Rhinoplasty - Septoplasty Flashcards
A 19-year-old man has numbness of the left lower lip four weeks after undergoing transoral placement of a Silastic chin implant. Physical examination shows superior displacement of the left wing of the implant. Which of the following is the most appropriate management?
(A) Injection of a corticosteroid
(B) Massage
(C) Observation
(D) Reoperation
(E) Taping
The correct response is Option D.
Reoperation should be done as soon as possible. The implant should be surgically revised to remove pressure on the mental nerve caused by superior displacement of the implant. In a patient with numbness, leaving an implant in place for eight weeks or more may lead to permanent loss of sensation due to fascicular pressure and may require nerve repair.
Observation without intervention could lead to permanent injury. Taping of the chin is unlikely to be effective and may put additional pressure on the mental nerve. Massage and corticosteroid injection are not appropriate because they would not correct the underlying problem and would delay surgery, which could lead to permanent injury.
A 35-year-old woman comes to the office for correction of an irregularity of the nasal dorsum following rhinoplasty performed 1 year ago. The patient wants nonsurgical treatment. Hyaluronic acid filler (0.6 mL) is injected into the upper third of the nasal dorsum. Immediately after injection, the patient reports partial loss of vision and pain in the right eye. Which of the following is the most appropriate next step?
A) Application of apraclonidine eye drops
B) Intravenous infusion of tissue plasminogen activator
C) Nasal subcutaneous injection of hyaluronidase
D) Percutaneous lateral canthotomy
E) Retrobulbar injection of hyaluronidase
The correct response is Option E.
This patient has symptoms of an intravascular injection of hyaluronic acid (HA) causing occlusion of the central retinal artery. This complication is extremely rare; however, when it occurs, treatment must be immediately instituted because the retinal circulation needs to be restored quickly (within 60 to 90 minutes) for possible reversal of symptoms.
The first line of treatment is to bathe the retinal circulation with hyaluronidase. This is achieved with a retrobulbar injection. Using a 25-gauge needle or cannula, enter the orbit along the orbital floor between the inferior and lateral rectus muscles. Advance the needle along the orbital for at least 1 inch beyond the orbital rim and inject 2 to 4 mL of undiluted hyaluronidase. Hyaluronidase adjacent to an occluded vessel can dissolve an HA embolus.
The likely mechanism of vascular occlusion is an intra-arterial injection of filler under pressure. In this case, the filler would have entered the dorsal nasal artery and traveled retrograde to the ophthalmic artery. Once the injection pressure is released, the filler would then flow antegrade into the central retinal artery which is the terminal branch of the ophthalmic artery.
Tissue plasminogen activator would be indicated for hematologic thrombosis or blood clot embolism, not HA embolus.
Subcutaneous injection of hyaluronidase is indicated for treatment for filler-related vascular compromise secondary to extravascular compression. The goal is to dissipate the extravascular compression of the artery. However, in patients with symptoms of vision loss, the likely diagnosis is a HA embolus and therefore the first injection should be retrobulbar.
Lateral canthotomy is indicated for decompression or a retrobulbar hemorrhage. Reassurance is not a reasonable treatment option as this is an emergency. Apraclonidine is a sympathomimetic eye drop use to stimulate Müller muscle and improve botulinum toxin type A–related ptosis.
A 21-year-old man comes to the office because of difficulty breathing through the left nostril after he was struck in the nose during a soccer game 1 year ago. He had a nosebleed at the time but did not seek medical treatment. Physical examination shows a depressed left nasal sidewall and a buckle in the nasal septum. He has increased difficulty breathing through the left naris when the right naris is occluded, although the nostril appears open. The right nasal passage is widely patent. Closed rhinoplasty with septoplasty is planned. In addition to submucous resection of septal cartilage, which of the following is the most appropriate technique for correction of the nasal airway obstruction?
A) Lateral osteotomies with a right spreader graft
B) Left lateral osteotomy with a columellar strut
C) Left lateral osteotomy with a left spreader graft
D) Medial osteotomies with bilateral spreader grafts
E) TRight medial osteotomy with a left alar batten graft
The correct response is Option C.
Fracturing the nose with medial and lateral osteotomies is necessary to mobilize the bony nasal pyramid and correct the collapsed left nasal bone by out-fracturing it. A left spreader graft is also necessary to keep the left internal nasal valve open and prevent the left nasal bone from collapsing and recurrence of the deformity.
A spreader graft is not necessary on the right because the right nasal passage is widely patent. Placing bilateral spreader grafts would give the nasal dorsum a wide appearance and is not required.
Since the rhinoplasty was performed through a closed technique, the columella is not destabilized, which can happen during the open rhinoplasty technique. A columellar strut is not necessary.
The patient has left internal nasal valve collapse, not external nasal valve collapse. An alar batten graft is not indicated in this situation.
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.
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.
A 19-year-old man has nasal obstruction on the left. Physical examination shows hypertrophy of the inferior turbinate. Which of the following is the most appropriate next step in management?
(A) Cottle test
(B) Evaluation for deviated septum
(C) Cephalography
(D) Needle biopsy
(E) Secretory IgA assay
The correct response is Option B.
The most appropriate next step in the management of this 19-year-old man with turbinate hypertrophy is evaluation for septal deviation. Because turbinate hypertrophy is also associated with nasal allergies, it is important to determine the underlying cause of the condition in order to appropriately treat it without causing excessive drying of the nasal mucosa and hemorrhage. The coronal CT scans shown above depict hypertrophy of the left inferior turbinate in a patient who has a mild septal deviation.
The Cottle test is used to diagnose collapse of the internal nasal valve, which is found at the junction of the septum and upper lateral cartilage. The caudal end of the upper lateral cartilage typically forms a 10- to 15-degree angle with the septum; if the angle is less than 10 degrees, air exchange is likely to be obstructed. The Cottle test is performed by placing lateral traction on the paranasal skin of the left cheek, which will distract the upper lateral cartilage away from the septum and open the angle of the internal nasal valve.
Cephalograms are used to identify disproportionate areas of the craniofacial skeleton in patients being considered for orthognathic surgery. The sella-nasion-point A (SNA) and sella-nasion-point B (SNB) angles are measured with this technique. Cephalograms would not be used to measure the inferior turbinates.
Needle biopsy is indicated only in rare instances in patients with intranasal malignancies, which are uncommon. In a patient who is suspected of having a neoplasm of the head and neck, direct nasal endoscopy and CT scans of the head are recommended.
Secretory IgA assay is not used in the diagnosis of turbinate hypertrophy.
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.
A 30-year-old man is undergoing evaluation for rhinoplasty. He has a 20 pack/year history of cigarette smoking and says that he has difficulty breathing through his nose. Evaluation of this patient’s breathing difficulties should address each of the following anatomic structures EXCEPT the
(A) dorsal nasal hump
(B) internal nasal valve
(C) nasal septum
(D) nasal vestibule
(E) turbinates
The correct response is Option A.
In a 30-year-old man who has breathing difficulties, the internal nasal valve, nasal septum, nasal vestibule, and turbinates should be evaluated. Obstruction can result from collapse or narrowing of the internal nasal valve that occurs as a result of scarring or excessive resection of cartilage. Deviation or perforation of the septum can cause obstruction or turbulent air flow; however, it is common to have significant septal deviation with no obstructive symptoms. The position of the nostrils and nasal vestibule may also affect breathing; ptosis of the nasal tip or an obtuse nasolabial angle can cause turbulent air flow. In addition, the middle and inferior turbinates regulate breathing. Chronic hypertrophy of the inferior turbinate is the most common cause of obstruction in a patient who has had no trauma or previous surgery. If this condition does not resolve with topical administration of decongestant agents, turbinectomy should be considered. Obstruction of the nasal passages may also be caused by vasomotor or allergic rhinitis and exposure to cigarette smoke or other environmental toxins.
The dorsal nasal hump is a bony and cartilaginous prominence that does not affect internal nasal air flow.
In a worm’s eye view of the Caucasian nose, which of the following is the most common ratio of the lobular portion of the nose to the columella?
(A) 3:1
(B) 2:1
(C) 1:1
(D) 1:2
(E) 1:3
The correct response is Option D.
The lobular portion of the nose from the worm €™s eye view should be in a 1:2 ratio with the columella and nasal apertures. The lobular portion comprises one third and the collumellar portion comprises two thirds of the total distance from the tip to the base. The nostrils should have a teardrop configuration with the diameter of the base slightly larger than the diameter of the apex. The long axis of each nostril points in a slight medial direction.
A 40-year-old woman undergoes rhinoplasty for correction of boxy tip deformity. Which of the following is the primary purpose of a transdomal suture during this procedure?
(A) Decrease in tip projection
(B) Improvement of columellar projection
(C) Narrowing of the domes
(D) Rotation of the tip
(E) Strengthening of the tip
The correct response is Option C.
Transdomal sutures are horizontal mattress sutures placed at the dome or in the lateral crus of the lower lateral cartilage during tip rhinoplasty. The primary purpose of the transdomal suture is to narrow the domes. The secondary purpose of the transdomal suture is to narrow the convexity of the lateral crura. At times, the transdomal suture may also have a tertiary effect of slight increase in tip projection.
Regarding suture technique for tip rhinoplasty, columellar projection and tip projection are more commonly affected by the interdomal suture. The columella-septal suture rotates the tip. Both the interdomal and columella-septal suture strengthen the tip. Both interdomal and transdomal sutures may control tip symmetry.
A 32-year-old woman is evaluated for rhinoplasty. In the course of evaluation, the Cottle maneuver is performed. This test is most likely performed to evaluate which of the following?
A) Collapse of the external nostrils
B) Hypertrophy of the inferior turbinate
C) Patency of the internal nasal valves
D) Presence of septal perforation
E) Septal mucosal thickening
The correct response is Option C.
Nasal airway obstruction is a common symptom among patients presenting for rhinoplasty. Evaluation of the nasal airway should be performed in all patients presenting for rhinoplasty. The key structures that affect nasal airflow include the external and internal nasal valves, the inferior turbinates, and the nasal septum. The patient should be examined for collapse of the external nasal valves on deep inspiration, and a Cottle maneuver should be performed to evaluate patency of the internal nasal valves. Internal nasal examination is aided with the use of a nasal speculum. Oxymetazoline nasal spray facilitates mucosal constriction if mucosal edema is present. Narrowing or collapse of the internal valves with inspiration should be noted, along with inferior turbinate hypertrophy, which typically occurs on the side opposite septal deviation.
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.
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.
Resection of the cephalic borders of the alar cartilages and caudal septum during rhinoplasty is most likely to have which of the following effects?
(A) Decrease the alar flare
(B) Lengthen the nose
(C) Lower the columella
(D) Move the tip cephalad
(E) Shorten the nasal bones
The correct response is Option D.
Resection of the cephalic borders of the alar cartilages and caudal septum is frequently done by directly accessing anatomic structures during open rhinoplasty or by intracartilaginous, infracartilaginous, marginal, or transfixion incisions when an intranasal approach is used. Cephalad resection of the lateral alar crus moves the tip of the nose cephalad, decreases its fullness, and increases the definition of the projecting points of the dome. During this surgery, care should be taken to avoid weakening the support of the nostril arch by overresecting.
The other effects listed do not occur with resection of the cephalic borders of the alar cartilages and caudal septum during rhinoplasty. Alar wedge (Weir) resection is commonly used to decrease alar flare. Resection of the caudal septum usually shortens the nose by allowing the tip of the nose to move cephalad with minimal change in the nasolabial angle. This maneuver also raises the columella relative to the alar margin and makes the upper lip appear longer. The nasal bones are not affected by manipulation of the soft-tissue tip-lobule complex.
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
The correct response is Option B.
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. The other options described supply blood to the posterior nasal septum (sphenopalatine artery), the upper lip (superior labial artery), and the upper central nasal septum (posterior ethmoid artery).
A 36-year-old woman comes to the office because she has persistent difficulty breathing through the nose two years after having rhinoplasty. Examination shows a deviated dorsum and an open roof deformity. Which of the following is the most appropriate method of reconstruction?
(A) Alar batten graft
(B) Columellar strut
(C) Dorsal onlay graft
(D) Lateral nasal wall graft
(E) Spreader grafts
The correct response is Option E.
Spreader grafts are usually paired and longitudinal, placed between the dorsal septum and the upper lateral cartilages in a submucoperichondrial pocket. Spreader grafts 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.
Alar batten grafts are nonanatomic grafts placed in a pocket extending from the piriform aperture to a paramedian position in the alar sidewall at the site of maximal, lateral, nasal wall collapse during inspiration.
The columellar strut helps maintain tip support and increase tip projection and also aids in shaping the columellar-lobular angle.
Dorsal sidewall onlay grafts are placed along the lateral side of the nose and are different shapes and sizes depending on the indications. They are used to combat localized lateral depressions or asymmetries of the body of the nose and especially to camouflage collapse of the upper lateral cartilages.
The lateral nasal wall graft is placed in an undermined pocket between the undersurface of the lateral crus and the vestibular skin; it is stabilized by suturing it to the crus. It is used to correct alar retraction, alar rim collapse, and concave, convex, or malpositioned lateral crura.
A 38-year-old man is evaluated because of nasal airway obstruction. The obstruction has been present since he underwent functional septorhinoplasty 9 months ago. Acoustic rhinometry shows external nasal valve collapse. Which of the following is the most effective treatment of this patient’s condition?
A ) Alar batten grafting
B ) Butterfly grafting
C ) Flaring sutures
D ) Splay grafting
E ) Spreader grafting
The correct response is Option A.
The most common treatment for the repair of external nasal valve collapse is the placement of alar batten grafts. These grafts help to augment and strengthen the weakened or absent lateral crus of the lower lateral cartilage. Dysfunction of the external nasal valve is most often seen after overresection of the lateral crus of the lower lateral cartilage from a previous rhinoplasty, in an attempt at tip modification. Butterfly grafts, flaring sutures, splay grafts, and spreader grafts and flaps are used to correct internal nasal valve collapse.
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.
A patient comes to the office because he is interested in rhinoplasty. He is generally satisfied with the shape of his nose when he is in repose, but he says that his nose becomes distorted when he laughs or talks. Which of the following muscles is the most likely cause of this finding?
A) Corrugator supercilii
B) Depressor septi nasi
C) Levator labii alaeque nasi
D) Orbicularis oris
E) Procerus
The correct response is Option B.
The depressor septi nasi originates on the upper lip and inserts at the base of the nose on both the septum and alae. When this muscle contracts in animation, it may pull the tip of the nose down, decrease the nasolabial angle, and elevate the upper lip. The labii alaeque nasi dilates the nostrils and lifts the upper lip. The procerus muscle lies between the eyebrows and functions to depress the medial eyebrows. Contraction creates the horizontal wrinkle at the nasion. Finally the corrugator supercilii is a pyramidal shaped muscle on the medial part of the supraorbital ridge which, when contracted, moves the eyebrows medially creating vertical wrinkles between the eyes.
A 17-year-old woman wants improvement of a large dorsal hump, hanging columella, and bulbous tip with vertically oriented lower lateral cartilages. The patient refuses the use of septal cartilage grafts. Which of the following surgical maneuvers will best avoid a dorsal inverted V deformity?
A) Internal silicone splint
B) Lateral crus mattress suture
C) Subdomalgraft
D) Tongue-in-groove tip support
E) Upper lateral spanning sutures
The correct response is Option E.
The inverted V deformity refers to the visibility of the caudal edge of the nasal bones caused by collapse of upper lateral cartilages. Dorsal reduction rhinoplasty removes the structural support provided by the connection of the dorsal septum to the paired upper lateral cartilages. The lateral cartilages have a tendency to then splay, distort, and collapse posteriorly. This can narrow the internal nasal valve and cause airway narrowing as well as aesthetic distortion of the dorsal aesthetic lines. Following takedown of a dorsal hump, upper lateral spanning sutures are used to re-establish the proper relationship of the dorsal medial edges of the upper lateral cartilages and the septum.
Use of spreader grafts will also re-establish this anatomy; however, it requires harvesting cartilage from the septum, more extensive surgery, and increased complications. In patients who require a wider angle at the internal nasal valve, the excess dorsal aspect of the upper lateral cartilages can be folded over on itself to create its own spreader graft, avoiding the need for a septal graft.
Tongue-in-groove refers to overlapping the medial crura onto the caudal septum. With an adequate caudal septum, this replaces the need for a columella graft but it will not effectively prevent inverted V deformity.
A subdomal graft is used to control the shape of the nasal tip. The cartilage removed from the dorsal hump can be used for this purpose without formal septal harvesting but the risk for a dorsal inverted V deformity does not change.
Lateral crus mattress sutures are used to straighten a concave or convex lateral crus.
Internal nasal splints are used to provide temporary postoperative support of the septum following septoplasty.
Which of the following regions accounts for the most marked contribution to total nasal airflow resistance?
A) Choanae
B) Internal nasal valve
C) Keystone area
D) Middle meatus
E) Nasal alae
The correct response is Option B.
The septum, the caudal border of the upper lateral cartilage, the pyriform aperture, and the anterior border of the inferior turbinate define the internal nasal valve. It is the narrowest portion of the nasal airway and accounts for approximately 50% of nasal airway resistance.
The entrance to the nostril is not an area of resistance in particular; however, the inner nostril can contribute to resistance particularly in the secondary rhinoplasty patient or a patient with weak lower lateral cartilages. This area is called the external nasal valve and is bounded by the caudal edge of the lateral crus of the lower lateral cartilage, the soft-tissue alae, the membranous septum, and the nostril sill.
The majority of airflow in the nose is through the middle meatus. It exits through the choanae posteriorly into the nasopharynx.
The choanae can be a source of resistance in the case of congenital choanal atresia where this region is blocked by bone or soft tissue. This would typically present shortly after birth.
The keystone area is the junction of the bony and cartilaginous septum with the bony dorsum. It is a structural landmark and does not describe a region of airflow.
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
The correct response is Option B.
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 over-resection of the lower lateral cartilages.
External nasal valve collapse results from weak or narrow lower lateral cartilages and is addressed by the use of batton grafts.
Middle nasal vault collapse is prevented by the use of spreader grafts.
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.
Which of the following deformities in a patient with nasal airway obstruction is best treated with a spreader graft?
A) Bulbous tip
B) Dorsal nasal hump
C) External orifice laxity
D) Inferior turbinate hypertrophy
E) Internal nasal valve narrowing
The correct response is Option E.
All of the options can create decreased airflow on inspiration and can be improved with surgical maneuvers. The spreader graft placed between the septum and upper lateral cartilages is used to increase the internal nasal valve angle, thereby increasing inspiratory nasal air flow. Septal deviation could cause airway obstruction, but would best be treated with a septoplasty to remove septal cartilage narrowing the airway on the affected side. Significant inferior turbinate hypertrophy would be treated surgically with either fracture or resection, and external skin laxity or external nasal valve collapse would best be treated with stabilization using a cartilage graft on the lateral alar segment. Placing a spreader graft to widen the internal valve would not improve airflow in any of the other choices. Dorsal nasal hump and bulbous tip are not addressed by this maneuver.
An otherwise healthy, 40-year-old woman has a nasal deformity requiring reconstruction. A composite auricular graft is planned. Problems in which of the following anatomic areas of the nose will most likely benefit from this kind of reconstructive method?
A) Dorsum
B) Internal nasal valve
C) Sidewall
D) Tip
E) Vestibular lining
The correct response is Option E.
The anatomic area of the nose where a composite auricular graft would most likely be used is in the vestibular lining. In the event of alar retraction secondary to vestibular lining shortage, composite grafts have proven to be very effective in providing cartilaginous support in addition to lining. Alar retraction is caused by a shortage of vestibular lining. This shortage may be intrinsic, but more often it is secondary to contraction from scarring or prior surgery. If the alar retraction is caused by a shortage of vestibular lining, replacement or recruitment of nasal lining is required for adequate correction. The auricular composite graft is one method of replacing vestibular lining while also providing cartilaginous support. Following harvest of a composite graft of conchal cartilage and skin, an incision is placed within the vestibule parallel to the alar rim in the area of deficiency. Dissection is carried out to release scarring and facilitate mobility for caudal repositioning of the alar rim. The composite graft is then placed as an intervening graft within the incision and sutured in place.
The other options are usually not areas where such grafts are used.
A 40-year-old man is referred for evaluation 1 year after undergoing rhinoplasty because he reports losing the sense of taste and smell. The patient states that this “complication of surgery” is affecting him in his daily activities. The patient’s inability to smell which of the following items most likely indicates that he is malingering?
A ) Alcohol
B ) Ammonia
C ) Cinnamon
D ) Licorice
E ) Mint
The correct response is Option B.
Although there are many prefabricated tests for anosmia, they all eventually rely on the fact that a patient who has olfactory disturbances can still identify irritants recognized by the trigeminal nervous system, eg, ammonia. In a recent study, malingering was found to be highly associated with self-reporting loss of smell and taste, involvement in litigation, and a report of broad negative effect on daily activities.
The internal nasal valve is comprised anatomically of the septum and which of the following structures?
(A) Caudal edge of the upper lateral cartilage and pyriform aperture
(B) Inferior turbinate and nasal floor
(C) Nasal floor and caudal edge of the upper lateral cartilage
(D) Pyriform aperture and vomer
(E) Vomer and inferior turbinate
The correct response is Option C.
The internasal nasal valve is a triangular shaped passage that is comprised of the septum, the nasal floor, and the caudal portion of the upper lateral cartilage. Patency of the internal nasal valve is crucial for breathing. The normal angle of the internal nasal valve is 10 to 15 degrees; if the angle is less than 10 degrees, airway occlusion at the internal nasal valve may result. Insertion of spreader grafts, which are stick-like strips of cartilage, is recommended to open the angle and improve the airway. The grafts are placed submucosally between the dorsum of the septum and the upper lateral cartilage. In contrast, infracture of the nasal bones will only narrow the angle and worsen breathing.
A 23-year old man comes to the office for follow-up examination four months after undergoing rhinoplasty and horizontal sliding osseous genioplasty with miniplate fixation. He says he has noticed increasing show of his lower teeth since the surgery. Physical examination shows ptosis of the lower lip and a deep inferior gingivobuccal sulcus. Which of the following is the most likely cause of these findings?
(A) Excessive traction by the digastric muscle
(B) Inadequate fixation of the osteotomy segment
(C) Inadequate repair of the mentalis muscle
(D) Injury to the marginal mandibular nerve
(E) Injury to the mental nerve
The correct response is Option C.
The patient described has a witch €™s chin deformity as a complication of a lower buccal sulcus incision for access during an osseous genioplasty. In making this incision, the mentalis muscle is divided. Leaving a cuff of muscle superiorly is helpful because it provides a good tissue base for suturing the muscle when closing the incision. This closure of the muscle helps to resuspend the soft tissue of the chin and prevents ptosis of the lower lip and soft tissues.
Excessive traction by the digastric muscle and inadequate fixation of the osteotomy segment are not likely causes for the findings in the patient described. Miniplate fixation should provide adequate fixation to the osteomy segment. Furthermore, relapse or traction of the osteotomy segment would not account for all of the findings in the patient described.
Injury to the marginal mandibular nerve is not likely to have caused the findings in the patient described because it is not in the field of dissection for the procedure.
Injury to the mental nerve would cause numbness of the lower lip on the side of the injury and would have no effect on lip position.
In addition to the septal cartilage, which of the following structures should be examined carefully in the evaluation of traumatic deviation of the nasal septum?
(A) Ethmoid and maxilla
(B) Ethmoid and vomer
(C) Nasal bones and sphenoid
(D) Sphenoid and vomer
(E) Vomer and nasal bones
The correct response is Option B.
In addition to the septal cartilage, the ethmoid and vomer should be examined carefully in a patient who is being evaluated for traumatic deviation of the nasal septum. The osseous component of the septum, which lies posterior to the cartilaginous component, is comprised primarily of the ethmoid bone in its superior portion and the vomer bone in its inferior portion. Because nasal septal deviation can be either developmental or traumatic (associated with fracture of the nasal bones and/or ethmoid complex), any person with obstruction of nasal airflow should be evaluated for deviation after other causes have been ruled out. This deviation can result from the mechanisms of buckling, fracture, or dislocation.
In patients with confirmed septal deviation, surgery should address both the cartilaginous and bony components. Treatment of the ethmoid and vomer should involve removal of bone and not refracture and repositioning. Excision of the septal cartilage will result in the formation of an L-shaped strut along the caudal and dorsal edges. Scoring of the concave cartilage will help re-establish contour.
Although the sphenoid, nasal, frontal, maxillary, and palatine bones can come into contact with the nasal septum, their contributions are peripheral and therefore do not need to be evaluated in a patient with suspected traumatic deviation.
The angle of divergence of the nasal tip is determined using which of the following structures of the lower cartilages?
A ) Middle and lateral crura
B ) Middle and medial crura
C ) Right and left foot plates
D ) Right and left lateral crura
E ) Right and left middle crura
The correct response is Option E.
The angle of divergence refers to the middle crura of the lower lateral cartilages. The angle of divergence is the angle between the right middle crus and the left middle crus, running from the medial genu to the lateral genu, while looking at the nose from the anteroposterior view. The angle from the middle and medial crura refers to the angle of rotation as the tip gently bends cephalad from the columella to the tip-defining point. There is no specific name given to the angle made by the lateral crura of the lower lateral cartilages. The septum and the upper lateral cartilage form the angle of the internal valve and relate to issues of occlusion of the airway. The middle and lateral crura form the lateral genu. The ideal angle of divergence is approximately 30 to 60 degrees. A more obtuse angle produces a long intercrural distance and a more “boxy” tip. A very acute angle of divergence creates a shorter intercrural distance and a narrow lobule. Optimally, the angle of rotation is approximately 60 degrees. A more obtuse angle often results in a lower nostril-lobule ratio and a more “square” tip. A shorter or absent middle crus will cause the tip to appear stubbed with inadequate projection.
A 30-year-old woman presents to the clinic with difficulty breathing. Clinical examination shows a septal deviation with contralateral inferior turbinate hypertrophy. On application of topical nasal decongestant, there is no resolution of the inferior turbinate hypertrophy. In addition to surgical correction of the deviated septum, which of the following is the most appropriate treatment for the contralateral inferior turbinate hypertrophy?
A) Complete inferior turbinectomy
B) Inferior turbinate outfracture
C) Submucosal resection
D) No additional correction is needed
The correct response is Option C.
Nasal septal deviations are commonly associated with nasal obstruction. Septal deviations can lead to compensatory hypertrophy of the contralateral inferior turbinate. It is important to differentiate between mucosal and bony hypertrophy. Mucosal hypertrophy typically responds well to topical nasal decongestant. This patient had no response with topical decongestant, signifying a primarily bony hypertrophy of the inferior turbinate.
While treating airway obstruction related to nasal septal deviations, it is important to address both the nasal septal deviation and the contralateral inferior turbinate hypertrophy, because straightening of the nasal septum will lead to narrowing of the airway if the contralateral inferior turbinate hypertrophy is not addressed.
The inferior turbinate has an important role in normal nasal physiology, and complete inferior turbinectomy is not advised since it leads to dryness, bleeding, mucosal crusting, ciliary dysfunction, chronic infection, malodorous nasal drainage, or atrophic rhinitis. In patients with nasal airway obstruction secondary to bony hypertrophy of the inferior turbinate, submucosal resection is the more appropriate treatment.
In patients with primarily mucosal hypertrophy of the inferior turbinate, inferior turbinate outfracture is usually adequate.
A 25-year-old man undergoes a submucous resection of the septum for airway obstruction. While the surgeon is scoring the remaining L-strut, the cartilage fractures along the dorsal strut. Reconstruction with which of the following grafts is the most appropriate next step in management?
A) Columella
B) Crural turnover
C) Dorsal onlay
D) Spreader
E) Spring
The correct response is Option D.
When performing a submucous resection for airway obstruction, leaving an intact L-strut is recommended for nasal support. When an L-strut fracture occurs, it should be repaired to avoid middle-third nasal collapse. The strut tends to rotate posteriorly, creating a saddle-nose deformity. Spreader grafts secured with sutures will act like a batten graft and secure the L-strut in place.
A columella graft is used to support the structure and position of the lower third of the nose.
A crural turnover graft is used to support weakened or deformed lower lateral cartilages.
A dorsal onlay graft is used for dorsal augmentation and would not adequately support the fracture.
A spring graft spans between both upper lateral cartilages and is used to widen the middle vault.
The above photographs are of a 34-year-old woman who is disappointed with the aesthetic result 18 months after undergoing primary rhinoplasty. She says that her lower nose looks pointy and that she has nasal obstruction with deep breathing. On examination, she has alar collapse with inspiration. ***NO PICTURE***
Which of the following is the most appropriate operative management?
(A) Cartilage grafting to increase tip support
(B) Cephalic trimming of the lower lateral cartilages to increase nasal projection
(C) Osteotomies to narrow the upper nose
(D) Weir resections to decrease alar flare
(E) Trimming of the dorsal septum to correct the polybeak deformity
The correct response is Option A.
This patient has a polybeak deformity caused by excessive reduction during the primary rhinoplasty procedure, combined with poor projection of the nasal tip. The obstruction with inspiration is suggestive of alar collapse; the nasal tip is pinched and lacks support. The most appropriate next step in management is cartilage grafting of the nasal tip and alae to increase support.
Although the alae appear flared because of the absence of tip support, the lower lateral cartilages have already been trimmed excessively, and their appearance would only worsen with further trimming. In the same way, the upper nose appears wide because of the tip deficiency, but is instead an appropriate width, as demonstrated by the smooth curve from the rim of the brow to the nose, and would not benefit from osteotomies. Weir resections would only accentuate the pinched nasal tip. Because this patient’s problems have resulted from excessive reduction of the dorsal septum, any further reduction would only worsen the deformity.
A 39-year-old man undergoes rhinoplasty at the practice. Six months after the procedure, he is displeased with the outcome and notes mild persistent tip deviation. After seeking three opinions from plastic surgeons in the community who all agree to care for him, he returns to the practice and insists that the original surgeon fix his nose because he knows that surgeon is “the best.” This patient most likely has which of the following psychological disorders?
A) Bipolar disorder
B) Body dysmorphic disorder
C) Histrionic personality disorder
D) Narcissistic personality disorder
The correct response is Option D.
Identification of various personality or psychiatric disorders prior to administering aesthetic care for patients can minimize social issues that can arise with the physician-patient relationship. Body dysmorphic disorder is hallmarked by pervasive and intrusive thoughts about a physical element (arm contour, for example) and may occupy several hours a day, causing severe distress and impairing one’s otherwise normal activities. The diagnosed individual is often the only person who can see the affliction. Histrionic personality disorder (HPD) is characterized by a pattern of excessive attention-seeking behaviors. This includes inappropriate seduction and an excessive desire for approval. People diagnosed with HPD are often lively, dramatic, vivacious, enthusiastic, and flirtatious. Narcissistic personality disorder (NPD) patients have a grandiose sense of self-importance and are preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. These patients have a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with their expectations). The ironic hallmark of the patient with NPD is that they often return for cosmetic surgery even if they are dissatisfied with the initial results. Bipolar disorder patients have extremes in mood/behavior: mania and depression. This mental illness is hallmarked by severe high and low moods and changes in sleep, energy, thinking, and behavior. These patients have periods of feeling overly happy and energized and other periods of feeling very sad, hopeless, and sluggish.
If adhering to aesthetic ideals, the radix is approximately located at?
A) At the level of the brow
B) At the upper limbus
C) At the interval between lash line and supratartsal crease
D) At the midpupil
Correct answer is option C.
The ideal location for the radix is approximately at the interval between the lash line and supratarsal crease. At the level of the brow would be too high, and at the upper limbus and mid-pupil would be too low.
Which of the following is the most likely adverse effect of performing infracture of the nasal bones?
(A) Development of an open roof deformity
(B) Development of a supratip deformity
(C) Narrowing of the internal nasal valve
(D) Narrowing of the nasal tip
(E) Retraction of the columella
The correct response is Option C.
Infracture of the nasal bones is performed to narrow the nasal dorsum. However, because the upper lateral cartilages are attached to the nasal bones, this technique may lead to an excessively acute angle (less than 10 degrees) between the upper lateral cartilages and the septum. Narrowing and occlusion of the internal nasal valve can result, causing breathing difficulties.
Infracture is also a method of correcting an open roof deformity.
Supratip deformities are generally caused by inadequate resection of the dorsal spine or excessive resection of the nasal dorsum.
The nasal tip and columella are relatively unaffected by infracture.
Two months after cosmetic rhinoplasty, a patient has numbness of the nasal tip. The most likely explanation is injury to which of the following nerves?
(A) Descending branch of the infraorbital
(B) Descending branch of the lesser palatine
(C) External branch of the anterior ethmoidal
(D) Medial branch of the infratrochlear
(E) Medial branch of the nasopalatine
The correct response is Option C.
Knowledge of the innervation of the nose is necessary for local anesthesia in rhinoplasty and nasal reconstruction.
The anterior ethmoidal nerve enters the nose near the crista galli and has two branches. The external branch emerges between the nasal bone and the lateral nasal cartilage and supplies the skin of the nasal tip and alae. It is vulnerable during tip cartilage dissection. The internal branch of the anterior ethmoidal supplies sensation to the septum and the internal nasal walls.
The infraorbital nerve supplies sensation to the cheek, lip, lower eyelid, and the upper gingiva. The nasopalatine runs anteroinferiorly on the nasal septum in a groove in the vomer. It supplies sensation to the septum and the hard palate.
The lesser palatine innervates the uvula, tonsil, and soft palate. The infratrochlear nerve supplies the skin of the radix. All of these nerves are branches of the fifth cranial nerve.
The photographs shown above are of a 62-year-old man who sustained a nasal septal fracture in a high-speed motor vehicle collision five days ago. Following reduction of the fracture, which of the following grafts is most appropriate for correction of the deformity?
(A) Alloplastic graft
(B) Columellar strut graft
(C) Shield graft
(D) Spreader septal graft
(E) Umbrella graft
The correct response is Option D.
Fractures of the nose can occur in three zones. Fractures of the upper vault of the nose involve the nasal bones, ethmoid, vomer, and cephalic septal border. Fractures of the middle vault involve the upper lateral cartilages, septum, and maxilla. In patients with fractures of the lower vault of the nose, the alar cartilages and inferior septum are affected. This patient has fractures involving both the upper and middle vaults of the nose. Following reduction of the septum and nasal bones, spreader grafts should be inserted to provide support to the septum.
Compared with autologous tissues, alloplastic grafts have higher rates of exposure and infection and are relatively contraindicated in a patient with recent trauma to the nose and multiple mucoperichondrial lacerations.
Columellar strut, shield, and umbrella grafts are used for correction of deformities in the lower vault of the nose.
When a cephalic trim is performed during primary rhinoplasty, which of the following is the minimum width of caudal lower lateral cartilage that should be left behind?
A) 4 mm
B) 6 mm
C) 8 mm
D) 10 mm
E) 12 mm
The correct response is Option B.
The nasal tip represents a complex nasal tripod. The paired lower lateral cartilages work synergistically to provide the main structural support for the nasal tip. Tip refinement is of course common in rhinoplasty, and a cephalic trim of excess lower lateral cartilage is a classic maneuver utilized in primary rhinoplasty. The cephalic trim acts to decrease vertical height of the lateral crura and to debulk to tip. It is crucial that enough cartilage be left behind when removing excess lower lateral cartilage from the cephalic portion. Classically, 6 mm (5 to 7 mm) of rim strip is the accepted standard of how much should be left behind at minimum to prevent stability compromise of the lower lateral cartilages. Resection in excess of this can weaken the lateral crus and cause retraction, notching, and/or external valve dysfunction.
A 32-year-old man with Bell palsy comes for evaluation of nasal obstruction. He says that the left side of his nose constantly feels clogged. Physical examination shows left facial paralysis and collapse of the left external valve. Which of the following muscles is most likely paralyzed?
A ) Depressor septi nasi
B ) Levator labii superioris
C ) Procerus
D ) Risorius
E ) Transverse nasalis
The correct response is Option B.
The muscles of the nose are crucial to the dynamic function of the nasal valve and airway. Patients with facial paralysis may often have symptoms of nasal airway dysfunction. The muscles of the nose are innervated by cranial nerve VII; therefore, nasal airway obstruction is noted on the ipsilateral side of the paralysis.
The levator labii superioris muscle dilates the nares. Paralysis of the muscle allows for collapse of the external valve resulting in airway obstruction.
Paralysis of these muscles would not result in collapse of the external nasal valve. The depressor septi nasi muscle depresses the nasal tip. The procerus muscle moves the eyebrows
Component dorsal hump reduction consists of which of the following?
A) Separation of the upper lateral cartilages
B) Rasping the nasal bones
C) Resection of septal cartilage
D) Restoration of the midvault
E) All of the above
Correct answer is E.
The component dorsal hump reduction was described by Rohrich RJ, et al. in 2004* to provide a graduated approach to the nasal dorsum for hump reduction while preserving the upper lateral cartilages and optimizing the dorsal aesthetic lines. He describes a five-step method that involves the following: (1) separation of the upper lateral cartilages from the septum; (2) reduction of the cartilaginous septum; (3) reduction of the bony septum; (4) verification by palpation; (5) reconstitution of the midvault.
Which incision is NOT typically used as part of the open rhinoplasty approach?
A) Hemitransfixion
B) Infracartilaginous
C) Transcolumellar
D) Killian
Correct answer is option D.
Killian incision is not typically used in standard open rhinoplasty technique. The Killian incision is oriented similarly as compared to the hemi-transfixion incision but more cranial and posterior. The Killian incision is made over the cartilaginous septum, whereas the hemi-transfixion is made over the membranous septum. The Killian incision is often used for isolated septoplasty or septal cartilage harvest. Infracartilaginous and transcolumellar incisions are done for standard open rhinoplasty.
A 40-year-old woman is to undergo rhinoplasty to increase projection of the nasal tip. In addition to tip grafting, which of the following techniques will provide the greatest tip projection?
(A) Resection of the lateral crura
(B) Resection of the lower lateral cartilages
(C) Resection of the nasal spine
(D) Suturing of the medial crura
(E) Transfixion incision
The correct response is Option D.
Projection of the nasal tip can be increased by applying a cartilage graft to the tip, suturing the medial crura, and placing a strut graft between the medial crura. In addition, the caudal margin of the septum and cephalic alar rim can be resected to rotate the nasal tip and increase its projection subtly.
Tip projection is decreased by resecting the lateral and medial crura and the nasal spine. Complete transfixion incision ultimately decreases projection because it weakens nasal support.
It should be noted that procedures to correct tip projection can lead to a broad-based appearance of the nose. Weir-type alar resection or nasal sill resection is appropriate for rectifying this problem.
Which of the following structures is associated with the anatomical boundaries of the internal nasal valve?
A) Anterior edge of the vomer
B) Anterior middle turbinate
C) Caudal border of the upper lateral cartilage
D) Cephalic border of the lower lateral cartilage
E) Foot plate of the medial crus
The correct response is option C.
The internal nasal valve is the narrowest point along the upper airway. Its cross-sectional area is determined by the anatomical boundaries. These comprise the caudal border of the upper lateral cartilage superiorly, the anterior inferior turbinate posteriorly, the caudal septum medially, the nasal floor inferiorly and the pyriform margin laterally. Numerous techniques have been described to stabilize internal nasal valve narrowing by graft/stabilization of the upper lateral cartilage to prevent collapse medially
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.
A 55-year-old woman comes to the office because she is dissatisfied with the appearance of her nose (shown), 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%
The correct response is Option C.
The patient described has body dysmorphic disorder (BDD), which affects 7 to 15% of all plastic surgery patients. 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. Most patients with BDD are single (70% never married), and up to 50% have suicidal ideation. Treatment involves referral to a psychiatrist where psychotherapy and pharmacotherapy are useful. Operating on these patients almost never leads to a satisfied patient; therefore, preoperative diagnosis is essential.
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.
A 45-year-old woman presents for rhinoplasty evaluation. The patient is dissatisfied with the downward movement of her nasal tip when she smiles. Which of the following muscles is responsible for this motion?
A) Alar nasalis
B) Depressor septi nasi
C) Levator labii superioris alaeque nasi
D) Procerus
E) Transverse nasalis
The correct response is Option B.
The muscles of the nose contribute to its dynamic motion. The depressor septi nasi originates from the incisive fossa of the maxilla and inserts into the nasal septum and posterior aspect of the alar nasalis. It depresses the nasal septum and causes the nasal tip to move downward on animation and narrows the columellar labial angle. Release of this muscle during rhinoplasty will reduce the nasal tip depression during animation, but can also cause upper lip ptosis.
The nasalis muscle consists of two parts: the alar nasalis and the transverse nasalis. The alar nasalis, also called the pars alaris or dilator naris, originates from the maxilla and inserts along the lateral crura. It has variable development and helps to open the external nasal valve.The transverse nasalis originates from the maxilla and traverses the nose, with a thin aponeurosis over the midline. It elongates the nose and constricts the nostrils.The levator labii superior alaeque nasi originates from the nasal bone and inserts into the nostril and upper lip, and dilates the nostrils and elevates the upper lip. It is also known as Otto’s muscle, and is the longest-named mammalian muscle.The procerus muscle depresses the glabella and assists in nostril flare.
What is the junction between the nasal bones and upper lateral cartilages called?
A) Scroll area
B) Keystone
C) Glabella
D) Supratip break
Correct answer is option B.
Keystone area is junction between the nasal bone and the upper lateral cartilages. The nasal bones will overlap the cranial aspect of the upper lateral cartilages by 2-3 mm.
Scroll area is the junction between the upper and lower lateral cartilages. Glabella is the region located between the brows above the root of the nose. Supratip break reflects a nasal contour best appreciated on the lateral view wherein the nasal tip is slightly more projected relative to the dorsum, often a desirable endpoint in female rhinoplasty.
