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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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24 4 Part II: Clinical Case 2
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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).
c. Tip light reflex is seen as one spot off the nasal
tip. (Frontal and Backward Tilting Views).
2. Medial Wall
a. The nasal airway improved after septoplasty and
submucous diathermy of inferior turbinates.
b. Protrusion of broken septum into right nasal aperture
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 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 and resection of the rim-sill folds. The defatted lateral 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. (Backward
Tilting and Nasal Aperture Views). The acute angle
flat tire appearance was overcome.
c. Alae nasi aesthetics improved. They look smaller
after resecting the posterior segments and became
better seen as they are medialized inwards.
d. Nasal aperture aesthetics improved after defatting and
resection of the rim-sill folds:
i. The size of the nasal openings became propor-
tionately smaller.
ii. The shapes have better aesthetic. They lost their
wide African shapes.
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. The post-operative photograph shows an overall reduc-
tion in the size while maintaining the same features of the
nose.
b. It is not enough to only deal with the fractured septum
and bony pyramid. All four areas of the nose must be
considered. In this case the wide alar base and ill defined
tip had to be addressed.
Preoperative
Postoperative
Frontal
Frontal
Smiling
Frontal
Middle Third
4 Part II: Clinical Case 2 25
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Preoperative
Postoperative
Direct Dorsal
Preoperative
Direct Dorsal
Smiling
Backward Tilting Backward Tilting
Overhead
Steeper
Overhead
Smiling
Preoperative
Postoperative
Right Nasal
Aperture
Postoperative
Right Nasal
Aperture
Rim Sill Test
Left Nasal
Aperture
Rim Sill Test
Left Nasal
Aperture
26 4 Part II: Clinical Case 2
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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
4 Part II: Clinical Case 2 27
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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 3
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5
Preoperative Analysis
1. Frontolateral walls
Nil of note.
2. Medial Wall
a. Mobile tip: the nasal tip moves inferiorly on smiling
(Lateral Smiling Views).
b. Sliding tip: the nasal tip moves posteriorly on smiling.
Note the prominent anterior septal angle as a result of
the receding nasal tip (Lateral Smiling and Basal
Views). The patient is holding the upper lip down
with her mouth in the preoperative Basal view.
3. Bony pyramid
a. Fracture of the nasal bones with prominent left bony
specule (Frontal, Backward Tilting, Nasal Aperture
and Oblique Views).
b. Wide base of the boney pyramid (Frontal, Direct
Dorsal and Backward Tilting Views).
4. Alar base
Nil of note.
Aims of Surgery
1. Correction of the fractured nasal bones.
2. Elevation and fixation of the tip to overcome the sliding
effect.
3. Abolish mobility of the tip.
3. Bony pyramid
a. Rasping of the broken, sharp edges of the nasal bone.
b. Osteotomies and medialization of the lateral bony
walls.
4. Alar base
Nil of note.
Surgical Procedure
As per Surgical Plan.
Post-Operative Analysis
1. Frontolateral Walls
Nil of note.
2. Medial Walls
a. Mobile tip disappeared.
b. Sliding tip was overcome.
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
Nil of note.
Commentary
Surgical Plan
1. Frontolateral walls
Nil of note.
2. Medial Wall
a. Wedge excision of the anterior part of the membra-
nous section.
b. Stitch the cartilaginous septum to the medial crurae.
c. Division of the Depressor Septi muscles.
© 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_5
a. This is an uncommon case of fracture of the nasal bones
only. The base of the boney pyramid i.e. the frontal
processes of the maxillae, were smooth and intact.
b. On smiling, the tip moved both downwards and
backwards:
i. Inferior movement of the nasal tip is described as a
mobile tip.
ii. Posterior movement of the nasal tip below the level
of the dorsum i.e. the anterior septal angel, is
described as a sliding tip.
29
30 5 Part II: Clinical Case 3
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iii. The anterior angle of the cartilaginous septum
became more prominent than the depressed tip. This
is seen in the basal view wi th the upper lip pulled
down by the patient. Both the downward and posterior movements are well demonstrated in the
smiling lateral views.
Frontal
Preoperative
c. It was important to deal with other unaesthetic areas of
the nose as well as the fractured nasal bones. In this case
it was the mobile and the sliding tip as well as the wide
base of the bony pyramid.
Frontal
Smiling
Frontal
Middle Third
Postoperative
5 Part II: Clinical Case 3 31
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Direct Dorsal
Direct Dorsal
Preoperative
Postoperative
Smiling
Preoperative
Postoperative
Steeper
Backward Tilting Backward Tilting
Basal
32 5 Part II: Clinical Case 3
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Preoperative
Postoperative
Right Nasal
Aperture
Right Oblique
Mid Cheek
Full Face
Left Oblique
Mid Cheek
Full Face
Right Oblique
Mid Cheek
Middle Third
Left Nasal
Aperture
Left Oblique
Mid Cheek
Middle Third
Preoperative
Postoperative
5 Part II: Clinical Case 3 33
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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
Part II: Clinical Case 4
https://t.me/medicina_free
6
Preoperative Assessment
1. Frontolateral walls
Nil of note.
2. Medial Wall
Nil of note.
3. Bony pyramid
a. The boney pyramid was fractured and deviated to the
right side. The left sidewall of the boney pyramid is
depressed, while the right side is elevated. (Frontal,
Direct Dorsal and Backward Tilting Views).
b. A boney spicule is protruding on the right side of the
top of the boney pyramid that looks broad.
c. Wide base of the boney pyramid. (Direct Dorsal and
Backward Tilting Views).
4. Alar base
Nil of note.
Aims of Surgery
1. Remove the bony spicule.
2. Reconstruction of the bony pyramid.
Surgical Plan
4. Alar base
Nil of note.
Surgical Procedure
a. As per Surgical Plan.
b. A depres sion was found at the left side of the mid vault
as a result of the old trauma. A cartilaginous graft was
used to fill this depression.
Post-Operative Analysis
1. Frontolateral Walls
Nil of note.
2. Medial Walls
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
Nil of note.
1. Frontolateral walls
Nil of note.
2. Medial Wall
Nil of note.
3. Bony pyramid
a. Rasping of the prominent boney spicu le.
b. Osteotomies and medialization of the lateral bony
walls.
© 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_6
Commentary
a. Only one of the four areas of Rhinoplasty was addressed
i.e. the bony pyramid. The other three areas of the nose
were aesthetically acceptable i.e. the nasal tip, wall and
alar base.
b. Correcting the deformity of the bony pyramid was suf-
ficient to produce an overall attractive nose.
35
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