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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4572_Библиотеки_им_академика_М_И_Перельмана
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Part III: Clinical Case 9
https://t.me/medicina_free
21
Preoperative Assessment
1. Frontolateral walls
a. Large, bulbous tip overshadowing the alae nasi
(Frontal, Direct Dorsal, Overhead and backward
Tilting Views).
b. The nasal tip was long and pointing inferiorly
(Frontal, Oblique and Lateral Views).
2. Medial Wall
a. Overall long nose and a high and long nasal septum
(Frontal and Lateral Views).
b. Hanging columella (Lateral Views).
c. Mobile tip (Lateral Smiling Views).
d. Left septal caudal deviation (Left Nasal Aperture
Views).
3. Bony pyramid
a. Wide base of the boney pyramid (Direct Dorsal,
Overhead and Backward Tilting Views).
b. Small osteocartilagenous hump (Oblique and Lateral
Views). The hump is predominantly cartilaginous.
4. Alar base
Alae nasi are slightly everted due to the oblique inferior
segments of the rim sill folds (Nasal Aperture and
Oblique views).
Aims of Surgery
1. Reduce the size of the nasal tip.
2. Reduce the length of the nose.
3. Abolish the mobile tip and the hanging columella.
4. Excision of the hump.
5. Improve the aesthetics 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 to reduce the size.
2. Medial Wall
a. Septoplasty to correct the caudal and septal
deviations.
i. Correction of the caudal deviation.
ii. Trim of a Stripe of the caudal membranous
septum including the cartilage.
b. Reduction of the height of the cartilaginous septum.
This is partly achieved while excising the osteocartilagenous hump.
c. Division of the depressor septi muscles.
3. Bony pyramid
a. Excision of the osteocartilaginous hump.
b. Osteotomies and medialization of the lateral bony
walls.
4. Alar base
Excision of the obli que inferior segments of the rim sill
folds.
Surgical Procedure
a. As per Surgical Plan.
b. Trim of almost 1 cm of caudal cartilaginous septum
including few mm of the loose skin of the membranous
septum were sufficient to reduce the hanging columella.
No direct surgery to the medial crurae was necess ary.
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
© 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_21
127
128 21 Part III: Clinical Case 9
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coupled with good aesthetic nasolabial angle (lateral
and oblique views).
c. Tip light reflex is seen as one spot off the nasal tip
(Backward Tilting and Frontal Views).
2. Medial Wall
a. Medial wall aesthetics improved so that:
i. Hanging columella disappeared. The lateral col-
umellar margin is seen just off the alar margins
in the Oblique and Lateral views. The columella
has better relation with alar margins.
ii. Mobile tip was overcome (Lateral Smiling 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).
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 aesthetic improved after defat-
ting and excision of the inferior segments of the
rim-sill folds. The alae nasi are pulled medialy and
their angles with the upper lip become wider (Nasal
Aperture, Oblique and Lateral Views).
c. Aesthetics of the alae nasi imp roved. They are in
better locations and their outer surfaces are better seen
(Backward Tilting, Basal, Nasal Aperture, Oblique
and Lateral Views).
d. Nasal aperture aesthetics improved after defatting and
excision of the inferior segments of the rim-sill folds:
i. The size of the nasal openings are smaller.
ii. Alar-columellar relations are better. The alae
nasi moved inferiorly after excision of the oblique inferior segments of the rim-sill folds.
iii. The shapes of nasal apertures improved after
defatting and excision of the inferior segments.
They 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 lady underwent surgery to the four areas of
Rhinoplasty in order to achieve the aesth etic goal. There
was no single predominant unaesthetic feature. Each of
the four areas had a subtle unaesthetic issue.
b. There is smoother continuation between the lateral crural
and upper lateral skins i.e. between the frontolateral wall
and the midvault skins. Dividing the subdermal bands
during defatting have released the crural skin from its
tight binding to the underlying cartilaginous capsules of
fat (Refer to Anatomy of the Nasal Skin in the Text).
Postoperative
Frontal
Frontal
Smiling
Frontal
Middle Third
21 Part III: Clinical Case 9 129
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Preoperative
Postoperative
Direct Dorsal
Direct Dorsal
Smiling
Steeper
Backward Tilting Backward Tilting
Overhead
Basal
Overhead
Smiling
Basal
Smiling
Preoperative
Postoperative
130 21 Part III: Clinical Case 9
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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
21 Part III: Clinical Case 9 131
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Preoperative
Postoperative
Combined excision of the inferior segments of the rim sill folds together with reduction of the hanging columella have repositioned the nasal tip
and the alar margins into more aesthetic location. Defatting, reduced the bulk of the tip. Note these changes in the frontal views
Preoperative
Postoperative
Right Lateral
Left Lateral
Right Lateral
Smiling
Left Lateral
Smiling
132 21 Part III: Clinical Case 9
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Preoperative
Postoperative
Right Lateral
Middle Third
Left Lateral
Middle Third
Part III: Clinical Case 10
https://t.me/medicina_free
22
Preoperative Assessment
1. Frontolateral walls
Bulbous bulky nasal tip overshadowing the alae nasi on
both sides (Frontal, Direct Dorsal, Overhead and Overhead Views).
2. Medial Wall
Nil of note.
3. Bony pyramid
Wide base of the boney pyramid (Direct Dorsal and
Backward Tilting Views).
4. Alar base
Nil of note.
Aims of Surgery
To reduce the overall size and bulk of the nose and make it
slimmer, higher and more defined.
Surgical Plan
1. Frontolateral walls
DDD excluding the weak triangle.
2. Medial Wall
Nil of note.
3. Bony pyramid
Osteotomies and medialisation of the pyramidal
sidewalls.
4. Alar base
Nil of note.
Surgical Procedure
1. As per Surgical Plan.
2. No cephalic trim of the lateral crurae was 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
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 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 by defatting.
The grooves become longer and deeper (Oblique,
Lateral and Direct Dorsal grooves).
b. Posterior alar groove aesthetics improved after
defatting alone. Defatting pulls the alae nasi medially
widening the angles of the posterior alar grooves
(Nasal Aperture and Oblique Views).
c. Alae nasi aesthetics improved. They are pulled
medially and are better seen (Frontal, Direct Dorsal,
Nasal Aperture 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_22
133
134 22 Part III: Clinical Case 10
https://t.me/medicina_free
d. Nasal aperture aesthetics improve after defatting. The
apertures are oval shaped, thinner walled aperture
despite remaining of the same size.
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. Only two of Rhinoplasty areas were addressed i.e. the
frontolateral walls and the bony pyramid.
b. The overall increase in the size of the nose had developed
over a period of the last decade of life due to the
increased fat deposition around the lower lateral cartilages and weak triangle.
c. The overall image of the lady was maintained despite the
simple surgical procedure.
Frontal
Smiling
Frontal
Middle Third
Postoperative
22 Part III: Clinical Case 10 135
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Preoperative
Postoperative
Direct Dorsal
Direct Dorsal
Smiling
Overhead
Overhead
Smiling
Preoperative
Postoperative
Steeper
Backward Tilting Backward Tilting
Basal
136 22 Part III: Clinical Case 10
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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
Mid Cheek
Middle Third
Left Nasal
Aperture
Left Oblique
Mid Cheek
Middle Third
Preoperative
Postoperative
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