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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1102_Библиотеки_им_академика_М_И_Перельмана
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17 Part III: Clinical Case 5 105
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Direct Dorsal
Overhead
Preoperative
Postoperative
Direct Dorsal
Smiling
Preoperative
Postoperative
Steeper
Backward Tilting Backward Tilting
Basal
Basal
Smiling
106 17 Part III: Clinical Case 5
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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
17 Part III: Clinical Case 5 107
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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
108 17 Part III: Clinical Case 5
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Preoperative
Postoperative
Right Lateral
Middle Third
Left Lateral
Middle Third
Part III: Clinical Case 6
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Preoperative Assessment
1. Frontolateral walls
Nil of note.
2. Nasal septum
a. The caudal septum is long and slightly deviated to the
right. Protrusion of the right medial crus is seen more
in the Oblique views.
b. Protruding columella (Direct Dorsal, Oblique and
Lateral Views).
3. Bony pyramid
Wide base of the boney pyramid.
4. Alar base
Nil of note.
Aims of Surgery
1. Reduction of the base of the bony pyramid.
2. Reduction of the protruding columella.
Surgical Plan
1. Frontolateral walls
Nil of note.
2. Nasal septum
Septoplasty and trimming of caudal margin.
3. Bony pyramid
Osteotomies and medialization of the lateral bony
pyramid.
4. Alar base
Nil of note.
Surgical Procedure
1. Septoplasty: The caudal septum was dissected. Two
millimeters were trimmed from the caudal side and the
inferior side. It was repositioned to the mid line. This was
enough to reduce the protruding columella.
2. Osteotomies and medialization of the lateral bony walls.
Post-operative Analysis
1. Frontolateral Walls
a. Tip projection improved after correction of columellar
protrusion.
b. The length of the nasal tip is more elegantly shorter
after trimming of the caudal septum (Direct Dorsal
Views).
c. Tip light reflex is seen as one spot off the nasal tip
(Frontal and Backward Tilting Views).
2. Medial Wall
Columellar aesthetic improved. It is just seen off the
inferior alar margins in the Oblique and Lateral views.
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
Nil of Note.
© 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_18
109
110 18 Part III: Clinical Case 6
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Commentary
a. Two Rhinoplasty areas were minimally addressed i.e. the
bony pyramid and the medial wall.
b. Impressive aesthetic impact is seen in the patients nose
and face despite the minimal surgical procedures.
Preoperative
c. This is a finesse Rhinoplasty in which this lady only
needed a reduction in the width of the bony pyramid.
Elevation of the protruding columella was suggested by
the surgeon as a simple addition to nasal aesthetic s.
d. No attempt was made to reduce the size of the nasal tip as
it looked aesthetically attractive and suited her broad face.
Frontal
Smiling
Postoperative
18 Part III: Clinical Case 6 111
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Direct Dorsal
Preoperative
Postoperative
Preoperative
Postoperative
Steeper
Backward Tilting Backward Tilting
112 18 Part III: Clinical Case 6
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Preoperative
Postoperative
Right Oblique
Mid Cheek
Full Face
Left Oblique
Mid Cheek
Full Face
Preoperative
Postoperative
Right Oblique
Cheek Margin
Full Face
Left Oblique
Cheek Margin
Full Face
18 Part III: Clinical Case 6 113
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Preoperative
Right Lateral
Left Lateral
Part III: Clinical Case 7
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19
Preoperative Assessment
1. Frontolateral walls
a. Large frontolateral walls with wide nasal flare on
smiling (Frontal Smiling and Non-Smiling Views).
b. Heavy looking, i.e. slightly bulky nasal tip over-
shadowing the alae nasi (Frontal, Di rect Dorsal and
Overhead Views).
c. Supra tip depression predominantly seen in the obli-
que, backward tilting and the lateral views. This is
due to the fact that the lateral crurae are concave
rather than convex.
d. The concave surface of the lateral crurae is similar to
the concave surface of a saucer which has a prominent peripheral margin. In this case, the lateral crurae
end inferiorly and laterally with prominent margins.
e. Minimal bifidity of the tip (Backward Tilting Views).
2. Medial Wall
a. Left caudal dislocation of cartilaginous septum
(Backward Tilting and Basal Views).
b. Deviated nasal cartilaginous and bony septu m to the
right.
c. Mobile tip (Lateral Smiling Views).
3. Bony pyramid
a. Osteocartilaginous hump (Oblique and Lateral
Views).
b. Wide base of the bony pyramid (Direct Dorsal,
Overhead and Backward Tilting Views).
c. Bilateral maxillary asymmetry. The bony pyramid is
oblique to the right side, i.e. the left cheek is wide and
low, while the right cheek is narrow and high
(Backward Tilting Views).
4. Alar base
a. Unequal nasal openings with differing shapes. The
right opening is triangular in shape with its long axis
almost vertical as seen in the basal views, while the
left opening is oblong with an oblique long axis.
b. The dislocated left caudal septum has two
consequences:
i. It pushes the left nasal sill at a lower level than
the right (Frontal Views).
ii. It elevates the medi al crus laterally into the left
nasal aperture space (Basal and Backward Tilting Views).
c. Wide alar base.
Aims of Surgery
1. Reduce the size of the frontolateral wall.
2. Smoothen the margins of the lateral crurae.
3. Abolish the bifidity of the tip.
4. Abolish the mobility of the tip.
5. Correction of the caudal deviation with the consequent
correction of the nasal aperture deformities.
6. Excision of the osteocartilaginous hump with correction
of its obliquity.
7. Reduction of the size of the alar base.
Surgical Plan
1. Frontolateral walls
a. DDD including the weak triangle to reduce the bulk.
b. Bilateral cephalic trim of the lateral crurae i.e.
removing the prominent margins superiorly and
laterally.
c. The excision of the inferior segments of the rim sill
folds that should greatly reduced the widening of the
alar base on smiling.
2. Medial Wall
a. Septoplasty. Scoring of the concave side of the
deviated cartage.
b. Trim 2 mm from the caudal cartilaginous margin.
c. Division of the Depressor Septi muscles.
© 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_19
115
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