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Part II: Clinical Case 6
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8
Preoperative Assessment
1. Frontolateral walls
a. Large and bulky tip overshadowing the alae nasi.
(Frontal, Direct Dorsal, Overhead and backward
Tilting Views).
b. Anterior bulge of the left middle crus due to left high
deviation of cartilaginous septum (Backward Tilting
View).
2. Nasal septum
a. Fracture dislocation of the caudal septum to the right
and consequently:
i. The medial crus is pushed laterally distorting
nasal apertures (basal views).
ii. The right nasal sill band is pushed inferiorly
(frontal views).
3. Bony pyramid
a. Osteocartilaginous hump. (Oblique and Lateral
Views).
b. The depression above the left side of the upper lateral
cartilage suggests the possibility of a defect in the left
side of the upper lateral cartilage (Frontal, Direct
dorsal, overhead and backward tilting views).
c. The boney pyramid is oblique and deviated to the right
side due to bilateral maxillary asymmetry (overhead
and backward tilting views). The left cheek is wide
and low while the right cheek is high and narrow (Backward tilting view). There was no fracture.
4. Alar base
a. Wide alar base due to long inferior segments of the
rim-sill folds. The alae nasi bend on the upper lip in
acute posterior alar groove angles giving the appearance of a flat tire.
b. Apparently asymmetrical nasal apertures due to
encroachment of the fractured dislocated caudal septum upon the right nasal aperture (Backward Tilting
and Basal Views).
Aims of Surgery
1. Reduction of the size and bulk of the nasal tip.
2. Correction of the septal deviation and dislocation.
3. Excision of the osteo cartilaginous hump.
4. Reduction of the size 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. Nasal septum
Septoplasty.
3. Bony pyramid
a. Rasping of the boney hump as well as an excision of
the cartilaginous hump.
b. Osteotomies and Kasanjian maneuver to the left side
i.e. cross fracture of the bony pyramid after osteotomies (see Surgery of the Bony Pyramid in the Text).
4. Alar base
Bilateral excision of only the inferior segments of the
rim-sill folds.
Surgical Procedure
a. As per Surgical Plan.
b. Septoplasty: three millimeters were excised from the
caudal septum. A strip of two millimeters was excised
from its posterior margin. The cartilaginous septum
was moved to its original place in the maxillary
groove. The deviated boney septum was fractured to
the mid line. Two millimeters o f excess skin over the
caudal septum what is excised.
c. The severe deviation of the septum obstructed the
access to tip surgery. Septoplasty was therefore carried out first before the tip work.
© 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_8
47
48 8 Part II: Clinical Case 6
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d. No defects were found over the left side of the upper
lateral cartilage and grafts were not necessary.
e. Only excision of the inferior segments of the rim-sill
folds were necessary, the alae nasi were sufficiently
pulled medially with wider posterior alar groove angles
and smaller apertures (Basal and nasal aperture views).
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
The caudal fractured dislocated septum was 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 excision. The defatted alae nasi are pulled
medially as they become semidetached from the
crurae, 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 flat tire appearance is gone.
c. Alae nasi aesthetics improved as they were pulled
medially to becom e more visible and smaller in size.
d. Nasal aperture aesthetics improved by defatting and
excision of the inferior segments of the rim-sill folds:
i. The size of the nasal openings are reduced.
ii. The shapes of nasal openings become more
elegantly oval on shape. (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).
Commentary
a. In these delayed post traumatic cases, it is not sufficient
to only correct the fractured nasal septum. Surgeon must
also proportionately reduce the size of the rest of the nose
after advising the patient and take his permission.
b. It is not uncommon for the fract ured nasal septum to be
overlooked. This gentleman have had other unaesthetics
issues to his nose which probably overshadowed the
deformed caudal fracture of the septum.
Preoperative
Postoperative
Frontal
Frontal
Smiling
Frontal
Middle Third
8 Part II: Clinical Case 6 49
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Preoperative
Postoperative
Direct Dorsal
Backward Tilting
Direct Dorsal
Smiling
Overhead
Basal
Preoperative
Postoperative
Preoperative
Postoperative
Right Nasal
Aperture
Right Nasal
Aperture
Rim Sill Test
Left Nasal
Aperture
Rim Sill Test
Note: The pale area of the
rim sill fold.
Left Nasal
Aperture
50 8 Part II: Clinical Case 6
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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
8 Part II: Clinical Case 6 51
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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 7
https://t.me/medicina_free
9
Preoperative Assessment
1. Frontolateral walls
Large and bulky nasal tip (Frontal Views)
2. Medial wall
a. Sever saddle deformity of the nose secondary to total
collapse of the cartilaginous nasal septum. The lower
two thirds of the nose was very soft denoting the
absence of any cartilaginous support from the septum.
(Oblique and Lateral Views).
b. No airway obstruction
3. Bony pyramid
a. Small, bony hump (Oblique and Lateral Views)
b. Wide base of bony pyramid (Frontal Direct Dorsal
and Backward Tilting Views)
4. Alar base
Wide alar base and large nasal apertures (Backward
Tilting, Basal and Nasal Aperture Views)
Aims of Surgery
1. Reducing the size and bulk of nasal tip
2. Reducing the size of the bony pyramid
3. Correcting the saddle deformity.
4. Reduction of the alar base and the size of nasal apertures
Surgical Plan
1. Frontolateral walls
a. D.D.D. including weak triangle to reduce the bulk
and size of the nasal tip.
b. Cephalic trim of the lateral crurae to further reduce
the size of the nasal tip.
2. Medial Wall
Augmentation graft to the saddle deformity
3. Bony pyramid
a. Excision of the bony hump.
b. Bilateral osteotomies and medialization of the lateral
bony walls.
4. Alar base
Bilateral resection of the posterior and inferior segments
of the rim-sill folds.
Surgical Procedure
a. As per surgical plan
b. Augmentation of the saddle deformity was achieved by
using trimming of the lateral crurae including their
overlying thick capsules of fat i.e. before the defatting
process.
Post-operative Analysis
1. Frontolateral Walls
a. Tip Definition: nasal tip is smaller with thin overlying
skin. It is more prominent and well identified from the
alae nasa on both sides. The alae nasi come into view
to become clearly visible and share in nasal aesthetic
(Frontal, Direct Dorsal, Backward Tilting and Basal
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)
c. The tip light reflex is seen as one spot off the nasal tip
(Frontal and Backward Tilting Views).
2. Medial Walls
The saddle deformity completely rectified (Oblique and
Lateral 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_9
53
54 9 Part II: Clinical Case 7
https://t.me/medicina_free
3. Bony Pyramid
a. Bony pyramid aesthetic 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. The superior alar groove is now clear of fat becomes
deeper, longer and visible (Direct Dorsal, Oblique and
lateral Views).
b. Posterior alar groove aesthetic improved. The angle of
the alae nasi with the upper lip is wider (Backward
Tilting, Basal and Nasal Aperture Views).
c. Alae nasi aestheticsimproved.They are pulled medially,
become better seen, smaller in size and share in nasal
aesthetics (Nasal Aperture, Oblique and Lateral Views).
d. Nasal aperture aesthetic improved after defatting and
excision of the rim-sill folds. They become more
elegantly oval in shape.
e. Marginal light reflexes are clearly seen at:
i. The inferior alar margins (Basal and Nasal Aperture
Views).
Lateral crural prominences (Lateral Views)
Commentary
1. The wide and deep dorsal saddle deformity was transformed into narrow ans shallow depression as a result of
the following procedures:
a. Defatting of the lateral and middle crurae as well as
weakening of the domes.
b. Excision of the bony hump
c. Osteotomies and medialization of the lateral bony
walls.
2. There was no need for the use of a large graft material
e.g. costal cartilages, ear conchal cartilage or multilayered septal graft.
3. Two layers of fat paddled cephalic trims of the lateral
crural cartilage were sufficient to fill the dorsal depression after reducing its size.
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56 9 Part II: Clinical Case 7
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