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Rhinoplasty (Part 7) Palpation. Review extranasal

SPREADER Grafts - Rhinoplasty CLOSED

Before the end of surgery is appropriate for the last maneuvers.

Septum

Controlled,

• if it was manipulated to obtain graft and remains "in situ" an "L" of the septum, which is structure that keeps the nasal framework.

• If your edge excessively protruding above the upper lip and columella angle - formed is very sharp lip is resected a few millimeters of the edge to restore the columella-labial angle and sharp corner should be removed and again obtuse blunt.
  
• If the columella-labial angle is very obtuse, open, due to a deep interior nasal spine is necessary to dry the spine to normalize the angle.
  

• Finally, before transfixing suture, the strut is placed in the tip-columella junction and / or membranous septum cartilaginous pillar ( subseptum)
  
  

  

• and spead grafts on each side, to reconstruct the internal nasal valve, placed in the space between the upper edge of septum and the space was withdrawn triangular strip of cartilage, either placed along the top edge to outline the back septal cartilage.
  
  

  

  
  
  

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Septum
GETTING TO CARTILAGE GRAFT IN TIP AND SUBSEPTUM. STRUT. Grafts


To permanent rotation and projection of the nasal tip ( nose tip) and get a lip columella nasolabial angle and aesthetically pleasing as requested by the patients,

addition cartilage resections cited in previous pages, proceed to place cartilage graft obtained from the cephalic resection of alar cartilages, this resection , which refines and nasal tip well or is inadequate cartilage resection for graft, is removed from the nasal septum to place a bowl (strut) in nasal tip cartilaginous pillar or in subseptum we favor this because if the patient has thin skin strut nasal tip is visible under the skin and cause for complaint of patients.
Both maneuvers are technically simple and can be applied to the same patient:

• Del cephalic border of alar resection is used to put in subseptum a pillar cartilage that is an extension of the anterior border septum and serves to maintain projected, rotated and sign nasal tip (nose tip). points are secured with front edge of the septum and subseptum.

Getting septal cartilage for grafting

• the septum is generally obtained good material for the nasal tip strut or pillar in subseptum.

The strut or bowl to tip is placed through a pocket made against the domus in the corner or tip-columella junction and with an inclination of 35 degrees and secured by wires to the skin that are removed a week.

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EXTERNAL FRACTURE BASE OF THE NASAL PYRAMID

external fracture of the base of the nasal pyramid starts with a sharp osteotome tip 3 mm wide, the maneuver is performed with a mini-incision with scalpel blade # 11 or directly with the edge of the osteotome previous identification with the index finger of the piriformis fossa. Here, we introduce the osteotome (chisel ) And parallel to the bone which is the ascending apophysis maxilla is "desperiostiza" upstream to the junction with the nasal bone.

osteotome is placed with its handle with his right hand sustained almost settled on the top right malar and perpendicular to the outer wall of the pyriform fossa, the left thumb or index finger, if the surgeon is skilled controls and follows the movements of the tip of the instrumental and maneuver starts to fracture the bone in the previously marked line. The surgery assistant in charge of giving soft hammer blows with rhinoplasty.

Osteotome external fracture of 3 mm. ( Surgery Dr Esteche )

The tip of the osteotome is moving upwards to create a fracture line that reaches the vicinity of the junction of the nasal bone and frontal bone, when necessary, if the naso-frontal angle is very obtuse also fractured the bone in the nasal root. We proceed similarly on the other side.

Once the fracture has been done on the contralateral side, both hands are necessary to reduce the fracture and thus bring the two fragments to the midline and see how thins the back bone.

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BACK BONE. GIBA OSEA. OSTEOTOMIA DE HUESO NASAL

Continuando con la técnica,  se llega al dorso óseo cuya  giba prominente o no, debe ser resecada o raspada para continuar la línea recta o ligeramente cóncava hacia arriba que representa el dorso cartilaginoso que ha sido remodelado(se resecaron los triangulares y  el dorso cartilaginoso septal, una fina lámina).

Se coloca a través de cartilaginous incision osteotome back a bone to "cut" the bony roof of the pyramid represented by the nasal bones. This instrument is well established and placed horizontally on the back and start the procedure with its edge directed caudal third of the nasal bones with the help of gentle hammering rhinoplasty are advancing in the cephalad hump on the bone to reach the root of the nose where it ends the maneuver and leaving an open pit (open roof) means that the back bone and cartilage were removed from the top.

Once the back bone resection, with a nose scratch, scratch, wear to make them soft to the touch the cutting edges of the nasal bones that remain after the osteotomy of the "bony roof ."

This scraping should be careful because it will become final after the osteotomy of the nasal base, mobilized bones are quite unstable and it becomes very difficult to wear the nose rasp.

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Back osteo-cartilaginous. Cartilage triangular, lateral or higher. Nasal bone


Through the incision intercartilaginous divulsion accessed for the entire back of the osteo-cartilaginous nasal pyramid and dry the cartilaginous hump.

With Aufricht separator lifting the skin that covers the entire back and displayed on the upper face of the triangular cartilage (side or top) and inferior nasal mucosa covered by , and its attachment to the septum where it forms the internal nasal valve .

At this point you can perform maneuvers that are bilateral and deberánn be very cautious and economic:

• scissors is placed, low and parallel to support its branches to the septum and cut the triangular junction of the septum cephalad including the mucosa covering the triangular resection releasing such a union and an isosceles triangle of remaining cartilage that rides on the back to prevent the formation of a supratrip at a later period to rhinoplasty.

If the top edge of the septum protrudes a lot, until it comes to dry straight. Subsequently, and after osteotomy of the nasal bones resections are performed corresponding to the edge is straight.

practice in cases of a large hump resection of cartilage and is an open triangular roof (back or open) will proceed to reconstruct the internal nasal valve placing spreader grafts in the back to be discussed later.

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INCISION intracartilaginous - TRANSACARTILAGINOSA
alar cartilage
NASAL TIP

This incision is made inside the nasal ala, nasal mucosa begins at 3 mm above the caudal edge of the side continuing to cross medially to the knee wing dome of the alar-domus-genu where it ends. With hooks or forceps Adson split both lips of the incision and separating the nasal mucosa received treatment on the underside of the cross wing side up genu (knee wing )

INCISION intracartilaginous ALAR - TRANSCARTILAGINOSA

Before incision alar cartilage cephalic border is divulsion the upper surface of the wing away from the skin to its full extent and reach the space to release interdomal domes fibroareolar tissue that binds and thus be able to approximate the domes wing and refine the tip to dry the cephalic border wing.

incision with scalpel blade No 15 Wing cephalic border begins in the lateral third and continues until its proximal third in the area of \u200b\u200bthe alar dome cartilage inclusive.Una after subsection taken with forceps and the incision is complete excision with scissors.

was taken, if indicated, resection of the subcutaneous tissue of the entire area and with more emphasis on the tip area to refine and make the edge more conspicuous, not bulbous, as requested by patients, but is a maneuver that should be done with extreme caution as is very prone to skin necrosis of blood flow deprivation.

always leaves a layer alar cartilage in situ of 3-4 mm and is used and under the nasal ala and prevents its collapse or pinching. Nor is handled in the lateral alar cartilages where the accessories and sesamoid.

excised cartilage is kept in saline solution and serve as a graft, when indicated, in the nasal tip, medial cross, back, in the grips where needed to maintain permeable cartilage or an internal nasal valve blockage .

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Incision Continued intercartilaginous . Septi Nasi Muscle depressor

The incision intercartilaginous remains in front of subseptum -caudal edge of the septum ( transfixing incision - Transfixion incision) to the anterior nasal spine and so the septum is released in full-flow edge.

The depressor Septi Nasi Muscle is bilaterally behind the columella between the feet and lower third of medial cross and heads up pits two dog. In the mobile prongs because septal angle slightly adherent domus, septal angle has lost its function of supporting the tip , the muscle may be hyperactive and overgrown and the tip drops when smiles or laughs, sometimes there is a wrinkle or transverse groove at the base of the columella or nasal tip also moves synchronously with the lips when speaking.

with delicate scissors, blunt, they received treatment in the right columellar base and going well under the skin it past the left clings to the muscle with the tip of the scissors and emerge with the muscle back into the right columellar base and proceed to resection knife.

Immediately, is seen as the nasal tip releases, projects and broken up.

The resection depressor Septi Nasi also performed via intraoral by to release their inserts dog pits.
resection the depressor septi causes increased height of the lips, no vermilion.

If septal cartilage invade the lip is necessary to remove the caudal border of septum for rotating and projecting upward nasal tip with other maneuvers to be discussed later.

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closed rhinoplasty. Incision intercartilaginous . Access to the nasal dorsum
Closed rhinoplasty

intercartilaginous incision is made

An incision 2 mm below the internal nasal valve , not cross the boundary between lateral and triangular continues medially by the edge of the wing head and continues down along the anterior border of septum - the subseptum ( membranous septum) - up to the anterior nasal spine (NAS)

The incisón intercartilaginous takes place every hand, bilateral and through it you can access using blunt scissors to delicate nasal divulsion back above the top of septum, below the triangular cartilage and above the nasal bone in a plane supraperiostal to nasal root.
divulsion continues in the same plane and bilaterally undocked the lateral nasal wall, the alveolar maxilla upward nasal root to link these apophyses with the nasal bones, lateral wall preparing osteotomy for later .

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Surgical technique.

Speed \u200b\u200b preoperatively. Preoperative markings

endorrinoplastia is called rhinoplasty or closed because no any external incision in the nose , as opposed to or exorrinoplastia Rethi incision in columella as a gateway to the nasal structures underlying skin.

This rhinoplasty is to mimic the nose leptorhines (thin, fine-tuned tip rotated and projected upward, nostrils with holes almost vertical and slightly oblique to the outside) generally well developed alar cartilage and osteo-cartlaginoso back with a slight concavity from the nasal root to nasal tip.

points and lines are marked anatomical reference for identifying cartilaginous structures and bone to be modified to be increased or decreased.

The most salient point of the domus marks the columella-tip angle will be rotated and projected at the end of surgery.

are marked: cephalic border to be excised from the lateral cross of alar cartilage, excessive osteo-cartilaginous dorsum to be removed and the osteotomy line base of the nasal pyramid.

And the tip is depressed downward by checking whether the tip has good support, if not return quickly to release the tip to its original position means you need support (graft) cartilage.

are observed nostrils in general and see if the outer parts beyond the imaginary line that runs to the inner edge, if so, you will need, probably alar resection , which is decided at the end of the rhinoplasty .