Chapter 59 - Rhinoplasty, Nasal Reconstruction

Question 1

Major tip support

Answer 1

LLC to septum (at medial crural footplate) and to ULC

Question 2

Internal nasal valve

Answer 2

ULC, nasal septum, floor

Question 3

2 causes of Polly beak

Answer 3

Loss of top support (tip descends, anterior septal angle produces convexity in supratip)
Supratip scar tissue (from overresection of dorsum –> dead space)
Tx: steroids/recon

Question 4

5 causes of saddle nose

Answer 4

Rhinoplasty
Septal hematoma 
Septal abscess 
Autoimmune
Cocaine 

This is loss of cartilage support for middle third of nose

Question 5

Brow tip aesthetic line

Answer 5

glabella to ipsilateral tip-defining point

Question 6

Internal nasal valve

Answer 6

1cm posterior to aperture
Inf Turb can crowd
Angle between ULC and septum is acute
Like sterling resistor: closes once threshold flow rate is reached

Question 7

External nasal valve

Answer 7

Incomplete ring around nostril opening formed by LLC

Prevents soft tissue collapse with inspiration

Question 8

How to correct nasal valve incompetence (one way for each)

Answer 8

Int: cartilage spreader graft (sutured to septum to lateralize ULC)

Ext: alar batten graft (placed over/under lateral crus)

Question 9

How much columellar show is normal on lateral view?

Answer 9

2-4mm

Question 10

Goode’s Ratio

Answer 10

Measure anterior projection of tip

Tip projection: Nasal length 0.55-0.6:1

Question 11

One way to correct internal valve collapse

Answer 11

spreader grafts, to either side of dorsal septum, to lateralize ULC

Question 12

One way to correct external valve collapse

Answer 12

alar batten grafts

place under or over lateral crus

Question 13

Where is the scroll region in the nose?

Answer 13

Attachment of lateral crura of LLC to ULC

Question 14

6 minor tip supports

Answer 14

Interdomal lig
dorsal septum
sesamoid complex
LLC to SMAS
nasal spine
membranous septum

Question 15

Transcolumellar and marginal incisions

Answer 15

T: narrowest, most convex point columella, inverted V

M: caudal margin of LLC

Question 16

Inter vs Transcartilaginous incisions

Answer 16

Inter: between LLC and ULC
Trans: caudal to junction of ULC and LLC, carry through overlying cartilage (remove as cephalic trim)

Question 17

ADV/DISV to closed rhinoplasty

Answer 17

ADV: less edema, shorter, no scar externally
DIS: compromised tip support/exposure

Question 18

ADV/DIS to open rhinoplasty

Answer 18

ADV: exposure, graft placement, visualization
DIS: longer, more edema, scar

Question 19

Tripod tip concept

Answer 19

paired medial crura
left lateral crus
right lateral crus
Lengthen/shorten either element will alter tip position

Question 20

How to get upward tip rotation

Answer 20

tip suspension sutures (pull lateral crus cephalically)
resect cartilage from cephalic portion of lateral crus –> scar
caudal septal extension graft
suture lateral crura
blunt nasolabial angle with plumping graft

Question 21

How to correct bulbous tip

Answer 21

excise cephalic trim (cephalic border of alar/lateral crus cartilage), preserve 8-10mm
Lateral crural strut graft

Question 22

Inverted V deformity

Answer 22

loss of ULC attach to septum, can see nasal bone shape through skin
Tx: spreader graft to resuspend ULC

Question 23

Healing post-rhinoplasty: how long?

Answer 23

up to 18 mo (majority in 8 wk though)
tip stiff for about 3-6 mo (scar)
Wait 6 mo at least for revision

Question 24

Numbness after rhinoplasty

Answer 24

nasal tip - neuropraxia nasopalatine nerve through incisive canal, resolved 3-6 mo

Question 25

Alloderm

Answer 25

acellular human debris

Question 26

Gore-Tex

Answer 26

expanded polytetrafluoroethylene

Question 27

Mepor

Answer 27

porous high density polyethylene

Question 28

PDS

Answer 28

polydioxanone plate