Rhinoplasty

Dr. Vishal Sharma

External nose anatomy
External nose anatomy
External nose anatomy
Keystone area
Bone
removal at
this area
leads to
nasal
collapse
External nose anatomy
Nasal valve
Naso-frontal & naso-labial angles
Facial proportions
Facial proportions
Changes of aging
 Etiology of nasal deformity
Hereditary: Large dorsal hump

Traumatic: Crooked nose from road accident

Iatrogenic: Unfavourable results from previous

rhinoplasty

Congenital: Cleft palate nasal deformity

 Pre-op photography
Frontal view

Basal view

Right lateral view

Left lateral view

Right lateral oblique view

Left lateral oblique view

Computerized planning
 Nasal anatomy analysis
General: skin vascularity, mobility, thickness

Nasal length

Nasal dorsum: upper 1/3, middle 1/3, lower 1/3

Nasal tip

Nasal base including nasal alae

Naso-labial angle & naso-frontal angle

Nasal septum
 Rhinoplasty Indications
Aesthetic deformity

Patient request for a change in nasal shape

Improvement of anatomic nasal obstruction

Best candidate = physically healthy, mentally stable

& realistic in expectation looking for

improvement & not perfection of nose

Rhinoplasty Contraindications
Unstable mental status e.g. schizophrenia

Unrealistic patient expectations

Previous rhinoplasty within last 9-12 months

History of multiple rhinoplasties resulting in an

atrophic skin & significant scarring

Nasal cocaine users

Rhinoplasty Incisions
 Inter-cartilaginous: b/w upper lateral & alar cartilage
Marginal (rim): along caudal border of lateral crus of
alar cartilage, continued anteriorly along anterior
border of medial crus
Intra-cartilaginous (cartilage splitting): midway b/w
marginal & cartilage slitting incision, through
lateral crus of alar cartilage
Rethi Goodman (gull wing or flying bird):
connecting B/L marginal incisions at foot end of
medial crus by transverse inverted V-shaped incision
across columellar skin
Endonasal incisions
Inter-cartilaginous incision
Inter-cartilaginous incision
Cartilage splitting incision
Marginal (rim) incision
Gull wing incision
 Rhinoplasty approaches
Endonasal (closed) approach:

Incisions placed inside nasal cavity only

External (open) approach:

Incisions placed inside nasal cavity & outside on

columella (Rethi Goodmans gull wing or flying bird

incision)
Open Rhinoplasty
 Rhinoplasty Techniques
1. Aesthetic Rhinoplasty
Augmentation rhinoplasty: for saddle nose
Reduction rhinoplasty: for hump nose
Corrective rhinoplasty: for crooked nose
Nasal tip rhinoplasty: for tip deformities
Alar rhinoplasty: for alar / basal deformities
Revision rhinoplasty: for surgical complication
2. Reconstructive Rhinoplasty: for soft tissue
defect (congenital, trauma, tumor surgery)
Augmentation
Rhinoplasty for
saddle nose
 Saddle nose
Saddle nose: structural compromise of naso-septal

cartilage causing loss of nasal dorsal height (> 3 mm)

from line joining nasal tip with nasion

Causes: A. Congenital

B. Acquired: Trauma, Iatrogenic (rhinoplasty, SMR),

Infection, Granulomatous disorders, Cocaine use

 Graft materials
Autograft: auricular cartilage, septal cartilage, rib
cartilage, iliac crest

Homograft: irradiated rib, pooled acellular dermis

Xenograft: duck's sternum, bovine cartilage

Metal: titanium, gold, silver

Inert bio-implant: coral, ivory

Synthetic: silicone, poly-tetra-fluoro-ethylene (Gore-

Tex), polyamide mesh
Harvesting of conchal
cartilage
Iliac crest bone graft
Gore-Tex
Pre-op vs. post-op
Pre-op vs. post-op
 Reduction
Rhinoplasty for
hump nose
Pre-operative planning
Removal of cartilaginous hump
Removal of cartilaginous hump
Removal of cartilaginous hump
Removal of bony hump
Removal of bony hump
Nasal Osteotomes
Nasal Rasps
Removal of bony hump
Pre-op vs. post-op
Pre-op vs. post-op
Rhinoplasty for
crooked nose
Types of external
nasal deformity
Right, Right, Right Left, Left, Left
Right, Right, Centre Left, Left, Centre
Centre, Right, Right Centre, Left, Left
Centre, Right, Centre Centre, Left, Centre
Nasal Osteotomy
Lateral & medial osteotomy
Lateral osteotomy
Medial & Lateral osteotomy
Pre-op vs. post-op
Pre-op vs. post-op
Alar Rhinoplasty
 Alar flare reduction

Weir technique Joseph technique

Alar flare reduction
Pre-op vs. post-op
Pre-op vs. post-op
Rx of nasal valve collapse
Rx with alar batten grafts
Rx with composite grafts
Alar rim collapse
Rx with alar rim grafts
Pre-op vs. post-op
Spreader graft
Tip Rhinoplasty
 Andersons tripod

right & left lateral crura comprise two legs of tripod,

two conjoined medial crura function as third leg
Lateral Crural Overlay
Lateral Crural Overlay
Lateral Crural Overlay
Medial Crural Overlay
Goldman technique
Tip narrowing
Tip narrowing
Tip narrowing
Shortening of long nose
Cephalic trimming of alar cartilage
Cephalic trimming of alar cartilage
Shield graft
Plumbing graft
Nasal pack + splint
Nasal splint
 Nasal Tip
Rhinoplasty
an
interesting case
Basal View
Lateral Views
Collapse of Nasal Tip
Nasal tip made free
Nasal tip pulled anteriorly
Nasal tip sutured
Pre-op vs. POD-14
Pre-op vs. POD-14
 Rhinoplasty
Complications
 Bossae formation: knuckling of lower lateral
cartilage at nasal tip due to contractural healing
forces on weakened cartilages
Polly-beak deformity: fullness of supra-tip area

Inverted V deformity: inadequate support of

upper lateral cartilages (after dorsal hump
removal) causing their infero-medial collapse
Rocker deformity: if osteotomy taken too high into
thick frontal bone, superior aspect of nasal bone
projects or rocks laterally
Scooped out nasal bridge
Tip bossae (knuckle)
Over-projected tip Polly beak deformity
Open roof (Rocker) deformity
Nasal valve collapse
Inverted-V deformity
Hanging columella Pig nose
Residual DNS
Summary of complications
Summary of complications
Reconstructive Rhinoplasty
Reconstructive Rhinoplasty
Reconstructive Rhinoplasty
Thank You