Atlas of Clinical Cases in Rhinoplasty: Volume II [1st ed. 2023] 3031122704, 9783031122705

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Motaz H. A. Shafy

Atlas of Clinical Cases in Rhinoplasty Volume II

Atlas of Clinical Cases in Rhinoplasty

Motaz H. A. Shafy

Atlas of Clinical Cases in Rhinoplasty Volume II

123

Motaz H. A. Shafy Shafy’s Clinics Al Nakheel Center Jeddah, Saudi Arabia

ISBN 978-3-031-12270-5 ISBN 978-3-031-12271-2 https://doi.org/10.1007/978-3-031-12271-2

(eBook)

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Acknowledgements

I would like to acknowledge and give special thanks to the following people without whom the following textbook and atlas would not have been possible. As a medical professional, I see surgery, specifically Rhinoplasty, as a work of art as well as a scientific endeavor. Every artist has their muse, or inspiration, for me this person was Mr. Tony R. Bull, F.R.C.S Consultant E.N.T Surgeon who was my mentor at the Royal National Throat, Nose and Ear Hospital in London. Mr. Bull’s creative approach, passion, and devotion towards the field of Rhinoplasty was what inspired me to develop my own innovative surgical techniques. Mr. Bull was also one of the people who has seen my early work and encouraged me to take my research further turning it from a research article to a full-fledged book. I would also like to thank my great friend and colleague, Mr. Bahir Skinner A.B.I.P.P, Medical Photographer, for his professional advice regarding medical photography and other technical details. Furthermore, I would like to show my gratitude towards Elia Anis Ishaak, M.Sc. Ph.D., Professor of Pathology, and Solafa Amin AbdulAziz, MD, Professor of Pathology who work at Cairo University for their help in the histology of the Inferior Vestibular Bands and the Vestibular Septum. Additionally, I am thankful towards Dr. Mohamed Saad Lotfy, CEO of Viral Media, his team, and Engineer Roshdy Al Bahlool, B.Sc. from Menoufia University of Egypt, for their technical expertise in conducting the medical artistic illustrations evidenced in this book. Moreover, I would like to thank Dr. Soliman Fakeeh and Dr. Mazen Fakeeh for providing their hospital’s facilities, including their O.R. and pathology department, where I conducted my Ear, Nose, and Throat surgeries. I would like to thank Eisel M. Monton, R.N.B.S.N for her diligent efforts in her secretarial assistance. I would like to thank Ms. Elizabeth Pope, Editor at Springer, for her professional guidance regarding the writing and reviewing of this book taking it to new heights. Last but not least, I would like to give a special thanks to my family, without whose support this book would not have been possible.

v

Contents

Part I

Introduction

1

Introduction to the Atlas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3

2

A Guide for Photographic Assessment and Analysis . . . . . . . . . . . . . . . . . . .

9

Part II

Fractured Nose Rhinoplasty

3

Part II: Clinical Case 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17

4

Part II: Clinical Case 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

23

5

Part II: Clinical Case 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

29

6

Part II: Clinical Case 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35

7

Part II: Clinical Case 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

41

8

Part II: Clinical Case 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

47

9

Part II: Clinical Case 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

53

10 Part II: Clinical Case 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

59

11 Part II: Clinical Case 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65

12 Part II: Clinical Case 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

71

Part III

Finesse Rhinoplasty

13 Part III: Clinical Case 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

79

14 Part III: Clinical Case 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

85

15 Part III: Clinical Case 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

91

16 Part III: Clinical Case 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

97

17 Part III: Clinical Case 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 18 Part III: Clinical Case 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 19 Part III: Clinical Case 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 20 Part III: Clinical Case 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 21 Part III: Clinical Case 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 22 Part III: Clinical Case 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 23 Part III: Clinical Case 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 24 Part III: Clinical Case 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 25 Part III: Clinical Case 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 vii

viii

Part IV

Contents

Secondary Rhinoplasty

26 Part IV: Clinical Case 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 27 Part IV: Clinical Case 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 28 Part IV: Clinical Case 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 29 Part IV: Clinical Case 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 30 Part IV: Clinical Case 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 31 Part IV: Clinical Case 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 32 Part IV: Clinical Case 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 Part V

Ethnic Rhinoplasty

33 Part V: Clinical Case 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 34 Part V: Clinical Case 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199 35 Part V: Clinical Case 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 36 Part V: Clinical Case 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209 37 Part V: Clinical Case 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 38 Part V: Clinical Case 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221 Part VI

Special Clinical Conditions

39 Part VI: Clinical Case 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229 40 Part VI: Clinical Case 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233 41 Part VI: Clinical Case 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239 42 Part VI: Clinical Case 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245 43 Part VI: Clinical Case 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251 44 Part VI: Clinical Case 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255 45 Part VI: Clinical Case 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261 Atlas Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267

About the Author

Motaz H. A. Shafy F.R.C.S. holds the following degrees: MBBCh, Cairo University; FRCS RCPSG (Glasgow); and FRCS (Edinburgh). Throughout his career, he has undertaken training and held consultancy posts in the United Kingdom, the Kingdom of Saudi Arabia and Egypt. Dr. Shafy’s previous roles included: House Surgeon and Physician, Cairo University Hospitals; Senior House Officer in ENT Surgery, Stobhill General Hospital, Teaching Hospital Glasgow University; Registrar, Senior Registrar, The Royal National Throat Nose and Ear Hospital, London; Consultant ENT Surgeon positions at Chase Farm Hospital, London; Consultant ENT Surgeon King Abdul Aziz University Hospital and Daghastani Hospital Kingdom of Saudi Arabia; Consultant ENT Surgeon in Shafy Clinics, Kingdom of Saudi Arabia and Shafy Center, Giza, Egypt. Dr Shafy’s main areas of clinical interest are the preservation of Aesthetic Rhinoplasty and Examination.

ix

Part I Introduction

1

Introduction to the Atlas

The concept of an Atlas is ideal for the surgery of Rhinoplasty. In this Atlas more than 4600 photographs of a wide range of clinical conditions that present for Rhinoplasty are displayed. These varieties of noses include; the large, the bulky, the deviated, the oblique, the crooked, the fractured, finesse, secondary, ethnic, pediatric and special clinical conditions. In each case the nose and face are looked at from multiple different angles through the standard and the newly introduced specialized photographic views. In the specialized views, each of the four anatomical subdivisions of the nose is clearly illustrated. Twenty-nine (29) photographs are taken to the nose and face pre-operatively and the same post operatively. A guide is written for assessment of the pre-operative photographs followed by the analysis of the post-operative photographs. Successes, difficulties as well as pitfalls are discussed and illustrated photographically. The art of displaying the pre-operative and post-operative photographs must be simple and easy for the eyes in order to clearly and immediately see the results. The aim that all photographs can be seen at a glance. The text must be well organized, simple, scientific and stereotyped so that it can be read at a glance. The principle theme of the Atlas is:

VI. Correct Surgical Techniques VII. Correct Post-Operative Analysis 2. The Necessity of Photography Photographs in Rhinoplasty are necessary for the following two important reasons: 1. Medicolegal Documentation. 2. Photographic Anatomy: A method designed to enhance diagnosis and improve surgical planning. The photographs highlight certain anatomical areas in the nose and face that are missed and could not be seen by the surgeon’s eyes at the time of the clinical examination in the first interview with the patient. Not all informations could be seen live. The surgeon needs time to study and absorb more facts. This can only be achieved by having the fixed documentations of the photographs. In a way this is similar to the forensic investigators who take photographs of the scene of an incident or a crime to critically and carefully study them later. They discover many details that were overlooked at the time of their first inspection of the place. Both sides, of the face and nose, could be seen at the same time e.g. two lateral, two oblique views, basal and over head views.

SAG—Seen at A Glance 3. Normal Individuals and NOT Patients RAG—Read at A Glance 1. The Seven Gold Standard Steps for Successful Rhinoplasty are I. Correct Clinical and Psychological Assessment II. Correct Photographic Documentation III. Correct Photographic Display IV. Correct Pre-Operative Surgical and Photographic Assessment V. Correct Surgical Planning

People seeking Rhinoplasty are not sick individuals. They cannot be called or referred to as a patients. They only becomes a patients if and when surgery is indicated. Dealing with these cases by the surgeons is partly informal and partly formal. A lady with a large nose is very much like a pregnant lady. Both are not sick. They cannot be called patients. They become patients if and when surgery is indicated i.e. when they sign the consent for surgery.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_1

3

4

1

Introduction to the Atlas

4. The Unpleasant Terms and Patients’ Psychology

6. The Standard and the Specialized Views

Some terms are commonly used among Rhinoplasty surgeons to describe certain nasal deformities e.g. “polly beak”, “Parrot beak” and “pig snout”. These terms are written in many of the renowned Rhinoplasty books. To the surgeons minds these terms describe specific anatomical abnormalities that need no further detailed explanations. They are used by the surgeon with the minimum or even no sensitivity. They don’t have any unpleasant impact. The sad fact that these terms are strongly unpleasant and quite offensive to ordinary people especially when it comes to the pig snout expression. As they reach the patients, these terms have quite negative impact on them. In addition to the state of dissatisfaction from their nasal condition, they become severely disturbed and unhappy to hear these terms. “It is best to be sensitive when describing peoples’ physical appearance” (Elizabeth Pope). Surgeons must be careful in using more acceptable descriptive words to their patients. With the clear advancement in anatomical knowledge these deformities could be described using more appropriate phrases. These terms are totally avoided in this text and hopefully from all future textbooks.

6:1. The Importance of the Standard Views There are four well known standard views for the nose and face i.e. the Frontal, Oblique, Lateral and Basal views. These are excellent views in showing the overall appearance of the nose in relation to the face from the defined different angles. 6:2. The Necessity for Specialized Views Advances in the surgical techniques of Rhinoplasty have lead the surgeons into further detailed procedures in the different anatomical areas of the nose. Highlighting the detailed anatomy of each of these areas by more specialized photographic views becomes a necessity. New views from different angles are therefore introduced. These views are: 1. The Direct Dorsal Views—non smiling and smiling 2. The Backward Tilting Views in two or three steps as the head is tilted backwards. 3. Nasal Aperture Views, right and left 4. Rim-sill tests in Nasal Aperture Views 5. The Overhead Views non smiling and smiling

5. Innovative Approach to Rhinoplasty Photography 6:3. Upgrading the Standard Views It is of great value to take multiple photographs in different specific views of the nose. The standard views are not sufficient to make clear detailed and scientific assessment of the different anatomical parts of the nose and face. They had to be modified and expanded to become of better value for the surgeon. The surgeon consequently is able to provide his patients with better assessment and clearer proposal for the surgery. There are now more editions to the standard views that provide better assessment for the nasofacial relation, the effects of smiling and the angles around the nose. Each anatomical area in the nose is studied by the newly introduced specialized views. These photographic views provide a wealth of tools for assessment planning. Each specific area of the nose is viewed better by the camera lens. Multiplicity of the photographs are only of great value and advantage if they are well displayed. As a three dimensional structure the nose can be seen from countless number of angles and views. A holistic view of the nose is important. A video recording of the nose and face from all directions seems like an ideal method to cover all of these angles and views. Nevertheless, a specific, well defined angle of photography captured by a fixed picture will give a solid document to each anatomical area targeted by this view.

More benefit is gained from the standard views by adding more views that demonstrate the effects of smiling as well as the middle third for the frontal, oblique and lateral views. 6:4. The Advantages of photographic Anatomy Studying of the photographs must include the detailed description of the anatomical findings in each views. The correlation between the specific photographic areas of the nose and its corresponding anatomical structures creates a complete picture of photographic anatomy in the surgeon’s mind. The normal and the abnormal anatomical areas are recognized, described, hence accurate diagnosis and decisions are greatly helped. 6:5. Aesthetic photography of the Nose The plan to take photographs of the patient must clearly focus on the following two important facts; (a) The main target is the nose (b) The main objective is aesthetics

1

Introduction to the Atlas

Aesthetic views for the nose must aim at taking photographs to the area of interest at a direct angle to have the complete view at the true maximal size of this area. Examples of these are: • In the nasal aperture views the camera directly faces each nasal aperture separately in their naturally different angulation in order to see the natural size and appearance of the aperture shape size and margins. • The nasal dorsum is best seen by a direct dorsal view where the camera directly faces the nasal dorsum. • In the oblique views the camera faces directly the lateral nasal wall. 7. The Four Areas of Rhinoplasty Aesthetic Rhinoplasty is not a single operation. Rhinoplasty is four different operations; one in each of the four anatomical areas of the nose. Each one of the four surgeries is a totally different procedure that has different guidelines and techniques. The outcome of all four surgeries must produce a harmonized, aesthetically attractive nose. These four surgeries are:

5

(10) Special clinical conditions: i. Developmental and Congenital anomalies e.g. dermoid cyst, Waadenburg syndrome, hypertelorism ii. Large Alae Nasi iii. Sliding tip In each of these conditions, the same basic surgical techniques are pursued. Special attention is paid for each special case. Each of the major groups will be studied in further details. 9. The Multiple Distinctive Views For accurate and comprehensive pre-operative photographic assessment, each patient needs multiple distinctive number of photographs. At least thirty photographs are needed. As well as the standard views, there are newly introduced editions to them, which added extra clinical significances. In addition the Specialized views are useful in scrutinizing each specific area of the nose. 9:1. The Standard Views The four standard views are:

i. Anterior and Lateral wall surgery for the Nasal tip and lateral crurae ii. Medial Wall Surgery for the Nasal septum, the medial crurae and columella iii. Surgery of the Bony Pyramid and Mid Vault iv. Alar Base Surgery for Rim-sill folds, vestibular floors, flat triangles (also known as soft triangles) and alae nasi. 8. Clinical Varieties of Noses Presenting for Rhinoplasty Patients seeking Rhinoplasty present with various nasal shapes and conditions. Each of these conditions required combined regional surgeries in one or more of the four areas of the nose. The common clinical presentations are: (1) (2) (3) (4) (5) (6) (7) (8) (9)

The Large Nose The Bulky Nose The Crooked Nose The Deviated Nose and The Oblique Nose The Fractured Nose Finesse Rhinoplasty Secondary Rhinoplasty Ethnic Nose Child Rhinoplasty

• • • •

Frontal view: one photo Oblique views, right and left: two photos Lateral views, right and left: two photos Basal view: one photo

9:1:1. New Editions to the Standard Views • The smiling full face, frontal view: one photo • The smiling full face right and left lateral views: 2 photos • The oblique midcheek and cheek marginal views: 2 photos • The middle third views: These are specially important in large faces and small noses, as commonly seen in Asian noses. – Frontal View:1 photo – Oblique views, right and left midcheek and cheek marginal views: 4 photos – Lateral views right and left: 2 photos • Smiling Basal View:1 photo 9:2. Specialized Views • Overhead views: 2 photos non-smiling and smiling • Direct Dorsal views: 2 photos non-smiling and smiling

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1

• Backward Tilting views: 2–3 photos in 2–3 backward steps • Nasal Aperture views, right and left: 2 photos • Rim-sill Tests, right and left: 2 photos Thirteen new photographic editions are added to the six standard views. The newly suggested specialized views are 10–11 views. The total number of photographs needed for pre-operative assessment is 29–30 photographs. Additional views are improvised in some individual cases.

Introduction to the Atlas

• Easy recognition of the abnormal anatomical areas versus the normal areas • Direct comparison between the right and left sides of the face and nose. • The effect of smiling on the nose, face, nasal base, cheeks and eyes. Comparison is made before and after surgeries. • Observations of the immediate, long term and post traumatic changes on the nose and face. 10. The Value of Correct Display of the Multiple Views Displaying photographs is made for many purposes:

9:3. The Advantages of Multiple Views of the Nose It is of great advantage to have the general appearance of the nose and face as well as the detailed study of every anatomical component of the four anatomical areas of the nose. The introduced new method of photographic display makes it easy for the surgeon to see all these details in an organized systematic way. The display of two photographs beside each other to compare the pre-operative with the post-operative views is good enough to show one specific angle of the nose and face, but it is not good enough for displaying a group of four or more photographs at the same time. The display of only two photographs is insufficient to study all areas of the nose that are involved in the surgery. Having multiple new views means that we have to display groups of at least four photographs or more at the same time e.g. the pre and post operative smiling and non-smiling, right and left lateral and right and left oblique views. The pre and post operative photographs should be displayed above each other. Example of this; if we display the pre operative two or three steps of the Backward Tilting views beside each other, and the same post operative views are placed exactly below them, it will be easy for the eyes to immediately and quickly see and compare the six photographs at a glance i.e. seen at a glance. Arrangement of the photographs should make it easy for the eyes of the surgeon to directly study and compare, not only between the preoperative and the postoperative photographs, but also to study many other anatomical facts that help in the preoperative assessment and post operative analysis. The following must be easily and clearly seen on displaying the photographs:

– Pre-operative assessment. Thirty photos or more are displayed – Post-operative Analysis. The overall number of the pre and post operative photographs may reach up to 60 photographs or more. – Tertiary study as in cases of multiple surgeries, long term changes or trauma. More than 70 photos are displayed 10:1. Displaying the Pre-operative Photographs For clear and direct display of pre-operative photographs many of the comparative or sequential anatomical areas of the nose and face must be seen closely beside each other. This is especially true in the following views: • The non-smiling and smiling views are placed beside each other in order to give the direct visual impression of the anatomical changes that take place on smiling. This is seen in the Frontal, Direct Dorsal, Overhead Basal and Lateral views. The right and left smiling lateral views are especially good example to see the extent of nasal tip animation. • The right and left oblique views must be seen side by side facing each other in the display. This is the best demonstration for comparison between the right and left sides of nasal dorsum. Nasal hump is more prominent on one side in cases of maxillary asymmetry. • The right and left lateral views must be seen side by side facing each other to directly compare profiles, paranasal and nasal angles as well as alar grooves and columella.

1

Introduction to the Atlas

• The two or three steps of the backward tilting views are placed beside each other for direct observation. • The right and left Nasal aperture views are beside each other. • The right and left rim sill tests must seen beside each other. 10:2. Displaying the Post-operative and Tertiary Photos The post-operative photographs, one or more sets, are arranged in exactly the same pattern as the pre-operative ones. The two comparative and sequential photographs are placed beside each other. Each post-operative photographs is then placed below the corresponding pre-operative photograph. The final presentation of the display is that the two comparative pre-operative photos are beside each other and the corresponding two post-operative photos are below them. All four photos are clearly and easily seen in one place at a glance. In cases of a third set of photographs i.e. second post-operative condition, photos are placed in a third row below the previous two rows of photographs. Examples of this is having the pre-operative full face Frontal non-smiling and smiling photos above their equivalent post-operative non-smiling and smiling photos. It is therefore possible to see the effect of smiling on the nose and face pre-operatively and the outcome of surgery post operatively, all at the same time. Another example is the pre-operative right and left rim-sill tests beside each other while their post-operative post-resection photos below them.

7

• The Lateral views full face (non-smiling and smiling) and middle third.

11. The Display of the Text The easy stereotyped display of photographs is associated with an equally easy stereotyped display of text. Each case is studied in exactly the same systematic pattern. In this way photographs are seen at a glance and the texts are read at a glance. The following items are discussed and the written before each case: • • • • • •

Pre-operative Assessment Aims of Surgery Surgical plan Surgical procedure Post-Operative Analysis Commentary

In each case pre-operative assessment, surgical plan, surgical procedure and post operative analysis are discussing the four areas of the nose and the corresponding four Rhinoplasty surgical procedures. The four areas and their corresponding four surgeries of the nose are:

10:3. The Order of Photographic Display

1. The Frontolateral Walls including the nasal tip 2. The Medial Wall, including the Columella and Nasal Septum 3. The Bony Pyramid and MidVault 4. The Nasal Base including the Alar base, the Vestibular Floors and the Flat Triangles.

Photographs are displayed in the order of their clinical significance which in turn reflects the extent of benefits. Arrangement of the views is made in the following order:

P.S. Surgical Delivery of the lower lateral cartilages, Defatting and Dome weakening is indicated in the Atlas as D.D.D.

• The Frontal Views full face (non-smiling and smiling) and mid third. • The Overhead Views (non-smiling and smiling). • The Direct Dorsal Views (non-smiling and smiling). • The Backward Tilting Views (2–3 steps backwards). • The Basal Views (non-smiling and smiling). • The Nasal Aperture views (Right and left). • The Rim-Sill tests (right and left). • The Oblique Views full face and middle third; mid cheek and cheek margins.

12. Conclusion The simple stereotyped pattern of the display of the photographs and the text makes them easy to see and read at a glance. SAG—Seen at A Glance RAG—Read at A Glance

8

1

Introduction to the Atlas

Display of photos Frontal View (F.V.)

Frontal View Smiling (F.V.S.)

Frontal View Middle Third (F.V.MT.)

Direct Dorsal View (D.D.V.)

Direct Dorsal View Smiling (D.D.V.S.)

Over Head View (O.H.V.)

Over Head View Smiling (O.H.V.S.)

Backward Tilting View (B.T.V.)

Steeper Backward Tilting View (S.B.T.V.)

Basal View (B.V.)

Basal View Smiling (B.V.S.)

Right Nasal Aperture View (R.N.A.V.)

Right Nasal Aperture View Rim Sill Test (R.N.A.V.R.S.T.)

Left Nasal Aperture View Rim Sill Test (L.N.A.V.R.S.T.)

Left Nasal Aperture View (L.N.A.V.)

Oblique View Full Face Mid-Cheek Right (O.V.FF.MC.Rt.)

Oblique View Mid-Cheek Left (O.V.MC.Lt.)

Oblique View Middle Third Mid-Cheek Right (O.V.MT.MC.Rt.)

Oblique View Middle Third Mid-Cheek Left (O.V.MT.MC.Lt.)

Oblique View Cheek Margin Right (O.V.CM.Rt.)

Oblique View Cheek Margin Left (O.V.CM.Lt.)

Oblique View Middle Third Cheek Margin Right (O.V.MT.CM.Rt.)

Oblique View Middle Third Cheek Margin Left (O.V.MT.CM.Lt.)

Right Lateral View Right (Rt.L.V.)

Left Lateral View (Lt.L.V.)

Right Lateral View Smiling (Rt.L.V.S.)

Left Lateral View Smiling (Lt.L.V.S.)

Right Lateral View Middle Third (Rt.L.V.MT.)

Left Lateral View Middle Third Left (Lt.L.V.MT.)

2

A Guide for Photographic Assessment and Analysis

The main objective of this guide is the critical assessment of the pre-operative photographs, followed by the comprehensive analysis of the post-operative photographs. A large number of photographs and texts are displayed in this Atlas in an easy way that could be seen and read fairly quickly. SAG and RAG i.e. Seen at A Glance and Read at A Glance. This guide meant to give an in depth study of the photographs. People may go to an art, science or history museum. Only those who have the informed knowledge, from the guiding notes, books or personnel, have the best benefit out of their visit. The following guide is by no means a comprehensive one. More detailed study is made in the section of photography in the book of “Innovation in Rhinoplasty”. Nevertheless the guide is a well informed foundation. From this start more information may be seen in each photograph, before and after surgery, for the best interest of the patients. 1. The Contribution of Photography to Successful Rhinoplasty Rhinoplasty photography is a major contributor to the seven Gold Standard Steps for Successful Rhinoplasty (see Introduction to Atlas) so that: 1:1. Photographic Documentation and Photographic Display These two steps are solely made by successful photography. A wide range of highly professional, accurately standardized photographs of the nose and face are lucidly displayed. 1:2. Pre-operative Assessment and Surgical Planning Critical assessment of the pre-operative photographs is of great help for better diagnosis, planning and consequently simple, short and correct surgical procedure with consistently better results. 1:3. Post-operative Analysis Analysis of the short and long term results of surgery can only be achieved by taking photographs of the

various views to the nose and face at different intervals. This is an excellent feedback for the surgeon to evaluate the different techniques in the different areas of the nose. Research work, future modifications and upgrading of many techniques can take place. 1:4. Conclusion Assessment of the pre-operative photographs is invaluable for best planning and execution of surgery in the shortest time with best results. Analysis of the post-operative photographs is invaluable for the best surgical evaluation, future advancement and avoiding mistakes. The importance of individual history: Unlike other types of surgeries, aesthetic or non-aesthetic, Rhinoplasty is not the same stereotyped operation. The nose is like a fingerprint every nose in this planet is different. Even the two sides of the same nose are different so that: (a) Each nose has its own individualized surgery. (b) The same nose may have different operation in different individuals according to their height, body built, social background, ethnicity and gender. (c) Personal references; every individual prefers a certain look to the nose, some are quite conservatives and others would like to have radical changes in their noses. (d) Rhinoplasty is associated with strong emotions and psychology. Candidates for Rhinoplasty are full of fear, hopes and dreams. Each candidate goes through five intensive psychological stages (see chapter of psychology of Rhinoplasy in Innovations of Rhinoplasty book). (e) Rhinoplasty is combined professional, artistic and emotional endeavor. Not every competent surgeon is readily prepared to perform Rhinoplasty, and not every person with a deformed nose is readily prepared to have Rhinopasty.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_2

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Benefits of individual history: (a) Understanding the reason behind the shape of each nose i.e. the cause of deformity, depression, enlargement or otherwise. (b) The personalized history puts life and humanize every individual case. Without this, it becomes too mechanical and too dry. (c) The medical history alone is insufficient, the general, build of the body, psychological and emotional state, personal overall preferences, gender, type of personality, social status, social life, individual hobbies and activities, all these are factors that help in making decisions of the type of surgery that suits this individual and to proceed for surgery or avoid it altogether. Important Note: In this Atlas the individual relevant history is omitted in all cases. Some may contain detailed personal information that is not suitable for publication. 2. Pre-operative Photographic Assessment Not all information could be seen at the time of clinical examination of patients. Photographs highlight specific anatomical areas that could not be seen by the clinicians eyes. Pre-operative photographic assessment proved of great value in surgical planning and decisions. Each of the four areas of Rhinoplasty is critically assessed. 2:1. Photographic Assessment of Frontolateral Walls Frontolateral walls study is mainly concerned about the nasal tip. Photographically the nasal tip is studied in its shape, position and size. The shape of the tip photographically expressed as tip definition while position of the tip is expressed as tip projection. 2:1:1. Tip Definition Tip definition means that the nasal tip, made by the two middle crurae, is small and prominently well identified from the surrounding alae nasi. This is to be distinguished from the flat ill defined, large and bulky nasal tips. A thick skinned nasal tip is usually large and bulky. It overshadows the alae nasi on both sides. The alae nasi may hardly be seen or not seen at all. The superior alar grooves, (see Anatomy section) are filled with the subdermal fat. They become short, flat and ill recognized. The subdermal fat of the middle and lateral crurae makes the tip amorphously continuous with the alae nasi on both sides. The tip is unrecognized and is ill defined. Defatting of the middle and lateral crurae results in a slim and small nasal tip without the need to directly stitch the domes. The superior alar grooves, being uncovered of all the fat, they become deep, long and visible. The alae nasi

2 A Guide for Photographic Assessment and Analysis

come into view, and share in nasal aesthetics with the nasal tip. How does defatting works i. The superior alar groove anatomically consists of two components: • Alar muscular groove i.e. between the ala nasi and the muscular triangle posteriorly • Alar crural groove i.e. between the ala nasi and the lateral crus anteriorly. Defatting the lateral crurae clears the fat off the junction between the lateral crurae and the alae nasi. The superior alar grooves become more apparently deeper and consequently longer. ii. The alae nasi becomes more apparent after defatting its junctional area with the lateral crurae. The bounderies of their bodies become clearer. As they are pulled medially, they became better seen and look smaller and well defined. Aesthetics of the alae nasi generally improve. iii. The nasal tip becomes smaller by defatting the middle crurae. Nasal tip definition is further enhanced by defatting the lateral crurae. The overlying skin becomes thinner. Tip definition is best seen in the following views: • • • • • •

Frontal Views. Over Head Views. Direct Dorsal Views Backward Tilting Views. Basal Views. Nasal Aperture Views.

The superior alar grooves are best seen in: • Direct Dorsal Views • Oblique Views • Lateral Views 2:1:2. Tip Projection This term is used to express the height and the shape of the tip at the end of the nasal dorsum. For aesthetically pleasing projection, the nasal tip should be at the same level or slightly higher than the nasal dorsum. In the lateral views the angle of the tip should be near to 90 degrees. This is best coupled with a 90 degrees nasolabial angle. Nasal tip projection is best seen in the lateral views and to lesser extend in the oblique views.

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A Guide for Photographic Assessment and Analysis

2:1:3. Tip Size Tip size is aesthetically significant. Too small ill defined or too large and bulky are two unaesthetic tips. It is directly related to the skin thickness and the sizes of the middle and lateral crurae. Bifidity or grooving of the middle crurae are unaesthetic. The size of nasal tip is seen in all views but predominantly better seen in the Frontal, Direct Dorsal, Backward Tilting and Basal views. 2:1:4. The Light Reflex The light reflex is looked for at the domes of the nasal tip. Bifid nasal tip reflects two spots of light reflex. An aesthetically pleasing nasal tip reflects one spot of light reflex. The light reflex of the nasal tip is better seen in the Frontal and Backward Tilting views. 2:2. Photographic Assessment of the Medial Wall The medial wall is made of the columella, the medial crurae and the caudal cartilagenous septum. The three subcutenous structures of the medial wall that are photographically significant are:

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a. Laterally • The deviated caudal septum pushes the medial crus including the I.V.B. (Inferior Vestibular Band) laterally distorting the shape of nasal aperture and produces unequal nasal openings in size and shape. This is best seen in the Backward Tilting, Basal and Nasal Aperture Views. b. Inferiorly The caudal septum may be elongated inferiorly: • Pushing the two components of the columella, the firm crurae and the soft fold, producing a protruded columella. This is best seen in the Frontal, Oblique and Lateral views. • The long caudal septum pushes the ipsilateral nasal sill band inferiorly to become at a lower level than the contralateral nasal sill band. This is best to seen in the Frontal and Backward Tilting views. • The severely deviated caudal margin of the cartilaginous septum may be seen through the nasal aperture cavity. The inferior changes are best seen in the Frontal, Oblique and Lateral view. Other specialized views demonstrates these changes to lesser extent. c. Anteriorly • The height of the anterior septal angles is shown in the supratip area i.e. the weak triangle as supra tip depression or supratip elevation in cases of low and high anterior septal angle consequently. Unilateral bulge of middle or lateral crurae may be caused by a high severely deviated cartilagenous septum. These changes are best seen in the Lateral, Oblique, Backward Tilting and Nasal Aperture Views.

1. The columella 2. The caudal cartilagenous septum including the anterior septal angle at the end of the nasal dorsum. 3. The Inferior Vestibular Bands (I.V.B.), including the nasal sill bands that go, abutting the posterior then the superior margins of the medial crurae on both sides (see the chapter of Histological Studies) • The columella has two component – The anterior firm part made by the medial crurae 2:2:2. Assessment of the Columella • The protruding and hanging columella are best – The posterior soft fold between the medial crurae seen in the Lateral and Oblique views. and the filtrium of the upper lip. • Thickness, bifidity and lateral columellar protrusions are best seen in the Basal and Nasal All views except the Direct Dorsal and Overhead Views Aperture views. are important in studying the medial wall. The Backward Tilting, Basal and the Nasal Aperture views are the specialized views for the medial wall photog- 2:2:3. The Light Reflex The light reflex of the columella is observed normally raphy. These are followed by the Oblique and Lateral views. as one spot or two spots in cases of grooving and bifidity. This is best seen in the Backward Tilting and 2:2:1. Assessement of the Deviated and/or Elongated Basal Views. Caudal Septum Aesthetic effects of caudal septal deviation and/or elongation may take place, laterally, inferiorly or anteriorly. Photographically the medial wall is looked for in the following areas:

2:3. Photographic Assessment of the Bony Pyramid The bony pyramid is assessed photographically for:

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2 A Guide for Photographic Assessment and Analysis

2:3:6. The Light Reflex 2:3:1. Height • Depression: supratip, midvault, saddle deformities or skislope depression. Depressions may be post The Light Reflex of the nasal dorsum of special aesthetic and photographic importance. It is best seen in the Direct Dorsal traumatic or development. • Elevation: osteocartilagenous humps and supratip Views. elevation. • Irregularities following trauma, accidental or 2:4. Photographic Assessment of the Alar Base surgical. The nasal base includes the alar base, flat triangles (also 2:3:2. Deviation known as the soft triangles), the vestibular floors and the nasal sill bands. The nasal openings are no more than two The bony pyramid may be deviated off the midline in the gaps that separate the vestibular floors posteriorly from the sagital plane. Deviation is best seen in the Frontal, Direct flat triangles anteriorly. Dorsal and Overhead Views. Deviated bony pyramid is commonly seen in develop- 2:4:1. Why the Alar Base and not the Nasal Base? mental bilateral maxillary asymmetry. The alar base is the most significant surgically of all of the 2:3:3. Obliquity three structures of the nasal base. The Alar Base is therefore referred to as the fourth area The bony pyramid may be oblique to one side in the axial of Rhinoplasty rather than the nasal base. plane. Oblique bony pyramid is best seem in the Backward Tilting Views. 2:4:2. The Alae Nasi Oblique bony pyramid is commonly seen following traumatic fracture or surgery. The alae nasi are photographically significant in its structural Combined deviation and obliquity of the bony pyramid body as well as its relations and attachments to the upper lip. is seen in bilateral maxillary asymmetry i.e. the developmentally oblique bony pyramid is always associated with 2:4:2:1. The Alar Bodies deviation of the nose to one side, while traumatically oblique bony pyramid is not associated with deviation of the nose. Alar bodies are best seen in the lateral and oblique views. The maxillary bone is larger in one side than the other. They are observed for: The oblique bony pyramid and bilateral maxillary asymmetry are best seen in Backward Tilting Views where one cheek is • The alar size and shape; columello alar relationship: high and narrow while the opposite cheek is low and wide. Too small alae nasi expose the lateral columellar walls and vice versa, too large alae nasi may become at a lower 2:3:4. Dorsum level than the columella which might be completely hidden. This is mostly seen in Asian noses. The dorsum of the bony pyramid, from the nasion at the • Alar-Tip Relationship nasofrontal angle to the anterior septal angle, is best seen in The alae nasi should appear anteriorly as two gentle the Lateral and Oblique views. protrusion on the sides of the nasal tip. This is best seen Other views demonstrates the dorsum and sidewalls in in the Frontal, Direct Dorsal and Overhead views. different and useful angles i.e. the nasal aperture views. Different angles of viewing the alae nasi are the Backward Tilting and Basal Views. 2:3:5. Side Walls Smiling and Alar Flare Smiling views demonstrates the extent of alar flare. It is Wide base, unequal or irregular sidewalls are unaesthetic. not uncommon to have asymmetrical sizes of alae nasi The sidewalls are seen in all views except Basal Views. and asymmetrical alar flare on smiling. Asymmetrical Each of the views has a special angle to the side wall. The smile is associated with different sizes and shapes of unequal sidewalls and wide base of the body pyramid are cheek balls, levels and shapes of the nasolabial folds as best seen in the Backward Tilting views. Irregularities of the well as different lateral angles of the lips. sidewalls are best seen in the Frontal and Oblique views.

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A Guide for Photographic Assessment and Analysis

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2:4:2:2. The Alar Grooves

2:5. The Light Reflex

The superior and posterior alar grooves are compared on their length and depth before and after surgeries.

The hairless glistening surfaces and margins of the nasal skin reflects lines and spots of light (refer to the main text):

• The superior alar groove is an alar nasal groove i.e. between the superior margin of the ala nasi and the lateral crus and the muscular triangle from before backwards (see anatomy section in anatomy section of Innovations in Rhinoplasty). It is mainly affected by the subdermal fatty layer that covers the lateral crurae.

a. Surface light reflex: i. Dorsal light reflex: a line of light is reflected off the skin of the nasal dorsum (Direct Dorsal Views). ii. Tip light reflex: one or more spots of light is reflected off the glistening skin cover of the domes of the nasal tip. (Frontal and Backward Tilting Views). b. Marginal light reflex:

The superior alar grooves are best seen in the Direct Dorsal, Overhead, Oblique and Lateral Views.

Light is reflected from the following margins: • The posterior alar groove is an alar lip groove i.e. between the posterior margin of the ala nasi and the upper lip (see anatomy section of Innovations in Rhinoplasty). It is mainly affected by the size and thickness of the posterior segments of the rim-sill folds. The posterior alar grooves are seen in the Basal, Backward Tilting and Nasal Aperture Views.

i. Inferior alar margins (Nasal Aperture and Basal Views). ii. Nasal sill bands (Nasal Aperture and Oblique Views). iii. Lateral columellar margins (Lateral Views). iv. Inferior margins of the flat triangles (Nasal Aperture Views). Absent Light Reflex

2:4:2:3. The Alar Margins • The inferior alar margins i.e. alar rims are best seen in the Backward Tilting, Basal and Nasal Aperture Views. The length, shape and light reflexes are observed. • The Rim Sill Test to demonstrates the posterior and inferior segments of the rim-sill folds. – A long inferior segment produces wide nasal aperture while thick posterior segment produces bulky alar base and bulky lower third of the nose. – Bulky posterior segment has an acute angle with the upper lip giving a flat tire appearance. – The posterior and inferior excisional segment scars are looked for and seen in post-operative photographs. – Light Reflexes are observed off the inferior margins (Basal and Nasal Aperture Views). 2:4:3. The Flat Triangles and the Vestibular Floors The Flat Triangles (also known as the soft triangles) and the Vestibular Floors Including the Nasal Sill Bands are best seen in the Backward Tilting, Basal and Nasal Aperture Views. Light Reflexes are observed at the margins of the flat triangles. (Nasal Aperture Views).

The light reflex is absent in: a. The weak and soft areas e.g. rim-sill folds and posterior columellar fold. b. Anatomically disturbed areas e.g. caudal dislocation or irregular dorsal anatomy. The presence or absence of light reflex is of aesthetic and surgical significances. Distorted preoperative light reflexes improve after surgery to become one regular line, in cases of dorsal and marginal light reflexes, and one spot in cases of the nasal tip light reflex. This is an additional method of assessing better postoperative surgical results. 3. Post-operative Analysis and Comments The post operative comprehensive analysis of aesthetics of each of four areas of Rhinoplasty is beneficial for the patients and the surgeons alike. Patients understand in more details the changes after surgery. Some patients surprisingly may forget what their noses looked like. Any residual deformity or misshapen area could be seen and discussed with the surgeon. Surgeons benefit from the feedback of successes, mistakes and failures. Long term results are significantly useful in all cases.

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Many lessons are learned so that surgeons are continuously improving, correcting and developing new techniques. In the post-operative analysis, the post-operative photographs are examined after going through the pre-operative photographic assessment, aims of surgery, surgical plan and the surgical procedure. Better aesthetic results in each of the four areas of Rhinoplasty are described in the different photographic views as follows: 3:1. Antrolateral Wall • Tip Definition: nasal tip is smaller with thinner and smoother overlying skin. It is more prominent and well identified from the alae nasi on both sides. The alae nasi come into view to become clearly visible and share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). • Tip projection: The nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). • The light reflex is clear and appear as one or two spots off the nasal tip. 3:2. The Medial Wall • Correction of septal deviation leads to: – Nasal apertures: Nasal openings are closer in size and shape to each other. – Unilateral bulge of medial crus overcome. – Unilateral inferior displacement of nasal sill band is amended. Both bands become at the same horizontal level. – The protrusion of the caudal cartilagenous margin is no longer seen. – Unilateral bulge of the middle or lateral crus have leveled. • Hanging columella or protrusion columella have gone. • Supratip elevation/or depression become more level. • Mobility of the tip is gone. • The light reflex is observed (Basal and Backward Tilting Views). 3:3. Bony Pyramid • Bony pyramid aesthetics: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views).

2 A Guide for Photographic Assessment and Analysis

• The light reflex is seen as an uninterrupted line off the nasal dorsum (Direct Dorsal Views). 3:4. Alar Base • Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves). • Posterior alar groove aesthetics improved: – By defatting alone: After defatting the lateral crurae the alae nasi are pulled medially and the angles of the posterior alar grooves become wider. Aesthetics of the alae nasi improve as they become clearly seen. (Backward Tilting and Nasal Aperture Views). – By defatting as well as excising the posterior segments of the rim-sill folds. The flat tire appearance is no longer present. (Backward Tilting, Basal and Nasal Aperture Views). • Alae nasi aesthetics improve by defatting alone or together with rim-sill fold excision. The alae nasi are pulled medially widening the posterior alar grooves. They become more visible and smaller in size. (Backward Tilting, Basal and Nasal Aperture Views). • Nasal aperture aesthetics: – The size of the nasal openings are reduced: i By defatting alone, in some, but not in all cases. ii By Defatting as well as excising the inferior segments of the rim-sill folds. (Backward Tilting, Basal and Nasal Aperture views). – The shape of nasal openings. – Defatting alone of the frontolateral walls enhances aesthetics of the nasal openings with or without affecting their size. They become more elegantly oval on shape. (Backward Tilting, Basal and Nasal Aperture views). – Defatting and excision of the rim-sill folds transforms the nasal apertures from thick walled wide and rounded openings with transverse long axes to thin walled, small oval openings with anterior long axes. (Backward Tilting, Basal and Nasal Aperture views). • The marginal light reflexes are observed off the inferior alar margins, nasal sill bands, margins of the flat triangle and the lateral columellar margins (Basal, Nasal Aperture, Oblique and Lateral views).

Part II Fractured Nose Rhinoplasty

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Part II: Clinical Case 1

Preoperative Assessment 1. Fronto-lateral walls a. Large and bulky nasal tip overshadowing the alae nasi (Frontal, Direct Dorsal and Overhead Views). b. A large bulge forward of the left lateral crus (Frontal, Backward Tilting and Basal Views). 2. The medial wall a. This is a type I fractured nose. Only the nasal septum is broken leading to a severe left sided deviation and dislocation. The caudal cartilage was widely displaced to the left and protruding out of the left nasal aperture (Backward Tilting, Basal and Nasal Aperture Views). b. The deviated septum has caused an obvious bulge of the left lower lateral cartilage. The outcome is a very large nasal tip (Backward Tilting and Basal Views). c. Mobile nasal tip (Lateral Smiling Views). 3. The bony pyramid a. Osteocartilagenous hump which was deviated to the left (Frontal, Direct Dorsal and Overhead Views) as well as being oblique to the left due to bilateral maxillary asymmetry (Backward Tilting Views). The right cheek is wide and low while the left cheek is narrow and high (Backward Tilting View). b. Wide base of the bony pyramid. There was no fracture of the bony pyramid (Frontal, Direct Dorsal and Backward Tilting Views). c. Deep nasofrontal angle (Lateral Views). 4. Alar Base a. The left nasal aperture was unpleasantly distorted by the left caudal septal deviation that was clearly seen through the nasal opening (Basal and Left Nasal Aperture Views). b. The left nasal opening was much wider than the right. They have completely different shapes (Backward Tilting, Basal and Nasal Aperture Views). c. The left nasal sill band is pushed inferiorly (Backward Tilting Views).

d. Asymmetrical gummy smile: the right angle of the mouth is more lateraralized than the left (frontal smiling and lateral smiling views). Aims of Surgery 1. Reduction of the size of the nasal tip. 2. Correction of the Fractured deviated septum. 3. Centralizing and reducing the width of the boney pyramid. 4. Elevation of the nasofrontal angle. Surgical Plan 1. Fronto-Lateral Walls a. DDD including the weak triangle to reduce the bulk. b. Cephalic trim of the lateral crurae to reduce the size. 2. Medial wall a. Septoplasty and correction of the caudal septal dislocation. b. Division of the depressor septi muscle. 3. Bony Pyramid a. Excision of the osteocartilagenous hump. b. Osteotomies and medialization of the bony sidewalls. c. U-shaped septal cartilaginous graft at the nasofrontal angle. 4. Alar Base Nil of note Surgical Procedure a. As in the Surgical Plan. b. The septal cartilage was dissected. The fracture line was at the junction of the caudal vestibular part with the proximal respiratory part of the cartilage. Excess 1– 2 mm was excised from the caudal and posterior margins of the cartilaginous septum. The deviated boney septum was fractured and pushed to the mid line. None of the

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_3

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boney parts were removed to avoid instability of the boney pyramid. c. Kassanjian Maneuver to the right, i.e. cross fracture of the boney pyramid was necessary to bring it to the mid-line (see Surgery of the Bony Pyramid in the Text). Post-operative Analysis 1. Frontolateral Wall a. Tip Definition: nasal tip is smaller with thinner and smoother overlying skin. It is more prominent and well identified from the alae nasi on both sides. The alae nasi come into view to become clearly visible and share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). b. Tip projection: The nasal tip is at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as one spot off the nasal tip (Frontal and Backward Tilting Views). 2. Medial Wall a. The caudal septum is replaced in its natural central location. b. The columella is in central position. 3. Bony Pyramid a. Bony pyramid aesthetics improved. The nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Dorsal light reflex is seen as an uninterrupted line off the nasal dorsum (Direct Dorsal Views). 4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves). b. Posterior alar groove aesthetics improved after defatting. The alae nasi pulled medially with better aesthetic posterior groove angle with the upper lip. c. Alae nasi aesthetics improved. They are pulled medially become better seen, smaller and share in nasal aesthetics (Nasal Aperture, Oblique and Lateral Views).

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Part II: Clinical Case 1

d. Nasal aperture aesthetics improved after defatting and correction of caudal septal deviation: i. The size of nasal aperture became equal and smaller than before. ii. The shapes and sizes of both apertures are the same. They both look more elegantly oval. e. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views). ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views). f. The smile of the patient is more symmetrical postoperatively no gums seen. Commentary a. This gentleman had a deviated boney pyramid to the left, secondary to bilateral maxillary asymmetry as clearly seen in the backward tilting, direct dorsal and overhead views. Direct frontal trauma further deviated the lower two thirds to the left. The outcome is a sever deviation of the whole nose to the left. b. The severe deviation of the cartilaginous septum has pushed the left lateral crus forward. It appeared as a large bulge externally. This has added to the misshapen and the increased size of the nasal tip. c. It is surprising how small the nasal tip became, after defatting without the use of tip grafts or direct crural stitching, This is the patient’s own crural cartilages and his own normal image. d. Despite the large size of the lower third, the patient did not need reduction in the sizes of nasal apertures. The nasal openings were proportionate in size to the rest of the nose. e. Excessive defatting of the left lateral crus resulted in a thin skinned area which usually corrects itself after a few months. This amount of defatting is impossible in open Rhinoplasty due to the division of the columellar arteries and the fear of tip ischaemia.

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Part II: Clinical Case 1

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Frontal Smiling

Frontal

Frontal Middle Third

Preoperative

Postoperative

Direct Dorsal

Preoperative

Postoperative

Overhead

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3

Backward Tilting

Basal

Basal Smiling

Preoperative

Postoperative

Right Nasal Aperture

Preoperative

Postoperative

Left Nasal Aperture

Part II: Clinical Case 1

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Part II: Clinical Case 1

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Right Oblique Mid Cheek Full Face

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Preoperative

Postoperative

Right Oblique Cheek Margin Full Face

Preoperative

Postoperative

Left Oblique Cheek Margin Full Face

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3

Right Lateral

Preoperative

Postoperative

Left Lateral

Right Lateral Smiling

Left Lateral Smiling

Part II: Clinical Case 1

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Part II: Clinical Case 2

Preoperative Assessment

Surgical Plan

1. Frontolateral walls a. Broad, flattened nasal tip (Frontal, Direct Dorsal, Overhead and Backward Tilting Views). b. The nasal tip was ill defined from the surrounding alae nasi. 2. Medial Wall a. Nasal septum had comminuted fractures that bulged on both sides blocking the nasal airways almost completely. b. Right caudal dislocation of broken cartilages protruding through the right nasal aperture (Backward tilting and Right Nasal Aperture Views). 3. Bony pyramid a. Wide base of the boney pyramid (Frontal, Direct Dorsal and Backward Tilting Views). b. The boney pyramid looks relatively short and high as a result of the traumatic depression of the lower two thirds of the nose (Frontal, Oblique and Lateral Views). 4. Alar base a. Wide alar base. The originally wide alar base has been exaggerated by the flattened nose after trauma. b. The flattened nasal tip has produced wide rounded nasal openings that is commonly seen in African noses, i.e. the axes of the nasal openings has transformed from vertical to a transverse one. c. The right nasal aperture is intruded upon by the broken caudal septum Resulting in unaesthetic and apparently asymmetrical nasal aperatures (Backward tilting and Right Nasal Aperture Views).

1. Frontolateral walls DDD not including the weak triangle to reduce the bulk of the nasal tip. 2. Medial Wall Septoplasty persuing a preservative attitude to maintain the stability of the 3-dimensional structure of the nose. 3. Bony pyramid a. Reducing the slight elevation of the height of the boney pyramid. b. Osteotomies and medialization of the lateral bony walls. 4. Alar base Resection of the inferior and posterior segments of the rim-sill folds.

Aims of Surgery 1. Reduce the size and bulk of the nasal tip. 2. Septoplasty to improve the nasal airways and nasal aperture aesthetics. 3. Reduce the width and irregularities of the bony pyramid. 4. Reduce the size and bulk of the alar base.

Surgical Procedure a. As per Surgical Plan. b. Submucous diathermy was performed to improve the airway. c. Supra tip graft was needed to fill in a defect that appeared during surgery. d. Despite the difficult and meticulous dissection of the septal mucosa, yet most of the broken bones and cartilages were preserved to maintain stability of the nose. e. Pieces of the nasal septum were kept in place by trans-septal stitches at different levels of the fracture. Post-operative Analysis 1. Frontolateral Wall a. Tip Definition: nasal tip is smaller with thinner and smoother overlying skin. It is more prominent and well identified from the alae nasi on both sides. The alae nasi come into view to become clearly visible and share in nasal aesthetics (Frontal, Direct Dorsal, Overhead and Backward Tilting Views).

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_4

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b. Tip projection: The nasal tip is at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as one spot off the nasal tip. (Frontal and Backward Tilting Views). 2. Medial Wall a. The nasal airway improved after septoplasty and submucous diathermy of inferior turbinates. b. Protrusion of broken septum into right nasal aperture is corrected. 3. Bony Pyramid a. Bony pyramid aesthetics improved: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Dorsal light reflex is seen as an uninterrupted line off the nasal dorsum (Direct Dorsal Views). 4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves). b. Posterior alar groove aesthetics improved by Defatting and resection of the rim-sill folds. The defatted lateral crurae are pulled medially as they become semidetached from the alae nasi, by the defatted superior alar grooves. The angles of the posterior alar

Frontal

Preoperative

Postoperative

Part II: Clinical Case 2

grooves with the upper lip become wider. (Backward Tilting and Nasal Aperture Views). The acute angle flat tire appearance was overcome. c. Alae nasi aesthetics improved. They look smaller after resecting the posterior segments and became better seen as they are medialized inwards. d. Nasal aperture aesthetics improved after defatting and resection of the rim-sill folds: i. The size of the nasal openings became proportionately smaller. ii. The shapes have better aesthetic. They lost their wide African shapes. e. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views). ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views). Commentary a. The post-operative photograph shows an overall reduction in the size while maintaining the same features of the nose. b. It is not enough to only deal with the fractured septum and bony pyramid. All four areas of the nose must be considered. In this case the wide alar base and ill defined tip had to be addressed.

Frontal Smiling

Frontal Middle Third

4

Part II: Clinical Case 2

25

Direct Dorsal

Direct Dorsal Smiling

Overhead

Backward Tilting

Steeper Backward Tilting

Overhead Smiling

Preoperative

Postoperative

Preoperative

Postoperative

Right Nasal Aperture

Preoperative

Postoperative

Right Nasal Aperture Rim Sill Test

Left Nasal Aperture Rim Sill Test

Left Nasal Aperture

26

4 Right Oblique Mid Cheek Full Face

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

Preoperative

Postoperative

Right Oblique Cheek Margin Full Face

Preoperative

Postoperative

Part II: Clinical Case 2

4

Part II: Clinical Case 2

27

Right Lateral

Left Lateral

Right Lateral Smiling

Right Lateral Middle Third

Left Lateral Middle Third

Preoperative

Postoperative

Preoperative

Postoperative

Left Lateral Smiling

5

Part II: Clinical Case 3

Preoperative Analysis 1. Frontolateral walls Nil of note. 2. Medial Wall a. Mobile tip: the nasal tip moves inferiorly on smiling (Lateral Smiling Views). b. Sliding tip: the nasal tip moves posteriorly on smiling. Note the prominent anterior septal angle as a result of the receding nasal tip (Lateral Smiling and Basal Views). The patient is holding the upper lip down with her mouth in the preoperative Basal view. 3. Bony pyramid a. Fracture of the nasal bones with prominent left bony specule (Frontal, Backward Tilting, Nasal Aperture and Oblique Views). b. Wide base of the boney pyramid (Frontal, Direct Dorsal and Backward Tilting Views). 4. Alar base Nil of note. Aims of Surgery 1. Correction of the fractured nasal bones. 2. Elevation and fixation of the tip to overcome the sliding effect. 3. Abolish mobility of the tip. Surgical Plan 1. Frontolateral walls Nil of note. 2. Medial Wall a. Wedge excision of the anterior part of the membranous section. b. Stitch the cartilaginous septum to the medial crurae. c. Division of the Depressor Septi muscles.

3. Bony pyramid a. Rasping of the broken, sharp edges of the nasal bone. b. Osteotomies and medialization of the lateral bony walls. 4. Alar base Nil of note. Surgical Procedure As per Surgical Plan. Post-Operative Analysis 1. Frontolateral Walls Nil of note. 2. Medial Walls a. Mobile tip disappeared. b. Sliding tip was overcome. 3. Bony Pyramid a. Bony pyramid aesthetics improved: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Dorsal light reflex is seen as an uninterrupted line off the nasal dorsum (Direct Dorsal Views). 4. Alar Base Nil of note. Commentary a. This is an uncommon case of fracture of the nasal bones only. The base of the boney pyramid i.e. the frontal processes of the maxillae, were smooth and intact. b. On smiling, the tip moved both downwards and backwards: i. Inferior movement of the nasal tip is described as a mobile tip. ii. Posterior movement of the nasal tip below the level of the dorsum i.e. the anterior septal angel, is described as a sliding tip.

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iii. The anterior angle of the cartilaginous septum became more prominent than the depressed tip. This is seen in the basal view with the upper lip pulled down by the patient. Both the downward and posterior movements are well demonstrated in the smiling lateral views.

Frontal

Preoperative

Postoperative

Part II: Clinical Case 3

c. It was important to deal with other unaesthetic areas of the nose as well as the fractured nasal bones. In this case it was the mobile and the sliding tip as well as the wide base of the bony pyramid.

Frontal Smiling

Frontal Middle Third

5

Part II: Clinical Case 3

31

Direct Dorsal

Direct Dorsal Smiling

Preoperative

Postoperative

Backward Tilting

Preoperative

Postoperative

Steeper Backward Tilting

Basal

32

5

Right Nasal Aperture

Left Nasal Aperture

Preoperative

Postoperative

Right Oblique Mid Cheek Full Face

Preoperative

Postoperative

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

Part II: Clinical Case 3

5

Part II: Clinical Case 3

33

Right Oblique Cheek Margin Full Face

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

Right Lateral

Left Lateral

Right Lateral Smiling

Left Lateral Smiling

Preoperative

Postoperative

Preoperative

Postoperative

6

Part II: Clinical Case 4

Preoperative Assessment 1. Frontolateral walls Nil of note. 2. Medial Wall Nil of note. 3. Bony pyramid a. The boney pyramid was fractured and deviated to the right side. The left sidewall of the boney pyramid is depressed, while the right side is elevated. (Frontal, Direct Dorsal and Backward Tilting Views). b. A boney spicule is protruding on the right side of the top of the boney pyramid that looks broad. c. Wide base of the boney pyramid. (Direct Dorsal and Backward Tilting Views). 4. Alar base Nil of note. Aims of Surgery 1. Remove the bony spicule. 2. Reconstruction of the bony pyramid. Surgical Plan 1. Frontolateral walls Nil of note. 2. Medial Wall Nil of note. 3. Bony pyramid a. Rasping of the prominent boney spicule. b. Osteotomies and medialization of the lateral bony walls.

4. Alar base Nil of note. Surgical Procedure a. As per Surgical Plan. b. A depression was found at the left side of the mid vault as a result of the old trauma. A cartilaginous graft was used to fill this depression. Post-Operative Analysis 1. Frontolateral Walls Nil of note. 2. Medial Walls Nil of note. 3. Bony Pyramid a. Bony pyramid aesthetics improved: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Dorsal light reflex is seen as an uninterrupted line off the nasal dorsum (Direct Dorsal Views). 4. Alar Base Nil of note. Commentary a. Only one of the four areas of Rhinoplasty was addressed i.e. the bony pyramid. The other three areas of the nose were aesthetically acceptable i.e. the nasal tip, wall and alar base. b. Correcting the deformity of the bony pyramid was sufficient to produce an overall attractive nose.

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Frontal Smiling

Frontal

Frontal Middle Third

Preoperative

Postoperative

Direct Dorsal

Preoperative

Postoperative

Direct Dorsal Smiling

Part II: Clinical Case 4

6

Part II: Clinical Case 4

37

Backward Tilting

Steeper Backward Tilting

Basal

Basal Smiling

Preoperative

Postoperative

Right Nasal Aperture

Right Nasal Aperture Rim Sill Test

Left Nasal Aperture Rim Sill Test

Left Nasal Aperture

Right Oblique Mid Cheek Full Face

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

Preoperative

Preoperative

Postoperative

38

6

Right Oblique Cheek Margin Full Face

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

Right Lateral

Left Lateral

Right Lateral Smiling

Left Lateral Smiling

Preoperative

Postoperative

Preoperative

Postoperative

Part II: Clinical Case 4

6

Part II: Clinical Case 4

39

Right Lateral Middle Third

Preoperative

Postoperative

Left Lateral Middle Third

7

Part II: Clinical Case 5

Preoperative Analysis

Surgical Plan

1. Frontolateral walls a. Large and bulky frontolateral walls overshadowing the alae nasi. (Frontal, Overhead, Direct Dorsal and Backward Tilting Views). b. The tip is counter deviated to the right. 2. Nasal septum a. Severe, traumatic fracture with left sided angulated deviation of the caudal nasal septum (Left Nasal Aperture Views). b. Mobile tip (Lateral Smiling Views). 3. Bony pyramid a. The bony pyramid is fractured and both oblique and deviated to left side. b. Bilateral maxillary asymmetry which is clearly seen in the backward tilting view. The right cheek is wide and low while the left cheek is narrow and high. The trauma together with the bilateral maxillary asymmetry has led to the extreme left Obliquity and deviation of the boney pyramid. (Frontal, Direct Dorsal and Overhead Views). c. Osteocartilaginous hump. (Backward Tilting, Oblique and lateral Views). 4. Alar base Wide and bulky alar base (Basal and Nasal Aperture Views).

1. Frontolateral walls a. DDD including the weak triangle to reduce the bulk. b. Cephalic trim of the lateral crurae, more on the left side to reduce the size. 2. Nasal septum a. Septoplasty. b. Division of the Depressor Septi muscles. 3. Bony pyramid a. Rasping of the boney hump. More rasping on the right of the pyramid. Excision of the cartilaginous hump. b. Bilateral osteotomies to reduce the size of the booty pyramidal base. c. Kassanjian maneuver to the right i.e. cross fracture of the bony pyramid after osteotomies (see Surgery of the Bony Pyramid in the Text). 4. Alar base Resection of the posterior and inferior segments of the rim sill folds. Surgical Procedure a. As per Surgical Plan. b. At the time of surgery, the right lateral crus was found to be too small for any further reduction. Cephalic trim was only performed to the left lateral crus only. c. Two pieces of crushed septal cartilage used to augment the right side of the upper lateral cartilage. d. Surprisingly after defatting and reduction the lateral crural sizes, the shape and sizes of nasal apertures greatly improved. No alar resections were needed.

Aims of Surgery 1. 2. 3. 4. 5.

Reduction of the size and bulk of the frontolateral walls. Abolish the mobile tip. Correction of the septal deviation. Excision of the osteocartilaginous hump. Centralizing and reducing the wide base of the boney pyramid. 6. Reduction of the width and bulk of the alar base.

Post-Operative Analysis 1. Frontolateral Wall a. Tip Definition: nasal tip is smaller with thinner and smoother overlying skin. It is more prominent and

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_7

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well identified from the alae nasi on both sides. The alae nasi come into view to become clearly visible and share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). b. Tip projection: the nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as one spot off the nasal tip. (Frontal and Backward Tilting). 2. Medial Wall The deviated septum was corrected. 3. Bony Pyramid a. Bony pyramid aesthetics improved: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Dorsal light reflex is seen as an uninterrupted line off the nasal dorsum (Direct Dorsal Views). 4. Alar Base a. Superior alar groove aesthetics improved after defatting. The grooves became longer and deeper (Oblique, Lateral and Direct Dorsal grooves). b. Posterior alar groove aesthetics improved even without alar resection. The alae nasi pulled medially resulting in wider posterior alar groove angles. The flat tire appearance was gone.

Frontal

Preoperative

Postoperative

Part II: Clinical Case 5

c. Alae nasi aesthetics improved. They look smaller and are better seen along the sides of the the thinner well defined nasal tip. d. Nasal aperture aesthetics improved with defatting alone. Nasal apertures look smaller and elegantly oval in shape. (Basal and Nasal Aperture Views). e. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views). ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views). Commentary a. The patient’s main complain was the fractured deviated bony pyramid. It is the role and duty of the treating surgeon to advice him to proportionately reduce the size of the lower third of the nose for better aesthetic results. b. The size of the right side of the upper lateral cartilage is smaller than the left as a result the facial asymmetry and the trauma in early life which may have affected its growth. A graft was needed to augment this defective area. c. The size of the nose was greatly reduced after DDD to the extent that both alae were elevated forward rather than lying backward. An alar resection was, therefore, unnecessary. d. No direct surgery was addressed to the lower lateral cartridges i.e. no direct stitching. No indirect camouflage surgery to the nasal tip i.e. tip grafts.

Frontal Smiling

7

Part II: Clinical Case 5

43

Direct Dorsal

Direct Dorsal Smiling

Overhead

Preoperative

Postoperative

Backward Tilting

Preoperative

Postoperative

Basal

44

7

Right Nasal Aperture

Right Nasal Aperture Rim Sill Test

Left Nasal Aperture Rim Sill Test

Left Nasal Aperture

Right Oblique Mid Cheek Full Face

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

Preoperative

Postoperative

Preoperative

Postoperative

Part II: Clinical Case 5

7

Part II: Clinical Case 5

45

Right Oblique Cheek Margin Full Face

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

Right Lateral

Left Lateral

Right Lateral Smiling

Left Lateral Smiling

Preoperative

Postoperative

Preoperative

Postoperative

46

7

Right Lateral Middle Third

Preoperative

Postoperative

Left Lateral Middle Third

Part II: Clinical Case 5

8

Part II: Clinical Case 6

Preoperative Assessment

Aims of Surgery

1. Frontolateral walls a. Large and bulky tip overshadowing the alae nasi. (Frontal, Direct Dorsal, Overhead and backward Tilting Views). b. Anterior bulge of the left middle crus due to left high deviation of cartilaginous septum (Backward Tilting View). 2. Nasal septum a. Fracture dislocation of the caudal septum to the right and consequently: i. The medial crus is pushed laterally distorting nasal apertures (basal views). ii. The right nasal sill band is pushed inferiorly (frontal views). 3. Bony pyramid a. Osteocartilaginous hump. (Oblique and Lateral Views). b. The depression above the left side of the upper lateral cartilage suggests the possibility of a defect in the left side of the upper lateral cartilage (Frontal, Direct dorsal, overhead and backward tilting views). c. The boney pyramid is oblique and deviated to the right side due to bilateral maxillary asymmetry (overhead and backward tilting views). The left cheek is wide and low while the right cheek is high and narrow (Backward tilting view). There was no fracture. 4. Alar base a. Wide alar base due to long inferior segments of the rim-sill folds. The alae nasi bend on the upper lip in acute posterior alar groove angles giving the appearance of a flat tire. b. Apparently asymmetrical nasal apertures due to encroachment of the fractured dislocated caudal septum upon the right nasal aperture (Backward Tilting and Basal Views).

1. 2. 3. 4.

Reduction of the size and bulk of the nasal tip. Correction of the septal deviation and dislocation. Excision of the osteocartilaginous hump. Reduction of the size of the alar base.

Surgical Plan 1. Frontolateral walls a. DDD including the weak triangle to reduce the bulk. b. Cephalic trim of the lateral crurae to reduce the size. 2. Nasal septum Septoplasty. 3. Bony pyramid a. Rasping of the boney hump as well as an excision of the cartilaginous hump. b. Osteotomies and Kasanjian maneuver to the left side i.e. cross fracture of the bony pyramid after osteotomies (see Surgery of the Bony Pyramid in the Text). 4. Alar base Bilateral excision of only the inferior segments of the rim-sill folds. Surgical Procedure a. As per Surgical Plan. b. Septoplasty: three millimeters were excised from the caudal septum. A strip of two millimeters was excised from its posterior margin. The cartilaginous septum was moved to its original place in the maxillary groove. The deviated boney septum was fractured to the mid line. Two millimeters of excess skin over the caudal septum what is excised. c. The severe deviation of the septum obstructed the access to tip surgery. Septoplasty was therefore carried out first before the tip work.

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d. No defects were found over the left side of the upper lateral cartilage and grafts were not necessary. e. Only excision of the inferior segments of the rim-sill folds were necessary, the alae nasi were sufficiently pulled medially with wider posterior alar groove angles and smaller apertures (Basal and nasal aperture views). Post-Operative Analysis 1. Frontolateral Wall a. Tip Definition: nasal tip is smaller with thinner and smoother overlying skin. It is more prominent and well identified from the alae nasi on both sides. The alae nasi come into view to become clearly visible and share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). b. Tip projection: the nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as one spot off the nasal tip. (Frontal and Backward Tilting Views). 2. Medial Wall The caudal fractured dislocated septum was corrected.

Part II: Clinical Case 6

4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves). b. Posterior alar groove aesthetics improved by Defatting and excision. The defatted alae nasi are pulled medially as they become semidetached from the crurae, by the defatted superior alar grooves. The angles of the posterior alar grooves with the upper lip become wider. (Backward Tilting and Nasal Aperture Views). The flat tire appearance is gone. c. Alae nasi aesthetics improved as they were pulled medially to become more visible and smaller in size. d. Nasal aperture aesthetics improved by defatting and excision of the inferior segments of the rim-sill folds: i. The size of the nasal openings are reduced. ii. The shapes of nasal openings become more elegantly oval on shape. (Backward Tilting, Basal and Nasal Aperture views). e. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views). ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views). Commentary

3. Bony Pyramid a. Bony pyramid aesthetics improved: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Dorsal light reflex is seen as an uninterrupted line off the nasal dorsum (Direct Dorsal Views).

Frontal

Preoperative

Postoperative

a. In these delayed post traumatic cases, it is not sufficient to only correct the fractured nasal septum. Surgeon must also proportionately reduce the size of the rest of the nose after advising the patient and take his permission. b. It is not uncommon for the fractured nasal septum to be overlooked. This gentleman have had other unaesthetics issues to his nose which probably overshadowed the deformed caudal fracture of the septum. Frontal Smiling

Frontal Middle Third

8

Part II: Clinical Case 6

49

Direct Dorsal

Direct Dorsal Smiling

Overhead

Preoperative

Postoperative

Basal

Backward Tilting

Preoperative

Postoperative

Right Nasal Aperture

Right Nasal Aperture Rim Sill Test

Left Nasal Aperture Rim Sill Test

Preoperative

Note: The pale area of the rim sill fold.

Postoperative

Left Nasal Aperture

50

8 Right Oblique Mid Cheek Full Face

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

Preoperative

Postoperative

Right Oblique Cheek Margin Full Face

Preoperative

Postoperative

Part II: Clinical Case 6

8

Part II: Clinical Case 6

51

Right Lateral

Left Lateral

Right Lateral Smiling

Preoperative

Postoperative

Right Lateral Middle Third

Preoperative

Postoperative

Left Lateral Middle Third

Left Lateral Smiling

9

Part II: Clinical Case 7

Preoperative Assessment 1. Frontolateral walls Large and bulky nasal tip (Frontal Views) 2. Medial wall a. Sever saddle deformity of the nose secondary to total collapse of the cartilaginous nasal septum. The lower two thirds of the nose was very soft denoting the absence of any cartilaginous support from the septum. (Oblique and Lateral Views). b. No airway obstruction 3. Bony pyramid a. Small, bony hump (Oblique and Lateral Views) b. Wide base of bony pyramid (Frontal Direct Dorsal and Backward Tilting Views) 4. Alar base Wide alar base and large nasal apertures (Backward Tilting, Basal and Nasal Aperture Views) Aims of Surgery 1. 2. 3. 4.

Reducing the size and bulk of nasal tip Reducing the size of the bony pyramid Correcting the saddle deformity. Reduction of the alar base and the size of nasal apertures

Surgical Plan 1. Frontolateral walls a. D.D.D. including weak triangle to reduce the bulk and size of the nasal tip. b. Cephalic trim of the lateral crurae to further reduce the size of the nasal tip. 2. Medial Wall Augmentation graft to the saddle deformity

3. Bony pyramid a. Excision of the bony hump. b. Bilateral osteotomies and medialization of the lateral bony walls. 4. Alar base Bilateral resection of the posterior and inferior segments of the rim-sill folds. Surgical Procedure a. As per surgical plan b. Augmentation of the saddle deformity was achieved by using trimming of the lateral crurae including their overlying thick capsules of fat i.e. before the defatting process. Post-operative Analysis 1. Frontolateral Walls a. Tip Definition: nasal tip is smaller with thin overlying skin. It is more prominent and well identified from the alae nasa on both sides. The alae nasi come into view to become clearly visible and share in nasal aesthetic (Frontal, Direct Dorsal, Backward Tilting and Basal Views). b. Tip projection: The nasal tip is at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (Lateral and Oblique views) c. The tip light reflex is seen as one spot off the nasal tip (Frontal and Backward Tilting Views). 2. Medial Walls The saddle deformity completely rectified (Oblique and Lateral Views).

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_9

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3. Bony Pyramid a. Bony pyramid aesthetic improved: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views) b. Dorsal light reflex is seen as an uninterrupted line off the nasal dorsum (Direct Dorsal Views) 4. Alar base a. The superior alar groove is now clear of fat becomes deeper, longer and visible (Direct Dorsal, Oblique and lateral Views). b. Posterior alar groove aesthetic improved. The angle of the alae nasi with the upper lip is wider (Backward Tilting, Basal and Nasal Aperture Views). c. Alae nasi aesthetics improved. They are pulled medially, become better seen, smaller in size and share in nasal aesthetics (Nasal Aperture, Oblique and Lateral Views). d. Nasal aperture aesthetic improved after defatting and excision of the rim-sill folds. They become more elegantly oval in shape.

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Part II: Clinical Case 7

e. Marginal light reflexes are clearly seen at: i. The inferior alar margins (Basal and Nasal Aperture Views). Lateral crural prominences (Lateral Views) Commentary 1. The wide and deep dorsal saddle deformity was transformed into narrow ans shallow depression as a result of the following procedures: a. Defatting of the lateral and middle crurae as well as weakening of the domes. b. Excision of the bony hump c. Osteotomies and medialization of the lateral bony walls. 2. There was no need for the use of a large graft material e.g. costal cartilages, ear conchal cartilage or multilayered septal graft. 3. Two layers of fat paddled cephalic trims of the lateral crural cartilage were sufficient to fill the dorsal depression after reducing its size.

9

Part II: Clinical Case 7

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Part II: Clinical Case 7

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Part II: Clinical Case 7

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Part II: Clinical Case 8

Preoperative Assessment 1. Frontolateral walls a. Relatively small but bulky nasal tip overshadowing the alae nasi (Frontal Views). b. Slight tip bifidity reflecting two spots of light. (Backward Tilting Views). 2. Nasal septum a. Traumatic septal deviation to the left (Backward Tilting and Basal Views; the red mucosa of the cartilaginous septum is seen through the left nasal opening blocking it almost completely). b. Slight columellar bifidity (Backward Tilting Views). 3. Bony pyramid a. Fracture of the boney pyramid deviating it to the left side. The right side of the pyramid is depressed while the left side is elevated with prominent fracture margin. (Frontal, Backward Tilting and Oblique Views). b. Wide base of the bony pyramid (Frontal and Backward Tilting Views). 4. Alar base Nil of note. Aims of Surgery 1. Proportionate reduction of the nasal tip bulk. 2. Correction of the septal deviation. 3. Balancing and centralizing the boney pyramid. Surgical Plan 1. Frontolateral walls DDD including the weak triangle to reduce the bulk of nasal tip. 2. Nasal septum Septoplasty.

10

3. Bony pyramid a. Rasping the prominent broken bone. b. Osteotomies as well as cross fracture of the boney pyramid to the right side (Kasanjian maneuver). 4. Alar base Nil of note. Surgical Procedure a. As per Surgical Plan. b. Small bone graft over the right side of the boney pyramid was needed to balance the two sides of the bony pyramid. Post-Operative Analysis 1. Frontolateral Wall a. Tip Definition: nasal tip is smaller with thinner and smoother overlying skin. It is more prominent and well identified from the alae nasi on both sides. The alae nasi come into view to become clearly visible and share in nasal aesthetics (Frontal, Direct Dorsal, Backward Tilting and Basal Views). b. Tip projection: the nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as one spot off the nasal tip. (Frontal and Backward Tilting Views). 2. Medial Wall a. The deviated septum was corrected (Backward Tilting and Basal views). b. Bifidity of the columellar was corrected only by defatting. This can be seen in almost all the views of the nose in particular the Backward Tilting Basal views. 3. Bony Pyramid a. Bony pyramid aesthetics improved: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views).

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b. Dorsal light reflex is seen as an uninterrupted line off the nasal dorsum (Direct Dorsal Views). 4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves). b. Posterior alar groove improved by defatting as the alae nasi pulled medially widening the posterior alar grooves. c. Alae nasi aesthetics improved as they were pulled medially, became more visible and of smaller sizes. (Nasal Aperture, Oblique and Lateral Views). Nasal aperture aesthetics are enhanced by defatting and correction of caudal septal deviation. They maintained the same size but they were transformed from

Frontal

Preoperative

Postoperative

Part II: Clinical Case 8

thick walled rounded openings into thin walled elegant oval apertures. d. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views). ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views). Commentary a. This is a case of a simple, uncomplicated fracture of the boney pyramid. It is an ideal case for beginners. b. Areas of defects on the depressed side of the fracture should be anticipated. A cartilaginous or bony graft is used to balance the sides of the boney pyramid. c. The bulky tip is a pre-existing unaesthetic part of the nose that should be addressed for better aesthetic result.

Frontal Smiling

Frontal Middle Third

10

Part II: Clinical Case 8

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Backward Tilting

Steeper Backward Tilting

Basal

Preoperative

Postoperative

Steeper Backward Tilting

Preoperative

Postoperative

Backward Tilting

Basal

62

10

Right Oblique Mid Cheek Full Face

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Preoperative

Postoperative

Right Oblique Cheek Margin Full Face

Preoperative

Postoperative

Left Oblique Cheek Margin Full Face

Left Oblique Mid Cheek Middle Third

Part II: Clinical Case 8

10

Part II: Clinical Case 8

63

Right Lateral

Preoperative

Postoperative

Left Lateral

Right Lateral Smiling

Left Lateral Smiling

Part II: Clinical Case 9

Preoperative Assessment 1. Frontolateral walls Bulbous and bulky nasal tip partially overshadowing the alae nasi (Frontal, Direct Dorsal and Overhead Views). 2. Medial Wall Mobile tip (Lateral Views). 3. Bony pyramid a. Wide base of the bony pyramid. (Direct Dorsal, Overhead and Backward Tilting Views). b. Localized hump at the distal end of the bony pyramid. On palpation it was a purely bony hump. It was not an osteocartilaginous hump. Palpating the area just distal to this hump, the nasal dorsum felt quite firm and the nasal septum could be clearly felt indicating that it had not collapsed by the trauma. A line drawn from the nasion to the nasal tip, i.e point of maximum convexity of the middle crus, is a straight line. (Lateral Views). c. The dorsal light reflex is distorted (Frontal and Direct Dorsal views). d. Deep naso-frontal angle (lateral views). 4. Alar base Wide alar base. Aims of Surgery 1. 2. 3. 4.

Reduction of the bulk of the nasal tip. Overall reduction of the size of the bony pyramid. Removal of the localized boney hump. Reduction of alar base size and bulk.

Surgical Plan 1. Frontolateral walls a. D.D.D. not including weak triangle to reduce the bulk of the nasal tip. b. Cephalic trim of lateral crurae to reduce the size.

11

2. Media Wall Division of depressor septi muscles. 3. Bony pyramid a. Excision of the pure bony hump. It is NOT an osteocartilaginous hump. b. Osteotomies and medialization of the lateral bony walls. c. Graft over the middle third of the nose is considered. 4. Alar base Resection of the inferior segments of the rim sill folds. Surgical Procedure a. As per Surgical Plan. b. Excision of the boney hump was performed using a sharp osteotome. c. The excised bone was used to augment the nasofrontal angle. d. A slight supratip depression was observed during surgery. This was due to minimal tissue damage to the upper lateral cartilage in the mid vault. The depression was corrected using septal graft and lateral crural trimmings. Post-Operative Analysis 1. Frontolateral Walls a. Tip Definition: nasal tip is smaller with thinner and smoother overlying skin. It is more prominent and well identified from the alae nasi on both sides. The alae nasi come into view to become clearly visible and share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). b. Tip projection: the nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as on spot light reflected from the nasal tip (Frontal and Backward Tilting Views).

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_11

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2. Medial Wall The mobile tip was abolished. 3. Bony Pyramid a. Bony pyramid aesthetics improved: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. The deep nasofrontal angle was more apparent after removal of the bony hump. Clinically and photographically it was not quite as clear. c. Dorsal light reflex is seen as an uninterrupted line off the nasal dorsum (Direct Dorsal Views). 4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves). b. Posterior alar groove aesthetics improved after defatting and excision of the inferior segments of rim-sill folds. The angles with the upper lip became wider. c. Alae nasi aesthetics improved. They were pulled medially by defatting and better seen. d. Nasal aperture aesthetic improved after defatting and excision of the inferior segments of the rim-sill folds: i. The size of nasal opening are smaller. ii. The shapes of the nasal openings became more elegantly oval. e. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views). ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views).

11

Part II: Clinical Case 9

Commentary a. This gentleman would have been very happy to just remove the hump on his nose. However, he has other features of common African/Middle Eastern nose which are in his case large, bulbous tip, wide alar base and deep nasofrontal angle. The attitude in this case should be to tackle all these areas in order to have a more aesthetically pleasing outcome. b. The deep nasofrontal angle was appreciated only after removal of the bony hump. c. It is important to know the exact mechanism of the trauma in order to understand the type of deformity. He was at a lower level than a heavy window type AC unit which slipped down onto the bridge of his nose as he was looking up. The direction of the trauma is anatomically from below in an upward direction. This led to a telescopic fracture of the nasal bones superiorly. This explains the unusual, large localized bony hump at the distal end of the boney pyramid which is followed inferiorly by the apparent depression. This is to be differentiated from the saddle deformity in the midvault secondary to cartilaginous septal collapse. As in all cases of post traumatic Rhinoplasty there is a degree of uncertainty with the Surgical Plan as the trauma is usually associated with irregular tissue damage and scattered pieces of broken bones. d. This gentleman would have been very happy to just remove the hump of his nose. However, he has other features of common African/Middle Eastern nose which are in his case large, bulbous tip, wide alar base and deep nasofrontal angle. The attitude in this case should be to tackle all these areas in order to have a more aesthetically pleasing outcome.

11

Part II: Clinical Case 9

67

Frontal

Frontal Smiling

Frontal Middle Third

Preoperative

Postoperative

Direct Dorsal

Preoperative

Postoperative

Direct Dorsal Smiling

Overhead

68

11

Backward Tilting

Steeper Backward Tilting

Basal

Preoperative

Postoperative

Right Nasal Aperture

Preoperative

Postoperative

Left Nasal Aperture

Part II: Clinical Case 9

11

Part II: Clinical Case 9

69

Right Oblique Mid Cheek Full Face

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

Preoperative

Postoperative

Right Oblique Cheek Margin Full Face

Preoperative

Postoperative

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

70

11

Right Lateral

Left Lateral

Right Lateral Smiling

Preoperative

Postoperative

Right Lateral Middle Third

Preoperative

Postoperative

Left Lateral Middle Third

Left Lateral Smiling

Part II: Clinical Case 9

Part II: Clinical Case 10

12

Preoperative Assessment

Surgical Plan

1. Frontolateral walls a. Small but bulky tip partially overshadowing the alae nasi. (Frontal and Direct Dorsal Views). b. There is unequal bulge of the domes. The broken deviated distal segment of the cartilaginous septum has displaced the dome of the left lower lateral cartilage forward and laterally, resulting in an unequal bulge of the lateral crurae and broadening of the nasal tip (backward tilting view). 2. Medial Wall The vertical fracture of the nasal septum have lead to a severe C-shaped deviation to the left. This curved shape of the septum have caused the following two deformities: i. Superior bulge of the right side of the upper lateral cartilage which is met with counter depression on the left side of the midvault. (Frontal, Direct Dorsal, Overhead and Backward Tilting Views). ii. Inferior bulge of the left lateral crus caused by the broken distal segment of the septum. (Frontal, Direct Dorsal, Overhead, Backward Tilting and Oblique Views). 3. Bony pyramid a. Wide base of the bony pyramid (Frontal, Direct Dorsal, Overhead and Backward Tilting Views). b. Depression over the left side of the upper lateral cartilage secondary to an old fracture of the tip of the left nasal bone leading to a “ski slope” deformity. 4. Alar base Nil of note.

1. Frontolateral walls a. DDD excluding the weak triangle to reduce the bulk of nasal tip. b. Bilateral cephalic trim of the lateral crurae to reduce the size of nasal tip. 2. Media Wall Septoplasty. 3. Bony pyramid a. Osteotomies and medialization of the lateral bony walls. b. Cartilaginous graft over left side of the upper lateral cartilage to correct the ski slope deformity. 4. Alar base Nil of note.

Aims of Surgery 1. Reduce the size and bulk of the nasal tip. 2. Reduce the bulges of the left dome and right midvault areas. 3. Elevate the left sided depression of the midvault. 4. Reduce the width of the boney pyramid.

Surgical Procedure a. As per surgical plan. b. The graft over the left side of the upper lateral cartlidge was fixed by external stitch to avoid graft displacement in the loose sub dermal layer after removal of the fatt layers i.e. defatting (Overhead, Left Oblique and Lateral Views). Post-Operative Analysis 1. Frontolateral Wall a. Tip Definition: nasal tip is smaller with thinner and smoother overlying skin. It is more prominent and well identified from the alae nasi on both sides. The alae nasi come into view to become clearly visible and share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). b. Tip projection: The nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views).

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_12

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c. Cephalic trim of the lateral crurae reduces the size of the nasal tip. It does not reduce the height of the nose. The lateral crurae are in the lateral walls of the nose and not in the dorsal midline. d. Tip light reflex is seen as one spot off the nasal tip. (Frontal and Backward Tilting Views). 2. Medial Wall Septoplasty have had two positive aesthetic effects: i. Repositioning the distal broken segment to midline have moved it away from the left dome that immediately receded back to the same level as the right dome. ii. Correcting the right higher septal deviation immediately reduced the right bulge of the upper lateral cartilage. 3. Bony Pyramid a. Osteotomies were necessary to reduce the width of the boney pyramid so that it matches with the new smaller size of the nasal tip. b. The counter depression of the left side of the upper lateral cartilage was due to the clip fracture of the left nasal bone long time ago. Filling the defect with cartilagenous graft was necessary. c. Grafts had to be externally fixed as they were placed in the nose after the procedure of DDD’s. Removing the fat leaves a wide subcutaneous space so that grafts would loosely move freely and never remain in the planned location.

Frontal

Part II: Clinical Case 10

d. Bony pyramid aesthetics improved: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). e. Dorsal light reflex is seen as an uninterrupted line off the nasal dorsum (Direct Dorsal Views). 4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves). b. Posterior alar groove aesthetics improved by defatting. The alae nasi pulled medially and the angles of the posterior alar groove became wider. c. Alae nasi aesthetics improved by defatting. They were pulled medially, became more visible and smaller in size (Oblique and Lateral Views). d. Nasal aperture aesthetics improved by defatting: they became smaller and more elegantly oval in shape (Backward Tilting and Basal Views). e. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views). ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views). Commentary Postoperative photographs were taken two weeks after surgery. The effects of defatting are quite clear, the size and shape of the nasal tip further improves in the long term.

Frontal Smiling

Frontal Middle Third

12

Part II: Clinical Case 10

73

Direct Dorsal

Overhead

Preoperative

Backward Tilting

Preoperative

Postoperative

Steeper Backward Tilting

Basal

74

12

Right Oblique Mid Cheek Full Face

Part II: Clinical Case 10

Left Oblique Mid Cheek Full Face

Preoperative

Postoperative

Right Oblique Cheek Margin Full Face

Preoperative

Postoperative

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

12

Part II: Clinical Case 10

75

Right Lateral

Left Lateral

Right Lateral Smiling

Preoperative

Postoperative

Right Lateral Middle Third

Preoperative

Postoperative

Left Lateral Middle Third

Left Lateral Smiling

Part III Finesse Rhinoplasty

Part III: Clinical Case 1

Preoperative Assessment 1. Frontolateral walls a. Bulbous tip partially overshadowing the alae nasi (Frontal, Direct Dorsal, Overhead and Backward Tilting Views). 2. Medial Wall Left caudal deviation of the septum (left nasal aperture view). 3. Bony pyramid a. The bony pyramid is deviated to the right due to bilateral maxillary asymmetry the left cheek being wide and low while the right cheek is narrow and high (backward tilting views). b. Lower third of the nose, including the nasal tip, is counter deviated to the left side as compared to the bony pyramid. 4. Alar base a. Wide alar base (Backward Tilting and Basal Views). b. Thes nasal openings are square in shape. A common finding in African noses. Aims of Surgery 1. To reduce the bulk of the lower third of the nose. 2. To correct the nasal crookedness. 3. Alar reduction in size and bulk. Surgical Plan 1. Frontolateral Walls D.D.D. including the weak triangle. 2. Medial Wall Septoplasty. 3. Bony pyramid Osteotomies and correction of deviation by Kassanjian maneuver to the left i.e. cross fracture of the bony pyramid after osteotomies (see Surgery of the Bony Pyramid in Text).

13

4. Alar base Resection of the inferior and posterior segments of the rim-sill folds. Surgical Procedure 1. As per surgical plan. 2. Kassanjian maneuver to left side. 3. Alar resection. Post-Operative Analysis 1. Frontolateral Wall a. Tip definition: nasal tip is smaller with thinner and smoother overlying skin. It is more prominent and well identified from the alae nasi on both sides. The alae nasi come into view to become clearly visible and share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). b. Tip projection: the nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as one spot off the nasal tip. (Frontal and Backward Tilting Views). 2. Medial Wall Caudal septal deviation is corrected. 3. Bony Pyramid a. Bony pyramid aesthetics improved: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Dorsal light reflex is a straight line post-operatively as compared to the interrupted reflex pre-operatively. (Direct Dorsal Views). 4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves).

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_13

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b. The posterior alar groove aesthetics improved by defatting and resection of the rim-sill folds. The alae nasi pulled medially with wider posterior alar grooves. Aesthetics of the alae nasi is better. c. Alae nasi aesthetics improved. They are pulled medially become better seen, smaller and share in nasal aesthetics. (Nasal Aperture, Oblique and Lateral Views). d. Aesthetics of nasal apertures improved by defatting and resection of the rim-sill folds: i. The size of nasal apertures are smaller. ii. The shapes are elegantly better. e. Marginal light reflexes are clearly seen at:

i. Inferior alar margins (Nasal Aperture Views). ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views). Commentary a. All four areas of Rhinoplasty were addressed. Surgery in the four areas were integrated to produce the same nasal image in a more refined aesthetic outcome. b. The heavy impression of the bulky tip and the diffuse amorphous appearance of the midvault, alae nasi and nasal dorsum, became sharper, neater and share in nasal aesthetics.

Frontal Smiling

Preoperative

Postoperative

Part III: Clinical Case 1

Frontal Middle Third

13

Part III: Clinical Case 1

81

Direct Dorsal

Direct Dorsal Smiling

Overhead

Overhead Smiling

Preoperative

Postoperative

Backward Tilting

Preoperative

Postoperative

Steeper Backward Tilting

Basal

Basal Smiling

82

13

Right Nasal Aperture

Right Nasal Aperture Rim Sill Test

Left Nasal Aperture Rim Sill Test

Part III: Clinical Case 1

Left Nasal Aperture

Preoperative

Postoperative

Right Oblique Mid Cheek Full Face

Preoperative

Postoperative

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

13

Part III: Clinical Case 1

83

Right Oblique Cheek Margin Full Face

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

Right Lateral

Left Lateral

Right Lateral Smiling

Left Lateral Smiling

Preoperative

Postoperative

Preoperative

Postoperative

84

13

Right Lateral Middle Third

Preoperative

Postoperative

Left Lateral Middle Third

Part III: Clinical Case 1

Part III: Clinical Case 2

Preoperative Assessment

Surgical Procedure

1. Frontolateral walls Medium size thick skinned naasal tip overshadowing the alae nasi (Frontal, Direct Dorsal and Overhead Views). 2. Medial Wall Nil of note. 3. Bony pyramid a. Wide base of the bony pyramid (Direct Dorsal, Overhead and Backward Tilting Views). b. Small osteocartilaginous hump. This is the natural concavoconvex anatomy of the nasal bones (see Anatomy in Text). 4. Alar base Nasal apertures were thick walled with transverse long axes of the nasal openings.

As per Surgical Plan.

Aims of Surgery a. Reduce the bulk of nasal tip. b. Reduce the size and the width of the bony pyramid. Surgical Plan 1. Frontolateral Walls a. DDD not including the weak triangle to reduce the bulk. b. Cephalic trim of the lateral crurae to reduce the size. 2. Medial Wall Nil of note. 3. Bony pyramid a. Excision of the osteocartilaginous hump i.e. rasping down the natural convexities of the nasal bones. b. Osteotomies and medialization of the lateral walls of the bony pyramid. 4. Alar base Nil of note.

14

Post-Operative Analysis 1. Frontolateral Wall a. Tip Definition: nasal tip is smaller with thinner and smoother overlying skin. It is more prominent and well identified from the alae nasi on both sides. The alae nasi come into view to become clearly visible and share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). b. Tip projection: The nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as one spot off the nasal tip. (Frontal and Backward Tilting Views). 2. Medial Wall Nil of Note. 3. Bony Pyramid a. Bony pyramid aesthetics: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Dorsal light reflex is a straight line post-operatively as compared to the interrupted reflex pre-operatively. (Direct Dorsal Views). 4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves). b. Posterior alar groove aesthetics improved by Defatting alone. The defatted crurae are pulled medially as they become semidetached from the alae nasi, by the defatted superior alar grooves. The angles of the posterior alar grooves with the upper lip become wider. Aesthetics of the alae nasi improved. (Backward Tilting and Nasal Aperture Views).

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_14

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c. Alae nasi aesthetics improved. They are pulled medially become better seen, smaller and share in nasal aesthetics. (Nasal Aperture, Oblique and Lateral Views). d. Nasal aperture aesthetics: i. The size of the nasal openings are reduced by defatting alone. ii. The shape of nasal openings: defatting enhanced aesthetics of the nasal openings. They become more elegantly oval on shape with thinner walls. (Backward Tilting, Basal and Nasal Aperture views). e. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views). ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views).

Frontal

Commentary a. This is a finesse Rhinoplasty in which the patient needed smaller and sharper looking nasal features. Postoperatively she had a narrower bony pyramid, narrower tip and smaller alar base. The narrow bony pyramid allowed her eyes to “shine” as a more prominent feature. b. The localized bulky tip of the nose may be seen in male or female patients. The above surgical technique can be used to produce different results. Less fat is removed from the male nose to maintain a manly facial appearance, while more fat is removed from the female nose to produce a more defined, feminine, petite nose.

Frontal Smiling

Frontal Middle Third

Direct Dorsal Smiling

Overhead

Preoperative

Postoperative

Direct Dorsal

Preoperative

Postoperative

Part III: Clinical Case 2

14

Part III: Clinical Case 2

87

Backward Tilting

Steeper Backward Tilting

Basal

Basal Smiling

Right Nasal Aperture

Right Nasal Aperture Rim Sill Test

Left Nasal Aperture Rim Sill Test

Left Nasal Aperture

Preoperative

Postoperative

Preoperative

Postoperative

Right Oblique Mid Cheek Full Face

Preoperative

Postoperative

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

88

14 Right Oblique Cheek Margin Full Face

Left Oblique Cheek Margin Full Face

Right Lateral

Left Lateral

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

Preoperative

Postoperative

Preoperative

Postoperative

Right Lateral Smiling

Left Lateral Smiling

Part III: Clinical Case 2

14

Part III: Clinical Case 2

89 Right Lateral Middle Third

Preoperative

Postoperative

Left Lateral Middle Third

Part III: Clinical Case 3

15

Preoperative Assessment

Surgical Plan

1. Frontolateral walls Broad, large and thick nasal tip overshadowing the alae nasi (Frontal, Direct Dorsal, Overhead and Backward Tilting Views). 2. Medial Wall a. Left caudal septal dislocation. (Basal and Left Nasal Aperture Views) The left medial crus is seen projecting into the nasal aperture producing apparent unequal openings (backward tilting views). The left nasal sill band is pushed inferiorly (frontal views). b. Mobile tip i.e. the nasal tip moves inferiorly on smiling. (Lateral Smiling Views). 3. Bony pyramid a. Wide base of the boney pyramid (Direct Dorsal, Overhead and Backward Tilting Views). b. Osteocartilaginous hump predominantly left side (Oblique and Lateral Views). c. There is bilateral maxillary asymmetry. The boney pyramid is deviated to the left side; the right cheek is narrow and high while the left cheek is wide and low (backward tilting views). 4. Alar base Wide unequal nasal openings due to left caudal septal deviation. (Basal Views).

1. Frontolateral walls a. DDD including the weak triangle to reduce the bulk. b. Cephalic trim of lateral crurae to reduce the size. 2. Medial Wall a. Septoplasty. b. Transoral devision of the depressor septi muscles. 3. Bony pyramid a. Excision of the osteocartilaginous hump. Osteotomies plus Kasanjian manouvre to the patient’s right side i.e. cross fracture of the bony pyramid after osteotomies (see Surgery of the Bony Pyramid in text). 4. Alar base Nil of note.

Aims of Surgery 1. Reduction of the overall size of the nose including the nasal tip and the boney pyramid. 2. Centralizing of the boney pyramid to the mid line. 3. Correction of the caudally displaced septum and mobile tip.

Surgical Procedure a. As per Surgical Plan. b. Transcolumellar stitch between the two nasal sill bands to medialize the crural prominence of both medial crurae. c. Sub-mucosal diathermy of the inferior turbinate heads to improve the nasal airway. Post-Operative Analysis 1. Frontolateral Wall a. Tip Definition: nasal tip is smaller with thinner and smoother overlying skin. It is more prominent and well identified from the alae nasi on both sides. The alae nasi come into view to become clearly visible and share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views).

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_15

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b. Tip projection: The nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as one spot off the nasal tip. (Frontal and Backward Tilting View). 2. Medial Wall Columellar aesthetics improved. It became central. The left medial crus replaced back to its natural anatomical place together with its surrounding inferior vestibular band. The light reflex is clearly seen of the inferior columellar surface. 3. Bony Pyramid a. Bony pyramid aesthetics improved: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). 4. Alar Base a. Superior alar groove aesthetics improved by defatting. The superior alar grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves). b. Posterior alar groove aesthetics improved by defatting alone. The defatted crurae are pulled medially as they become semidetached from the alae nasi, by the defatted superior alar grooves. The angles of the posterior alar grooves with the upper lip become

Frontal

Preoperative

Postoperative

Part III: Clinical Case 3

wider. Aesthetics of the alae nasi improved. (Backward Tilting and Nasal Aperture Views). c. Alae nasi aesthetics improved. They are pulled medially become better seen, smaller and share in nasal aesthetics. (Nasal Aperture, Oblique and Lateral Views). d. Nasal aperture aesthetics improved by defatting: i. The size of the nasal openings are reduced (Basal and Nasal Aperture views). ii. The shape of nasal openings became more elegantly oval. (Backward Tilting, Basal and Nasal Aperture views). iii. The light reflex is observed off the inferior alar margins in the Basal and Nasal Aperture views. e. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views). ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views). Commentary The patient maintained her original nasal image i.e. the nasal print, despite the major changes in the three Rhinoplasty areas i.e. nasal tip, bony pyramid and nasal septum.

Frontal Smiling

Frontal Middle Third

15

Part III: Clinical Case 3

93

Direct Dorsal

Direct Dorsal Smiling

Overhead

Overhead Smiling

Backward Tilting

Steeper Backward Tilting

Basal

Basal Smiling

Preoperative

Postoperative

Preoperative

Postoperative

Right Nasal Aperture

Preoperative

Postoperative

Right Nasal Aperture Rim Sill Test

Left Nasal Aperture Rim Sill Test

Left Nasal Aperture

94

15 Right Oblique Mid Cheek Full Face

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

Right Oblique Cheek Margin Full Face

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

Preoperative

Postoperative

Preoperative

Postoperative

Part III: Clinical Case 3

15

Part III: Clinical Case 3

95

Right Lateral

Left Lateral

Right Lateral Smiling

Preoperative

Postoperative

Right Lateral Middle Third

Preoperative

Postoperative

Left Lateral Middle Third

Left Lateral Smiling

Part III: Clinical Case 4

16

Post-operative Analysis Preoperative Assessment 1. Frontolateral walls Small but bulky bulbous tip, overshadowing the appearance of the alae nasi (Frontal, Direct Dorsal and Overhead views). 2. Medial Wall Nil of note. 3. Bony pyramid Wide base of the bony pyramid (Frontal, Direct Dorsal, Overhead and Backward Tilting views). 4. Alar base Nil of note. Aims of Surgery 1. Reduce the size and bulk of the nasal tip. 2. Reduce the width of the base of the bony pyramid. Surgical Plan 1. Frontolateral walls DDD not including the weak triangle to reduce the bulk. 2. Medial Wall Nil of note. 3. Bony pyramid Osteotomies and medialization of the lateral bony walls. 4. Alar base Nil of note. Surgical Procedure As per Surgical Plan.

1. Frontolateral Wall a. Tip Definition: nasal tip is smaller with thinner and smoother overlying skin. It is more prominent and well identified from the alae nasi on both sides. The alae nasi come into view to become clearly visible and share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). b. Tip projection: The nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as one spot off the nasal tip (Frontal and Backward Tilting Views). 2. Medial Wall Nil of Note. 3. Bony Pyramid a. Bony pyramid aesthetics: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Dorsal light reflex is seen as an uninterrupted line off the nasal dorsum (Direct Dorsal Views). 4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves). b. Posterior alar groove aesthetics improved by Defatting alone. The defatted crurae are pulled medially as they become semidetached from the alae nasi, by the defatted superior alar grooves. The angles of the posterior alar grooves with the upper lip become wider. Aesthetics of the alae nasi improved (Backward Tilting and Nasal Aperture Views).

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_16

97

98

16

c. Alae nasi aesthetics improved. They are pulled medially become better seen, smaller and share in nasal aesthetics (Nasal Aperture, Oblique and Lateral Views). d. Nasal aperture aesthetics improved by defatting: i. The size of the nasal openings are reduced. ii. The shape of nasal openings become more elegantly oval on shape with thinner walls (Backward Tilting, Basal and Nasal Aperture views). e. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views). ii. Nasal sill bands (Oblique Views).

Frontal

iii. Lateral crural prominences (Lateral Views). Commentary Only two areas of Rhinoplasty needed to be addressed in these types of Finesse Rhinoplasty i.e. the nasal tip and the bony pyramid. Debulking of the first and reducing the size of the latter have given the nose the extra sharp and defined appearance with no change in the nasal image and nasal print. The nose looked more neat and attractive in an originally attractive nose and face. Frontal Smiling

Frontal Middle Third

Preoperative

Postoperative

Direct Dorsal

Preoperative

Postoperative

Part III: Clinical Case 4

Direct Dorsal Smiling

Overhead

16

Part III: Clinical Case 4

99

Backward Tilting

Steeper Backward Tilting

Basal

Preoperative

Postoperative

Right Nasal Aperture

Right Nasal Aperture Rim Sill Test

Left Nasal Aperture Rim Sill Test

Left Nasal Aperture

Right Oblique Mid Cheek Full Face

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

Preoperative

Postoperative

Preoperative

Postoperative

100

16 Right Oblique Cheek Margin Full Face

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

Preoperative

Postoperative

Right Lateral

Preoperative

Postoperative

Left Lateral

Right Lateral Smiling

Left Lateral Smiling

Part III: Clinical Case 4

16

Part III: Clinical Case 4

101 Right Lateral Middle Third

Preoperative

Postoperative

Left Lateral Middle Third

Part III: Clinical Case 5

Preoperative Assessment 1. Frontolateral walls a. Large bulbous and bulky tip which semi-separated from the upper two thirds of the nose (Frontal Views). b. The Bulky tip completely overshadowed the alae nasi on both sides (Frontal and Direct Dorsal Views). 2. Medial Wall Slight columellar protrusion (Lateral Views). 3. Bony pyramid a. Wide base of the bony pyramid (Frontal, Direct Dorsal and Backward Tilting Views). b. Small osteocartilagenous hump (Oblique and Lateral Views). This is the natural concavoconvex anatomy of the nasal bones from above downwards (see Anatomy Section in the Text). 4. Alar base The nasal opening were unpleasantly thick walled and rounded in shape (Backward Tilting, Basal and Nasal Aperture Views). Aims of Surgery 1. Reducing the bulk of the frontolateral walls. 2. Overall reduction of the nasal size. 3. Reduction of the nasal hump. Surgical Plan 1. Frontolateral walls a. DDD including the weak triangle to reduce the bulk. b. Cephalic trim of lateral crurae to reduce the size. 2. Medial Wall Nil of note. 3. Bony pyramid a. Excision of the osteocartilaginous hump. b. Osteotomies and medialization of the lateral bony walls.

17

4. Alar base Nil of note. Surgical Procedure As per Surgical Plan. Post-operative Analysis 1. Frontolateral Wall a. Tip Definition: nasal tip is smaller with thinner and smoother overlying skin. It is more prominent and well identified from the alae nasi on both sides. The alae nasi come into view to become clearly visible and share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). b. Tip projection: The nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. The nasal tip is integrated with the upper two thirds of the nose. The dissociation between the two components disappeared. d. Tip light reflex is clear as one spot off the nasal tip (Frontal and Backward Tilting View). 2. Medial Wall Columellar protrusion was reduced. 3. Bony Pyramid a. Bony pyramid aesthetics: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Dorsal light reflex is seen as an uninterrupted line off the nasal dorsum (Direct Dorsal Views). 4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves).

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_17

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104

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b. Posterior alar groove aesthetics improved by Defatting alone. The defatted crurae are pulled medially as they become semidetached from the alae nasi, by the defatted superior alar grooves. The angles of the posterior alar grooves with the upper lip become wider. Aesthetics of the alae nasi improved (Backward Tilting and Nasal Aperture Views). c. Alae nasi aesthetics improved. They are pulled medially become better seen, smaller and share in nasal aesthetics (Nasal Aperture, Oblique and Lateral Views). d. Nasal aperture aesthetics improved by defatting: i. The sizes of the nasal openings are reduced. ii. The shape of nasal openings become more elegantly oval on shape. (Backward Tilting, Basal and Nasal Aperture views).

Frontal

Postoperative

Part III: Clinical Case 5

e. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views). ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views). Commentary Defatting the middle and lateral crurae have released the frontolateral skin from the binding subdermal bands that connect the dermis to the envelops of fatty capsules of the crurae. (See Anatomy of the Skin). The skin becomes softer, thinner, smoother and continuous with the upper lateral skin. The demarcation and dissociation between the lower third and upper two third thus naturally overcome (see Anatomy of Nasal Skin in Text).

Frontal Smiling

Frontal Middle Third

17

Part III: Clinical Case 5

105

Direct Dorsal

Direct Dorsal Smiling

Overhead

Preoperative

Postoperative

Backward Tilting

Preoperative

Postoperative

Steeper Backward Tilting

Basal

Basal Smiling

106

17

Part III: Clinical Case 5

Right Nasal Aperture

Right Nasal Aperture Rim Sill Test

Left Nasal Aperture Rim Sill Test

Left Nasal Aperture

Right Oblique Mid Cheek Full Face

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

Preoperative

Postoperative

Preoperative

Postoperative

17

Part III: Clinical Case 5

107

Right Oblique Cheek Margin Full Face

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

Right Lateral

Left Lateral

Right Lateral Smiling

Left Lateral Smiling

Preoperative

Postoperative

Preoperative

Postoperative

108

17

Right Lateral Middle Third

Preoperative

Postoperative

Left Lateral Middle Third

Part III: Clinical Case 5

Part III: Clinical Case 6

18

Preoperative Assessment

Surgical Procedure

1. Frontolateral walls Nil of note. 2. Nasal septum a. The caudal septum is long and slightly deviated to the right. Protrusion of the right medial crus is seen more in the Oblique views. b. Protruding columella (Direct Dorsal, Oblique and Lateral Views). 3. Bony pyramid Wide base of the boney pyramid. 4. Alar base Nil of note.

1. Septoplasty: The caudal septum was dissected. Two millimeters were trimmed from the caudal side and the inferior side. It was repositioned to the mid line. This was enough to reduce the protruding columella. 2. Osteotomies and medialization of the lateral bony walls.

Aims of Surgery 1. Reduction of the base of the bony pyramid. 2. Reduction of the protruding columella. Surgical Plan 1. Frontolateral walls Nil of note. 2. Nasal septum Septoplasty and trimming of caudal margin. 3. Bony pyramid Osteotomies and medialization of the lateral bony pyramid. 4. Alar base Nil of note.

Post-operative Analysis 1. Frontolateral Walls a. Tip projection improved after correction of columellar protrusion. b. The length of the nasal tip is more elegantly shorter after trimming of the caudal septum (Direct Dorsal Views). c. Tip light reflex is seen as one spot off the nasal tip (Frontal and Backward Tilting Views). 2. Medial Wall Columellar aesthetic improved. It is just seen off the inferior alar margins in the Oblique and Lateral views. 3. Bony Pyramid a. Bony pyramid aesthetics improved: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Dorsal light reflex is seen as an uninterrupted line off the nasal dorsum (Direct Dorsal Views). 4. Alar Base Nil of Note.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_18

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Commentary a. Two Rhinoplasty areas were minimally addressed i.e. the bony pyramid and the medial wall. b. Impressive aesthetic impact is seen in the patients nose and face despite the minimal surgical procedures.

c. This is a finesse Rhinoplasty in which this lady only needed a reduction in the width of the bony pyramid. Elevation of the protruding columella was suggested by the surgeon as a simple addition to nasal aesthetics. d. No attempt was made to reduce the size of the nasal tip as it looked aesthetically attractive and suited her broad face.

Frontal Smiling

Preoperative

Postoperative

Part III: Clinical Case 6

18

Part III: Clinical Case 6

111

Direct Dorsal

Preoperative

Postoperative

Backward Tilting

Preoperative

Postoperative

Steeper Backward Tilting

112

18

Right Oblique Mid Cheek Full Face

Left Oblique Mid Cheek Full Face

Preoperative

Postoperative

Right Oblique Cheek Margin Full Face

Preoperative

Postoperative

Left Oblique Cheek Margin Full Face

Part III: Clinical Case 6

18

Part III: Clinical Case 6

113

Right Lateral

Preoperative

Left Lateral

Part III: Clinical Case 7

b. The dislocated left caudal septum has two consequences: i. It pushes the left nasal sill at a lower level than the right (Frontal Views). ii. It elevates the medial crus laterally into the left nasal aperture space (Basal and Backward Tilting Views). c. Wide alar base.

Preoperative Assessment 1. Frontolateral walls a. Large frontolateral walls with wide nasal flare on smiling (Frontal Smiling and Non-Smiling Views). b. Heavy looking, i.e. slightly bulky nasal tip overshadowing the alae nasi (Frontal, Direct Dorsal and Overhead Views). c. Supra tip depression predominantly seen in the oblique, backward tilting and the lateral views. This is due to the fact that the lateral crurae are concave rather than convex. d. The concave surface of the lateral crurae is similar to the concave surface of a saucer which has a prominent peripheral margin. In this case, the lateral crurae end inferiorly and laterally with prominent margins. e. Minimal bifidity of the tip (Backward Tilting Views). 2. Medial Wall a. Left caudal dislocation of cartilaginous septum (Backward Tilting and Basal Views). b. Deviated nasal cartilaginous and bony septum to the right. c. Mobile tip (Lateral Smiling Views). 3. Bony pyramid a. Osteocartilaginous hump (Oblique and Lateral Views). b. Wide base of the bony pyramid (Direct Dorsal, Overhead and Backward Tilting Views). c. Bilateral maxillary asymmetry. The bony pyramid is oblique to the right side, i.e. the left cheek is wide and low, while the right cheek is narrow and high (Backward Tilting Views). 4. Alar base a. Unequal nasal openings with differing shapes. The right opening is triangular in shape with its long axis almost vertical as seen in the basal views, while the left opening is oblong with an oblique long axis.

19

Aims of Surgery 1. 2. 3. 4. 5.

Reduce the size of the frontolateral wall. Smoothen the margins of the lateral crurae. Abolish the bifidity of the tip. Abolish the mobility of the tip. Correction of the caudal deviation with the consequent correction of the nasal aperture deformities. 6. Excision of the osteocartilaginous hump with correction of its obliquity. 7. Reduction of the size of the alar base.

Surgical Plan 1. Frontolateral walls a. DDD including the weak triangle to reduce the bulk. b. Bilateral cephalic trim of the lateral crurae i.e. removing the prominent margins superiorly and laterally. c. The excision of the inferior segments of the rim sill folds that should greatly reduced the widening of the alar base on smiling. 2. Medial Wall a. Septoplasty. Scoring of the concave side of the deviated cartage. b. Trim 2 mm from the caudal cartilaginous margin. c. Division of the Depressor Septi muscles.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_19

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3. Bony pyramid a. Excision of the osteocartilaginous hump. b. Osteotomies with Kassanjian maneuver to the left i.e. cross fracture of the bony pyramid after osteotomies (see Surgery of the Bony Pyramid in Text). 4. Alar base a. Bilateral resection of the posterior and inferior segments of the rim sill folds. Surgical Procedure a. As per Surgical Plan. b. Division of the Depressor Septi muscles was done intranasally. Post-operative Analysis 1. Frontolateral Wall a. Tip definition: i. The tip is smaller with thinner overlying skin. It is more prominent and well identified from the alae nasion both sides. The alae nasi become clearly visible (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). ii. Defatting of the middle crurae in this case was sufficient to bring the two domes closer together overcoming the bifidity. There was no need to further approximate the domes by stitching. iii. The supra tip depression disappeared after removing the prominent margins of the lateral crurae. b. Tip projection: The nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as one spot off the nasal tip (Frontal and Backward Tilting Views). 2. Medial Wall a. Medial wall aesthetics improved after septoplasty. Columella becomes centrally in midline. Nasal apertures are closer in shape to each other. b. Mobility of the tip was abolished.

19

Part III: Clinical Case 7

3. Bony Pyramid a. Bony pyramid aesthetics improved: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Dorsal light reflex appears as a straight line postoperatively as compared to the interrupted reflex pre-operatively (Direct Dorsal Views). 4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves). b. Posterior alar groove: the posterior segments of rim-sill folds were incompletely removed. This resulted in left sided angulation. Nevertheless the angle of the alae nasi with the upper lip improved with better looking alae nasi and improved posterior alar groove aesthetics. c. Alae nasi aesthetics improved. They are pulled medially become better seen, smaller and share in nasal aesthetics (Nasal Aperture, Oblique and Lateral Views). d. Nasal aperture aesthetics: improve alar groove aesthetics after defatting and excision of the rim-sill folds: i. The sizes of nasal apertures are smaller. ii. The shapes of nasal apertures became closer to each other in shapes and more elegantly oval. e. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views). ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views). Commentary The post operative nasal aperture view should have clear arrow and writings on the Photograph and under the photograph. This is not seen in the displayed photograph. a. All four areas were addressed in this case. The outcome is a more refined nose that kept its original features and nasal print. b. Alar flare was greatly reduced after excision of the inferior segments of the rim-sill folds.

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Part III: Clinical Case 7

117

Frontal Smiling

Frontal

Frontal Middle Third

Postoperative

Direct Dorsal

Preoperative

Postoperative

Direct Dorsal Smiling

Overhead

Overhead Smiling

118

19

Part III: Clinical Case 7

Backward Tilting

Steeper Backward Tilting

Basal

Basal Smiling

Right Nasal Aperture

Right Nasal Aperture Rim Sill Test

Left Nasal Aperture Rim Sill Test

Left Nasal Aperture

Preoperative

Postoperative

Preoperative

Note: The pale area of the rim sill fold.

Postoperative

19

Part III: Clinical Case 7

119

Right Oblique Mid Cheek Full Face

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

Right Oblique Cheek Margin Full Face

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

Preoperative

Postoperative

Preoperative

Postoperative

120

19

Right Lateral Right Lateral

Left Lateral

Preoperative

Postoperative

Right Lateral Middle Third

Preoperative

Postoperative

Left Lateral Middle Third

Part III: Clinical Case 7

Left Lateral

Part III: Clinical Case 8

20

Preoperative Assessment

Post-operative Analysis

1. Frontolateral Wall Nil to note. 2. Medial Wall Nil to note. 3. Bony Pyramid a. Low dorsum (Backward Tilting, Oblique and Lateral Views). b. Wide base of the bony pyramid (Frontal, Backward Tilting, Oblique and Lateral Views). 4. Alar base Wide and thick alar base due to long inferior segments and thick posterior segments of the rim-sill folds.

1. Frontolateral Walls Nil of Note. 2. Medial Walls Nil of Note. 3. Bony Pyramid a. Bony pyramid aesthetics improved: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Dorsal light reflex is seen as an uninterrupted line off the nasal dorsum (Frontal Views). 4. Alar Base a. Posterior alar groove aesthetics improved after excision of the rim-sill folds. They have wider angels with the upper lip and the thick posterior segments of the rim-sill folds are gone. b. Alae nasi aesthetics improved. They are pulled medially become better seen, smaller and share in nasal aesthetics (Nasal Aperture, Oblique and Lateral Views). c. Nasal aperture aesthetics improved: the size are smaller and the shapes are oval. d. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views). ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views).

Aims of Surgery 1. To elevate and narrow the nasal dorsum. 2. Reduce the alar base width and thickness. Surgical Plan 1. Frontolateral walls Nil to note. 2. Nasal septum Nil to note. 3. Bony pyramid a. Bilateral osteotomies and medialization of the lateral bony walls. b. Dorsal augmentation using a septal graft. 4. Alar base Bilateral resection of the posterior and inferior segments of the rim-sill folds. Surgical Procedure As per Surgical Plan.

Commentary a. This lady needed minimal surgery to only two of the four areas of Rhinoplasty to achieve the aesthetic goal. These two areas are: 1. The bony pyramid : osteotomies and dorsal augmentation. 2. The alar base: Resection of the rim-sill folds. b. The overall aesthetics of the nose improved. It became slimmer, higher with smaller nasal apertures.

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122

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Frontal

Frontal Middle Third

Postoperative

Backward Tilting

Preoperative

Postoperative

Steeper Backward Tilting

Part III: Clinical Case 8

20

Part III: Clinical Case 8

123

Right Nasal Aperture

Right Nasal Aperture Rim Sill Test

Left Nasal Aperture Rim Sill Test

Left Nasal Aperture

Preoperative

Postoperative INFERIOR SEGMENT SCAR

POSTERIOR SEGMENT SCAR

The scar of the posterior segment is above the posterior alar groove.

Right Oblique Mid Cheek Full Face

Preoperative

Postoperative

Left Oblique Mid Cheek Full Face

124

20

Right Oblique Cheek Margin Full Face

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Preoperative

Postoperative

Right Lateral

Preoperative

Postoperative

Left Lateral

Part III: Clinical Case 8

Left Oblique Cheek Margin Middle Third

20

Part III: Clinical Case 8

125

Right Lateral Middle Third

Preoperative

Postoperative

Left Lateral Middle Third

Part III: Clinical Case 9

Preoperative Assessment 1. Frontolateral walls a. Large, bulbous tip overshadowing the alae nasi (Frontal, Direct Dorsal, Overhead and backward Tilting Views). b. The nasal tip was long and pointing inferiorly (Frontal, Oblique and Lateral Views). 2. Medial Wall a. Overall long nose and a high and long nasal septum (Frontal and Lateral Views). b. Hanging columella (Lateral Views). c. Mobile tip (Lateral Smiling Views). d. Left septal caudal deviation (Left Nasal Aperture Views). 3. Bony pyramid a. Wide base of the boney pyramid (Direct Dorsal, Overhead and Backward Tilting Views). b. Small osteocartilagenous hump (Oblique and Lateral Views). The hump is predominantly cartilaginous. 4. Alar base Alae nasi are slightly everted due to the oblique inferior segments of the rim sill folds (Nasal Aperture and Oblique views).

21

2. Medial Wall a. Septoplasty to correct the caudal and septal deviations. i. Correction of the caudal deviation. ii. Trim of a Stripe of the caudal membranous septum including the cartilage. b. Reduction of the height of the cartilaginous septum. This is partly achieved while excising the osteocartilagenous hump. c. Division of the depressor septi muscles. 3. Bony pyramid a. Excision of the osteocartilaginous hump. b. Osteotomies and medialization of the lateral bony walls. 4. Alar base Excision of the oblique inferior segments of the rim sill folds. Surgical Procedure a. As per Surgical Plan. b. Trim of almost 1 cm of caudal cartilaginous septum including few mm of the loose skin of the membranous septum were sufficient to reduce the hanging columella. No direct surgery to the medial crurae was necessary.

Aims of Surgery Post-operative Analysis 1. 2. 3. 4. 5.

Reduce the size of the nasal tip. Reduce the length of the nose. Abolish the mobile tip and the hanging columella. Excision of the hump. Improve the aesthetics of the alar base.

Surgical Plan 1. Frontolateral walls a. DDD including the weak triangle to reduce the bulk. b. Cephalic trim of the lateral crurae to reduce the size.

1. Frontolateral Wall a. Tip Definition: nasal tip is smaller with thinner and smoother overlying skin. It is more prominent and well identified from the alae nasi on both sides. The alae nasi come into view to become clearly visible and share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). b. Tip projection: The nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_21

127

128

21

coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as one spot off the nasal tip (Backward Tilting and Frontal Views). 2. Medial Wall a. Medial wall aesthetics improved so that: i. Hanging columella disappeared. The lateral columellar margin is seen just off the alar margins in the Oblique and Lateral views. The columella has better relation with alar margins. ii. Mobile tip was overcome (Lateral Smiling Views). 3. Bony Pyramid a. Bony pyramid aesthetics improved: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Dorsal light reflex is seen as an uninterrupted line off the nasal dorsum (Direct Dorsal Views). 4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves). b. Posterior alar groove aesthetic improved after defatting and excision of the inferior segments of the rim-sill folds. The alae nasi are pulled medialy and their angles with the upper lip become wider (Nasal Aperture, Oblique and Lateral Views). c. Aesthetics of the alae nasi improved. They are in better locations and their outer surfaces are better seen

Frontal

Postoperative

Part III: Clinical Case 9

(Backward Tilting, Basal, Nasal Aperture, Oblique and Lateral Views). d. Nasal aperture aesthetics improved after defatting and excision of the inferior segments of the rim-sill folds: i. The size of the nasal openings are smaller. ii. Alar-columellar relations are better. The alae nasi moved inferiorly after excision of the oblique inferior segments of the rim-sill folds. iii. The shapes of nasal apertures improved after defatting and excision of the inferior segments. They became more elegantly oval. e. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views). ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views). Commentary a. This lady underwent surgery to the four areas of Rhinoplasty in order to achieve the aesthetic goal. There was no single predominant unaesthetic feature. Each of the four areas had a subtle unaesthetic issue. b. There is smoother continuation between the lateral crural and upper lateral skins i.e. between the frontolateral wall and the midvault skins. Dividing the subdermal bands during defatting have released the crural skin from its tight binding to the underlying cartilaginous capsules of fat (Refer to Anatomy of the Nasal Skin in the Text). Frontal Smiling

Frontal Middle Third

21

Part III: Clinical Case 9

129

Direct Dorsal

Direct Dorsal Smiling

Overhead

Overhead Smiling

Backward Tilting

Steeper Backward Tilting

Basal

Basal Smiling

Preoperative

Postoperative

Preoperative

Postoperative

130

21

Right Nasal Aperture

Preoperative

Postoperative

Preoperative

Postoperative

Right Nasal Aperture Rim Sill Test

Left Nasal Aperture Rim Sill Test

Left Nasal Aperture

Part III: Clinical Case 9

21

Part III: Clinical Case 9

131

Preoperative

Postoperative

Combined excision of the inferior segments of the rim sill folds together with reduction of the hanging columella have repositioned the nasal tip and the alar margins into more aesthetic location. Defatting, reduced the bulk of the tip. Note these changes in the frontal views

Right Lateral

Preoperative

Postoperative

Left Lateral

Right Lateral Smiling

Left Lateral Smiling

132

21

Right Lateral Middle Third

Preoperative

Postoperative

Left Lateral Middle Third

Part III: Clinical Case 9

Part III: Clinical Case 10

22

Preoperative Assessment

Post-operative Analysis

1. Frontolateral walls Bulbous bulky nasal tip overshadowing the alae nasi on both sides (Frontal, Direct Dorsal, Overhead and Overhead Views). 2. Medial Wall Nil of note. 3. Bony pyramid Wide base of the boney pyramid (Direct Dorsal and Backward Tilting Views). 4. Alar base Nil of note.

1. Frontolateral Wall a. Tip Definition: nasal tip is smaller with thinner and smoother overlying skin. It is more prominent and well identified from the alae nasi on both sides. The alae nasi come into view to become clearly visible and share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). b. Tip projection: The nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as one spot off the nasal tip (Frontal and Backward Tilting Views). 2. Medial Wall Nil of Note. 3. Bony Pyramid a. Bony pyramid aesthetics improved: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Dorsal light reflex is seen as an uninterrupted line off the nasal dorsum (Direct Dorsal Views). 4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves). b. Posterior alar groove aesthetics improved after defatting alone. Defatting pulls the alae nasi medially widening the angles of the posterior alar grooves (Nasal Aperture and Oblique Views). c. Alae nasi aesthetics improved. They are pulled medially and are better seen (Frontal, Direct Dorsal, Nasal Aperture and Oblique Views).

Aims of Surgery To reduce the overall size and bulk of the nose and make it slimmer, higher and more defined. Surgical Plan 1. Frontolateral walls DDD excluding the weak triangle. 2. Medial Wall Nil of note. 3. Bony pyramid Osteotomies and medialisation of sidewalls. 4. Alar base Nil of note.

the

pyramidal

Surgical Procedure 1. As per Surgical Plan. 2. No cephalic trim of the lateral crurae was needed.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_22

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134

22

d. Nasal aperture aesthetics improve after defatting. The apertures are oval shaped, thinner walled aperture despite remaining of the same size. e. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views). ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views).

Frontal

Preoperative

Postoperative

Part III: Clinical Case 10

Commentary a. Only two of Rhinoplasty areas were addressed i.e. the frontolateral walls and the bony pyramid. b. The overall increase in the size of the nose had developed over a period of the last decade of life due to the increased fat deposition around the lower lateral cartilages and weak triangle. c. The overall image of the lady was maintained despite the simple surgical procedure. Frontal Smiling

Frontal Middle Third

22

Part III: Clinical Case 10

135

Direct Dorsal

Direct Dorsal Smiling

Overhead

Backward Tilting

Steeper Backward Tilting

Basal

Preoperative

Postoperative

Preoperative

Postoperative

Overhead Smiling

136

22

Part III: Clinical Case 10

Right Nasal Aperture

Right Nasal Aperture Rim Sill Test

Left Nasal Aperture Rim Sill Test

Left Nasal Aperture

Right Oblique Mid Cheek Full Face

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

Preoperative

Postoperative

Preoperative

Postoperative

22

Part III: Clinical Case 10

137

Right Oblique Cheek Margin Full Face

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

Right Lateral

Left Lateral

Right Lateral Smiling

Left Lateral Smiling

Preoperative

Postoperative

Preoperative

Postoperative

138

22

Right Lateral Middle Third

Preoperative

Postoperative

Left Lateral Middle Third

Part III: Clinical Case 10

Part III: Clinical Case 11

Preoperative Assessment 1. Frontolateral walls Large and bulky tip overshadowing the alae nasi (Frontal Views). 2. Nasal Septum Protruding columella (lateral and oblique views). 3. Bony pyramid a. Wide base of the bony pyramid (Backward Tilting Views). b. Small osteocartilagenous hump (Oblique and Lateral Views). 4. Alar base a. Wide alar base due to long inferior segments of rim-sill folds (Backward Tilting and Basal Views). b. Long and thick inferior segments of the rim sill folds have given the nasal apertures quadrangular shapes (Basal Views). Aims of Surgery 1. Reduction of the tip size and bulk. 2. Reduction of the protruding columella. 3. Reduction of the size of the boney pyramid and excision of the hump. 4. Improve aesthetics of the alar base. Surgical Plan 1. Frontolateral walls DDD including the weak triangle. 2. Nasal Septum Septoplasty and trim of the caudal 2mm of the cartilagenous septum. 3. Bony pyramid a. Excisionof the osteocartilaginous hump. b. Osteotomies and medialization of the lateral bony walls.

23

4. Alar base Bilateral resection of the inferior segments of the rim sill folds. Surgical Procedure As per Surgical Plan. Post-operative Analysis 1. Frontolateral Wall a. Tip Definition: nasal tip is smaller with thinner and smoother overlying skin. It is more prominent and well identified from the alae nasi on both sides. The alae nasi come into view to become clearly visible and share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). b. Tip projection: The nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as one spot off the nasal tip (Frontal View). 2. Medial Wall Collumelar protrusion is corrected. The alae nasi have excellent aesthetic relations with the columella (Lateral and Oblique Views). 3. Bony Pyramid Bony pyramid aesthetics improved: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). 4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves). b. Posterior alar groove aesthetics improved by defatting as well as excising the inferior segments of the rim-sill folds. The flat tire appearance of the alae nasi on the upper lip is no longer present i.e. the

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_23

139

140

23

posterior alar groove angle is wider (Backward Tilting, Basal and Nasal Aperture Views). c. Alae nasi aesthetics improved. They are pulled medially become better seen, smaller and share in nasal aesthetics (Nasal Aperture, Oblique and Lateral Views). d. Nasal aperture aesthetics: i. The size of the nasal openings are reduced by defatting as well as excising the inferior segments of the rim-sill folds. (Backward Tilting, Basal and Nasal Aperture views). ii. The shapes of nasal openings improves by defatting and excision of the rim-sill folds transforming the nasal apertures from thick

heavy wide and quadrangular opening to thin delicate small oval openings with anterior long axes (Backward Tilting, Basal and Nasal Aperture views). e. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views). ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views). Commentary All of the four areas of Rhinoplasty are minimally addressed in this finesse case viz the nasal tip, bony pyramid, the nasal septum and alar base.

Frontal

Preoperative

Postoperative

Part III: Clinical Case 11

23

Part III: Clinical Case 11

141

Right Oblique Cheek Margin Middle Third

Preoperative

Postoperative

Left Oblique Cheek Margin Middle Third

142

23

Right Lateral

Preoperative

Postoperative

Left Lateral

Part III: Clinical Case 11

Part III: Clinical Case 12

24

Preoperative Assessment

Surgical Plan

1. Frontolateral walls Slightly bulbous frontolateral walls overshadowing both ali nasi predominantly the right side (Frontal, Overhead and Direct Dorsal Views). 2. Medial Wall a. Left caudal septal deviation and dislocation. The left medial crus is pushed laterally and the left nasal sill band is displaced inferiorly (frontal, backward tilting, Basal and Left Nasal aperture views). b. Protruding columella. The lateral surfaces of the medial crurae are exposed. It is not quite a hanging columella (lateral and oblique views). 3. Bony pyramid a. Osteocartilagenous hump, predominantly cartilaginous. The hump is oblique to the left due to minor bilateral maxillary asymmetry. The right cheek is wide and low while the left cheek is narrow and high (backward tilting view). b. Wide base of bony pyramid (Direct Dorsal, Overhead and Backward Tilting View). c. The nose is long. It looks as if pulled forward with dissociation between the upper third and lower two thirds. 4. Alar base The left nasal aperture is encroached upon by the left caudally deviated cartilaginous septum (Basal and Left Nasal Aperture Views).

1. Frontolateral walls DDD including the weak triangle to reduce the bulk. 2. Medial Wall Septoplasty and trim of few millimeters from the caudal septum. Trim of the anterior septal margin to reduce the nasal height. 3. Bony pyramid a. Excision of the osteocartilagenous hump, as well as trim of few millimeters off the dorsal septum down to the anterior septal angle. b. Osteotomies and medialization of lateral bony walls. 4. Alar base Nil of Note.

Aims of Surgery 1. Reduce the bulk of the frontolateral walls. 2. Correction of the columellar protrusion. 3. Reduction of the size of the bony Paremyd and mid-vault.

Surgical Procedure As per surgical plan. Post-operative Analysis 1. Frontolateral Wall a. Tip definition: the nasal tip is smaller with thinner and smoother overlying skin. It is more prominent and well identified from the alae nasi on both sides. The alae nasi come into view to become clearly visible and share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). b. Tip projection: The nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as one spot off the nasal tip (Frontal and Backward Tilting Views).

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_24

143

144

2. Medial Wall a. Correction of caudal deviation. b. Protruding columella disappeared. 3. Bony Pyramid a. Bony pyramid aesthetics improved. The nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Dorsal light reflex is seen as an uninterrupted line off the nasal dorsum (Direct Dorsal Views). 4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves). b. Posterior alar groove aesthetics improved by defatting alone. The defatted crurae are pulled medially as they become semidetached from the alae nasi, by the defatted superior alar grooves. The angles of the posterior alar grooves with the upper lip become wider. (Backward Tilting and Nasal Aperture Views). c. Alae nasi aesthetics improved. They are pulled medially become better seen, smaller and share in nasal aesthetics (Nasal Aperture, Oblique and Lateral Views).

24

Part III: Clinical Case 12

d. Nasal aperture aesthetics improved after defatting and correction of caudal septal deviation: i. The size of the two nasal openings became equal. ii. The shapes are more elegantly oval. e. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views). ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views). Commentary a. Three of the four Rhinoplasty areas were addressed i.e. the frontolateral walls, medial wall and the bony pyramid. b. There was minimal fat over the middle and lateral crurae, yet defatting had positive aesthetic effects. c. Maintaining her original image i.e. “nasal print“, the patient is more attractive with positive psychological impact. Friends and relatives did not notice the changes in her nose and face. They thought she was on a diet or changed her makeup. d. The dissociation between the upper third and the lower two thirds of the nose disappeared. The nose is now one unit, smaller than before.

24

Part III: Clinical Case 12

145

146

24

Part III: Clinical Case 12

Basal

Basal Smiling

Left Nasal Aperture Rim Sill Test

Left Nasal Aperture

Preoperative

Postoperative

Right Nasal Aperture

Preoperative

Po&operative

Right Nasal Aperture Rim Sill Test

24

Part III: Clinical Case 12

147

Right Oblique Mid Cheek Full Face

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

Right Oblique Cheek Margin Full Face

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

Preoperative

Postoperative

Preoperative

Postoperative

148

24

Right Lateral

Left Lateral

Right Lateral Middle Third

Left Lateral Middle Third

Preoperative

Postoperative

Preoperative

Postoperative

Right Lateral Smiling

Part III: Clinical Case 12

Left Lateral Smiling

Part III: Clinical Case 13

Pre-operative Assessment

Aims of Surgery

1. Frontolateral Wall a. The tip is of good aesthetic size, yet the sidewalls of the lateral crurae were slightly large and bulky overshadowing the alae nasi (Frontal and Direct Dorsal Views). b. Grooving is minimally seen reflecting two light points at the backward tilting views. 2. Medial Wall a. Slight right caudal septal deviation. The right nasal sill was pushed at a lower level than the left (Oblique Views). b. The columella was at a lower level than the alar margin, more in the right than the left due to the caudal deviation (Oblique and Lateral Views) and the oblique inferior segments of the rim-sill folds. 3. Bony Pyramid a. Slight dorsal elevation with flat nasofrontal angle (Lateral and Oblique Views). This is the normal anatomical concavo-convex bodies of the nasal bones from above downwards (see Anatomy Section in Text). b. Wide base of bony pyramid (Direct Dorsal and Backward Tilting). 4. Alar Base a. The inferior margins of alae nasi are at a slightly higher level than the level of the lateral columellar prominences. This is more predominant in the right side (Oblique and Lateral Views). This is due to: i. Right caudal septal deviation. ii. Oblique inferior segments of the rim-sill fold. They connect the highly placed alar rims to the inferiorly placed nasal sill bands (Nasal Aperture and Oblique Views). b. Slightly thick posterior segments of rim-sill folds.

a. b. c. d. e.

25

Reduction of the frontolateral wall bulk. Correction of caudal septal deviation. Reduction in the size and height of bony pyramid. Deepening of nasofrontal nasofrontal angle. Improve aesthetics of the rim-sill folds.

Surgical Plan 1. Frontolateral Walls a. D.D.D. including the weak triangle to reduce the bulk. b. Cephalic trim of lateral crurae to reduce the size. 2. Medial Wall Septoplasty: correction of the right caudal deviation. 3. Bony pyramid a. Rasp down the normal anatomical convexities of the nasal bones till they become level with the nasofrontal angle. b. Bilateral osteotomies and medialization of the lateral bony walls. 4. Alar Base Bilateral excision of the inferior and posterior segments of the rim-sill folds. Surgical Procedure As per surgical plan. Post-operative Analysis 1. Antrolateral Wall a. Tip Definition: nasal tip is smaller with thinner and smoother overlying skin. It is more prominent and well identified from the alae nasi on both sides. The

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_25

149

150

alae nasi come into view to become clearly visible and share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). b. Bifidity of the tip was overcome by defatting. The light reflex is seen as one spot out to the nasal tip (Frontal and Backward Tilting Views). c. Tip projection: The nasal tip is at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). d. Tip light reflex is seen as one spot off the nasal tip (Frontal and Backward Tilting Views). 2. Medial Wall a. Right caudal deviation corrected. The right nasal sill is elevated to its normal location (Right Oblique Views). b. Columello-Alar relationship were amended. The columella is just seen off the inferior alar margins (Oblique and Lateral Views). 3. Bony Pyramid a. Bony pyramid aesthetics: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Nasofrontal angle is seen aesthetically better. c. Dorsal light reflex is as a straight line post-operatively as compared to the interrupted reflex pre-operatively (Direct Dorsal Views). 4. Alar Base a. Superior alar groove aesthetics improved after defatting. The grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves). b. Posterior alar groove aesthetics improved by defatting and excision of the rim-sill folds. The posterior alar angle with the upper lip is wider. c. Excision of the oblique inferior segments of the rim-sill folds have pulled the alae nasi down to the

25

Part III: Clinical Case 13

acceptable aesthetic level with the columella. The alar columellar relationship is exemplary. The inferior columellar margins are just seen off the inferior alar margins (Oblique and Lateral Views on both sides). d. Alae nasi aesthetic improved i.e. better in shapes and positions (Oblique and Lateral Views). e. Nasal aperture aesthetics improved by defatting and excision of the rim-sill folds: i. Aperture sizes are smaller. ii. Aperture shapes became more elegantly oval than before. f. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views). ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views). Commentary a. It is very easy to make this nose worse and very difficult to make it better. b. Each of the four areas of the nose needed an extremely gentle and subtle modification: i. Subtle defatting of frontolateral walls. ii. Subtle correction of caudal septal deviation. iii. Subtle reduction of osteocartilagenous dorsum and narrowing of the bony sidewalls. iv. The inferior segments of the rim-sill folds were short and the posterior segments were small. They needed subtle excision in order to improve nasal aperture aesthetics and alar marginal relation with the columella. c. Aesthetics of each of the four areas was better. Collectively they all harmonized in producing an attractive nose that maintained its exact own image i.e. the same nasal print.

25

Part III: Clinical Case 13

151

Frontal Smiling

Frontal Middle Third

Preoperative

Postoperative

Direct Dorsal

Preoperative

Postoperative

Direct Dorsal Smiling

Overhead

Overhead Smiling

152

25

Backward Tilting

Steeper Backward Tilting

Part III: Clinical Case 13

Basal

Basal Smiling

Left Nasal Aperture Rim Sill Test

Left Nasal Aperture

Preoperative

Postoperative

Right Nasal Aperture

Preoperative

Postoperative

Right Nasal Aperture Rim Sill Test

25

Part III: Clinical Case 13

153

Right Oblique Mid Cheek Full Face

Left Oblique Mid Cheek Full Face

Right Oblique Cheek Margin Full Face

Left Oblique Cheek Margin Full Face

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

Preoperative

Postoperative

Preoperative

Postoperative

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

154

25

Right Lateral

Left Lateral

Right Lateral Middle Third

Left Lateral Middle Third

Preoperative

Postoperative

Preoperative

Postoperative

Right Lateral Smiling

Part III: Clinical Case 13

Left Lateral Smiling

Part IV Secondary Rhinoplasty

Part IV: Clinical Case 1

Preoperative Assessment 1. Frontolateral walls Bulbous tip which is semidetached from the midvault and the alae nasi (Frontal and Backward Tilting). 2. Medial Wall a. Hanging columella (Lateral View). b. Mobile tip i.e. the nasal tip moves on inferiorly on smiling (Lateral Smiling). 3. Bony pyramid a. Wide base of the bony pyramid (Frontal, Direct Dorsal and Backward Tilting Views). b. Open roof deformity c. Maxillary asymmetry, the right cheek is low and wide, the left cheek is high and narrow (backward tilting views). 4. Alar base Nil of note. Aims of Surgery 1. Reduction of the size and bulk of the bulbous tip and integrate it with the rest of the nose. 2. Reduction of the width of the bony pyramid and close the open roof deformity. 3. Reduction of the hanging columella. 4. Abolish the mobile tip. Surgical Plan 1. Frontolateral walls DDD including weak triangle. 2. Medial Wall a. Trimming of the membranous septum. b. Division of the Depressor Septi muscles. 3. Bony pyramid a. Osteotomies and medialization of the lateral bony walls.

26

b. Kassanjian maneuver to the right i.e. cross fracture of the bony pyramid after osteotomies (Refer to Chapter of Surgery of the Bony Pyramid in the text). 4. Alar base Nil of note. Surgical Procedure As per Surgical Plan. Post-operative Analysis 1. Frontolateral Walls a. Tip definition improved i.e. the tip is slimmer and prominently well identified. The alae nasi come into view to share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). b. Tip projection: The nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as one spot off the nasal tip (Backward Tilting Views). 2. Medial Wall a. Hanging columella was overcome by trimming of the caudal cartilagenous and membranous septum (Lateral Views). b. Mobile tip was amended (lateral smiling view). 3. Bony Pyramid a. Bony pyramid aesthetics: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Dorsal light reflex is seen as an uninterrupted line off the nasal dorsum (Direct Dorsal Views). 4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves).

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_26

157

158

26

b. Posterior alar groove aesthetics improved. After defatting the alae nasi are pulled mediately with better aesthetic posterior groove angle with the upper lip. c. Alae nasi aesthetics improved after defatting. They are medialized with wider posterior alar grooves. They become better seen and look more elegant. d. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views). ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views).

Frontal

Frontal Smiling

Direct Dorsal

Direct Dorsal Smiling

Commentary a. Analysis of the short comings of the primary surgery: i. Only bilateral cephalic trim of the lateral crurae was done. No deafening was performed. ii. Excision of the osteocartilaginous hump resulted in an open-roof deformity. Closing the roof is simply achieved by lateral osteotomies. b. The previous surgeon omitted the reduction of the hanging columella as well as the mobile tip. c. Three of the four Rhinoplasty areas were addressed in this case viz the nasal tip, nasal septum and the bony pyramid. d. Post-operative photographs were taken two months after surgery. Long term results in better tip definition.

Preoperative

Postoperative

Preoperative

Postoperative

Part IV: Clinical Case 1

Overhead

Overhead Smiling

26

Part IV: Clinical Case 1

159

Backward Tilting

Steeper Backward Tilting

Basal

Basal Smiling

Preoperative

Postoperative

Right Nasal Aperture

Preoperative

Postoperative

Left Nasal Aperture

160

26

Part IV: Clinical Case 1

Right Oblique Mid Cheek Full Face

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

Right Oblique Cheek Margin Full Face

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

Preoperative

Postoperative

Preoperative

Postoperative

26

Part IV: Clinical Case 1

161

Right Lateral

Left Lateral

Right Lateral Middle Third

Left Lateral Middle Third

Preoperative

Postoperative

Preoperative

Postoperative

Right Lateral Smiling

Left Lateral Smiling

Part IV: Clinical Case 2

27

Preoperative Assessment

Surgical Plan

1. Frontolateral walls a. Bulky nasal tip with irregular lateral walls over the lateral crurae. The alae nasi disappeared behind the bulky tip predominantly the left side (Frontal Views). 2. Media Wall Sliding tip: the nasal tip moves posterior to the level of the anterior septal angle i.e. the end point of the nasal dorsum (Lateral Smiling Views). The nasolabial angle is approximately 90 degrees and does not change on smiling. This is to be differentiated from a mobile tip that moves inferiorly on smiling, and the nasolabial angle becomes acute. 3. Bony pyramid a. Wide base of the boney pyramid (Frontal, Direct Dorsal and Backward Tilting Views). b. Bulge of left side of the upper lateral cartilage secondary to left sided septal deviation (Frontal, Overhead, Direct Dorsal and Backward Tilting Views). 4. Alar base Asymmetrical smile. It was claimed to be worse after the primary surgery. The left cheek ball is different in size and shape from the right. The left angle of the mouth is narrower than the right (Frontal and Lateral Smiling Views).

1. Frontolateral walls a. DDD including the weak triangle to reduce the bulk of the nasal tip. b. Cephalic trim of the lateral crurae to reduce the size of the nasal tip. 2. Medial Wall a. Septoplasty. b. Trim of the membranous septum. The caudal septum to be transfixed to the medial crurae to correct the sliding tip. 3. Bony pyramid Osteotomies and medialization of the bony sidewalls. 4. Alar base Nil of note.

Aims of Surgery 1. Reduce the size and overcome the irregularities of the lower third of the nose. 2. Reduce the width of the bony pyramid and overcome the bulge of the left side of the upper lateral Cartilage. 3. Correction of the sliding tip.

Surgical Procedure As per Surgical Plan. Post-operative Analysis 1. Frontolateral Walls a. Tip definition improved i.e. the tip is slimmer and prominently well identified. The alae nasi come into view to share in nasal aesthetics. Both alae nasi become almost equal in size and appearance (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). Note the clear light reflex off the nasal tip as one spot (Backward Tilting Views). b. Tip projection: The nasal tip is at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views).

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_27

163

164

c. Tip light reflex seen as one spot reflected off the nasal tip (Frontal and Backward Tilting Views). 2. Medial Walls Sliding tip was completely amended. 3. Bony Pyramid a. Bony pyramid aesthetics: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. The bulge of the left side of upper lateral cartilage disappeared after septoplasty. c. Dorsal light reflex is seen as a regular one line off the nasal dorsum (Direct Dorsal Views). 4. Alar Base a. Post-operative smile became more symmetrical (Post-operative Smiling Frontal and lateral Views). b. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral, Direct Dorsal and Overhead Views). c. Posterior alar groove aesthetics improved by defatting alone. The angle with the upper lip is wider (Nasal Aperture and Oblique Views). d. Alae nasi aesthetics improved. They are pulled medially, became smaller and more elegant (Nasal Aperture and Oblique Views). e. Marginal light reflexes are clearly seen at:

27

Part IV: Clinical Case 2

i. Inferior alar margins (Nasal Aperture Views). ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views). Commentary 1. Analysis of the shortcomings of the primary surgery: a. The irregularities over the lateral crura were due to the excessive fibro-fatty tissues, as well as scarring in the subdermal layer, from the primary surgery. Septoplasty was omitted. i. The external bulge of the upper lateral cartilage was the result of deviation of the of the septal cartilage. ii. The sliding tip was not corrected. b. Osteotomies were omitted resulting in the wide base of the boney pyramid. 2. Three of the four areas if Rhinoplasty were addressed: a. The nasal tip: Meticulous scrapping of the subdermal layer down to the shiny crural cartilages, as well as to the fibrous dermal layer were performed. b. Septoplasty as well as trimming of the membranous septum. c. The bony pyramid: bilateral osteotomies and medialization of the bony sidewalls.

27

Part IV: Clinical Case 2

165

Frontal

Frontal Smiling

Frontal Middle Third

Direct Dorsal

Direct Dorsal Smiling

Overhead

Preoperative

Postoperative

Preoperative

Postoperative

166

27

Steeper Backward Tilting

Backward Tilting

Basal

Basal Smiling

Preoperative

Postoperative

Right Nasal Aperture

Preoperative

Po&operative

Left Nasal Aperture

Part IV: Clinical Case 2

27

Part IV: Clinical Case 2

167

Right Oblique Mid Cheek Full Face

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

Right Oblique Cheek Margin Full Face

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

Preoperative

Postoperative

Preoperative

Postoperative

168

27

Right Lateral

Left Lateral

Right Lateral Middle Third

Left Lateral Middle Third

Preoperative

Postoperative

Preoperative

Postoperative

Right Lateral Smiling

Left Lateral Smiling

Part IV: Clinical Case 2

Part IV: Clinical Case 3

28

Preoperative Assessment

Surgical Plan

1. Frontolateral walls a. Thick ill defined tip overshadowing the lateral crurae (Direct Dorsal, Overhead, Backward Tilting, Basal and Nasal Aperture Views). b. Nasal tip deviation to the right side i.e. counter deviated to the bony pyramid (Frontal, Direct Dorsal, Overhead and Backward Tilting Views). 2. Media Wall a. Left caudal septal deviation, which droves the nasal tip off the central position to the right side. (Frontal, Direct Dorsal and Overhead Views). b. C-shaped septal deviation to the left (Direct Dorsal Views). 3. Bony pyramid a. Wide base of the boney pyramid (Direct Dorsal and Backward Tilting Views). b. Residual osteocartilagenous hump (Oblique and Lateral Views). c. Bony pyramid was oblique to the left side due to bilateral maxillary asymmetry, i.e. the right cheek is narrow and high, while the left cheek is wide and low, (Backward Tilting Views). 4. Alar base Apparent unequal nasal opening secondary to right caudal septal deviation (Basal and Nasal Aperture Views).

1. Frontolateral walls a. DDD including the weak triangle. b. Bilateral cephalic trim of the lateral crurae. 2. Media Wall Septoplasty. 3. Bony pyramid a. Excision of the osteocartilagenous hump. b. Osteotomies with Kasanjian maneuver to the right i.e. cross fracture of the bony pyramid after osteotomies (refer to Chapter of Surgery of the Bony Pyramid in the text). 4. Alar base Nil of note. Surgical Procedure a. As per Surgical Plan. b. Supra tip depression appeared during surgery which was filled by cartilaginous graft. Cephalis trimmings of the lateral crurae were used as the graft material.

Aims of Surgery 1. Straighten the nasal septum, which will reposition the nasal tip to the mid-line. 2. Reduction of the size and correction of the deviation of the boney pyramid. 3. Excision of the osteocartilagenous hump.

Post-operative Analysis 1. Frontolateral Walls a. Tip definition improved i.e. the tip is slimmer and prominently well identified. The alae nasi come into view to share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). b. Tip projection: The nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as one spot reflected off the nasal tip. (Backward Tilting Views). 2. Medial Walls Septoplasty have leads to: a. Correction of tip position.

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169

170

28

b. Equal nasal aperture sizes. 3. Bony Pyramid a. Bony pyramid aesthetics: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Dorsal light reflex is seen as a regular one line off the nasal dorsum (Direct Dorsal Views). 4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves). b. Posterior alar groove aesthetics improved by Defatting alone (Backward Tilting, Basal and Nasal Aperture Views). c. Alae nasi aesthetics improved. They are pulled medially become better seen, smaller and share in nasal aesthetics. (Nasal Aperture, Oblique and Lateral Views). d. Nasal aperture aesthetics: The shape of nasal apertures became more elegantly oval by defatting. e. Marginal light reflexes are clearly seen at:

Frontal

Preoperative

Postoperative

Part IV: Clinical Case 3

i. Inferior alar margins (Nasal Aperture Views). ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views). Commentary 1. The shortcomings of the primary surgery are as follows: a. Osteotomies were not completed by medialization of the sidewalls of the boney pyramid. Bilateral Maxillary asymmetry and deviation of the pyramid were not compensated for by the Kassanjian Maneuver, i.e. the pyramid was not centralized. b. No attempt was made to correct the caudal septal deviation. This resulted in nasal tip deviation and apparent nasal aperture asymmetry. 2. Minimal surgery was performed to three of the four areas of Rhinoplasty: a. Defatting of frontolateral walls. b. Septoplasty. c. Bilateral osteotomies and medialization of the sidewalls of the bony pyramid.

Frontal Smiling

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Part IV: Clinical Case 3

171

Direct Dorsal

Direct Dorsal Smiling

Overhead

Backward Tilting

Steeper Backward Tilting

Basal

Preoperative

Postoperative

Preoperative

Postoperative

Overhead Smiling

172

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Right Nasal Aperture

Left Nasal Aperture

Preoperative

Postoperative

Right Oblique Mid Cheek Full Face

Preoperative

Postoperative

Part IV: Clinical Case 3

Left Oblique Mid Cheek Full Face

28

Part IV: Clinical Case 3

173

Right Oblique Cheek Margin Full Face

Left Oblique Cheek Margin Full Face

Right Lateral

Left Lateral

Preoperative

Postoperative

Preoperative

Postoperative

Right Lateral Smiling

Left Lateral Smiling

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Part IV: Clinical Case 4

Preoperative Assessment 1. Frontolateral walls Overprojecting nasal tip due to excessively large tip graft (Frontal, Backward Tilting, Oblique and Lateral Views). 2. Nasal Septum Nil to note. 3. Bony pyramid Nil to note. 4. Alar base Nil of note.

2. Nasal Septum Nil to note. 3. Bony pyramid Nil to note. 4. Alar base Nil of note. Surgical Procedure Endonasal approach. The anterior end of the graft was trimmed away. Post-Operative Analysis

Aims of Surgery Tip projection is better aesthetically than before surgery. Remodeling the nasal tip to an aesthetically better shape. Commentary Surgical Plan 1. Frontolateral walls Trimming of the anterior over-projecting parts of the graft.

In secondary Rhinoplasty tissues are quite stiff and not easily manageable.

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176

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Frontal Middle Third

Backward Tilting

Right Lateral Middle Third

Left Lateral Middle Third

Part IV: Clinical Case 4

Preoperative

Postoperative

Preoperative

Postoperative

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

Part IV: Clinical Case 5

Preoperative Assessment 1. Fron to lat eral walls a. Bulbous tip over shadowing the alae nasi (Frontal, Overhead and Direct Dorsal, Backward tilting and Basal Views). b. Left lateral crural bulge secondary to high left septal deviation (Direct Dorsal, Overhead, Backward Tilting, Nasal Aperture and Oblique Views). 2. Medial Wall a. Left caudal septal dislocation. The left medial crus is pushed laterally (backward tilting, Basal, and Nasal Aperture Views), while the nasal sill band is pushed inferiorly (Frontal views). b. Right supra tip depression and bulge of left lateral crus. This deformity is caused by the left sided deviation of nasal septum (Frontal, Backward Tilting and Nasal Aperture Views). c. Tight upper lip (Lateral smiling views). 3. Bony Pyramid a. Wide base of bony pyramid (Frontal, Direct Dorsal, Overhead and Backward Tilting Views). b. Small nasal hump caused by the natural convexities of the nasal bones. c. Dorsal light reflex defused. 4. Alar Base Apparent unequal nasal apertures due to left caudal septal deviation. The right opening is thick walled rounded shaped and the left one is thick-walled slit like by the intrusion of the medial crus and caudal septum (Backward Tilting, Basal and Nasal Aperture View).

30

2. Correction of the caudal septal dislocation, supra tip depression and nasal hump, 3. Release the tight upper lip. Surgical Plan 1. Frontolateral walls DDD including the weak triangle. 2. Medial wall a. Septoplasty. b. Trans-oral division of Depressor septi muscles and frenulum. 3. Bony pyramid a. Excision of osteocartilagenous hump. b. Osteotomies and medialization of the lateral bony walls. 4. Alar Base Nil of Note. Surgical Procedure a. As per Surgical Plan. b. The caudal cartilage was found to be severely fibrosed and fragmented. Small fragments were excised. The caudal 3mm of the membranous septum were trimmed. c. The supra tip depression was filled by the corrected caudal septum. d. A transcollumelar stitch was placed to reduce the lateral crural prominences of the medial crurae. e. Sub-mucosal diathermy of the heads of the inferior turbinates to improve the nasal airway.

Aims of Surgery Post-Operative Analysis 1. To reduce the overall size of the nose. This includes reduction of the sizes of the nasal tip and the bony pyramid.

1. Frontolateral Walls a. Tip definition improved i.e. the tip is slimmer and prominently well identified. The alae nasi come into view to share in nasal aesthetics (Frontal, Direct

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Dorsal, Overhead, Backward Tilting and Basal Views). Note the clear light reflex off the nasal tip as one spot. (Backward Tilting Views). b. Tip projection: The nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as one spot off the nasal tip. (Frontal and Backward Tilting Views). 2. Medial Walls a. Septoplasty had the following consequences: i. The left lateral crural bulge and right supratip depression disappeared. ii. The unaesthetic distortion of the left nasal aperture is corrected. iii. The two nasal apertures became equal. b. The tight upper lip and mobile tip were abolished by dividing the frenulum and Depressor Septi muscles successively. 3. Bony Pyramid a. Bony pyramid aesthetics: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Dorsal light reflex is seen as a regular one line off the nasal dorsum (Direct Dorsal Views). 4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves).

Frontal

Preoperative

Postoperative

Part IV: Clinical Case 5

b. Posterior alar groove aesthetics improved by defatting the frontolateral walls and correction of caudal septal deviation. c. Alae nasi aesthetics improved. They are pulled medially become better seen, smaller and share in nasal aesthetics. (Nasal Aperture, Oblique and Lateral Views). d. Nasal aperture aesthetics improved by defatting and correction of caudal septal deviation. They became equal, thin walled and elegantly oval in shape. e. Marginal light reflexes are clearly seen at: i. Alar light reflex (Basal View). ii. Lateral crural prominences (Lateral Views).

Commentary 1. Analysis of the shortcomings of the primary surgery: a. Caudal septal dislocation was not corrected. b. Incomplete osteotomies. c. No attempt was made to reduce the size of the nasal tip. d. The tight upper lip was not attended to. 2. Three of the four areas of Rhinoplasty were addressed: a. Defatting the nasal tip that becomes more defined: b. Septoplasty together with defatting have improved the aesthetics of the nasal openings. c. Osteotomies and medialization of the bony pyramidal sidewalls.

Frontal Smiling

Part IV: Clinical Case 5

179

Direct Dorsal

Direct Dorsal Smiling

Overhead

Overhead Smiling

Backward Tilting

Steeper Backward Tilting

Basal

Basal Smiling

Preoperative

Postoperative

Preoperative

Postoperative

180

30

Left Nasal Aperture

Right Nasal Aperture

Preoperative

Postoperative

Right Oblique Mid Cheek Full Face

Preoperative

Postoperative

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

Part IV: Clinical Case 5

Part IV: Clinical Case 5

181

Right Oblique Cheek Margin Full Face

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

Right Lateral

Left Lateral

Right Lateral Smiling

Left Lateral Smiling

Preoperative

Postoperative

Preoperative

Postoperative

Part IV: Clinical Case 6

Preoperative Assessment 1. Frontolateral walls Nil of note. 2. Nasal Septum a. The cartilaginous and boney septum were mostly replaced by thick fibrous tissue 3. Bony pyramid Wide base of the boney pyramid. Severe dorsal depression leading to severe saddle Deformity. 4. Alar base Nil of note. Aims of Surgery 1. To correct the saddle deformity. 2. To reduce the base of the boney pyramid. Surgical Plan 1. Frontolateral walls Nil of note. 2. Nasal Septum Costal cartilage rib graft was used. 3. Bony pyramid Osteotomies and medialization of the bony sidewalls.

31

4. Alar base Nil of note. Surgical Procedure a. A three centimeter costal cartilage graft was harvested from the right side of the chest. b. The costal cartilage was introduced via an intercartilaginous incision after being refashioned to the exact size of the defect. Commentary a. Despite the simplicity of this procedure, it had a great aesthetic and psychological impacts on the patient, his family, friends and colleagues. b. There is a tendency for the costal cartilage graft to bend despite careful harvesting and shaping of the graft. The graft was placed in normal saline for half an hour, before using it inside the nose. c. The post-operative photographs were taken six months after surgery. Observe the straight light reflex from the nasal dorsum.

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Part IV: Clinical Case 6

Frontal Middle Third

Preoperative

Postoperative

Right Oblique Cheek Margin Middle Third

Preoperative

Postoperative

Left Oblique Cheek Margin Middle Third

Right Lateral Middle Third

Left Lateral Middle Third

Part IV: Clinical Case 7

Preoperative Assessment 1. Frontolateral walls Large and bulky frontolateral walls. The nasal tip is flat and ill defined from the large alae nasi on both sides. (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). 2. Medial Wall Irregular septal deviations by the broken bones and cartilages. 3. Bony pyramid a. Wide base of bony pyramid (Frontal, Direct Dorsal, Overhead and Backward Tilting Views). b. Broad midvault (the same views as in a.). 4. Alar base a. Unpleasantly wide nasal apertures (Backward Tilting, Basal and Nasal Aperture Views). b. The inferior segments of the rim-sill folds were long and the posterior segments were thick and heavily lying on the upper lip like flat tires. (Backward Tilting, Basal and Nasal Aperture Views). c. The right flat triangle was severely scarred and deformed. (Pre-operative Backward Tilting, Nasal Aperture and Oblique Views). Aims of Surgery 1. 2. 3. 4. 5.

Reduce the size and bulk of the frontolateral walls. Reduce the width of the bony pyramid and midvault. Fill the unpleasant depression of the right flat triangle. Reduce the sizes of nasal apertures. Improves the nasal airway.

Surgical Plan 1. Frontolateral walls DDD of frontolateral walls.

32

2. Medial Wall a. Correction of the broken septal deviations by refracturing to midline. Small specules had to be removed. b. Submucus diathermy of inferior turbinates. 3. Bony pyramid a. Osteotomies and medialisation of the bony sidewalls. b. Defatting of the area of the weak triangle and distal part of the upper lateral cartilage. 4. Alar base a. Bilateral resection of the posterior and inferior segments of the rim-sill folds. b. Filling the right flat triangle with a bone graft between its two skin layers. Surgical Procedure 1. As per surgical plan. 2. The two fatty subdermal layer of the frontolateral walls were completely replaced by tough fibrous tissues from the previous surgery. These tissues were cut by the scissor and thinned out by using rasps. 3. Bone graft was harvested from the nasal septum. The external and vestibular skin layers of the flat triangle were dissected from each other. The bone graft was then inserted to fill the space. 4. The left lateral crus was intact. Residuals of the right lateral crus maintained the shape of the lateral wall of the nose and therefore was not touched. 5. Submucosal diathermy of the inferior turbinates. Post-operative Analysis 1. Frontolateral Walls a. Tip definition improved i.e. the tip is slimmer and prominently well identified. The alae nasi come into view to share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal

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185

186

Views). Note the clear light reflex off the nasal tip as one spot. (Backward Tilting Views). b. Tip projection: The nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as one spot off the nasal tip. (Frontal and Backward Tilting). 2. Medial Walls Nasal airway improved after septal and turbinate surgeries. 3. Bony Pyramid a. Bony pyramid aesthetics: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Dorsal light reflex is seen as a regular one line off the nasal dorsum (Direct Dorsal Views). 4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves). b. Posterior alar groove aesthetics improved by defatting as well as excising the posterior segments of the rim-sill folds. The flat tire appearance is no longer present. (Backward Tilting, Basal and Nasal Aperture Views). c. Nasal aperture aesthetics: i. The size of the nasal openings are reduced by defatting as well as excising the inferior segments of the rim-sill folds. (Backward Tilting, Basal and Nasal Aperture views). ii. The shape of nasal openings improved by defatting and excision of the rim-sill folds transforms the nasal apertures from thick walled

32

Part IV: Clinical Case 7

wide and rounded openings with transverse long axes to thin walled small oval openings with anterior long axes. (Backward Tilting, Basal and Nasal Aperture views). d. Alae nasi aesthetics improved. They are pulled medially, better seen and smaller in size. e. Aesthetics of the right flat triangle improved after filling it with bone graft (Backward Tilting, Basal, Nasal Aperture and Oblique Views). f. Marginal light reflex: light reflex of inferior alar margin is seen. Flat triangular margins are smaller. (Basal and Nasal Aperture Views). Commentary 1. All four areas of the nose are to be examined before proceeding for surgery in this case. 2. The bony pyramid: osteotomies were omitted in the previous surgery and was dealt with as primary surgery. 3. The alar base was not touched and therefore dealt with as primary surgery. 4. The nasal septum was corrected for better airway, but it did not have any aesthetic role in this case. 5. The three predominant challenges were the frontolateral walls, the alar base and the left flat triangle. 6. The hypersensitivity of the skin disappeared after surgery. No clear explanation was found for this phenomena before surgery but it may be that rasping of the subdermal layer of the frontolateral walls have overcome this problem post-operatively. 7. Post-operative photographs were taken one month after the surgery. Better tip and bony pyramid definitions improve in long term.

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Part IV: Clinical Case 7

187

Frontal

Frontal Smiling

Frontal Middle Third

Direct Dorsal

Direct Dorsal Smiling

Overhead

Preoperative

Postoperative

Preoperative

Postoperative

Overhead Smiling

188

32

Part IV: Clinical Case 7

Backward Tilting

Steeper Backward Tilting

Basal

Basal Smiling

Right Nasal Aperture

Right Nasal Aperture Rim Sill Test

Left Nasal Aperture Rim Sill Test

Left Nasal Aperture

Preoperative

Postoperative

Preoperative

Postoperative

32

Part IV: Clinical Case 7

189

Right Oblique Mid Cheek Full Face

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

Right Oblique Cheek Margin Full Face

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

Preoperative

Postoperative

Preoperative

Postoperative

190

32

Right Lateral

Left Lateral

Right Lateral Middle Third

Left Lateral

Preoperative

Postoperative

Preoperative

Postoperative

Middle Third

Part IV: Clinical Case 7

Right Lateral

Left Lateral

Smiling

Smiling

Part V Ethnic Rhinoplasty

Part V: Clinical Case 1

Preoperative Assessment 1. Frontolateral walls Bulky nasal tip overshadowing the alae nasi predominantly the right side of the nose. (Frontal, Direct Dorsal and Overhead Views). 2. Nasal septum Nil of note. 3. Bony pyramid Wide base of the boney pyramid. The height of the bony bridge is not as low as commonly seen on African noses (Frontal, Direct Dorsal and Backward Tilting). 4. Alar base Wide alar base with thick posterior and long inferior segments of rim-sill folds. (frontal, direct dorsal and basal views). Asymmetrical Smile only seen in the post operative forced smiling view. Aims of Surgery 1. Narrow nasal tip. 2. High, narrow dorsum of the nose. 3. Narrow alar base. Surgical Plan 1. Frontolateral walls a. DDD excluding the weak triangle to reduce the bulk of the nasal tip. b. Bilateral cephalic trim of the lateral crurae to reduce the size of the nasal tip. 2. Nasal septum Nil of note. 3. Bony pyramid Osteotomies and medialization of the lateral bony walls.

33

4. Alar base Bilateral resection of the posterior and inferior segments of the rim sill folds. Surgical Procedure 1. As per Surgical Plan. 2. The cephalic parts of the lateral crurae were only cut laterally, then they were curved superiorly and stitched together to augment the dorsum. The stitches were taken through the skin and fixed externally. Post-operative Analysis 1. Frontolateral Wall a. Tip definition: defatting have thinned the tip size and thinned its covering skin. The alae nasi came into view to share in nasal aesthetics. (Frontal, Direct Dorsal, Over Head, Backward Tilting and Basal Views). No tip grafts were used. This is the patient’s own tip and own nasal print. b. Tip projection: The nasal tip is at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as one spot off the nasal tip. (Frontal and Backward Tilting Views). 2. Medial Wall Nil of Note. 3. Bony Pyramid a. Using the lateral crural cartilages to augment the dorsum gave the nose natural appearance. Aesthetics of the nasal dorsum and bony side walls improved (Frontal, Direct Dorsal, Backward Tilting, Nasal Aperture, Oblique and Lateral Views). b. Dorsal light reflex is a straight line post-operatively as compared to the interrupted reflex pre-operatively (Direct Dorsal Views).

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193

194

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4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves). b. Posterior alar groove aesthetics improved by defatting as well as excising the posterior segments of the rim-sill folds. The flat tire appearance is no longer present i.e. the angles of the alae nasi with the upper lip became wider (Backward Tilting, Basal and Nasal Aperture Views). c. Alae nasi aesthetics improved. They are pulled medially became better seen, smaller and share in nasal aesthetics (Nasal Aperture, Oblique and Lateral Views). d. Nasal aperture aesthetics improved after defatting and excision of the rim-sill folds: i. The size of the nasal openings are smaller (Backward Tilting, Basal and Nasal Aperture views).

Frontal

Preoperative

Postoperative

Part V: Clinical Case 1

ii. The shapes of nasal openings transformed from thick walled wide and rounded openings with transverse long axes to thin walled small oval openings with anterior long axes (Backward Tilting, Basal and Nasal Aperture views). e. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views). ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views). Commentary (a) This lady is of mixed African and Asian (Yemeni) roots. She has the large thick skinned flat nose as commonly seen in Africans and the lighter skin color as commonly seen in Yemeni ladies. (b) Resection of the rim-sill folds together with defatting have greatly reduced and almost abolished the bulk and size of the lower third of the nose. The thick heavy appearance of the nose was transformed into a thin delicate looking nose.

Frontal Smiling

33

Part V: Clinical Case 1

195

Direct Dorsal

Direct Dorsal Smiling

Overhead

Preoperative

Postoperative

Steeper Backward Tilting

Preoperative

Postoperative

Backward Tilting

Basal

Basal Smiling

196

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Part V: Clinical Case 1

Right Nasal Aperture

Right Nasal Aperture Rim Sill Test

Left Nasal Aperture Rim Sill Test

Left Nasal Aperture

Right Oblique Mid Cheek Full Face

Left Oblique Mid Cheek Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

Preoperative

Postoperative

Preoperative

Postoperative

33

Part V: Clinical Case 1

Right Lateral

Preoperative

Postoperative

197

Left Lateral

Right Lateral Smiling

Left Lateral Smiling

Part V: Clinical Case 2

Preoperative Assessment

Surgical Procedure

1. Frontolateral walls Bulky large nasal tip overshadowing the alae nasi (Frontal, Direct Dorsal and Backward Tilting Views). 2. Medial Wall Nil of note. 3. Bony pyramid Wide base of the boney pyramid, but not as low as commonly seen in African noses (Direct Dorsal, Backward Tilting, Oblique and Lateral Views). 4. Alar base Thick round nasal apertures but not wide.

a. As per Surgical Plan. b. No alar resection was necessary after defatting.

Aims of Surgery 1. Narrow the nasal tip and reduction of its bulk. 2. High, narrow dorsum of the nose. 3. Narrow alar base and reduction of its bulk. Surgical Plan 1. Frontolateral walls a. DDD excluding the weak triangle to reduce the bulk of the frontolateral walls. b. Bilateral cephalic trim of the lateral crurae to reduce the size. 2. Nasal septum Nil of note. 3. Bony pyramid Osteotomies and medialization of the lateral bony walls. 4. Alar base Bilateral resection of the rim sill folds, including the posterior and inferior segments.

34

Post-operative Analysis 1. Frontolateral Walls a. Tip definition: Defatting have thinned the nasal tip and its covering skin. The alae nasi came into view to share in the nasal aesthetics (Frontal, Direct Dorsal, Backward Tilting and Basal views). b. No tip grafts were used. The nose keeps its original nasal image and nasal print. c. The nasal tip and columella maintain their natural soft feeling. The columella maintain its physiological role in facial expression and movement with the nose and upper lip. d. Tip projection: The nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). e. Tip light reflex is seen as one spot off the nasal tip (Frontal and Backward Tilting Views). 2. Medial Wall Nil of Note. 3. Bony Pyramid a. Bony pyramid aesthetics: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Dorsal light reflex is seen as an uninterrupted line off the nasal dorsum (Direct Dorsal Views). 4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral, and Direct Dorsal grooves).

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200

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b. Posterior alar groove aesthetics improved: the angle between the alae nasi and the upper lip become wider (Basal, Oblique and Lateral Views). c. Nasal aperture aesthetics: defatting the anterolateral walls did not affect the sizes of nasal apertures, but the shapes became more elegantly oval. The light reflex could be seen from the inferior alar margins (Backward Tilting and Basal Views). d. Alae nasi aesthetics improved. They are pulled medially become better seen, smaller and share in nasal aesthetics (Nasal Aperture, Oblique and Lateral Views).

Frontal

Preoperative

Postoperative

Part V: Clinical Case 2

e. Marginal light reflexes: The inferior alar margins reflects the light (Basal Views). Note the size of the flat triangles became smaller post-operatively. Commentary A simple uncomplicated surgery was sufficient to produce a good aesthetic result. Only two of the four areas of Rhinoplasty were addressed i.e. the frontolateral walls by defatting and the bony pyramid by osteotomies.

Frontal Smiling

34

Part V: Clinical Case 2

201

Direct Dorsal

Direct Dorsal Smiling

Preoperative

Postoperative

Backward Tilting

Preoperative

Postoperative

Steeper Backward Tilting

Basal

Basal Smiling

202

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Part V: Clinical Case 2

Right Oblique Cheek Margin Full Face

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

Right Lateral

Left Lateral

Right Lateral Middle Third

Left Lateral Middle Third

Preoperative

Postoperative

Preoperative

Postoperative

Part V: Clinical Case 3

Preoperative Assessment 1. Frontolateral walls Small, flat tip which was ill defined and amorphously continuous with the wide flat alae nasi on both sides (Frontal, Direct Dorsal, Backward Tilting and Basal Views). 2. Nasal septum Nil of note. 3. Bony pyramid Wide base, flat bony pyramid (preoperative Frontal, Direct Dorsal, Backward Tilting, Oblique and Lateral Views). 4. Alar base a. Wide alar base due to long inferior and bulky posterior segments of the rim-sill folds. The posterior segments have acute alar lip angles i.e. flat tire appearance (Pre-operative Basal and Nasal Aperture Views). b. Note that the right rim-sill fold was stretched by the testing probe (Right rim-sill test). Aims of Surgery 1. Provide good tip definition and tip projection. 2. Elevation and narrowing of the boney pyramid. 3. Reduction of the bulk and width of the alar base with transformation of the horizontal axes of the nasal openings into vertical ones. Surgical Plan 1. Frontolateral walls a. DDD excluding the weak triangle to reduce the bulk of the nasal tip. b. Bilateral cephalic trim of lateral crurae to reduce the size of the nasal tip.

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2. Nasal septum Nil of note. 3. Bony pyramid Osteotomies and medialization of the lateral bony walls. 4. Alar base Resection of the posterior and inferior segments of the rim sill folds. Surgical Procedure 1. As per Surgical Plan. 2. Nasolabial and supratip cartilage grafts were needed. Post-operative Analysis 1. Frontolateral Wall a. Tip definition: the nasal tip is slimmer, more prominent and well identified from the alae nasi on both sides. The alae nasi become clearly visible and share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). b. Tip projection: the nasal tip is at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as one spot off the nasal tip (Frontal and Backward Tilting Views). 2. Medial Wall Nil of Note. 3. Bony Pyramid a. Bony pyramid aesthetics: the nasal dorsum is high, straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Dorsal light reflex is seen as a regular one line off the nasal dorsum (Direct Dorsal Views). 4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves became longer and deeper (Oblique, Lateral and Direct Dorsal grooves).

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_35

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204

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b. Posterior alar groove aesthetics improved by excising the posterior segment of the rim-sill folds. Flat tire appearance is no longer present (Backward Tilting, Basal and Nasal Aperture Views). c. Nasal aperture aesthetics: i. The size of the nasal openings are reduced by defatting of the frontolateral walls and resection of the rim-sill folds. ii. The shape of nasal openings: defatting and resection of the rim-sill folds enhanced the aesthetics of the nasal openings. They become more elegantly oval in shape (Backward Tilting, Basal and Nasal Aperture views). d. Alae nasi aesthetics improved. They are pulled medially become better seen, smaller and share in nasal aesthetics (Nasal Aperture, Oblique and Lateral Views). e. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views).

Frontal

Preoperative

Postoperative

Part V: Clinical Case 3

ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views). Commentary a. The overall wide flat, thick skinned heavy looking nose was transformed into slim, high thin skinned gentle looking nose. The overall size and bulk of the nose was reduced. b. Three of the four areas of Rhinoplasty were addressed i.e. the frontolateral walls, the bony pyramid and the alar base. No tip or dorsal grafts were used. The supratip and nasolabial grafts were needed in these junctional areas for aesthetic enhancement. They neither affect the natural soft sensation of the nose, nor do they affect the normal physiological mobilities of the nose. c. These changes had such a positive boost to the patient’s psychology that he changed his career from a car mechanic to a sales representative in a famous food company. Frontal Smiling

Frontal Middle Third

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Part V: Clinical Case 3

205

Direct Dorsal

Direct Dorsal Smiling

Preoperative

Postoperative

Backward Tilting

Preoperative

Postoperative

Steeper Backward Tilting

Basal

Basal Smiling

206

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Right Nasal Aperture

Right Nasal Aperture Rim Sill Test

Left Nasal Aperture Rim Sill Test

Part V: Clinical Case 3

Left Nasal Aperture

Preoperative

Postoperative

Right Oblique Mid Cheek Full Face

Preoperative

Postoperative

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

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Part V: Clinical Case 3

207

Right Oblique Cheek Margin Full Face

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

Right Lateral

Left Lateral

Right Lateral Smiling

Left Lateral Smiling

Preoperative

Postoperative

Preoperative

Postoperative

208

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Right Lateral Middle Third

Preoperative

Postoperative

Left Lateral Middle Third

Part V: Clinical Case 3

Part V: Clinical Case 4

Preoperative Assessment 1. Frontolateral walls a. Nasal tip is slightly elevated and tilted backwards (Lateral and Oblique Views). b. The nasal tip felt hard and solid when palpated secondary to previous surgery. 2. Media Wall Nil of note. 3. Bony pyramid a. Wide base of boney pyramid. No signs of previous surgery in this area (Direct Dorsal and Backward Tilting Views). b. The bony pyramid is small in size and length, as seen in a child’s nose, confirmed by palpation. c. The dorsum is flat and ill defined. The upper two thirds of the nose is dissociated from the nasal tip (Frontal, Direct Dorsal and Backward Tilting Views). 4. Alar base Previous alar base surgery.

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4. Alar base Nil of note. Surgical Procedure As per Surgical Plan. Post-operative Analysis

To enhance the aesthetics of nasal dorsum and sidewalls of the bony pyramid and mid vault.

a. Bony pyramid aesthetics: the bony pyramid was not touched in the previous surgery. It was dealt with as primary surgery. The nasal bones are short and small compared to the size of the nose. Osteotomies alone would not have been sufficient to give enough height to the dorsum. Additional height by using a septal graft was necessary. b. The dorsal graft has achieved the following: i. Elevated the nasal dorsum. ii. Increased the size of the nose. iii. Increased the length of the nose which had consequently corrected the backward tilt of the nasal tip and pushed it down to a better aesthetic position. iv. Improved the visual effect of the large forehead, cheeks and protruding chin. c. Dorsal light reflex of nasal dorsum appears as one uninterrupted line (Direct Dorsal Views).

Surgical Plan

Commentary

1. Frontolateral walls Nil of note. 2. Media Wall Harvesting cartilage and boney septal grafts. 3. Bony pyramid a. Osteotomies and medialization of the lateral bony walls. b. Dorsal septal graft.

a. The middle third photographs in this lady are well appreciated. In full face photographs the large sizes of the forehead, cheeks and mandibles over shadow the small size of the nose. Aesthetics of the nose are not very well appreciated, but the patient is quite aware of any minor changes in her small nose. b. This case is all about making the correct decisions. The primary surgeon should have attempted to increase the

Aims of Surgery

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size, height and the length of the nose rather than reducing its size. c. No attempt was made to explore the nasal tip. As tissues were quite tough and fibrosed any surgical modification would have been risky.

d. The nasal tip and the alae nasi looked apparently large pre-operatively taking 1/2 of the total size of the nose. Post-operatively the natural proportionate sizes of the upper two thirds and lower third was regained.

Frontal

Preoperative

Postoperative

Direct Dorsal

Preoperative

Postoperative

Part V: Clinical Case 4

Direct Dorsal Smiling

36

Part V: Clinical Case 4

211

Backward Tilting

Steeper Backward Tilting

Basal

Basal Smiling

Preoperative

Postoperative

Right Nasal Aperture

Preoperative

Postoperative

Right Nasal Aperture Rim Sill Test

Left Nasal Aperture Rim Sill Test

Left Nasal Aperture

212

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Right Oblique Mid Cheek Full Face

Left Oblique Mid Cheek Full Face

Part V: Clinical Case 4

Right Oblique Mid Cheek Middle Third

Preoperative

Postoperative

Right Oblique Cheek Margin Full Face

Preoperative

Postoperative

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

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Part V: Clinical Case 4

213

Right Lateral

Left Lateral

Right Lateral Smiling

Preoperative

Postoperative

Right Lateral Middle Third

Preoperative

Postoperative

Left Lateral Middle Third

Left Lateral Smiling

Part V: Clinical Case 5

Preoperative Assessment 1. Frontolateral walls a. Bulbous tip overshadowing the alae nasi (frontal and direct dorsal views). 2. Medial wall Nil of note. 3. Bony pyramid Wide base of the bony pyramid (Frontal, Direct Dorsal Views). 4. Alar base a. The nasal openings are irregular and dissimilar in shape, yet they are similar in size. b. The right nasal opening is triangular in shape, while the left nasal opening is pear shaped (Basal Views). c. The posterior alar margin is attached to the upper lip at the lower level than the columella. Aims of Surgery 1. Reduction of the size and bulk of the bulbous tip. 2. Creating better tip definition and better tip projection. 3. Narrowing the side walls of the bony pyramid and elevation of nasal dorsum. 4. Reduction of the size of the alar base. Surgical Plan 1. Frontolateral walls a. DDD including the weak triangle. b. Cephalic trim of the lateral crurae. 2. Media wall Nil of note. 3. Bony pyramid Osteotomies and medialization of the lateral bony walls.

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4. Alar base Resection of the inferior segments of the rim sill folds. Surgical Procedure a. As per Surgical Plan. b. Crushed cartilage tip graft was necessary. Post-operative Analysis 1. Frontolateral wall a. Tip definition: There is better definition of the nasal tip is smaller with thinner and smoother overlying skin. It is more prominent and well identified from the alae nasi on both sides. The alae nasi come into view to become clearly visible and share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). b. Tip projection: The nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as one spot off the nasal tip. (Frontal and Backward Tilting Views). 2. Medial wall Nil of note. 3. Bony Pyramid a. Bony pyramid aesthetics improved the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Dorsal light reflex is seen as a regular one line off the nasal dorsum (Direct Dorsal Views). 4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves). b. Posterior alar groove aesthetics improved by defatting and excision of the inferior segments of the rim-sill

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c.

d.

e.

f.

folds. The defatted crurae are pulled medially as they become semidetached from the alae nasi, by the defatted superior alar grooves. The angles of the posterior alar grooves with the upper lip become wider. (Backward Tilting and Nasal Aperture Views). Excision of the inferior segments of the rim sill folds has elevated the alar margins to the same level as the columella. The lateral columellar margin is seen post-operatively in the Oblique views. Alae nasi aesthetics improved. They are pulled medially become better seen, smaller in size and share in nasal aesthetics. (Nasal Aperture, Oblique and Lateral Views). Nasal aperture aesthetics improved: The nasal openings are smaller in size, yet the shapes remain as different as before. If the sizes of the two nasal openings were widely different, they appear strikingly unaesthetic whether they are the same shape or not. They do not appear unaesthetic if they have the same size and different shapes. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views).

Frontal

Preoperative

Postoperative

Part V: Clinical Case 5

ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views). Commentary a. This lady has mixed Asian and African facial features. The forehead and cheeks are large and wide as commonly seen in Asians. The mouth is large with thick lips as commonly seen in Africans. The nose is mixed small Asian type and thick skinned bulky Africa type. b. The shortcomings of the primary surgery: i. The nasal tip was not touched and remained bulky and bulbous looking. ii. No attempt was made to reduce the width and increase the height of the bony pyramid. iii. The size of the alar base was not sufficiently reduced. c. The middle third photography is important in this lady as the nose is comparatively small to the surrounding large cheeks and forehead. d. Changes in the small nose may seem unimpressive but if the large forehead and cheeks are excluded then these changes are quite noticeable and aesthetically pleasing, especially to the patient who is quite conscious of.

Frontal Smiling

Frontal Middle Third

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Part V: Clinical Case 5

217

Direct Dorsal

Direct Dorsal Smiling

Preoperative

Postoperative

Backward Tilting

Preoperative

Postoperative

Steeper Backward Tilting

Basal

Basal Smiling

218

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Part V: Clinical Case 5

Right Nasal Aperture

Right Nasal Aperture Rim Sill Test

Left Nasal Aperture Rim Sill Test

Left Nasal Aperture

Right Oblique Mid Cheek Full Face

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

Preoperative

Postoperative

Preoperative

Postoperative

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Part V: Clinical Case 5

Right Oblique Cheek Margin Full Face

219

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

Left Lateral

Right Lateral Smiling

Left Lateral Smiling

Preoperative

Postoperative

Right Lateral

Preoperative

Postoperative

220

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Right Lateral Middle Third

Preoperative

Postoperative

Left Lateral Middle Third

Part V: Clinical Case 5

Part V: Clinical Case 6

Preoperative Assessment 1. Frontolateral walls a. Bulbous tip, partially overshadowing the alae nasi predominantly the left side. (Frontal and Direct Dorsal Views). 2. Medial wall a. Right caudal septal deviation (Backward Tilting and Right Nasal Aperture Views). The medial crus is pushed laterally i.e. lateral crural prominence (Basal Views). b. Slightly mobile tip (Lateral Smiling Views). 3. Bony pyramid a. Wide base of bony pyramid (Frontal, Direct Dorsal and Backward Tilting Views). b. Osteocartilaginous hump deviated to the left due to bilateral maxillary asymmetry. The right cheek is wide and low, the left cheek is high and narrow (backward tilting views). c. Deep nasofrontal angle (Lateral, Oblique, Backward Tilting and Frontal Views). 4. Alar base a. Asymmetrical smile. On smiling, the right cheek is larger in size and different in shape than the left cheek and the right ala nasi is larger and more prominent than the left. (preoperative Smiling Frontal view). b. Nasal apertures are thick walled and encroached upon by lateral crural prominences of the medial crurae. There was apparent asymmetrical sizes of the two nasal openings due to protrusion of the right caudal cartilaginous septum into the right nasal aperture (Backward Tilting, Basal and Nasal Aperture Views). Aims of Surgery 1. Reduction of thickness frontolateral walls. 2. Reduction of the height and size of the bony pyramid. Adjusting the obliquity of the pyramid.

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3. Providing extra length to the nose i.e. giving the nose its normal natural length by leveling the nasofrontal depression with the nasal dorsum. Surgical Plan 1. Frontolateral walls D. D. D. including the weak triangle to reduce the bulk of nasal tip. 2. Medial wall a. Septoplasty to correct the right septal caudal deviation. b. Division of depressor septi muscles. 3. Bony pyramid a. Excision of osteocartilaginous hump. b. Osteotomies and Kassanjean maneuver to the right i.e. cross fracture of the bony pyramid after osteotomies (see Surgery of the Bony Pyramid in the text). c. Filling the nasofrontal angle using a septal graft. 4. Alar base Transcrural stitch to medialize the lateral crural prominences. Surgical Procedure a. As per surgical plan. b. An accurately measured cartilaginous septal graft was used to fill the nasofrontal depression. Deep longitudinal scoring were made on one side to give the graft the same external rounded surface as the nasal dorsum. Further height was provided to the graft by inserting more graft material on the concave side. c. The transcrural stitch: a no. 3/0 nylon transfixing stitch on a straight needle is passed across the two medial crurae, going superior and then coming back inferior to the inferior vestibular bands on both sides (see Surgery of Columella in the text). The stitch is remove in 4–6 weeks.

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Post-operative Analysis 1. Frontolateral walls a. Tip definition, the nasal tip lost its bulk and became nice and slim with thinner skin, matching with her facial features. (Frontal, Direct Dorsal, Backward Tilting and Basal Views). The alae nasi came into view to share in nasal aesthetics. They became of almost equal sizes. b. Tip projection. The tip is at the same height as the nasal dorsum with good angle. This is coupled with excellent nasolabial angle. (Lateral and the Oblique views). c. Tip light reflex is seen as one spot off the nasal tip. (Frontal and Backward Tilting Views). 2. Medial wall a. The lateral crural prominences disappeared especially on the right side after septoplasty and the trans-crural stitch (Backward Tilting, Basal and Right Nasal Aperture Views). b. Caudal deviation of the septum. 3. Bony pyramid a. Bony pyramid aesthetics improved: the nasal dorsum is straight and the sidewalls are smooth and narrow. Filling the deep naso-frontal angle have added an extra length to nasal dorsum. The long nose matches better with the tall stature of the patient (all views except the Basal Views). b. Dorsal light reflex is seen as an uninterrupted line off the nasal dorsum (Direct Dorsal Views). 4. Alar base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves).

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Part V: Clinical Case 6

b. Posterior alar groove aesthetics improved by defatting. There are wider posterior groove angles. (Basal and Nasal Aperture Views). c. Alae nasi aesthetics improved. They are pulled medially become better seen, smaller and share in nasal aesthetics. (Nasal Aperture, Oblique and Lateral Views). d. Nasal aperture aesthetics improved by defatting only of the frontolateral walls. The aperture look more elegantly oval in shape. The nasal apertures became similar in size after reducing the caudal septal deviation and the lateral crural prominences. e. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views). ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views). Commentary 1. Post-operative photographs were taken five years after surgery. 2. All goals of surgery were achieved so that: a. She has a high dorsum, long nose, the size and length of which matches perfectly with size and length of her face and body. b. The body of the left ala nasi become clearer and bigger after defatting the frontolateral walls. The two alae are closer in size to each other than before surgery. c. There was visual improvement of the epicanthi especially to left one.

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Part V: Clinical Case 6

223

Frontal Smiling

Frontal

Frontal Middle Third

Preoperative

Postoperative

Direct Dorsal

Preoperative

Postoperative

Direct Dorsal Smiling

Overhead

Overhead Smiling

224

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Steeper Backward Tilting

Backward Tilting

Basal

Part V: Clinical Case 6

Basal Smiling

Preoperative

Postoperative

Right Nasal Aperture

Preoperative

Po&operative

Left Nasal Aperture

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Part V: Clinical Case 6

225

Right Oblique Mid Cheek Full Face

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

Right Oblique Cheek Margin Full Face

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

Preoperative

Postoperative

Preoperative

Postoperative

226

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Right Lateral

Left Lateral

Right Lateral Smiling

Preoperative

Postoperative

Right Lateral Middle Third

Preoperative

Postoperative

Left Lateral Middle Third

Part V: Clinical Case 6

Left Lateral Smiling

Part VI Special Clinical Conditions

Part VI: Clinical Case 1

Preoperative Assessment 1. Frontolateral walls Nil of note. 2. Medial wall Left caudal septal deviation. (Basal Views). 3. Bony pyramid Wide base of bony pyramid. 4. Alar base a. Wide alar flare on smiling due to long inferior segments of the rim-still folds. b. Asymmetrical smile. The left ala nasi and left nasolabial fold was at higher level and more lateralized on smiling. The left cheek ball is different in size and shape from the right cheek ball (Frontal Smiling Views). c. Asymmetrical sizes of nasal openings due to right caudal septal deviation that encroach upon the right nasal aperture. Aims of Surgery The main target in of surgery not only to reduce the width of the alar base, on smiling, but also to reduce the size of the lower third of the nose that became wide on smiling. Surgical Plan 1. Frontolateral walls Nil of note. 2. Medial wall Septoplasty to overcome asymmetrical sizes of the nasal apertures after reduction of alar base. 3. Bony pyramid Bilateral osteotomies. The side walls of the bony pyramid had to be medialised to match the medialization of the alae nasi after alar base reduction.

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4. Alar base a. Bilateral resection of the inferior segments of the rim-still folds. b. Skin excision extended inwards through the vestibular floors up to the mucocutaneous junction. Surgical Procedure As per surgical plan. Post-operative Analysis and Commentary a. The request of the patient was quite simple, and the the surgical solution apparently looked equally simple i.e. no more than excision of the rim-still folds. But in fact there was some other considerations that the surgeon had to deal with: i. Septoplasty was a must otherwise nasal apertures would become unequal. Although asymmetrical smile continued postoperatively yet it was less noticeable. ii. Osteotomies were necessary to avoid a barrel shaped appearance of the nose as the bony sidewalls will appear wider than the alar base. b. Widening of nasal apertures on smiling is usually due to the stretch of the inferior segments of the rim-sill folds. In the case of this lady smiling produced widening of the whole lower third of the nose as well as the nasal apertures. It was necessary to resect the rim-sill folds as well as segments from the loose skin of the vestibular floors i.e. 2–3 mm just medial to the posterior alar margins up to the level of the mucocutaneous junction. c. Post-operatively alar flare continued to be reduced even ten years after surgery. She enjoyed taking photographs in her naturally active social life.

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Frontal

Part VI: Clinical Case 1

Frontal Smiling

Preoperative

Postoperative

10 years postoperatively, maintaining a pleasant smile, ala nasi are not embarrassingly wide.

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Part VI: Clinical Case 1

Backward Tilting

231

Steeper Backward Tilting

Basal

Right Nasal Aperture Rim Sill Test

Left Nasal Aperture Rim Sill Test

Preoperative

Postoperative

Preoperative

Postoperative

Basal Smiling

232

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Right Oblique Cheek Margin Full Face

Preoperative

Postoperative

Left Oblique Cheek Margin Full Face

Right Lateral

Part VI: Clinical Case 1

Left Lateral

Part VI: Clinical Case 2

Preoperative Assessment

Surgical Procedure

1. Frontolateral walls a. Plunging tip i.e. drooping inferiorly with acute nasolabial angle (Lateral Smiling Views) b. Bulbous tip overshadowing the alae nasi (Frontal and Direct Dorsal Views) 2. Medial Wall Hanging collumela (Frontal, Lateral and Oblique Views) 3. Bony pyramid a. Osteocartilagenous hump (Backward Tilting, Lateral and Oblique Views) b. Wide base of the bony pyramid (Direct Dorsal and Backward Tilting Views) 4. Alar base Nil of note.

a. b. c. d.

Aims of Surgery 1. Correction of the plunging nasal tip (drooping nose). 2. Correction of the hanging collumela. 3. Reduction of the boney hump. Surgical Plan 1. Frontolateral walls a. DDD including the weak triangle. 2. Medial Wall a. Reduction of the membranous septum b. Direct reduction of the size of medial crurae. c. Division of depressor septi muscles. 3. Bony pyramid a. Excision of the osteo-cartilaginous hump. b. Osteotomies and medialization of the lateral bony walls. 4. Alar base Nil of note.

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As per Surgical Plan. Trim of 2 mm of the caudal cartilaginous septum. Partial trim of the anterior nasal spine. Direct reduction of the medial crural size. An inferior marginal incision is made on each medial crus at the junction of the adherent and non-adherent loose external skin. The inferior margin of the cartilaginous crus was gradually removed until the collumela became at an aesthetically acceptable level with the alar margin.

Post-operative Analysis 1. Antrolateral Walls a. Tip definition: nasal tip is slimmer, more prominent and well identified from the alae nasi on both sides. The alae nasi become clearly visible and share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). b. Tip projection: The nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as one spot off the nasal tip (Frontal and Backward Tilting Views). 2. Medial Wall Hanging columella and mobile tip have been rectified. The naso-labial angle is aesthetically attractive. 3. Bony Pyramid a. Bony pyramid aesthetics: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Dorsal light reflex is seen as a straight line (Direct Dorsal Views). 4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves).

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b. The posterior alar groove aesthetics improved after defatting (Backward tilting, Basal, Nasal Aperture, Oblique and Lateral View). c. Aesthetics of the alae nasi are better. They moved medially after defatting and are better seen Nasal Aperture and Oblique Views). d. Nasal aperture aesthetics: the shapes of nasal apertures improved by defatting. The lateral angulations of alae nasi were straightened after defatting with better oval shaped apertures. e. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views).

Frontal

Postoperative

Part VI: Clinical Case 2

ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views). Commentary a. The amount of tissues to be removed from the areas of the caudal cartilaginous septum, membranous septum, anterior nasal spine and the medial crural cartilages are variable according to the size of the nose and the extent of the deviation of each of these structures from the acceptable aesthetic relationships. This has to be judged by the surgeon in each individual nose.

Frontal Smiling

Frontal Middle Third

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Part VI: Clinical Case 2

235

Direct Dorsal

Direct Dorsal Smiling

Preoperative

Postoperative

Basal

Preoperative

Postoperative

Basal Smiling

236

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Right Nasal Aperture

Part VI: Clinical Case 2

Left Nasal Aperture

Preoperative

Postoperative

Right Oblique Mid Cheek Full Face

Preoperative

Postoperative

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

40

Part VI: Clinical Case 2

237

Right Oblique Cheek Margin Full Face

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

Right Lateral

Left Lateral

Right Lateral Smiling

Left Lateral Smiling

Preoperative

Postoperative

Preoperative

Postoperative

238

40

Right Lateral Middle Third

Preoperative

Postoperative

Left Latera l Middle Third

Part VI: Clinical Case 2

Part VI: Clinical Case 3

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Preoperative Assessment

Surgical Plan

1. Frontolateral walls a. Large, bulky tip. Slightly ill defined tip despite of good projection. b. Mobile tip (Lateral Smiling Views). c. Supra-tip congenital fistula that communicates with the nasal cavity (Frontal Views). 2. Nasal Septum a. Deeply grooved columella (Backward Tilting and Basal Views). b. Mobile tip i.e. the nasal tip moves inferiorly on smiling. 3. Bony pyramid a. Small bony hump that is more prominent on the patient’s left side due to bilateral maxillary asymmetry. The right cheek is wide and low while the left cheek is high and narrow (Backward Tilting Views). b. Very wide base of the bony pyramid. This lady have mild hypertelorism i.e. excessive width between the two eyes (Frontal, Direct Dorsal, Overhead and Backward Tilting Views). c. Irregular dorsal light reflexes (Direct Dorsal Views). 4. Alar base Wide alar base mainly due to long inferior segments and slightly thick posterior segments of the rim-sill folds (Backward Tilting, Basal and Nasal Aperture Views).

1. Frontolateral walls a. DDD excluding the weak triangle. b. Closure of the supra-tip congenital fistula. 2. Nasal Septum Division of the depressor septi muscles. 3. Bony pyramid a. Excision of the osteocartilagenous hump. b. Osteotomies and medialization of the lateral bony walls to reduce the width of the bony pyramid. 4. Alar base Resection of the posterior and inferior segments of the rim-sill folds.

Aims of Surgery 1. To produce a slimmer nose including the dorsum, tip and alar base. 2. Closure of the supra-tip congenital fistula. 3. Abolishing the mobility of the tip.

Surgical Procedure a. As per Surgical Plan. b. Insertion of a supratip cartilage graft. Post-operative Analysis 1. Frontolateral Walls a. Tip Definition: nasal tip is slimmer, more prominent and well identified from the alae nasi on both sides. The alae nasi become clearly visible and share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). b. Tip projection: The nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as one spot (Frontal and Backward Tilting Views). d. The supratip fistula is closed.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_41

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2. Medial Wall Grooving of the columellar disappeared by defatting. 3. Bony Pyramid a. Bony pyramid aesthetics: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Dorsal light reflex appears as uninterrupted line of light (Direct Dorsal Views). 4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves became longer and deeper (Oblique, Lateral and Direct Dorsal grooves). b. Posterior alar groove aesthetics improved: by defatting as well as excising the rim-sill folds. (Backward Tilting, Basal and Nasal Aperture Views). c. Alae nasi aesthetics improved. They are pulled medially become better seen, smaller and share in nasal aesthetics. d. Nasal apertures aesthetics improved by defatting and excision of the rim-sill folds: i. Nasal apertures are smaller.

Frontal

Postoperative

Part VI: Clinical Case 3

ii. The shapes of nasal aperture become elegantly oval. e. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views). ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views). Commentary a. Removing the fistula has taken away some of the subcutaneous fat and tissues that needed to be replaced by supratip cartilage graft. The graft mitigates the risk of the fistula reopening. b. Although the distance between the eyes is the same, yet post operatively the visual impact of her hypertelorism is reduced and was more aesthetically attractive. The slim high nasal dorsum was visually better than the broad one. c. Post-operative photographs were taken only few weeks after surgery. Slimming of the tip with better tip definition as well as bony pyramidal aesthetics will continue to improve by time. Frontal Smiling

Frontal Middle Third

41

Part VI: Clinical Case 3

241

Direct Dorsal

Direct Dorsal Smiling

Overhead

Preoperative

Postoperative

Backward Tilting

Preoperative

Postoperative

Steeper Backward Tilting

Basal

Basal Smiling

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Part VI: Clinical Case 3

Right Nasal Aperture

Right Nasal Aperture Rim Sill Test

Left Nasal Aperture Rim Sill Test

Left Nasal Aperture

Right Oblique Mid Cheek Full Face

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

Preoperative

Postoperative

Preoperative

Postoperative

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Part VI: Clinical Case 3

243

Right Oblique Cheek Margin Full Face

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

Right Lateral

Left Lateral

Right Lateral Smiling

Left Lateral Smiling

Preoperative

Postoperative

Preoperative

Postoperative

244

41

Right Lateral Middle Third

Preoperative

Postoperative

Left Lateral Middle Third

Part VI: Clinical Case 3

Part VI: Clinical Case 4

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Preoperative Assessment

Surgical Procedure

1. Frontolateral walls a. Small but bulky tip overshadowing the alae nasi (Frontal, Direct Dorsal, and Overhead Views). b. Left dome higher than right dome (Backward Tilting Views). 2. Nasal Septum Nil of note. 3. Bony pyramid a. Wide base of the bony pyramid. The side walls of the bony pyramid were widely expanded by the effect of the chronic internal disease, i.e. nasal polyposis (Frontal, Direct Dorsal and Backward Tilting Views). b. The mid vault is depressed, especially in the supratip area (Backward Tilting, Oblique and lateral Views). 4. Alar base Unequal alae nasi (Frontal View).

a. As per Surgical Plan. b. After defatting of the frontolateral walls, the alar base was found to be relatively wide. Resection of the transverse segments of the rim sill folds was necessary. c. Osteotomies and defatting of the crurae were insufficient to elevate the supratip depression. A supratip graft using the lateral crural trimmings.

Aims of Surgery 1. Reduce the bulk of the nasal tip. 2. Reduce the width of the bony pyramid and mid vault. 3. Fill the depression in the supratip area. Surgical Plan 1. Frontolateral walls a. D.D.D. not including weak triangle to reduce the bulk of nasal tip. b. Cephalic trim of lateral crurae with less trimming of right side. 2. Nasal Septum Nil of note. 3. Bony pyramid Osteotomies with medial displacement of the lateral bony walls to reduce the width of the bony pyramid. 4. Alar base Nil of note.

Post-Operative Analysis 1. Frontolateral Walls a. Tip definition improved i.e. the tip is slimmer and prominently well identified. The alae nasi come into view to share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). Note the clear light reflex off the nasal tip as one spot (Backward Tilting Views). b. Tip projection: The nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as one spot (Frontal and Backward Tilting Views). 2. Medial Walls Nil of Note. 3. Bony Pyramid a. Bony pyramid aesthetics: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. The light reflex is seen as a regular one line off the nasal dorsum (Direct Dorsal Views). c. Post-operative photos were taken one month after surgery. Further slimming of the nasal tip and bony side walls take place after few more months or years. d. Dorsal light reflex is a straight line post-operatively as compared to the interrupted reflex pre-operatively (Direct Dorsal Views).

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_42

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4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral and Direct Dorsal grooves). b. Posterior alar groove aesthetics improved by Defatting. After defatting of the lateral crurae, the alae nasi are pulled medially and the angles of the posterior alar grooves become wider. (Backward Tilting and Nasal Aperture Views). c. Alae nasi aesthetics improved. They are pulled medially become better seen, smaller and share in nasal aesthetics. (Nasal Aperture, Oblique and Lateral Views). d. Nasal aperture aesthetics improved after defatting and excision of the rim-sill folds: i. The size of the nasal openings are smaller (Backward Tilting, Basal and Nasal Aperture views). ii. The shape of nasal openings transformed from thick walled wide and rounded openings with

Frontal

Postoperative

Part VI: Clinical Case 4

transverse long axes to thin walled small oval openings with anterior long axes (Backward Tilting, Basal and Nasal Aperture views). e. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views). ii. Nasal sill bands (Oblique Views). iii. Lateral crural prominences (Lateral Views). Commentary a. Osteotomies have narrowed the base of the bony pyramid as well as the attached lateral walls of the mid vault. Note that postoperative photographs are only 3 months after surgery. Swelling around the bony pyramid will be less on the long term. b. The size of the nasal tip was reduced only by defatting process, no grafts were used. Tip definition improved anteriorly and inferiorly. Frontal Smiling

Frontal Middle Third

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Part VI: Clinical Case 4

Direct Dorsal

247

Direct Dorsal Smiling

Overhead

Overhead Smiling

Preoperative

Postoperative

Backward Tilting

Preoperative

Postoperative

Steeper Backward Tilting

Basal

Basal Smiling

248

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Right Nasal Aperture

Part VI: Clinical Case 4

Left Nasal Aperture

Preoperative

Postoperative

Right Oblique Mid Cheek Full Face

Preoperative

Postoperative

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

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Part VI: Clinical Case 4

249

Right Oblique Cheek Margin Full Face

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

Right Lateral

Left Lateral

Right Lateral Smiling

Left Lateral Smiling

Preoperative

Postoperative

Preoperative

Postoperative

250

42

Right Lateral Middle Third

Preoperative

Postoperative

Left Lateral Middle Third

Part VI: Clinical Case 4

Part VI: Clinical Case 5

Preoperative Assessment 1. Frontolateral walls a. Bulbous tip i.e. large and bulky overshadowing the alae nasi (Frontal Views). b. Bifid tip (Frontal Views). 2. Medial Wall Sliding tip: the nasal tip is at a lower level i.e. posterior to the anterior septal angle, which is the end point of the nasal dorsum. This is due to a loose membranous septum associated with an overactive depressor septi muscles. On smiling the nasal tip moves further posteriorly as well as inferiorly. This is to be differentiated from a mobile tip that moves only strictly inferiorly on smiling (Lateral Smiling and Non-smiling Views). 3. Bony pyramid Wide base of the bony pyramid. There was no osteo-cartilaginous hump. The nasal bones are naturally concavoconvex from above downloads. 4. Alar base Nil of note. Aims of Surgery 1. Overall reduction in the size of the nose. 2. Elevation and fixation of the sliding tip. Surgical Plan 1. Frontolateral walls a. DDD not including the weak triangle to reduce the bulk of the nasal tip. b. Cephalic trim of the lateral crurae to reduce the size of the nasal tip. 2. Media Wall a. Excision of the membranous septum and 2 mm trim of the caudal cartilagenous septum. The later is to be

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stitched to the medial crurae by two transfixing stitches. b. Transnasal division of the depressor septi muscles. 3. Bony pyramid a. Rasping of the natural convexities of the nasal bones. b. Osteotomies and medialization of the lateral bony walls. 4. Alar base Nil of note. Surgical Procedure As per surgical plan. Post-Operative Analysis 1. Antrolateral Walls a. Tip definition: nasal tip is slimmer, more prominent and well identified from the alae nasi on both sides. The alae nasi become clearly visible and share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). b. Tip projection: The nasal tip is at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as one spot (Frontal and Backward Tilting Views). 2. Medial Wall Sliding tip is abolished. 3. Bony pyramid Bony pyramid aesthetics: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views).

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_43

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4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral, and Direct Dorsal grooves). b. Alae nasi aesthetics improved. They are pulled medially become better seen, smaller and share in nasal aesthetics.

Commentary This gentleman’s only request was to elevate and fix the drooping nasal tip. It is the surgeons role to advice him to reduce the bulk and size of the nasal tip and bony pyramid for better aesthetic result (frontal and oblique views). Better aesthetic result is achieved; the nasal tip is elevated as well as looking more elegantly slim.

Frontal

Right Oblique Cheek Margin Full Face

Part VI: Clinical Case 5

Left Oblique Cheek Margin Full Face

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Part VI: Clinical Case 5

Right Lateral

Preoperative

253

Left Lateral

Right Lateral Smiling

Left Lateral Smiling

Part VI: Clinical Case 6

44

Preoperative Assessment

Surgical Plan

1. Frontolateral walls a. Bulbous tip: large thick skinned nasal tip overshadowing the alae nasi (Frontal Backward Tilting and Basal Views). b. Right supratip depression that deviates her nasal tip to the same side and become exaggerated on smiling (Frontal nonsmiling and smiling views). She had a parent to asymmetrical smile. 2. Media Wall Nil of note. 3. Bony pyramid a. This lady has “Waadenburg syndrome”. She wears hearing aids for her deafness and has a white forlock for which she used a black dye to hide. As well as the deafness and the white forelock, she has a wide distance between her two eyes. b. Wide base of the bony pyramid coupled with wide distance between the inner canthi (Frontal and Backward Tilting Views). 4. Alar base a. Wide alar base. The posterior segments of the rim-sill folds are thick and heavy looking. They have wide angles with the upper lip. b. The nasal openings are unpleasantly round and wide (Basal View).

1. Frontolateral walls a. DDD excluding the weak triangle to reduce the bank and the size of the nasal tip. Defatting the week triangle will lead to more supra-tip depression. b. Cephalic trim of the lateral crurae to reduce the size of the nasal tip. 2. Media Wall Nil of note. 3. Bony pyramid Osteotomies and medialization of the lateral bony walls to reduce the width of the bony pyramid. 4. Alar base Excision of the posterior and inferior segments of the rim sill folds to reduce the size and bulk of nasal apertures.

Aims of Surgery 1. Reduction of the bulk of the nasal tip. 2. Reduction of the width of the boney pyramid. 3. Reduction of the width and bulk of the alar base.

Surgical Procedure As per Surgical Plan. Post-operative Analysis 1. Frontolateral Walls a. Tip definition: nasal tip is slimmer, more prominent, thinner overlying skin and well identified from the alae nasi on both sides. The alae nasi become clearly visible and share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). b. Tip projection: The nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). c. Tip light reflex is seen as one spot (Frontal and Backward Tilting Views).

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_44

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2. Medial Wall Nil of Note. 3. Bony Pyramid a. The side walls of the boney pyramid preoperatively were very close to the inner canthi. Aesthetically, the C- shaped line that is drawn from the lower margin of the eyebrow, the bony side wall reaching to the outer curve of the alae nasi should have all these structures medial to it, so that the line runs smoothly on their surfaces. Note, that preoperatively the base of the bony pyramid is bulging lateral to this line on both sides. Postoperatively, the base of the bony pyramid is just touching the line. b. Bony pyramid aesthetics: the nasal dorsum is straight and the sidewalls are smooth and narrow (all views except the Basal Views). 4. Alar Base a. Superior alar groove aesthetics improved by defatting. The grooves become longer and deeper (Oblique, Lateral, and Direct Dorsal grooves). b. Posterior alar groove aesthetics: i. The wide angle of the posterior alar groove was an absolute contraindication for alar base surgery. Placing the incision in the exact locations of the posterior and inferior segments of the rim sill folds has overcome this problem. Healing in these locations leaves barely visible scars. In fact it is quite the opposite, the posterior scar created a posterior alar groove that was not present preoperatively. ii. Excision of the posterior segment of the rim sill folds have deepen the wide angles of the posterior groove, i.e. between the alae nasi and the upper lip (Basal and Nasal Aperture Views).

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Part VI: Clinical Case 6

c. Alae nasi aesthetics improved. The alae nasi are pulled medially become better seen, smaller and share in nasal aesthetics (Nasal Aperture, Oblique and Lateral Views). d. Nasal aperture aesthetics: i. The size of the nasal openings are reduced by defatting as well as excising the inferior segments of the rim-sill folds (Backward Tilting, Basal and Nasal Aperture views). ii. The shape of nasal openings improved by defatting and excision of the rim-sill folds transforming the nasal apertures from thick walled wide and rounded openings with transverse long axes to thin walled small oval openings with anterior long axes (Backward Tilting, Basal and Nasal Aperture views). e. Marginal light reflexes are clearly seen at: i. The light reflex is observed off the inferior alar margins (Basal and Nasal Aperture Views). ii. The lateral columellar light reflex (lateral views). Commentary a. The narrower boney pyramid and smaller nasal tip have given the impression of a longer nose and face which in turn makes the inner canthi visually look closer to each other. b. Nasal aperture aesthetics improved from wide rounded thick walled openings to oval small thin walled openings. c. Smile became symmetrical post-operatively. Defatting of the middle and lateral crurae and sparing the fat in the supratip area was sufficient to overcome the right supratip depression. No graft was needed.

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Part VI: Clinical Case 6

257

Frontal

Frontal Smiling

Postoperative

Backward Tilting

Preoperative

Postoperative

Steeper Backward Tilting

Basal

258

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Right Nasal Aperture

Right Nasal Aperture Rim Sill Test

Left Nasal Aperture Rim Sill Test

Preoperative

Postoperative POSTERIOR SEGMENT SCAR

INFER SEGME SCAR

Right Oblique Mid Cheek Full Face

Preoperative

Postoperative

Left Oblique Mid Cheek Full Face

Part VI: Clinical Case 6

Left Nasal Aperture

44

Part VI: Clinical Case 6

259

Right Oblique Cheek Margin Full Face

Left Oblique Cheek Margin Full Face

Right Lateral

Left Lateral

Right Oblique Cheek Margin Middle Third

Left Oblique Cheek Margin Middle Third

Preoperative

Postoperative

Preoperative

Postoperative

Right Lateral Middle Third

Left Lateral MIddle Third

Part VI: Clinical Case 7

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Preoperative Assessment

Aims of Surgery

1. Frontolateral walls a. Bulky and large nasal tip. The nasal tip was ill defined due to the flat middle crurae and excess fat cover of the superior alar grooves. 2. Medial Wall The columella is short and at a higher level than the alae nasi. 3. Bony pyramid a. Wide base of bony pyramid (Frontal, Direct Dorsal and Backward Tilting Views). b. The size and width of the bony pyramid was comparatively small to the size, width and bulk of the lower third of the nose (Frontal, Direct Dorsal and Backward Tilting Views). c. There was complete dissociation between the upper 2/3rds and the lower third of the nose. The lower third is almost the same length as the upper two thirds and three times its size and width (Frontal, Direct Dorsal and Backward Tilting Views). 4. Alar base a. Very wide nasal apertures (Backward Tilting, Basal and Nasal Aperture Views). b. Large bodies of the alae nasi. Their Inferior margins were at a much lower level than the columellar margin (Frontal non-smiling, Oblique and Lateral Views). The nose looked most unpleasant in the frontal nonsmiling view. Both alae nasi carved down on the sides making an arc that looked quite unpleasant. There was wide flare on smiling (Frontal not smiling and Frontal smiling views). c. The rim sill folds are very small in size. They were almost non-exitent.

1. Reduce the bulk and size of the frontolateral walls. 2. Elevate the nasal dorsum and educe the width of the bony pyramid. 3. Reduce the sizes of nasal apertures. 4. Reduce the size of alar bodies and elevate their inferior margins to match with the level of the columella. Surgical Plan 1. Anterolateral Walls DDD including the weak triangle to reduse the bulk of the tip and supra-tip area. 2. Medial Wall Nil of Note. 3. Bony pyramid Bilateral osteotomies and medialisation of the bony side walls to reduce the width of the bony pyramid and elevate the dorsum. 4. Alar base a. Excision of the rim still folds. b. Direct reduction of the size of alar bodies. Surgical Procedure 1. As per surgical plan. 2. Excision of the rim still folds did not achieve the goal of reducing the size of nasal apertures. The rim sill folds were quite small in size i.e. they hardly contributed to the bulk or length of the alar base. The nasal sill bands were partially trimmed laterally to reduce the width of nasal apertures i.e. the alar base. Stripes of vestibular floor skins, starting from the aperture margin just inside the

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2_45

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sill bands back to the muco-cutaneous junction, were excised in order to reduce the size of nasal aperture tubes i.e. the whole of the lower third of the nose. Excision should strictly include the loose skins of the vestibular floors and avoid adherent skin cover of the alae nasi. 3. The bodies of the alae nasi were addressed directly in order to reduce their size. Their inferior margins were trimmed gradually till they became at the same level of the columella.

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Part VI: Clinical Case 7

iii. The arc of the inferior margins of the alae nasi disappeared. Alar flare is greatly reduced on smiling (Smiling Frontal Views). d. Marginal light reflexes are clearly seen at: i. Inferior alar margins (Nasal Aperture Views). ii. The nasal sill and lateral crural prominences are too small to be seen (Oblique and Lateral Views). Commentary

Post-operative Analysis 1. Frontolateral Wall a. Tip definition: nasal tip is smaller with thinner and smoother overlying skin. It is more prominent and well identified from the alae nasi on both sides. The alae nasi are now of reasonable size and share in nasal aesthetics (Frontal, Direct Dorsal, Overhead, Backward Tilting and Basal Views). b. Tip projection: The nasal tip at the same level of the nasal dorsum with good aesthetic angle. This is coupled with good aesthetic nasolabial angle (lateral and oblique views). 2. Medial Wall Nil of Note. 3. Bony Pyramid a. Bony pyramid aesthetics: the nasal dorsum is higher, straight and the sidewalls are smooth and narrow (all views except the Basal Views). b. Dorsal light reflex is seen as an uninterrupted off the nasal dorsum (Direct Dorsal Views). 4. Alar Base a. Superior alar groove aesthetics: they became shorter and more elegant (Oblique and Lateral Views). b. Posterior alar groove aesthetics: they became shorter and more elegant (Oblique and Lateral Views). c. Nasal Aperture aesthetics: i. The size of nasal apertures are smaller (Backward Tilting, Basal and Nasal Aperture Views). ii. The shapes are more elegant with small thinner lateral alar walls (Backward Tilting, Basal Views and Nasal Aperture Views).

a. This patient maintained her exact features post-operatively as she wished. The nose print is the same. b. The smaller nose now matches the size of the eyes, lips and chin. c. There were four major problems in her nose: i. Bulky tip. ii. Wide base of bony pyramid. iii. Wide alar base: The rim sill folds were very small. The posterior margins of the alae nasi were attached to the Orbicularis Oris muscle along its full length. Normally the lower third of the posterior alar margins are separated from the Orbicularis Oris by the posterior segments of the rim sill folds and from the nasal sill bands by the inferior segments. The inferior segments were almost non-existent. This explains the low attachments of the alae nasi and their elevation on contraction of the Orbicularis Oris on smiling. iv. Large alar bodies: there was no choice for reducing the size of the fibrofatty walls of the alae nasi but direct surgical excision. Inferior marginal scars were unavoidable. Clinically they were hardly noticeable. d. The bony pyramid and mid vault of the nose regained their natural proportion to constitute the upper 2/3rds of the nose. The nasal tip and alae nasi regained their normal regular size as a lower third of the nose. The dissociation between them disappeared and the nose became one unit. e. The superior alar groove is shorter and more elegant (Oblique and Lateral Views). f. The posterior alar groove has wide angle with the upper lip due to absent of posterior segment of rim-sill fold.

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Part VI: Clinical Case 7

263

Frontal

Frontal Smiling

Preoperative

Postoperative

Direct Dorsal Smiling

Preoperative

Postoperative

Frontal Middle Third

264

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Backward Tilting

Steeper Backward Tilting

Basal

Basal Smiling

Right Nasal Aperture

Right Nasal Aperture Rim Sill Test

Left Nasal Aperture Rim Sill Test

Left Nasal Aperture

Right Oblique Mid Cheek Full Face

Left Oblique Mid Cheek Full Face

Right Oblique Mid Cheek Middle Third

Left Oblique Mid Cheek Middle Third

Preoperative

Postoperative

Preoperative

Postoperative

Preoperative

Postoperative

Part VI: Clinical Case 7

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Part VI: Clinical Case 7

265 Right Oblique Cheek Margin Full Face

Left Oblique Cheek Margin Full Face

Right Oblique Cheek Margin Middle Third

Preoperative

Postoperative

Right Lateral

Preoperative

Postoperative

Left Lateral

Left Oblique Cheek Margin Middle Third

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Right Lateral Middle Third

Preoperative

Postoperative

Left Lateral Middle Third

Part VI: Clinical Case 7

Atlas Glossary

The concept of an Atlas is ideal for the surgery of Rhinoplasty. In this Atlas more than 4600 photographs of a wide range of clinical conditions that present for Rhinoplasty are displayed. These varieties of noses include; the large, bulky, deviated, oblique, crooked, fractured, finesse, secondary, ethnic, pediatric and special clinical conditions. In each case the nose and face are looked at from multiple different angles through the standard and the newly introduced specialized photographic views. In the specialized views, each of the four anatomical subdivisions of the nose is clearly illustrated. Twenty nine (29) photographs are taken to the nose and face pre-operatively and the same post-operatively.

A clear guide is written for assessment of the pre-operative photographs followed by the analysis of the post-operative photographs. Successes, difficulties as well as pitfalls are discussed and illustrated photographically. The art of displaying the pre-operative and post-operative photographs is simple and easy for the eyes to immediately see and compare the results. The aim that all photographs are seen at a glance. The texts are equally organized in a simple, scientific and stereotyped pattern so that they are read at a glance. The principle theme of the Atlas is: SAG—Seen at A Glance RAG—Read at A Glance

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 M. H. A. Shafy, Atlas of Clinical Cases in Rhinoplasty, https://doi.org/10.1007/978-3-031-12271-2

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