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18.04.2019

Wide bridge of the nose or how to get rid of an unpleasant defect. Plastic surgery to correct the bridge of the nose

Options for the location of the nasal bridge and the choice of access during corrective operations

All options for the location of the nasal bridge can be divided into three main groups: 1) high nasal bridge; 2) a low nasal bridge and 3) a modified nasal bridge (Fig. 36.6.1).


Rice. 36.6.1. Basic options for the location of the nasal bridge.
a — normal b — high; c - with a modified slope; g - low.


Within each group it is possible various options location of the nasal dorsum, which can be combined with its acquired deformities.

The choice of approach when correcting the nasal dorsum depends on many factors. Closed, and in particular intercartilaginous, access can be used in two main cases:

1) with thick skin (regardless of the volume of intervention), since it masks the unevenness of the treated surface of the back of the nose;

2) when the volume of tissue removed is small and corrective osteotomy is not required.

Open access is appropriate:
1) with thin and normal skin, if the scope of the operation requires resection of a significant amount of tissue and subsequent performance of corrective osteotomy;

2) in complex cases of installation of relatively large cartilage grafts on the dorsum of the nose, when additional fixation with the help of flexible material is required.

If it is necessary to resect one of the sections (or the entire) dorsum of the nose, it is most advantageous for the surgeon to first correct the position of the tip of the nose and thus obtain a landmark, the use of which allows one to accurately plan the extent of resection of the dorsum of the nose. Another sequence of stages of the operation is possible, when the surgeon begins reconstruction from the root of the nose, moving towards its tip.

In most cases, resection of the nasal dorsum is preceded by the collection of cartilage grafts from the posteromedial part of the nasal septum.

Correction of a high nasal bridge

The high bridge of the nose (Fig. 36.6.1, b) is characterized by the following anatomical features:
1) normal or high level the bridge of the nose with its excessive or normal depth;
2) high location of the bone and cartilaginous parts of the dorsum of the nose;
3) hyperprojection of the tip of the nose.

With a lower position of the root of the nose, its high back is perceived as a hump. The following options for its structure are possible (Fig. 36.6.2):
1) convex shape of the high bridge of the nose;
2) high and smooth bridge of the nose with normal level bridge of the nose;
3) a slight or moderate elevation in the area of ​​the osteochondral junction with a normal level of the bridge of the nose and the cartilaginous part of the dorsum of the nose.



Rice. 36.6.2. The main options for the structure of a high nasal bridge.
a - normal; b - convex shape of the high bridge of the nose; c — high and level bridge of the nose with a normal level of the bridge of the nose; d - small or moderate elevation in the area of ​​the osteochondral junction.


A small hump can be easily removed with a rasp from a closed area. With a combination of a normal level of the bridge of the nose and a high bridge of the nose, two options are possible:
1) resection of the high bridge of the nose to the level of the bridge of the nose;
2) less significant resection of the high part of the nasal bridge combined with a decrease in the depth of the bridge of the nose by implanting a cartilage graft into the area of ​​the nasal root.

Thus, in the second case, the surgeon’s actions are similar to his tactics for the nasal bridge with a changed inclination.

When the nasal bridge is high and at the same level, the main tasks of the surgeon are, as a rule, to reduce the height of the nasal bridge (including the bridge of the nose) and reduce the projection of the nasal tip.

Before resection of the high nasal dorsum, the surgeon must separate the surface of the osteochondral vault from the soft tissue covering it. If it is planned to remove a significant part of the vault, then many surgeons consider it advisable to separate the mucoperichondral flap from deep surface the superolateral cartilages and the upper part of the nasal septum, as well as the deep surface of the nasal bones, followed by separation of the superolateral cartilages and the nasal septum. This allows each of these elements to be processed with maximum precision while the mucous membrane is intact.

The apex of the osteochondral vault can be removed en bloc or in stages.

Removal in one block can lead to excessive removal of tissue from the nasal dorsum, so it is preferable to remove the hump in stages, which can begin with resection of the cartilaginous part or, conversely, with intervention on the bones.

Resection of the cartilaginous part of the nasal dorsum can be performed using angularly curved scissors, which are used to resect the superolateral cartilages, and then the dorsum of the nasal septum (Fig. 36.6.3).


Rice. 36.6.3. Stages of resection of the cartilaginous part of the nasal dorsum.
a — resection of the edge of the superior latsral cartilage; b — resection of the dorsal edge of the nasal septum.


Small fragments of the cartilaginous part of the nasal dorsum can be removed using a scalpel No. 15 (blindly) or No. 11 (with visual inspection - Fig. 36.6.4)



Rice. 36.6.4. Resection of the cartilaginous part of the nasal dorsum from the intercartilaginous approach (explanation in the text).


Resection of the bony part of the nasal dorsum. After resection of the cartilaginous part of the nasal dorsum, the amount of resection of the nasal bones is determined (Fig. 36.6.5).



Rice. 36.6.5. Assessment of the level of resection of the nasal dorsum.
Ko - bone part planned for resection (shaded); XP processed cartilaginous part.


With a normal level and depth of the bridge of the nose, relatively small and even medium-sized sections of the nasal bones can be removed in the simplest and most predictable way - using a rasp (Fig. 36.6.6). The great advantage of this approach is the gradual impact on the bone, which virtually eliminates its excessive removal. However, if it is necessary to remove a significant portion of the thick nasal bone or deepen the bridge of the nose, it is better to use chisels (Fig. 36.6.7).



Rice. 36.6.6. Stages of processing the bony part of the back of the nose with a rasp.
a - treatment of the apex of the bony vault; b — smoothing the edges of the bone sawdust.




Rice. 36.6.7. Resection of the bony part of the nasal dorsum using a chisel.


Please note that attempting to do this in one step may result in the formation of an uneven back of the nose due to the formation of chips on the surface of the nasal bones. Therefore, it is advisable to remove a slightly smaller volume first bone tissue(compared to the calculated one), and remove the remaining part using a rasp.

When removing a significant part of the nasal bones, the latter can be cut using a sheet file, the plane of which should be perpendicular to the surface of the bone (Fig. 36.6.8).



Rice. 36.6.8. Resection of the nasal bones using a sheet saw.


“Open roof” and its correction. After resection of a significant thick section of the nasal dorsum, the nasal pyramid on the cross section takes the shape of a truncated cone. The bridge of the nose becomes wide with easily palpable, and with thin skin, visible to the eye outer edges and the nasal septum in the middle (symptom of “open roof” - Fig. 36.6.9).



Rice. 36.6.9. View of the nasal dorsum after resection of a section of significant thickness (symptom of “open roof”).


If this condition is not eliminated, the skin will grow together with the mucous membrane, after which, with a noticeable external defect, a syndrome of increased pain and cold sensitivity of the nose may develop.

The “open roof” is most often eliminated by osteotomy of the edge of the frontal process, which forms the pyriform opening, as well as the nasal bones, which makes it possible to bring the lateral walls of the nose closer together and thereby narrow its dorsum (Fig. 36.6.10).



Rice. 36.6.10. Elimination of the “open roof” using osteotomy.
a — osteotomy levels (dotted line); 6 - after moving the post of the walls of the nasal pyramid.


R. Daniel proposed a classification of the length of the “open roof”, which makes it possible to justify methods for its correction (Table 36.6.1, Fig. 36.6.11).

Table 36.6.1 Classification and characteristics of “open roof” (according to R. Daniel, 1993)




Rice. 36.6.11. Relationship between the volume of resection of the osteochondral vault and the size of the “open roof”.
a - small; b - average; c - extensive.


A small “open roof” is formed by removing a relatively small area and is distinguished not only by its smaller size, but also by the fact that nasal septum It is represented only by cartilaginous tissue and has a significant width.

Accordingly, the openings of the “roof” are narrow, and caudal to them the cartilaginous dorsum of the nose remains intact.

If the nasal dorsum is wide, correction is achieved by lateral osteotomy; if the nasal dorsum is narrow, additional narrowing of the nasal dorsum is impractical and even dangerous, as it can lead to insufficiency of the internal nasal valve. In this case, with thick skin, the surgeon must provide only a flat surface of the cartilaginous skeleton of the nasal dorsum with rounded edges. If the skin is thin, two cartilage grafts can be used to cover the holes (Fig. 36.6.12).



Rice. 36.6.12. Scheme for eliminating a small and medium-sized “open roof” using two cartilage grafts (explanation in the text).


The average "open roof" is characterized by the fact that the nasal septum, which runs along its midline, is narrow and the openings are wide. In most cases, open roof is effectively corrected by a lateral transverse osteotomy. If necessary, longitudinally located cartilage grafts are used.

Extensive "open roof". The significant size of the “roof” openings requires complete mobilization and significant movement of the lateral walls of the nose. However, this is often not enough and wide cartilage grafts have to be used. With their help, the width and shape of the nasal bridge are restored and the collapse of the middle section of the osteochondral vault is prevented (Fig. 36.6.13, a). If there is a wide opening, collapse of the superolateral cartilages can be prevented by using a sufficiently wide dorsal graft. However, in order to ensure that its edges do not protrude under the skin, this requires the additional use of two lateral grafts (Fig. 36.6.13, b).



Rice. 36.6.13. Options for plastic surgery of an extensive “open roof” using cartilage grafts.
a — use of one graft; b — use of three grafts (explanation in the text).


Osteotomies. The most common purpose of osteotomy is to eliminate the “open roof” and also to narrow the bony base of the nose.

Kinds. According to the direction of the line of intersection of the bone, medial (median, oblique and transverse), lateral (bottom-up, bottom-down, double) and combined osteotomies are distinguished (Fig. 36.6.14).


Rice. 36.6.14. Types of osteotomy.
a - medial oblique; 6 - medial middle; c - lateral from bottom to top; g - lateral from bottom to bottom; d - lateral double; e - combined.


Osteotomy is performed from bottom to bottom at the base of the frontal process upper jaw along its entire length. The main advantage of this procedure is the uniform narrowing of the lateral bony walls of the nose. At the same time, the distance from the “roof” to the level of the osteotomy is significant, and it is more difficult to obtain a “greenstick” fracture. The latter sometimes requires additional transverse or oblique osteotomy.

The superior osteotomy corrects the outer wall of the base of the nose and is performed using a 2-mm chisel through the nasal bones and the frontal process of the maxilla.

Inferior osteotomy (from bottom to bottom) is performed with a straight osteotome, moving the selected area of ​​bone in the medial direction. This ensures a narrowing of the base of the nose. Note that in patients with an asymmetric nose, the levels of osteotomy may be different on both sides.

Technique. Osteotomy from bottom to top can be performed with a curved osteotome with a limiter (Fig. 36.6.15, a).
More accurate and less traumatic is percutaneous osteotomy, performed using a 2-mm chisel (Fig. 36.6.15, b). To do this, two micro-incisions are made: behind the wing of the nose and near the root of the nose (or in the area of ​​the inside of the eyebrow). From the first approach, an osteotomy of the caudal segment is performed, and from the second, an osteotomy of the cephalic segment and a transverse (oblique) osteotomy are performed.



Rice. 36.6.15. Options for osteotomy when eliminating the “open roof”.
a - with a curved chisel; 6 — percutaneous osteotomy with a straight two-millimeter chisel: 1 — transbrow access; 2-3 - other accesses.


When choosing the level of osteotomy, it is important not to shift its line towards the back of the nose, otherwise, after moving the bones in the medial direction, a step-like deformation will form noticeable under the skin (Fig. 36.6.16).



Rice. 36.6.16. Selecting the osteotomy level.
a — correctly (2) and incorrectly (1) selected levels; b formation of step-like deformation after osteotomy at an incorrectly selected level (1).


In most cases, the osteotomy is incomplete and displacement of the lateral walls of the nose is achieved by pressing on them with the surgeon’s fingers, which is accompanied by “greenstick” bone fractures (Fig. 36.6.17).



Rice. 36.6.17. Creating a greenstick fracture after an incomplete osteotomy.


With thick nasal bones, a transverse (oblique) osteotomy is also necessary, the line of which connects the top of the “open roof” hole with the top of the lateral osteotomy.

In some situations (usually when correcting a crooked nasal bridge), the surgeon must perform a complete osteotomy, as a result of which the lateral walls of the nose and nasal bones are easily displaced under the pressure of the surgeon's fingers.

Indications for osteotomy largely depend on the initial width of the nasal dorsum. Thus, with a very narrow nasal dorsum, its resection can normalize its width and then, even if significant correction is necessary, osteotomy is not necessary. But even with a wide bridge of her nose top part in some cases it has a mushroom-shaped thickening and removal of the top layer, even without osteotomy, can significantly improve the shape of the nasal dorsum.

For normal and especially thin skin great importance has the elimination of disturbances in the relief of the newly created nasal bridge. This is achieved by additional use cartilage graft, which, if necessary, can cover the entire bridge of the nose.

In this case, a sufficiently long fragment of nasal septum cartilage is required as a donor source.

Another option for receiving flat surface of the nasal dorsum is a transplantation of a section of the temporal fascia (Fig. 36.6.18).



Rice. 36.6.18. Transplantation of a section of the temporal fascia to improve the relief of the nasal dorsum (according to T.Baker and E.Courtiss, 1994).


One of serious complications, which can occur after osteotomy and reposition of the bone walls of the nasal pyramid, is retraction of the nasal dorsum. This situation occurs after a complete osteotomy of the nasal bones when their bases are too close at the time of reposition (Fig. 36.6.19).



Rice. 36.6.19. Slipping bone wall of the nasal pyramid into the cavity of the nasal passage (b) with excessive approximation of the walls of the bony vault after osteotomy (a).


There are three options for getting out of this dangerous situation:
1) reverse reposition of displaced nasal bones with restoration of their support on the bone base by acting on the bones from the inside, from the side of the nasal passage;

2) fixation of the displaced bases of the nasal bones with transversely held knitting needles, which should reliably hold the displaced bones throughout the postoperative period until the resulting scars ensure their sufficient fixation in the new position;

3) plastic surgery of the nasal dorsum with a graft of sufficient thickness with its support on the area of ​​the bridge of the nose and on a durable graft that strengthens the area of ​​the column.

IN AND. Arkhangelsky, V.F. Kirillov

The tiny area between the eyes is called the “root of the mountain” in Chinese, i.e. back of the nose. This platform is very important because it relates to a person's possible aspirations in life and whether he will experience success or failure during the prime years of his life. In this article you will learn how to determine character by the bridge of the nose.

How does the back of the nose affect a person’s character?

A high bridge of the nose speaks of a loyal individual with close family ties. She also points to long life. If this area is flat, but full, then this means that this person is warm-hearted and sincere, and if married, he is happy.

If this area has a break with a depression and horizontal lines crossing the back of the nose (Fig. 68), then this indicates poor health and, possibly, early death. If the bridge of the nose is low and combined with fierce, overhanging eyebrows and the bridge of the nose is deviated to the side, then this indicates that the individual will have poor health in middle age and/or be involved in criminal activities.

However, if in the previous case the general outline of the face is sufficiently long and straight, internal energy strong enough, the skin color is light and clear, the voice is loud and clear, then the difficulties that will arise in front of him will not be so serious. A word of caution: the effect of a kink or hollow can only be truly analyzed by comparison with other facial features, especially the eyebrows and eyes.

Determining a person's character by the back of the nose

The bridge of the nose plays a big role in determining artistry. The ideal bridge of the nose should be high, straight and smooth. She foretells a long life.

A person with a full, well-rounded bridge of the nose is very artistic and will be happy in marriage. On the other hand, a full and well-rounded dorsum of the nose, extending from position 28 down to the tip of the nose, without any defect, portends exceptionally good success, wide fame and universal recognition.

The area specifically associated with longevity is best seen in profile. If positions 44 and 45 are low and sloping to one side, this foretells an early death.

If the nose is narrow and looks like the edge of a sword, then this portends a life of hard, exhausting work. If the bridge of the nose is flat, large and well balanced by both wings of the nose, then this indicates wealth and a cold, calculating nature.

What does the bridge of the nose mean in men and women?

  • How to determine the character of the back of the nose if it is flattened and intersected by horizontal lines? Misfortune awaits this person.
  • If the back of the nose is broken, and with many small ridges, then this indicates poverty and deprivation.
  • A nasal bridge that widens in the middle and is only lightly covered with flesh, combined with low cheekbones and small nostrils, signifies a dull, banal life of hard work with meager rewards. A woman with such a nose is destined to be a widow.
  • The bridge of the nose, crossed by deep lines, portends serious disasters in life.
  • For women, it also means a difficult marriage, ending in separation and divorce. If veins are visible there, then this indicates illicit love affairs.

A weak back indicates early success and late failure in life. This is easily determined by the presence of a depression between the eyes (position 41). A person whose bridge of the nose is neither high nor low, but slopes to the side, will probably have unloving children and will be constantly haunted by failure.

A high bridge of the nose with low and weak cheekbones and jaws indicates birth in a family with a high social position. But such a person will encounter disasters in middle age, and hardships in later years.

Now you know how to determine character by the bridge of the nose.

If the nose or its individual parts are too large in proportion, the face loses a significant part of its attractiveness. If the situation is too wide, it can be radically corrected with rhinoplasty. There are also less traumatic methods, but they give a temporary effect.

Read in this article

The essence of the method

The nose may look wide due to the disproportion of its back, nostrils or wings. Sometimes all these parts require correction. During rhinoplasty, part of the cartilage is removed, and the remaining parts of it are brought closer together and connected.

If the nose is wide due to bone characteristics, an osteotomy is performed. And then they are given a new position to make the nose look thinner. Sometimes grafts are used for this purpose, with the help of which the height of the back is increased. The nose thus visually narrows.


Wide nose correction option

Pros and cons of rhinoplasty

When deciding to undergo surgery, it is worth considering all its pros and cons. The first include:

  • the opportunity to get rid of the disadvantage forever;
  • elimination of psychological problems associated with an unsightly nose;
  • a chance to correct the nuances that interfere with free breathing.

The intervention also has disadvantages:

  • you will have to endure pain, lead a solitary life with restrictions for some time;
  • the result may not be satisfactory, and a repeat operation can only be done in a year;
  • there is a risk of complications;
  • need to get used to a different view own person, which is not always easy.

Indications for changing the shape of the nose

Rhinoplasty should be done if harmony is disturbed:

  • nostrils too wide;
  • the back “blurred” on the face;
  • wide wings;
  • defects along the entire length of the nose.

The operation will help if he was like this from birth, or the deficiencies were formed due to injury.

Contraindications for rhinoplasty

The intervention is not performed if:

  • pathologies of the heart and blood vessels;
  • infections;
  • oncological diseases;
  • diabetes mellitus;
  • poor blood clotting;
  • suppressed immunity.

In most cases, it is contraindicated in patients under 18 years of age.

Preparing for surgery

Before the intervention, the patient undergoes a preliminary stage. Necessary:

  • pass general tests blood and urine, coagulogram, for infections, do an ECG, fluorography, X-ray, CT scan of the sinuses;

CT scan of the sinuses
  • get advice from a therapist, otorhinolaryngologist, surgeon and anesthesiologist;
  • 2 weeks before plastic surgery, stop smoking and alcohol, taking blood thinning medications and staying under ultraviolet rays;
  • Eat a light meal the day before and do not have breakfast on the day of surgery.

How is rhinoplasty of a wide nose (tip and back) performed?

The operation has its own subtleties, if corrected different areas nose It is usually done under general anesthesia, but if only work with cartilage is intended, local is also used. Incisions are made at the base of the nose, exposing the areas to be changed. If a closed method is chosen, access is made through incisions on the mucous membrane, inside. There are 2 types of operations:

  • Back correction. The goal here is to bring the widely spaced bones closer together. They are broken using a tool and excess segments are removed. Sometimes just an osteotomy and moving the bones is enough to narrow the nose.
  • Tip correction. This part is made wide by excess cartilage tissue. It is removed and the remaining parts are connected. Sometimes it is possible to do without resection of the lower cartilage. The widely spaced components of the tip are pulled together with surgical sutures.

Rhinoplasty is completed by suturing the wound. Tampons are placed in the nostrils and a plaster bandage is fixed on top.

To learn how wide nose rhinoplasty is performed, watch this video:

Recovery after

During the rehabilitation period, measures are needed to alleviate the patient’s condition and promote healing:

  • wear a bandage for up to 10 - 14 days, removing it to treat the stitches;
  • rinse the nasal passages with drops prescribed by the doctor;
  • protect yourself from injuries, that is, sleep on your back, do not engage in sports and physical labor (the restriction is valid for 6 - 12 months);
  • do not eat hot or cold food;
  • do not do thermal procedures.

Result before and after

The effect of a high-quality intervention includes several signs:

  • the width of the nose corresponds to the proportions of the face;
  • the back, tip and wings are freed from the tissues that give them excessive size;
  • the postoperative suture is invisible.

Sometimes the new nose may not look like the computer modeled one before rhinoplasty. But it must be taken into account that the final assessment of the result is given only a year after it.

ABOUT rehabilitation period after rhinoplasty, before and after results, see this video:

Why does my nose become wider after rhinoplasty?

Immediately after the intervention there is a presence on the face severe swelling. This makes the nose appear wide. As the swelling disappears, its size becomes more consistent with expectations.

But sometimes, months after surgery, it is obvious that the nose remains wide. The reason for this is the large thickness of scar tissue formed in areas of trauma. You need to go to the doctor with the problem, you may have to do a new operation.

Complications that may occur

Rhinoplasty can leave not only an unsatisfactory external effect, but also bring other problems:

  • bleeding;
  • long lasting external and internal swelling;
  • chronic runny nose;
  • infection;
  • pronounced scars;
  • difficulty breathing;
  • numbness of the skin.

Cost of correcting the shape of the nose

The price of the operation depends on its volume, the qualifications of the surgeon, and the region. If you need to reduce the tip of your nose, it will cost 150,000 - 250,000 rubles. Correcting it along its entire length can cost 300,000 - 500,000 rubles.

Alternative options

You can make your nose thinner and more graceful with:

  • Skillfully applied makeup. Use tone or powder to darken the sides of the back and tip, and, on the contrary, lighten the middle line.

Lateral curvatures of the nasal dorsum (deviations) are often the result of injuries, including birth injuries.

There are 4 degrees of lateral curvature of the nasal dorsum:

  • I degree. Lateral displacement of the nasal bridge by no more than 1/2 of its width.
  • II degree. The lateral displacement of the nasal bridge is no more than the value of its width.
  • III degree . Lateral displacement of the nasal bridge by more than its width.
  • IV degree. Excessive displacement of the nasal bridge to the side.

The external manifestations of a curvature of the nasal bridge may vary. With thin and long nose the same degree of curvature of the back will be more pronounced than with a thick and short nose.

With deformities of the nasal dorsum of II-IV degrees, patients are also diagnosed with trauma to the nasal septum (straight vertical fracture, C-shaped fracture).

Correction of the first degree of curvature of the nasal bridge

Elimination of even minor curvatures of the nasal bridge involves performing a rather complex operation, the result of which is extremely difficult to predict 100%.

If the apex of the deformity is in its bone part, then in this case the optimal solution is to process it with a rasp. If the deformation is more pronounced, then the plastic surgeon needs to perform intervention on all elements of the nose, which undoubtedly significantly increases the complexity of the operation.

Correction of II - IV degrees of curvature of the nasal dorsum

Most often, when correcting this kind of curvature of the nasal bridge, the plastic surgeon is faced with the task of eliminating the deformation at two levels: cephalic and caudal.

Cephalic deformity is located in the area of ​​the fracture of the base of the nasal bones. The apex of the cephalic deformity is located in the area of ​​the bridge of the nose and is often partially masked by soft tissues.

The apex of the caudal deformity is mainly located at the level of the osteochondral junction and/or the cartilaginous part of the nasal dorsum. In this case, as a rule, there is damage to the cartilaginous part of the back of the nose, deformation of the nasal septum, which causes disturbances in nasal breathing.

When eliminating lateral curvatures of the nasal bridge, the plastic surgeon faces the following list of tasks:

  • eliminate cephalic deformity;
  • eliminate caudal deformation;
  • correction of the location of the nasal septum.

Surgical correction often involves performing certain sequences of actions:

  • application of open access;
  • submucosal excision of deformed parts of the nasal septum and vomer;
  • submucosal separation of the elements of the cartilaginous part of the nasal dorsum;
  • osteotomy with comparison of displaced areas of the nasal bones;
  • elimination of deformation of the cartilaginous part of the nasal dorsum;
  • final manipulations on the back of the nose.

First of all, correction of the nasal septum is performed, which subsequently creates conditions for successful comparison of displaced sections of the nasal bones. At the same time, the elements of the cartilaginous part of the nasal dorsum are separated. Afterwards, the position of the bones and cartilage of the nasal dorsum is corrected.

Correcting the position of the nasal bones involves performing an osteotomy.

Correction of deformities of the cartilaginous part of the nasal dorsum

Often, when correcting the cartilaginous part of the nasal dorsum, the plastic surgeon is faced with the following tasks: eliminating deformation of the cartilage of the nasal dorsum; correction of the position of the lateral cartilaginous walls of the nose after osteotomy; change in the height of the nasal bridge; in case of deformation of the caudal part of the nasal septum, it is eliminated.

Elimination of curvature of the cartilage of the nasal dorsum can be achieved by straightening it in the opposite direction. If this is not enough to eliminate the deformation, then additional manipulations are performed.

Correction of the position of nasal cartilage. After an injury, as a result of displacement of the lateral walls of the nasal pyramid, a significant difference in their height may occur. This is most typical for the consequences of perinatal trauma.

With severe curvature, moving the lateral walls of the nose into the desired position leads to the emergence of counteracting forces, which are eliminated after submucosal separation of the superolateral cartilages and nasal septum. In this case, after comparing the displaced areas, one of the cartilages is located above the level of the nasal septum, the other below. Subsequent partial excision of the protruding sections of cartilage makes it possible to obtain the nasal dorsum of the required height. Such manipulations are effective both in eliminating lateral displacement and in reducing the height of the nasal bridge.

Change in the height of the cartilage of the nasal dorsum. IN in rare cases due to the crushing of the cartilage, depression of the nasal bridge is observed at the level of its cartilaginous part. To eliminate such deformation, a plastic surgeon installs cartilage grafts, thereby restoring the damaged relief of the nasal dorsum.

A) Technique of rhinoplasty of the nasal dorsum. After exposing the tip of the nose and giving it the desired shape, it is possible to carry out manipulations on the back of the nose. Soft tissues are separated by sharp or blunt means above the perichondrium of the upper lateral cartilages and the dorsal part of the nasal septum. After reaching the caudal edge of the nasal bones, the periosteum must be separated from it using a periosteal rasp.

Cartilaginous part nasal hump deleted sharp way. In this case, damage to the underlying nasal mucosa should be avoided to prevent the development of nasal valve stenosis. Large bone humps are removed using an osteotome; small humps can be cut down successively with a rasp.

Usually after removal of the bone part of the hump an “open roof” is formed up to the level of the nasal root (separation of the nasal bones along the dorsum), otherwise, for the final medial separation of the nasal bones on both sides, osteotomies are performed with a unilateral osteotome. To prevent collapse of the internal nasal valve after removal of the cartilaginous part of the hump, expansion grafts are installed between the upper lateral cartilages and the nasal septum on both sides.

Lateral osteotomies required to close the “open roof” and to narrow the dorsum of the nose. To do this, an incision is made in the mucous membrane immediately lateral front seat attachment of the inferior nasal concha, through which then soft fabrics separated from the junction of the upper jaw and nasal bones. After this, osteotomies are performed. It is necessary to preserve a piece of bone triangular shape(“Webster’s triangle”), located in the inferolateral corner of the pyriform aperture to prevent medial collapse of the nasal ala in postoperative period. Gradually, the osteotome moves upward, to the junction of the lateral osteotomy line with the medial osteotomy.

If medial osteotomy lines turned out to be located in a paramedial position, when completing lateral osteotomies, the osteotome should be turned inward. After this, the nasal bones become fully mobile, and the surgeon can give them the desired position. If the nasal bones are located asymmetrically or their width is very large, intermediate osteotomies are performed. To do this, after completing the medial osteotomies, but before starting the lateral ones, in the incision through which the lateral osteotomies will be performed, the osteotome is deployed medially along the caudal edge of the nasal bones.

Unilateral intermediate osteotomies are used for unilateral correction of abnormalities in the shape of the nasal bone, and bilateral intermediate osteotomies are used to narrow an excessively wide bony pyramid.

Excess tissue of the cartilage of the nasal dorsum
successively removed with a scalpel No. 11.
(a) After detachment of the periosteum from the nasal bones,
(b) An osteotome is used to remove a large bony hump.
a - Medial oblique osteotomies promote complete medialization of the nasal bones.
b - Osteotomies are used to change the shape and position of the nasal bones. Medial osteotomies are performed paramedially.
Lateral osteotomies pass through the ascending process of the maxilla, preserving a small triangular area at the inferolateral edge of the pyriform aperture.
Intermediate osteotomies are performed between the first two, either for a very wide nose or to correct the shape of the nasal bones. When performing a lateral osteotomy, the bone is divided
from the level of the pyriform aperture to the line of the medial osteotomy.

The shape of the nasal bridge was corrected and the tip was gently reshaped.

b) Correction of the base of the nasal wings. The width of the wings of the nose should be in harmony with both the width of the tip of the nose and the width of its back; its approximate size corresponds to the distance between the vertical lines descending from the medial corners of the eyes. When viewed from below, the wings of the nose and the tip should form an equilateral triangle. The reason for the widening of the wings of the nose may be the thickening of their walls, widening and excessive rounding of the nostrils, or a combination of these two reasons.

Correction of the base of the nasal wings is usually performed after completion of manipulations with the tip and bridge of the nose. The incision is made along the nasal fold and continues into the vestibule of the nose. Then, to reduce the internal or external dimensions of the nasal wing (or both), triangular or wedge-shaped tissue fragments are removed; if necessary, the incision is continued further into the vestibule of the nose or along the nasal fold. Absorbable suture material is used to bring the cartilage segments together. The incision in the vestibule of the nose is also sutured with absorbable suture material. The external incision is sutured with 5-0 or 6-0 continuous monofilament sutures.


Correction of the base of the nasal alae can be used to reduce (a) the thresholds of the nostrils, (b) the edges of the alae, (c) the nostrils themselves.

V) Postoperative care . After placing absorbable sutures on the intranasal incisions and permanent monofilament sutures on the columella incision, a cast is placed on the dorsum of the nose. On the seventh day, the columella sutures and cast are removed, after which a bandage must be applied to the bridge of the nose and tip for another seven days.

G) Complications of rhinoplasty. Complications are quite rare, but do occur. Severe bleeding develops in less than 2-5% of cases, infectious complications are rare. Incomplete osteotomies result in an “open roof” deformity. If the lateral osteotomies were performed too high, a “rocker” type deformity is formed, in which the upper portion of the nasal bones protrudes to the side, and the lower, on the contrary, is medialized, since the lateral osteotomy was performed along the concave part of the bone above the root of the nose.

Reason difficulty breathing through the nose there may be excessive narrowing of the bony pyramid, insufficient correction deviated septum nose or enlarged inferior turbinates, stenosis or collapse of the external and/or internal nasal valves. A “parrot's beak” deformity is formed as a result of thickening of the soft tissues of the tip of the nose, excessive resection of the bony part of the nasal dorsum, and loss of the supporting function of the tip of the nose. Early or late deformities of the nasal tip develop either due to excessive resection of cartilage or damage followed by fibrosis, and are especially common in patients with thin skin, because in them any irregularities in the contour are quite noticeable.

Damage internal nasal valve, uncorrected deformation of the nasal septum or hypertrophy of the inferior turbinates, as well as excessive narrowing of the nose can lead to nasal breathing problems. As a rule, rhinoplasty is successful with patient satisfaction in at least 90% of cases. Repeated operations are successful only in 80% of cases, due to difficulties caused by previous surgery.


Patient before (a) and after (b) rhinoplasty.
The nasal dorsum was augmented, the projection of the nasal tip was increased, and the tip itself became more defined.
To restore the symmetry of the tip of the nose, correction of the base of the wings was required.

:
Septal hematoma
Perforation of the septum
Saddle deformity
Uncorrected hump
Crooked nose
“Open roof” deformation
Rocking-type deformation
Contour irregularities
Parrot beak deformity
Insufficient or excessive rotation/projection of the nasal tip
Difficulty in nasal breathing
Bleeding
Collapse/stenosis of the internal nasal valve
Nasal retraction
Sagging columella

G) Key points :
It is necessary to know the main and minor mechanisms of support of the tip of the nose
It is necessary to understand the concept of the “tripod”
The function of the nose should never be sacrificed for its shape.
The height of the nose (from the root of the nose to the nasolabial angle) usually does not change. The position of the tip of the nose and its back largely depends on the height
One thing to keep in mind is the 3-4-5 right triangle nose concept.
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