasal tip and supra tip area.
b. Bilateral cephalic trim of lateral crurae to reduce the
size.
2. Medial Wall
Nil of note.
3. Bony pyramid
a. Excision of the osteocartilaginous hump.
b. Osteotomies and medialization of the lateral bony
walls to reduce width of the bony pyramid.
4. Alar base
Lowering inferior margins of the alae nasi using bony
septal grafts.
Surgical Procedure
a. As per Surgical Plan.
b. Boney, septal grafts were used to reinforce the inferior
margins of the alae nasi.
Post-Operative Analysis
1. Frontolateral Walls
a. Tip definition improved i.e. the tip is slimmer and
prominently well identified. The overlying skin is
thinner. The alae nasi come into view to share in
nasal aesthetics (Frontal, Direct Dorsal, Overhead,
Backward Tilting and Basal Views).
b. Tip projection: the nasal tip is 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: 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. 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 by defat-
ting. Flat tire appearance is no longer present as
the posterior alar groove angle with the upper lip
became wider. (Backward Tilting, Basal and Nasal
Aperture Views).
c. Nasal aperture aesthetics aesthetics improved by
defatting:
© 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_5
29
30 5 Part II: Clinical Case 3
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i. The size of the nasal openings are reduced , only
by defatting.
ii. The shapes of nasal openings become more ele-
gantly oval. (Backward Tilting, Basal and Nasal
Aperture views).
d. Aesthetics of the alae nasi improved:
i. The alar margins become at a lower level with
better relation with the columella.
ii. The bodies of alae nasi are pulled medially after
defatting, widening the posterior alar grooves.
They are better seen and look smaller in size.
(Nasal Apaerture, Basal and Oblique Views).
Frontal
Preoperative
e. Marginal light reflexes are clearly seen at:
i. Inferior alar margins (Nasal Aperture Views).
ii. The nasal sills are too short to be seen in the
oblique views.
iii. Lateral crural prominences (Lateral Views).
Commentary
a. The post operative photographs were taken on the 10th
post operative day.
b. The inferior alar margins are aesthetically in a better
location with improved columello-alar relationship.
Frontal
Smiling
Postoperative
5 Part II: Clinical Case 3 31
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Direct Dorsal
Direct Dorsal
Preoperative
Postoperative
Smiling
Preoperative
Postoperative
Steeper
Backward Tilting Backward Tilting
Basal
32 5 Part II: Clinical Case 3
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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
5 Part II: Clinical Case 3 33
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Preoperative
Postoperative
Right Oblique
Cheek Margin
Full Face
Left Oblique
Cheek Margin
Full Face
Preoperative
Postoperative
Right Lateral
Left Lateral
Right Lateral
Smiling
Left Lateral
Smiling
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