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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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158 26 Part IV: Clinical Case 1
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b. Posterior alar groove aesthetics improved. After
defatting the alae nasi are pulled mediately with better
aesthetic posterior groove angle with the upper lip.
c. Alae nasi aesthetics improved after defatting. They
are medialized with wider posterior alar grooves.
They become better seen and look more elegant.
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).
Frontal
Preoperative
Frontal
Smiling
Commentary
a. Analysis of the short comings of the primary surgery:
i. Only bilateral cephalic trim of the lateral crurae was
done. No deafening was performed.
ii. Excision of the osteocartilaginous hump resulted in
an open-roof deformity. Closing the roof is simply
achieved by lateral osteotomies.
b. The previous surgeon omitted the reduction of the
hanging columella as well as the mobile tip.
c. Three of the four Rhinoplasty areas were addressed in
this case viz the nasal tip, nasal septum and the bony
pyramid.
d. Post-operative photographs were taken two months after
surgery. Long term results in better tip definition.
Postoperative
Preoperative
Postoperative
Direct Dorsal
Direct Dorsal
Smiling
Overhead
Overhead
Smiling
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Preoperative
Postoperative
Preoperative
Steeper
Backward Tilting Backward Tilting
Right Nasal
Aperture
Basal
Basal
Smiling
Left Nasal
Aperture
Postoperative
160 26 Part IV: Clinical Case 1
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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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Preoperative
Postoperative
Right Lateral
Right Lateral
Middle Third
Left Lateral
Left Lateral
Middle Third
Right Lateral
Smiling
Left Lateral
Smiling
Preoperative
Postoperative
Part IV: Clinical Case 2
https://t.me/medicina_free
27
Preoperative Assessment
1. Frontolateral walls
a. Bulky nasal tip with irregular lateral walls over the
lateral crurae. The alae nasi disappeared behind
the bulky tip predominantly the left side (Frontal
Views).
2. Media Wall
Sliding tip: the nasal tip moves posterior to the level of
the anterior septal angle i.e. the end point of the nasal
dorsum (Lateral Smiling Views). The nasolabial angle is
approximately 90 degrees and does not change on smiling. This is to be differentiated from a mobile tip that
moves inferiorly on smiling, and the nasolabial angle
becomes acute.
3. Bony pyramid
a. Wide base of the boney pyramid (Frontal, Direct
Dorsal and Backward Tilting Views).
b. Bulge of left side of the upper lateral cartilage sec-
ondary to left sided septal deviation (Frontal, Overhead, Direct Dorsal and Backward Tilting Views).
4. Alar base
Asymmetrical smile. It was claimed to be worse after the
primary surgery. The left cheek ball is different in size
and shape from the right. The left angle of the mouth is
narrower than the right (Frontal and Lateral Smiling
Views).
Aims of Surgery
1. Reduce the size and overcome the irregularities of the
lower third of the nose.
2. Reduce the width of the bony pyramid and overcome
the bulge of the left side of the upper lateral Cartilage.
3. Correction of the sliding tip.
Surgical Plan
1. Frontolateral walls
a. DDD including the weak triangle to reduce the bulk
of the nasal tip.
b. Cephalic trim of the lateral crurae to reduce the size
of the nasal tip.
2. Medial Wall
a. Septoplasty.
b. Trim of the membranous septum. The caudal septum
to be transfixed to the medial crurae to correct the
sliding tip.
3. Bony pyramid
Osteotomies and medialization of the bony sidewalls.
4. Alar base
Nil of note.
Surgical Procedure
As per Surgical Plan.
Post-operative Analysis
1. Frontolateral Walls
a. Tip definition improved i.e. the tip is slimmer and
prominently well identified. The alae nasi come into
view to share in nasal aesthetics. Both alae nasi become almost equal in size and appearance (Frontal,
Direct Dorsal, Overhead, Backward Tilting and Basal
Views). Note the clear light reflex off the nasal tip as
one spot (Backward Tilting Views).
b. Tip projection: The nasal tip is 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_27
163
164 27 Part IV: Clinical Case 2
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c. Tip light reflex seen as one spot reflected off the nasal
tip (Frontal and Backward Tilting Views).
2. Medial Walls
Sliding tip was completely amended.
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. The bulge of the left side of upper lateral cartilage
disappeared after septoplasty.
c. Dorsal light reflex is seen as a regular one line off the
nasal dorsum (Direct Dorsal Views).
4. Alar Base
a. Post-operative smile became more symmetrical
(Post-operative Smiling Frontal and lateral Views).
b. Superior alar groove aesthetics improved by defatting.
The grooves become longer and deeper (Oblique,
Lateral, Direct Dorsal and Overhead Views).
c. Posterior alar groove aesthetics improved by defatting
alone. The angle wi th the upper lip is wider (Nasal
Aperture and Oblique Views).
d. Alae nasi aesthetics improved. They are pulled
medially, became smaller and more elegant (Nasal
Aperture and Oblique 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
1. Analysis of the shortcomings of the primary surgery:
a. The irregularities over the lateral crura were due to the
excessive fibro-fatty tissues, as well as scarring in the
subdermal layer, from the primary surgery. Septoplasty was omitted.
i. The external bulge of the upper lateral cartilage
was the result of deviation of the of the septal
cartilage.
ii. The sliding tip was not corrected.
b. Osteotomies were omitted resulting in the wide base
of the boney pyramid.
2. Three of the four areas if Rhinoplasty were addressed:
a. The nasal tip: Meticulous scrapping of the subdermal
layer down to the shiny crural cartilages, as well as to
the fibrous dermal layer were performed.
b. Septoplasty as well as trimming of the membranous
septum.
c. The bony pyramid: bilateral osteotomies and medi-
alization of the bony sidewalls.
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Preoperative
Postoperative
Frontal
Frontal
Smiling
Frontal
Middle Third
Preoperative
Postoperative
Direct Dorsal
Direct Dorsal
Smiling
Overhead
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Preoperative
Postoperative
Preoperative
Steeper
Backward Tilting Backward Tilting
Right Nasal
Aperture
Basal
Basal
Smiling
Left Nasal
Aperture
Po&operative
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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
168 27 Part IV: Clinical Case 2
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Preoperative
Postoperative
Right Lateral
Right Lateral
Middle Third
Left Lateral
Left Lateral
Middle Third
Right Lateral
Smiling
Left Lateral
Smiling
Preoperative
Postoperative
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