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Part IV: Clinical Case 3
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28
Preoperative Assessment
1. Frontolateral walls
a. Thick ill defined tip overshadowing the lateral cru-
rae (Direct Dorsal, Overhead, Backward Tilting, Basal
and Nasal Aperture Views).
b. Nasal tip deviation to the right side i.e. counter
deviated to the bony pyramid (Frontal, Direct Dorsal, Overhead and Backward Tilting Views).
2. Media Wall
a. Left caudal septal deviation, which droves the nasal
tip off the central position to the right side. (Frontal,
Direct Dorsal and Overhead Views).
b. C-shaped septal deviation to the left (Direct Dorsal
Views).
3. Bony pyramid
a. Wide base of the boney pyramid (Direct Dorsal and
Backward Tilting Views).
b. Residual osteocartilagenous hump (Oblique and Lat-
eral Views).
c. Bony pyramid was oblique to the left side due to
bilateral maxillary asymmetry, i.e. the right cheek is
narrow and high, while the left cheek is wide and low,
(Backward Tilting Views).
4. Alar base
Apparent unequal nasal opening secondary to right caudal septal deviation (Basal and Nasal Aperture Views).
Aims of Surgery
1. Straighten the nasal septum, which will reposition the
nasal tip to the mid-line.
2. Reduction of the size and correction of the deviation of
the boney pyramid.
3. Excision of the osteo cartilagenous hump.
Surgical Plan
1. Frontolateral walls
a. DDD including the weak triangle.
b. Bilateral cephalic trim of the lateral crurae.
2. Media Wall
Septoplasty.
3. Bony pyramid
a. Excision of the osteocartilagenous hump.
b. Osteotomies with Kasanjian maneuver to the right i.e.
cross fracture of the bony pyramid after osteotomies
(refer to Chapter of Surgery of the Bony Pyramid in
the text).
4. Alar base
Nil of note.
Surgical Procedure
a. As per Surgical Plan.
b. Supra tip depression appeared during surgery which
was filled by cartilaginous graft. Cephalis trimmings
of the lateral crurae were used as the graft material.
Post-operative Analysis
1. Frontolateral Walls
a. Tip definition improved i.e. the tip is slimmer and
prominently well identified. 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 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 re flex is seen as one spot reflected off the
nasal tip. (Backward Tilting Views).
2. Medial Walls
Septoplasty have leads to:
a. Correction of tip position.
© 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_28
169
170 28 Part IV: Clinical Case 3
https://t.me/medicina_free
b. Equal nasal aperture sizes.
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. 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, 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: The shape of nasal aper-
tures became more elegantly oval by defatting.
e. Marginal light reflexes are clearly seen at:
Frontal
i. Inferior alar margins (Nasal Aperture Views).
ii. Nasal sill bands (Oblique Views).
iii. Lateral crural prominences (Lateral Views).
Commentary
1. The shortcomings of the primary surgery are as follows:
a. Osteotomies were not completed by medialization of
the sidewalls of the boney pyramid. Bilateral Maxillary asymmetry and deviation of the pyramid were
not compensated for by the Kassanjian Maneuver, i.e.
the pyramid was not centralized.
b. No attempt was made to correct the caudal septal
deviation. This resulted in nasal tip deviation and
apparent nasal aperture asymmetry.
2. Minimal surgery was performed to three of the four areas
of Rhinoplasty:
a. Defatting of frontolateral walls.
b. Septoplasty.
c. Bilateral osteotomies and medialization of the side-
walls of the bony pyramid.
Frontal
Smiling
Preoperative
Postoperative
28 Part IV: Clinical Case 3 171
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Preoperative
Postoperative
Direct Dorsal
Direct Dorsal
Smiling
Steeper
Backward Tilting Backward Tilting
Overhead
Basal
Overhead
Smiling
Preoperative
Postoperative
172 28 Part IV: Clinical Case 3
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Preoperative
Postoperative
Right Nasal
Aperture
Right Oblique
Mid Cheek
Full Face
Left Nasal
Aperture
Left Oblique
Mid Cheek
Full Face
Preoperative
Postoperative
28 Part IV: Clinical Case 3 173
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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
Part IV: Clinical Case 4
https://t.me/medicina_free
29
Preoperative Assessment
1. Frontolateral walls
Overprojecting nasal tip due to excessively large tip
graft (Frontal, Backward Tilting, Oblique and Lateral
Views).
2. Nasal Septum
Nil to note.
3. Bony pyramid
Nil to note.
4. Alar base
Nil of note.
Aims of Surgery
Remodeling the nasal tip to an aesthetically better shape.
Surgical Plan
1. Frontolateral walls
Trimming of the anterior over-projecting parts of the
graft.
2. Nasal Septum
Nil to note.
3. Bony pyramid
Nil to note.
4. Alar base
Nil of note.
Surgical Procedure
Endonasal approach. The anterior end of the graft was
trimmed away.
Post-Operative Analysis
Tip projection is better aesthetically than before surgery.
Commentary
In secondary Rhinoplasty tissues are quite stiff and not easily
manageable.
© 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_29
175
176 29 Part IV: Clinical Case 4
https://t.me/medicina_free
Preoperative
Postoperative
Frontal
Middle Third
Backward Tilting
Preoperative
Postoperative
Right Lateral
Middle Third
Right Oblique
Left Lateral Mid Cheek
Middle Third Middle Third
Left Oblique
Mid Cheek
Middle Third
Part IV: Clinical Case 5
https://t.me/medicina_free
30
Preoperative Assessment
1. Fron to lat eral walls
a. Bulbous tip over shadowing the alae nasi (Frontal,
Overhead and Direct Dorsal, Backward tilting and
Basal Views).
b. Left lateral crural bulge secondary to high left septal
deviation (Direct Dorsal, Overhead, Backward Tilting, Nasal Aperture and Oblique Views).
2. Medial Wall
a. Left caudal septal dislocation. The left medial crus is
pushed laterally (backward tilting, Basal, and Nasal
Aperture Views), while the nasal sill band is pushed
inferiorly (Frontal views).
b. Right supra tip depression and bulge of left lateral
crus. This deformity is caused by the left sided
deviation of nasal septum (Frontal, Backward Tilting
and Nasal Aperture Views).
c. Tight upper lip (Lateral smiling view s).
3. Bony Pyramid
a. Wide base of bony pyramid (Frontal, Direct Dorsal,
Overhead and Backward Tilting Views).
b. Small nasal hump caused by the natural convexities
of the nasal bones.
c. Dorsal light reflex defused.
4. Alar Base
Apparent unequal nasal apertures due to left caudal septal
deviation. The right opening is thick walled rounded
shaped and the left one is thick-walled slit like by the
intrusion of the medial crus and caudal septum (Backward Tilting, Basal and Nasal Aperture View).
Aims of Surgery
1. To reduce the overall size of the nose. This includes
reduction of the sizes of the nasal tip and the bony
pyramid.
2. Correction of the caudal septal dislocation, supra tip
depression and nasal hump,
3. Release the tight upper lip.
Surgical Plan
1. Frontolateral walls
DDD including the weak triangle.
2. Medial wall
a. Septoplasty.
b. Trans-oral division of Depressor septi muscles and
frenulum.
3. Bony pyramid
a. Excision of osteocartilagenous hump.
b. Osteotomies and medialization of the lateral bony
walls.
4. Alar Base
Nil of Note.
Surgical Procedure
a. As per Surgical Plan.
b. The caudal cartilage was found to be severely fibrosed
and fragmented. Small fragments were excised.
The caudal 3mm of the membranous septum were
trimmed.
c. The supra tip depression was filled by the corrected
caudal septum.
d. A transcollumelar stitch was placed to reduce the lateral
crural prominences of the medial crurae.
e. Sub-mucosal diathermy of the heads of the inferior tur-
binates to improve the nasal airway.
Post-Operative Analysis
1. Frontolateral Walls
a. Tip definition improved i.e. the tip is slimmer and
prominently well identified. The alae nasi come into
view to share in nasal aesthetics (Frontal, Direct
© 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_30
177
178 30 Part IV: Clinical Case 5
https://t.me/medicina_free
Dorsal, Overhead, Backward Tilting and Basal
Views). Note the clear light reflex off the nasal tip as
one spot. (Backward Tilting 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.
(Frontal and Backward Tilting Views).
2. Medial Walls
a. Septoplasty had the following consequences:
i. The left lateral crural bulge and right supratip
depression disappeared.
ii. The unaesthetic distortion of the left nasal aperture
is corrected.
iii. The two nasal apertures became equal.
b. The tight upper lip and mobile tip were abolished by
dividing the frenulum and Depressor Septi muscles
successively.
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. 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
the frontolateral walls and correction of caudal septal
deviation.
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 by defatting and
correction of caudal septal deviation. They became
equal, thin walled and elegantly oval in shape.
e. Marginal light reflexes are clearly seen at:
i. Alar light reflex (Basal View).
ii. Lateral crural prominences (Lateral Views).
Commentary
1. Analysis of the shortcomings of the primary surgery:
a. Caudal septal dislocation was not corrected.
b. Incomplete osteotomies.
c. No attempt was made to reduce the size of the nasal
tip.
d. The tight upper lip was not attended to.
2. Three of the four areas of Rhinoplasty were addressed:
a. Defatting the nasal tip that becom es more defined:
b. Septoplasty together with defatting have improved the
aesthetics of the nasal openings.
c. Osteotomies and medialization of the bony pyramidal
sidewalls.
Preoperative
Postoperative
Frontal
Frontal
Smiling
Part IV: Clinical Case 5 179
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Preoperative
Postoperative
Direct Dorsal
Direct Dorsal
Smiling
Steeper
Backward Tilting Backward Tilting
Overhead
Basal
Overhead
Smiling
Basal
Smiling
Preoperative
Postoperative
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