Rhinoplasty : Correction of the tipDept. of Oral and Maxillofacial Surgery S.C.Ahn

AnatomyBony compartmentCartilaginous compartmentConnective tissue

AnatomyBony pyramid (upper 1 / 3)1) Nasal bone 2) Frontal process of maxilla3) Nasal process of frontal bone

Anatomycartilaginous vault - lower 2 / 3 1) Upper lateral cartilage 2) Lower lateral cartilage = alar cartilage (major) (1) lateral crus (2) medial crus 3) Lesser alar = minor alar cartilage

Anatomy 4) sesamoid cartilage = accessory cartilage 5) septal cartilage = quadrangular cartilage

AnatomyBlood supply 1) Facial artery and its branches 2) Dorsal nasal artery from ophthalmic artery 3) Angular vein

AnatomyThrombophlebitis arising from a furuncle of the upper lip or the nose can spread via the ophthalmic vein to the cavernous sinus to cause a cavernous sinus thrombosis(or thrombophlebitis) Danger area of face : Triangle made of lines from glabella to both mouth corners

AnatomySensory nerve 1) ophthalmic nerve a. nasociliary b. external nasal c. infratrochlear 2) maxillary nerve 3)infraorbital nerve

AnatomyMuscles 1) procerus 2) nasalis (transverse + alar parts) 3) levator labii superioris alaeque nasi 4) depressor septi 5) dilator naris (anterior + posterior)

Landmarks 1. infratip lobule 2. columella 3. alar sidewall 4. facet, or soft-tissue triangle 5. nostril 6. columella-labial angle or junction 7. alar-facial groove or junction 8. tip defining points 9. Medial crural footplate

Orientationanterior(dorsal) posterior(ventral)cephalic caudal

Tip support mechanism Major tip supports1)The thickness, size, shape, contour of the alar cartilages2) The connective tissue relationship between the caudal margin of the upper lateral cartilage and the cephalic margin of the alar cartilage 3) The medial crural footplate attachment to the caudal quadrangular cartilage

Tip support mechanismMinor tip supports1) The nasal tip interdomal ligaments2)The cartilaginous dorsum3)The nasal spine4)The strength, length, resilience of the medial and intermediate crura5)The thickness of the tip skin-subcuta neous tissue complex6)The supportive strength of the alar sidewalls

ProcedureIncisions : methods to gain access to nasal tip structuresApproaches : divided into delivery and nondelivery categoriesTechniques : those sculpturing modifications carried out on the alar cartilages

Incision Does the incision1)Provide reasonably unencumbered visuali-zation and access to the alar cartilages?2)Preserve whenever possible the important tip support mechanisms?3)Avoid interference with other incisions contemplated in the same area?4)Lend itself well to healing without contraction or undue scarring?

IncisionAlar cartilage incisionsIntercartilaginous incisionTranscartilaginous incisionMarginal incision

IncisionSeptal incisions(transfixion incisions)Complete-Partial(limited)-Hemi-High-Columella incisions

ApproachNondelivery approach to the lower lateral cartilage (1) Transcartilaginous approach (2) Retrograde or eversion approachDelivery of the lower lateral cartilage (1) Bipedicle chondrocutaneous flap approach (2) External or open approach

Transcartilaginous approach

Retrograde or eversion approach

Bipedicle chondrocutaneous flap approach

External or open approach Advantages Adequately expose deformities, abnormalities and asymmetries. Accurately diagnose deformities, abnormalities and asymmetriesBinocular vision and bimanual surgical dissectionMicrocautery for exacting hemostasis

External or open approachDisadvantages Transcolumellar external scarInterruption to the ideal structures in no need of changeProlonged tip edema

External or open approachPotential excess trauma by manipulation and retractionIncreased operative timeMore traumaticDemanding suture fixation of any grafts positioned to contour or support the nasal bone

External or open approach

External or open approach

Sculpturing of cartilagePrinciples1) Almost all tip techniques share the principle of volume reduction of alar cartilage2) The more alar cartilage left undisturbed consistent with adequate esthetic tip correction, the more predictable is the healing process3)The laterocephalic portion of the lateral crus should be left intact and not resected.

Sculpturing of cartilage4) Identifying and preserving the tip defining point of the alar cartilage dome is mandatory for optimum tip definition and projection.5) A shape and attitude change may be induced in the residual caudal strip with suture techniques without resorting to a vertical incisional interruption of the complete strip

Sculpturing of cartilage6) The overlying skin canopy must be of sufficient thickness to camouflage any irregularities or offsets that would otherwise become palpable and/or visible in the long-term post-op period

Sculpturing of cartilageVolume reduction1) Cephalic cartilage volume reduction with preservation of an intact complete caudal cartilage strip2)Cephalic cartilage volume reduction with caudal complete strip preservation with a shape change induced by sutures or by cartilage attenuation procedures3)Cephalic cartilage volume reduction with vertical division of the dome and/or lateral crus, medially or laterally

Sculpturing of cartilage

Complete strip

Sculpturing of cartilageWeakened complete strip

Sculpturing of cartilageIncomplete(Interrupted) strip

Nasal tip augmentation 1)

Interdomal suture Transdomal suture Domal creation suture Alar cartilage suturing Sheens method

Nasal tip augmentation Pecks method Flowers method

Unfavorable nasal tipProjecting nasal tip1) McCarthy-Wood-Smith method2)Sheens methodPointed nasal tip1)Aufrichts method2)Rotation of tip3)Nasal tip graft

Unfavorable nasal tipBroad or Bulbous nasal tip 1) Alar cartilage suture 2)Rotation of tip 3)Partial resection of alar cartilage or skin resection.Bifid nasal tipDeviated nasal tipPlunging nasal tip Type I, II, IIISmiling or mobile nasal tip

Correction of plunging tip(type I)Correction of plunging tip(type II)Correction of smiling tip