Rhinoplasty

rhinoplasty ppt

1. RHINOPLASTY Dr.Disha sharma Junior Resident ENT-HNS

2. HISTORY Began - ancient egypt and I ndia. Description of nasal reconstruction in Susruta samhita (500 B.C.) 1887 - John Orlando Roe performed first intranasal rhinoplasty . Jacques joseph – father of modern facial plastic surgery – published his Treatise on rhinoplasty .

3. Anatomy

4. Surface landmarks

5. Key stone area

6. Weak zone

7. Facial aesthetics

8. Facial aesthetics

9. Facial analysis – tip rotation Tip rotation generally occurs along an arc produced by a radius based at the external auditory canal.

10. Tip projection An ideal nasal profile in a patient in whom the nasal tip leads the supratip cartilaginous dorsum by 1 to 2 mm.

11. Simon’s nasal projection is approximately equal to the length of the upper lip with a ratio of 1:1.

12. Goode’s method of tip projection. Nasofacial angle (30 to 40 degrees).

13. Clinical Assessment Routine investigation Clinical assessment Assess external nasal deformity Quality of skin Facial analysis Photographic documents

14. Basic principles to be taken care…… Be conservative Should know where to stop Never promise miraculous results after surgery Beware of psychotic patients C onsent

15. External nasal deformities Tip Bulbous Bifid Overprojected Underprojected Tip ptosis Columella Retracted Deviated Broadened

16. Alar cartilage Pinching/flaring Osseocartilagenous vault Deviated Bony/ cartilagenous /both Saddle Bony/ cartilagenous /both Hump Bony/ cartilagenous /both Tension nose

17. Tip deformities

18. Tip Recoil Tip Recoil is defined as the inherent strength and support of the nasal tip. It can be evaluated by depressing the tip towards the upper lip and watching for the tip's supportive structure to spring back into position. If the recoil is good, and the tip cartilages resist the deforming influence, then tip surgery can usually be performed without fear of substantial support loss. 9/25/2016 Prof Sameer ALI Bafaqeeh 26

19. Columellar defects

20. Alar cartilage deformity Pinched alar cartilage .flared alar cartilage

21. Osteocartilagenous vault deformities

22. Quality of skin Thick skin Masks refinement and definition Failure to contract – excess soft tissue scar Does not show small irregularities Thin skin Small irregularities become visible Early healing Less oedema Ensure that all bony, cartilageneous grafts or implants are precisely positioned and smoothly contoured.

23. Facial analysis Nasal tip Rotation Projection Nasofrontal angle Facial aesthetics

24. Clinical photographs

25. Types of rhinoplasty Open approach Closed approach External rhinoplasty endonasal rhinoplasty Trans columellar incision incisions positioned inside the nostril

26. External rhinoplasty

27. Indications Extensive revision surgery Severe nasal trauma Congenital deformities: cleft lip nose Marked tip deformities Elaborate reduction and augmentation procedures Correction of extreme overprojection

28. Principles of external rhinoplasty Incision- mid- columella incision connected to bilateral marginal incision Dissection in subperiosteal and subperichondrial planes Division of medial intercrural tissue offers access to caudal septum and premaxillary spine Division of upper lateral cartilages from quadrilateral cartilage offers acccessability to whole of septum

29. Advantages Extensive exposure for both septal and rhinoplasty surgery Binocular vision Use of both hands Control of bleeding and diathermy precise placement and suturing of struts,battens and shield grafts Valve area preserved

30. Techniques Cartilage resections Lateral /medial crura Alar cartilage modifications and reorientation Complete strip Interrupted strip

31. Surgical technique Broken transcolumellar incision If columella short in case of cleft lip-V incision Mid- columella incision situated above medial crural foot plates Vertical columellar incision made 1.5-2mm inside vestibule Separate lateral incision given which is joined medially over the domes

32. Surgical technique…… Dissection carried in midline just cephalic to dome subperichondrial plane Dissection of soft tissue of bony pyramid should start above caudal end of nasal bone Nasal septum- between medial crurae of lower lateral cartilage or hemitransfixion incision Strut used to correct buckled medial crura ,strengthen weak medial crura ,correct tip asymmetries ,stable base for tip graft

33. Specific applications The bony pyramid in external rhinoplasty Allows use of burr or reduction of the soft tissue envelope at nasion to deepen the nasofrontal angle Application of soft tissue onlay grafts Bony dehumping together with lateral, medial, and intermediate osteotomies The middle nasal vault Placement of cartilaginous strips or spreader grafts to open up the nasal valve area and angles

34. Middle nasal vault Shaded areas showing placement of spreader grafts

35. Reduction Rhinoplasty

36. Indications… Patients with ideal height and position of the nasion associated with excess dorsal convexity Oversized alar cartilages producing increase tip and lobule volume

37. Aims Aim-strong nasal dorsum in lateral profile-relates to ideal nasion height Tip defining point-projecting just above dorsal line-to create supratip break. In males may be on a straight line with dorsum

38. Contraindications Underprojected tip pseudohumps Deep radix (deep root) of nose Short over-rotated nose Triad of thin skin delicate alar side walls bifidity

39. Techniques Nasal tip surgery Dehump Osteotomies

40. Tip surgery Cephalic trim for volume reduction of lower lateral cartilage done Transcartilagenous incision 5mm of continous Strip of lateral crus of Lower lateral cartilage Is preserved . for rotation excision Of caudal end of septum

41. Cartilage strip incision for cephalic strip excision of lower lateral cartilage

42. Dehump Nasal hump Bony Cartilagenous Both Minimal bony hump can be reduced by using endonasal approach with just rasping Small cartilagenous humps only require shaving of cartilagenous ridges of the septal dorsum Dorsal hump which involves both cartilagenous and bony vault open approach is preferred

43. Cartilagenous dorsum is reduced first. Blade no. 15 is held at the key area in horizontal plane to incise across left upper lateral cartilage, quadrilateral cartilage and right upper lateral . Advanced caudally in the plane of reduction this transects the upper lateral cartilage and cartilagenous septum. Osteotome is then inserted under the cartilagenous segment removing the osteocartilagenous hump en bloc

44. The Dorsal Hump

45. Osteotomies Medial osteotomy Lateral osteotomy Low to high Low to low Transverse osteotomy Intermediate osteotomy

46. Medial osteotomy It seperates the nasal bone from the septum Made on both side Nasal bone seperated at intranasal suture Short intercartilageneous given

47. Outer peritosteun is pushed to the side Osteotome is placed at about 2mm paramedially Osteotome is worked through the bone slightly below the level of frontal bone

48. Lateral osteotomy

49. It seperates the lateral bony wall of pyramid from nasal process of maxilla Short lateral incision is given Medial to lateral subperiosteal tunnel is formed upto level of medial canthus Osteotome placed across frontal process of maxilla Lateral osteotomy done upto the level of frontal bone

50. Tranverse osteotomy Seperates the bony pyramid from frontal bone and nasal spine of frontal bone Osteotomy made at a level just below nasion

51. Complications Polybeak appearance Inverted v deformity Flat nose Senstivity and pain

52. Augmentation rhinoplasty

53. Saddle nose Pug nose or boxer nose

54. Aetiology Trauma Nasal surgery Familial/ethnic Infections Chronic Inflammatory conditions tumour

55. Daniel and Brenner Classification for saddle nose TYPE TERM DESCRIPTION pseudosaddle relative depression of cartilaginous dorsum relative to bony septum

56. Type 1 minor minor decrease in septal support cosmetic supratip depression and columella concealment retraction

57. Type 2 moderate cartilage vault collapse, columella cartilage retraction,loss of tip support vault reduced projection restoration

58. Type3 major obvious depression, flattening of composite of middle vault,drop in septal dorsum reconstruction and roof. Upward rotation of nasal tip

59. Type 4 severe large septal deformity involving bony structural vault reconstrution

60. Type 5 catastrophic massive defect requiring total construction

61. Properties of implant materials Noncarcinogenic and nonimmunogenic Not toxic Nondestructive , should not impede healing Physical properties match the local tissues Nonresorbable Easily available Cost effective easy to sterilize

62. Graft Materials Autografts - cartilage, bone, dermis and fascia Homografts - Irradiated rib, pooled acellular dermis Xenografts - Leather, duck's sternum, bovine cartilage Precious metals - Titanium, gold, silver, metal alloys Inert bioimplants - Coral, ivory Synthetic compounds - Silicone, polytetrafluoroethylenes , polyamide mesh

63. Synthetic biomaterials Silicone Teflon Proplast Gore-tex Medpore Mersiline Titanium ceramics

64. Type of autografts Septal cartilage Auricular cartilage Costal cartilage Bone graft

65. Septal cartilage graft H arvested using hemitransfixion /transfixion/external approach H arvested posterior to an imaginary line drawn from anterior nasal spine to osteocartilagenous junction Septal cartilage is more rigid and easier to carve and shape

66. Conchal cartilage Conchal cartilage of 3.5cm in length ,antihelix fold to be kept intact Can be harvested by anterior or posterior approach For anterior approach incision is given just anterior and deep to antihelical fold Skin is elevated from underlying cartilage by blunt dissection upto the posterior edge of external auditory meatus

67. Costal cartilage Straight rib cartilage harvested from 6 th to 8 th rib through 3-4cm skin incision Rectus muscle is split vertically and retracted

68. Management .. Surgical approach External approach preferred Suture fixation Reduces risk of infection Preparation of graft and implant Use template to achieve the exact size Avoid abrupt edges Suture fixation in case layered cartilage graft

69. Preparation of bed Level base to avoid rocking Rasped to remove irregularities Splinting Percutaneous securing sutures Taping the skin of the nose down External nasal splint

70. Deviated nose

71. Principles of surgical correction Deviation and a dorsal hump – reduction technique Deviated nose without dorsal hump- septal surgery Deviation with saddling- augmentation

72. Treatment of upper nasal third (bony pyramid) Medial ,lateral ,transverse percutaneous osteotomies at the level of medial canthus allow shifting of the pyramid back to the midline Minor deformity treated by unilateral osteotomies Disruption of key stone area can lead to notching of dorsum,saddling .

73. Septal reconstruction Bony septum Resection of most prominent and curved part Cartilagenous septum Resection of redundant and displaced cartilage Scoring concave surface of carilage Correction of subluxated caudal septum

74. Treatment of middle third Shaving of the convex part of the septum Use of bilateral and unilateral spreader graft Staggered cuts to weaken bowed cartilage

75. Treatment of lower third If nasal spine central –post septal angle should be sutured with figure of eight Locking technique- untrimmed displaced caudal septum is placed on contralateral side of thinned nasal spine Absent caudal septum with deviated tip will require replacement with graft.

76. Nasal tip and nasolabial angle

77. Tip Support Mechanisms Major: size, shape, and resiliency of the medial and lateral crura . fibrous attachment of the medial crural footplates to the caudal septum. attachment of the caudal margin of the upper lateral cartilages to the cephalic margin of the alar cartilage. Minor: dorsal cartilaginous septum, interdomal ligaments, membranous septum, nasal spine, surrounding skin and soft tissues, and alar sidewalls.

78. Tripod Theory 9/25/2016 97

79. Surgical approach Incisions Transcartilaginous Intercartilaginous Columellar break incision Marginal incision Approaches Delivery of tip cartilages Non-delivery of tip cartilages Open approach Retrograde approach Techniques Volume reduction with residual complete strip Volume reduction with suture reorientation of residual strip Interrupted strip

80. Transcartilagenous Incision Incise through vestibular skin Similar to intercartilaginous , but 3-5 mm caudal to the cephalic end of LLC This is caudal to the nasal valve Decreases risk of nasal obstruction (avoids scar contracture of the valve)

81. Transcollumellar and marginal incision External approach Crosses collumella just above flared ends of the medial crura Vertical columellar incision placed 1-2 mm inside the vestibule Separate lateral incision given along the caudal margin of lower lateral cartilage joined medially over the domes.

82. Tip defining procedures Methods Removal of cephalic strip of lower lateral cartilage Vertical division with or without strip excision of lower lateral cartilage Tip suturing Tip graft Approximately 10mm of lower lateral cartilage left intact Lateral part of the cartilage left intact

83. Tip suturing technique Interdomal suture –to narrrow the nasal cartllage Technique for narrowing and rotation of the nasal tip Suture contouring of the nasal tip used to support grafts such as columellar strut to strengthen media; crura and enable tip projection

84. Underprojected nasal tip Cause Small alar cartilage Middle and upper third disproportionately large Maxillary n mandibular abnormality Methods of increasing tip projection Goldman tip Onlay graft Lateral crural steal Shield graft

85. goldman tip and crural strut Vertical dome division of dome 2mm or lateral to the apex cause lengthening of medial crura segment Allows increase tip projection Cartilage strut 3-4 mm wide placed and sutured between medial cruras Onlay graft graft over the alar cartilage

86. onlay tip grafts

87. lateral crural steal Alar cartilage resected in intermediate crural area alar cartilage may be delivered lateral crura advanced to medial crura and sutured tip advancement and tip rotation

88. Shield grafts In 1975 by Sheen Indication- Narrow middle nasal Vault Underprojected tip Weak lower lateral Cartilage Incision- marginal Or via external rhinoplasty

89. Columellar struts

90. Overprojecting tip Cause Overdevelopment of alar cartilage/ nasal spine/caudal Septum/quadrangular cartilage dorsum Elongated columella Iatrogenic overprojection Methods of reduction transfixion excision Vertical dome division ( goldman ) Medial and lateral vertical segment excision

91. Vertical dome division – Irwing Goldman in 1957 Tip delivery approach Vertical division of alar dome 1mm lateral to highest point of dome intermediate crura rotated anteriorly intermediate crura sutured with medial crura Medial crura stabilized their height trimmed

92. Tip Rotation T echniques Complete strip technique Interrupted strip technique Lateral interruption Medial interruption Lateral interruption with suture rotation

93. Complete Strip Techniques 9/25/2016 118

94. Interrupted Strip Techniques

95. Revision rhinoplasty

96. common deformities…. Polybeak Dropping tips Uncorrected broad nasal tip Irregularities on nasal dorsum

97. Polybeak deformity Causes Drooping of nasal tip Absolute or relative high septal angle Reconstruction Increase of tip projection Reduction of cartilagenous nasal dorsum Combination of both

98. Nasal Dorsal Irregularities More prominent in thin skinned patients- tension nose Most common site is K area Small bony irregularities can be easily rasped Cartilagenous are made smooth with knife or scissors Autogenous grafts-from radix to septal cartilage Crushed septal cartilage strut preferred

99. Columella deformities Acute nasolabial angle Retraction of columella Cause- Overresection of caudal septal end Resection of anterior nasal spine Creation of columella pocket between medial crura Correction- Distance between columellar skin and caudal septum by inserting a cartilage strut

100. Overshortened Nose Patients with this tend to take legal Action Too much cartilage or vestibular Skin removed from lateral cartilage

101. 1 septal-columella graft 2 spreaded graft between upper lateral cartilage 3interposition graft B/w upper and Lower lateral cartilage

102. Thank you