Rhinoplasty

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jvirbalas
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219289
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Rhinoplasty
Updated:
2014-01-05 22:34:22
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Rhinoplasty
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Rhinoplasty
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  1. What branches of the ECA contribute to the blood supply of the nose?
    • Facial artery > superior labial artery
    • IMax > sphenopalatine > greater palatine and septal branches
  2. What branches of the ICA contribute to the blood supply of the nose?
    ophthalmic artery branches into anterior and posterior ethmoidal arteries
  3. sensory supply to the internal nose is via which nerves?
    branches of the V1 and V2
  4. Standard photodocumentation views for rhinoplasty
    Frontal, both lateral, both oblique, basal
  5. How do you measure tip projection?
    distance to the nasal tip from the vetical facial plane (perpendicular to the frankfort line) as measured from the alar crease
  6. What is the ideal tip projection?
    • Goode: 0.55-.6 of the nasal length (nasion to nasal tip).  Reminder, nasion is most posterior part of the forehead 
    • Crummley: nasion, nasal tip, alar crease should be 3:4:5 triangle
  7. What surgical techniques can be used to increase tip projection?
    • Minor (1-2mm): columellar-septal suture
    • Moderate: create columellar strut, possible interdomal suture over strut
    • Major: both other techniques with tip graft
  8. How would you correct overprojection of the nasal tip?
    • Minor (1-2 mm): large volume reduction of cephalic lateral crura.
    • Minor (2-3 mm): add full transfixion
    • Moderate: shorten lateral crura.  Trim to 5mm width, then excise 3-4 mm segment
    • Major: complete transfixion, dorsal hump reduction, caudal septal resection with insertion of crural strut.  Cut middle crura transversely, undermine.
  9. 3 approaches to addressing a boxy nasal tip
    • 1. suture reshaping of the domes.  May also conservatively resect cephalic edge of the lower lats.
    • 2. Vertically dividing the dome, breaking the lateral spring.
    • 3. Cartilage onlay graft to nasal tip to increase definition.
  10. Major tip support mechanisms
    • size, shape, and resilience of medial and lateral crura
    • fibrous attachment of medial crura to caudal border of the quadrangular cartilage
    • fibrous attachment of the alar cartilages to the upper lateral cartilages
  11. minor nasal support mechanisms
    • cartilaginous septal dorsum
    • interdomal ligament
    • membranous septum
    • nasal spine
    • sesamoid complex or minor alar cartilages of the lower lateral cartilages
    • attachments of lower lateral cartilages to soft tissue envelope
  12. describe the tripod concept of tip dynamics
    • lateral crura constitute two superior legs, medial crura constitute one inferior leg.
    • Lengthening inferior limb causes upward tip rotation and increases projection
    • Shortening superior limb length rotates and deprojects the tip
  13. How do you assess external nasal valve collapse?
    modified cottle: place a cerumen curette intranasally to support the nasal vestibule and determine whether this improves airflow
  14. How do you correct external nasal valve collapse
    alar batten graft
  15. What is the cause of a pollybeak deformity
    • post-operative fullness of supratip region, pushing tip down
    • failure to maintain adequate tip support
    • inadequate cartilaginous hump removal (anterior septal angle)
    • supratip dead space or scar
  16. What forms the external nasal valve?
    Columella, nasal floor, nasal rim (caudal border of the lower lateral cartilages).
  17. 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.
  18. 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.
  19. 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
  20. What kind of deformity can result from separation between the nasal bones and their attachement to the ULCs?
    Inverted V deformity
  21. 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
  22. 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
  23. Elements of minor tip support
    • interdomal ligament between lower lateral cartilages
    • sesamoid complex
    • soft tissue envelope (skin/muscle and its attachement to the alar cartilage)
    • anterior nasal spine
    • cartilaginous septal dorsum
    • membranous septum
  24. Nasofrontal angle
    angle between external nose and forehead, 115-130 degrees (more obtuse end more favorable in females)
  25. Nasomental angle
    • angle defined by nasion-to-tip line intersecting with tip-to-pogonion line
    • 120-132 degrees
  26. nasofacial angle
    • glabella-to-pogonion intersecting with nasion to tip line.
    • 30 to 40 degrees
  27. How is tip rotation measured?  What are the ideal angles in men and women?
    Nasolabial angle

    • male: 90-105
    • female:95-110
  28. 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
  29. Appropriate amount of columellar show
    2-4 mm
  30. What is appropriate lobular height?
    • 1/3 of nasal height (from nasion to subnasale)
    • 1/2 of the length of the columella
  31. 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.
  32. Which internal nasal vestibule incision is most associated with obstructive scarring?
    intercartilagenous: disrupts lower and upper lateral cartilages, incision involves the nasal valve.
  33. 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)
  34. methods to decrease tip projection
    • complete transfixion of caudal septum
    • partial excision and suture of lateral and/or medial crura
    • detachment of lateral crura
  35. 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
    • Shortened columella
    • Excessive excision of dome of alar cartilages
  36. Six ways to manage pollybeak deformity
    • Supratip massage
    • Resect prominent tissue or scar for soft deformities
    • Graft dorsum
    • Augment lower lateral cartilages
    • Steroid injection
    • Columellar struts to maintain position and rotation
  37. Define glabella
    most prominent midline point of forehead
  38. define nasion
    most posterior midline point of forehead, typically corresponds to nasofrontal suture
  39. define rhinion
    soft tissue correlate of osseocartilaginous junction at nasal dorsum
  40. define subnasale
    junction of columella and upper lip
  41. define pogonion
    most anterior midline soft tissue point on the chin
  42. define menton
    most inferior point on the chin
  43. define the frankfort line
    line from the most superior point on the auditory canal to most inferior point on the infraorbital rim.
  44. What is the ideal columella:lobule ration?
    2:1
  45. Describe the facial thirds
    • Upper: trichion to glabella
    • Middle: Glabella to subnasale
    • Lower: Subnasale to menton

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