special considerations in rhinoplasty edward buckingham, m.d. karen calhoun, m.d. grand rounds...
TRANSCRIPT
![Page 1: Special Considerations in Rhinoplasty Edward Buckingham, M.D. Karen Calhoun, M.D. Grand Rounds 12/20/00](https://reader035.vdocuments.us/reader035/viewer/2022062417/5517c3475503461b658b485c/html5/thumbnails/1.jpg)
Special Considerations in Rhinoplasty
Edward Buckingham, M.D.Karen Calhoun, M.D.
Grand Rounds 12/20/00
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Itroduction Alar base Crooked/Twisted nose Saddle nose Non-Caucasian nose Aging and rhinoplasty
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Alar Base Frontal, lateral, and basal views Overall facial symmetry
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Alar Base Frontal View Inner canthus Vertical 5ths Horizontal 3rds
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Alar Base Lateral View Alar Facial Junction 2-3 mm show
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Alar Base Lateral View Alar Facial Junction 2-3 mm show Cephalic location
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Alar Base Lateral View Alar Facial Junction 2-3 mm show Cephalic location Alar hooding
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Alar Base Basal View Isoscles triangle Columellar-lobule
relationship 2:1 Medal crural
footplates 1:1 Significant ethnic
differences
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Alar Base Ethnicity
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Alar Modification Caucasian rhinoplasty Black and Oriental Indications
Alar flaring Bulbosity Excess width Wide nostril floor Imbalance after tip narrowing
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Alar Modification Conservatism Anatomic factors
Internal (medial) length External (lateral)
length, shape, thickness, flare of alar margin
Width, shape nostril floor/sill
Shape of nostril aperture
Length of lateral sidewalls of nose
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Alar Modification Techniques
General guidelines Graduated fashion 1-2 mm above alar-
facial crease Precise repair,
buried interrupted suture, 5-0 mild catgut if needed
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Alar modification Decrease flare,
elongate Decrease width Sill intact
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Alar Reduction
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Alar Reduction
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Alar Reduction
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Alar Reduction
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Crooked Nose Difficult problem Contributions
Septum, bony and cartilaginous dorsum, tip
Manipulations must not compromise support
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Crooked Nose
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Crooked Nose
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Crooked Nose
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Crooked Nose Lower 3rd support mechanisms
Structural integrity of lower lateral cartilages
Fibrous attachment cepahlic lateral crura and caudal upper lateral
Soft tissue attachment cephalic margin medial crura and caudal nasal septum
Interdomal ligament attachment to anterior septal angle
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Crooked Nose
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Crooked Nose Diagnosis Facial symmetry Lower 2/3
deviation
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Crooked Nose Diagnosis Facial symmetry Lower 2/3
deviation Palpation Tip recoil
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Crooked Nose Correction Pitfalls
Deviations of the caudal, dorsal septum
Irregularities upper lateral catilages
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Crooked Nose Dorsum Hump removal Less from
vertically oriented
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Crooked Nose Dorsum Hump removal Less from
vertically oriented Intermediate
osteotomies Don’t elevate
periosteum
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Crooked Nose Lower 2/3 Free upper lats Prevent collapse
Mucosa intact Suture into position
Open approach Visualize deviated
portions dorsal septum
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Crooked Nose Lower 2/3 Dorsal septal
deviation
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Crooked Nose Lower 2/3 Dorsal septal
deviation Shave convex,
unilateral spreader graft
Further correction, on-lay grafts
Airway Obstruction
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Crooked Nose Lower 2/3 Ethmoid bone
stenting Cartilage
crosshatching
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Crooked Nose Lower 2/3 Caudal septal
deviation
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Crooked Nose Lower 2/3 Caudal septal deviation Cartilage manipulation and suture Triangular wedge Replacement Columellar strut
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Crooked Nose Post-op Abx for 7 days External cast 5-7
days Suture removal 5
days Nasal bone
massage
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Saddle Nose Loss of profile,
bony and cartilaginous dorsum
Ethnic, trauma, infection, hematoma, overzealous profile reduction
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Saddle Nose Repair Dorsal augmentation Variety of techniques Variety of materials
Septal,conchal cartilage Autogenous cartilage, bone Synthetic, alloplastic Heterografts, homografts
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Saddle Nose Repair Resorption, Extrusion Precisely sculpted, bevel edges Careful preoperative diagnosis and
planning Constant supratip depression
cartilaginous dorsum Columellar retraction
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Saddle Nose Classifiction Minimal
Moderate tip-supratip differential Mildly accentuated bony hump Little columellar retraction Overwide nose Minimal supratip augmentation Contouring hump
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Saddle Nose-Minimal
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Saddle Nose Classification Moderate
Significant quadrangular cartilage dorsal height loss
Significant collumellar retraction acute nasolabial angle
Blunt trauma, bony pyramid broad and flattened
Major All stigmata of moderate to greater degree Childhood or massive trauma, major nasal
twist, septal deformity
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Saddle Nose-Moderate
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Saddle Nose-Major
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Saddle Nose Correction Mark supratip depression Anesthetic infiltration Exacting pocket Midline axial intercartilaginous stab Blunt pocket dissection 1-2 mm
larger than grafts Peroxide palpation
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Saddle Nose Correction Example
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Non-Caucasian Nose Difficult Strengthening weak cartilaginous
structures Preservation major support
mechanisms Careful S-STE manipulation
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Non-Caucasian Nose Characteristics Flat, broad, short Infantile dorsum, lacking projection Tip rounded poorly defined Acute nasolabial angle Thick, flaring, wide based alae,
overhanging columella Alar skin thick, fatty, inelastic,
sebaceous glands
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Non-Caucasian Nose Characteristics Nostrils round, horizontally ovoid Poorly defined nasofrontal angle Anterior septal angle obtuse,
cephalic Pyriform aperature wide decreased
bone to cartilage ratio Nasal bones, domes more obtuse
angle
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Non-Caucasian Nose
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Non-Caucasian Nose Tardy
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Non-Caucasian Nose Limiting Factors
Thick, inelastic S-STE Thick, short columella may preclude
closure Weak thin lateral crura, little support Thin, small septum Preserve ethnicity
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Non-Caucasian Nose Many recommend open approach Strut graft, maybe doubled Most no rotation, no cephalic trim Transect domes, no resection, suture at more
acute angle Dorsal grafting, narrowing Multi-layered tip grafts Excise fibro-fatty tissue Cartilage plumping grafts Alar reduction
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Non-Caucasian Nose Post-op 3-4 weeks for 6 months Kenalog 10 mg/dL
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Aging and Rhinoplasty Special consideration Young, purely cosmetic
15 and 17 Animal models Conservative alar, septoplasty
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Aging and Rhinoplasty Consultation
Time and money Self image Changes of aging Longstanding recent dissatisfaction Undesired life change Medical problems
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Aging and Rhinoplasty Tip support
weakens Descent of nasal
tip Nasal elongation Nasolabial angle
changes
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Aging and Rhinoplasty Cadaveric studies
Alar cartilage flattened, fragmented Loss of upper lower attachments Thin nasal bones Skin thinner less elastic
Skin heals less aggressive, finer scars
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Aging and Rhinoplasty Changes in surrounding face Maintain tip support mechanisms
Columellar strut useful Care of septal mucosa Wide undermining of skin possibly Use of external incisions(dorsal) Fine 2-3 mm osteotomes Extended taping
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Aging and Rhinoplasty
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Aging and Rhinoplasty
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Case
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Case
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Case
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Case Keys include correction of underlying
septal deformities, release of the upper lateral cartilages with re-suturing to prevent collapse, asymmetric hump removal.
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Summary Challenging Special consideration and technique