Rhinoplasty oral and maxillofacial surgery

Rhinoplasty

1. Rhinoplasty

2. 2

3. Introduction DEFINITION Procedures aimed at improving the form and/or function of the nose and associated structures.

4. Bony Vault Paired nasal bones Anatomy 4

5. Bony septum: vomer inferior, ethmoid superior 5

6. Cartilaginous Vault Cartilaginous septum Paired upper lateral cartilages (ULC) Paired lower lateral cartilages (LLC) 6

7. Nasofrontal angle: 115–135 °. Nasofacial angle: 30–40 °. Angle formed from a vertical tangent to the glabella through the pogonion and intersecting the line formed through the nasal tip. Ideal Anatomic Relationships 7

8. Nasomental angle: 120–132 °. The angle formed by the tangent line from nasion to the nasal tip and the nasal tip to pogonion . Radix should be 4–9 mm anterior to corneal plane. 8

9. Nasal projection Simons ’ method: length of the upper lip from the vermillion border to columella , and columella to tip ratio should be 1:1. 9

10. Goode method: ratio of radix-nasal tip (RT) and the line drawn from RT to the alar groove should be 0.55–0.6 RT. Retains nasofacial angle from 36 to 40°  10

11. Clinical examination for Rhinoplasty 11

12. Correction of Functional Nasal Deformities 1. Septal deformity : Deviated nasal septum, bone spurs, and internal and external nasal valve deformities 2. Intranasal abnormalities : turbinate hypertrophy, septal perforations , and intranasal pathology 3. Saddle Nose 4. Wide Alar base 5. Bulbous/ boxy tip 6. Over/under rotated tip 7. Deviated nose Indications 12

13. Uncontrolled systemic illness Large septal perforations Unstable nasal support structures secondary to trauma Multiply operated rhinoplasty patient with a scarred or avascular skin–soft tissue envelope (S-STE) Heavy smoker Psychological disorders, such as body dysmorphic disorder, depression , and personality disorders Contraindications 13

14. Open approach or the open structure rhinoplasty approach Closed or the endonasal approach. Surgical Approaches 14

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16. 16 Open or external Approach c Local administration of anesthetic agent Open or external Approach c Marking of Marginal & Transcolumelar incision

17. 17 Incision through the marked lines Use of scissors to dissect the columellar skin off the medial cruse in the subperichondrial plane.

18. 18 Large columellar vein usually encountered Separation of alar cartilage from the skin Dissection carried out in the sub perichondrial plane

19. 19 Dissection of the nasal skin from the alar cartilages. Connections between the septal cartilage and scroll area with the overlying skin

20. 20 Scissors used to dissect through the interdomal ligaments, allowing separation of the lower lateral cartilages Incision on the septal cartilage after removal of inter domal ligaments & dissection of membranous septum

21. 21 Exposure of the nasal septum in the sub periosteal and subchondral plane. Closure after bone augmentation or reduction.

22. 22 Endonasal Approach Marking of Inter cartilaginous incision, Marginal incision & Trans fixation Incision

23. 23 Retraction of the Ala for easy placement of IC, M & TF incision Placement of Inter Cartilagenous Incision

24. 24 Retraction of the Ala for easy placement of IC, M & TF incision Retraction of the Ala for easy placement of IC, M & TF incision

25. 25 Sub mucous elevation of the septum and floor of the nose

26. 26 Submucosal dissection of the septum above and below the areas of adherence followed by closure

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30. Case Report 1 30

31. PERSONAL DETAILS NAME: Mrs. NurJiara AGE/GENDER: 28 years/ Female OPD NO.: 20221110209 ADDRESS : Assam OCCUPATION: Housewife 31

32. CHIEF COMPLAINT Patient complains of gross facial asymmetry since two years. 32

33. History of present Illness Patient was apparently asymptomatic 2 year’s back when there was an argument with her husband which led to physical violence and assault. He hit her with a hammer on the right midface region. Bleeding from mouth was noticed at the time of assault. He took her to the nearest hospital but they denied treatment until the police case resolved. Later after 5 days, she was admitted in GMC guwahati hospital where they advised her to undergo facial correction surgery. She visited ITS dental college for further treatment after 2 years from the time of incident. 33

34. OTHER RELEVANT HISTORY- Dental and Medical history were not relevant. No history of hypertension or Diabetes. 34

35. PERSONAL HISTORY 35 Adequate sleep and appetite. No history of Arecanut chewing or alcohol consumption.

36. General physical examination MENTAL STATE: The patient was fully conscious and oriented to time and place. GAIT: Normal. BUILD AND STATE OF NUTRITION: The patient had a moderate built. (Body weight: 74 kg) Vitals (at the time of admission): Pulse : 72 beats/min Respiratory rate: R egular at 26 breaths/min Temperature: Afebrile (98.6˚F) Blood pressure: 140/90 mm Hg 36

37. PALLOR: ICTERUS: CLUBBING: CYANOSIS: SKIN ERUPTIONS: ABSENT 37

38. Lymph nodes – Non tender, non palpable. Inter incisal distance- 35mm TMJ movements- Normal 38

39. Saddle nose deformity. Depressed maxilla 39

40. Gross facial asymmetry present. \Scar present on left and right ala of the nose. Telecanthus (Widening of the nasal bridge) Lip connected to Ala No pre maxilla Loss of commisure on the right side. 2 tissue tags seen on the left nose. Extra Oral Examination INSPECTION 40

41. Extra oral- Palpation Flattening of fronto -nasal suture 41

42. Intra oral- INSPECTION Deranged occlusion. Palatal malunion on the right side. Loss of labial frenum. Vestibular obliteration in maxillary front tooth region. Maxillary bone shifted medially due to trauma. Collapsed nasal bridge. 42

43. Intra-oral Palpation Fibrosis present on labial vestibule. Healed mid palatal # 43

44. Soft tissue examination- Lips- Distorted, superiorly placed labial commisure at the level of ala of nose. Vestibular depth obliteration from 11 to 15. Loss of tissue in right lip region. Labial mucosa, gingiva and tongue appears to be normal. 44

45. Hard tissue examination- Missing wrt 11,12,13,14,15 and 18. Fracture wrt 31, 41 and 42 Attrition wrt 44, 45 Loss of contact points wrt 1 st and 4 th quadrant. Mild stains and calculus. 45

46. Examination of nose Nasofrontal angle: 148°. Normal range: 115–135°. Nasofacial angle : 32° Normal range: 30–40° 46

47. Examination of nose Distance of Radix to corneal plane = 4 mm Normal range: 4 to 9 mm 47

48. Examination of nose Naso – mental angle = 140° Normal range - 120–132 °. 48

49. Simon’s criteria  ratio was 1.7: 6 49

50. Provisional Diagnosis Residual deformity of nose/maxilla and lip. 50

51. OPG 51

52. Radiographic Evaluation 52

53. Final Diagnosis Post traumatic residual deformity 53

54. Treatment Plan Rhinoplasty and lip revision by buccal advancement flap followed by prosthetic rehabilitation 54

55. Pre Operative Investigations Complete blood count LFT, KFT Bleeding time: 3:30 mins and clotting time: 5:40 mins Random blood sugar: 119.2 mg/Dl Viral markers: HIV 1 & 2, HCV, HBsAg – Non-reactive. Chest X-ray and ECG was done for pre- anaesthetic evaluation of the patient. 55

56. Intra operative procedure- Informed consent was obtained from the patient after describing the complete procedure, benefits and potential risks related to the procedure, administration of general anaesthesia , and post operative complications. Tab. Augmentin 625 mg B.D Tab. Metrogyl 400 mg T.D.S Tab. Dynapar 75mg T.D.S Tab. Rantac 150mg B.D Tab. Emcet 4mg 1 hr before surgery. Establish IV fluids (RL/DNS) @100ml 1 hour before surgery. 56 PRE OP MEDICATIONS

57. Surgical Management Patient was wheeled in the OT with all the necessary investigations at 9:00 am on 16 th Nov/22 Endotracheal intubation was done using left nostril. Patient was draped and painted with povidone iodine solution 5% and then draped under strict aseptic conditions. L.A was infiltered with concentration of 1:2Lac over the planned surgical site using 15 no. blade . 57

58. Standard incision for open rhinoplasty was given starting from the tip of nose and extending to the ala on both sides. Careful dissection was done to expose the cartilaginous area. 58

59. Tunneling was done from the tip of nose extending to the fronto -nasal area, and for bone grafting costochondral graft was obtained using the 6 th rib from the right side. 59

60. 60 L.A was infiltered and incision of about 7mm was given using the electrocautry . Subcutaneous fat tissue was dissected and exposure of pectoralis major and minor muscles were done.

61. 61 5mm rib was harvested and trimming and shaping of fragments was done.

62. Surgical site after rib harvesting 62

63. 63 Drain was placed and secured. Suturing was done using 3’0 vicryl .

64. 64 Placement of bony struts for nasal bridge augmentation

65. Closure of the nasal incision 65

66. LIP CORRECTION Using the existing scar tissue, a Z plasty incision was given on right commisure area and dissection was carried out. 66

67. 67

68. Orbicularis oris was dissected and the fibrosed are was freed from the labial aspect. Muscle was rotated superiorly and a suture was placed by pulling it upwards. 68

69. Skin was sutured using 3’0 vicryl and soframycin soaked gauge was placed in the nostrils followed by placement of plaster pack on the surgical site for initial stability. 69

70. 70 Reversal of GA was done and entire procedure was uneventful.

71. POST-OPERATIVE INSTRUCTIONS AND MEDICATIONS NPO to be maintained till 8:00 pm. Head end elevated at 15 degrees. TPR charting every 2 hourly. Vitals to be maintained. No touching of the surgical site. 71

72. POST-OPERATIVE MEDICATIONS: Inj. Augmentin 1.2 gm I.V. (B.D.) Inj. Metronidazole 100 ml I.V. (T.D.S.) Inj. Rantac 50 mg I.V. (B.D.) Inj. Dynapar 75mg I.V. (TDS) Inj. Dexona 4mg B.D Inj. Emset 4mg I.V. sos POST-OPERATIVE VITALS: Blood pressure- 164/97 mm Hg Pulse- 84 beats/min Respiratory rate- 20 cycles/min Temperature- 98.8° F 72

73. Follow up pictures- Immediate 73

74. After 2 months 74

75. Pre v/s post operative result – Radix to corneal plane Pre operatively  4 mm Postoperatively  7 mm 75

76. Naso – frontal angle Pre operatively  148° 76 Post operatively  150°

77. Naso – mental angle 77 Pre operatively  140° Post operatively  136°

78. Simon’s criteria  ratio was 17: 6 (pre operative) Simon’s criteria  ratio was 19: 14(post operative ) 78

79. Comparative chart – Pre & post operative Anatomic Relations 79 Anatomic Relation Pre Operative Post Operative Normal Range Naso - frontal angle 148 150 115 – 135 Naso mental Angle 140 138 120 - 132 Radix to Corneal Plane 4 mm 7 mm 4 – 9 Simon’s Criteria 17:6 19: 14 1:1

80. Discussion Primary cosmetic rhinoplasty refers to the surgical manipulation of the previously unoperated nose for esthetic enhancement. The alteration of the nose cannot be planned solely in conjunction with the nasal anatomy (radix, septum, dorsum, tip, base) but in relation to the rest of the face. The concept of balanced rhinoplasty refers to alterations of nasal anatomy by reduction, augmentation, or alteration to achieve the anatomic harmony between the radix, dorsum, tip, and alar base. 80

81. The transcolumellar incision with bilateral marginal extensions, also described as the open rhinoplasty technique, has become progressively popular since the 1980s. Reduction of the dorsum is usually done by rasp or osteotomes . 81

82. A thermoplastic nasal splint is used after nasal osteotomies to stabilize the segments, and is kept in place for 1 to 2 weeks. 82

83. A success rate of 94.4% was seen for bone augmentation for rhinoplasty with costal grafts. The incidence of wound infection with costal cartilage was 20%,septal cartilage 17% and auricular cartilage 10%. The incidence of dorsal site morbidity with costal cartilage was 20%,septal cartilage 33% and auricular cartilage 10%. 83 Saeed M, Mian FA. Use of autologus cartilage grafts in augmentation rhinoplasty . Annals of Punjab Medical College (APMC). 2010 Dec 14;4(2):117-21.

84. For smaller defects, non surgical rhinoplasty also called as liquid rhinoplasty can be used but, surgical procedure is much desirable as it is permanent and predictable. Liquid rhinoplasty in the hands of an inexperienced clinician may bring out disastrous effects quite contrary to the expectation of the patient 84 Rohrich RJ, Mohan R. Male rhinoplasty: update. Plastic and reconstructive surgery. 2020 Apr 1;145(4):744e-53e.

85. Also, in non surgical procedures, addition is limitless, but if reduction of the septal height is required, the patient has to go under the knife. Surgery can not only fix the aesthetics but also the functional discrepancies of the patient, which is not possible with non surgical procedures 85

86. Carefully evaluate the nasal anatomy and physiology and patient’s mental state Establish realistic aesthetic and functional goals for the patient and for yourself Prepare a detailed preoperative evaluation and surgical plan Maintain nasal airway function Perform revision procedures only when truly warranted. Conclusion 86