Rhinoplasty Flashcards

Question 1

Q

Describe the 3 anatomic segments of the nose

Answer

A

Framework = osseocartilaginous vault
Support = ligaments and CT connecting frameowrk together
Coverage = skin and soft tissue lining

Question 2

Q

Describe features of the osseocartilaginous framework

Answer

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

Question 3

Q

What creates the dorsal hump

Answer

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

Question 4

Q

Define the tip lobular complex

Answer

A

Tip: transversely between tip defining point and vertically between supratip break and columellar break
Lobule: area covering over entire ala

Question 5

Q

Which aesthetic measurements help to guide correction the tip lobular complex

Answer

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

Question 6

Q

What is th eblood suppyl tot he nose

Answer

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

Question 7

Q

What is the sensory innervation of the nose

Answer

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

Question 8

Q

What forms Kiessaelbachs plexus

Answer

A

Superior labial artery
Anterior ethmoid
Sphenopalatine
Greater palatine

Question 9

Q

What are ideal nasal aesthetics are defined by Byrd

Answer

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>

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Question 10

Q

Describe your history and physical of a patient presenting for rhinoplasty

Answer

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

Question 11

Q

How do male and female noses differ

Answer

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

Question 12

Q

What are advantages and disadvantages of open vs closed rhinoplasty

Answer

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
*

Question 13

Q

Describe the open approach and closed approach

Answer

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

Question 14

Q

What are indications for open approach

Answer

A

revision
post-traumatic
cleft
wide, flat, underprojected tip
twisted nose deformity
moderate to substantial tip modification
severely thick skin

Question 15

Q

Describe technqiues for altering Framework (osseocartilaginous vault)

Answer

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

Question 16

Q

Describe nasal osteotomies

Answer

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

Question 17

Q

Indications and options for spreader grafts

Answer

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)

Question 18

Q

What are important sources of tip support

Answer

A

Anterior septal angle
Interdomal ligament
LLC attachment to accessory cartilages
aponeurosis b/w ULC and LLC
medail crural footplates on caudal septum

Question 19

Q

What are techniques for improveing the tip lobular complex

Answer

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)

Question 20

Q

Describe tip graft indications and options

Answer

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

Question 21

Q

What is the purpose of a submucous resectino

Answer

A

for correction of defomrities in the midseptum

to harvest cartilage for grafts

Question 22

Q

What is a normal ala-columell arelationship and what are deformities of this relationship?

Answer

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

Question 23

Q

How do you correct each of the deformities of the ala-columella deformities

Answer

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

Question 24

Q

How do you treat overactive DSN

Answer

A

Drooping tip wiht animation due to hyperactive DSN muscle

intraoral transection and trasnposition

Question 25

Q

How do you improve airflow obstruction w turbinate hypertrophy

Answer

A

turbinate outfrature
partial excision (FT anterior 1/3)
total inferior turbinectomy

Question 26

Q

What are complications post-rhinoplasty

Answer

A

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
*

Question 27

Q

What is th epolybeak deformity, causes and management

Answer

A

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

Question 28

Q

What r the short nose deformity features post rhinoplaty, causes and management

Answer

A

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

Question 29

Q

What are features of the non-caucasian nose and management

Answer

A

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

Question 30

Q

What are alloplastic materials availbale for augmentation rhinoplasty

Answer

A

Polyfluoroethylene (goretex)
High density polythylene (Medpor)
Plydioxane (PDS)
Irradiated homograft costal cartialge
Silicone
Acellular dermal matrix

Question 31

Q

List causes of supratip deformity post-rhinoplasty (polybeak)

Answer

A

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

Question 32

Q

What structures contribute to tip support

Answer

A

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

Question 33

Q

Question 34

Q

describe your general appraoch to open rhinoplasty

Answer

A

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 1^st 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

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Rhinoplasty Flashcards

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