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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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70 11 Part II: Clinical Case 9
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Preoperative
Postoperative
Right Lateral
Left Lateral
Right Lateral
Middle Third
Right Lateral
Smiling
Left Lateral
Middle Third
Left Lateral
Smiling
Preoperative
Postoperative
Part II: Clinical Case 10
https://t.me/medicina_free
12
Preoperative Assessment
1. Frontolateral walls
a. Small but bulky tip partially overshadowing the alae
nasi. (Frontal and Direct Dorsal Views).
b. There is unequal bulge of the domes. The broken
deviated distal segment of the cartilaginous septum
has displaced the dome of the left lower lateral cartilage forward and laterally, resulting in an unequal
bulge of the lateral crurae and broadening of the nasal
tip (backward tilting view).
2. Medial Wall
The vertical fracture of the nasal septum have lead to a
severe C-shaped deviation to the left. This curved shape
of the septum have caused the following two deformities:
i. Superior bulge of the right side of the upper lateral
cartilage which is met with counter depression on
the left side of the midvault. (Frontal, Direct Dorsal,
Overhead and Backward Tilting Views).
ii. Inferior bulge of the left lateral crus caused by the
broken distal segment of the septum. (Frontal, Direct
Dorsal, Overhead, Backward Tilting and Oblique
Views).
3. Bony pyramid
a. Wide base of the bony pyramid (Frontal, Direct
Dorsal, Overhead and Backward Tilting Views).
b. Depression over the left side of the upper lateral
cartilage secondary to an old fracture of the tip of the
left nasal bone leading to a “ski slope” deformity.
4. Alar base
Nil of note.
Aims of Surgery
1. Reduce the size and bulk of the nasal tip.
2. Reduce the bulges of the left dome and right midvault
areas.
3. Elevate the left sided depression of the midvault.
4. Reduce the width of the boney pyramid.
Surgical Plan
1. Frontolateral walls
a. DDD excluding the weak triangle to reduce the bulk
of nasal tip.
b. Bilateral cephalic trim of the lateral crurae to reduce
the size of nasal tip.
2. Media Wall
Septoplasty.
3. Bony pyramid
a. Osteotomies and medialization of the lateral bony
walls.
b. Cartilaginous graft over left side of the upper lateral
cartilage to correct the ski slope deformity.
4. Alar base
Nil of note.
Surgical Procedure
a. As per surgical plan.
b. The graft over the left side of the upper lateral cartlidge
was fixed by external stitch to avoid graft displacement in
the loose sub dermal layer after removal of the fatt layers
i.e. defatting (Overhead, Left Oblique and Lateral Views).
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,
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).
© 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_12
71
72 12 Part II: Clinical Case 10
https://t.me/medicina_free
c. Cephalic trim of the lateral crurae reduces the size of
the nasal tip. It does not reduce the height of the nose.
The lateral crurae are in the lateral walls of the nose
and not in the dorsal midline.
d. Tip light reflex is seen as one spot off the nasal
tip. (Frontal and Backward Tilting Views).
2. Medial Wall
Septoplasty have had two positive aesthetic effects:
i. Repositioning the distal broken segment to midline
have moved it away from the left dome that immediately receded back to the same level as the right dome.
ii. Correcting the right higher septal deviation imme-
diately reduced the right bulge of the upper lateral
cartilage.
3. Bony Pyramid
a. Osteotomies were necessary to reduce the width of
the boney pyramid so that it matches with the new
smaller size of the nasal tip.
b. The counter depression of the left side of the upper
lateral cartilage was due to the clip fracture of the left
nasal bone long time ago. Filling the defect with
cartilagenous graft was necessary.
c. Grafts had to be externally fixed as they were placed
in the nose after the procedure of DDD’s. Removing
the fat leaves a wide subcutaneous space so that grafts
would loosely move freely and never remain in the
planned location.
d. Bony pyramid aesthetics improved: the nasal dorsum
is straight and the sidewalls are smooth and narrow
(all views except the Basal Views).
e. 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 by defat-
ting. The alae nasi pulled medially and the angles of
the posterior alar groove became wider.
c. Alae nasi aesthetics improved by defatting. They
were pulled medially, became more visible and
smaller in size (Oblique and Lateral Views).
d. Nasal aperture aesthetics improved by defatting: they
became smaller and more elegantly oval in shape
(Backward Tilting and Basal 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
Postoperative photographs were taken two weeks after surgery. The effects of defatting are quite clear, the size and
shape of the nasal tip further imp roves in the long term.
Frontal
Frontal
Smiling
Frontal
Middle Third
12 Part II: Clinical Case 10 73
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Preoperative
Direct Dorsal
Overhead
Preoperative
Postoperative
Steeper
Backward Tilting Backward Tilting Basal
74 12 Part II: Clinical Case 10
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Preoperative
Postoperative
Right Oblique
Mid Cheek
Full Face
Left Oblique
Mid Cheek
Full Face
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
12 Part II: Clinical Case 10 75
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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
Part III
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RhinoplastyFinesse
Part III: Clinical Case 1
https://t.me/medicina_free
13
Preoperative Assessment
1. Frontolateral walls
a. Bulbous tip partially overshadowing the alae nasi
(Frontal, Direct Dorsal, Overhead and Backward
Tilting Views).
2. Medial Wall
Left caudal deviation of the septum (left nasal aperture
view).
3. Bony pyramid
a. The bony pyramid is deviated to the right due to
bilateral maxillary asymmetry the left cheek being
wide and low while the right cheek is narrow and high
(backward tilting views).
b. Lower third of the nose, including the nasal tip, is
counter deviated to the left side as compared to the
bony pyramid.
4. Alar base
a. Wide alar base (Backward Tilting and Basal Views).
b. Thes nasal openings are square in shape. A common
finding in African noses.
Aims of Surgery
1. To reduce the bulk of the lower third of the nose.
2. To correct the nasal crookedness.
3. Alar reduction in size and bulk.
Surgical Plan
1. Frontolateral Walls
D.D.D. including the weak triangle.
2. Medial Wall
Septoplasty.
3. Bony pyramid
Osteotomies and correction of deviation by Kassanjian
maneuver to the left i.e. cross fracture of the bony
pyramid after osteotomies (see Surgery of the Bony
Pyramid in Text).
4. Alar base
Resection of the inferior and posterior segments of the
rim-sill folds.
Surgical Procedure
1. As per surgical plan.
2. Kassanjian maneuver to left side.
3. Alar resection.
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,
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 Views).
2. Medial Wall
Caudal septal deviation is 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 re flex is a straight line post-operatively as
compared to the interrupted reflex pre-operatively.
(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_13
79
80 13 Part III: Clinical Case 1
https://t.me/medicina_free
b. The posterior alar groove aesthetics improved by
defatting and resection of the rim-sill folds. The alae
nasi pulled medially with wider posterior alar
grooves. Aesthetics of the alae nasi is better.
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. Aesthetics of nasal apertures improved by defatting
and resection of the rim-sill folds:
i. The size of nasal apertures are smaller.
ii. The shapes are elegantly better.
e. Marginal light reflexes are clearly seen at:
Preoperative
i. Inferior alar margins (Nasal Aperture Views).
ii. Nasal sill bands (Oblique Views).
iii. Lateral crural prominences (Lateral Views).
Commentary
a. All four areas of Rhinoplasty were addressed. Surgery in
the four areas were integrated to produce the same nasal
image in a more refined aesthetic outcome.
b. The heavy impression of the bulky tip and the diffuse
amorphous appearance of the midvault, alae nasi and
nasal dorsum, became sharper, neater and share in nasal
aesthetics.
Frontal
Smiling
Frontal
Middle Third
Postoperative
13 Part III: Clinical Case 1 81
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Direct Dorsal
Direct Dorsal
Preoperative
Postoperative
Smiling
Steeper
Backward Tilting Backward Tilting
Overhead
Basal
Overhead
Smiling
Basal
Smiling
Preoperative
Postoperative
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