RHINOPLASTY RAMA RAJU

INCISIONS MAIN INCISIONS

1. Caudal septal incision (hemitransfixion)

2. Intercartilaginous incision3. Vestibular incision4. Infracartilaginous incision5. Transcolumellar inverted-V-incision

CAUDAL SEPTAL INCISION Aka hemitransfixion

Made 2 mm above and parallel to the caudal margin of cartilaginous septum

Incision provides access to;1. Septum2. Premaxilla and anterior

nasal spine3. Nasal dorsum4. Columella5. Floor of nasal cavity

Intercartilaginous incision Is a 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. Valve3. lobule

Vestibular incisions 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 area2. Pyriform aperture3. Lateral wall of nasal

cavity

Infracartilaginous 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 cartilages2. Cartilaginous

vault

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 to1. Lobular cartilages2. Cartilaginous dorsum3. Anterior septum

SPECIAL INCISIONS EXTERNAL

1. Labiogingival incision2. Sublabial incision3. Paranasal incision4. Lateral columellar5. Rim incision6. Alarfacial incision7. ‘v’ incision of

columellar base8. Dorsal incisions

INTERNAL

1. Transfixion incision2. Transcartilaginous

incision3. Incisios in the

turbinate mucosa4. Incisions in the

septal mucosa

Pyramid surgeryOne of basic procedures in functional

reconstructive nasal surgery

It involves Mobilizing the bony pyramid Repositioning and fixation of bony

pyramid

steps for mobilizing the bony pyramid

1. Mobilizing and correcting the septum

2. Outlining the osteotomies3. Undermining the skin over the

pyramid4. Bilateral paramedian osteotomies5. Bilateral lateral osteotomies6. Bilateral transverse osteotomies7. Mobilizing the bony pyramid

Types of osteotomy1. Paramedian

osteotomy2. Lateral

osteotomy3. Transverse

osteotomy4. Intermediate

osteotomy5. Oblique

osteotomy

Paramedian osteotomies: It separates the

nasal bone from each other as well as from septum ,they are made on both sides

The nasal bones are separated at intranasal suture.

Mostly done through intraseptal approach

Paramedian osteotomy intraseptal approach technique

Lateral osteotomy It separates the

lateral bony wall of pyramid from nasal process of maxilla.

A cut is made into the bone above and more or less parallel to NBL

Lateral osteotomy through endonasal-subperiosteal technique

Transverse osteotomy A transverse

osteotomy separates the bony pyramid from the frontal bone and the nasal spine of the frontal bone.

This osteotomy is usually made at a level just below the nasion

Transverse osteotomy through endonasal – subperiosteal approach

Repositioning the bony pyramid After mobilizing, bony pyramid is

repositioned using maneuvers like1. Bilateral infracture2. Bilateral outfracture3. Rotation by unilateral infracture and

outfracture on opposite side4. Rotation following u/l wedge resection5. Push down with bilateral infracture6. Letdown following b/l wedge resection7. Push up

Bilateral infracture Both lateral walls of

the bony pyramid are moved inwards (medially).

This requires paramedian , lateral and transverse osteotomies on both sides.

Bilateral outfracture Lateral walls of the

bony pyramid are moved outward (laterally), thus widening the pyramid and valve area

Requires paramedian , lateral and transverse osteotomies.

Rotation by u/l infracture and outfracture on opposite side Long ,shallow side is

infractured Short steep is

outfractured Lateral osteotomy on

the longer side is performed somewhat higher than on short side so that distance b/w osteotomies and dorsum become symmetrical

Rotation by u/l wedge rotation A wedge of bone

is resected at the base of long side of pyramid

Used in patients with severely deviated bony pyramid

Push down with b/l infracture The bony pyramid is

pushed down and b/l infractured

Projection is reduced and pyramid is narrowed

Requires resection of basal horizontal and posterior vertical strip from septum in combination with osteotomies

Let down following b/l wedge resection

Bony pyramid is let down after performing osteotomies and b/l wedge resection

This technique allows lowering of the bony pyramid without concominant narrowing.

HUMP REMOVAL TYPES OF HUMP

1. Bony hump 2. Bony and cartilaginous hump3. Cartilaginous hump

Surgical techniques:1. Reduction by rasp and file2. Resection3. Push-down with infracture of

pyramid4. Let down of pyramid following

bilateral wedge resection

Correcting bony hump with rasp and file

Is performed through intercartilaginous incision

Only bony bumps can be corrected with this .

Not effective on cartilage

Resection of bony and/or cartilaginous hump

Most common way to correct bony and/or cartilaginous hump

Had several drawbacks We resect the bony part of hump first

and f/b cartilaginous part The bony part is resected with chisel ,f/b

smoothing the defect with rasp The cartilaginous hump is then resected

by using straight or angled scissors

Resecting bony hump The hump to be

resected is outlined on the skin

The dorsum is approached by combining the right intercartilaginous with the CSI. This is f/b wide undermining of the dorsal skin

The skin over the bony and cartilaginous dorsum is undermined subperichondrially and subperiosteally

Resection is done with chisel

Bevel up –first part Bevel down-upper

part

Resecting a cartilaginous hump The triangular

cartilages are separated intraseptally from septal cartilage using no.64 beaver knife

The cartilaginous hump is resected stepwise , the height of the cartilaginous pyramid is adjusted to the height of the modified bony pyramid

The triangular cartilages are sutured to the septal cartilage to close the cartilaginous pyramid

saddle nose correction Types of saddling

1. bony and cartilaginous saddle nose

2. Low , wide pyramid syndrome3. Bony saddle4. Cartilaginous saddling

Bony and cartilaginous saddle nose

both bony and cartilage pyramid severely depressed.

Corrected by reconstruction of septum ,narrowing and push up of bony pyramid following osteotomies and dorsal transplant.

Low wide pyramid syndrome both bony and

cartilaginous pyramid are severely depressed and lobule is wide and low

Valve area is lowered and widened ,valve angle is increased (>90 degress)

Is corrected the same way as for bony and cartilaginous saddle nose

Bony saddle Dorsum is severely

depressed, while cartilaginous pyramid and cartilaginous septum are normal

Corrected by narrowing and push up of the bony pyramid following osteotomies and insertion of a dorsal transplant.

Cartilaginous saddling Cartilaginous pyramid

is severely or moderately depressed and broadened .

There may be atropy or balloning of triangular cartilages

Most common cause is killian-freer submucous septal resection

This is corrected by anterior rotation of septal cartilage.

Surgical techniques Repositioning and reconstruction of

anterior septum Narrowing and push up of bony

pyramid following osteotomies Augmentation of pyramid by inserting

a dorsal implant Increasing lobular projection and

narrowing lobular width Lengthening and lowering the

columella

Repositioning and reconstruction the septum

Done through CSI incision Through antero-superior

tunnel and inferior tunnel ,premaxilla and anterior nasal spine is exposed

Anterior septum is detached from base and bony septum

Guide wires are fixed to caudal end of septum at its ventrocaudal angle and its base

Augmentation by dorsal implant

Limited degree of cartilage sagging is corrected by inserting crushed sepatal cartilage through intercartilaginous or caudal septal incision.

Autografts such as conchal cartilage , rib cartilage can be used for augmentation.

Inserted through IC incision

Undermining of dorsal skin

Pocked created between two domes to accomdate caudal end of transplant

Held in place by external stenting

Tip surgery

“The one who masters tip masters nose”

tip surgery is never related to improvement of function ,but is always done for aesthetic reasons.

Characteristics of tip most prominent point or area of external

nasal pyramid

Built by:1. Two lobular cartilages2. Inter-domal soft tissue3. Overlying skin

Tip is defined by two domes ,should be visible as separate structures.

Projection of tip Aka tip prominence Too high- narrow pyramid

syndrome Too low-wide pyramid

syndrome (saddle nose)

Projection related to :1. Lobular base line2. Nasal base line3. Prominence of bony

cartilaginous pyramid4. Nasal lenghth

Position of tip Position of tip in vertical and

horizontal axis of face is determined by above mentioned factors.

Upwardly rotated tip Pendant or drooping tip

Tip abnormalities1. Broad ,bullous,square,ball tip2. Bifid tip3. Asymmetrical tip4. Underprojected tip5. Overprojected tip6. Upwardly rotated tip7. Hanging (pendant ,drooping )tip

Broad,bullous,square,ball tip Broad tip- domes apart Bullous-domes are wide and

massive Square tip-domes are not

arched but rectangular Ball tip-domes rounded

Is due thickness of both cartilage , lobular skin and subcutaneous tissue

Requires narrowing procedure without compromising function.

Bifid tip Tip is duplicated due

to an abnormally large distance between the two domes with an excessive amount of interdomal connective tissue.

Requires dissection and repositioning of the lobular cartilage

Asymmetrical tip Domes are

asymmetrical .

It is isolated variety or in combination with bifidity

Underprojected tip The projection of the

tip is abnormally low compared with that of bony and cartilaginous pyramid

Requires complete septorhinoplasty

Projection of domes may be increased by redraping the lobular cartilage ,columellat strut ,or by applying tip graft

Overprojected tip it is abnormally

prominent when compared to projection of cartilaginous and bony dorsum

Requires complete suptorhinoplasty

Projection of domes dimnished by redraping of lobular cartilages or by minor resections

Upwardly rotated tip Tip is more cranial

than normal Upwardly rotated

tip is usually overprojected

Nasolabial angle is large

Hanging tip Tip is more caudal

than normal and underprojected at the same time .

The nasolabial angle is abnormally smaill

Surgical technique

1. Narrowing tip and supratip area2. Increasing tip projection3. Reducing tip projection4. Upward positioning (rotation) of tip5. Downward positioning of tip

Narrowing tip and supratip area it is narrowed by1. Resecting a strip or wedge of

cartilage from the cranial margin of lateral crus

2. Suturing the domes together3. Redraping the lobular cartilage

Resecting a strip or wedge of cartilage

Done by intercatilaginous incision and using retrograde technique

The cranial margin of the lateral crus is inverted by hook and the vestibular skin and the cranial part of the lateral crus is cut

Suturing the domes together Done by external

approach

If required resections or incisions are made to break the spring

Both domes are brought together by suturing

Redraping the lobular cartilage Done using external

approach The lateral crus and dome

are dissected from underlying vestibular skin leaving the medial crura

The lateral crura are moved in ventral direction making the domes more projecting

Now transcrural and transdomal sutures applied

Reducing tip projection Reduced by various ways

1. Let down of pyramid and lobule2. Lowering domes by dome

resection and reconstruction technique

3. Resecting strips from medial crura

Let down of pyramid and lobule when overprojected tip

is part of narrow pyramid syndrome

Removing of horizontal and vertical strip of septal cartilage along with bilateral wedge resection

Procedure will broaden lobule and reduces tip

Dome resection and reconstruction technique

Delivery approach is required

Tip projection is decreased by resecting small strips from the lateral and medial crus just lateral and medial to domes , the strips are removed and domes are repositioned

The domes are sutured to medial and lateral crura

Resecting strips of medial crura External approach is

mandatory Tip projection is

decreased by resecting nonopposing strips from the medial crura

The lateral ends of lateral crura is somewhat shortened to allow reduction of lateral leg of tripod

Upward positioning of tip1. Resecting a triangle of cartilage from

the caudal septal end,with or without resecting a triangle of skin from the membranous septum

2. Trimming the cranial margin of the lateral crus with resection of a triangle of vestibular skin

3. Resecting a triangle of cartilage,skin and mucosa from the lower margin of triangular cartilage

Upward rotation and shortening of nasal length by resections from

1. Caudal end of septum2. The caudal margin of

lateral crura3. The caudal margin of

triangular cartilage

Upward rotation of the tip and shortening of nasal length by resecting a ventrally based triangle of cartilage from the caudal septal margin

A triangle of vestibular skin resected from membranous septum

The medial part of cranial margin of the lateral crus is resected together with triangle of vestibular skin

A triangle of cartilage is resected from the lower margin of the triangular cartilage

Increasing tip projection

1. a columellar strut (in combination with anterior septal reconstruction)

2. A tip graft (a shield graft)3. Redraping of the lateral crura and

domes with lateral crural steal

Columellar strut External or

endonasal approach Anterior septum

reconstructed A strut with 3mm

width and 20-25mm length is positioned on the anterior nasal spine between the medial crura

Strut is fixed 2 or 3 transverse sutures

Tip graft or shield graft Placed by either

external approach or CSI

Sculpted according to requirement

Sutured to domes with resorbable sutures