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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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36 6 Part II: Clinical Case 4
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Preoperative
Postoperative
Frontal
Frontal
Smiling
Frontal
Middle Third
Preoperative
Postoperative
Direct Dorsal
Direct Dorsal
Smiling
6 Part II: Clinical Case 4 37
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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
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
38 6 Part II: Clinical Case 4
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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
6 Part II: Clinical Case 4 39
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Preoperative
Postoperative
Right Lateral
Middle Third
Left Lateral
Middle Third
Part II: Clinical Case 5
https://t.me/medicina_free
7
Preoperative Analysis
1. Frontolateral walls
a. Large and bulky frontolateral walls overshadowing
the alae nasi. (Frontal, Overhead, Direct Dorsal and
Backward Tilting Views).
b. The tip is counter deviated to the right.
2. Nasal septum
a. Severe, traumatic fracture with left sided angulated
deviation of the caudal nasal septum (Left Nasal
Aperture Views).
b. Mobile tip (Lateral Smiling Views).
3. Bony pyramid
a. The bony pyramid is fractured and both oblique
and deviated to left side.
b. Bilateral maxillary asymmetry which is clearly seen
in the backward tilting view. The right cheek is wide
and low while the left cheek is narrow and high. The
trauma together with the bilateral maxillary asym-
metry has led to the extreme left Obliquity and de-
viation of the boney pyramid. (Frontal, Direct Dorsal
and Overhead Views).
c. Osteocartilaginous hump. (Backward Tilting, Oblique
and lateral Views).
4. Alar base
Wide and bulky alar base (Basal and Nasal Aperture
Views).
Aims of Surgery
1. Reduction of the size and bulk of the frontolateral walls.
2. Abolish the mobile tip.
3. Correction of the septal deviation.
4. Excision of the osteo cartilaginous hump.
5. Centralizing and reducing the wide base of the boney
pyramid.
6. Reduction of the width and bulk of the alar base.
Surgical Plan
1. Frontolateral walls
a. DDD including the weak triangle to reduce the bulk.
b. Cephalic trim of the lateral crurae, more on the left
side to reduce the size.
2. Nasal septum
a. Septoplasty.
b. Division of the Depressor Septi muscles.
3. Bony pyramid
a. Rasping of the boney hump. More rasping on the
right of the pyramid. Excision of the cartilaginous
hump.
b. Bilateral osteotomies to reduce the size of the booty
pyramidal base.
c. Kassanjian maneuver to the right i.e. cross fracture of
the bony pyramid after osteotomies (see Surgery of
the Bony Pyramid in the Text).
4. Alar base
Resection of the posterior and inferior segments of the
rim sill folds.
Surgical Procedure
a. As per Surgical Plan.
b. At the time of surgery, the right lateral crus was found
to be too small for any further reduction.
Cephalic trim was only performed to the left lateral
crus only.
c. Two pieces of crushed septal cartilage used to aug-
ment the right side of the upper lateral cartilage.
d. Surprisingly after defatting and reduction the lateral
crural sizes, the shape and sizes of nasal apertures
greatly improved. No alar resections were needed.
Post-Operative Analysis
1. Frontolateral Wall
a. Tip Definition: nasal tip is smaller with thinner and
smoother overlying skin. It is more prominent and
© 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_7
41
42 7 Part II: Clinical Case 5
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well identified from the alae nasi on both sides. The
alae nasi come into view to become clearly visible
and 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 reflex is seen as one spot off the nasal
tip. (Frontal and Backward Tilting).
2. Medial Wall
The deviated septum was corrected.
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
a. Superior alar groove aesthetics improved after
defatting. The grooves became longer and deeper
(Oblique, Lateral and Direct Dorsal grooves).
b. Posterior alar groove aesthetics improved even with-
out alar resection. The alae nasi pulled medially
resulting in wider posterior alar groove angles. The
flat tire appearance was gone.
c. Alae nasi aesthetics improved. They look smaller and
are better seen along the sides of the the thinner well defined nasal tip.
d. Nasal aperture aesthetics improved with defatting
alone. Nasal apertures look smaller and elegantly oval
in shape. (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. The patient’s main complain was the fractured deviated
bony pyramid. It is the role and duty of the treating
surgeon to advice him to proportionately reduce the size
of the lower third of the nose for better aesthetic results.
b. The size of the right side of the upper lateral cartilage is
smaller than the left as a result the facial asymmetry and the
trauma in early life which may have affected its growth.
A graft was needed to augment this defective area.
c. The size of the nose was greatly reduced after DDD to the
extent that both alae were elevated forward rather than lying
backward. An alar resection was, therefore, unnecessary.
d. No direct surgery was addressed to the lower lateral
cartridges i.e. no direct stitching. No indirect camouflage
surgery to the nasal tip i.e. tip grafts.
Preoperative
Postoperative
Frontal
Frontal
Smiling
7 Part II: Clinical Case 5 43
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Direct Dorsal
Overhead
Preoperative
Postoperative
Direct Dorsal
Smiling
Preoperative
Postoperative
Backward Tilting
Basal
44 7 Part II: 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 Nasal
Aperture
Rim Sill Test
Left Oblique Right Oblique
Mid Cheek Mid Cheek
Full Face Middle Third
Left Nasal
Aperture
Left Oblique
Mid Cheek
Middle Third
Preoperative
Postoperative
7 Part II: Clinical Case 5 45
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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
46 7 Part II: Clinical Case 5
https://t.me/medicina_free
Preoperative
Postoperative
Right Lateral
Middle Third
Left Lateral
Middle Third
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