Seminar on rhinoplasty

1. SEMINAR ON ON RHINOPLASTY
DEPARTMENT OF ORALAND MAXILLOFACIAL SURGERY
MAHARANA PRATAP COLLEGE OF DENTISTRY AND RESEARCH CENTRE (GWALIOR)
PRESENTED BY : DR.MRINALINI SINGH
PG 3RD YEAR
GUIDED BY:
DR.NITIN JAGGI(PROF.HOD)
DR. ASHISH SINGH(PROF )
DR. NIKHIL PUROHIT(READER)

2. CONTENT
1.INTRODUCTION
2. HISTORY
3. PREFERRED ANATOMIC TERMS FOR RHINOPLASTY
4. SURGICALANATOMY OF NOSE
5. NASAL PHYSIOLOGY
6. ARMAMENTARIUM FOR RHINOPLASTY
7. CLINICAL EXAMINATION
8. INVESTIGATIONS
9. GENERAL OPERATIVE TECHNIQUES / SURGICAL APPROACHES
10. GRAFTS USED IN RHINOPLASTY
11. POST OPERATIVE CARE AND COMPLICATIONS
13. REFERENCE

3. INTRODUCTION
 Rhinos, “Nose” + Plaskitos, “to shape”
 Rhinoplasty is defined by the American Academy of Otolaryngology (AAO) “as a
surgical procedure that alters the shape or appearence of the nose” with functional
rhinoplasty specially aimed at “enhancing the nasal airway.”
 Rhinoplasty is one of the most complex surgical procedures in Plastic Surgery.
 The nose occupies the centre of the face and receives enormous attention as a key
aesthetic element. It is also an important organ contributing to vital function of
breathing and olfaction.
[Rhinoplasty-Edited by Michael J. Brenner]

4.  The history of plastic surgery/rhinoplasty in India dates as far back or before the Vedic times nearly 4000 years ago
 Rhinoplasty techniques were carried out in ancient India by the ayurvedic physician Sushruta in 800 BC
(Sushruta has been rightly called the “Father of Plastic Surgery” and “Hippocrates” of the 6th or 7th
century BC)
 Johann Friedrich Dieffenbach (1794-1847), a Prussian surgeon, made the first recorded attempt to
reshape a nose.
 Jacques Joseph (1865-1934) from Berlin, The surgical saws, chisels, and clamps he invented are still
in use today.
 Fomon (1889-1971), Cottle (1898-1981) and Goldman (1898-1975) all developed further the
Joseph and Safian techniques and greatly contributed to the teaching of rhinoplasty by their courses, books, articles and instruments.
Goldman's tip technique, to improve tip projection, is still practised today.
 The master rhinoplasty surgeons of the last twenty years (1980-2000) such as Robert Simons, Gaylon McCollough, M.E. Tardy,
R.W.H. Kridel, Rollin Daniel, Webster, Dean Toriumi of the United States, and Tony Bull from the United Kingdom and others, have
greatly contributed to the advances in our techniques today.
 Around 1946 Dr. C. Balkrishnan, was a devoted and dynamic plastic surgeon, He succeeded in establishing the first Department of
Plastic and Maxillofacial surgery at the Govt. Medical College and Hospital, Nagpur.
HISTORY
[History of plastic surgery in India. 2002,Vol.: 48 Page : 76-8]

5. ANATOMIC TERMS FOR RHINOPLASTY
 NASION: Depression at the junction of the nose with the forehead. Deepest point
at the root of the nose
 RADIX: Area centred around the nasion.
 RHINION: The point located at the osseocartilaginous junction over the dorsum of the
nose.
 SUPRATIP AREA: Area just cephalad to the nasal tip at the caudal portion of the nasal
dorsum.
 NASAL TIP: The most anterior point of the lobule.
 INFRATIP LOBULE: Portion of the tip between the tip defining points and apex of nostrils.

6.  COLUMELLA: The central "column" separating the right and left nostrils as seen on base
view, composed of skin and the paired right and left medial crura.
 ALA (PLURAL: ALAE) :The paired crescent-shaped convexities flanking the nasal tip that
partially surround the nostril openings. The medial aspect of the ala is supported by the lateral
crus of the alar cartilage. No cartilage is present in the outer portion of the ala.
 ALAR RIM: The outer edge of the nostril opening as seen on front view, and the caudal
border of the ala as seen on profile view (cephalad to the columella).
 ALAR GROOVE: Oblique skin depression between the tip and the ala.

7.  NASAL DORSUM/ NASAL BRIDGE
The upper two-thirds of the nose consisting of the middle (cartilaginous) vault and the upper(bony) vault.
 MIDDLE VAULT
The middle third of the nose composed entirely of cartilage, the middle vault is formed by the mid-line dorsal septum and the right and left
upper lateral (sidewall) cartilages.
 ALAR CARTILAGES:
Also called the lower lateral cartilages. Each arch is subdivided into the medial crus (columellar segment), intermediate crus (infra-tip
segment), dome, and lateral crus (alar segment).
line diagram showing medial crus (yellow),
intermediate crus (red) and lateral crus (grey)

8.  ALAR BASE:
Lower-most portion of the nose. Ideal width of the alar base is approximately
equal to the inter-canthal distance (distance between the eyes).
NASOLABIALANGLE
The angle formed between the columella and the upper lip as seen on profile.
Typically more obtuse in females.
 NASOFRONTALANGLE
The angle formed between the nasal bridge and the forehead (glabella) as
seen on profile view.
ALAR BASE,"GULL WING IN FLIGHT"
[Glossary of Rhinoplasty Terms By Dr.Richard E. Davis, MD, FACS]

9. SURGICAL ANATOMY OF THE NOSE
 Classification based on the framework:
NOSE
EXTERNAL
ANATOMY
SKIN AND
UNDERLYING
TISSUES
EXTERNAL VAULT
UPPER THIRD
MIDDLE THIRD
LOWER THIRD
TIP
SUPRA TIP
INFRA TIP
INTERNAL
ANATOMY
MUSCLES
BLOOD SUPPLY
AND
INNERVATIONS
NASAL SEPTUM
LATERAL NASAL
WALL
[Rhinoplasty: current therapy; omfs clinics of north America, feb2012,vol24][

10.  SKIN:
 The average skin thickness at the radix (measuring 1.25 mm) and at the Rhinion (0.6 mm).
 The supra-tip area has abundant sebaceous glands especially in adolescent males.
 Skin thickness is reduced in the columella and mid-alar area and increased in the alar base area.
 Clinical Applications :
 The type, texture, and sebaceous content of the skin must be carefully analyzed, because it will
influence the final result.
 For example, in patients with thin skin, has a high capacity to contract and re-drape over the
sculpted framework. Additionally, slight imperfections of contour, asymmetries, and graft edges
are more likely to be visible and/or palpable postoperatively.
 Thick sebaceous skin tends to offer less postoperative contraction, warranting more aggressive
alterations of the underlying framework in order to obtain a significant definition of contour.

11.  NASAL VAULTS
 The nose possesses three vaults: A) Bony (upper 3rd)
B) Upper cartilaginous ( middle 3rd)
C) Lower cartilaginous vaults ( lower 3rd) [15]
It is generally pyramidal in shape and Composes one third of the external nose.
The nasal bones average 2.5 cm in length, are much thicker and denser above the level of the medial
canthus at the radix, and thin progressively toward the tip.
Clinical Applications:
Osteotomies may be performed to narrow or widen the nasal base, repair an open-roof deformity
after dorsal hump resection, and correct symmetrical or asymmetrical bone deformities. Reliable
and predictable osteoomies may be executed at the transition zone.
Contraindications: 1) Short nasal bone, 2) low and broad noses 3) Elder patient.
A. BONY VAULT
[Tardy ME, Denney JC. Micro-osteotomies in rhinoplasty. Facial Plast Surg 3:137-145, 1984]

12. UPPER CARTILAGINOUS VAULT:
 An important component of the upper cartilaginous vault is the internal nasal valve,
which is bordered by the septum medially, the nasal floor inferiorly, the inferior
turbinate laterally, and the caudal border of the upper lateral cartilage superiorly.
 The junction of the upper lateral cartilages with the nasal bones and the septum defines the keystone area.
 The nasal bones actually overlap the cephalic edge of the upper lateral cartilages by 6 to 8 mm.
 The angle between the septum and upper lateral cartilage is normally 10 to 15 degrees.
Clinical application:
Injury and/or destabilization of the
keystone area
Impaired airflow
[Sheen JH. Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg 73:230-239, 1984]

13. LOWER CARTILAGINOUS VAULT:
 The external nasal valve exists at the level of the inner nostril. It is formed by the
caudal edge of the lateral crus of the lower lateral cartilage, the soft tissue alae,
the membranous septum, and the sill of the nostril.
Clinical applications:
• The cartilaginous framework of the tip has been described as a tripod.
• In theory, if the base of the tripod is fixed, reduction or augmentation of the length of the legs
should change variables such as projection and tip rotation. [27]
The framework of the nasal tip is formed by the medial, middle, and lateral crura of the lower
lateral cartilages. Additionally, the accessory cartilages connect each lateral crus to the piriform
aperture. All of these cartilages are bound together and gives stability to the cartilages and act as
a single structural and functional unit and this unit is called as LATERAL CRURAL
COMPLEX.
[Text book of rhinoplasty, Dalla’s 3rd edition]

14. MUSCLES:
The muscles of the nose are divided into an intrinsic group of seven paired muscles (having both origin and insertion within the
perinasal area), and an extrinsic group containing three paired muscles.
Clinical applications:
All this muscular tissue should be pro-
tected during rhinoplasty, since its injury
can cause a rigid appearance and immo-
vability of the nose. A tension nose can
be regarded as an exception to this rule.
Surgical division of the M. depressor septi
to release the pull at the nasal tip can then
be advocated.
1. Procerus
2. Lavator labii alaeque nasi
3. Nasalis
4. Depressor septi
5. Dilator naris
6. Orbicularis oris
[G.J NOLST TRENITE, RHINOPLASTY. A PRACTICAL GUIDE TO FUNCTIONAL AND AESTHETIC SURGERY OF NOSE]

15. BLOOD SUPPLY:
Radix and rhinion: Supratrochlear termination of the ophthalmic nerve.
Nose tip: Anterior ethmoidal nerve, [(18].
The lateral nasal walls, columella, and vestibule: infraorbital nerve .
[(18].
Clinical application:
In endonasal or in open rhinoplasty, this nerve bundle may be damaged
and resulting in a numb nasal tip.
Blood supply is important to consider during preoperative injection for
hemostasis, flap design, and nasal incisions.
Superiorly- anterior and posterior ethmoidal artery
Inferiorly- labial angular artery
Alar groove: lateral nasal artery
Columella –superior labial artery

16. NASAL SEPTUM
• It is a singular, midline structure comprising the perpendicular plate of the ethmoid
superiorly, and the vomer inferiorly.
• The perpendicular plate of the ethmoid is continuous superiorly with the cribriform
plate and Inferior to the vomer, the nasal crest of the maxilla is positioned anteriorly,
and the nasal crest of the palatine bone is positioned posteriorly.
• Clinical application:
• CSF leak /or anosmia.
• Nasal crest of the maxilla, and the nasal crest of the palatine bone are thin pieces of
bone , but may be deviated or dislocated to form inferior septal spurs that should be
resected during septoplasty.

17. 1. Respiration
2. Purification of inspired air
3. Humidification and warming of inspired air:
4. Olfaction
5. Part of the buttress function of the facial skeleton:
6. Adding tone to the speech.
7. Lightening of the facial skeleton over the neck: Caused by the pneumatization of
the nose and paranasal sinuses.
NASAL PHYSIOLOGY:
[Maha Allhaidan, Shatha Al-Shanqeeti, Arwa Almashaan Nose I: Nasal Anatomy and Physiology]

18. ARMAMENTARIUM FOR RHINOPLASTY:
(1) Cotton applicators,
(2) 1/4” x 3” stringed pledgets,
(3) Smooth forceps,
(4) Clamp
(5) 6700 Beaver blade,
(6) #15 blade,
(7) Joseph saws,
(8) 2 and 4 mm hooks,
(9) Anderson McCullough elevator,
(10) Curved, blunt iris scissor,
(11) Converse scissor,
(12 and 13) Nasal specula,
(14) Brown Adson forcep,
(15) Converse retractors,
(16) Right angle scissor,
(17) Bayonet forcep,
(18) Mallet,
(19) Nasal rasps,
(20) Guarded, curved 4 mm
osteotomes,
(21) Gauze
[A Practical Approach for Learning Rhinoplasty Surgery, Lee J Kaplowitz, 2, Eric M Joseph, International Journal of Head and Neck Surgery, January-March 2016;7(1):33-46]

19. CLINICAL EXAMINATION:
FACIAL NASAL
Airway/breathing Intercanthal distance Skin quality
Bleeding disorders Inter-eyebrow distance Nasal bone—width, length and symmetry
Hypertension Frontal-bossing/glabellar projection ULC (Upper Lateral Cartilage)—width and
symmetry
Diabetes/ immunosuppression Upper lip position LLC (Lower Lateral Cartilage)
• Cephalic malposition
• Asymmetry of light reflecting points
• Lobule position
• Nostril-columellar relation
Psychological assessment Chin position Alar base •
• Inter alar distance (should be 2 mm wider than
intercanthal distance)
• Insertion of the alar base
GENERAL/SYSTEMIC LOCAL
[Khan HA. Rhinoplasty: initial consultation and examination. OralMaxillofac Surg Clin North Am. 2012;24(1):11–24. Review.]

20. PRE SURGICALASSESSMENT:
 A. EXAMINATION OF FACE AND NOSE :
 The face in the frontal view is divided into thirds and fifths for assessment of proportion and harmony of various structures. It is studied in
LATERAL; FRONTAL and BASAL views.
a)–(c) Examination of face and nose; frontal, lateral, basal. (b1) Ni - Ideal nasion, Ti Ideal tip. (b2) STB - Supra Tip Break, CLA - Columella Labial
Angle. (b3) Nasal Length is measured from nasal radix to nasal tip (A–B), Nasal projection (C–B) is length from Naso-labial junction to nasal tip. The
ratio between AB and CB (Goode’s Ratio) should be ideally 0.55 to 0.60.

21. There are four important photographic views that are used for analysis of the nose, namely, frontal, basal, lateral (at rest and
smiling) and oblique views.
frontal Basal
Lateral Oblique
3. Photographic assessment:

22. INVESTIGATIONS:
 Inspection with speculum will demonstrate any septal curvatures, angulations or spurs.
Computed tomography is helpful if sinus
pathology is suspected.
• Tests for functions of internal nasal and
external nasal valves should be done. Careful
observation of the nasal valves while the patient
is asked to inspire will provide a significant
amount of information. A speculum or Q tip
facilitates proper examination. Cottle’s
Maneuver helps in localizing obstruction due to
nasal valve dysfunction.

23.  Rhinomanometry has also been widely accepted and used as an objective method to
assess nasal patency. However, these tools may not necessarily show clinical correlation.
 Acoustic rhinometry is a recently developed objective technique for assessment of geometry of
the nasal cavity. The technique is based on the analysis of sound waves reflected from the nasal
cavities. It measures cross-sectional areas and nasal volume.
• Endoscopy of the middle meatus should be done to rule out clinical evidence of sinus disease.
Andre RF, Vuyk HD, Ahmed A, Graamans K, Nolst Trenite GJ. Correlation between subjective and objective evaluation of the nasal airway. A systematic review of the highest level of evidence.
Clini Otolaryngol. 2009;34(6):518–25.

24.  Surgical Approaches for Rhinoplasty
 Rhinoplastic approaches: (1) open approach or the open structure rhinoplasty approach
(2) closed or the endonasal approach.
 Several unique incisions are useful to expose and alter important structural elements in
rhinoplasty.
 INTERCARTILAGENOUS INCISION
OPEN V/S CLOSED APPROACH
GENERAL OPERATIVE TECHNIQUES
Incision is made at junction of caudal end of ULC
and cephalic margin of LLC.
INTRACARTILAGINOUS INCISION Incision is made at several mm above the caudal end of
LLC and extend from dome area (laterally) to the mid
segment of LLC.

25.  MARGINAL INCISION :
.
Follows the inferior margin of LLC from mid
columellar to mid alar on each side.
COMPLETE TRANSFIXION
Incision made caudal to both the medial crura and through
the membranous septum.
TRANSCOLUMELLAR INCISION: It connects the 2 marginal incisions at a mid columellar
point in a V OR Z design.
KILLIAN’S INCISION: Incision is made several millimeters cephalad to the
caudal edge of the septum..

26. OPEN STRUCTURE RHINOPLASTY
 The open rhinoplasty technique is used to correct both the cosmetic and functional deficits of the nose.
 Indications
 Marked asymmetry
 Secondary rhinoplasty,
 Need for structural grafting
 Post traumatic nasal deformity
 Nasal valve correction
 Advantages
 Excellent visual control of entire nasal framework
 Enhanced surgical access
 Accurate structural grafting under direct vision
 Ideal for demonstration and teaching
 Predictable results
Disadvantage
• Potentially increased oedema
• Extended surgical time
• Destabilized cartilaginous framework
• External trans-columellar scar.

27.  SEQUENCE OF TREATMENT
1. Local anesthesia
2. Bilateral marginal incisions
3. Columellar incision
4. Skeletonization of upper and lower lateral cartilages and nasal dorsum
5. Dorsal reduction
6. Dome division if access is needed.
7. Septoplasty (if needed)
8. Lateral nasal osteotomies
9. Tip modification (i.e., cephalic strips/cartilage grafting/suture techniques)
10. Alar base modification
11. Closure, taping, and splinting

28. Technique:

29. [Jon D, Perenack and shahrouj zarrabi rhinoplasty atlas of operative oral and maxillofacial surgery published 2015 nby john wiley.]

30. CLOSED RHINOPLASTY
 Indications:
1) Minimal tip correction
2) Access to dorsum and middle vault
3) Volume reduction of LLC
4) Septal surgery
5) Bony and cartilaginous hump removal
 Advantages:
1) Less invasive.
2) Less disruption of support mechanisms of nasal tip.
3) May be used for septal cartilage harvesting.
 Limitations
1) No binocular vision
2) Limits assistant’s view of exposures
3) Difficult to perform complex nasal tip surgery

31. Technique:
 LA
 Incision
NON DELIVERY APPROACH:
Inter-cartilaginous incision  eversion of mucosa is performed with hook
( b/w ULC and LLC) and excess cartilage is detached.
 Indication: Mild cephalic rotation of the tip
Bulbous tip
DELIVERY APPROACH:
It encompasses two incisions:
marginal incision, inter-cartilaginous incision
Soft tissue b/w the marginal and inter cartilaginous incision
is dissected. So that, the LLC can be delivered out
Trimming of cephalic portion of upper LLC
Inter domal suture
Tip graft
soft tissues are separated from the cartilaginous and bony
dorsum in a subperichondrial and subperiosteal plane

32. Treatment of dorsum:
Reduction of dorsum:
• Cartilage dorsal reduction are preferred with scissor / scalpel
• Bony dorsal reduction are performed with rasp / osteotome / ultra sonic device
Augmentation of dorsum:
 Performed to strengthen this area and improve contour imperfections
 Secondary rhinoplasty
Lateral Osteotomies:
If the patient has a wide bony vault, open roof deformity, deviated nose, osteotomies are necessary in order to maintain aesthetic dorsal
lines.
Septoplasty:
In favor of correcting a septal deviation or if cartilage harvesting is needed, septoplasty might be performed.
Tip Modifications: The nasal tip approach requires careful planning and execution. Tip projection, definition, symmetry, and morphology
may be altered and can be corrected by the use of different techniques.
SCISSOR REMOVAL OF THE
CARTILAGINOUS SEPTUM
REDUCTION OF BONY DORSUM
WITH AN OSTEOTOME
REDUCTION OF BONY DORSUM
WITH A RASP
[Rohrich Rj Mujaffar AR Janis JE, component dorsal hump reduction, THE importance of maintaining dorsal aesthetic line in rhinoplasty. Plast. Reconstructive surgery.2000.
oct114;(5):1298-13098]

33.  Turbinectomy:
 Inferior turbinate hypertrophy is a common finding that can produce varying amounts of airway obstruction.
 Its treatment will depend on the extent of the obstruction.
 Conventional methods include submucous turbinectomy, turbinoplasty, and laser.
 Closure and Dressing:
 Mucosal incisions are closed with resorbable sutures,
 Silastic splints are placed and sutured to each side of the septum in order to provide septal support and enhance mucosal
healing.
 Several strips of paper tape are distributed over the dorsum and cast over it, which is removed 7 days postoperatively.

34. SEPTOPLASTY
 In rhinoplasty surgery, there are several reasons to access the nasal septum:
 To correct nasal airflow obstruction,
 To assist in the correction of asymmetries, and
 To harvest cartilage for tip grafting.
 Deformities that require correction of the septum are:
 Tension Nose
 Saddle Nose
 Septal perforation

35. SURGICAL PROCEDURE
LA
INCISION PLACED
DISSECTION USING A JOSEPH/COTTLE ELEVATOR
LIGHT BLUE COLOR OF CARTILAGE ENSURES CORRECT PLANE OF DISSECTION
ANTERIOR TUNNEL FOLLOWED BY INFERIOR TUNNEL  EXPOSE THE ENTIRE SEPTUM
PLANE IS EXPANDED USING KILLIAN FORCEPS
BONY SPURS OR ANGULATIONS ARE IDENTIFIED
OSTEO-CARTILAGINOUS DYSJUNCTION DONE
BONY SPURS ARE NIBBLED AWAY
1. anterior
cartilaginous septum
2. perpendicular
plate of
the ethmoid
.3) vomer

36. IF CARTILAGE IS TO BE HARVESTED POSTERIOR TO KEY AREA
STABILISATION  PDS SUTURE ANCHORING THE DISSECTED SEPTUM TO THE ANS
CLOSURE DONE

37. OSTEOTOMY
 Osteotomy is one of the most crucial and difficult steps in rhinoplasty.
 Types of osteotomies :
 A) Lateral osteotomies:
The low-to-high osteotomy
Begins low at the piriform aperture,
extends cephalad toward the intercanthal
line, and ends high on the nasal dorsum.
Used to mobilize a moderately wide
nasal base or to correct a small open
roof deformity.[104]
Low to low osteotomy:
Starts low along the piriform aperture and
remains low along the base of the bony
vault ending at a location near the
intercanthal line. Frequently, a medial
osteotomy is performed along with it.
Used to correct a large open roof
deformity or to narrow an excessively
wide nasal base.
Double level osteotomy
Consists of an osteotomy along the inferior
border of the nasal bone.
parallel to and combined with a low to low
osteotomy.
The goal is to reduce the convexity of the
lateral wall

38.  B) Medial osteotomies:
Transverse osteotomies:
 A vertical stab incision is made just above medial canthus, 2mm osteotome is used to completely fracture the lateral wall transversely
from just above medial canthus upward. Usually it is followed by low to low osteotomy
Medial oblique osteotomies:
 A curved osteotome is placed at the cephalic end of the open roof and driven downward toward the medial canthus. It is designed to
narrow the broad bony dorsum and is coupled with low to low lateral osteotomy.
Paramedian osteotomies:
 Straight osteotomies made 3-5mm parallel to the dorsal midline. It is used in the broad nose when one does not wish to change dorsal
midline.
[103. KARIMA ISMAIL, M.D.; MARIAM ISMAIL, M.D. and AHMED ISMAIL, M.D Assessment of Different Types of Osteotomies in Rhinoplasty Patients Egypt, J. Plast. Reconstr. Surg., Vol. 44,
No. 1, January: 65-68, 2020]

39.  Tip surgery is the base stone and the key for a successful rhinoplasty.
 Types of nasal tip deformities:
1. Broad nasal tip: bulbous, boxy, trapezoid, wide and/ or thick skinned.
2. Underprojected, dropped, drooping, under-rotated, short columella.
3. Overprojecting.
4. Hanging columella.
5. Retracted columella.
6. Tip asymmetry.
 Surgery for the nasal tip can be performed either through a closed or open structure rhinoplasty approach
1. Bulbous/Boxy Tip
 Bulbous tips have problems associated with thick SSTE (skin & soft tissue envelope),
excessive subcutaneous fat, bulky lateral crura.
 Surgical management:
 This involves careful degloving of the SSTE leaving the subcutaneous fibrofatty tissue on the lateral
crura. Careful defattening and thinning of the subcutaneous plane should be performed. A modest
cephalic trim is performed to correct the large and bulky lateral crura.
TIP PLASTY

40. 2. Wide Nasal Tip
 A tip is considered abnormally wide when the width of the tip is greater than the width of the dorsum.
 Surgical management:
 Steps for correction of a wide nasal tip include reduction of the interdomal width by placing a
permanent interdomal suture with 5-0 prolene or 5-0 PDS (semipermanent). This is followed
by the creation of a new domal angle (transdomal suture followed by the interdomal suture).
 One should also consider surgical removal/excision of a segment of the intermediate crus for
better tip definition.
 Transdomal Suture:
Transdomal sutures are used to narrow the nasal dome angles,
Eg, Bulbous and boxy tips
 Interdomal Suture:
 This is a simple suture that is placed between the domes of the middle crura of each lower lateral
cartilage. It is used to narrow tip width, enhance the infratip region, and increase projection.

41. Over-projected Nasal Tip
 Nasal projection is defined as the distance along a perpendicular line from the vertical facial
plane to the anterior most point on the nasal tip.
 This may be due to the increased length of the anterior nasal spine, excess caudal septal
height or overtly long alar cartilages.
 Surgical management:
 The anterior nasal spine is reduced judiciously followed by the resuspension of the upper lip
to the ANS. The anterior septal angle is lowered to achieve further deprojection.
 Deformities of the alar cartilage may be varied and may require division and overlap of the
medial crura, division or resection of the medial footplates

42. Under-projected Tip
Under-projected Tip
 It is important to establish the cause for under-projection prior to treatment.
 Causes of under-projection may include.
 Short medial crura (short columella.)
 Underdeveloped lower lateral cartilages e.g. binders
 Deficient height of caudal septum.
 Deficient or absent anterior nasal spine/premaxilla.
Bilateral cleft lip nose.
Surgical management:
The columella is strengthened with a strut graft, a transdomal suture is placed to project the dome.
A shield, may be used to increase tip projection. A caudal septal extension graft is added to strengthen the septal support and
increase projection.
In patients with the deficiency of the premaxilla or the total bony maxilla (cleft maxillary hypoplasia) advancement of the
maxilla or Onlay grafting of the premaxillary segment may offer the correct solutions.

43. CLEFT RHINOPLASTY
 Introduction:
 Blair and brown first describes the cleft nose 1931, critically identifying the nuance of the pathology.
 Problems:
 Cosmetic Problem
 Impaired nasal airflow
 Septal deflections, atretic nostrils, turbinate hypertrophy, and cleft lips and palates
 Although the cleft nose grows as the patient ages, it remains 30% smaller than that of patients without cleft lip
deformity.

44. Unilateral cleft lip nose deformity Bilateral Cleft Lip Nose Deformity
• Maxilla on the cleft side is deficient.
• The alar base on the cleft side does not not fuse in the midline
and is positioned more posterior, lateral, and inferior than the
alar base on the noncleft side.
• The lateral crus of the lower lateral cartilage on the cleft side
is lengthened and the medial crura is shortened in relation to
the Lower Lateral Cartilage on the noncleft side.
• The septum is attached to the noncleft maxilla inferiorly, which
causes the septum to be deviated to the noncleft side caudally.
• Anterior septal deflection to the noncleft side.
• The maxilla is deficient bilaterally,
• The alar bases are displaced in a more posterior, lateral, and
inferior position
• The deficient skeletal base leads to longer lateral crura bilaterally
and short, splayed medial crura.
• This creates an under projected, broad, and flat nasal tip.
• The columella is short.
• Broad and snubbed nasal tip.
• Bilateral Insertion of the orbicularis oris musculature into the alar
base contributes to the widening of the nose and flattening of the
lower lateral cartilage
[Sykes JM, Senders CW. Surgery of the cleft lip and nasal deformity.]Oper Tech Otolaryngol Head Neck Surg. 1990;1:219–24]

45.  Timing of cleft nasal repair:
 For unilateral cleft lip deformity
1. Presurgical orthopedics (naso-alveolar molding) - 0 to 3 months of age
2. Primary cleft nasal repair at the time of cheiloplasty (= 3 months of age)
3. Secondary cleft rhinoplasty (14 to 16 years of age for girls and 16 to 18 years of age for boys).
For bilateral cleft is similar, with the exception that the primary nasal repair is divided in two stages:
1. At the time of the primary cheiloplasty, the nasal repair is limited to alar repositioning and lateral nasal lining augmentation.
2. At approximately 18 months of age, the columella is lengthened, and the nasal domes are unified.
3. Definitive adult/adolescent rhinoplasty until the age of 14 years in females and 16 years in male.
OPERATIVE TECHNIQUE
 For most cleft nasal deformities, we prefer an open rhinoplasty approach.
 Presurgical Nasoalveolar Molding
 Nasoalveolar molding can be used in patients with wide or very asymmetric clefts.
 Reposition the malaligned alveolar segments
 Narrow the cleft gap
 Improve nasal tip symmetry in unilateral clefts
 Elongate the columella
 Expand the nasal soft tissues in bilateral clefts.

46. Primary Rhinoplasty
 The purpose of primary rhinoplasty is to close the anterior nasal floor,
to relocate the displaced alar base,
bring early symmetry to the nasal base and tip.
 This approach allows for both a functional and aesthetic improvement .
 After the cleft lip incisions are made, the muscle and soft tissues of the alar base are separated from their maxillary
attachments.
 The closure is first started with re-approximation of the musculature of the
nasal base to be reconstructed in a manner that mirrors to the non cleft alar base.
 It is important not to narrow the sill too much.
 After adequate soft tissue dissection the alar base is repositioned.
 Reposition the cleft nasal tip into a more projected, symmetric position.
 Intermediate rhinoplasty:
 is defined as any nasal surgery performed between the time of initial lip repair and the time of definitive rhinoplasty.
Mulliken JB, Martinez-Perez D. The principle of rotation advancement for the repair of unilateral complete cleft lip and nasal deformity: Technical variations and analysis of results.
Plast ReconstrSurg. 1999;104:1247–9

47.  Secondary (Definitive) Rhinoplasty:
 The goals of the secondary rhinoplasty are
 The creation of symmetry
 Definition of the nasal base and tip
 Relief of nasal obstruction
 Management of nasal scarring and webbing
 SURGICAL TECHNIQUES :These treatment goals include septal reconstruction and treatment of the nasal tip, alar rim, alar base,
columella, and nasal sill.
 Open or External approach.
 Inverted-V columellar Incision.
 V incision [vertical limb of the V should be longer on the cleft side]
 Dissect across the columella between the skin and anterior edge of the medial crura
 The columellar flap is retracted with a double skin hook. Dissection is extended upto the caudal end of the nasal bones.
 Septoplasty or septal repositioning..
 Alar cartilages are exposed and Cephalic trimming of the alar cartilages is done on either sides & they are hitched together.
 Spreader grafts are positioned between the nasal septum & the upper lateral cartilages
& secured using 5-0 prolene suture.
 Columellar strut graft is positioned to support the nasal tip.
[Kaufman Y, Buchanan EP, Wolfswinkel EM, Wethers WM,Stal S. Cleft nasal deformity and rhinoplasty. Semin Plast Surg.2012;26:184–90]

48. GRAFTS USED IN RHINOPLASTY:
 1.AUTOLOGOUS GRAFT MATERIAL:
NASAL SEPTAL
CARTILAGE
Best grafting material.
Insufficient when large
amounts are needed.
AURICULAR CARTILAGE
Used if nasal septal cartilage
is not adequate.
COSTOCHONDRAL
GRAFTS
Abundant supply.
TEMPORALIS FASCIA
Used for cartilage-fascia
grafts in primary and
revision rhinoplasty.

49. 2. ALLOPLASTIC GRAFT MATERIALS:
a) Silicone
b) Med-por [high density polyethylene]
c) Gore-tex [expanded poly-tetrafluoro-ethylene (PTFE)
3. INJECTABLE FILLER MATERIALS
 Bovine collagen, human-derived collagen, hydroxyapatite microspheres, hyaluronic acid:
Overview of Rhinoplasty Grafts by Region:
A) GRAFTS OF NASAL DORSUM:
1. Radix graft:
A radix graft is a single or layered dorsal graft
placed in a tight pocket that is created over the radix.
2. Spreader Grafts
Spreader grafts are usually paired, longitudinal grafts
placed between the dorsal septum and the upper lateral
cartilages
[Becker DG, Pastorek NJ. The radix graft in cosmetic rhinoplasty. Arch Facial Plast Surg 3:115-119,2001.

50.  3. Septal Extension Grafts:
 Septal extension grafts are used to control the projection, support, shape, and
rotation of the tip and are dependent on the presence of a stable caudal septum.
 B) GRAFTS OF THE NASAL TIP:
 Columellar strut graft:
 A columellar strut is a graft placed in a tight
pocket that is dissected between the medial crura through
a small incision.
Shield graft:
This shield-shaped graft is placed adjacent to the
caudal edges of the anterior middle crura,
extending into the tip.
[Sheen JH. Achieving more nasal tip projection by the use of a small autogenous vomer or septal cartilage graft. A preliminary report. Plast Reconstr Surg 56:35-40, 1975]

51.  Postoperative care starts with the application of an adequate internal and external nose dressing.
 Internal nose dressing
 Packing (telfa gauge) applied too tightly and for too long disrupts adequate
venous and lymphatic drainage.
 The packing can generally be removed after 24 hours.
 External nose dressing:
 The goal of the external nose dressing is:
 to fix the skin on the under-layer.
 to prevent hematomas and swelling.
 to prevent displacement by outside trauma.
 to prevent widening of the lateral walls by intranasal edema.
POST-OPERATIVE CARE

52.  The external nose dressing consists of three layers: hypo-allergenic paper-tape, adhesive cloth-tape and splint
 The skin of the nose is rubbed with Tinctura Benzoin or Mastisol followed by the application of a piece of gel foam,
GEL FOAM HYPO-ALLERGENIC PAPER TAPE
AND A SLING OF
PAPER TAPE TO ENCLOSE THE
LOBULE
SECOND LAYER OF CLOTH-TAPE
A TWO-PIECE DENVER® SPLINT. External nose dressings are generally
removed after one week.

53. POSTOPERATIVE COMPLICATIONS
1. Haemorrhage
2. Infection
3. Persistent Structural Nasal Obstruction
4. Postoperative Septal Problems
5. Supratip Swelling:
6. The Most Common Postoperative Visible Deformities
. Asymmetry of the bony vault Asymmetry of the middle vault Saddle nose deformity

54. Nostril asymmetry Alar retraction
Pollybeak deformity Tip asymmetry Pinched tip
[G.J NOLST TRENITE, RHINOPLASTY. A PRACTICAL GUIDE TO FUNCTIONAL AND AESTHETIC SURGERY OF NOSE]

55. REFERENCES:
1. Rhinoplasty-Edited by Michael J. Brenner
2. History of plastic surgery in India. 2002,Vol.: 48 Page : 76-8]
3. Glossary of Rhinoplasty Terms By Dr.Richard E. Davis, MD, FACS.
4. Rhinoplasty: current therapy; omfs clinics of north America, feb2012,vol24
5. Tardy ME, Denney JC. Micro-osteotomies in rhinoplasty. Facial Plast Surg 3:137-145, 1984
6. Sheen JH. Spreader graft: a method of reconstructing the roof of the middle nasal vault following
rhinoplasty. Plast Reconstr Surg 73:230-239, 1984.
7. Text book of rhinoplasty, Dalla’s 3rd edition
8. G.J NOLST TRENITE, RHINOPLASTY. A PRACTICAL GUIDE TO FUNCTIONAL AND AESTHETIC SURGERY OF NOSE
9. Maha Allhaidan, Shatha Al-Shanqeeti, Arwa Almashaan Nose I: Nasal Anatomy and physiology
10. A Practical Approach for Learning Rhinoplasty Surgery, Lee J Kaplowitz, 2, Eric M Joseph, International journal of Head and
Neck Surgery, January-March 2016;7(1):33-46
11. Khan HA. Rhinoplasty: initial consultation and examination. OralMaxillofac Surg Clin North Am. 2012;24(1):11–24. Review.
Andre RF, Vuyk HD, Ahmed A, Graamans K, Nolst Trenite GJ. Correlation between subjective and objective evaluation of the
nasal airway. A systematic review of the highest level of evidence. Clini Otolaryngol. 2009;34(6):518–25.
12. Jon D, Perenack and shahrouj zarrabi rhinoplasty atlas of operative oral and maxillofacial surgery published 2015 nby john wiley.
13. KARIMA ISMAIL, M.D.; MARIAM ISMAIL, M.D. and AHMED ISMAIL, M.D Assessment of Different Types of osteotomies
in Rhinoplasty Patients Egypt, J. Plast. Reconstr. Surg., Vol. 44, No. 1, January: 65-68, 2020
14. Rohrich Rj Mujaffar AR Janis JE, COMPONENT DORSAL HUMP REDUCTION, THE importance of maintaining dorsal
aesthetic line in rhinoplasty. Plast. Reconstructive surgery.2000. oct114;(5):1298-13098]

56. 15.Sykes JM, Senders CW. Surgery of the cleft lip and nasal deformity.Oper Tech Otolaryngol Head
Neck Surg. 1990;1:219–24
16. Mulliken JB, Martinez-Perez D. The principle of rotation advancement for the repair of
unilateral complete cleft lip and nasal deformity: Technical variations and analysis of results. Plast
ReconstrSurg. 1999;104:1247–9
17. Kaufman Y, Buchanan EP, Wolfswinkel EM, Wethers WM,Stal S. Cleft nasal deformity and
rhinoplasty. Semin Plast Surg.2012;26:184–90
18.Becker DG, Pastorek NJ. The radix graft in cosmetic rhinoplasty. Arch Facial Plast Surg 3:115-
119,
2001.

57. THANKYOU