Rhinoplasty Slide 2 Slide 3 Skin , sebaceous glands,
subcutaneous tissue , least ideal skin type Slide 4 skin
subcutaneous tissue cushion Slide 5 Tip recoil. If the recoil is
instantaneous and vigorous, and the tip cartilages resist the
deforming influence of the finger, more definitive tip surgery can
usually be performed. Slide 6 Slide 7 A three-way mirror facial
photographs, and even computer imaging important communication
process between the expectant patient and the cautious surgeon.
Slide 8 Realistic expectations and thoroughly informed consent are
the keystones on which the most important surgical outcomea happy
patientis achieved Slide 9 The concentration of 1% lidocaine is
sufficient to produce excellent anesthesia and has an effective
duration of 1.5 to 2 hours. No effort is made to block specific
nerves. Slide 10 lateral wall of the dorsum, hugging the
perichondrium of the upper lateral cartilages and the periosteum of
the nasal bones. Slide 11 Identification of this plane is enhanced
by lifting the soft tissues overlying the nasal dorsum with thumb
and forefinger. Slide 12 Osteotomy Old fractured nose local
anesthetic ascending process bleeding lateral osteotomy Slide 13
Slide 14 Slide 15 Slide 16 Slide 17 Slide 18 Slide 19 Slide 20
Slide 21 Slide 22 Slide 23 Slide 24 Slide 25 Noncaucasian
Rhinoplasty Nasal tip skin is thick and sebaceous, lower lateral
cartilages and septum are paradoxically small, weak, and deficient.
The nasal bones are broad and flat. The low radix and
underprojected nasal tip are common features. Slide 26 Noncaucasian
Rhinoplasty Augmentation to the tip and dorsum remain the workhorse
maneuvers Implants should not leave pressure on the overlying skin.
Alar base surgery should be performed only judiciously. Slide 27
Slide 28 preparing the recipient site and corresponding surface of
the implant, so that the implant will fit snugly against roughened
nasal bones. The undersurface of the implant should be concave to
fit the curvature of the dorsum of the nose. Slide 29 A
three-dimensional concept must be kept in mind when shaping the
graft. The dorsal aspect of the graft should be nearly straight and
extend the full length of the nose. Grafts may be layered to
increase the magnitude of augmentation. Slide 30 Slide 31 Slide 32
Slide 33 Silicone Slide 34 Slide 35 Slide 36 Slide 37 Slide 38
Slide 39 Slide 40 The nasolabial angle defines the angular
inclination of the columella as it meets the upper lip. This angle
should measure 95 to 110 degrees in women and 90 to 95 degrees in
men. Slide 41 Slide 42 The nasofacial angle represents the angle
formed from a vertical line tangent from the glabella through the
pogonion intersecting a line from the nasion through the nasal tip.
This angle ideally measures 36 degrees but can vary from 30 to 40
degrees. Slide 43 Slide 44 In patients with extremely thin skin,
delicate alar side walls, and bulbous cartilage, predictable
narrowing refinement can be achieved by transdomal suturing of the
complete strips with horizontal mattress sutures. Slide 45 Slide 46
Slide 47 Solid medical grade silicone rubber, have been used for
restoration of tip, alar, and septal defects and for saddle
deformities Disadvantages include a high extrusion rate, foreign
body reaction, and susceptibility to infection. Slide 48 Nasal Base
Sculpting An incision is made from the base of the sill and carried
out 1 to 2 mm above the alar- facial crease. The alar flap can be
advanced medially, and a conservative amount of the ala can be
excised. To avoid visible scaring, the cut edges should be
carefully reapproximated. Slide 49 Nasal Base Sculpting A 5-0
chromic suture should be used to reapproximate the alar rim, and
one or two subcutaneous 5-0 Vicryl sutures should be placed to
reapproximate the alar-facial junction incision. A few 6-0 nylon
sutures are used to reapproximate the skin edges. Slide 50 Slide 51
Slide 52 Slide 53 Septoplasty Slide 54 The injection is started at
the caudal end of the septum. the contralateral membrane the area
of the nasal floor around the maxillary crest Slide 55 Infiltration
of the local anesthetic into this plane results in a hydraulic
elevation of the septal flap, facilitating elevation and
preservation of flap integrity Slide 56 Killian incision,
approximately 1- to 2-cm posterior to the caudal septal margin
within the respiratory epithelium. Slide 57 Slide 58
Hemitransfixion or transfixion incision made at the caudal border
of the septum allows access to the deviated caudal septum and any
posterior deflections. Slide 59 The incision is created within the
squamous epithelium of the vestibule. Slide 60 The No. 15 blade is
then used to incise mucosa down to and through the perichondrium.
Identification of the proper plane is now of utmost importance.
Slide 61 It is created by first identifying the caudal end of the
septum itself. Inserting the nasal speculum into the nose and
gently retracting the slightly opened speculum clearly reveals the
caudal septal edge. Slide 62 Dissecting within a subperichondrial
plane ensures little bleeding and a hardier flap with less
likelihood of perforation. Slide 63 Slide 64 Before advancing
posterior to the bony- cartilaginous junction, elevation of the
mucoperiosteum along the nasal floor is frequently necessary to
address Slide 65 -any maxillary crest deviation -the septum that
has shifted off of the crest and is found to be obstructing the
inferior airway. Slide 66 A second plane exists in the
submucoperichondrial and submucoperiosteal spaces flanking the
nasal septum. Slide 67 By elevating above the crest or deviated
floor segment and then elevating below the segment, the surgeon
creates two pockets or tunnels. Slide 68 Incising the nasal floor
deflection or connecting the two tunnels directly helps to avoid
mucosal tears Slide 69 If bilateral membrane wrents are noted,
interposition graft of crushed cartilage Slide 70 Bilateral
membrane elevation followed by septal incision using a Becker
septal scissor above and below any deviated septal segment or spur
allows increased mobility of the deflected segment. Slide 71 To
decrease the potential for loss of dorsal or tip support, preserves
at least a 1-cm dorsal and 1-cm caudal septal segment, which has
been termed the L-strut Slide 72 L-strut Slide 73
