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RHINOPLASTY indications and complications
- 2. HISTORY Began in Ancient Egypt and India Description of nasal reconstruction in Susruta Samhita (500 B.C ) 1887 John Orlando Roe performed first intranasal rhinoplasty. Jacques Joseph Father of Modern facial Plastic surgery published his Treatise on Rhinoplasty.
- 4. GLABELLA : Most prominent point of forehead in mid saggital plane. NASION : Anterior most point of fronto nasal suture that joins the nasal part of frontal bone and nasal bones. RHINION : Midline point of junction of nasal bones & upper lateral cartilages. PHILTRUM : A vertical indentation in the middle area of the upper lip. COLUMELLA : Inferior margin of the nasal septum. EXTERNAL NOSE
- 5. TIP DEFINING POINT : Located at the apex of the tip lobule & formed by the junction of the medial & lateral crura of each Lower lateral cartilage.
- 6. NASOLABIAL ANGLE : between the columella & the upper lip. SUBNASALE : Junction of columella & upper lip in mid saggital plane.
- 8. OSSEOCARTILAGINOUS FRAMEWORK OF NOSE The upper 1/3rd is bony & forms bridge of the nose. Lower 2/3 rd is cartilaginous & forms dorsum of the nose. BONY PART: The 2 nasal bones meet in the midline and fuse with the nasal process of the frontal bone. They are held between the frontal process of maxilla.
- 9. CARTILAGINOUS PART Upper lateral cartilage : (Paired ) They fuse sideways with the upper border of septal cartilage & forms dorsal surface of nose. The lower free margin forms limen vestibuli or nasal valve Lower lateral cartilage : ( Paired ) This U shaped Alar cartilage has 2 crura lateral & medial. The lateral crus forms the ala while medial crus lies in columella.
- 10. Lesser Alar/ Sesamoid cartilage : (Paired) They may be 2 or more in number & lie above & lateral to alar cartilages. Septal cartilage : is unpaired.
- 11. SKIN AND MUSCLES OF EXTERNAL NOSE Nasal skin in thin & loosely adherent over the dorsum and sides of the nose. Skin is thicker & more adherant over the nasal tip & alar cartilage where it contains numerous sebaceous glands. Muscles are all supplied by branches of facial nerve.
- 12. The nasal elevators are: Procerus, Leavtor labii- superioris alaeque nasi, & anamolous nasi muscles The depressors include Alar nasalis & depressor septi nasi muscles
- 13. Compressor muscles include transverse nasalis & Compressor nasium minor The Dilator naris anterior muscle acts as a minor dilator.
- 14. NASAL CAVITY 1. Median nasal wall : formed by the septum. The Columella forms the most caudal part of the medial wall 2. Lateral Nasal wall : formed by the turbinates, fibrofatty tissue & cartilages 3. Nasal floor : formed by the floor of the nasal cavity & the nasal vestibule sill.
- 15. TERMINOLOGIES USED IN NASAL & SEPTAL ORIENTATION Red arrow : nasal cavity Green arrow : nasal septum
- 16. Nasal septum functions : 1. Separation of the nasal airway into 2 nasal cavities 2. Support of the nasal dorsum 3. Maintenance of the nasal tip 4. Forms part of the nasal valves Deviation leads to significant nasal airway obstruction and cosmetic deformity. ANATOMY OF NASAL SEPTUM
- 17. Nasal septum consists of three parts: Bony Cartilaginous Membranous portion Anterior septal angle : junction of dorsal & caudal borders. Posterior septal angle : junction between caudal & inferior border anchored to the anterior nasal spine.
- 18. The cartilaginous portion consists of septal or quadrilateral cartilage. Septal cartilage is continuous with the upper lateral cartilage towards the bridge of the nose. Projection of the septal cartilage known as Septal tail extends posteriorly between Vomer and perpendicular plate of Ethmoid. Septal tail is used as an additional source of cartilage to harvest during Revision Rhinoplasty.
- 19. NASAL VALVE Narrowest point of upper airway. Small changes in nasal septal structure can have significant effects of airflow resistance & sensation of obstruction. Internal Nasal valve : triangular area bounded by caudal edge of upper lateral cartilage laterally, septum medially, nasal cavity floor inferiorlly.
- 20. LATERAL NASAL WALL The inferior, middle & superior turbinates are found along the lateral wall. The space between the lateral nasal wall & the inferior, middle & superior turbinates are called as inferior, middle & superior meatus respectively
- 21. BLOOD SUPPLY OF NASAL SEPTUM External carotid artery branches : Sphenopalatine & Greater palatine arteries (branches of the internal maxillary artery ) The Sphenopalatine artery supplies the posteroinferior septum by a branch called the Posterior Septal artery. It is the basis for nasoseptal mucosal flap. Greater palatine artery supplies the anteroinferior part. The septal branch of the superior labial artery ( branch of the facial artery ) supplies caudal septum & Columella.
- 22. Internal Carotid artery branches: Anterior & Posterior Ethmoidal arteries ( branches of the ophthalmic artery ). They supply the anterosuperior & posterosuperior postion of the septum. The Anterior Ethmoidal & Posterior septal artery form the Kisselbachs plexus.
- 23. NERVE SUPPLY OF THE NASAL SEPTUM General sensory nerves derived from the branches of the trigeminal nerve are distributed to the whole of the lateral wall: The anterosuperior quadrant is supplied by the anterior ethmoidal nerve The anteroinerior quadrant is supplied by the anterior superior alveolar nerve, branch of maxillary nerve. The posterosuperior quadrant is supplied by the posterior superior lateral nasal branches from the pterygoplatine ganglion suspended by the maxillary nerve.
- 24. The posteroinferior quadrant is supplied by the anterior or greater palatine branch from the pterygopalatine ganglion . Special sensory nerves or olfactory are distributed to the upper part of lateral wall just below the cribriform plate of the ethmoid up to the superior concha.
- 25. PTERYGOPALATINE GANGLION The pterygopalatine (Sphenopalatine) ganglion is the largest parasympathetic ganglion. It serves as a relay station for secretomotor fibres to the lacrimal gland & to the mucous glands of the nose, the paranasal sinuses, the palate & the pharynx.
- 26. BRANCHES 1. Orbital branches : pass through the inferioir orbital fissure 2. Palatine branches : the greater or anterior palatine nerve descends through the greater palatine canal & supplies the hard palate & the lateral wall of the nose inferior concha & adjoining meatuses.The lesser or middle & posterior palatine nerve supply the soft palate and tonsil
- 28. 3. Nasal branches enter the nasal cavity through the sphenopaltine foramen The lateral posterior superior nasal nerves supply the posterior part of superior & middle cocncha The medial posterior superior nasal nerves supply the posterior part of roof of the nose & the septum. The largest of these nerves is known as Nasopalatine nerve which descend upto the anterior part of the hard palate
- 29. 4. The Pharyngeal branch supplies the part of the nasopharynx behind the auditory tube 5. Lacrimal branch : secretomotor fibres to the lacrimal gland
- 31. FACIALAESTHETICS
- 32. ANGLES OF THE AESTHETIC TRIANGLE Powell & Humphrey described the ideal angles of facial aesthetic triangle Nasofrontal angle : 115-1350 Nasofacial angle : 30- 400 Nasomental angle : 120 1320 Mentocervical angle : 80- 950
- 35. FACIALANALYSIS TIP ROTATION Tip rotation generally occurs along an arc produced by a radius based at the external auditory canal.
- 36. TIP PROJECTION An ideal nasal profile in a patient in whom the nasal tip leads the supratip cartilaginous dorsum by 1 to 2 mm.
- 37. Simons nasal projection is approximately equal to the length of the upper lip with a ratio of 1:1.
- 38. Goodes method of tip projection. Nasofacial angle (30 to 40 degrees).
- 39. CLINICALASSESSMENT Routine investigation Clinical assessment Assess external nasal deformity Quality of skin Facial analysis Photographic documents
- 40. Basic principles to be taken care Be conservative Should know where to stop Never promise miraculous results after surgery Beware of psychotic patients Consent
- 41. EXTERNAL NASAL DEFORMITIES TIP DEFORMITIES Bulbous Bifid Overprojected Underprojected Tip ptosis
- 42. BULBOUS TIP BEFORE & AFTER
- 43. BIFID NOSE - BEFORE & AFTER
- 44. OVER PROJECTED Over projected tip (before and after)
- 46. TIP PTOSIS BEFORE & AFTER
- 47. TIP RECOIL Tip Recoil is defined as the inherent strength and support of the nasal tip. It can be evaluated by depressing the tip towards the upper lip and watching for the tip's supportive structure to spring back into position. If the recoil is good, and the tip cartilages resist the deforming influence, then tip surgery can usually be performed without fear of substantial support loss.
- 48. COLUMELLAR DEFECTS Type 1 deformities (caudal septum and/or spine) Type 2 (medial crura) Type 3 (soft tissue) Type 4 (combination)
- 49. ALAR CARTILAGE DEFORMITY PINCHED ALAR CARTILAGE FLARED ALAR CARTILAGE
- 50. OSSEOCARTOLAGENOUS VAULT DEFORMITY DEVIATED NOSE SADDLE NOSE
- 51. TENSION NOSE DORSAL HUMP
- 52. QUALITY OF SKIN Thick skin Masks refinement and definition Failure to contract excess soft tissue scar Does not show small irregularities Thin skin Small irregularities become visible Early healing Less oedema Ensure that all bony, cartilageneous grafts or implants are precisely positioned and smoothly contoured.
- 53. FACIALANALYSIS Nasal tip Rotation Projection Nasofrontal angle Facial aesthetics
- 54. CLINICAL PHOTOGRAPHS Blue is chosen as the background colour as it provides an excellent contrast to the colour of flesh and hair. Typically consist of a full-face frontal view, with oblique and lateral views on the side of the defect. If the defect extends to the infra tip lobule or alar margin, a base view is also obtained. Close-up views of the defect may be obtained when appropriate.
- 55. TYPES OF RHINOPLASTY OPEN APPROACH External rhinoplasty Trans columellar incision Closed approach Endonasal rhinoplasty Incisions positioned inside the nostril
- 56. INCISIONS MAIN INCISIONS Caudal septal incision (hemitransfixion) Intercartilaginous incision Vestibular incision Infracartilaginous incision Transcolumellar inverted-V-incision
- 57. CAUDAL SEPTAL INCISION Also known as hemi-transfixion incision Made 2 mm above and parallel to the caudal margin of cartilaginous septum Incision provides access to- 1. Septum 2. Premaxilla and anterior nasal spine 3. Nasal dorsum 4. Columella 5. Floor of nasal cavity
- 58. INTERCARTILAGENOUS INCISION Cut made in the vestibular skin just cranial to the caudal end of triangular cartilage Incision starts halfway along the lower end of cartilage and continues past . Provides access to : 1. Nasal dorsum(cartlaginous and bony vault) 2. Valve 3. Lobule
- 59. VESTIBULAR INCISION Vestibular incision is a slightly curved cut made in the vestibular skin just lateral to the margin of pyriform aperture. It is used to access: 1. Paranasal area 2. Pyriform aperture 3. Lateral wall of nasal cavity
- 60. INFRACARTILAGENOUS INCISION It is an incision at the caudal margin of the lateral crus, dome and medial crus of the lobular cartilage. It gives access to : 1. Lobular cartilages 2. Cartilaginous vault
- 61. TRANSCOLUMELLAR INVERTED V INCISION It is a horizontal reversed-v- shaped incision of the columella at about one-third of the distance from its base, it is made in combination with infracartilaginous incision on both sides in the external approach Access to 1. Lobular cartilages 2. Cartilaginous dorsum 3. Anterior septum
- 62. SPECIAL INCISIONS EXTERNAL 1. Labiogingival incision 2. Sublabial incision 3. Paranasal incision 4. Lateral columellar 5. Rim incision 6. Alarfacial incision 7. v incision of columellar base 8. Dorsal incisions INTERNAL 1. Transfixion incision 2. Transcartilaginous incision 3. Incisions in the turbinate mucosa 4. Incisions in the septal mucosa
- 64. INDICATIONS Extensive revision surgery Severe nasal trauma Congenital deformities: cleft lip nose Marked tip deformities Elaborate reduction and augmentation procedures Correction of extreme overprojection
- 65. PRINCIPLES OF EXTERNAL RHINOPLASTY Incision- mid-columella incision connected to bilateral marginal incision Dissection in subperiosteal and subperichondrial planes Division of medial intercrural tissue offers access to caudal septum and premaxillary spine Division of upper lateral cartilages from quadrilateral cartilage offers acccessability to whole of septum
- 66. ADVANTAGES Extensive exposure for both septal and rhinoplasty surgery Binocular vision Useof both hands Control of bleeding and diathermy Precise placement and suturing of struts,battens and shield grafts Valve area preserved
- 67. TECHNIQUES Cartilage resections Lateral /medial crura Alar cartilage modifications and reorientation Complete strip Interrupted strip
- 68. SURGICAL PROCEDURE Broken transcolumellar incision If columella short in case of cleft lip-V incision Mid-columella incision situated above medial crural foot plates Vertical columellar incision made 1.5-2mm inside vestibule Separate lateral incision given which is joined medially over the domes
- 69. Dissection carried in midline just cephalic to dome subperichondrial plane Dissection of soft tissue of bony pyramid should start above caudal end of nasal bone Nasal septum- between medial crurae of lower lateral cartilage or hemitransfixion incision Strut used to correct buckled medial crura strengthen weak medial crura correct tip asymmetries stable base for tip graft
- 70. VIDEO
- 71. SPECIFIC APPLICATIONS The bony pyramid in external rhinoplasty Allows use of burr or reduction of the soft tissue envelope at nasion to deepen the nasofrontal angle Application of soft tissue onlay grafts Bony dehumping together with lateral, medial, and intermediate osteotomies
- 72. The middle nasal vault Placement of cartilaginous strips or spreader grafts to open up the nasal valve area and angles Shaded areas showing placement of spreader grafts
- 74. INDICATIONS Patients with ideal height and position of the nasion associated with excess dorsal convexity Oversized alar cartilages producing increase tip and lobule volume
- 75. AIMS Aim- strong nasal dorsum in lateral profile-relates to ideal nasion height Tip defining point-projecting just above dorsal line-to create supratip break. In males may be on a straight line with dorsum
- 76. CONTRAINDICATIONS Underprojected tip Deep radix (deep root) of nose Short over-rotated nose TRIAD PSEUDOHUMP thin skin delicate alar side walls bifidity
- 78. TECHNIQUES Nasal tip surgery Dehump Osteotomies
- 79. Tip surgery Cephalic trim for volume reduction of lower lateral cartilage done Transcartilagenous incision 5mm of continous strip of lateral crus of lower lateral cartilage is preserved For rotation excision of caudal end of septum
- 80. Cartilage strip incision for cephalic strip excision of lower lateral cartilage
- 81. DEHUMP Nasal hump 1. Bony 2. Cartilagenous 3. Both Minimal bony hump can be reduced by using endonasal approach with just rasping. Small cartilagenous humps only require shaving of cartilagenous ridges of the septal dorsum. Dorsal hump which involves both cartilagenous and bony vault open approach is preferred.
- 82. Cartilagenous dorsum is reduced first. Blade no.15 is held at the key area in horizontal plane to incise across left upper lateral cartilage, quadrilateral cartilage and right upper lateral . Advanced caudally in the plane of reduction this transects the upper lateral cartilage and cartilagenous septum. Osteotome is then inserted under the cartilagenous segment removing the osteocartilagenous hump en bloc
- 83. DORSAL HUMP
- 84. OSTEOTOMIES Medial osteotomy Lateral osteotomy Low to high Low to low Transverse osteotomy Intermediate osteotomy
- 85. MEDIAL OSTEOTOMY It seperates the nasal bone from the septum Made on both side Nasal bone seperated at intranasal suture Short intercartilageneous incision given
- 86. 1. Outer peritosteun is pushed to the side 2. Osteotome is placed at about 2mm paramedially 3. Osteotome is worked through the bone slightly below the level of frontal bone
- 87. LATERAL OSTEOTOMY It seperates the lateral bony wall of pyramid from nasal process of maxilla Short lateral incision is given Medial to lateral subperiosteal tunnel is formed upto level of medial canthus Osteotome placed across frontal process of maxilla Lateral osteotomy done upto the level of frontal bone
- 90. TRANSVERSE OSTEOTOMY Seperates the bony pyramid from frontal bone and nasal spine of frontal bone Osteotomy made at a level just below nasion
- 91. COMPLICATIONS Polybeak appearance Inverted v deformity Flat nose Senstivity and pain
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