Rhinoplasty

Nasal Anatomy & Pre-op Eval - Blueprinting the Beak

• Bony Vault: Nasal bones, maxilla (frontal process).
• Cartilaginous Vault:
  • Septal cartilage: Key for dorsal/caudal support.
  • Upper Lateral Cartilages (ULCs): Articulate with nasal bones superiorly, septum medially, LLCs inferiorly.
  • Lower Lateral Cartilages (LLCs): Medial, middle, lateral crura; define tip shape & projection.
• Nasal Tip Support Mechanisms:
  • Major: LLC size/strength, medial crura attachment to caudal septum, ULC-LLC scroll area.
  • Minor: Interdomal ligaments, sesamoid cartilages, skin-SMAS envelope.
• Pre-operative Evaluation:
  • History: Aesthetic goals, functional symptoms (e.g., obstruction).
  • Examination: Skin thickness, palpation of bony/cartilaginous framework.
  • Frankfort Horizontal Plane: Tragion to infraorbital rim; standard for facial analysis.
  • Photographic Views: Standard 6 views (AP, base, R/L lateral, R/L oblique).
  • Indications: Aesthetic deformity, post-traumatic defects, functional airway compromise.
  • Contraindications: Unrealistic expectations, Body Dysmorphic Disorder (BDD), active nasal/sinus infection, significant coagulopathy.

⭐ The scroll area, the junction of the caudal edge of the ULCs and the cephalic edge of the LLCs, plays a crucial role in internal nasal valve function and airway resistance.

Rhinoplasty Techniques - Sculpting the Snout

• Approaches: Decision based on complexity & surgeon preference.

• Key Maneuvers:
  • Hump Reduction: Cartilaginous (Scrubb technique) & bony (osteotomes/rasps).
  • Osteotomies: To narrow nasal bones or close open roof deformity.
    • Lateral: From pyriform aperture to medial canthus (curved/straight).
    • Medial: Oblique or transverse, from caudal bony dorsum.
  • Tip Modification:
    • Suturing: Cephalic trim, interdomal, transdomal sutures.
    • Grafts: Columellar strut (tip support), tip grafts (definition).
  • Spreader Grafts: Placed between upper lateral cartilages & septum.

⭐ Spreader grafts are crucial for widening the middle nasal vault and improving internal nasal valve function, addressing nasal obstruction.

• Other Grafts: Dorsal onlay, alar batten, rim grafts.
• Closure: Meticulous, multi-layered closure for optimal healing.

Grafts & Implants - Borrowing Beauty Bits

• 📌 Autograft sources: Septal, Conchal, Costal (SCC).

Post-op Care & Complications - Nose Job Aftermath

• Immediate Post-op:
  • Nasal packing (optional, up to 24-48h); external splint (7-10 days).
  • Head elevation, ice packs for edema/ecchymosis (peaks 48-72h).
  • Analgesia, prophylactic antibiotics.
• Early Complications:
  • Bleeding: Most common. Packing, vasoconstrictors, or cautery.
  • Infection: Cellulitis, abscess. Systemic antibiotics.
  • Septal Hematoma: Fluctuant, bluish septal swelling. Urgent I&D to prevent cartilage necrosis.

• Late Complications:
  • Pollybeak Deformity: Supratip fullness.

    ⭐ Pollybeak deformity is often due to under-resection of supratip cartilage, over-resection of bony dorsum, or excessive scar tissue.

  • Inverted V Deformity: Visible upper lateral cartilage (ULC) edges.
  • Saddle Nose: Dorsal nasal collapse.
  • Nasal Valve Collapse: Airway obstruction.
  • Persistent asymmetry, numbness, or pain.
• Management: Varies; observation, medical (e.g., steroid injections for scar), or revision surgery for persistent functional/aesthetic issues.

High‑Yield Points - ⚡ Biggest Takeaways

• The nasal dorsum consists of bony (nasal bones, maxillary frontal process) and cartilaginous (Upper Lateral Cartilages, septum) parts.
• Major tip support mechanisms involve alar cartilages, medial crural footplate attachment to septum, and the scroll region (interlocking ULCs and LLCs).
• Open rhinoplasty employs a transcolumellar incision for wide exposure; closed approaches use endonasal incisions (e.g., marginal, intercartilaginous).
• Septal cartilage is the preferred graft material due to its strength and proximity; conchal and costal cartilage are alternatives.
• Common complications include saddle nose deformity (dorsal collapse), pollybeak deformity (supratip fullness), and persistent nasal obstruction.
• The Cottle maneuver (lateral cheek traction) helps diagnose internal nasal valve collapse as a cause of obstruction.
• Ideal nasolabial angle is 90-95° for males and 95-105° for females; crucial for aesthetic outcomes.