Reconstruction of nasal skin loss(Double lobe flap)

Ø Bilobed flaps are used when the defect created by the primary flap (i.e., the banner flap) is too large to close primarily.
Ø The flaps are designed on a 45- to 90-degree axis to the primary defect and the flaps are elevated in the subcutaneous plane.
Ø Generally, the primary flap may be drawn somewhat smaller than the defect and is designed, as much as possible, to place the scars along minimal tension lines and within natural skin creases. Flaps designed at 45-degree angles minimize dog-ear formation.
Ø The resultant scars are complex and may be quite conspicuous.

Rhinoplasty (augmentaion by Rib cartilage)

Rhinoplasty, Augmentation:

Intraoperative Details
Decongestion of the nasal mucosa with oxymetazoline, phenylephrine, allows adequate endonasal visualization. Injection of the nasal soft tissues with lidocaine and epinephrine allows adequate vasoconstriction and decreases intraoperative bleeding.
Augmentation performed via an open rhinoplasty approach. An open approach involves elevation of the skin and soft tissue envelope via a transcolumellar incision that is carried along the medial crura and the caudal aspect of the lower lateral cartilages. The entire cartilaginous skeleton of the lower and upper lateral cartilages should be exposed.
Dissection should proceed in a submuscular aponeurotic plane. Dissection superficial to this plane results in compromise of the vascular supply to the soft tissues and makes the dissection very difficult.
At the bony cartilaginous junction, the periosteum over the nasal bones is elevated and the dissection is carried in this plane up to the nasofrontal angle. The entire nasal skeleton should be adequately visualized.
Once the anatomy and the defects are adequately visualized harvesting of the rib cartilage was done. The rib is harvested through an incision along the chest wall to remove the cartilage portion of the rib, leaving behind the bony portion of the rib.
Grafts are fashioned and sculpted to the desired size and shape and are sutured in the desired location. The graft is secured in place with carefully placed, multiple 5-0 clear nylon.
Corrections are performed until the desired outcome is achieved. After augmentation is complete, the skin and soft tissue envelope are carefully red raped over the nasal skeleton and sutured in place with 6-0 nylon. An external nasal splint was performed.

pre- and post-operative finding:

Rhinoplasty( crocked nase)

pre- and posoperative photography:

Intraoperative Details:

Correcting the deviated septum

A crooked nose is almost always associated with a crooked septum.
Deviating cartilage not included in the vital 1.5 cm dorsal caudal L strut can be resected without concern for loss of middle-vault support. Bony obstruction and deviations of the perpendicular plate of the ethmoid and vomer may be rongeured gently.
The caudal anterior septum is often displaced off the maxillary crest, which results in tip deviation. Corrective efforts include swinging the septum back onto its pedestal. This is performed by excising a triangular wedge of cartilage from the inferior septum at the posterior septal angle. The septal base is then stabilized to the maxillary crest periosteum with a strong, permanent suture.

recorrction through endonasal approach

In cases in which a twisted nose is accompanied by a lateral wall defect causing obstruction, treatment may be performed via the endonasal approach.
Although visualization is less than with the external rhinoplasty approach, combination of structural stenting and camouflaging may be adequate to achieve a straight dorsum. This approach allows for functional improvement without disrupting a well-supported tip.

Management of a crooked bony dorsum

A 2- or 3-mm straight osteotome is desirable; however, this small of an instrument has an associated learning curve. The 4-mm guarded osteotome is effective for lateral osteotomies and can be used with minimal trauma, especially when the guard is placed on the inner surface of the pyramid.
When indicated, medial osteotomies are performed before lateral osteotomies. This provides a safe back fracture and allows for a complete break. Incomplete breaks or green-stick fractures lead to bony irregularities and postoperative shifting of the bones. Medial osteotomies are performed with the aid of a 6-mm curved osteotome placed at the junction of the nasal bones and septum. The osteotome is directed 25° lateral from the midline. Medial osteotomies, however, are not always needed. If a large open roof exists following hump resection, bony walls may be mobilized fully with lateral osteotomies alone.
Lateral osteotomies are usually performed in a high-low-high direction. This path allows for protection of the nasal airway at the nasal base by initiating osteotomy at an elevated (high) position on the pyriform aperture. This leaves a triangle of bone at the base of the pyriform aperture (Webster triangle), avoiding compromise of the nasal airway width. The osteotome then travels in a low path along the mid dorsum to maximize narrowing and then back high to prevent over-narrowing of the nasal root. If the nasal bones do medialize, internal stabilization with splints may be necessary to prevent support without outward migration.

rhinoplasty (reduction)4

Rhinoplasty (tip reposition)

Rhinoplasty, Tip Surgery:

Surgical maneuvers must be implemented based on thorough preoperative plans designed to treat specific nasal tip deformities.
A t bulbous nose can be corrected into a more triangular nose by excising the cephalic lateral crura. However, leave at least a 6-mm strip of cartilage or otherwise risk alar collapse and a resulting pinched nose deformity.
The broad tip nose develops secondary to an increased angle of divergence between the middle crura. Treatment involves the use of sutures to narrow the interdomal distance.
Various stitching techniques have been described to effectively alter the structural support underlying the nasal tip. A transdomal stitch spans a single dome and, in effect, narrows the dome and improves nasal tip projection.
An intercrural stitch is placed through the caudal aspect of the medial crura; this horizontal mattress stitch is placed such that the columella is narrowed and the central tip support is augmented. The lateral crural spanning stitch spans the lateral crura and narrows the cephalad aspect of the tip (used for a bulbous tip), thus providing increased projection.
In general, for all the presented nasal tip stitches, 4-0 and 5-0 nylon clear sutures are used because they help maintain adequate and persistent strength.