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Rhinoplasty

Hwang Won-Hyo

Surgical anatomy

Surgical anatomy
Levator labii superioris alaeque nasi Procerus Anomalous nasi depressor septi nasi

Surgical anatomy

Surgical anatomy

CN V( trigeminal nerve )
opthalmic nerve( V1) supratrochlear n. - infratrochlear n. maxillary nerve( V2) ext. nasal br. of anterior ethmoidal n. - infraorbital n.

Nasal vault
Bony vault Cartilaginous vault
- (,)

Surgical anatomy

Surgical anatomy
Key stone area
1/3

(nasal bone) (perpendicular plate of ethmoid bone) 210mm , (cartilaginous septum)

Surgical anatomy
Nasal valve


: (external nasal valve) (allar collapse) : , , : (lateral crural graft, (batten graft)), (lateral crural spanning graft)

( valvuloplasty)

(Spreader graft)

Tip support mechanism

1.

Major tip support

Minor tip support

Size, shape and strength of LLC 2. Medial footplate attachment to caudal septal cartilage 3. ULC attachment to LLC

1. Interdormal ligament 2. Cartilaginous dorsum 3. Soft tissue-sesamoid complex attaching lateral crus to piriform wall 4. LLC attachment to skin and soft tissue 5. Nasal spine 6. Membranous septum

Landmarks
Glabella : most prominent midline point of forehead Nasion : most post. Midline point of forehead(NF suture) Radix : point on the midline nasal dorsum at the level of supratarsal folds or 6mm above inner canthus (root of nose, NF angle) Rhinion : soft tissue correlate of osseocartilaginous juction of nasal dorsum Supratip : point cephalic to the tip Tip : midline point of the nasal tip at the level of dome projecting points of LLC Subnasale : junction of culumella and upper lip Stomion : midline point at the junction of upper and lower lip vermilion Pogonion : most ant. midline soft tissue point of chin Menton : most inf. point on chin

Nasal proportion

Nasal proportion

Nasal proportion

Nasal proportion


- SIMON Emotional dissatisfaction

Standard photodocumentation

Frontal view Lateral view Oblique view

Basal view

Surgical technique
G/A Local injection 5cc, 2~4cc , , , , , incision(marginal)

Surgical technique

A
a. b. c. d.

B
Sercer

V
Stair-step Jugo Padovan

Approach
Nondelivery approaches to the lower lateral cartilage Transcartilaginous approach Retrograde eversion approach Delivery of the lower lateral cartilages Bipedicled chondrocutaneous flap approach External or open approach

Approach

Non delivery Cartilage splitting

Approach

Delivery approach

Approach

Open approach

. . . . .

collumelar skin . nasal tip edema . separation . graft suture stabilization .

Endonasal approach

dissection . pocket . pocket percutaneous fixation . Vascular bridge . . .

. . . alar cartilage malposition-ing dissection .

Surgery of nasal dorsum(nasal valut)


Surgical correction upper 1/3 deviation Surgical correction middle 1/3 deviation Surgical correction lower 1/3 deviation( tip deviation)

Surgical correction upper 1/3 deviations


Osteotomies
Lateral osteotomy - from head of IT to medial canthal area - too par superiorly, rocker deformity Medial osteotomy - may require in significant deviation - through intercartilaginous incision or the cuadal border of nasal bone Intermediate osteotomy - extreme asymmetry of bony sidewall

Fracture of bony septum Camouflage graft

Osteotomy

Percutaneous osteotomy

Surgical correction middle 1/3 deviations


Spreader graft Camouflage graft Straightening the dorsal septum

Hump removal

Surgical correction lower 1/3 deviations


Straighten the caudal septum
Lower lateral cartilage trimming & equalization

Pollybeak deformity

: 10-15% : :

(pollybeak deformity)

: . : .

( nasal tip surgery )

Tripod theory

Tip modification technique


Classification
Cartilage sculpturing Excision: Volume reduction of lateral crus Complete strip Incomplete strip Incision Suture technique Interdomal suture Transdomal suture Graft Columellar strut Shield graft Onlay graft

Tip rotation
(Cephalic resection, Complete strip, Cephalic trim)

Tip rotation
Incomplete or Interrupted strip

Tip rotation
Different techniques of tip rotation

Suture technique
Transdomal suture

Interdormal suture

Increase tip projection

Plumping graft Lat. Crural steal Premaxillary graft Septocolumellar sutures Columellar strut Caudal extension graft Shield graft On-lay graft Interdomal suture

Decrease tip projection


Complete transfixion incision Volume reduction

Dorsal lowering
Resection of caudal septum

Special rhinoplasty techniques


(1) ( alar base resection ) (2) (3) ( valvuloplasty ) (4) (5) (6) (7) ( adjunctive rhinoplasty ) (8) ( cleft lip nose )

( alar base resection )



13-16 . 16-17

nasoseptal growth center


,
.

90 .

ULC, LLC ,
.

Alar-columellar relationship

( retracted columella)
:

Early complications
Within 6 weeks after surgery Extensive edema and ecchymosis Allergic skin reaction to cloth-tape Hematomas Infections Skin ischemia and necrosis

Late complications
Later 6 weeks after surgery Nose passage disorders 20% of deviated nose Septal perforation Irregularities of the dorsum thin-skinnned patients careless smoothing of the bony and cartilaginous dorsum Deviation Insufficient mobilization of the ossa nasalia Strong septum deviation being left untreated Paranasal callus arise after a paranasal hematoma left-over crushed bone or splinters most cases the callus disappears spontaneously

Implant related complications


Hematoma Infection Implant deviation and migration Extrusion Absorption autologous cartilage:5%, autologous bone : 10-30% Warping Donor site complicaitons Cosmetic flaw

Postop instructions
Raise the head of the bed when resting or sleeping Apply cold compresses regularly (pop 1d) Prevent blowing the nose fiercely Sneeze through the mouth Do not drink alcohol or smoke (pop 7d) Do not use any agents containing salicyl (pop 10d) Avoid any intensive phsical activity or traumatizing sports (pop 6wks) Do not wear spectacles resting on an operated nose bridge (pop 6wks)

References
1. .

2002, P923-91.
2. Sharp HR, Rowejones JM. Assessing outcome in aesthetic

rhinoplasty. Clin Otolaryngol 2003;28:430-435.


3. Toriumi DM. Structural approach to primary rhinoplasty.

Aesthetic Surg J 2002;22:72-84.


4. 2002, P59-70. 5. 9