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256 44 Part VI: Clinical Case 6
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2. Medial Wall
Nil of Note.
3. Bony Pyramid
a. The side walls of the boney pyramid preoperatively
were very close to the inner canthi. Aesthetically, the
C- shaped line that is drawn from the lower margin of
the eyebrow, the bony side wall reaching to the outer
curve of the alae nasi should have all these structures
medial to it, so that the line runs smoo thly on their
surfaces. Note, that preoperatively the base of the
bony pyramid is bulging lateral to this line on both
sides. Postoperatively, the base of the bony pyramid
is just touching the line.
b. Bony pyramid aesthetics: 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 grooves become longer and deeper (Oblique,
Lateral, and Direct Dorsal grooves).
b. Posterior alar groove aesthetics:
i. The wide angle of the posterior alar groove was an
absolute contraindication for alar base surgery.
Placing the incision in the exact locations of the
posterior and inferior segments of the rim sill folds
has overcome this problem. Healing in these locations leaves barely visible scars. In fact it is quite the
opposite, the posterior scar created a posterior alar
groove that was not present preoperatively.
ii. Excision of the posterior segment of the rim sill
folds have deepen the wide angles of the posterior groove, i.e. between the alae nasi and the
upper lip (Basal and Nasal Aperture Views).
c. Alae nasi aesthetics improved. The alae nasi 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 as well as excising the inferior segments of the rim-sill folds (Backward Tilting,
Basal and Nasal Aperture views).
ii. The shape of nasal openings improved by de-
fatting and excision of the rim-sill folds transforming the nasal apertures from thick walled
wide and rounded openings with transverse long
axes to thin walled smal l oval openings with
anterior long axes (Backward Tilting, Basal and
Nasal Aperture views).
e. Marginal light reflexes are clearly seen at:
i. The light reflex is observed off the inferior alar
margins (Basal and Nasal Aperture Views).
ii. The lateral columellar light reflex (lateral views).
Commentary
a. The narrower boney pyramid and smaller nasal tip have
given the impression of a longer nose and face which in
turn makes the inner canthi visually look closer to each
other.
b. Nasal aperture aesthetics improved from wide rounded
thick walled openings to oval small thin walled openings.
c. Smile became symmetrical post-operatively. Defatting of
the middle and lateral crurae and sparing the fat in the
supratip area was sufficient to overcome the right supratip
depression. No graft was needed.
44 Part VI: Clinical Case 6 257
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Frontal
Frontal
Postoperative
Smiling
Preoperative
Postoperative
Steeper
Backward Tilting Backward Tilting
Basal
258 44 Part VI: Clinical Case 6
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Preoperative
Postoperative
Right Nasal
Aperture
POSTERIOR
SEGMENT
SCAR
INFE R
SEGME
SCAR
Right Nasal
Aperture
Rim Sill Test
Right Oblique
Mid Cheek
Full Face
Left Nasal
Aperture
Rim Sill Test
Left Oblique
Mid Cheek
Full Face
Left Nasal
Aperture
Preoperative
Postoperative
44 Part VI: Clinical Case 6 259
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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
Middle Third
Left Lateral
MIddle Third
Part VI: Clinical Case 7
https://t.me/medicina_free
45
Preoperative Assessment
1. Frontolateral walls
a. Bulky and large nasal tip. The nasal tip was ill
defined due to the flat middle crurae and excess fat
cover of the superior alar grooves.
2. Medial Wall
The columella is short and at a higher level than the alae
nasi.
3. Bony pyramid
a. Wide base of bony pyramid (Frontal, Direct Dorsal
and Backward Tilting Views).
b. The size and width of the bony pyramid was com-
paratively small to the size, width and bulk of the
lower third of the nose (Frontal, Direct Dorsal and
Backward Tilting Views).
c. There was complete dissociation between the upper
2/3rds and the lower third of the nose. The lower third
is almost the same length as the upper two thirds and
three times its size and width (Frontal, Direct Dorsal
and Backward Tilting Views).
4. Alar base
a. Very wide nasal apertures (Backward Tilting, Basal
and Nasal Aperture Views).
b. Large bodies of the alae nasi. Their Inferior margins
were at a much lower level than the columellar margin
(Frontal non-smiling, Oblique and Lateral Views).
The nose looked most unpleasant in the frontal nonsmiling view. Both alae nasi carved down on the sides
making an arc that looked quite unpleasant. There
was wide flare on smiling (Frontal not smiling and
Frontal smiling views).
c. The rim sill folds are very small in size. They were
almost non-exitent.
Aims of Surgery
1. Reduce the bulk and size of the frontolateral walls.
2. Elevate the nasal dorsum and educe the width of the
bony pyramid.
3. Reduce the sizes of nasal apertures.
4. Reduce the size of alar bodies and elevate their inferior
margins to match with the level of the columella.
Surgical Plan
1. Anterolateral Walls
DDD including the weak triangle to reduse the bulk of
the tip and supra-tip area.
2. Medial Wall
Nil of Note.
3. Bony pyramid
Bilateral osteotomies and medialisation of the bony side
walls to reduce the width of the bony pyramid and elevate the dorsum.
4. Alar base
a. Excision of the rim still folds.
b. Direct reduction of the size of alar bodies.
Surgical Procedure
1. As per surgical plan.
2. Excision of the rim still folds did not achieve the goal of
reducing the size of nasal apertures. The rim sill folds
were quite small in size i.e. they hardly contributed to the
bulk or length of the alar base. The nasal sill bands were
partially trimmed laterally to reduce the width of nasal
apertures i.e. the alar base. Stripes of vestibular floor
skins, starting from the aperture margin just inside the
© 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_45
261
262 45 Part VI: Clinical Case 7
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sill bands back to the muco-cutaneous junction, were
excised in order to reduce the size of nasal aperture tubes
i.e. the whole of the lower third of the nose. Excision
should strictly include the loose skins of the vestibular floors and avoid adherent skin cover of the alae nasi.
3. The bodies of the alae nasi were addressed directly in
order to reduce their size. Their inferior margins were
trimmed gradually till they became at the same level of
the columella.
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 are now of reasonable size 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).
2. Medial Wall
Nil of Note.
3. Bony Pyramid
a. Bony pyramid aesthetics: the nasal dorsum is higher,
straight and the sidewalls are smooth and narrow (all
views except the Basal Views).
b. Dorsal light reflex is seen as an uninterrupted off the
nasal dorsum (Direct Dorsal Views).
4. Alar Base
a. Superior alar groove aesthetics: they became shorter
and more elegant (Oblique and Lateral Views).
b. Posterior alar groove aesthetics: they became shorter
and more elegant (Oblique and Lateral Views).
c. Nasal Aperture aesthetics:
i. The size of nasal apertures are smaller (Back-
ward Tilting, Basal and Nasal Aperture Views).
ii. The shapes are more elegant with small thinner
lateral alar walls (Backward Tilting, Basal
Views and Nasal Aperture Views).
iii. The arc of the inferior margins of the alae
nasi disappeared. Alar flare is greatly reduced
on smiling (Smiling Frontal Views).
d. Marginal light reflexes are clearly seen at:
i. Inferior alar margins (Nasal Aperture Views).
ii. The nasal sill and lateral crural prominences are
too small to be seen (Oblique and Lateral
Views).
Commentary
a. This patient maintained her exact features post-operati-
vely as she wished. The nose print is the same.
b. The smaller nose now matches the size of the eyes, lips
and chin.
c. There were four major problems in her nose:
i. Bulky tip.
ii. Wide base of bony pyramid.
iii. Wide alar base:
The rim sill folds were very small. The posterior
margins of the alae nasi were attached to the Orbicularis Oris muscle along its full length. Normally the
lower third of the posterior alar margins are separated
from the Orbicularis Oris by the posterior segments of
the rim sill folds and from the nasal sill bands by the
inferior segments. The inferior segments were almost
non-existent. This explains the low attachments of the
alae nasi and their elevation on contraction of the
Orbicularis Oris on smiling.
iv. Large alar bodies: there was no choice for reducing
the size of the fibrofatty walls of the alae nasi but
direct surgical excision. Inferior marginal scars were
unavoidable. Clinically they were hardly noticeable.
d. The bony pyramid and mid vault of the nose regained
their natural proportion to constitute the upper 2/3rds of
the nose. The nasal tip and alae nasi regained their normal
regular size as a lower third of the nose. The dissociation
between them disappeared and the nose became one unit.
e. The superior alar groove is shorter and more elegant
(Oblique and Lateral Views).
f. The posterior alar groove has wide angle with the upper
lip due to absent of posterior segm ent of rim-sill fold.
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Preoperative
Postoperative
Frontal
Frontal
Smiling
Direct Dorsal
Smiling
Frontal
Middle Third
Preoperative
Postoperative
264 45 Part VI: Clinical Case 7
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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
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Preoperative
Postoperative
Right Oblique
Cheek Margin
Full Face
Left Oblique Right Oblique
Cheek Margin Cheek Margin
Full Face Middle Third
Right Lateral
Left Lateral
Left Oblique
Cheek Margin
Middle Third
Preoperative
Postoperative
266 45 Part VI: Clinical Case 7
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Preoperative
Postoperative
Right Lateral
Middle Third
Left Lateral
Middle Third
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