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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 II: Clinical Case 8
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10
Preoperative Assessment
1. Frontolateral walls
a. Relatively small but bulky nasal tip overshadowing
the alae nasi (Frontal Views).
b. Slight tip bifidity reflecting two spots of light.
(Backward Tilting Views).
2. Nasal septum
a. Traumatic septal deviation to the left (Backward
Tilting and Basal Views; the red mucosa of the cartilaginous septum is seen through the left nasal opening
blocking it almost completely).
b. Slight columellar bifidity (Backward Tilting Views).
3. Bony pyramid
a. Fracture of the boney pyramid deviating it to the left
side. The right side of the pyramid is depressed while
the left side is elevated with prominent fracture
margin. (Frontal, Backward Tilting and Oblique
Views).
b. Wide base of the bony pyramid (Frontal and Back-
ward Tilting Views).
4. Alar base
Nil of note.
Aims of Surgery
1. Proportionate reduction of the nasal tip bulk.
2. Correction of the septal deviation.
3. Balancing and centralizing the boney pyramid.
Surgical Plan
1. Frontolateral walls
DDD including the weak triangle to reduce the bulk of
nasal tip.
2. Nasal septum
Septoplasty.
3. Bony pyramid
a. Rasping the prominent broken bone.
b. Osteotomies as well as cross fracture of the boney
pyramid to the right side (Kasanjian maneuver).
4. Alar base
Nil of note.
Surgical Procedure
a. As per Surgical Plan.
b. Small bone graft over the right side of the boney pyramid
was needed to balance the two sides of the bony pyramid.
Post-Operative Analysis
1. Frontolateral Wall
a. Tip Definition: nasal tip is smaller with thinner and
smoother overlying skin. It is more prominent and
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,
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 Views).
2. Medial Wall
a. The deviated septum was corrected (Backward Tilt-
ing and Basal views).
b. Bifidity of the columellar was corrected only by
defatting. This can be seen in almost all the views of the
nose in particular the Backward Tilting Basal 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).
© 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_10
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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).
b. Posterior alar groove improved by defatting as the
alae nasi pulled medially widening the posterior alar
grooves.
c. Alae nasi aesthetics improved as they were pulled
medially, became more visible and of smaller sizes.
(Nasal Aperture, Oblique and Lateral Views). Nasal
aperture aesthetics are enhanced by defatting and
correction of caudal septal deviation. They maintained the same size but they were transformed from
Frontal
thick walled rounded openings into thin walled elegant oval apertures.
d. 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 is a case of a simple, uncomplicated fracture of the
boney pyramid. It is an ideal case for beginners.
b. Areas of defects on the depressed side of the fracture
should be anticipated. A cartilaginous or bony graft is
used to balance the sides of the boney pyramid.
c. The bulky tip is a pre-existing unaesthetic part of the
nose that should be addressed for better aesthetic result.
Frontal
Smiling
Frontal
Middle Third
Preoperative
Postoperative
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Steeper
Backward Tilting Backward Tilting
Preoperative
Postoperative
Basal
Preoperative
Postoperative
Steeper
Backward Tilting Backward Tilting
Basal
62 10 Part II: Clinical Case 8
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Preoperative
Postoperative
Right Oblique
Mid Cheek
Full Face
Left Oblique
Mid Cheek
Full Face
Right Oblique
Cheek Margin
Full Face
Right Oblique
Mid Cheek
Middle Third
Left Oblique
Cheek Margin
Full Face
Left Oblique
Mid Cheek
Middle Third
Preoperative
Postoperative
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Preoperative
Postoperative
Right Lateral
Left Lateral
Right Lateral
Smiling
Left Lateral
Smiling
Part II: Clinical Case 9
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11
Preoperative Assessment
1. Frontolateral walls
Bulbous and bulky nasal tip partially overshadowing the
alae nasi (Frontal, Direct Dorsal and Overhead Views).
2. Medial Wall
Mobile tip (Lateral Views).
3. Bony pyramid
a. Wide base of the bony pyramid. (Direct Dorsal,
Overhead and Backward Tilting Views).
b. Localized hump at the distal end of the bony pyramid.
On palpation it was a purely bony hump. It was not
an osteocartilaginous hump. Palpating the area just
distal to this hump, the nasal dorsum felt quite firm
and the nasal septum could be clearly felt indicating
that it had not collapsed by the trauma. A line drawn
from the nasion to the nasal tip, i.e point of maximum
convexity of the middle crus, is a straight line. (Lateral Views).
c. The dorsal light reflex is distorted (Frontal and Direct
Dorsal views).
d. Deep naso-frontal angle (lateral views).
4. Alar base
Wide alar base.
2. Media Wall
Division of depressor septi muscles.
3. Bony pyramid
a. Excision of the pure bony hump. It is NOT an
osteocartilaginous hump.
b. Osteotomies and medialization of the lateral bony
walls.
c. Graft over the middle third of the nose is considered.
4. Alar base
Resection of the inferior segments of the rim sill folds.
Surgical Procedure
a. As per Surgical Plan.
b. Excision of the boney hump was performed using a sharp
osteotome.
c. The excised bone was used to augment the nasofrontal
angle.
d. A slight supratip depression was observed during sur-
gery. This was due to minimal tissue damage to the upper
lateral cartilage in the mid vault. The depression was
corrected using septal graft and lateral crural trimmings.
Post-Operative Analysis
Aims of Surgery
1. Reduction of the bulk of the nasal tip.
2. Overall reduction of the size of the bony pyramid.
3. Removal of the localized boney hump.
4. Reduction of alar base size and bulk.
Surgical Plan
1. Frontolateral walls
a. D.D.D. not including weak triangle to reduce the bulk
of the nasal tip.
b. Cephalic trim of lateral crurae to reduce the size.
© 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_11
1. Frontolateral Walls
a. Tip Definition: nasal tip is smaller with thinner and
smoother overlying skin. It is more prominent and
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 on spot light reflected from
the nasal tip (Frontal and Backward Tilting Views).
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2. Medial Wall
The mobile tip was abolished.
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. The deep nasofrontal angle was more apparent after
removal of the bony hump. Clinically and photographically it was not quite as clear.
c. 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).
b. Posterior alar groove aesthetics improved after
defatting and excision of the inferior segments of
rim-sill folds. The angles with the upper lip became
wider.
c. Alae nasi aesthetics improved. They were pulled
medially by defatting and better seen.
d. Nasal aperture aesthetic improved after defatting and
excision of the inferior segments of the rim-sill folds:
i. The size of nasal opening are smaller.
ii. The shapes of the nasal openings became more
elegantly oval.
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 gentleman would have been very happy to just
remove the hump on his nose. However, he has other
features of common African/Middle Eastern nose which
are in his case large, bulbous tip, wide alar base and deep
nasofrontal angle. The attitude in this case should be to
tackle all these areas in order to have a more aesthetically
pleasing outcome.
b. The deep nasofrontal angle was appreciated only after
removal of the bony hump.
c. It is important to know the exact mechanism of the
trauma in order to understand the type of deformity. He
was at a lower level than a heavy window type AC unit
which slipped down onto the bridge of his nose as he was
looking up. The direction of the trauma is anatomically
from below in an upward direction. This led to a telescopic fracture of the nasal bones superiorly. This
explains the unusual, large local ized bony hump at the
distal end of the boney pyramid which is followed
inferiorly by the apparent depression. This is to be differentiated from the saddle deformity in the midvault
secondary to cartilaginous septal collapse. As in all cases
of post traumatic Rhinoplasty there is a degree of
uncertainty with the Surgical Plan as the trauma is usually associated with irregular tissue damage and scattered pieces of broken bones.
d. This gentleman would have been very happy to just
remove the hump of his nose. However, he has other
features of common African/Middle Eastern nose which
are in his case large, bulbous tip, wide alar base and deep
nasofrontal angle. The attitude in this case should be to
tackle all these areas in order to have a more aesthetically
pleasing outcome.
11 Part II: Clinical Case 9 67
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Preoperative
Postoperative
Frontal
Frontal
Smiling
Frontal
Middle Third
Preoperative
Postoperative
Direct Dorsal
Direct Dorsal
Smiling
Overhead
68 11 Part II: Clinical Case 9
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Steeper
Backward Tilting Backward Tilting
Preoperative
Postoperative
Basal
Preoperative
Postoperative
Right Nasal
Aperture
Left Nasal
Aperture
11 Part II: Clinical Case 9 69
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Preoperative
Postoperative
Right Oblique
Mid Cheek
Full Face
Right Oblique
Cheek Margin
Full Face
Left Oblique
Mid Cheek
Full Face
Right Oblique
Mid Cheek
Middle Third
Left Oblique Right Oblique
Cheek Margin Cheek Margin
Full Face Middle Third
Left Oblique
Mid Cheek
Middle Third
Left Oblique
Cheek Margin
Middle Third
Preoperative
Postoperative
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