Because many postoperative rhinoplasty problems are directly related to the techniques used, the following tips will help to minimize undesirable results.
Useful tips and pitfalls which will help to minimize postrhinoplasty problems:
- Preoperative judgement:
- List obvious deformities:
Hump, deviation, wide tip, short columella, depressions, etc.…
- Do not confuse between true and false hump, true and false pollybeak.
False hump: it is due to tip underprojection, therefore, when the tip is lifted up the dorsum becomes straight. (Fig. 8 – 36)
False pollybeak: it is due to hump overcorrection, therefore, when the bony dorsum is lifted up the nose becomes straight. (Fig. 13 – 21)
- Listen to what the patient likes and dislikes about his nose.
- List obvious deformities:
- Operative judgement:
Judiciously performed rhinoplasty on properly selected patient will minimize the postoperative complications:
Rhinoplasty is a multiple steps procedure, following each step think… re-think if next step is indicated. Remember, there is no standard rhinoplasty.
- Do not over-reduce the hump at the beginning of the procedure. Leave final refinement and adjustment of the dorsum profile until after tip plasty. Never trim the superior septal angle in a patient with a bony and cartilagenous hump, short columella and underprojected tip. Actually, in such patients the superior septal angle may need to be augmented during the procedure following hump reduction and tip plasty. (Figs. 6 – 4,15 an Fig. 8 – 2)
- Perform septal correction if needed.
- Use auto grafts:
Septal or conchal.
- When indicated perform:
- Intermediate osteotomy to break the banana shape (concave and convex) nasal bones.
- Transverse osteotomy to correct nasal root deviation.
- Fully mobilize the nasal bones to avoid open roof deformity and crooked like nose.
- Check the supratip region:
- High: trim dorsum septum and upper lateral cartilage.
- Low: consider supratip grafts.
- Consider pressure taping to prevent collection of fluids, which may result in later fibrosis and pollybeak.
- Dorsum refinement:
Make sure that there are no irregularities. Remove bone debris and avoid too much rasping. Use dorsum grafts or fascia if needed.
- In crooked noses:
- Do not remove the hump until after performing the osteotomy because the hump may be due to overlapping of the nasal bones and not due to extra bone. In many cases the deviated hump disappears after bone repositioning.
- Consider dorsum grafts as indicated:
Grafts will treat dorsum collapse and smooth the dorsum.
- Never do endonasal transcartilagenous cephalic trimming of the lateral crus without compensatory supportive tip measures. The rhinoplasty routine incisions and excisions divide the anatomical factors maintaining the tip support. Therefore, tip supportive means are required in order to avoid the unpleasant postrhinoplasty problems such as dropped tip, pollybeak, asymmetry, hanging columella and wide nares. The recommended tip plasty manoeuvres are: new dome creation or the Bizrah modification of Goldman’s tip, suture fixation, columellar strut, tip graft and septocolumellar sutures.
- Preserve at least eight mm of vertical lateral crus.
- Leave alar wedge resection as the last step of rhinoplasty.
- Use a septo-columellar suture to preserve tip projection and rotation. Make sure that the desired dorsum to tip profile has been achieved before suturing the incisions. Do not rely on sutures to achieve the desired profile. The effects of this suture will diminish in the early postoperative period, as will any tip support afforded by them.
- Listen to what the patient dislikes about his nose but don’t let the patient direct you. For example, the patient with a hump and an underprojected tip, might tell you to only do the hump and not to touch the tip. If you do so, the results will be low narrow dorsum with wide underprojected tip and possible pollybeak. Of course the patient will be unhappy and will forget what he instructed you before operation and even if he remembers he’ll tell you that you are the surgeon and not him. This will give a poor reflection of your skills.
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