Rhinoplasty Flashcards
A 55-year-old woman comes to the office because she is dissatisfied with the appearance of her nose, specifically the scars left by acne as a young adult. She has undergone scar revision by punch biopsy and closure as well as dermabrasion by four different physicians but has never been satisfied with the results. She spends approximately 1.5 hours per day putting makeup on her face before leaving the house. She has never married and feels embarrassed to be seen in public because she feels that everyone is staring at her nose. Which of the following most accurately represents the prevalence of this diagnosis in patients who undergo plastic surgery? A) Less than 1% B) 2 to 4% C) 7 to 15% D) 22 to 25%
C) 7 to 15%
The patient described has body dysmorphic disorder (BDD), which affects 7 to 15% of all plastic surgery patients. In
What percent of plastic surgery patients are affected by body dysmorphic disorder?
7 to 15% of all plastic surgery patients.
Body dysmorphic disorder
In this disorder, the patient’s degree of concern is far greater than the degree of actual deformity. This perception may involve the entire body or just one area. The patient is generally unaware that his or her concerns are excessive. BDD can be associated with other diagnoses, including depression, substance abuse, social phobia, and/or obsessive-compulsive disorder. The patient is preoccupied with his or her appearance so much that a significant amount of time is spent trying to camouflage or change the outward appearance with makeup.
Demographic of patients with body dysmorphic disorder
Most patients with BDD are single (70% never married), and up to 50% have suicidal ideation.
The prevalence of BDD has been shown to be significantly higher in the plastic surgery population than in the general population (1 to 3%). It does not appear to have a gender or cultural predilection.
Operating on a patient with body dysmorphic disorder
Operating on these patients almost never leads to a satisfied patient; therefore, preoperative diagnosis is essential.
A 21-year-old woman comes to the office because of difficulty breathing through the right nostril and dissatisfaction with the appearance of a “bump” in her nose and a wide tip. History includes three untreated nasal fractures and intermittent seasonal allergic symptoms. Functional septorhinoplasty with spreader grafts and a reduction of the nasal tip and dorsum are performed. One week postoperatively, a fluid collection that tests positive for MRSA infection is noted along the nasal dorsum. Drainage is performed, and oral antibiotics are administered. The patient comes to the office for follow-up 4 weeks postoperatively, and she says she is dissatisfied with the appearance of her nose despite significant functional and cosmetic improvement. Which of the following is the most appropriate strategy to avoid further patient dissatisfaction?
A) Ask the patient to return weekly for the next 6 weeks
B) Explain to the patient that this is a normal postoperative course and ask her to return in 4 months
C) Offer to revise her surgery, explaining that she will have to pay the facility and anesthesia charges
D) Transfer care to another surgeon
A) Ask the patient to return weekly for the next 6 weeks
Patient dissatisfaction following aesthetic surgery has many origins, including unrealistic patient expectations, inappropriate motivation for surgery, poor patient choice on behalf of the surgeon, and underlying psychopathology.
Most common reasons for dissatisfaction with aesthetic rhinoplasty
Aesthetic septorhinoplasty cases comprise avery large portion of the dissatisfied patient population. The most common reasons include unsatisfactory results, visible irregularities or scars, continued breathing difficulty, asymmetry, “emotional distress,” and the cost of revision surgery.
Patients to avoid in aesthetic surgery
Several groups of patients with certain characteristics should be avoided. These include patients with unrealistic or overly idealized expectations, excessively demanding patients, indecisive patients, immature patients, secretive patients, patients motivated to seek surgery by others, patients with unstable personalities, patients with body dysmorphic disorder, patients you simply do not like, and “surgiholics,” or “doctor shoppers.”
Key to dealing with dissatisfied patients postoperatively
Proper communication and frequent contact with the patient postoperatively.
Successful communication requires empathy, compassion, and reflective listening to make sure the patients understandthat their concerns are valid and important. The common denominator of litigation in plastic surgery is poor communication.
Preoperative considerations for potential needs for later revision surgery
It is important to establish a revision fee structure prior to embarking on the initial surgery.
The principal blood supply to the nasal tip is provided by which of the following arteries in a patient who undergoes open rhinoplasty via a transverse columellar incision? A) Columellar B) Lateral nasal C) Posterior ethmoid D) Sphenopalatine E) Superior labial
B) Lateral nasal
Principal blood supply to the nasal tip following division of the columellar skin
The principal blood supply to the nasal tip following division of the columellar skin is the lateral nasal artery, a branch of the anterior ethmoid artery (internal carotid circulation).
When rhinoplasty is conducted via stepped incision in the external approach, the columellar artery, a branch of the superior labial artery (external carotid circulation) component, may be abolished by division or cautery.
Blood supply to the upper lip
superior labialartery
Blood supply to the posterior nasal septum
sphenopalatine artery
Blood supply to the upper central nasal septum
posterior ethmoid artery
Blood supply to the nasal tip
We conclude that nasal tip blood supply is derived primarily from the lateral nasal arteries, with a variable contribution from the columellar arteries. - Rohrich, 1995
A 45-year-old man comes to the office because of a chronic “stuffy nose” that is worse in the mornings than in the evenings. After decongestion, examination shows a slight posterior bony septal deviation, internal nasal valve angle of 12 degrees, and bilateral inferior turbinate hypertrophy. After a failed course of medical management, which of the following is the most appropriate single treatment? A) Alar batten grafts B) Flaring sutures C) Inferior turbinate reduction D) Septoplasty E) Spreader grafts
C) Inferior turbinate reduction
Most common cause of nasal airway obstruction
bilateral inferior turbinate hypertrophy
The normal internal valve angle is:
The normal internal valve angle is 10 to 15 degreesThe normal internal valve angle is 10 to 15 degrees
Commonest cause of nasal obstruction
Rhinitis is the common cause of nasal obstruction. Medical treatment should be instituted for turbinate hypertrophy before committing to surgery.
Pathogenesis of rhinitis
The most common type, infectious rhinitis, is nearly always caused by a virus (rhinovirus, or the common cold).
Another common cause of nasal obstruction is allergic rhinitis, which is an antigen-antibody reaction mediated by immunoglobulin E.
Treatment of allergic rhinitis
Another common cause of nasal obstruction is allergic rhinitis, which is an antigen-antibody reaction mediated by immunoglobulin E.
Many medication options are available for conservative medical management, each having its own specific indications for use. The most useful classes of medications include decongestants, second-generation antihistamines, cromolyn sodium nasal spray (mast cell stabilizer), nasal topical corticosteroids, ipratropium bromide nasal spray (anticholinergic), and corticosteroid injection of the inferior turbinate.
___________________ help with internal nasal valve collapse, but are not the most beneficial in this instance.
Spreader grafts and flaring sutures help with internal nasal valve collapse, but are not the most beneficial in this instance.
A 45-year-old woman is being evaluated because of discrete, red, facial capillaries that she would like to have removed. Which of the following lasers is most appropriate to ablate the vessels? A ) KTP (532-595 nm) B ) Q-switched ruby (694 nm) C ) Nd:YAG (1064 nm) D ) Er:YAG (2940 nm) E ) Carbon dioxide (10,600 nm)
A ) KTP (532-595 nm)
The 532-595 nm wavelength is the most appropriate choice, as it has the highest affinity for the vessels and can be more effective with the appropriate settings.
A 32-year-old man with no drug allergies is scheduled to undergo rhinoplasty with cartilage grafting. Which of the following is the primary prophylactic antibiotic of choice for this patient? A ) Cefazolin B ) Levofloxacin C ) Linezolid D ) Trimethoprim and sulfamethoxazole E ) Vancomycin
A ) Cefazolin
Primary periop antibiotic of choice for plastic surgery patients
Currently, 1 g of cefazolin administered 30 to 60 minutes prior to incision is the primary antibiotic choice in nonallergic patients for most plastic surgery procedures. For beta-lactam allergic patients, clindamycin is recommended as the prophylactic antibiotic of choice. For long (greater than 3.5 hours) or excessively bloody procedures, the recommendation is to consider an intraoperative (second) dose of cefazolin or clindamycin, respectively, not to administer vancomycin.
Indication for perioperative Vanc in plastic surgery patients
Vancomycin should be used only when absolutely indicated (high methicillin-resistant Staphylococcus aureus rate, one dose only)
A 36-year-old woman is scheduled to undergo secondary rhinoplasty to correct an inverted-V deformity. Which ofthe following operative steps is most likely to correct this deformity?
A ) Infracturing of the frontal processes of the maxilla
B ) Nasal bone rasping
C ) Placement of a spreader graft
D ) Resection of the caudal septum
E ) Weir excisions
C ) Placement of a spreader graft
In the scenario described, spreader grafts fashioned from septal cartilage can be used to correct this deformity. Spreader grafts can also restore an open roof deformity after aggressive hump reduction and recreate the dorsal aesthetic lines while simultaneously maintaining patency of the internal valve.
Cause of nasal inverted-V deformity
The inverted-V deformity is often attributed to avulsion of the upper lateral cartilages. It can also be caused by excessive removal of the transverse portion of the upper lateral cartilage during dorsal septal resection. When the transverse portion of the upper lateral cartilage is over-resected, collapse of the nasal sidewalls occurs with retraction of the upper lateral cartilage and exposure of the shape of the nasal bones in the keystone area.
Nasal hump deformity is usually corrected with:
Nasal hump deformity is usually corrected with nasal bone rasping.
Weir excisions
Weir excisions are resections of the alar bases used to reduce wide or flaring nostrils.
Resection of the caudal septum is used to:
Resection of the caudal septum is used to correct the hanging columella.
Osteotomy of the frontal process of the maxilla helps:
Osteotomy of the frontal process of the maxilla helps reduce or narrow a wide nasal bridge.
A 26-year-old man is referred for evaluation for nasal surgery. He is satisfied with the appearance of the nose, but he has difficulty breathing through it. A Cottle maneuver significantly improves the patient’s breathing. On examination, an anterior rhinoscopy is performed using a nasal speculum. No marked anatomic abnormalities are noted. Which of the following is the most appropriate management?
A ) Placement of a columellar strut
B ) Placement of a lateral crural strut
C ) Placement of a spreader graft
D ) Septoplasty
E ) Submucous resection of inferior turbinate
B ) Placement of a lateral crural strut
The Cottle maneuver test for:
The Cottle maneuver is performed by placing lateral traction on the cheek skin. This displaces the lateral nasal wall, thus opening the internal nasal valve.
Treatment for narrowed internal nasal valve
The most appropriate management for a narrowed internal nasal valve is the placement of a spreader graft to increase this angle.
Treatment for obstruction at external nasal valve
Lateral crural strut
Anterior rhinoscopy
An anterior rhinoscopy is the inspection of the anterior portion of the nasal cavity with or without the aid of a nasal speculum.
A 25-year-old man undergoes primary rhinoplasty and develops a septal hematoma. Which of the following is the most likely resulting nasal deformity? A ) Midnasal asymmetry B ) Pollybeak C ) Retracted columella D ) Saddle nose
D ) Saddle nose
Deformation following septal hematoma
Saddle nose deformity
Columella retraction after rhinoplasty
Columella retraction may result from over-resection of the caudal end of the septal cartilage and/or the nasal spine along with caudal rotation of the cartilaginous septum following overmobilization and/or vertical shortening.
A 45-year-old man is scheduled to undergo submucous resection septoplasty to correct left-sided nasal airway obstruction. Which of the following complications is most likely to occur if the surgeon uses a full-transfixion incision instead of a Killian (hemi-transfixion) incision? A ) Bilateral alar notching B ) Decreased tip projection C ) External nasal valve collapse D ) Middle nasal vault collapse E ) Saddle nose deformity
B ) Decreased tip projection
A full-transfixion incision can lead to:
A full-transfixion incision can lead to decreased tip projection, especially if dissected down over the anterior nasal spine. Support for the nasal tip is lost. A columellar strut can help add support.
Alar notching results from:
Alar notching results from over-resection of the lower lateral cartilages
External nasal valve collapse results from:
External nasal valve collapse results from weak or narrow lowerlateral cartilages and is addressed by the use of batton grafts
Middle nasal vault collapse is prevented by:
Middle nasal vault collapse is prevented by the use of spreader grafts.
How much caudal septum should be preserved in a submucous resection septoplasty.
Saddle nose deformity is created by over-resection of the dorsal septum. At least 10 mm of dorsal septum and 10 mm of caudal septum should be preserved in a submucous resection septoplasty.
A 35-year-old man has persistent numbness of the nasal tip three years after undergoing cosmetic rhinoplasty through an endonasal approach. Injury to which of the following nerves is the most likely cause of the numbness? A ) Anterior ethmoidal B ) Infraorbital C ) Infratrochlear D ) Supraorbital E ) Supratrochlear
A ) Anterior ethmoidal
The anterior ethmoidal nerve
The anterior ethmoidal nerve is particularly vulnerable to damage during endonasal rhinoplasty procedures. The nerve emanates from between the nasal bone and the lateral nasal cartilage, supplying sensation to the skin at the distal nasal dorsum and tip.
What provides sensation to the skin at the distal nasal dorsum and tip?
The anterior ethmoidal nerve
The infraorbital nerve - sensation to the nose
The infraorbital nerve supplies sensory enervation to the lower lateral half of the nose and columellar skin
The infratrochlear nerve - sensation to the nose
The infratrochlear nerve supplies the cephalic portion of the nasal sidewalls and the skin overlying the radix.
An open rhinoplasty that includes Weir resection for alar flare and tip modification is planned. Which of the following will decrease the risk of columellar flap necrosis?
(A) Limited lateral dissection above the alar groove
(B) Minimal dissection of the septal cartilage
(C) Minimal superior dissection of the osseocartilaginous framework
(D) No use of epinephrine in local anesthetic
(E) Use of only bipolar cautery during dissection
(A) Limited lateral dissection above the alar groove
Minimizing risk of loss to the nasal tip and columella
Limited dissection above the alar groove will spare injury to the lateral branch of the angular artery, which is one of five vessels contributing to the blood supply for the nasal tip and columella. However, it is the one source that could contribute to tissue loss if injured.
A 22-year-old woman undergoes an open tip septorhinoplasty. Which of the following arteries is the terminal blood supply to the skin envelope? (A) Angular (B) Columellar (C) Facial D) Lateral nasal (E) Superior labial
D) Lateral nasal
Lateral nasal artery
The lateral nasal artery, which is a branch of the angular artery, supplies the vascular arcade that keeps the nasal tip viable during an open tip septorhinoplasty
A 24-year-old man comes to the office because he has had difficulty breathing through the nose, particularly on forced inspiration, for the past six months. He underwent cosmetic rhinoplasty one year ago. He does not have seasonal allergies or sinus problems. Physical examination shows a small dorsal hump; the nose is otherwise aesthetically pleasing and well proportioned. Intranasal speculum examination shows the septum minimally deviated anteriorly to the left. Cottle maneuver is positive on the right. Which of the following is the most appropriate management?
(A) Placement of alar graft
(B) Placement of radix graft
(C) Placement of spreader graft
(D) Reduction of the component dorsal hump
(E) Resection of the submucous septum
(C) Placement of spreader graft
The patient described requires placement of a spreader graft to stent the right internal nasal valve. The Cottle maneuver confirms the presence of internal nasal valve pathology.
Treatment for collapse of internal nasal valve causing breathing problems (post-rhinoplasty)
spreader graft
Post-rhinoplasty treatment of overresection of the lower lateral cartilages/inspiratory collapse
The patient described requires placement of a spreader graft to stent the right internal nasal valve. The Cottle maneuver confirms the presence of internal nasal valve pathology.
A 35-year-old man comes to the office for consultation about a white spot on the tip of the nose. He first noticed it three months ago, and it has gradually become more prominent since then. He underwent rhinoplasty one year ago. Physical examination shows a 3-mm-diameter white area on the nasal tip between the medial crura. Gentle pressure on the surrounding skin makes the white area more prominent. Which of the following is the most likely diagnosis?
(A) Devascularization of the skin as a result of surgery
(B) Displacement of the caudal septum
(C) Fungal infection of the epidermis
(D) Growth of a squamous cell carcinoma
(E) Pressure on the skin of the nasal tip from a graft
(E) Pressure on the skin of the nasal tip from a graft
Although devascularization might show some skin discoloration, it is unlikely to be localized to a small spot.
Displacement of the caudal septum is not an appropriate response, because this usually causes problems with the columella, not the tip.
A 30-year-old woman comes to the office for consultation regarding aesthetic improvement of the nasal tip. Examination shows a narrow angulation of the lateral genu (dome) and a 90-degree angle of divergence of the middle crura with an intercrural distance of 8 mm. Which of the following is the most appropriate description of this variation? (A) Boxy tip (B) Lateral crus malposition (C) Narrow lobule (D) Nostril-lobular disproportion (E) Supratip deformity
(A) Boxy tip
The boxy tip has been described as a square perimeter of the nasal base that is caused by the position of the lower lateral cartilage. The angle of divergence of the middle crura (and their length) determines the intercrural distance. A wide angle of divergence results in the lateral positioning of the domes appearing like the corners of a box. An angle of divergence of 90 degrees would give a long intercrural distance and a boxy tip. The optimal angle of divergence is approximately 30 to 60 degrees, depending on the literature.
Optimal angle of divergence (nose)
30 to 60 degrees
A wide angle of divergence results in: (nose)
A wide angle of divergence results in the lateral positioning of the domes appearing like the corners of a box.
What determines intercrural distance?
The angle of divergence of the middle crura (and their length) determines the intercrural distance.
Type I boxy tip
- increased intercrural angle of divergence (greater than 30 degrees)
- normal domal arc (4 mm or less)
^^ manifesting as the tip-defining points
Type II boxy tip
- normal angle of divergence (30 degrees or less)
- a widened domal arc (greater than 4 mm)
- increased angulation of the domes of the lower lateral segments of cartilage
