Surgical assessment in rhinoplasty

Surgical Assessment in
Rhinoplasty

DJ Menger

International Course in Modern Rhinoplasty Techniques
The Netherlands

www.rhinoplastycourse.nl

Dear colleague,

This presentation outlines the importance of adequate surgical assessment. Pre-operative pictures
together with clinical information will be shown, based on this an assessment of the surgical plan will be
presented. Training of surgical assessment is an important teaching tool and a unique opportunity to gain
knowledge of the surgical anatomy and to study the postoperative outcome of the applied surgical
techniques. Note, there is never just one solution, modifications- or other surgical techniques might
always be an option.

CAUTION: The lecture can contain pictures taken during surgery, which might be shocking. The lecture is
intended for colleagues and is part of the "International Course in Modern Rhinoplasty Techniques".

Dirk Jan Menger, MD
Course Director

The Netherlands


Preoperative evaluation.
This patient had a long nasal dorsum with a short upper-lip.


Surgical Assessment

• limited hump removal

• osteotomies (lateral/oblique)

• septal correction

• reduction of the caudal septum, upper laterals and nasal spine

• thin spreader grafts

• upward rotation of the tip using the "tongue in groove technique"


Pre- and postoperative frontal view.


Pre- and postoperative lateral view.


Pre- and postoperative basal view.


This patient had a slight deviation of the cartilaginous dorsum to the left side, over-projection of the nasal tip
and dorsum, a short and "crowded" upper-lip and malocclusion.


Assessment

• external approach rhinoplasty


• osteotomies; lateral / oblique

• septal correction, harvesting cartilage

• spreader grafts

• tip:
– medial crural overlay
– lateral crural overlay
– suturing

• augmentation of the naso-frontal angle and reduction of the nasal spine


Preoperative condition.
This patient had a collapse of the external nose due to destruction of the cartilaginous nasal septum, as a result
a saddle nose deformity and columellar retraction.


Assessment

• external approach

• irradiated homologous costal cartilage
– dorsal onlay graft
– septal reconstruction
– columellar strut graft

• osteotomies, medial- and oblique


This patient had a severe deviation of the cartilaginous- and bony dorsum.


Assessment


• mild hump resection

• osteotomies; lateral / oblique and intermediate on the left side

• septoplasty

• spreader/splint graft on the left side

• medial- and lateral crural overlay

• reduction of the nasal spine


This patient had a hump deformation, over-projection and under-rotation of the nasal tip and too much
columellar show.


Assessment

• hump reduction


• spreader grafts


• reduction caudal septum and upper laterals

• tip:
– medial- and lateral crural overlay technique
– tongue in groove technique
– cephalic resections
– trans- and interdomal sutures

• wedge resection inner-lining “mucosa” (not skin)


This patient had a pseudo hump deformation, a saddle nose deformity and columellar retraction which was
caused by destruction of the cartilaginous nasal septum.


Assessment




• dorsal onlay graft

• caudal septal extension graft (auricular)


This patient had a very thin skin in combination with bulbous/broad lower lateral cartilages and bony dorsum.


Assessment



• cephalic reduction of the LC

• dome creation sutures and limited medial crural overlay


Pre- and postoperative helicopter view.


This patient had a bulbous, drooping tip and a hump of the cartilaginous/bony dorsum.


Assessment




• sepal correction and harvesting cartilage

• columellar strut graft

• cephalic trim of the LC

• tip sutures; inter- and transdomal


Pre- and postoperative oblique view.


This patient had very prominent domes of the lower lateral cartilages, over-projection of the nasal tip and some
columellar retraction


Assessment


• limited lateral- and medial crural overlay



This patient had a broad nasal dorsum after septoplasty, insufficient support of the upper lateral cartilages.


Assessment


• reconstruction of the L-strut of the nasal septum

• lateral and oblique osteotomies, infraction of the bony pyramid

• small dorsal onlay graft (auricular or rib)


This patient had a very broad nasal dorsum and breathing problems due to a severe septal deviation.


Assessment

• septoplasty

• osteotomies, medial-, lateral- and oblique

• limited strip of the upper laterals (caudal to cephalic orientation)


This patient a mild hump deformation, over-projection of the nasal tip with mild under-rotation.


Assessment




• cephalic strip of the lateral crura

• lateral crural steal, suture technique

• medial crural overlay



This patient had collapse of the cartilaginous nasal skeleton due to over-resection of the nasal septum.


Assessment


• septal reconstrucution of the L-strut

• osteotomies, lateral- and oblique; infraction of the pyramid

• dorsal onlay graft (auricular or rib)



Pre-operative condition.
This patient a mild hump deformation and over-projection of the nasal tip.


Assessment




• spreader grafts

• limited medial- and lateral crural overlay


This patient had a deviation of the nasal dorsum to the right side.


Assessment



• osteotomies; lateral / oblique and intermediate on the left side (long nasal bone)

• septoplasty

• spreader/splint on the left side

• limited cephalic resection of the lateral crus

• tip sutures; inter- and transdomal


This patient had a deviation of the nasal dorsum to the left side in combination with over-projection of the
nasal tip.


Pre-operative condition.
The caudal part of the nasal septum was deviated to the left side.


Assessment


– Fixation of the caudal border to the anterior nasal spine
– "splinting" technique

• reduction of the cartilaginous septum

• osteotomies, lateral and oblique

• spreader grafts

• tip: inter- and transdomal sutures, limited cephalic strip of the LC’s


This patient a deviation of the cartilaginous and bony dorsum to the right side.


This patient had a hump deformation and too much columellar show due to a combination of a long caudal
septum / nasal spine and mild retraction of the ala.


Assessment


• hump resection



• reduction of the anterior nasal spine and caudal septum

• composite graft alongside the lateral crus (reduce alar retraction)


• trans- interdomal suture techniques


This patient had a deviation of the very narrow cartilaginous dorsum to the right side.


Assessment


• septoplasty

• osteotomies: lateral / oblique

• spreader / splint grafts

• small alar batten grafts


This patient had underdevelopment of the nasal dorsum and a deviation of the nasal septum.


Assessment



• dorsal onlay graft

• septoplasty and caudal septal extension graft


This patient had a mild concavity on the left side of the cartilaginous- and bony nasal dorsum.


Assessment



• spreader graft on the left side

• tip; inter- and transdomal sutures


Preoperative evaluation
This patient had over-projection of the nasal dorsum and tip, with a crowded upper-lip.


Assessment




• spreader grafts

• cephalic trim of the lateral crura


• trans- and interdomal sutures

• augmentation of the naso-frontal angle


This patient had complaints of an irregular and over-projected nasal dorsum and tip. There was a concavity in
the mid nasal third on the right side and breathing problems due to a strong deviation of caudal nasal septum.


Assessment


• reduction of the cartilaginous- and bony dorsum

• osteotomies: lateral and oblique

• septoplasty, including splinting of the caudal septum

• spreader graft on the right side

• medial- and lateral crural overlay technique


• trans- and interdomal sutures


This patient had a mild deviation of the cartilaginous and bony nasal dorsum to the left side.


Assessment


• osteotomies; lateral / oblique and intermediate on the right side

• septoplasty

• spreader / splint graft on the right side


This patient had a severe saddle nose deformity


This patient had a deviation of the nasal tip to the left side due to an under-development of the ala on the left
side. In the lateral view a hump deformation, drooping tip with very acute naso-labial angle and a deep naso-
frontal angle.


Assessment




• septoplasty

• spreader grafts


• reconstruction of the lateral crus on the left side and Z-plasty of the ala

• lateral crural overlay of the right LC

• tongue in groove technique

• trans- and interdomal suture techniques www.rhinoplastycourse.nl

This patient had a thick soft-tissue envelope, a hump deformation and under-projection of the nasal tip.


Assessment





• shield graft

• alar rim grafts


This patient had nasal trauma in the past, complete destruction of the nasal septum in childhood. The nasal
skeleton is underdeveloped.


Assessment



• dorsal onlay graft (rib cartilage)

• caudal septal extension graft (auricular cartilage)

• Columellar strut graft

• Tip sutures, inter- and transdomal


This patient had a hump deformation and deviation of the nasal dorsum to the right side, a bulbous- and
drooping nasal tip.


Assessment




• septoplasty


• cephalic trim of the lower laterals

• trans- and interdomal suturing


This patient had a mild hump deformation and over-projection of the nasal tip.


Assessment





• lateral- and medial crural overlay



This patient had a saddle nose deformity due to destruction of septal cartilage after septoplasty performed
elswhere. Note the columellar retraction and the relative long upper-lip due to absence of the caudal part of
the septum.


Assessment




• dorsal onlay graft (rib / auricular)

• reconstruction of the L-strut / septal replacement graft (auricular)


This patient had a concavity of the bony- and cartilaginous dorsum on the left side.


Assessment


• septoplasty

• osteotomies; lateral and oblique, out-fracture on the left side

• spreader graft on the left side

• limited cephalic resection of the LC's



This patient had severe retraction of the ala on the left side with too much columellar show.


Assessment

• Auricular composite graft alongside the lateral crus on the left side.

• Shortening the caudal septum


This patient had a saddle nose deformity due to displacement of the nasal septum after trauma, insufficient
support of the nasal dorsum.


Assessment


• mild hump reduction


• septoplasty

• dorsal onlay graft (auricular)



This patient had a concavity on the right side of the nasal dorsum and a bony- and cartilaginous hump.


Assessment


• hump reduction


• spreader graft on the right side


• cephalic reduction of the LC's




This patient had insufficient support of the cartilaginous dorsum and nasal tip.


Assessment


• bony hump reduction

• lateral- and oblique osteotomies

• reconstruction of the L-stut of the nasal septum (rib grafts)

• lateral crural steal suture technique


• spreader grafts


This patient had under-rotation of the nasal tip, a mild hump and deviation of the dorsum to the left side.


Assessment



• osteotomies; lateral- and oblique

• septoplasty


• lateral crural steal suture technique



This patient had over-projection and too much upward rotation of the nasal tip.


Assessment

• external approach

• reduction of the cartilaginous dorsum

• septoplasty and caudal septal extension of the dorsal part


• reduction of the anterior nasal spine

• columellar strut


This patient had a hump deformation, over-projection and downward rotation of the nasal tip and a "crowded
upper-lip"


Assessment


• hump reduction

• osteotomies; lateral and oblique






This patient had a deviation of the bony- and cartilaginous dorsum to the right side.


Assessment


• osteotomies; lateral and oblique and intermediate on the left side

• septoplasty

• spreader / splint on the left side

• trans- and interdomal tip sutures


This patient had a hump deformation, over-projection and under-rotation of the nasal tip.


Assessment


• hump resection

• osteotomies; lateral and oblique

• spreader grafts

• medial- and lateral crural overlay technique




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Surgical assessment in rhinoplasty

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