Cosmetic Rhinoplasty Flashcards
A patient is evaluated because of nasal airway obstruction that is worse on the right side. Physical examination shows the inferior nasal turbinate has significant anterior extension and mucosal thickening with bony hypertrophy. There is a posttraumatic septal deviation and a 10-degree internal nasal valve angle. In consideration of surgery to improve the nasal airflow, which of the following factors is most important in determining the need for a submucous resection of the turbinate?
A) Anterior extension of the turbinate
B) Bony hypertrophy
C) Decreased internal nasal valve angle
D) Deviated septum
E) Mucosal thickening
The correct response is Option B.
All of the answers listed can play a part in this patient’s nasal obstruction and poor airflow in the right nostril. Of the answers listed, the bony hypertrophy of the inferior turbinate is the finding which most suggests the need for a submucous resection. The anterior extension of the inferior turbinate certainly can play a role in decreased air flow, but this by itself does not suggest the need for submucous resection. Simple mucosal thickening of the inferior turbinate without bony hypertrophy can be addressed with outfracture. Septal deviation can be addressed with septoplasty. Decreased internal nasal valve angle can be addressed with, for instance, a spreader graft.
2018
A 35-year-old man comes to the office for a consultation because he is dissatisfied with the result of a rhinoplasty performed 2 years ago. The patient reports that his nasal openings collapse on deep inspiration and his nasal tip is deformed. Physical examination shows collapse of the external nasal valve on deep inspiration and bilateral asymmetric alar rim collapse with alar retraction of 1 to 2 mm. Revision rhinoplasty is planned. Which of the following grafts is most appropriate to correct these conditions?
A) Columella strut
B) Composite alar rim
C) Lateral crural strut
D) Spreader
E) Subdomal
The correct response is Option C.
The lateral crural strut graft is a strip of septal cartilage that (if available for harvest) is sutured to the underside of the lower lateral cartilage and provides increased support and position control. It is a very powerful graft that can reposition lower lateral cartilages, correct alar retraction, and correct external valve collapse.
The columella strut graft is for increased tip projection and support.
The composite alar rim graft includes both skin and cartilage. This graft is used for severe alar retraction and soft tissue loss of the alar rim.
Spreader grafts are used to increase airflow through the internal nasal valve as well as straighten a deviated dorsal septum and improve dorsal aesthetic lines.
The subdomal graft is placed under the domes of the lower cartilages and can correct asymmetry of the nasal tip and improve a pinched tip.
2018
A 23-year-old woman of Asian ancestry comes to the office to discuss augmentation rhinoplasty to address dorsal projection. She refuses harvest of graft material from a secondary donor site. Which of the following materials would most likely provide the desired augmentation, the least surgical risk, and the greatest longevity of result?
A) Ear cartilage
B) Homologous irradiated rib cartilage
C) Porous polyethylene implant
D) Septal cartilage
E) Stacked acellular dermal matrix
The correct response is Option D.
There are many options for materials to use for augmentation rhinoplasty. Most options fall into one of several categories including autologous soft tissue, cartilage, and bone; processed allografts such as acellular dermal matrix; homologous grafts, most often irradiated rib; and alloplastic materials including silicone, ePTFE (expanded polytetrafluoroethylene sheeting), and porous polyethylene. There are advantages and disadvantages of each. In this case, the patient refuses a donor site outside of the nasal surgery, which eliminates the options of ear or rib cartilage and the option of cultured autologous auricular chondrocytes, as this too requires harvest of ear cartilage prior to the rhinoplasty. Homologous irradiated rib cartilage is a good alternative to autologous cartilage grafts and requires no donor site but has a somewhat higher risk profile than autologous septal cartilage. Silicone implants, and alloplastic implants in general, are popular in Asian augmentation rhinoplasties and have the advantage of availability, affordability, and no donor site, but they carry a higher risk for postoperative complications, including extrusion, skin changes, and infection, all of which create significant issues when they require secondary rhinoplasty procedures. Acellular dermal matrix has the disadvantage of a resorption rate of 20 to 30 percent, too much to perform precise corrections. An ear cartilage graft would be from a secondary site.
2018
During secondary open rhinoplasty through an existing transcolumellar incision, division of which of the following arteries is most likely to result in vascular ischemia of the nasal tip?
A) Anterior ethmoid
B) Columellar
C) Dorsal nasal
D) External nasal
E) Lateral nasal
The correct response is Option E.
A detailed knowledge of the nasal tip blood supply is critical for safe conduct when using a transcolumellar incision during primary or secondary rhinoplasty. There are several sources of arterial blood supply to the nasal tip. Some of these can be sacrificed without compromising the viability of the nasal tip skin. Rohrich et al. determined that the nasal tip has a dual blood supply derived from the ophthalmic and facial arteries. While contributions from the ophthalmic circulation’s anterior ethmoid, dorsal nasal, and external nasal arteries are present, the dominant supply is derived from branches of the facial artery. Its branches, the columellar artery (present in 68.2% of cadavers in one study) and the lateral nasal artery (present in 100% of cadavers), are more likely to provide the nasal tip with inflow even if the ophthalmic arterial branches are sacrificed during the dissection. Regardless of the presence of a prior transcolumellar incision, the nasal tip blood supply is secure if the lateral nasal arteries are preserved. Guidelines for assuring that the lateral nasal arteries remain uninjured include “hugging” the cartilage of the lateral crura in a subperichondrial plane, limiting dissection superiorly to the level of the alar groove, limiting alar base excision to a level below the alar grooves, and limited defatting of the subdermal plane of the tip.
2018
At the keystone area of the nose, which of the following most accurately describes the anatomic position of the upper lateral cartilage in relation to the nasal bones?
A) Anterior to the nasal bones
B) Caudal to the nasal bones with a 1 to 2 mm fibrous gap
C) Edge to edge with the nasal bones with no overlap
D) Posterior to the nasal bones
The correct response is Option D.
The keystone area of the nose is where the nasal bones overlap the upper lateral cartilages. This is usually the widest part of the nasal dorsum.
At the dorsal keystone area, the nasal bones overlap the upper lateral cartilages for a distance of 4 to 14 mm.
When reducing a dorsal hump, rasping of the bone at the keystone area uncovers the underlying cartilages, which often dictate the width of this area. Once uncovered, these structures may need to be reduced for a more aesthetic dorsal line.
In large cadaver studies, all noses demonstrate that the upper lateral cartilages are posterior to the nasal bones at the keystone area, and as such all other answer choices are incorrect.
2017
A 30-year-old man comes to the office because of a frontal headache and persistent watery drainage from the right nostril 2 weeks after undergoing septorhinoplasty. Which of the following is the most appropriate next step in management?
A) Place nasal packing for 48 hours
B) Start oral antihistamines
C) Start vasoconstrictor nasal spray
D) Test nasal discharge for beta-2 transferrin
E) Reassure the patient that these symptoms are normal
The correct response is Option D.
Postoperative cerebrospinal fluid (CSF) leak is a rare but known complication following septoplasty. It is related to an error in surgical technique, with overly forceful manipulation of the perpendicular plate region resulting in a cribriform plate defect. The cardinal symptoms are frontal headache and a clear, watery persistent rhinorrhea. If nasal packing is present, the patient may report a metallic or salty-tasting post-nasal drip. Prompt diagnosis is required to avoid complications, particularly meningitis and pneumocephalus. CSF rhinorrhea is more common on the right side, reflecting a predominance of left-sided surgical approaches. It may present in an early manner, as in this case, or have a delayed presentation; some documented reports have a 20-year delay between septoplasty and diagnosis of CSF leak.
While imaging is beneficial, initial diagnosis of CSF leak can be made with the beta-2 transferrin or Beta-trace protein testing, which are both specific and sensitive for CSF. Both are more accurate than the traditional “halo” sign or measuring the glucose level of the fluid.
The other options listed are incorrect, as they do not diagnose or effectively treat the underlying problem.
2017
Which of the following structures is an anatomical component of the internal nasal valve?
A) Anterior portion of the middle turbinate
B) Caudal edge of the upper lateral cartilage
C) Cribriform plate of the ethmoid
D) Ostium of the maxillary sinus
E) Superior border of the nasal bone
The correct response is Option B.
The internal nasal valve is an anatomical structure composed of several parts. Its cross-sectional dimension determines the quantity of airflow that passes through the nose while breathing both at rest and during exercise. Because it is the narrowest part of the entire airway, compromise of any of its elements correlates with symptoms of nasal obstruction. The internal nasal valve is bounded by the caudal border of the upper lateral cartilage superiorly, the nasal septum medially, the floor of the nasal vestibule inferiorly, the anterior part of the inferior turbinate posteriorly, and the bony edge of the pyriform aperture laterally. Internal nasal valve narrowing may be due to one or more of several factors, including septal deviation, turbinate hypertrophy, collapse of the upper lateral cartilage due to surgical disruption of the ligaments which support it to adjacent structures, and loss of cartilage strength due to aging. A variety of techniques have been described for restoration of the internal valve function. Most of these involve stiffening the upper lateral cartilage with cartilage graft struts, submucous resection of the nasal septum, reduction of hypertrophic turbinates, or combinations of these procedures.
2017
A healthy 26-year-old woman undergoes rhinoplasty using a spreader graft. Which of the following is the most likely cause of decreased airway resistance after placement of the spreader graft?
A) Decreased angle at the external nasal valve
B) Decreased area of airway
C) Decreased radius at the internal nasal valve
D) Increased angle at the external nasal valve
E) Increased radius at the internal nasal valve
The correct response is Option E.
A spreader graft is placed between the septum and the upper lateral cartilages. Poiseuille law states that resistance = (viscosity × length)/radius4. About half of nasal airway resistance occurs at the internal nasal valve. The internal nasal valve, formed at the junction of the septum (medially), the nasal floor (inferiorly), the inferior turbinate (laterally), and the caudal border of the upper lateral cartilages (superiorly), accounts for a significant amount of airway resistance. Maneuvers that increase the radius at the internal nasal valve will decrease resistance exponentially.
2016
A 35-year-old woman is dissatisfied with the appearance of her nose. Physical examination shows parenthesis tip deformity with vertically oriented lower lateral cartilages. Which of the following grafts is most appropriate for correction of this deformity?
A) Caudal septal extension
B) Crural turnover
C) Lateral crural strut
D) Spreader
E) Spring
The correct response is Option C.
This patient presents with a parenthesis deformity with vertically oriented lower lateral cartilages. To correct this deformity, the lower lateral cartilages must be rotated inferiorly. A lateral crural strut graft is a strip of cartilage 3 to 4 mm in width sutured to the deep surface of the lateral crura and then either buried or sutured to the soft tissue of the pyriform aperture. In this way, the native lower lateral cartilage can be rotated inferiorly and held in place.
A caudal septal extension graft is sutured to the caudal septum and is used to control nasal tip projection as well as lengthen an overly shortened nose.
A crural turnover graft is created by folding the cephalic portion of the upper lateral cartilage inferiorly onto itself. It thereby strengthens itself and is used to support weakened or collapsed lower lateral cartilages.
Spreader grafts are placed at the dorsal edge of the septum to correct internal nasal valve collapse and support the upper lateral cartilages.
A spring graft widens the middle vault by spanning between both upper lateral cartilages.
2016
A 22-year-old woman is evaluated for revision rhinoplasty. A closed approach is planned. The alar margin is in an appropriate position. On lateral view, excessive columellar show is noted. Which of the following incisions is most appropriate for management of this deformity?
A) Alar rim
B) Intercartilaginous
C) Intracartilaginous
D) Killian
E) Transfixion
The correct response is Option E.
On anterior/posterior view, the alar margin and columella have been described as ideally having the appearance of a gentle gull wing in flight. The columella represents the body of the gull and in this patient it is noted to be elongated with the wings (alar margin) appearing to be normal. On lateral view, the nostril should have an oval shape. A line drawn along the long axis should bisect it into equal halves with the alar rim being 1 to 2 mm above this line and the columella 1 to 2 mm below.
The patient described exhibits findings consistent with a hanging columella. The etiology of this problem is due to either a long caudal septum, long medial crura, or combination of the two. The transfixion incision is in the membranous septum at the border of the caudal septum. It is the only incision listed above that allows access to the caudal septum for excision and can also resect any redundant membranous septum that may develop as a result of the setback.
An intracartilaginous incision is made within the substance of the lateral crus of the lower lateral cartilage. It can be used in a closed approach to combine the incision for the access to the nose with the removal of the cartilage superior to the incision to accomplish a cephalic trim of the lower lateral cartilage.
A Killian incision is used for access to the septum. It is placed 1 to 2 cm posterior to the caudal border of the septal cartilage.
An alar rim incision is made in the vestibular skin just inside the border of the nostril. This incision can be used as an approach to create a pocket for a nonanatomical rim graft.
The intercartilaginous incision is made between the upper and lower lateral cartilages and would not improve columellar show.
2016
A 23-year-old woman comes to the office for consultation regarding rhinoplasty because she is dissatisfied with her smile. Physical examination shows a drooping nasal tip, shortened upper lip, and transverse upper lip crease when the patient smiles. Which of the following muscles is the most likely cause of these findings?
A) Depressor anguli oris
B) Depressor septi nasi
C) Levator anguli oris
D) Levator labii superioris
E) Nasalis
The correct response is Option B.
The depressor septi nasi muscle is a small, paired muscle located on both sides of the nasal septum, originating from the medial crural footplates. Its action pulls the nasal tip downward and shortens the upper lip. The overactive muscle can cause the “smiling deformity” in the patient described. It is important to evaluate the smile of the rhinoplasty patient to determine whether the depressor septi nasi muscle needs to be addressed during the procedure in order to optimize results. The depressor septi nasi muscle can be released from the medial crura through the trans-nasal approach. If the patient has tethering of the frenulum, a depressor septi nasi muscle dissection and transposition can be performed through the trans-oral approach.
The depressor anguli oris originates from the mandible and inserts into the angle of the mouth. It depresses the corner of the mouth and is associated with frowning, and does not affect the nasal tip or upper lip.
The nasalis consists of two parts: transverse and alar. The transverse part arises from the maxilla, above and lateral to the incisive fossa; its fibers proceed upward and medial, expanding into a thin aponeurosis which is continuous on the bridge of the nose with that of the muscle of the opposite side, and with the aponeurosis of the procerus. The alar part is attached by one end to the greater alar cartilage, and by the other to the integument at the point of the nose. The transverse part compresses the nostrils, drawing them toward the septum. The alar part dilates, or flares, the nostrils. While the nasalis is involved in nasal movement, it does not cause the smile deformity described.
The levator anguli oris arises from the canine fossa, located under the infraorbital foramen. The muscle’s fibers insert at the mouth’s angle, and it intermingles with the zygomaticus, triangularis, and orbicularis oris muscles. Although the muscle is involved in and helps form the smile, it elevates the angle of the mouth at the corner and is not involved in nasal tip drooping and shortened upper lip.
The levator labii superioris is a broad, flat, quadrangle muscle, and may be considered as three parts extending between the lateral side of the nose and the zygoma in the infraorbital area: angular (medial), infraorbital (intermediate), and zygomatic (lateral) head. The medial part of the angular head inserts into the greater part of the lower lateral cartilages and nasal skin, and helps dilate the nostrils. The lateral part of the angular head, infraorbital, and zygomatic head all insert by merging with fibers of the orbicularis oris, and serve to elevate and evert the upper lip, the primary function of the muscle. Although it may contribute to shortening the upper lip upon activation, it does not cause nasal tip droop.
2016
A 27-year-old woman comes to the office for evaluation of her nasal tip. She asks for rhinoplasty for improvement of her aesthetic appearance. Physical examination shows asymmetric projection of the nasal tip with a pinched nasal deformity. Which of the following cartilage grafts would best correct this deformity?
A) Columellar strut
B) Lateral crural strut
C) Septal extension
D) Spreader
E) Subdomal
The correct response is Option E.
Correction of aesthetic and functional deformities of the nasal tip requires an understanding of the underlying anatomy and the use of cartilage grafting. A pinched nasal tip deformity results from decreased interdomal distance or narrow domal arches of the lower lateral cartilages.
Subdomal grafts can be used to correct a pinched nasal tip deformity as well as asymmetry of the domes. The subdomal graft is bar shaped, spanning beneath both domes, controlling the horizontal and vertical orientation of the domes.
The columellar strut graft corrects an underprojecting tip by increasing tip projection. The lateral crural graft is utilized to correct alar contour deformities secondary to deformed lateral crus of the lower lateral cartilages. Septal extension grafts control projection, shape, and rotation of the nasal tip. The spreader graft will expand the internal nasal valve and middle one-third of the nose but not correct a pinched tip.
2016
The intercartilaginous incision in rhinoplasty follows the caudal border of which of the following?
A) Alar lateral crus
B) Caudal septum
C) Lower lateral cartilage
D) Middle crus
E) Upper lateral cartilage
The correct response is Option E.
The intercartilaginous incision follows the caudal border of the upper lateral cartilage and is located between it and the cephalad border of the alar lateral crus. This incision may connect, and frequently does, with a transfixion incision at the caudal border of the septum at the septal angle.
2015
A 30-year-old man comes to the office because of symptoms of nasal airway obstruction. Physical examination shows a septal C-shaped deformity without dorsal deviation; Cottle maneuver is negative, and external nasal valves are competent. Which of the following is the most appropriate surgical management?
A) Alar batten grafting
B) Columellar strut grafting
C) Septoplasty
D) Spreader grafting
E) Submucous septal resection
The correct response is Option E.
In the patient described, the most appropriate surgical management is submucous septal resection. The important structures that affect nasal airflow and lead to obstruction are the internal and external nasal valves, the inferior turbinates, and the nasal septum. According to the classifications of the deviated nose, the patient described exhibits caudal septal deviation, with a concave (C-shaped) deformity of the septum. This is the most likely cause of this patient’s obstruction symptoms. In the absence of internal (negative Cottle maneuver) and external nasal valve collapse, resection of the deviated septum is the maneuver most likely to improve the patient’s nasal airflow and alleviate obstruction symptoms. It is of the utmost importance to preserve 9 to 10 mm L-strut of septal cartilage to maintain structural integrity.
Alar batten grafts are placed in a pocket extending from the piriform aperture to a paramedian position in the alar sidewall. They prevent lateral nasal wall collapse and alar retraction during inspiration. They are also effective in providing strength and competency to the external nasal valves. The patient has competent external nasal valves, and thus, alar batten grafts alone will not address his nasal airway obstruction, which is caused by his deviated septum. Alar batten grafts are also used as an adjunct graft to correct a caudal septum deviation after septal resection.
Columellar strut graft is placed between the medial crura for nasal tip shaping and support. Open rhinoplasty approach may cause mild loss of tip projection caused by disruption of ligamentous support and increased skin undermining, and a columellar strut will help maintain tip support. It can be used to increase nasal tip projection effectively. It does not play a role in alleviating airway obstruction caused by septal deviation.
Septoplasty is the scoring of the quadrangle cartilage to influence its shape, in an attempt to straighten it. The cartilage will bend away from the scored surface. It is an important adjunct to septal resection to shapen and straighten a deviated septum. It is likely not powerful or predictable enough to correct a septal C-shaped deformity on its own and alleviate nasal obstruction.
Spreader grafts are usually paired, longitudinal grafts placed between the dorsal septum and the upper lateral cartilages in a submucoperichondrial pocket. They are used to restore or maintain the internal nasal valve, straighten a deviated dorsal septum, improve the dorsal aesthetic lines, and reconstruct an open roof deformity. They are often placed in addition to septal resection. In the patient described, without internal nasal valve collapse and a deviated septum, spreader grafts alone will not likely improve nasal airway obstruction.
2015
A 25-year-old woman undergoes rhinoplasty to correct a bulbous tip. After a cephalic trim leaving 6 mm of the lower lateral cartilage, transdomal sutures, and infracture, the tip continues to look bulbous. Which of the following techniques is most likely to improve this persistent deformity?
A) Additional cephalic trimming
B) Columellar strut grafting
C) Lateral crural mattress suture
D) Shield grafting
E) Spreader grafting
The correct response is Option C.
The most likely cause for a persistent bulbous tip after traditional maneuvers is convexity of the lower lateral cartilages. Lateral crural mattress sutures are effective in improving this convexity. These sutures are placed spanning the convexity and then tightened to straighten the curvature. Another option would be an alar batten graft, which is a graft placed on the medial surface of the lower lateral cartilage. Additional cephalic trim could lead to weakening of the nasal tip support and would not correct the problem. Columellar strut grafting, shield grafting, and spreader grafting will not effectively improve a naturally convex lower lateral cartilage.
2015
Which of the following is the most appropriate method for demonstrating objective, dynamic nasal cavity patency and nasal function?
A) Anterior rhinoscopy
B) Cottle maneuver
C) Nasal endoscopy
D) Rhinomanometry
E) Sound wave analysis
The correct response is Option D.
Subjectively, the nasal valve can be assessed using the Cottle test. Anterior rhinoscopy is an objective way to evaluate the nasal cavity; however, the examiner’s assessment of how much of the nasal cavity is obstructed or patent is subjective. Nasal endoscopy, CT scan, and MRI are described as tests capable to assess the nasal cavities, helping in the diagnosis of anatomical variations associated with nasal disorders. Objectively speaking, rhinomanometry is a dynamic way to assess nasal cavity patency and nasal function; it aims at establishing nasal resistance, which is the difficulty of passing air through the nose, through the measurement of transnasal pressure and airflow. Analysis of sound waves is a static way to assess nasal patency and geometry quantifying the areas of nostril cross section all the way to the nasopharynx and nasal cavity volume between the two cross-sectional areas chosen.
2014
A 32-year-old Korean man comes to the office for evaluation of a wide nose with decreased projection. He desires rhinoplasty for an improved aesthetic appearance. Compared with Caucasian nasal anatomy, which of the following is most likely in this patient?
A) Height of the lower lateral cartilage is shorter
B) Height of the upper lateral cartilage is longer
C) Length of the septal cartilage is longer
D) Length of the upper lateral cartilage is shorter
E) Overlapping length of the upper lateral cartilage and the nasal bone is shorter
The correct response is Option A.
The cartilaginous structures of Asian noses are substantially different from those of Caucasian noses in terms of the shape, size, thickness, and relationship to other structures. The lengths of the upper and lower lateral cartilage of Asian noses are similar to those of Caucasian noses. However, the heights of the upper and lower lateral cartilage of Asian noses are shorter than those of Caucasian noses. Therefore, rhinoplasty with cephalic resection of the lower lateral cartilage in Asian noses should be approached with caution to prevent overresection. The overlapping length of upper lateral cartilage and nasal bone is similar in both Asians and Caucasians.
2014
A 35-year-old man comes to the office 4 weeks after undergoing open rhinoplasty and submucous resection of a deviated septum. He reports nasal crusting, bleeding, and a whistling sound from his nose. Which of the following is the most likely diagnosis?
A) Exposed conchal bone
B) Internal nasal valve collapse
C) “L” strut fracture
D) Septal perforation
E) Submucous hematoma
The correct response is Option D.
Symptoms of septal perforations include crusting along the septal defect, bleeding, and whistling. The whistling sound is due to the altered airflow pattern. Perforations can be caused by trauma, cocaine snorting, and infectious or inflammatory causes. In this patient, surgical trauma is the most likely cause. Treatments for symptomatic septal perforations include flaps and grafts. Asymptomatic perforations do not require treatment.
The symptoms of internal nasal valve collapse, and submucous hematoma would be restricted airflow. “L” strut fracture or collapse would occur with an external deformity and not the symptoms described. Exposed conchal bone is caused by overresection of inferior turbinate mucosa. When performing a submucosal resection of the inferior turbinate, this would not occur with a submucous resection of the septum.
2014
