Rhinoplasty

Give us a diagram of the nerves and vessels of the nose.

Help us understand the anatomy of the nasal cartilages.

Discuss nasal proportions and landmarks.

Reference(s):

Springer, I. N., Zernial, O., Nolke, F., Warnke, P. H., Wiltfang, J., Russo, P. A. J., … Wolfart, S. (2008). Gender and nasal shape: measures for rhinoplasty. Plastic and Reconstructive Surgery, 121(2), 629–637.

Major and minor tip support mechanisms. What is the “tripod” theory?

What are the standard photodocumentation views for a rhinoplasty?

A 27-year-old male patient requesting rhinoplasty with unreasonable expectations. What is the SIMON complex? Beware!

Reference(s):

Picavet, V. A., Prokopakis, E. P., Gabriels, L., Jorissen, M., & Hellings, P. W. (2011). High prevalence of body dysmorphic disorder symptoms in patients seeking rhinoplasty. Plastic and Reconstructive Surgery, 128(2), 509–517.

Does insurance cover a rhinoplasty for an old fracture? What if the patient has a deviated septum but you are also doing cosmetic work on the tip?  How would you code for this?

Evaluate the depressor septi of your co-residents.  What problems does it cause in rhinoplasty and what should you do about it?

Reference(s):

Rohrich, R. J., Huynh, B., Muzaffar, A. R., Adams, W. P. J., & Robinson, J. B. J. (2000). Importance of the depressor septi nasi muscle in rhinoplasty: anatomic study and  clinical application. Plastic and Reconstructive Surgery, 105(1), 376–378.

Compare and contrast the endonasal vs. open approach.

Reference(s):

Goodman, W.S., Charbonneau, P.A. (2015). External approach to rhinoplasty. Laryngoscope, 125(7), 1505-11.

Cafferty, A, Becker, D.G. (2016). Open and Closed Rhinoplasty. Clin Plast Surg, 43(1), 17-27.

Describe intanasal incisions.

How do you perform osteotomies? Describe the various incisions used to gain access to the lower lateral cartilage.  What are the advantages and disadvantages of each?

Should you always do medial, as well as lateral osteotomies?

Reference(s):

Azizzadeh, B., & Reilly, M. (2016). Dorsal Hump Reduction and Osteotomies. Clinics in Plastic Surgery, 43(1), 47–58.

What are the various methods of infracturing?  What different exposures can be used?

What surgical techniques can be used to increase projection of a nasal tip? Decrease projection?

What surgical techniques can help get rid of a boxy tip?

How do you fix a crooked nose?

Reference(s):

Yeung, A., Hassouneh, B., & Kim, D. W. (2016). Outcome of Nasal Valve Obstruction After Functional and Aesthetic-Functional Rhinoplasty. JAMA Facial Plastic Surgery, 18(2), 128–134.

When and why should we use alar wedge excisions?  Where do the incisions go?

I hate my nose and am going to be your first rhinoplasty patient.  Analyze my nose (be kind) and tell me how you can make me pretty.  Ask Dr. (your facial plastic surgeon) for help.

What surgical techniques can be used to increase projection of a nasal tip? Decrease projection?

What are the various alloplastic implants that can be used in augmentation rhinoplasty?  What are the advantages and disadvantages of each? When would you use cartilage rather than alloplast?

Reference(s):

Peled, Z.M., Warren, A.G., Johnston, P, Yaremchuk, M.J. (2008). The use of alloplastic materials in rhinoplasty surgery: a meta-analysis. Plast Reconstr Surg, 121(3), 85e-92e.

Sherris, D.A., Oriel, B.S. (2011). Human acelluar dermal matrix grafts for rhinoplasty. Aesthet Surg, 31(7), 95S-100S.

What are nasal tip bossae and why do they occur? Can this be corrected?

Reference(s):

Kridel, R. W. H., Yoon, P. J., & Koch, R. J. (2003). Prevention and correction of nasal tip bossae in rhinoplasty. Archives of Facial Plastic Surgery, 5(5), 416–422.

Your first patient as a facial plastics fellow wants surgery to correct his asymmetric nostrils. Impress your new attending with your knowledge on this topic.

Reference(s):

Kim, S.M., Rah,m D.K., Leung, S.C., Yun, I.S. (2013). Surgical considerations in secondary rhinoplasty for effective correction of an asymmetric nostril. J Craniofac Surg, 24(3), 716-9.

How can one narrow a wide nasal dorsum without altering its projection?

Reference(s):

Harris, M. O., & Baker, S. R. (2004). Management of the wide nasal dorsum. Archives of Facial Plastic Surgery, 6(1), 41–48.

Internal and external nasal valves-what are they, how do you evaluate for collapse and how would you correct it?

Septoplasty is considered routine surgery. Tell us how to avoid and manage complications.

Discuss the management of saddle nose deformity. Etiologies?

Lateral nasal wall collapse: compare and contrast various surgical treatments.

Reference(s):

Weissman, J. D., & Most, S. P. (2015). Radiofrequency thermotherapy vs bone-anchored suspension for treatment of lateral nasal wall insufficiency: a randomized clinical trial. JAMA Facial Plastic Surgery, 17(2), 84–89.

What are some common rhinoplasty complications? Can they be prevented?

Reference(s):

Cochran, C. S., & Landecker, A. (2008). Prevention and management of rhinoplasty complications. Plastic and Reconstructive Surgery, 122(2), 60e–7e.

Your rhinoplasty patient is very unhappy two weeks after surgery because her nose is not quite straight and the tip is still boxy.  What should you do?

Describe the pollybeak deformity.  How can you prevent it?

Are patients happy with rhinoplasties? What are revision rates?

Reference(s):

Menick, F. J. (2012). An approach to the late revision of a failed nasal reconstruction. Plastic and Reconstructive Surgery, 129(1), 92e–103e.