Rhinoplasties in reconstructive surgery

Docteur Ahcene Madjoudj

Personal experience

Docteur Ahcene Madjoudj

Plastic Surgeon.

I practice in the liberal sector in Algiers (Algeria).

I also collaborate with neuro-surgery departments of CHU

Blida and Bab-El-Oued mainly in spina-bifida and Cranio-

facial surgery.

I am a member of the Canadian Society for Aesthetic

Plastic Surgery (csaps).

Definition Rhinoplasty is surgery of the nose shape which aims is

to harmonize it with the rest of the face. In this presentation we address more specifically the

reconstructive rhinoplasty, secondary to traumas or deformities.

Unlike cosmetic rhinoplasty, the reconstructive one, is not codified.

This surgery require technical gestures that will be described on some clinical cases in this presentation.

Issue

Post-traumatic Reconstructive rhinoplasties

Injuries are mostly caused by:

• Traffic accidents , violence. • Mutilation. • Burns. • After Surgery for cancer.

Preoperative The consultation: the patient must not wear nothing that could hide parts of his

face (glasses,cap..) Close attention will be paid to the patient's expectations,

explaining clearly the intervention outcomes and limits . Radiological exams are demanded if needed. The nose exam will determine : Lesions on the nasal pyramidal structure ( bone, cartilage) The impact on the nasal respiratory . Speculum nasal exam must be conducted to look for possible

septal and endo-nasal bones lesions We will evaluate the associated lesions of the face.

Clinical cases

During the intervention both aspects, the aesthetical and functional ,should be considered equally. Both aspects should be treated in the same operatory time

when it is posssible.

General Approach

Post-traumatic rhinoplasties

Will use the hump to fill the isolated cartilaginous dorsum saddles .(personal technique) the bone grafts are taken from the iliac crest or from the

skull(clavarial) In saddles ,Grafts are not always necessary.

General considerations

The saddles

They may concern the cartilage dorsum only or the whole dorsum (bone and cartilage).

Post-traumatic saddle: case I Unilateral intercartilaginous incision. minimal dissection of skin and subperiostal dorsum . Removal of the hump with lateral osteotomies . Iliac bone graft is slept into the saddle .

Post-traumatic saddle:case II No bone graft. Hump removed , lateral osteotomies and bones drawn

together Hump reinclusion on the cartilaginous saddle.

Post-traumatic: case III

Saddle dorsum osteocartilaginous from childhood. Intercatilaginous incision with a minima subcutaneous

dissection . Setting up of two two iliac bone grafts. No columellar strut .

Post-traumatic: case IV Post traumatic saddle No bone graft. No reinclusion paramedian osteotomies Lateral osteotomies draw together the bones on the median line .

Post-traumatic: case V

Cartilaginous saddle post surgery lateral and paramedian osteotomies. auricular cartilage graft affixed on the saddle.

Post mutilation rhinoplasty

• The forehead flap is often the best indication when themutilation is severe.

General considerations

Amputation of the cartilaginous portion of the nose dueto an act of mutilation. Placing the forehead flap weaned at day 21 Defatting were needed .

Rhinoplasty after burn

General considerations Isolated nose burn is rare. Often burn spreads all over the face. The forehead flap reparation is often indicated when

lesions occur on the nose tip. The inflammatory and scarring processes make the

surgical repair very challenging.

Sequels of burns of the face with loss of the nasal tip. Tissues retraction on the nose and the upper lip. Short forehead . To bring the forehead flap to the nasal tip, we

performed : Rhinoplasty with resection of the osteocartilaginous

dorsum to lower it. Lateral osteotomies Placed the forehead flap with some difficulties due to

scarring problems. 4 surgeries revisions were needed .

Patient Case I

Post cancer surgery rhinoplasty

We use the forehead flap technique when theamputation is not important, otherwise we use theforearm to make a composite free flap .

General considerations

Patient case I Nose tip cancer. Wide resection with satisfactory extemporaneous

pathological examination. Placing the forehead flap weaned at day 21. sample’s pathological exam satisfactory.

Patient case II: Sclero-dermiforme epithelioma case

Recurrences are frequent despite pathological findingsoncologically satisfactory. sclero-dermiform ephitelioma recurence occurred each

and every time after surgery. After the third operation, the patient underwent a

radiotherapy which helped stop the cancerous process.

Rhinoplasty in malformations

Binder's syndrome

Lefort II is the best solution in malocclusions. In other cases , results are very gratifying by just

using bone grafts (nasal, maxillar and malar ).

General considerations

Patient case I

• Minor case• Bone graft apposition on the dorsum was enough.

Patient case II significant retrusion of nasomaxillary area without occlusion

problem . Open rhinoplasty. Taking of Iliac bone grafts. Thin and large bone graft is inserted between the septal

mucosas. Next we put a large bone graft to rebuild the dorsum.

Patient case III

affixing of iliac bone grafts on malars, maxillary and thenose

Rhinoplasty post lip and palate cleft surgery

General considerations Those cases are very common and the surgery is very

challenging .

Patient case I

lip alignment surgical revision .For the nose: Open rhinoplasty , alar cartilages dissection Setting up of a columellar strut. suture both alar domes to create the nose tip.

Patient case II Open rhinoplasty No struts , just alars dissection . Suture of the hypoplasic alar to the septum and homolateral

triangular cartilage. suture both alar domes to create the nose tip.

Patient case III

Setting up of a columellar strut. Suture of the hypoplasic alar to the septum and to the

homolateral triangular cartilage. suture both alar domes to create the nose tip.

Conclusion

Although the surgery greatly improves the patients appearance , results are often far below their expectations. It is important to provide them with a rigorous and objective information about the surgery limits to avoid future disappointments.

Thank you. The slides are available on :

www.chirurgieesthetiquealgerie.com