Follow Dr. Nassif into the operating room as he utilizes a technique for placement of rhinoplasty spreader grafts.
Dr. Nassif: So this patient has a very long thing middle vault you can see how thin the upper lateral cartilages are attached to the septum. And what I’m going to do is make sure that the mucoperichondrium tunnel is elevated all the way up between the upper lateral cartilage and the septum. So it’s released. Now I want to incise the upper lateral cartilage and I’m going to hide the septum when I do this. We want to keep as much cartilage as possible.
Ok so we released the upper lateral cartilage from the septum. So I’m going underneath the bone and it’s free; following the septum. Ok so now that is free. So after we just released the upper lateral cartilages we’re going to take the bony hump. We’re rasping down the bony hump. We’re not taking down the cartilage much at all, just the bone. So we just finished rasping down the bone it was a smooth transition but this is a very short nasal bone. The rest of the hump that you see here is all cartilage so she’s got an extremely longcartilaginous hump from here all the way to here. So we have to make sure our septum is long enough.
Ok so our next part of the surgery will be to reduce the cartilaginous hump. Ok so we released the upper lateral cartilages and they retracted back and here is the septum. You can see here’s our hump so we’re going to remove-most of the hump is not in the front of the nose it’s more as we go towards the back so we’re going to start conservatively and remove the hump. So we’re just doing the finesse aspect of removing the cartilaginous dorsum. And I can always take more but I never want to be too aggressive. I want to create a nice super tip break.
So we’re trimming the spreader grafts, this is from septo-cartilage along the floor of the nose. As you can see it’s very thin, we might need an alternative source for cartilage because we don’t have a lot of cartilage. Our next step is to perform osteotomies. Ok we’re taking down a good four or five millimeters of hump. The right middle vault is a lot more narrow than the left middle vault. And we’re going to bring the spreader grafts, we really need long ones but we’ll bring them to the keystone area.
Which one is the bigger one out of the two? Let’s see here. This would appear to be the longer and better one. Ok so the trick here is going to be suturing these in. So we just placed the spreader grafts and they’ve been approximated to the septum. I’ll trim them down to make sure they’re absolutely at the same level in the septum. They’re nice and long. Next we’re going to take a look and see where the septum is and then suture the upper lateral cartilages to the spreader grafts and to the septum. We put in our first spreader amount of grafts but we still don’t have some residual narrowing on this right side. So I’m going to take a peek to see if we can put in an extra smaller spreader graft along there to pop it out.
Preoperatively the patient was more narrow on this right side. So now we’re going to put a second spreader graft and try to lateralize the nasal bone a little bit. Since we’re more narrow on the right side we need to put a smaller spreader graft and we might have to trim this to be able to move the lateral nasal wall and the nasal bone out in the lateral direction. This will help symmetrize. This may be too thick but we’ll put it in and see how it looks.
This is a little long we’re going to trim this and shrink it down down a little bit. I’m just going to taper it off but fitting it. You can see that this upper lateral cartilage has more volume than this side. So we’re going to start to stitch everything back together.We just finished placing the spreader grafts. It’s nice and symmetric; ok I think we’re done.