FPRS Rhinoplasty and Nasal Reconstruction Flashcards Preview

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Flashcards in FPRS Rhinoplasty and Nasal Reconstruction Deck (63)
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1
Q

What are the subunits of the nose?

A

Dorsum, root, sidewalls (two), tip, columella, soft tissue
triangles (two), ala (two). If more than 50% of a subunit is
injured or resected, the remaining portion should be
removed before reconstruction.

2
Q

Which arteries supply the nasal septum?

A

● Sphenopalatine artery
● Anterior and posterior ethmoid arteries
● Superior labial artery
● Greater palatine artery

3
Q

Which arteries supply the external nose?

A
● Facial artery
● Angular artery
● Superior labial artery
● Infraorbital artery
● Ophthalmic artery
4
Q

What are some of the unique characteristics that may be found in the Asian nose?

A

Thick, sebaceous skin, low radix, weak lower lateral

cartilages

5
Q

What are some of the typical differences in the appearance of a child’s nose compared with an
adult’s nose?

A

A child’s nose displays a more obtuse nasolabial angle, more

circular nares, shorter dorsum and columella, less defined and projected nasal tip, and decreased dorsal projection.

6
Q

What is the primary concern of septal surgery in

prepubertal children?

A

Underdevelopment of the nose and maxilla

7
Q

How is the nasofrontal angle determined?

A

A line tangent to the nasal dorsum is intersected with a line tangent to the glabella and nasion.

8
Q

How is the nasofacial angle determined?

A

In lateral view, it is the angle created by the intersection of a line parallel to the nasal dorsum intersecting the tip and nasion and a vertical line from the glabella to the
pogonion.

9
Q

How is the nasolabial angle determined?

A

In lateral view, it is the angle created by a line drawn perpendicular to the Frankfort horizontal at the subnasale
and a second line drawn through the midpoint of the nostril aperture.

10
Q

What is meant by the term tip-defining point in the

context of nasal analysis?

A

The anterior most projection of the domes, which are
represented by two distinct light reflexes on the skin of the
nasal undertip

11
Q

Describe the Simons method of determining nasal

projection.

A

A line drawn from the subnasale to the nasal tip is
compared with a line drawn from the subnasale to the
vermilion border of the upper lip. In an ideal nose, the
length of these lines should be equal.

12
Q

Describe the Crumley method for determining

nasal projection.

A

In lateral view, the nose is seen as a 3–4–5 triangle with
points at the alar facial crease, tip, and nasion. The shortest
arm of the triangle is between the tip and the alar facial
crease. The longest arm is between the tip and the nasion.
Another alternative is to measure the distance from the
subnasale to the nasal tip and compare it with the distance from the subnasale to the vermilion border of the upper lip.
If the distance from the subnasale to the tip is greater than
the distance from the subnasale to the upper lip, the nose is
overprojected.

13
Q

Describe the Goode method for determining nasal

projection.

A

A horizontal line drawn from the alar facial crease to the
nasal tip is 0.55 to 0.6 the length of a line drawn from the
nasion to the nasal tip. If the ratio is less than 0.55, the nose
is underprojected. If the ratio is greater than 0.6, the nose is
overprojected.

14
Q

How is the ideal width of the nasal base

determined?

A

It should lie within vertical lines drawn inferiorly from the
medial canthi.

15
Q

What is the ideal ratio of the nasal lobule and columella on basal view of the nose?

A

The nasal tip should occupy the upper third and the
columella the lower two-thirds. The nasal tip should be
approximately 45% the width of the base of the nose.

16
Q

What is the ideal ratio of nasal lobule to columella

on base view?

A

1:2

17
Q

On lateral view, what is the ideal amount of

columellar show?

A

2 to 4 mm

18
Q

Describe the anatomy of the nasal bones.

A

Superiorly, the nasal skeleton is composed of paired nasal
bones. The premaxilla and palatine bones constitute the
floor. The lateral wall of the nose is formed by the medial
walls of the maxilla. The superior, middle, and inferior conchal
bones are attached to the lateral nasal walls. The cribriform
plate is the roof of the nose. The bony septum is formed by
the vomer and the perpendicular plate of the ethmoid.

19
Q

Describe the skeletal support of the nose.

A

The upper third of the nose is supported by the nasal bones
and the medial portion of the frontal process of the maxilla.
The dorsal septum and upper lateral cartilages are the
framework for the middle third of the nose. The anterior
septal angle and the lower lateral cartilages suspend the lower third of the nose.

20
Q

What are the major tip-supporting structures of

the nose?

A

● The intrinsic length and strength of the lower lateral
cartilages
● Attachment of the medial crura to the caudal aspect of
the quadrangular cartilage
● Attachment of the cephalic border of the lower lateral
cartilages to the caudal aspect of the upper lateral
cartilages

21
Q

What are the minor tip-supporting structures of

the nose?

A

Anterior nasal spine, attachment of the skin and soft tissue

to the lower lateral cartilages, membranous septum, cartilagenous septal dorsum, sesamoid complex, interdomal ligament

22
Q

What is the rhinion?

A

The rhinion is the point that corresponds with the junction of the bony and cartilaginous dorsum.

23
Q

Which structures form the internal nasal valve?

A

● Medially, the nasal septum
● Laterally, the caudal border of the upper lateral cartilage
and piriform aperture
● Inferiorly and posteriorly, the head of the inferior
turbinate

24
Q

What structures constitute the external nasal valve?

A

● Laterally, the pyriform aperture, lateral crus of the lower
lateral cartilage, fibrofatty tissue, and alar rim
● Superolaterally, the caudal aspect of the upper lateral
cartilage
● Medially, the septum and columella

25
Q

What are some surgical techniques to correct

external nasal valve collapse?

A

The technique chosen depends on the cause of valve
compromise. Options include alar batten grafts, lateral
crural strut grafts, narrowing of a wide columella, repair of
caudal septal deflection, and alar flaring sutures.

26
Q

What muscles constitute the nasal compressor

group?

A

Procerus, quadratus (levator labii and nasi superioris),

nasalis (pars tranversalis and pars alaris), depressor septi

27
Q

What muscles constitute the nasal dilator group?

A

The dilator naris posterior and the dilator naris anterior

28
Q

What muscle lowers the nasal tip?

A

Depressor septi nasi muscle. Results in the unfavorable
appearance of a rounded, depressed, and lengthened tip,
which can be corrected during rhinoplasty by transecting
the insertions of these muscles at the base of the columella.

29
Q

What is a marginal incision in rhinoplasty?

A

An incision made along the caudal aspect of the lower lateral cartilage

30
Q

What is a rim incision in rhinoplasty?

A

An incision made along the alar rim. This approach has been largely abandoned secondary to subsequent alar notching.

31
Q

What transcolumellar incisions may be used

during external approach rhinoplasty?

A

V shaped, inverted-v, stair-step, or slightly curvilinear

32
Q

Describe the surgical approaches to the nasal tip.

A

Endonasal approaches can be divided into nondelivery and
delivery techniques. Nondelivery techniques include trans-cartilaginous and intercartilaginous with retrograde dis-
section. Delivery techniques include making intercartilaginous and marginal incisions to create a chondrocutaeous flap. An open (external) approach involves a midcolumellar and bilateral marginal incisions.

33
Q

List some techniques to increase nasal projection.

A

Lateral crural steal, shield graft, advancement of medial
crura along the caudal septum, columellar strut graft,
vertical dome division, interdomal suture placement,
premaxillary graft

34
Q

List some techniques to decrease nasal projection.

A

● Combined medial and lateral crural flap
● Full transfixion incision
● Reduction of the nasal septum

35
Q

List some techniques to increase nasal rotation.

A

● Lateral crural steal
● Tip graft
● Vertical dome division

36
Q

Describe the Goldman technique of vertical dome

division.

A

The lower lateral cartilages are delivered through marginal and intercartilaginous incisions. A vertical incision is made
through the dome, resulting in a transfer of cartilage from
the lateral crus to the medial crus. The incision goes
through the overlying vestibular skin and mucosa. This
results in increased length of the middle leg of the tripod, in
turn increasing projection and improving tip refinement.

37
Q

Describe the Simons modification of vertical dome

division.

A

It is performed the same way as the Goldman technique
except for the following:
● The vestibular skin and mucosa are not incised.
● A triangular piece of cartilage is excised in the region of
dome division.
● The medial crura are resecured in a superiorly oriented
vector.

38
Q

What are some factors that might predispose a
patient to the development of internal nasal valve
obstruction after rhinoplasty?

A

● Weak upper lateral cartilages
● Short nasal bones
● Thin skin
● History of prior surgery or trauma

39
Q

What techniques should be used to decrease the
likelihood of postsurgical middle vault deformities
after rhinoplasty?

A

● Preservation of middle vault mucosa
● Reattachment of the upper lateral cartilages with the
nasal dorsum if disrupted
● Conservative dorsal hump reduction
● Avoidance of overaggressive osteotomies

40
Q

What are some surgical techniques used to correct

internal nasal valve narrowing?

A

The technique chosen depends on the cause of valve
compromise. Options include spreader grafts, valvulopasty,
conchal cartilage butterfly graft, flaring sutures, septoplasty, and inferior turbinate reduction.

41
Q

During rhinoplasty, how much lateral crural cartilage should be preserved after horizontal
cephalic excision to minimize the risk of alar collapse?

A

6 to 8 mm

42
Q

Review some causes of saddle-nose deformity.

A

Prior surgery resulting in inadequate support of the upper lateral cartilages or loss of adequate dorsal and caudal septal struts (each should have at least 1-cm height);
history of trauma with septal hematoma/abscess and loss of
septal support; self-inflicted from use of cocaine or neurotic
nasal picking; medical condition, including Wegener gran-
ulomatosis, relapsing polychondritis, and syphilis.

43
Q

What autologous tissues may be used for reconstruction of the dorsal nasal skeleton?

A

Rib cartilage, conchal cartilage, calvarial bone, iliac crest

44
Q

What are some contraindications to repair of a

saddle-nose deformity?

A

● Use of intranasal cocaine
● Poor general health
● Poorly controlled relapsing polychondritis

45
Q

Describe the order in which medial, lateral, and intermediate osteotomies should be performed.

A
Medial osteotomies are performed first, followed by
intermediate osteotomies (if needed), and finally lateral osteotomies. If lateral osteotomies are performed first, it is difficult for the osteotome to gain purchase for the medial osteotomies on a mobile segment of bone.
46
Q

What is the cause of inverted-V deformity following rhinoplasty?

A

Collapse of the upper lateral cartilages with narrowing of
the angle between the upper lateral cartilages and nasal
septum, resulting in pinching of the middle nasal vault and internal nasal valve collapse

47
Q

What is the cause of an open roof deformity

following rhinoplasty?

A

Incomplete lateral osteotomies after osseous dorsum
reduction that result in a gap between the bilateral nasal
bones

48
Q

What is the cause of a step deformity following

rhinoplasty?

A

A step deformity occurs when the lateral osteotomy is

placed too far medially, resulting in a visible step off in the nasal sidewall.

49
Q

What is a rocker deformity?

A

If osteotomies are extended too far superiorly, the thicker frontal bone may be included in the fracture line. When the nasal bones are fractured in medially, the thicker superior
frontal bone will “rock” out laterally.

50
Q

What is a pollybeak deformity?

A

Excessive supratip fullness in relation to the tip.

51
Q

What are some of the causes of pollybeak

deformity?

A

Under-resection of the cartilaginous dorsal hump, over-

resection of the nasal bones, loss of tip support, and excessive scar formation in the supratip region

52
Q

What are nasal bossae?

A

Prominent, often sharply demarcated, protuberances of

lower lateral cartilage in the domal region

53
Q

What are some causes of alar retraction after

rhinoplasty?

A

Over-resection of the lateral crura, excision of vestibular

mucosa, rim incision

54
Q

What is the most common donor site for

composite grafts used in facial reconstruction?

A

The ear, incorporating auricular cartilage

55
Q

What is a tent pole deformity?

A

Excessive length of the medial crura relative to the lateral
crura leading to a visible step-off and an overprojected, pinched tip, which may occur secondary to over-recruitment of the lateral crura in a vertical dome division procedure

56
Q

What are some of the physical examination

findings associated with a retruded premaxilla?

A

Acute nasolabial angle, difficulty maintaining the lips in a closed position at rest, nasal tip ptosis

57
Q

What are some of the materials that can be used for premaxillary augmentation?

A

● Autografts: Rib cartilage, split calvarial bone graft, iliac
crest, conchal cartilage, septal cartilage
● Homografts: Cadaveric acellular human dermis, irradiated rib
● Synthetics: Silicone, hydroxyapatite, polytetrafluoroethy-
lene

58
Q

Describe two early signs of rhinophyma.

A

Dilated (patulous) pores and telangiectatic vessels on the distal nose

59
Q

Rhinophyma may manifest as the final stage of

what other skin disease?

A

Acne rosacea, although not all patients with rhinophyma

have a history of rosacea

60
Q

What nasal disorder results from hypertrophy of

the sebaceous glands in the nasal skin and fibrosis?

A

Rhinophyma

61
Q

What malignant condition can be associated with

rhinophyma?

A

Basal cell carcinoma

62
Q

Which patient population(s) is most commonly

affected by rhinophyma?

A

Whereas acne rosacea is more common in women (3:1) compared with men, rhinophyma almost always affects men (30:1). The disease typically afflicts white men in their
50 through 70 s.

63
Q

How is rhinophyma managed?

A

Inflammation can be managed conservatively, similar to rosacea. For significant hypertrophy, deformity, and nasal
obstruction, surgical recontouring can be performed using,
most commonly, a carbon dioxide laser with or without
dermabrasion.