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- Surgical Technique :
- Bilateral intercartilagenous incision.
- Hemitransfixion incision.
- Perform septoplasty:
- Leave adequate caudal margin. (Fig. 9 – 3)
- Leave adequate dorsal margin.
- Correct caudal dislocation.
- Try to preserve cartilage as much as you can.
- Remove crooked and angled pieces of cartilage and bone.
- Correct maxillary crest.
- Dissection of the skin from dorsum. Just deep to the SMAS layer, close to the perichondrium and beneath the periosteum.
- Division of the upper lateral cartilage from the dorsum septum. (Fig. 9 – 4)
- Trimming of the curved caudal end of the upper lateral cartilage to achieve normal anatomical shape. (Fig. 17 – 9)
- Correction of caudal dislocation: (Figs. 8 – 36,39,47,60 and Figs. 9 – 1,20,21)
In some cases the caudal dislocation pushes the tip component to one side causing deviation of the lower two thirds of the nose. In such cases correction of the caudal septum with consideration of tip support by columellar strut may be adequate to correct the deformity. The deviated caudal septum is conservatively trimmed with 11-blade. Excessive trimming may cause columella retraction and dropped tip. (Fig. 9 – 12, Fig. 16 – 4 and Fig. 17 – 9)
- Alar delivery: (Fig. 17 -12)
- Marginal incision.
- Delivery of the proximal lateral and medial crura and the dome.
- Removal of fat and scarred tissue from the cartilage.
- Excision of cephalic strip of lateral crus in order to leave at least eight mm of alar, make sure that both sides left behind are symmetrical and equal.
- New dome creation:
Achieving the highest possible domal position, in order to achieve symmetry, elevation and projection. (Fig. 17 – 13)
- Scoring the new dome:
Vertical scoring at the highest domal level.
- Suture fixation of the new dome:
PDS to suture the highest scored dome. (Fig. 17 – 14)
|Fig. 9 – 5. Tip plasty: achieving symmetrical tripod of conjoined lateral to medial crura supported by columellar and tip grafts. (New dome creation, scoring, suture fixation, columellar and tip grafts).|
|Fig. 9 – 6. 1. Medial osteotomy|
2. Lateral osteotomy
- Columellar graft insertion (Fig. 17 – 15)
- Columella support :
Suturing the bilateral medial crus of alar with the columellar graft in between using 4/0 Dexon. (Fig. 9 – 5)
Aim: Tip elevation _ Tip symmetry
Prevent columellar retraction
- Tip shield (Sheen) graft: Bevelled, triangular shaped graft is sutured to the new dome of alar cartilage with 4/0 Dexon. (Fig. 17 – 16)
Aim : To achieve tip elevation, definition, projection, symmetry and rotation.
- Putting the dome cartilages with the tip and columellar grafts back into the normal position.
- Lateral crura overlay technique:
Is very useful at this stage in order to obtain a symmetrical tip. If one lateral crura is larger than the other, do not overtrim. The use of the unilateral crura overlay technique on the larger side will achieve tip symmetry. (Fig. 17 – 17)
- Alignment of the dorsum:
- Cartilagenous and bony.
- Bony roof should be straight and regular. Upper lateral cartilage and septum should be lowered equally.
If hump is present, remove the cartilagenous first, then the bony part.
- Cartilagenous hump:
The upper lateral cartilage and nasal septum is lowered with Fomon scissors. (Figs. 6 – 4,5 and Figs. 17 – 10,11)
- Bony hump removed using T-shape osteotome (twelve cm), and the area is made smooth with a rasp, making sure that the bone and cartilage are on the same level.
- Osteotomies :
- Medial osteotomy
- Lateral osteotomy
- Intermediate osteotomy
- Transverse osteotomy