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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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82 13 Part III: Clinical Case 1
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Preoperative
Postoperative
Right Nasal
Aperture
Right Nasal
Aperture
Rim Sill Test
Left Nasal
Aperture
Rim Sill Test
Left Nasal
Aperture
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
13 Part III: Clinical Case 1 83
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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
Smiling
Left Lateral
Smiling
84 13 Part III: Clinical Case 1
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Preoperative
Postoperative
Right Lateral
Middle Third
Left Lateral
Middle Third
Part III: Clinical Case 2
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14
Preoperative Assessment
1. Frontolateral walls
Medium size thick skinned naasal tip overshadowing the
alae nasi (Frontal, Direct Dorsal and Overhead Views).
2. Medial Wall
Nil of note.
3. Bony pyramid
a. Wide base of the bony pyramid (Direct Dorsal,
Overhead and Backward Tilting Views).
b. Small osteocartilaginous hump. This is the natural
concavoconvex anatomy of the nasal bones (see
Anatomy in Text).
4. Alar base
Nasal apertures were thick walled with transverse long
axes of the nasal openings.
Aims of Surgery
a. Reduce the bulk of nasal tip.
b. Reduce the size and the width of the bony pyramid.
Surgical Plan
1. Frontolateral Walls
a. DDD not including the weak triangle to reduce the bulk.
b. Cephalic trim of the lateral crurae to reduce the size.
2. Medial Wall
Nil of note.
3. Bony pyramid
a. Excision of the osteocartilaginous hump i.e. rasping
down the natural convexities of the nasal bones.
b. Osteotomies and medialization of the lateral walls of
the bony pyramid.
4. Alar base
Nil of note.
Surgical Procedure
As per Surgical Plan.
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
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 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).
b. Posterior alar groove aesthetics improved by Defat-
ting alone. The defatted crurae are pulled medially as
they become semidetached from the alae nasi, by the
defatted superior alar grooves. The angles of the
posterior alar grooves with the upper lip become
wider. Aesthetics of the alae nasi improved. (Backward Tilting and Nasal Aperture 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_14
85
86 14 Part III: Clinical Case 2
https://t.me/medicina_free
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. Nasal aperture aesthetics:
i. The size of the nasal openings are reduced by
defatting alone.
ii. The shape of nasal openings: defatting enhanced
aesthetics of the nasal openings. They becomemore
elegantly oval on shape with thinner walls. (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).
Frontal
Preoperative
Commentary
a. This is a finesse Rhinoplasty in which the patient needed
smaller and sharper looking nasal features. Postoperatively she had a narrower bony pyramid, narrower tip and
smaller alar base. The narrow bony pyramid allowed her
eyes to “shine” as a more prominent feature.
b. The localized bulky tip of the nose may be seen in male
or female patients. The above surgical technique can be
used to produce different results. Less fat is removed
from the male nose to maintain a manly facial appearance, while more fat is removed from the female nose to
produce a more defined, feminine, petite nose.
Frontal
Smiling
Frontal
Middle Third
Postoperative
Preoperative
Postoperative
Direct Dorsal
Direct Dorsal
Smiling
Overhead
14 Part III: Clinical Case 2 87
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Preoperative
Postoperative
Preoperative
Backward Tilting Backward Tilting
Steeper
Right Nasal
Right Nasal
Aperture
Aperture
Rim Sill Test
Basal
Left Nasal
Aperture
Rim Sill Test
Basal
Smiling
Left Nasal
Aperture
Postoperative
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
88 14 Part III: Clinical Case 2
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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
14 Part III: Clinical Case 2 89
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Preoperative
Postoperative
Right Lateral
Middle Third
Left Lateral
Middle Third
Part III: Clinical Case 3
https://t.me/medicina_free
15
Preoperative Assessment
1. Frontolateral walls
Broad, large and thick nasal tip overshadowing the alae
nasi (Frontal, Direct Dorsal, Overhead and Backward
Tilting Views).
2. Medial Wall
a. Left caudal septal dislocation. (Basal and Left Nasal
Aperture Views) The left medial crus is seen projecting into the nasal aperture producing apparent
unequal openings (backward tilting views). The left
nasal sill band is pushed inferiorly (frontal views).
b. Mobile tip i.e. the nasal tip moves inferiorly on smil-
ing. (Lateral Smiling Views).
3. Bony pyramid
a. Wide base of the boney pyramid (Direct Dorsal,
Overhead and Backward Tilting Views).
b. Osteocartilaginous hump predominantly left side
(Oblique and Lateral Views).
c. There is bilateral maxillary asymmetry. The boney
pyramid is deviated to the left side; the right cheek is
narrow and high while the left cheek is wide and low
(backward tilting views).
4. Alar base
Wide unequal nasal openings due to left caudal septal
deviation. (Basal Views).
Aims of Surgery
1. Reduction of the overall size of the nose including the
nasal tip and the boney pyramid.
2. Centralizing of the boney pyramid to the mid line.
3. Correction of the caudally displaced septum and mobile
tip.
Surgical Plan
1. Frontolateral walls
a. DDD including the weak triangle to reduce the bulk.
b. Cephalic trim of lateral crurae to reduce the size.
2. Medial Wall
a. Septoplasty.
b. Transoral devision of the depressor septi muscles.
3. Bony pyramid
a. Excision of the osteocartilaginous hump. Osteotomies
plus Kasanjian manouvre to the patient’s right side
i.e. cross fracture of the bony pyramid after osteotomies (see Surgery of the Bony Pyramid in text).
4. Alar base
Nil of note.
Surgical Procedure
a. As per Surgical Plan.
b. Transcolumellar stitch between the two nasal sill bands
to medialize the crural prominence of both medial crurae.
c. Sub-mucosal diathermy of the inferior turbinate heads to
improve the nasal airway.
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).
© 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_15
91
92 15 Part III: Clinical Case 3
https://t.me/medicina_free
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 View).
2. Medial Wall
Columellar aesthetics improved. It became central. The
left medial crus replaced back to its natural anatomical
place together with its surrounding inferior vestibular
band. The light reflex is clearly seen of the inferior columellar surface.
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).
4. Alar Base
a. Superior alar groove aesthetics improved by defatting.
The superior alar grooves become longer and deeper
(Oblique, Lateral and Direct Dorsal grooves).
b. Posterior alar groove aesthetics improved by defat-
ting alone. The defatted crurae are pulled medially as
they become semidetached from the alae nasi, by the
defatted superior alar grooves. The angles of the
posterior alar grooves with the upper lip become
wider. Aesthetics of the alae nasi improved. (Backward Tilting and Nasal Aperture Views).
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. Nasal aperture aesthetics improved by defatting:
i. The size of the nasal openings are reduced
(Basal and Nasal Aperture views).
ii. The shape of nasal openings became more ele-
gantly oval. (Backward Tilting, Basal and Nasal
Aperture views).
iii. The light reflex is observed off the inferior alar
margins in the 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
The patient maintained her original nasal image i.e. the
nasal print, despite the major changes in the three
Rhinoplasty areas i.e. nasal tip, bony pyramid and nasal
septum.
Preoperative
Postoperative
Frontal
Frontal
Smiling
Frontal
Middle Third
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