Rhinoplasty

• Aesthetic: Large nose, nasal hump, wide nose, droopy nasal tip (Figure 1)
• Functional: Difficult breathing and deviated septum
• Congenital: Cleft lip and palate, congenital nasal abnormalities
• Traumatic nasal fracture
• Inflammatory conditions: connective tissue disorders, immune disorders
• Iatrogenic: recreational drug use, cocaine

Figure 1. Rhinoplasty candidates.

• Cartilages
• Lower lateral cartilages (Figure 2)
• Upper lateral cartilages
• Septal cartilage
• Nasal bones
• Nasal superficial muscular aponeurotic system (SMAS)
• Soft tissue envelope beneath skin and above bone and cartilage
• Continuous with SMAS layer of forehead
• Skin envelope

Figure 2. Caption.

• Rotation versus counter-rotation (Figure 3)
• Projection versus deprojection
• Dorsal versus caudal

Figure 3. Caption.

• Surgical
• Open: skin incision in columellar base of nose
• Closed: no exterior incision, interior incision hidden from external view
• Nonsurgical: fillers used to augment nose

• General
• Sedation
• Local with adrenaline used to reduce hemorrhage and dissect tissue planes

• Packing of nasal cavity with vasoconstrictor
• Septoplasty if required
• Full transfixation incision
• Partial transfixation incision
• Killian incision (Figure 4)
• Mid-columellar incision
• Bilateral marginal incisions
• Tip surgery including tip augmentation, elevation, support, projection, commonly cephalic trim of lower lateral cartilages
• Nasal dorsum: commonly reduction of hump
• Alteration of projection
• Deprojection (Figure 2)
• Increased projection with grafts
• Osteotomies to narrow nasal bones
• Transcutaneous versus endonasal osteotomies
• Lateral and medial osteotomies
• Shape of osteotomy, e.g., high to low
• Closure of skin and mucosa
• Alar reduction if required
• Packing of nose internally if required
• Splinting of nose with thermoplastic splint

Figure 4. Killian incision.

• Autologous
• Septal cartilage
• Auricular cartilage
• Costal cartilage
• Nonautologous
• Silicone
• Medpore
• Gortex

• Intraoperative complications
• Hemorrhage
• Collapse of boney pyramid
• Osteotomies
• Rocker deformity: This deformity results when the medial osteotomy creates a fracture higher in the thicker part of the nasal bones, resulting in loose nasal bones.
• Open roof deformity: After reduction of a nasal hump, the bones are insufficiently narrowed, resulting in a wide nasal dorsum.
• Step deformity: Uneven reduction in nasal bones resulting in visible boney ridge
• Trauma/tears: skin, mucoperichondrium, septum
• Early postoperative complications
• Hemorrhage
• Epistaxis
• Septal hematoma
• Swelling
• Infection
• Skin necrosis
• Cerebrospinal fluid rhinorrhea
• Numbness and pain
• Transient episodes of anxiety or depression
• Late postoperative complications
• Polly beak nasal deformity
• Septal perforation (3%-25%)
• Tip: Nasal bossae, droop, hanging columella
• Aesthetic misjudgments
• Scarring
• Revision rhinoplasty 5-15%
• Persistent psychological complications

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