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العربية العربية

Rhinoplasty Bizrah: BONY WALL MOBILIZATION

March 27, 2017 by basharbizrah0

OSTEOTOMIES
Aims

  1. Mobilization and repositioning of the lateral nasal bones to achieve the desired satisfactory position.
  2. Prevention of open roof deformity.

Types

  1. Medial Osteotomies.
  2. Lateral Osteotomies.

Additional Osteotomies: This may be needed in crooked noses:

  1. Intermediate osteotomies.
  2. Transverse osteotomy.

Techniques: We use the following techniques:

  1. Medial Osteotomies
    1. The instrument used is Masing’s single guarded osteotome:
      Right curved, left curved and straight. (Fig. 17 – 4)
    2. Usually performed after hump removal or even without hump removal if needed to narrow the bony pyramid. (Fig. 17 – 18)
    3. Start with left single guarded Masing’s osteotome on the left side, push the osteotome between the upper lateral cartilage and nasal septum until it reaches the osteocartilagenous junction, try to be as close to the midline as you can. Start tapping and while the osteotome is moving cephalically guard it with your index finger and direct it towards the medial canthus curving laterally. This leaves a more natural root to the nose and avoids cribriform plate injury. Then repeat the same on the right side. (Figs. 7 – 1,2)
  2. Lateral Osteotomies
    1. Cottle’s two mm osteotome is used.
    2. The osteotomy is carried out via an external stab incision (Bull’s technique).
    3. Push the osteotome into the small stab incision and create a subperiosteal tunnel. The tunnel should be as close to the face as possible starting at the inferior border of the bony pyramid one millimeter above the face and moving up cephalically along the desirable path to meet the cephalic end of the medial osteotomy which has already been performed. (Figs. 7 – 1,2)
1. Medial Osteotomy
2. Lateral Osteotomy
Fig. 7 – 1. Outlining the sites for medial and lateral osteotomies.
Fig. 7 – 2
    1. Medial osteotomy: performed by right or left Masing’s single guarded osteotome.
  1. Lateral osteotomy performed, through a “nick” on the skin by Cottle’s two mm osteotome.

 

(A)
(B)
Fig. 7 – 3. (A) The main indication for transverse osteotomy is when deviation starts from the root of the nose.
Main indications of intermediate osteotomy are the spindle shaped, banana shaped and wide bulky lateral bony walls.
(B) Outstanding:

  1. Transverse osteotomy
  2. Medial osteotomy
  3. Intermediate osteotomy
  4. Lateral osteotomy

 

  1. The two mm osteotome should not penetrate the endosteum (periosteum of the medial wall of nasal bone). The surgeon knows this when the tone of tapping changes or from your experience. Stop at this endosteum otherwise the lateral nasal wall will collapse in and become depressed. (Fig. 7 – 4)
  2. It is essential that the lateral walls are completely mobile for accurate repositioning. The lateral nasal bones are put at the end of the procedure into a satisfactory desired position by careful manipulation with the thumb and index fingers. Bilateral incomplete mobilization leads to an open roof deformity and wide bony pyramid. Unilateral incomplete mobilization leads to the appearance of a crooked nose. (Fig. 17 – 18)
  1. Transverse Osteotomy
    1. One main indication is a crooked nose with deviation that starts from the root of the nose.
    2. Performed with two mm Cottle’s osteotome.
    3. The osteotome is pushed through the small tab incision at the nasion with the osteotomy then performed between the two cephalic ends of the medial osteotomies. (Fig. 7 – 3)
    4. This transverse osteotomy should be performed after medial and lateral osteotomies, if complete mobilization of the lateral wall was incomplete.
  2. Intermediate Osteotomy
    1. Main indications :
      • Crooked nose
      • Curved convex lateral nasal wall (Spindle shaped)
      • Banana shaped nasal wall
      • Wide nasal wall
    2. With the above mentioned indications if we only do medial and lateral osteotomies, we will only be moving the nose towards the midline and preserving the abnormal shape (banana, spindle). Therefore, intermediate osteotomy is essential to break the convex and concave surfaces of the nasal bones (break the banana or spindle shape), in order to achieve full mobilization and accurate repositioning of the nasal bones. (Fig. 7 – 3)
    3. Technique: It is performed in a similar manner to the lateral osteotomy but at a level between medial and lateral osteotomies, usually parallel to the lateral osteotomy or slightly curve obliquely inferiorly towards the face according to the desired path. (Fig. 17 – 18)
Fig. 7 – 4. A broad bony dorsum: Using a bone nippler, a gap is created in the midline at the junction of the nasal bones, then lateral osteotomies are considered to close the gap and narrow the dorsum.
A
Board bony dorsum
B
A gap is created in the midline
C
Narrowed dorsum The gap is closed by lateral osteotomies
Fig. 7 – 5. Correction of broad bony dorsum.

Dubai

Bizrah Medical Center
Al Sarraf Avenue 2nd Floor
Umm Al Sheif, Dubai
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M: +971 55 575 1770
M: +971 56 832 8505
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Email: info@bizrahmc.com

London

Visiting Surgeon at the
London Welbeck Hospital
27 Welbeck St, Marylebone
London, UK
Tel: +44 20 7224 2242
Email: info@bizrahmc.com

Jeddah

Residence in Saudi Arabia
can contact pioneer-cosmo in
Jeddah to book their surgery in
advance with Dr. Bashar in Dubai
Tel: +966-2-665 3780
Tel: +966-2-669 6446
Email: info@bizrahmc.com

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