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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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180 30 Part IV: Clinical Case 5
https://t.me/medicina_free
Preoperative
Postoperative
Preoperative
Right Nasal
Aperture
Right Oblique
Mid Cheek
Full Face
Left Oblique
Mid Cheek
Full Face
Right Oblique
Mid Cheek
Middle Third
Left Nasal
Aperture
Left Oblique
Mid Cheek
Middle Third
Postoperative
Part IV: Clinical Case 5 181
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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
Part IV: Clinical Case 6
https://t.me/medicina_free
31
Preoperative Assessment
1. Frontolateral walls
Nil of note.
2. Nasal Septum
a. The cartilaginous and boney septum were mostly
replaced by thick fibrous tissue
3. Bony pyramid
Wide base of the boney pyramid. Severe dorsal depression leading to severe saddle Deformity.
4. Alar base
Nil of note.
Aims of Surgery
1. To correct the saddle deformity.
2. To reduce the base of the boney pyramid.
Surgical Plan
1. Frontolateral walls
Nil of note.
2. Nasal Septum
Costal cartilage rib graft was used.
3. Bony pyramid
Osteotomies and medialization of the bony sidewalls.
4. Alar base
Nil of note.
Surgical Procedure
a. A three centimeter costal cartilage graft was harvested
from the right side of the chest.
b. The costal cartilage was introduced via an intercarti-
laginous incision after being refashioned to the exact size
of the defect.
Commentary
a. Despite the simplicity of this procedure, it had a great
aesthetic and psychological impacts on the patient, his
family, friends and colleagues.
b. There is a tendency for the costal cartilage graft to bend
despite careful harvesting and shaping of the graft. The
graft was placed in normal saline for half an hour, before
using it inside the nose.
c. The post-operative photographs were taken six months
after surgery. Observe the straight light reflex from the
nasal dorsum.
© 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_31
183
184 31 Part IV: Clinical Case 6
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Frontal
Middle Third
Preoperative
Postoperative
Preoperative
Postoperative
Right Oblique
Cheek Margin
Middle Third
Left Oblique
Cheek Margin Right Lateral
Middle Third Middle Third
Left Lateral
Middle Third
Part IV: Clinical Case 7
https://t.me/medicina_free
32
Preoperative Assessment
1. Frontolateral walls
Large and bulky frontolateral walls. The nasal tip is flat
and ill defined from the large alae nasi on both sides.
(Frontal, Direct Dorsal, Overhead, Backward Tilting and
Basal Views).
2. Medial Wall
Irregular septal deviations by the broken bones and
cartilages.
3. Bony pyramid
a. Wide base of bony pyramid (Frontal, Direct Dorsal,
Overhead and Backward Tilting Views).
b. Broad midvault (the same views as in a.).
4. Alar base
a. Unpleasantly wide nasal apertures (Backward Tilt-
ing, Basal and Nasal Aperture Views).
b. The inferior segments of the rim-sill folds were long
and the posterior segments were thick and heavily
lying on the upper lip like flat tires. (Backward Tilting, Basal and Nasal Aperture Views).
c. The right flat triangle was severely scarred and
deformed. (Pre-operative Backward Tilting, Nasal
Aperture and Oblique Views).
Aims of Surgery
1. Reduce the size and bulk of the frontolateral walls.
2. Reduce the width of the bony pyramid and midvault.
3. Fill the unpleasant depression of the right flat triangle.
4. Reduce the sizes of nasal apertures.
5. Improves the nasal airway.
Surgical Plan
1. Frontolateral walls
DDD of frontolateral walls.
2. Medial Wall
a. Correction of the broken septal deviations by refrac-
turing to midline. Small specules had to be removed.
b. Submucus diathermy of inferior turbinates.
3. Bony pyramid
a. Osteotomies and medialisation of the bony sidewalls.
b. Defatting of the area of the weak triangle and distal
part of the upper lateral cartilage.
4. Alar base
a. Bilateral resection of the posterior and inferior seg-
ments of the rim-sill folds.
b. Filling the right flat triangle with a bone graft between
its two skin layers.
Surgical Procedure
1. As per surgical plan.
2. The two fatty subdermal layer of the frontolateral walls
were completely replaced by tough fibrous tissues from
the previous surgery. These tissues were cut by the
scissor and thinned out by using rasps.
3. Bone graft was harvested from the nasal septum. The
external and vestibular skin layers of the flat triangle
were dissected from each other. The bone graft was then
inserted to fill the space.
4. The left lateral crus was intact. Residuals of the right
lateral crus maintained the shape of the lateral wall of the
nose and therefore was not touched.
5. Submucosal diathermy of the inferior turbinates.
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
© 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_32
185
186 32 Part IV: Clinical Case 7
https://t.me/medicina_free
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).
2. Medial Walls
Nasal airway improved after septal and turbinate
surgeries.
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
as well as excising the posterior segments of the rim-sill
folds. The flat tire appearance is no longer present.
(Backward Tilting, Basal and Nasal Aperture Views).
c. Nasal aperture aesthetics:
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 by
defatting and excision of the rim-sill folds
transforms the nasal apertures from thick walled
wide and rounded openings with transverse long
axes to thin walled smal l oval openings with
anterior long axes. (Backward Tilting, Basal and
Nasal Aperture views).
d. Alae nasi aesthetics improved. They are pulled
medially, better seen and smaller in size.
e. Aesthetics of the right flat triangle improved after
filling it with bone graft (Backward Tilting, Basal,
Nasal Aperture and Oblique Views).
f. Marginal light reflex: light reflex of inferior alar
margin is seen. Flat triangular margins are smaller.
(Basal and Nasal Aperture Views).
Commentary
1. All four areas of the nose are to be examined before
proceeding for surgery in this case.
2. The bony pyramid: osteotomies were omitted in the
previous surgery and was dealt with as primary surgery.
3. The alar base was not touched and therefore dealt with as
primary surgery.
4. The nasal septum was corrected for better airway, but
it did not have any aesthetic role in this case.
5. The three predominant challenges were the frontolateral
walls, the alar base and the left flat triangle.
6. The hypersensitivity of the skin disappeared after surgery. No clear explanation was found for this phenomena
before surgery but it may be that rasping of the subdermal layer of the frontolateral walls have overcome this
problem post-operatively.
7. Post-operative photographs were taken one month after
the surgery. Better tip and bony pyramid definitions
improve in long term.
32 Part IV: Clinical Case 7 187
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Preoperative
Postoperative
Frontal
Frontal
Smiling
Frontal
Middle Third
Preoperative
Postoperative
Direct Dorsal
Direct Dorsal
Smiling
Overhead
Overhead
Smiling
188 32 Part IV: Clinical Case 7
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Preoperative
Postoperative
Steeper
Backward Tilting Backward Tilting
Right Nasal
Right Nasal
Aperture
Aperture
Rim Sill Test
Basal
Left Nasal
Aperture
Rim Sill Test
Basal
Smiling
Left Nasal
Aperture
Preoperative
Postoperative
32 Part IV: Clinical Case 7 189
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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
190 32 Part IV: Clinical Case 7
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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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