– Dorsum undermining.
– Division of upper lateral cartilages from septum.
– Caudal trimming of upper lateral cartilages.
– Conservative trimming of the caudal septum.
- Dorsum undermining:
Following the intercartilagenous incision:
- Use a sharp scissors to identify the right plane of the caudal upper lateral cartilages.
- Next, use blunt scissors to proceed with skin elevation. Stay close to the cartilage and then adjacent to the nasal bones up to the glabella. (Fig. 5-5)
- Now, Aufricht’s retractor is used to visualize the dorsum.
- Do not undermine too much laterally, elevate only the dorsum in a way that you identify the hump borders, depressions of the deformity to be corrected. Too much lateral dissection may cause bone collapse following lateral or intermediate osteotomy.
- Avoid injury to the SMAS layer and subcutaneous tissue. So stay close to the cartilage and bone. Injury to the SMAS causes intraoperative bleeding, postoperative oedema, later fibrosis, scarring and possible pollybeak formation.
- Do not go beyond the glabella as it will lead to postoperative forehead oedema.
- Division of the upper lateral cartilages
- Subperichondrial bilateral tunnels are made at the junction of the septum to the upper lateral cartilages. (Fig. 5-6)
- A blade No. 11 is pushed through the tunnel and in an upward motion, the septum is divided from the upper lateral cartilage. The Aufricht’s retractor provides exposure and helps to protect the nasal akin.
- It is of most importance that the upper lateral cartilages are divided as closely as possible to the nasal septum in order to avoid the formation of the T-shaped structure. When the T-shaped structure is wrongly formed, it may later cause pollybeak. But if the T-shaped structure is trimmed to lower the dorsum septum, it may lead to supratip collapse. That is because the medial border of the upper lateral cartilages are involved with the trimmed T-shaped structure and will not adequately overlap the dorsum septum, leading to depression of the supratip region.
Fig 5 – 5. Dorsum undermining: Stay close to the cartilage and bone. Do not undermine too much laterally in order to avoid bone collapse following lateral osteotomies and to reduce the postoperative oedma.
Fig 5 – 6. Division of upper lateral cartilages: the upper lateral cartilages are divided as closely as possible to the septum in order to avoid the formation of the T-shaped structure with the later possibility of pollybeak or supratip collapse.
Fig 5 – 7. Trimming of the upper lateral cartilages: If the caudal ends are projecting at the end of the procedure, a small triangle of not more than 1.5mm is excised with preservation of mucosa and vestibular skin. Aggressive excision leads to valve collapse.
Fig 5 – 8. Trimming of the caudal septum is considered in order to obtain an aesthetic nasolabial angle of 90o or slightly greater. When rotation is required the outer third is trimmed. In drooped tiip, long nose or caudal dislocation, the outer two thirds or the entire caudal septum is trimmed.
- Trimming the upper lateral cartilages
- This manoeuvre is necessary in a long nose, drooped tip and crooked nose with upper lateral cartilage asymmetry. However, it is not required in all rhinoplasties.
- At the end of the procedure, if the caudal ends are projecting too far caudally, a small triangle of not more than 1.5mm is excised, with preservation of the mucosa and vestibular skin. (Fig. 5-7)
- Aggressive excision leads to valve collapse and obstructed breathing due to scarring and pinching in this area. (Fig. 5-9)
- Fatty fibrous tissue on the upper lateral cartilages may be excised with the small cartilagenous caudal triangle when the central third of the nose is wide in order to enhance the narrowing effects. (Fig. 17-9)
- Trimming of the caudal septum
- Long nose
- Drooping tip
- Caudal dislocation
- To achieve tip rotation
- To obtain an aesthetic nasolabial angle of 90 degree or slightly greater.
- Trimming of the caudal septum is performed following the intercartilagenous and transfixion incisions, skin elevation and division of upper lateral cartilage from the septum. In the author’s experience, that part of the caudal septum which is projecting caudally beyond the caudal margin of the transfixion incision, on the resting position, should be trimmed. (Fig. 5-8, Fig. 9-12 and Fig 17-10)
- The caudal septum is divided into thirds. If only rotation is required, the outer third is excised. In drooped tip and columellar the outer two thirds are
Fig. 5-9. Trimming of the curved end of the upper lateral cartilage. (Fig. 17-9)
- trimmed. In more advanced cases of long nose, overprojected tip and overdeveloped caudal septum the entire caudal septum is trimmed and may be, as required, the nasal spine is partially reduced. (Fig. 17-19)
- Following trimming of the caudal septum. It is of most importance to consider supportive means to compensate for the loss of the tip support caused by our incision and excisions which divide the natural anatomical ligaments and attachments of the tip to the caudal septum, superior septal angle and upper lateral cartilages. Disregarding these supportive means will end with dropped tip, retracted or hanging columella, pollybeak and wide nares.