ent

1. Name : Ahmed Mohamed Mohamed Aly
ID : 105

2. - Definition: It‘s a surgical approach in which , all incisions are confined to the nasal
vestibule and surgery is conducted entirely through the nostrils.
- Incisions : 1) hemitransfixion incision or Killian incision
2) intercartilaginous incision
3) transcartilaginous or intracartilaginous incision
4) marginal incision
Closed Rhinoplasty
Types
Non delivery
Cartilage
Splitting
Retrograde
Delivery

3. 1)Tip Reshaping in Closed Rhinoplasty:
- marginal+IC incisions = Delivery
- Reshaping ( Suturing or Sculpting )
Surgical Procedures :
DisadvantagesAdvantages of Closed Rhinoplasty
1.Requires experience and great
reliance on accurate preoperative
diagnosis
2.Prohibits simultaneous
visualization of surgical field by
teaching surgeon and students
3.Makes dissection of alar
cartilage difficult, particularly in
cases of alar malposition
Leaves no external scar.1
Limits Dissection to areas needing modification.2
3.Permits creation of precise pocket so graft material fits
exactly without need for fixation
4.Allows percutaneous fixation when large pockets are
made..
Promotes healing by maintaining vascular bridges.5
6.Encourages accurate preoperative diagnosis and
planning
Reduces operating time.7
Results in fast recovery.8
2)Closed Rhinoplasty Bridge Reshaping
- IC Incision+Elevator = up to the radix
- Skin Retractor then bridge reshaping

4. •Scar hypertrophy
•Polly beak nasal deformity
•Septal perforation
•Nasal valve collapse
•Nasal stenosis
•Bossa formation
•Aesthetic surgical misjudgments
•nasal deformities
•Hemorrhage
•Septal hematoma
•Infection
•Dehiscence of incisions
•Persistent edema
•Skin necrosis
•Sequestra formation
•Cerebrospinal fluid rhinorrhea
•Contact dermatitis
•Nasal blockage
•Olfactory disturbances
•Carotid-cavernous fistula
• Airway obstruction
• Anaphylaxis
• Visual impairment
•Excessive bleeding
•Tears of mucoperichondrial flaps
•Buttonholing of skin & Cautery
burns
•Collapse of bony pyramid
•Disarticulation of upper lateral
cartilage
•Osteotomy complications
Intraoperativ
e
Immediate
postoperative
Late
postoperative
Early
postoperative
Complications

5. A) Intraoperative complications:
1) Excessive bleeding (genetic or acquired) : Coagulopathy ,Primary fibrinolysis,
Inadequate local hemostasis.
2) Tears of mucoperichondrial flaps : previously operated (traumatized) , unilateral
heals , bilateral perforation (suturing+grafts) , opposing tears lead to synechia
3) Buttonholing of skin & Cautery burns : undermining of skin or cauterization ,
avoided by attention.
4) Collapse of bony pyramid : During osteotomy ( previously operated,trauma )
Rasping is indicated instead . Rectification + splint support during healing.
5) Disarticulation of upper lateral cartilage: During rasping , if bilateral = V deformity
Unitlateral=assymetry in the middle third , spreader graft for fixing
6) Osteotomy complications:
-Rocker Deformity:attempted medial narrowing= fracture at the frontonasal+laterlization
Fixed by assuring central septum+medial mobilization of the bone segment(open roof too)
-"Open roof" deformity:the lateral segments fail to align with the septal dorsum = gap
Causes : Greenstick F, failure of medialization , exessive packing , deviated PP of ethmoid.
-"Step" deformity: single lateral osteotomy is performed far too medial=visible ridge
Fixed by repeating the osteotomy at the correct level.
-Perinasal trauma: at Osteotomy(ex-trauma) any previous fracture could be recreated
Orbital cellulitis,nasolacrimal app injury or orbital haemorrhage require ophtalmologist.

6. B) Immediate postoperative complications
1) Airway obstruction ( nasal pack,splint aspiration) : Post-extubation aspiration of blood
= laryngospasm. TTT: a muscle relaxant and reintubation or +ve pressure ventilation.
2) Anaphylaxis: intraoperative antibiotic(bacitracin packing)=Anaphylactic shock.
3) Visual impairment: after local anesthetic and vasoconstrictor injection. This may relate
to vasospasm or thromboembolism causing ophthalmic ischemia.
C) Early postoperative complications:
1) Hemorrhage: source localization after VC, then ligation or cautery (pack&ab cover)
2) Septal hematoma: daily aspiration or large incision and drainage + pack&ab cover to
prevebt septal abcess formtion. 3) Infection
SinusitisIntracranial
infections
bacterial
endocard
itis
TSSSeptice
mia:
Wound
infection
-surgery may
contribute to
ostiomeatal
dysfunction
-If medical TTT
fails , functional
endoscopic
surgery is
indicated.
-Proximity ,Trauma
and blood spread
-meningitis, subdural
empyema, cerebral
abscess, or cavernous
sinus thrombosis
Signs : Headache,
drowsiness, fever,
epilepsy, focal
hemisphere, and
cranial nerve signs
- cardiac
murmur is
a risk
-abs
prophylaxi
s
-Blood
cultures
and
consultati
n.
-caused by s.aureus
-symp:fever, vomiting, diarrhea,
hypotension
erythematous sunburnlike rash
TTT:
-remove packing+cultures
-antistaph abs
-multisystem
investigations+life support
mechanisms
-hemodynmic resuscitation (
O2 perfusion lvls)
-Very
serious
complicati
on
-antibiotic
medication
, steroids,
manageme
nt of
circulatory
failure.
-Localized
cellulitis,
abscesses,
or
granuloma
may
respond to
antibiotics
and
drainage

7. 4) Dehiscence of incisions: Internal=unnoticed(heals) unless synechia formation. The
transcolumellar incision must be considered immediately, or a scar will form.
5) Persistent edema : Factors , TTT , persistent in ext rhinoplasty
6) Skin necrosis:damage=no blood supply,TTT dermabrasion,laser,steroids,skin flap
7) Sequestra formation: infection, extrusion, and deformity (which may be aesthetic
or functional). the infection is first controlled with abs and/or surgical debridement
then reconstruction.
8)Cerebrospinal fluid rhinorrhea: trauma or congenital defect . Detected by Beta2
transferrin. Mostly heals. Persisting leaks need localization and repair by extracranial
and/or intracranial techniques.
9)Contact dermatitis: Dressing in sensitive patient , TTT removal + antihistaminics and
steroids.
10)Nasal blockage: transient=post-op trauma and edema , persistent : vasomotor
rhinopathy or allergic rhinitis that require surgical turbinate debulking if causative.
11) Olfactory disturbances:Transient hyposmia caused by edema , trauma to
neuroepithelium&drugs

8. D) Late postoperative complications
1) Scar hypertrophy: follows ext.rhinoplasty , TTT reduction by intranasal steroids
,laser,dermabrasion by surgical revision
2) Polly beak nasal deformity: loss of Supra tip dib which may be hard(dorsal undercorrection of the
superior part of the septum that’s treated by reduction) or soft ( collection of soft tissue scars that needs
to be excised).
3) Septal perforation Surgical closure with smaller symptomatic perforations. a septal button is
always available.
4) Nasal valve collapse: caused by exessive cephalic trimming of LLC = airway distress . TTT: graft
fixation.
5) Nasal stenosis: related to circumscribed incisions with exessive lining removal . Reconstruction is
essential as it causes airway obstruction .
6) Bossa formation Bossae are protuberances that may arise in the region of the nasal tip. Caused by
destructive rhinoplasty techniques, tip grafts, thin skin, and excessive scarring.
7) Aesthetic surgical misjudgments : Unde or overcorrection = persistence or new deformity
(revision>12months).
8) Upper third deformities deep/shallow nasofrontal angle, widening convexity, overreduction.
9) Middle third deformities : Widening , convexity or saddling
10) Lower third deformities : widening , tip ( boxy tip , pinched tip , projection ) , wide or hanging
columella , alar ( notching , collapse ) nasolabial angle ( retraction , protraction ) . different surgical
interventions are indicated for each deformity.

9. Thank You