Innovations in Rhinoplasty: Anatomy, Photography and Surgical Techniques

Preface
	Innovative Approach to Nasal Anatomy
		Definitions and Terminology
			Definitions
			Terminology
			Examples of terminology
		Nasal Attachments to the Face
		The Four Walls of the Lower Third of the Nose
		The Thirteen Weak and Soft Areas in the Nasal Walls
	The Nasal Valves and The Physiology of Nasal Respiration
	The Seven Types of Nasal Skin and Surgical Significance
	The Surgical Significance of Nasal Base Attachments to the Orbicularis Oris
	Anatomical Variations of the Nose
	Rhinoplasty Photography
		Photographic Assessment and Standardization
	Surgical Techniques
		Closed Versus Open Rhinoplasty
		The Surgical Difficulties of Rhinoplasty
		The Importance of Psychology of the Patient and the Surgeon
	The Four Anatomical Areas of the Nose
	Rhinoplasty: Four Surgeries in One
	Clinical Varieties of Rhinoplasty
Acknowledgements
Introduction
Contents
Clinical Varieties of Rhinoplasty
1 A Guide to the Three-Dimensional Visualization and Examination of the Nose
	Abstract
	1.1 The Significance of Maintaining the Nasal Three Dimensions
	1.2 Difficulties of Studying the Three-Dimensional Anatomy
	1.3 Guide for the Three-Dimensional Study of Nasal Anatomy
		1.3.1 Knowledge and Definitions of Anatomical Parts of the Nose
			1.3.1.1 The Basic Anatomical Facts
			1.3.1.2 Accurate Anatomical Definitions
			1.3.1.3 Surgical Anatomical Subdivisions of the Nose
		1.3.2 Clinical Examination
			1.3.2.1 Live Clinical Assessment
				Inspection
				Palpation
				Clinical Tests
		1.3.3 Photography
		1.3.4 Imagination
	1.4 Conclusion
2 Innovative Approach to Anatomy of the External Nose
	Abstract
	2.1 Gross Anatomy of the External Nose
		2.1.1 The Four Components of the External Nose
			2.1.1.1 The Fixed Bony Part
			2.1.1.2 The Fixed Cartilaginous Part
			2.1.1.4 The Actively Mobile Fibro-Fatty Part
		2.1.2 The Bony Opening of the Nose
		2.1.3 Attachments of the External Nose to the Face
			2.1.3.1 Skeletal Attachments
			2.1.3.2 Soft Tissue Attachments
	2.2 Anatomy of the Upper Two-Thirds of the Nose
		2.2.1 Anatomy of the Bony Pyramid
			2.2.1.1 Nasal Bony Attachments to the Face
			2.2.1.2 Definition of the Bony Pyramid
			2.2.1.3 Anatomical Components of the Bony Pyramid
				The Nasal Bones
			2.2.1.4 Inferior Attachments of the Bony Pyramid
				The Key Stone Area
				The Fibrous Membrane
			2.2.1.5 Stability and Support of the Bony Pyramid
				Stabilizing Factors of the Nasal Bony Pyramid
					The Bony Septum
			2.2.1.6 Bilateral Maxillary Asymmetry
				Consequences of Bilateral Maxillary Asymmetry
					Unequal Wide Base of Bony Pyramid
					Nasal Hump
					Oblique Bony Pyramid
					Deviated Bony Pyramid
				Differential Diagnosis of Maxillary Asymmetry
		2.2.2 Anatomy of the Upper Lateral Cartilage the MidVault
			2.2.2.1 Boundaries of the Upper Lateral Cartilage
			2.2.2.2 Anatomy of the Upper Lateral Cartilage
		2.2.3 Anatomy of the Nasal Septum
			2.2.3.2 The Cartilaginous Septum
			2.2.3.3 The Membranous Septum “The Weak Area of the Nose”
				The Weak Area of the Nose
	2.3 Anatomy of the Lower Third of the Nose
		2.3.1 The Four Walled Structure of the Lower Third of the Nose
			2.3.1.1 The Lower Third is not a Solid-Walled Tube
			2.3.1.2 The Physiological Role of the Lower Third
			2.3.1.3 The Shape of the Nasal Aperture Tubes
			2.3.1.4 The Openings of the Nasal Aperture Tubes
				The Triangular Shaped Opening of the Four Walled Tube
					The Inferior Margins of the Nasal Aperture Tube
					The Superior Margins of the Nasal Aperture Tube
				Surface Anatomy of the Superior Internal Aperture
				The Four Walls of the Nasal Aperture Tube
					The Anterior Wall
					The Lateral Wall
					The Inferior Wall
					The Medial Wall
		2.3.2 Anatomy of the Four Walls
			2.3.2.1 Anatomy of the Medial Wall
				The Columella
					Anatomy of the Columella
					Aesthetic Conditions of the Columella
				The Medial Curae
					Location of the Medial Crus
					Anatomical Course of the Medial Crus
					Curves of the Medial Crus
					The Lateral Columella Margin
					The Lateral Crural Prominence
					The Skin Cover of the Medial Crurae
					Surgical Significance
					Exploration of the Medial Crus
					A Transcolumellar Stitch is Sometimes Used to Reduce the Medial Crural Prominence (Refer to Surgical Section)
			2.3.2.2 Anatomy of the Lateral Wall
				The Lateral Crus
					Anatomical Course of the Lateral Crus
					Surgical Significance
					The Skin Cover of the Lateral Crus
				The Alae Nasi
					The Size and Shape of the Ala Nasi
					Position of the Ala Nasi “The Alar Flare”
					Skin Cover of the Alae Nasi
					Relations of the Alae Nasi
					The Bodies of the Alae Nasi
					The Physiological Role of the Alae Nasi
					Factors Affecting the Alar Flare
				The Middle Crurae
					Definition of the Middle Crus
					Definition of the Medial Genu
					Definition of the Lateral Genu
					The Three-Dimensional Movements in the Body of the Middle Crus
					The Nasal Tip
					The Dome
					Skin Cover of the Middle Crus
					The Angle of Divergence of the Domes
				Aesthetic Effects of the Middle Crus
			2.3.2.4 Anatomy of the Inferior Nasal Wall
				The Vestibular Floor
					The Shape and Position of the Vestibular Floor
				The Flat Triangle
					Why the Term Flat Triangle and not Soft Triangle
					The Surgical Significances
					Aesthetics of the Flat Triangle
					Management of Injury of the Flat Triangle
3 The Weak Areas and Soft Folds in the Nasal Walls
	Abstract
	3.1 Significance of the Weak Areas and Soft Folds
	3.2 Locations of the Gaps
		3.2.1 Gaps in the Medial Nasal wall: “Midline Gaps”
			3.2.1.1 The Membranous Septum, the Weak Area of the Nose
			3.2.1.2 The Posterior Columellar Fold
		3.2.2 Gaps in the Lateral Nasal Walls
			3.2.2.1 The Rim-Sill Folds
			3.2.2.2 The Muscular Triangles
		3.2.3 Anterior Wall Gap “The Weak Triangle”
		3.2.4 Gaps in the Inferior Nasal Walls
			3.2.4.1 Two Vestibular Floors
			3.2.4.2 Two Flat Triangles
			3.2.4.3 The Two Nasal Openings
	3.3 The Posterior Columellar Fold
		3.3.1 Boundaries
		3.3.2 Skin Cover
		3.3.3 Contents
	3.4 The Rim-Sill Folds
		3.4.1 Boundaries
			3.4.1.1 Elevation
			3.4.1.2 Evertion
			3.4.1.3 Backward Tilting
		3.4.2 Anatomy and Histology of the Rim-Sill Fold
			3.4.2.1 The Posterior Segment
		3.4.3 Aesthetics of the Rim-Sill Fold
		3.4.4 Surgical Significances
			3.4.4.1 Effects on the Size and Bulk of Nasal Aperture
			3.4.4.2 Effects on Smiling
			3.4.4.3 Surgical Incisions
				The Posterior Segment
				The Inferior Segment
			3.4.4.4 Exploration of Nasal Vestibule
			3.4.4.5 Unaesthetic Rim-Sill Fold
				The Inferior Segment
				The Posterior Segment
			3.4.4.6 The Light Reflex
	3.5 The Muscular Triangle “The Hinge Area”
		3.5.1 Boundaries
		3.5.2 Roof and Floor
		3.5.3 Contents
		3.5.4 Surgical Significances
	3.6 The Weak Triangle
		3.6.1 Boundaries of the Weak Triangle
		3.6.2 Angles of the Weak Triangle
		3.6.3 Contents
		3.6.4 Support:
		3.6.5 Roof and Floor
		3.6.6 Surgical Importance of the Weak Triangle
			3.6.6.1 The Medial Muco-Cutaneous Fold
4 Significance of Nasal Base Attachment to the Orbicularis Oris
	Abstract
	4.1 Surgical Anatomy of the Orbicularis Oris
		4.1.1 Pars Peripheralis
		4.1.2 Pars Marginalis
		4.1.3 Direct Labial Tractors
	4.2 Effects of the Orbicularis Oris on Nasal Base
	4.3 Nasal Base Attachments of the Orbicularis Oris
		4.3.1 Alar Attachments
		4.3.2 Vestibular Floor Attachments
		4.3.3 Caudal Cartilaginous Septal Attachment
	4.4 Effect of Upper Lip Skin on Nasal Stability
	4.5 The Oro-Nasal Act of Smiling
		4.5.1 The Lips
		4.5.2 The Alae Nasi
		4.5.3 The Nasal Septum and Medial Crurae
	4.6 Smile Asymmetry
5 The Seven Types of Nasal Skin Anatomy and Surgical Significance
	Abstract
	5.1 Basic Anatomy of Skin
		5.1.2 The Dermis
		5.1.3 The Hypodermis
		5.1.4 The Deep Fascial Layer
	5.2 The Seven Types of Nasal Skin
		5.2.1 The Skin Cover of the Bony Pyramid
		5.2.2 The Skin Cover of the Upper Lateral Cartilage
		5.2.3 The Skin Cover of the Lower Lateral Cartilages
			5.2.3.1 The Dermis
		5.2.4 The Skin Cover of the Alae Nasi
		5.2.5 The Vestibular Skin
			5.2.5.1 The Lateral Vestibular Wall
			5.2.5.2 The Anterior Vestibular Wall
			5.2.5.3 The Inferior Vestibular Wall
			5.2.5.4 The Medial Vestibular Wall
		5.2.6 Skin Cover of the Weak Areas and Soft Folds
		5.2.7 Skin Cover of Transitional Areas
	5.3 Incisions and Scars of Nasal Skin
		5.3.1 Location of Incision
		5.3.2 Time of Stitching
		5.3.3 Types of Stitch
		5.3.4 Layers of Stitch
6 Histological Studies of New Anatomical Structures
	Abstract
	6.1 The Inferior Vestibular Band
		6.1.1 Material and Methods
		6.1.2 Histological Findings
		6.1.3 Conclusion
	6.2 The Vestibular Septum
		6.2.1 Material and Methods
		6.2.2 Histological Findings
			6.2.2.2 Transitional Area
			6.2.2.3 Area of Pseudo-Stratified Columnar Epithelium With Goblet Cells
7 The Anatomy and Physiology of Nasal Respiration
	Abstract
	7.1 The Nasal Valve
		7.1.1 Anatomy of the Nasal Valve
			7.1.1.1 The External Valve
			7.1.1.2 The Internal Valve
			7.1.1.3 The Walls of the Internal Valve
			7.1.1.4 The Anterior Angle of the Internal Valve
	7.2 The Physiology of Nasal Respiration
		7.2.1 Physiological Definitions
		7.2.2 Inspiration
			7.2.2.2 Changing the Direction of the Inspired Air
			7.2.2.3 The Middle Meatal Cleft
		7.2.3 Expiration
	7.3 Surgical Significance of the Nasal Valve
	7.4 Factors Affecting the Nasal Valve
		7.4.2 Factors Affecting the Static Posterior Parts of the Nasal Valve
		7.4.3 Extra-Valvular Factors
	7.5 The Physiological Role of the Nasal Septum
	7.6 Clinical Picture of Nasal Valve Disorders
		7.6.1 Inspection
		7.6.2 Examination
	7.7 Management of Nasal Valve Lesions
8 Anatomical Variations of the Nose
	Abstract
	8.1 Variations in the Three-Walled Upper Two-Thirds of the Nose
		8.1.1 The Bony Pyramid
		8.1.2 The Upper Lateral Cartilage
	8.2 Variations in the Four-Walled Lower Third of the Nose
		8.2.1 The Lateral Wall
		8.2.2 The Medial Wall
		8.2.3 The Inferior Wall
		8.2.4 The Anterior Wall
		8.2.5 The Weak Areas and Soft Folds
		8.2.6 The Lateral Wall
			8.2.6.1 The Ala Nasi
				The Size of the Ala Nasi
					Small Ala Nasi
					Large Ala Nasi
					Unequal Alae Nasi
				The Shape of the Ala Nasi
				The Position of the Ala Nasi
					High or Low Alar Margin
					Eversion
					Inversion
					Lateral Attachment of the Posterior Alar Margin
				The Indirect Effects of Alar variations
					The Alar Grooves
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			8.2.6.2 The Lateral Crus
				Size
				Shape
				Position
			8.2.6.3 The Prominent Superior Overlap of the Lateral Crus
		8.2.7 The Medial Wall
			8.2.7.1 The Columella and the Medial Crurae
				Length
				Thickness
				Position
		8.2.8 The Inferior Aperture Wall
			8.2.8.1 Variations in the Nasal Sill Band
				Length
				Thickness and Prominence
				Position
				The upper lateral fold of nasal sill
			8.2.8.2 The Flat Triangle
		8.2.9 The Anterior Wall
			8.2.9.1 The Middle Crurae
				Size
				Shape
				Position
		8.2.10 The Weak Areas and Soft Folds
			8.2.10.1 The Weak Triangle
			8.2.10.2 The Rim-Sill Fold
				Length
				Thickness
				Position
	8.3 Nasal Skin Variations
	8.4 Ethnographic Variations
		8.4.1 The Caucasian Noses
		8.4.2 The African Noses
		8.4.3 The Asian Nose
		8.4.4 The Middle Eastern and Hispanic Noses
	8.5 Bilateral Nasal Variations
		8.5.1 Bony Pyramid
		8.5.2 The Upper Lateral Cartilage
		8.5.3 The Lower Lateral Cartilages
		8.5.4 Alae Nasi
		8.5.5 Unequal Nasal Openings
		8.5.6 The Natural Unilateral Nasal Defects
Rhinoplasty Photography of Surgeons
9 Rhinoplasty Photography of Surgeons
	Abstract
	9.1 Patient Consent for Photography
	9.2 The Necessity of Photography
		9.2.1 Medicolegal Documentation
		9.2.2 Photographic Anatomy
	9.3 Photographic Equipment
		9.3.2 The Lens
			Outline placeholder
				f-stop in the Omicron System (Depth of Field)
				Omicron System
			9.3.3.2 Combined Direct and Indirect Ring Flash
			9.3.3.3 Indirect Ring Flash
10 Standardization of Rhinoplasty Photography
	Abstract
	10.1 Importance of Standardization
	10.2 Achieving Standardization
		10.2.1 The Setup
			10.2.1.1 The Place for Photography
			10.2.1.2 The Floor Marking Lines
				Location of the Patient’s Chair
				Location of the Photographer’s Chair
			10.2.1.3 The Type of Chairs
				The Patient’s Chair
				The Photographer’s Chair
		10.2.2 Preparing the Patient
			10.2.2.1 Positioning the Patient’s Head
			10.2.2.2 Defining the Horizontal Level
			10.2.2.3 The Frankfort Plane and Reid’s Line
		10.2.3 Positioning the Camera
			10.2.3.2 The Distance of the Lens
			10.2.3.3 Orientation of the Camera Back
		10.2.4 Camera Settings for Photography
			10.2.4.1 Full Face Photographs
			10.2.4.2 Close-up Photographs
11 The Significance of the Light Reflexes of the Nose
	Abstract
	11.1 The Marginal Light Reflexes
		11.1.1 Photographic Views of the Marginal Reflexes
	11.2 The Frontal Surface Light Reflexes
		11.2.1 Photographic Views of the Frontal Surface Light Reflexes
			11.2.1.1 Nasal Dorsal Light Reflex
			11.2.1.2 Nasal Tip Light Reflex
			11.2.1.3 Flat Triangle Marginal Light Reflex
	11.3 Absent Light Reflex
		11.3.1 The Weak Areas and Soft Folds
		11.3.2 Anatomically Distorted Areas
	11.4 Clinical Use of the Light Reflex
		11.4.1 Photographic Pre-operative Assessment
		11.4.2 During Surgery
12 The Rim-Sill Test
	Abstract
	12.1 Defining the Rim-Sill Test
	12.2 How to Perform the Rim-Sill Test
	12.3 The Rim-Sill Test in Thick Skin
	12.4 The Rim-Sill Test in Extremely Thick Skin
	12.5 Important Points in Performing the Rim-Sill Test
	12.6 The Clinical Use of the Rim-Sill Test
13 Photographic Views of the Nose
	Abstract
	13.1 Introduction
		13.1.1 The Importance of the Standard Views
		13.1.2 The Necessity for Specialized Views
		13.1.3 The Advantages of Photographic Anatomy
	13.2 The Four Standard Views
		13.2.1 The Frontal Views
			13.2.1.1 The Setup
				The Patient
				The photographer
			13.2.1.2 Camera Setting
			13.2.1.3 The Camera View
			13.2.1.4 Photographs Taken
				Non-smiling
				Smiling Full
				The Mid Face
				The Nasofacial Relationship:
				The Levels of the Nasal Sills
				The Effects of Smiling on the Face
			13.2.1.6 Facial Aesthetic Lines
				The Vertical Guidelines for the Alar Base
				The Curved Guidelines for the Nasal Sidewall
			13.2.1.7 Smiling Asymmetry
		13.2.2 The Lateral Views
			13.2.2.1 The Setup
				The Patient
				The Photographer
			13.2.2.2 Camera Setting
			13.2.2.3 The Camera View
			13.2.2.4 Photographs Taken
				Full Face Non-smiling
				Smiling Full Face
				Midface
			13.2.2.5 Clinical Assessment of Photographs
				The Nasofacial Relationship
					The Size
					The Height of the Nasal Dorsum
					The Length
					The Shape
				The Nasal Tip
					The Tip Projection
					The Mobile Tip and the Sliding Tip
				The Paranasal Angles
					The Nasofrontal Angle
					The Naso-Labial Angle
				Alar-Columellar Relationship
				Effects of Smiling
		13.2.3 The Oblique Views
			13.2.3.1 The Difficulties of the Oblique Views:
				The Strictly Forty-Five Degrees Technique:
				The Direct Lateral Nasal Wall Technique
			13.2.3.2 The Setup
				The Patient
				The Photographer
			13.2.3.3 Camera Settings
			13.2.3.4 The Camera View
			13.2.3.5 Photographs Taken
			13.2.3.6 Clinical Assessment of the Photographs
				The Nasofacial Relationship
				The Sidewall Profile
					The Osteocartilagenous Sidewall
					The Lower Lateral Cartilaginous Walls
					The alae nasi
				The Nasal Dorsum
				The Neighboring Structures
					Nasal Sills and Lateral Columellar Margins
					Flat Triangles
		13.2.4 The Basal Views
			13.2.4.1 The Setup
				The Patient
				The photographer
			13.2.4.2 The Camera
			13.2.4.3 The Camera View
			13.2.4.4 Photographs Taken
				Non-smiling Basal View
				Smiling Basal View
			13.2.4.5 Clinical Assessment of the Photographs
				The Nasofacial Relationships
					The Nasal Base
					The Nasal Openings
					The Nasal Tip
					The Columella
					The Flat Triangles
					The Alae Nasi
					The Nasal Sills
					The Rim-sill Folds
	13.3 The Five Specialized Views
		13.3.1 The Direct Dorsal Views
			13.3.1.1 The Setup
				The Patient:
				The Photographer
			13.3.1.2 Camera Settings
			13.3.1.3 The Camera View
			13.3.1.4 Photographs Taken
				Non-smiling Direct Dorsal View (Fig. 13.47).
				Smiling Direct Dorsal View (Fig. 13.48).
			13.3.1.5 Clinical Assessment of the Photographs
				The Nasofacial Relationship
					The Forehead
				The Cheeks
				The Nasal Features
				The Nasal Dorsum
					The Nasion
					The Osteocartilagenous Dorsum
					The Nasal Tip
					The Light Reflex
					The Alae Nasi
				The Effects of Smiling
		13.3.2 The Backward Tilting Views
			13.3.2.1 The Setup
				The Patient
				The Photographer
			13.3.2.2 Camera Settings
			13.3.2.3 The Camera View
			13.3.2.4 Photographs Taken
			13.3.2.5 Clinical Assessment of Photographs
				The Nasofacial Relationship
				The Nasal Features
					The Nasal Apertures:
					The Nasal Dorsum
					The Sidewalls of the Nose
		13.3.3 The Nasal Aperture Views
			13.3.3.1 The setup
				The Patient
				The Photographer
			13.3.3.2 Camera Settings
			13.3.3.3 The Camera View
			13.3.3.4 Photographs Taken
			13.3.3.5 Clinical Assessment of the Photographs
				The Nasofacial Relationship:
				Anatomical Structures of the Nasal Aperture:
					The Rim-Sill Folds
					The membranous Septum
					Other Nasal Structures
		13.3.4 The Overhead Views
			13.3.4.1 The Setup
				The patient
				The Photographer
			13.3.4.2 Camera Settings
			13.3.4.3 The Camera View
			13.3.4.4 Photographs Taken
				Non-smiling
				Smiling
			13.3.4.5 Clinical assessment of the photographs
				The Nasofrontal Relationship
				Deformities and Deviations
14 The Workflow of Photography Taking, Filing and Displaying
	Abstract
	14.1 Introduction
	14.2 Photographic Workflow
		14.2.2 Phase II: Downloading to the Computer
		14.2.3 Phase III: Editing and Saving
			14.2.3.1 Backing up of the Stored Photographs
		14.2.4 Phase IV: Retrieval and Display of Photographs
			14.2.4.2 Advantages of the Large Number of Photographs
			14.2.4.3 Methodology of Displaying the Photographs
			14.2.4.4 The Order of Photographic Display
			14.2.4.5 The Display of the Text
	14.3 Conclusion
Surgical Techniques
15 Closed Versus Open Rhinoplasty an Academic Approach
	Abstract
	15.1 A Preservative incisional approach versus an Invasive surgical procedure
	15.2 History of Open Rhinoplasty
	15.3 The Three-Dimensional Structure of the Lower Third of the Nose
		15.3.1 The Solid Upper Third
		15.3.2 The Firm Midvault
		15.3.3 The Soft Lower Third
		15.3.4 The Weak Triangle and the Weak Area of the Nose
		15.3.5 The Superior and Inferior Supports of the Lower Third
		15.3.6 The Hard, Firm and Delicate Principle
	15.4 The Structural and Aesthetic Roles of the Skin of the Lower Third of the Nose
		15.4.1 The Paradox of the Nasal Skin
		15.4.2 The Paradox of the Nasal Walls
		15.4.3 Skin Cover of the Lower Third
			15.4.3.1 Skin Cover of the Alae Nasi
			15.4.3.2 Skin Cover of the Middle and Lateral Crurae
		15.4.4 The Importance of the Hypodermal Fatty Layers
		15.4.5 The Three-Step Exploration of the Hypodermal Layer
	15.5 The Columella
		15.5.1 Physiology of the Columella
		15.5.2 Surgical Anatomy of the Columella
			15.5.2.1 The Firm Anterior Segment
			15.5.2.2 The Soft Posterior Fold
		15.5.3 Skin Cover of the Columella
		15.5.4 Contents of the Columella
		15.5.5 Blood Supply of the Columella
		15.5.6 How the Columella Supports the Lower Third
			15.5.6.1 Internal Factors
			15.5.6.2 External Factors
		15.5.7 Why the Columella is not a Single Solid Structure
	15.6 Surgical Steps for Open Rhinoplasty
		15.6.1 The Surgical Steps
			15.6.1.1 The Columellar Incision
			15.6.1.2 The Inferior Marginal Incisions
	15.7 Consequences of the Open Approach
		15.7.1 Dismantlement of the Columella
		15.7.3 The Effects on Nasal Tip and the Three-Dimensional Structure
		15.7.4 Division of the Columellar Arteries
		15.7.5 Prolonged Swelling and Delayed Healing
	15.8 Surgical Procedures that Follow Open Rhinoplasty
		15.8.1 Reconstructive Phase
		15.8.2 Aesthetic Phase
	15.9 Open Rhinoplasty is a Graft-Dependent Surgery
	15.10 Pitfalls of Grafts
	15.11 A Visible Columellar Scar
	15.12 Indications for Open Rhinoplasty
	15.13 New Advances in Endonasal Techniques
	15.14 Preservation Incisions in Closed Rhinoplasty
16 Clinical Subdivisions and Clinical Varieties of Rhinoplasty
	Abstract
	16.1 Introduction
	16.2 The Four Areas of Rhinoplasty
	16.3 Varieties of Noses Presenting for Rhinoplasty
	16.4 Clinical Assessment of Rhinoplasty Patient
	16.5 Clinical Assessment
		16.5.1 History
		16.5.2 Examination
		16.5.3 General Examination
		16.5.4 Nasal Examination
			16.5.4.1 The Frontolateral Walls
			16.5.4.2 The Medial Wall
			16.5.4.3 The Bony Pyramid and Midvault
17 Clinical Assessment of Rhinoplasty Patient
	Abstract
	17.1 Clinical Assessment
		17.1.1 History
		17.1.2 Examination
		17.1.3 General Examination
		17.1.4 Nasal Examination
			17.1.4.2 The Medial Wall
				The Columella
	17.2 Photographic Assessment
	17.3 Consent for Surgery
	17.4 Consent for Photography
	17.5 Investigations
18 Immediate Pre-operative, Operative and Post-operative Rhinoplasty
	Abstract
	18.1 How the Surgeon Prepares Himself for the Surgery
		18.1.1 Review Patient’s History and Photographs
			18.1.1.1 Written Plan for Surgery
	18.2 Preparing the Patient for Surgery
		18.2.1 Preoperative Discussion
		18.2.2 Preparation of the Operating Theater
			18.2.2.1 Display of Photographs
			18.2.2.2 Position of the Patient and the Operating Table
			18.2.2.3 Placing the Anesthetic Tube
	18.3 The Surgery
		18.3.1 Preliminary Surgical Preparation
			18.3.1.1 Shaving of the Vestibular Hair
			18.3.1.2 Additional Local Anesthesia
		18.3.2 Incisions and Skeletonization
			18.3.2.1 The Intercartilaginous Incisions
			18.3.2.2 The Columellar Incision
			18.3.2.3 Communicating the Incisions
			18.3.2.4 Skeletonization
	18.4 Closure of Wounds
		18.4.1 The Intercartilaginous Incision
		18.4.2 The Columellar Incision
		18.4.3 The Marginal Incisions
		18.4.4 Trans-septal Stitching
	18.5 Final Dressing of the Nose
		18.5.1 Preparing the External Skin
		18.5.2 Steri-strip Dressing
		18.5.3 Plaster of Paris Dressing (POP)
19 Difficulties Associated with Rhinoplasty
	Abstract
	19.1 Introduction
	19.2 Difficulties Before the Surgery
		19.2.1 Difficult Pre-operative Assessment
			19.2.1.1 Defective Areas
			19.2.1.2 Nasal Aperture Discrepancies
		19.2.2 Difficulties of Standardized Photography
		19.2.3 A Lack of Holistic Approach to Nasal Assessment
		19.2.4 Many Factors Affect the Surgical Technique
		19.2.5 Psychological Readiness of Surgery
	19.3 Difficulties During Surgery
		19.3.1 Different Tissues in a Small Organ
		19.3.2 Rhinoplasty is of Four Surgeries
		19.3.3 Nasal Stability
	19.4 Difficulties After the Surgery
		19.4.1 The Paradox of Tissue Healing
		19.4.2 Variability of Post-operative Outcomes
		19.4.3 Psychological Factor
20 Psychology of Rhinoplasty
	Abstract
	20.1 Introduction
	20.2 Surgeon’s Attitude During Patient Assessment
	20.3 Consent and Patient Psychology
	20.4 The Five Stages of the Patient’s Psychology
		20.4.1 The Stage of Discontent
		20.4.2 The Stage of Decision
		20.4.3 The Stage of Action
			20.4.3.1 Searching for a Surgeon
			20.4.3.2 The First Consultation
			20.4.3.3 Setting a Date for Surgery
			20.4.3.4 The Day of Surgery
		20.4.4 Immediate Reaction After Removing the Cast
		20.4.5 Stage of Facing Reality
	20.5 Successful Rhinoplasty
	20.6 Relationship with the Mirror “Mirror Sign”
	20.7 Unsuccessful Surgeries
	20.8 The Surgeon’s Attitude Post-Operatively
	20.9 The Unpleasant Terms and Patients’ Psychology
21 Surgery of the Four Areas of the Nose
	Abstract
	21.1 Innovative Preservation Surgery of the Anterolateral Walls
		21.1.1 Structured Aesthetic Surgery
		21.1.2 Preservation Aesthetic Surgery
			21.1.2.1 Delivery of the Lower Lateral Cartilages
				Definition of Delivery
				The Surgical Technique
					Preparation
					Shaving the Nasal Vibrissae
					Local Anesthesia Iinjection
					Intercartilaginous Incision
					The Marginal Incisions
					Procedures that Follow the Delivery:
	21.2 Surgery of the Alae Nasi
		21.2.1 Small Ala Nasi
			21.2.1.1 Surgical Technique
	21.3 Surgery of the Columella
		21.3.1 Surgery of the Firm Anterior Columellar Segment and Surgery of the Medial Crurae
			21.3.1.1 Bifid Ccolumella
			21.3.1.3 Overprojecting Medial Crurae
				External Lintercrural Stitch (Linter-Sill Band)
				Internal Medial Crural Approximation
		21.3.2 Surgery of the Soft Posterior Columellar Fold
			21.3.2.1 Factors Affecting the Posterior Columellar Fold
				The Medial Crurae
				The Anterior Nasal Spine
			21.3.2.2 Position of the Anterior Nasal Spine
			21.3.2.3 Size of the Anterior Nasal Spine
	21.4 Surgery of the Nasal Septum
		21.4.1 The Essential Role of the Nasal Septum in Rhinoplasty
			21.4.1.1 Stability and Support
			21.4.1.2 Maintaining Dorsal Height
			21.4.1.3 Direction of the Nose
			21.4.1.4 Source of Graft Material
			21.4.1.5 Nasal Airway
		21.4.2 Nasal Septal Deviation
			21.4.2.1 The Bony Deviations
			21.4.2.2 The Osteocartilagenous Deviations
			21.4.2.3 The Cartilaginous Deviations
		21.4.3 General Principles of Septal Surgery in Rhinoplasty
			21.4.3.2 Intraoperative Timing of Septoplasty
			21.4.3.3 Maintaining the Integrity of the Septum
		21.4.4 Technical Details of Septal Surgery
			21.4.4.1 Subperichondrial Septoplasty
			21.4.4.2 Preparation for Septal Surgery
			21.4.4.3 Instruments
			21.4.4.4 Surgical Steps
				The Incision
				Septal Exploration before Osteotomies
				Completion of Septoplasty After Osteotomies
				Managing the Nasal Septum
		21.4.5 The Membranous Septum
			21.4.5.1 The Direct Effects of the Membranous Septum
				Clinical Significance
				Aesthetic Significance
				Physiological Significance
					Accurate Height and Length
					Straight
					Firm
					Midline
			21.4.5.2 The Indirect Effects of the Membranous Septum
				The Sliding Tip
				Surgical Correction of the Sliding Tip
	21.5 Nasal Stability and Rhinoplasty
	21.7 Indications for Osteotomies
		21.7.1 Wide Bony Base
		21.7.2 Bony Hump
		21.7.3 Facial Asymmetry and Oblique Pyramid
		21.7.4 Traumatic Fracture of the Nose
		21.7.5 Wide Alar Base
	21.8 Osteotomy Techniques
		21.8.1 The Lateral Osteotomies
			21.8.1.1 Internal Lateral Osteotomies
			21.8.1.2 External Lateral Osteotomies
		21.8.2 Superior Osteotomies
		21.8.3 Medial Osteotomies
			21.8.3.1 The Technique of Medial Osteotomies
	21.9 Infracture
	21.10 Pitfall of Osteotomies and Infracture
		21.10.1 Failure of Infracture
			21.10.1.1 Technique of Outfracture of Bony Sidewall
		21.10.2 Oblique Bony Pyramid
		21.10.3 Deviated Bony Septum
		21.10.4 Defective Area
		21.10.5 Step Deformity
	21.11 The Nasal Dorsal Hump
		21.11.1 The Normal Anatomy
		21.11.2 Anatomy of the Dorsal Hump
		21.11.3 The Large Nose
		21.11.4 Associated Deformities
			21.11.4.1 Deviated and/or Oblique Bony Pyramid
			21.11.4.2 Flat Naso-frontal Angle
			21.11.4.3 Areas of Defects
			21.11.4.4 The Trumpet Deformity
			21.11.4.5 Post-traumatic Bony Pyramid
				Class 1 Nasal Fracture “Chevallet”
				Class 2 Nasal Fracture
				Traumatic Saddle Deformity
				Comminuted Bony Trauma
				Childhood and Forgotten Trauma
		21.11.5 Techniques of Hump Removal
			21.11.5.1 Preservation Pushdown and Let Down Technique
			21.11.5.2 The Osteotomy Technique
			21.11.5.3 The Saw Technique
			21.11.5.4 The Rasping Technique
	21.12 Surgery of the Upper Lateral Cartilage
		21.12.1 Cartilagenous Hump Excision
		21.12.2 Unequal Sides of Upper Lateral Crurae
		21.12.3 Broad Middle Third
		21.12.4 The Subdermal Fat
		21.13.1 Alar Base Enlargement Surgery
			21.13.1.1 Lateral Angulation and Alar Flattening
			21.13.1.2 Anterior Vestibular Stenosis
		21.13.2 Alar Base Aesthetic Enhancement Surgery
		21.13.3 Alar Base Reduction Surgery
			21.13.3.1 The Surgical Significance of the Rim-Sill Fold
			21.13.3.2 Defining the Location of the Rim-Sill Fold
			21.13.3.3 Surgery of the Rim-sill Fold
				Planning for the Incisions
				Marking
					The Sill Line
					The Alar Line
					The Vestibular Line
					The Marginal Lines
				Surgical Excision of the Rim-Sill Folds
				Type of Rim-Sill Aesthetic Surgeries
				Rim-Sill Post-excision Reconstruction
					The Submarginal Approximation
					Skin Closure
				Management of the Wide Nasal Aperture Tube
					Closure of a Wide Aperture Wound
					Reducing the Alar-Sill Gap
				Closure of the Vestibular Floor Wound
				Medialization of a Lateralized Ala Nasi
				Finalization of the Alar Wounds
				Aesthetic Outcome of Alar Wounds
	21.14 Surgery of the Flat Triangle
		21.14.1 Acute Injury of the Flat Triangle
		21.14.2 Chronic Damage of the Flat Triangle
			21.14.2.1 Management
22 Clinical Varieties of Rhinoplasty
	Abstract
	22.1 Part I: Finesse Rhinoplasty
		22.1.1 The Frontolateral Walls
		22.1.2 The Medial Wall
		22.1.3 The Bony Pyramid
		22.1.4 The Nasal Base
		22.1.5 Combinations
	22.2 Part II: The Large Nose and the Bulky Nose: Differences and Surgical Management
		22.2.1 Nasal Size
		22.2.2 Nasal Bulk
		22.2.3 Causes of the Large Nose and the Bulky Nose
			22.2.3.1 Large Bony Pyramid
			22.2.3.2 Large Upper Lateral Cartilage
			22.2.3.3 Large and/or Bulky Lower Lateral Cartilages
			22.2.3.4 Bulky Lateral Crural Overlap (Scroll Area)
			22.2.3.5 Large and Bulky Alae Nasi
			22.2.3.6 The Length and Thickness of the Rim-Sill Folds
			22.2.3.7 Bulky External Skin
		22.2.4 Surgical Reduction of the Size and the Bulk of the Nose
			22.2.4.1 Reduction of the Size of the Bony Pyramid
			22.2.4.2 Reduction of the Size and Bulk of the Alae Nasi
			22.2.4.3 Reduction of the Length and/or Thickness of the Rim-Sill Folds
			22.2.4.4 Reduction in the Size and Bulk of the Lower Lateral Cartilages
				The Size of the Medial Crurae
				The Middle Crural Domes
				The Lateral Crurae
					Defatting: The Two-Step Reduction of Crural Bulk and Size
					Special Defatting Conditions
					Anatomical Effects of Defatting
					The Eight Aesthetic Benefits of Defatting
	22.3 Part III: The Deviated Nose and the Crooked Nose: Differences and Surgical Management
		22.3.1 The Deviated Nose
			22.3.1.1 Bilateral Maxillary Asymmetry
			22.3.1.2 The Unaesthetic Outcomes of Maxillary Asymmetry
				Oblique and Deviated Bony Pyramid
				Osteocartilagenous Hump
				Asymmetrical Maxillary Bodies and Cheeks
		22.3.2 The Crooked Nose
			22.3.2.1 The Developmental Crooked Nose
			22.3.2.2 The Post-Traumatic Crooked Nose
		22.3.3 Clinical Assessment of the Deviated and the Crooked Nose
			22.3.3.1 History
			22.3.3.2 Examination
			22.3.3.3 Photographic Diagnosis
		22.3.4 Management of the Deviated Nose
		22.3.5 Management of the Crooked Nose
	22.4 Part IV: Rhinoplasty of the Fractured Nose: Types and Surgical Management
		22.4.1 Fracture of the Nasal Septum
			22.4.1.1 Fracture of the Cartilaginous Septum
				Aesthetic Effects of the Vertical Fracture
					Unequal Nasal Openings
					Unilateral Domal Bulge
					Duplication of the Septal Cartilage
					Saddling
					Immediate Saddling
			22.4.1.2 Fracture of the Bony Septum
		22.4.2 Fracture of the Nasal Bones
		22.4.3 Fracture of the Frontal Process of Maxilla
		22.4.4 The Aesthetic Management of the Fractured Nose
			22.4.4.1 Management of the Fractured Septum
				The Laterally Displaced Broken Distal Segment
				Duplication of the Distal Segment
				Excess Redundant Skin
				Traumatic Dislocation, Fracture and Deviation
				Saddling
			22.4.4.2 Management of the Fractured Bony Pyramid
				Isolated Nasal Bone Fracture
				Fracture of Frontal Process of the Maxilla
				Areas of Prominences and Defects
	22.5 Part V: Secondary Rhinoplasty
		22.5.1 Surgical Challenges
		22.5.2 Psychological Challenges
		22.5.3 Matching the History with the Clinical Findings
		22.5.4 Management of Secondary Rhinoplasty
			22.5.4.1 Clinical Assessment
				Clinical Varieties of Secondary Rhinoplasty
					Omitted Surgery
					Completed Surgery
					Uncompleted Surgery
					Faulty Surgery
				Clinical Examination of the Four Areas of the Nose
					Frontolateral Walls
					Medial Wall
					The Bony Pyramid and Midvault
					Alar Base
		22.5.5 Acceptance and Plans for Surgery
		22.5.6 Guidelines for Surgery in Secondary Rhinoplasty
			22.5.6.1 Timing of Surgery
			22.5.6.2 Conservative Attitude
		22.5.7 Strategy of Secondary Rhinoplasty
			22.5.7.1 Omitted Areas
			22.5.7.2 Areas of the Completed Surgery
			22.5.7.3 Areas of the Uncompleted Surgery
			22.5.7.4 Areas of Faulty Surgery
			22.5.7.5 Areas of Omitted Surgery