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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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Part V
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RhinoplastyEthnic
Part V: Clinical Case 1
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33
Preoperative Assessment
1. Frontolateral walls
Bulky nasal tip overshadowing the alae nasi predominantly the right side of the nose. (Frontal, Direct Dorsal
and Overhead Views).
2. Nasal septum
Nil of note.
3. Bony pyramid
Wide base of the boney pyramid. The height of the bony
bridge is not as low as commonly seen on African noses
(Frontal, Direct Dorsal and Backward Tilting).
4. Alar base
Wide alar base with thick posterior and long inferior
segments of rim-sill folds. (frontal, direct dorsal and
basal views). Asymmetrical Smile only seen in the post
operative forced smiling view.
Aims of Surgery
1. Narrow nasal tip.
2. High, narrow dorsum of the nose.
3. Narrow alar base.
Surgical Plan
1. Frontolateral walls
a. DDD excluding the weak triangle to reduce the bulk
of the nasal tip.
b. Bilateral cephalic trim of the lateral crurae to
reduce the size of the nasal tip.
2. Nasal septum
Nil of note.
3. Bony pyramid
Osteotomies and medialization of the lateral bony walls.
4. Alar base
Bilateral resection of the posterior and inferior segments
of the rim sill folds.
Surgical Procedure
1. As per Surgical Plan.
2. The cephalic parts of the lateral crurae were only cut
laterally, then they were curved superiorly and stitched
together to augment the dorsum. The stitches were taken
through the skin and fixed externally.
Post-operative Analysis
1. Frontolateral Wall
a. Tip definition: defatting have thinned the tip size and
thinned its covering skin. The alae nasi came into
view to share in nasal aesthetics. (Frontal, Direct
Dorsal, Over Head, Backward Tilting and Basal
Views). No tip grafts were used. This is the patient’s
own tip and own nasal print.
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. Using the lateral crural cartilages to augment the
dorsum gave the nose natural appearance. Aesthetics
of the nasal dorsum and bony side walls improved
(Frontal, Direct Dorsal, Backward Tilting, Nasal
Aperture, Oblique and Lateral Views).
b. Dorsal light re flex is a straight line post-operatively as
© 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_33
(Direct Dorsal Views).
193
194 33 Part V: Clinical Case 1
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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 i.e. the angles of the alae nasi with the upper
lip became wider (Backward Tilting, Basal and Nasal
Aperture Views).
c. Alae nasi aesthetics improved. They are pulled
medially became better seen, smaller and share in
nasal aesthetics (Nasal Aperture, Oblique and Lateral
Views).
d. Nasal aperture aesthetics improved after defatting and
excision of the rim-sill folds:
i. The size of the nasal openings are smaller
(Backward Tilting, Basal and Nasal Aperture
views).
Frontal
ii. The shapes of nasal openings transformed from
thick walled wide and rounded openings with
transverse long axes to thin walled small oval
openings with anterior long axes (Backward
Tilting, Basal and Nasal Aperture views).
e. Marginal light reflexes are clearly seen at:
i. Inferior alar margins (Nasal Aperture Views).
ii. Nasal sill bands (Oblique Views).
iii. Lateral crural prominences (Lateral Views).
Commentary
(a) This lady is of mixed African and Asian (Yemeni) roots.
She has the large thick skinned flat nose as commonly seen
in Africans and the lighter skin color as commonly seen in
Yemeni ladies.
(b) Resection of the rim-sill folds together with defatting
have greatly reduced and almost abolished the bulk and size
of the lower third of the nose. The thick heavy appearance of
the nose was transformed into a thin delicate looking nose.
Frontal
Smiling
Preoperative
Postoperative
33 Part V: Clinical Case 1 195
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Direct Dorsal
Overhead
Preoperative
Postoperative
Direct Dorsal
Smiling
Preoperative
Postoperative
Steeper
Backward Tilting Backward Tilting
Basal
Basal
Smiling
196 33 Part V: Clinical Case 1
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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
Cheek Margin
Middle Third
Left Nasal
Aperture
Left Oblique
Cheek Margin
Middle Third
Preoperative
Postoperative
33 Part V: Clinical Case 1 197
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Preoperative
Postoperative
Right Lateral
Left Lateral
Right Lateral
Smiling
Left Lateral
Smiling
Part V: Clinical Case 2
https://t.me/medicina_free
34
Preoperative Assessment
1. Frontolateral walls
Bulky large nasal tip overshadowing the alae nasi
(Frontal, Direct Dorsal and Backward Tilting Views).
2. Medial Wall
Nil of note.
3. Bony pyramid
Wide base of the boney pyramid, but not as low as
commonly seen in African noses (Direct Dorsal, Backward Tilting, Oblique and Lateral Views).
4. Alar base
Thick round nasal apertures but not wide.
Aims of Surgery
1. Narrow the nasal tip and reduction of its bulk.
2. High, narrow dorsum of the nose.
3. Narrow alar base and reduction of its bulk.
Surgical Plan
1. Frontolateral walls
a. DDD excluding the weak triangle to reduce the bulk
of the frontolateral walls.
b. Bilateral cephalic trim of the lateral crurae to reduce
the size.
2. Nasal septum
Nil of note.
3. Bony pyramid
Osteotomies and medialization of the lateral bony walls.
4. Alar base
Bilateral resection of the rim sill folds, including the
posterior and inferior segments.
Surgical Procedure
a. As per Surgical Plan.
b. No alar resection was necessary after defatting.
Post-operative Analysis
1. Frontolateral Walls
a. Tip definition: Defatting have thinned the nasal tip
and its covering skin. The alae nasi came into view to
share in the nasal aesthetics (Frontal, Direct Dorsal,
Backward Tilting and Basal views).
b. No tip grafts were used. The nose keeps its original
nasal image and nasal print.
c. The nasal tip and columella maintain their natural soft
feeling. The columella maintain its physiological role
in facial expression and movement with the nose and
upper lip.
d. 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).
e. 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 an uninterrupted 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).
© 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_34
199
200 34 Part V: Clinical Case 2
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b. Posterior alar groove aesthetic s improved: the angle
between the alae nasi and the upper lip become wider
(Basal, Oblique and Lateral Views).
c. Nasal aperture aesthetics: defatting the anterolateral
walls did not affect the sizes of nasal apertures, but
the shapes became more elegantly oval. The light
reflex could be seen from the inferior alar margins
(Backward Tilting and Basal Views).
d. Alae nasi aesthetics improved. They are pulled medially
become better seen, smaller and share in nasal aesthetics
(Nasal Aperture, Oblique and Lateral Views).
Frontal
Preoperative
e. Marginal light reflexes: The inferior alar margins
reflects the light (Basal Views). Note the size of the
flat triangles became smaller post-operatively.
Commentary
A simple uncomplicated surgery was sufficient to produce a
good aesthetic result. Only two of the four areas of Rhinoplasty were addressed i.e. the frontolateral walls by defatting
and the bony pyramid by osteotomies.
Frontal
Smiling
Postoperative
34 Part V: Clinical Case 2 201
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Direct Dorsal
Direct Dorsal
Preoperative
Postoperative
Smiling
Preoperative
Postoperative
Steeper
Backward Tilting Backward Tilting Basal
Basal
Smiling
202 34 Part V: Clinical Case 2
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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
Preoperative
Postoperative
Right Lateral
Left Lateral
Right Lateral
Middle Third
Left Lateral
Middle Third
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