Rhinoplasty Flashcards
1
Q
Describe the 3 anatomic segments of the nose
A
- Framework = osseocartilaginous vault
- Support = ligaments and CT connecting frameowrk together
- Coverage = skin and soft tissue lining
2
Q
Describe features of the osseocartilaginous framework
A
- Bony vault
- paired nasal bones
- paired frontal process of maxilla
- frontal bone and frontal bone spine
- Nasal bones flare at NF suture, narrow at NF angle and flare again at keystone
- Nasal bone is thickess at NF angle (level of medial canthus)
- Cartilaginous vault
- paired ULC - overlapped by nasal bones above (keystone) and by LLC below (Scroll area)
- supported by dorsal septal cartilage
3
Q
What creates the dorsal hump
A
mainly cartilage (60%), +/-nasal bone prominence (40%)
- Ideal Height of dorsum defined by Nasofacial angle measured from nasion to tip.
- In W, NF angle ideal 34 with slight concavity
- In M, NF angle ideal 36 and straight
- Ideal Width of dorsum defined by dorsal aesthetic lines - should be as wide as philtral colums
- Bony vault at base - max width - should be intercanthal distance
4
Q
Define the tip lobular complex
A
- Tip: transversely between tip defining point and vertically between supratip break and columellar break
- Lobule: area covering over entire ala
5
Q
Which aesthetic measurements help to guide correction the tip lobular complex
A
- Tip Rotation angle
- angle b/w columella and lobule
- Domal Divergeance angle
- angle b/w domes at domal junction
- Tip Projection
- AB- distance between alar cheek jx and tip
- max projection of upper lip vertically seperates the A (tip) and B(ala). A = 50-60% of AB
- Can be also determined by nasal length (Nasion-Tip). AT = 0.67Nasion-tip
6
Q
What is th eblood suppyl tot he nose
A
INTERNAL CAROTID
- Ophthalmic artery:
- anterior ethmoid
- posterior ethmoid
- External nasal
- Dorsal nasal
- Supraorbital
- SupraTrochlear
- Infratrochlear
EXTERNAL CAROTID
- Internal Maxillary
- Greater palatine
- Sphenopalatine
- Facial artery
- superior labial artery (columellar branches)
- lateral nasal branches
7
Q
What is the sensory innervation of the nose
A
- Nasociliary (V1)
- enters cavity within anterior ethmoid artery and is then names anterior ethmoid nerve
- gives off following:
- external nasal
- infratrochlear
- long ciliary
- posterior ethmoidal
- Nasopalatine (V2)
- enters cavity via sphenopalatine foramen
- gives off
- greater palatine n
8
Q
What forms Kiessaelbachs plexus
A
- Superior labial artery
- Anterior ethmoid
- Sphenopalatine
- Greater palatine
9
Q
What are ideal nasal aesthetics are defined by Byrd
A
- MFH <lfh>
</lfh><li>R-Ti = 0.67 MFH</li><li>Tip projection = 0.67 R-Ti</li><li>Nasofacial angle 30-36</li><li>Nasolabial angle M 90-95, W 95-105</li><li>Lobular columellar angle 30-45</li><li>columellar show 2-3mm below alar rim</li>
</lfh>
10
Q
Describe your history and physical of a patient presenting for rhinoplasty
A
HISTORY
- Expectations/Desires
- Function
- PMHX: allergic rhinitis, sinusitis, bronchitis, vasomotor rhinitis, nasal sprays, previous nasal trauma, surgery
PE - nasofacial analysis
- Skin type Fitz
- facial proportions
-
RADIX
- Nasofacial angle
- Radix position
-
DORSUM
- Dorsal aesthetic lines
- width, Height of dorsum
- ULC, Nasal bones
-
TIP
- Supratip break
- Projection, Rotation
- Symmetry, tip defining points
-
BASE
- alar base width
- ala collapse
- alar notching
-
INTERNAL
- septum
- turbinates
- INV
- donor material
11
Q
How do male and female noses differ
A
- Radix: NF angle less in Men
- Dorsum: no concavity to dorsum, 2mm behind parallel to R-Ti for female
- Supratip breask absent in Men
- Tip: less rotation, more bulbous
- Skin envelope - thicker in men
- Chin stronger - more projecting
12
Q
What are advantages and disadvantages of open vs closed rhinoplasty
A
OPEN
ADVANTAGES
- binocular visualization
- precise diagnosis of problem
- better control of bleeding
- tip work
- teaching
DISADVANTAGES
- longer OR
- prolonged tip edema, risk delayed healing
- tip paresthesia
- disruption of tip support
- external scar
- require graft suturing for placement
CLOSED
ADVANTAGES
- No external scar
- less OR time
- less tip edema, faster recovery
- precise pocket creation for graft material
- can be converted to open
DISADVANTAGES
- difficult visualizetion, control of bleeding
- relying on pre-op diagnosis
- difficult for tip modifications
*
13
Q
Describe the open approach and closed approach
A
OPEN
- Infracartilaginous incision and trasncollumelar incision
- LLC are visualized an sub SMAS tunnels are created to raise flap off UC and nasal bones (above perichondrium and periosteum
CLOSED
2 methods of addressign tip
- Transcartilaginous - 5mm above caudal end of LLC, incse through vestibule and LLC, performins lateral cephalic trim
- Delivery method - both infracartilaginous and intercartilaginous are performed and LLC dissected off superficial connections ot skin, LLC can then be delivered
14
Q
What are indications for open approach
A
- revision
- post-traumatic
- cleft
- wide, flat, underprojected tip
- twisted nose deformity
- moderate to substantial tip modification
- severely thick skin
15
Q
Describe technqiues for altering Framework (osseocartilaginous vault)
A
-
Dorsal Hump reduction
- Bony vault - rasp or osteotome for reduction
- Cartilaginous Septum - seprated ULC from septum to prevent mucosal tears, then using knife or serrated scissors, reduce cartilage
-
Nasal Osteotomies
- Indicated - wide bony base, open roof, asymmetry
- Contraindicated - nasal bone length <25% of R-Ti, elderly, wears glasses
- Classified as percutaneous, intranasal,
- Classifed by techqniue: lateral, medial, transverse, combo
-
Radix lowering
- NF jx needs to descend- can be done with burr
16
Q
Describe nasal osteotomies
A
- Lateral
- Low-to-low
- Low-to-high - low at frontal process and towards radix
- double level
- Medial
- oblique
- paramedian
- transverse
If minimal to moderate movement if required
- low to high osteotomy and infracture greenstick (cut toward level of medial canthus) -leaving bone hinged
If major movement is required
- low to low and medial oblique osteomtoy
17
Q
Indications and options for spreader grafts
A
Indications
- correct INV colapse
- correct inverted V deformity
- prevent collapse post dorsal reduction
- widen/correct dorsal aesthetic line asymmetry
Options
- created from cartilage graft (ideal 25x3x1mm)
- autospreader grafts (created from ULC)
18
Q
What are important sources of tip support
A
- Anterior septal angle
- Interdomal ligament
- LLC attachment to accessory cartilages
- aponeurosis b/w ULC and LLC
- medail crural footplates on caudal septum
19
Q
What are techniques for improveing the tip lobular complex
A
Suturing
- Transdomal - within one dome - to improve tip definition, projection
- Interdomal - between 2 domes - tip definition, narrow tip, improve symmetry, projection
- medail crural - narrow columella, secure strut grafts
- lateral crural - reduce lateral crural convexity
- columella-septal - increase ROTATION, projection, elevate hanging columella
Resection
- lateral crural resection (cephalic trim) => increase ROTATION, improve tip definign points, weaken alar support, decrease tip projection
Augmentation (grafts)
20
Q
Describe tip graft indications and options
A
INDICATIONS
- increase tip defining points
- increase tip projection
OPTIONS
- Onlay (Peck)
- Infratip Shield (Sheen)
- combination
Support increased with
- alar batten graft - along lateral crura
- alar rim graft- non anatomic ot prevent inched tip/ENV collapse
- septal extension - secured to septum
- columella strut - secured in columella pocket
21
Q
What is the purpose of a submucous resectino
A
for correction of defomrities in the midseptum
- to harvest cartilage for grafts
22
Q
What is a normal ala-columell arelationship and what are deformities of this relationship?
A
Ala columela - draw line along long axis of nostril - alar rim and columela show be within 1-2mm of this long axis
Hanging columella - increased inferior distance
Retracted ala - increased superior distance w/r/t long axis of nostril
Or both
Hanging ala - decreased superior distance
Retracted columella - decreased inferior distance
Or both
23
Q
How do you correct each of the deformities of the ala-columella deformities
A
Hanging columella - resection of caudal septum, medial or middle crura
Retracted ala - release Lateral crura from accessory cartilage or place graft between lateral and middle crus to lower retraction
If both, do both
Hanging ala - excision of ellipse of ?vestibular skin
Retracted columella - columell astrut graft placed in subcut pocket
24
Q
How do you treat overactive DSN
A
Drooping tip wiht animation due to hyperactive DSN muscle
- intraoral transection and trasnposition
25
How do you improve airflow obstruction w turbinate hypertrophy
* turbinate outfrature
* partial excision (FT anterior 1/3)
* total inferior turbinectomy
26
What are complications post-rhinoplasty
**Traumatic**
* L strut fracture
* cribiform plate f#, CSF leak
* lacrimal sac/NF duct injury
**Infectious**
* cellulitis
* abscess
* TSS
**Functional**
* INV, ENV collapse
* synechiae
* vestibule stenosis
* septal perforation
**Aesthetic**
* dorsum, tip deformity, asymmetry
* lack of tip definition
* deviation
* alar notching, retraction
* Invester V, polybeak, Rocker deformity
**Hemorrhage**
* septal hematoma
* epistaxis
**Soft tissue**
* prolonged edema
* scar retraction/HTS
* skin nerosis
*
27
What is th epolybeak deformity, causes and management
Polybeak = convexity at supratip due to dorsal hump and underrotation of tip
Causes
* under resection of distal septum
* loss of tip projection
* poor soft tissue redraping - leading to supratip fullness
Management
* Thin skin - reduce dorsal hump, cephalic trim of lateral crura (will increase tip rotation)
* Thick skin - augment tip and dorsum
28
What r the short nose deformity features post rhinoplaty, causes and management
Features of short nose complx
* Short RTi distance (\<0.67 MFH)
* Over rotated tip, Nasolabial angle \>110
* increased nostril show
Causes
* All that reduces Rti: over resection of dorsum/caudal septum, cephalic LLC trim
* all that increase NL angle: columella strut, tip graft
Mangement
* release ST at ULC/LLc jx, septum ULC and allow ti pto descend
* Graft: dorsum, septal extension graft, infratip graft
* Ala columella release
29
What are features of the non-caucasian nose and management
Asian and africian features
* flat nasal dorsum
* lack of tip defining point
* short columella
* flared nostrils, slanted
Mangement
Asian: dorsal augmentation, alar wedge excisions
Africain: dorsal augmentation, lengthen columella and increase tip projection, alar rim excisions, or interalar narrowing w cinch suture
30
What are alloplastic materials availbale for augmentation rhinoplasty
* Polyfluoroethylene (goretex)
* High density polythylene (Medpor)
* Plydioxane (PDS)
* Irradiated homograft costal cartialge
* Silicone
* Acellular dermal matrix
31
List causes of supratip deformity post-rhinoplasty (polybeak)
* over resection of caudal septum =\>augment
* under resection of dorsal septum or supratip sseptum=\>resect
* excessive narrowing- collapse of ULC =\> spreader graft
* excessive nasal width =\>infracture
* residual fat/thick tip skin
32
What structures contribute to tip support
* Anterior septal angle
* Abutment to pyriform via accessory cartilage
* **Medial crural foot plate attachment to quadrangular cartilage**
* interdomal ligament
* **ULC aponeurosis**
* **alar cartilage size and shape**
* cartilaginous dorsum
* membranous septum
* alar cartialge atatchment to skin
* nasal spine
33
34
describe your general appraoch to open rhinoplasty
## Footnote
DECONSTRUCTION
·Incisions: type of columellar (usu. stair-step, vs. “V”) and lobule incision (infra-cartilaginous along columella, dome, laterally)
oOther lobule incisions: marginal, inter-cartilaginous, intra-cartilaginous
·Elevation: elevate the skin envelope in submuscular plane, extramucosal tunnels (reflecting the mucosa off the upper septum and beneath the osseocartilaginous vault), release of ULC from cephalic septum
·Release interdomal ligament
·Expose septum – Transfixation (or hemi-transfixion) incision and submucous dissection
·Re-Assessment: desired tip projection, distortion to nasal base from LLC (tripod), hump, deviation/symmetry
REDUCTION
·Dorsal hump reduction – bone rasp, cephalic septal trim (Many say do bony dorsum 1st to characterize extent of cephalic cartilaginous excess; JF does cartilage dorsum before bony dorsum; includes reduction of cephalic cartilaginous septum if indicated)
oIsolate ULCs from septum to avoid mucosal tear
oConsider: tip projection adequate/excessive à dorsal reduction first vs. tip projection inadequate à tip first
·Submucous cartilaginous resection (maintain \>10-15mm dorsal strut / L-strut) (ie septoplasty and septal harvest)
oIndication
§ Midseptal obstructive deformities (remaining cartilage can then be realigned by septoplasty techniques)
§ Harvesting septal cartilage for grafts
§ Septal deviation
·Osteotomies
oWhy? To narrow bony vault; Correct bony asymmetry; Close open roof after dorsal hump reduction (if wide bony vault, otherwise onlay graft)
oWhy not (relative c/i): Short nasal bones (\< ¼ the distance from radix to septal angle);When the internal nasal valve is narrow (less than 10 degrees); Thin nasal bone in elderly; Patient with eyeglasses
oApproach: intra-nasal vs. percutaneous
oType: low-low (most-common), low-high, double level
§ Osteotome inserted through small cut at piriform aperture, up to (but never across) medial canthus, apply digital pressure to mobilize lateral nasal wall
oReasons why osteotomy site may not move
§ A wide septal border
§ Inadequate fracture of the nasal root
§ A deviated septum
§ Interposition of soft tissues
·Cephalic trim (_\>_ 6-7mm caudal LLC remains); reduces tip fullness and increases the definition of the dome projecting points
·Reduction of LLC (at base) and/or medial crura footplate
·Re-Address dorsal hump reduction
CONSTRUCTION
·Grafts can improve tip projection when manipulation of the existing cartilages alone fails
·Septal cartilage is the best choice, followed by ear (rib is reserved for major reconstructive procedures)
·Spreader graft
oCan be made to augment dorsum, create supratip break, and define tip
oWhy? Restore patency of INV; prevent collapse after dorsal reduction; Correct “inverted-V” deformity; Primary rhino – thin bones, short weak cartilages (likely to collapse); Secondary rhino – collapsed ULC or asymmetry (e.g. cleft lip noses)
oIdeally from septum, 25x3x1mm; consider auto-spreader flap from medial portion of now excess ULC
·Lateral crural strut (or batten or both) - add support to the lateral crus
·Columellar strut: maintain projection after dissection of open approach, may increase projection 1-2mm (placed between two medial crura)
·Tip refining sutures
·Increased tip projection 1-2mm; refine tip and improve definition (often depends on how tightly they are tied)
o **Medial crural** (horizontal mattress between medial crura)
§ narrow columella, decrease infratip flare, secure strut grafts
o **Transdomal** (between medial & lateral portions of a single LLC)
§ decrease bulbosity, refine tip, slightly increase projection
o **Interdomal** (between domes of two LLC)
§ narrow tip, improve projection, strengthen tip, improve symmetry, improve infratip projection
o **Medial crural septal** (between medial crura and caudal septum)
§ unify medial crura, often used with columellar strut, slight increased projection
·Tip defining grafts
oRectangular tip onlay (Peck)
oShield Infratip lobule (Sheen)
oCombination graft (Rohrich)
oProjection & angularity at the dome (Peck, Sheen)
oAngulation at the columella-lobule junction (Sheen)
oAdd additional support to the medial crura-columella area
·[Dorsal augmentation]
·Autologous – Septal, auricular, costal, irradiated cartilage, diced/morselized; Can be covered with ADM, dermal graft
·Alloplastic – silicone, PTFE, MedPor
