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Rhinoplasty Bizrah: BONY WALL MOBILIZATION :OSTEOTOMIES: Hints and complications:

March 27, 2017 by basharbizrah0

Hints and complications:

  1. Medial osteotomy, if performed aggressively and the medial osteotome is pushed too much towards the root of the nose, may result in:
    • Loss of sense of smell due to fracture of the cribriform plate.
    • Dislocation of the perpendicular plate of the ethmoid causing septal collapse and an intraoperative saddling, which will be followed by additional augmentation procedures.
    • Postoperative frontal oedema and ecchymosis.
  2. Lateral osteotomy
    • Periorbital oedema and ecchymosis.
    • Incomplete mobilization of the lateral wall causes an open roof deformity or the appearance of a crooked nose.
    • Excessive mobilization causes depression on the lateral nasal wall.
  3. To prevent step deformity. Keep lateral osteotomy close to the face.
  4. At the end of the osteotomy procedure and after nasal bone approximation, it is important to check the level of the septum and upper cartilage. The upper lower cartilage and septum may need to be lowered, because of the overlapping following osteotomies.
  5. If the nasal bony dorsum is wide and there is no hump, and even after medial, lateral and intermediate osteotomies are performed, there may still be difficulty in approximating the nasal bones due to thick bone at the dorsum. Therefore, it is important to create a gap at the midline of the bony dorsum by removing some of the dorsum bone by a bone nippler, in order to approximate the nasal bone and obtain a narrower bony dorsum. The gap is closed by the approximated nasal bone borders. (Fig. 7 – 5)
  6. Performing osteotomies needs a lot of concentration and judgement. Assess the situation very carefully, plan the osteotomy lines and decide if there is the need for intermediate or transverse osteotomies. There are no routine or standard rhinoplasty procedures, therefore osteotomies are not routinely indicated in every rhinoplasty we perform.
  7. Cast application: Plaster should be applied like a clip above the lateral osteotomies in order to avoid bone displacement. (Fig. 7 – 6)
Do not penetrate Endostrium
Fig. 7 – 6. The two mm osteotome should not penetrate the endostrium in order to avoid lateral bony wall collapse.
How to apply cast
Fig. 7 – 7. Plaster should be applied like a clip above the lateral osteotomies in order to avoid bone displacement. A large plaster will leave the nasal bones loose with inaccurate positioning.

 


(A)
Fig. 7 – 8. A post traumatic tip. A banana shaped nasal bones. The situation was dealt with medial, lateral and intermediate osteotomies


(B)
Fig. 7 – 9. A patient has spindle shape nasal bones. Medial, lateral and intermediate osteotomies were performed in order to achieve accurate repositioning of the middle nasal bones.

 

Refrences
Bony Wall Mobilization: Osteotomies
 

1. Ford, C.N., Battaglia, D.G., and Gentry, L.R. Reservation of periosteal attachment in lateral osteotomy. Ann. Plast. Surg. 13:107, 1984.
2. Guyuron, B. Precision rhinoplasty. Part II. Prediction. Plast. Reconstr. Surg. 81:500, 1988.
3. Joseph, J. Nasenplastik und sonstige gesichtsplastik nebst einem Anbang ueber Mammaplastik. Leipzig: Kabitsch, 1931.
4. Murakami C., Larrabee W.F. Jr.: Comparison of osteotomy techniques in the treatment of nasal fractures. Facial Plastic Surgery 8:209, 1992.
5. Parkes M.L., Kamer F., Morga W.R., et al: Double lateral osteotomy in rhinoplasty. Arch. Otolaryngol 103:348, 1977
6. Parkes M.L., Kanodiar: Avulsion of the upper lateral cartilage: Etiology, diagnosis, surgical anatomy, and management. Laryngoscope 91:758-764, 1981.
7. Stucker F.J., Smith T.E.: The nasal bony dorsum and cartilaginous vault. Arch. Otolaryngol. 102:695-698, 1976.
8. Wright W.K.: Surgery of the bony and cartilaginous dorsum. Otolaryngol. Clin. North Am. 8:575-598, 1975.

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