Columella, nasal floor, nasal rim (caudal border of the lower lateral cartilages).
What comprises the internal nasal valve?
Junction of dorsal septum and the medial edge of the ULC. The head of the inferior turbinate also contributes to airway resistance.
Summarize the intranasal incisions
Intercartilaginous – made between the caudal margin of the ULC and cephalic margin of LLC. Transcartilaginous incision – made 5-8mm cephalic to the caudal margin of the lateral crus of the LLC. Marginal incision – made just caudal to the caudal edge of the LLC.
Should you begin with medial or lateral osteotomies?
Medial osteotomies are performed before
lateral osteotomies to prevent creation
of a free floating segment of nasal bone
What kind of deformity can result from separation between the nasal bones and their attachement to the ULCs?
Inverted V deformity
What surgical techniques can help get rid of a boxy tip?
Suture reshaping the domes (interdomal and transdomal sutures), vertical dome division, nasal tip cartilage onlay graft, shield graft
Major sources of nasal tip support
- direction, strength, resiliency of lower lateral cartilage
- medial crura attachment to the inferior septal angle
- attachment of the lower and upper lateral cartilage
Elements of minor tip support
interdomal ligament between lower lateral cartilages
soft tissue envelope (skin/muscle and its attachement to the alar cartilage)
anterior nasal spine
cartilaginous septal dorsum
angle between external nose and forehead, 115-130 degrees (more obtuse end more favorable in females)
angle defined by nasion-to-tip line intersecting with tip-to-pogonion line
glabella-to-pogonion intersecting with nasion to tip line.
30 to 40 degrees
How is tip rotation measured? What are the ideal angles in men and women?
What is the ideal tip projection?
3:4:5 rule. Columella:base:dorsum
Goode method: from nasal tip to alar crease divided by nasion to nasal tip should be 0.55-0.6
Appropriate amount of columellar show
What is appropriate lobular height?
1/3 of nasal height (from nasion to subnasale)
1/2 of the length of the columella
Ideal chin projection
Should align with vertical line perpendicular to frankfort line passing through vermillion border of lower lip. Can be posterior to this line in women.
Which internal nasal vestibule incision is most associated with obstructive scarring?
intercartilagenous: disrupts lower and upper lateral cartilages, incision involves the nasal valve.
methods to increase tip projection
suture medial crura together
supradomal graft of shield graft (increases 1-2 mm of projection)
columellar strut (maintains projection)
plumping grafts (placed at columellar, increases nasolabial angle-> illusion of increased projection)
methods to decrease tip projection
complete transfixion of caudal septum
partial excision and suture of lateral and/or medial crura
detachment of lateral crura
Six causes of pollybeak deformity
Overresection of nasal dorsum (paradoxical enlargement due to increased dead space and scarring.
Inadequate resection of cartilagenous dorsum
Loss of nasal tip support
Insufficient lowering of dorsal septal borders
Excessive excision of dome of alar cartilages
Six ways to manage pollybeak deformity
Resect prominent tissue or scar for soft deformities
Augment lower lateral cartilages
Columellar struts to maintain position and rotation
most prominent midline point of forehead
most posterior midline point of forehead, typically corresponds to nasofrontal suture
soft tissue correlate of osseocartilaginous junction at nasal dorsum
junction of columella and upper lip
most anterior midline soft tissue point on the chin
most inferior point on the chin
define the frankfort line
line from the most superior point on the auditory canal to most inferior point on the infraorbital rim.