Fig. 17 – 22. (95) Dorsum conchal graft. The edges are trimmed and bevelled. (96,97,98) Examples of Silicon implant. (99,100,101,102) Suitably designed x-ray sheets are applied on the sides of the nose and fixed with steri-strips in order to stabilize and secure the dorsum graft to avoid mobilization.
Fig. 17 – 25. (116,117,118,119,120,121,122,123) Alar wedge excision: Modified Weir excision should be the last step of the septorhinoplasty precedure and it should be made in natural creases. Vestibular skin should be preserved to avoid notching. Indications are: to reduce flare of the rim, reduce wide nostril floor and reduce both flaring and wide floor.
Fig. 17 – 26. (124,125) Closure of the alar wedge excision is obtained by 4/0 Dexon or 4/0 Vicryl.(126,127,128,129) At the end of the rhinoplasty procedure steri-strips and plaster of paris are applied on the nose. Properly applied nasal dressing plays a more important role in good rhinoplasty results than many surgeons realise. Steri-strips obliterates dead space and may help to prevent hematoma, oedema and later pollybeak formation. It also secures tip projection and rotation. The splint is moulded over the nose and secured in position with another layer of wider steri-strips. The nasal splint may help to stabilize and fix the nasal bones and reduce postoperative oedema.
The Bizrah Modification of Vertical Dome Division
Fig. 17 – 28. (138,139,140,141,142,143,144,145) Special modified technique for theunderprojected tip (Bizrah’s technique) The principles are: vertical dome division, medial crus delivery and I-beam without lateral crus delivery. (1) Marginal columellar incision from mid-columella and up to the level of the external soft triangle and junction of intermediate to lateral crura. There is no marginal incision along the caudal margin of the lateral crura. (2) Vertical dome division: the incision starts just lateral to the external soft triangle at a right angled backwards to just lateral to the internal soft triangle dividing the vestibular skin and cartilage. (3) The bilateral intermediate and medial crura are delivered to one side. (4) A pocket is created between the medial crura, then columellar strut is inserted and sutured to both medial crura. (5) Shield tip graft is positioned and sutured to the caudal margin of the intermediate and medial crus. Advantages: (1) Preservation of the entire alar rim of the alar sidewalls. Thus preventing alar retraction, notching, collapse dimpling and asymmetry. (2) Trimming of cephalic lateral crus is made more visible, more accurate and has better control. (3) Less postoperative oedema and crustation. (4) More natural looking alar sidewall. (5) Stretches the alar sidewalls and reduces the alar flare.
Fig. 17 – 29. (150,151,152,153) On the operating table, pre and immediate post operation photograph of patients with modification of Goldman’s tip technique ((Bizrah’s technique).
Note: Tip projection, definition and refinement with symmetry of the nares.