Description

He underwent a Preservation Rhinoplasty, Septoplasty. Valve repair, Costal Cartilage grafts, SEG, Dorsal onlay, Butterfly, Left Batten, turbinate out-fracture, and turbinate reduction.

An inverted V columellar incision and marginal incisions were marked out and incised. The soft tissue envelope was lifted off the cartilage and bony framework. The periosteum over the nasal bones was incised and elevated. We developed a Snoz-flap. The medial crura were sharply divided. The anterior septal angle was identified. A left mucoperichondrial flap was elevated. Dissection proceeded anteriorly around the caudal end of the septum allowing elevation of a mucoperichondrial flap on the right. There was severe right sided deviation. Portions of deviated bone and septum were resected. We needed to use the Piezo saw to remove portions of deviated bone off of the maxillary spine. The caudal septum was dissociated from the maxillary crest we made a sagittal cut through the spine to help seat the caudal end this was secured with a 4-0 pds. suture.

An incision was then made along the pyriform aperture and the skin and soft tissue was elevated off the maxilla and nasal bones to prepare for osteotomies. The piezo saw was then used to make low-low-high osteotomies as well as a horizontal osteotomy at the nasion. The dorsal roof remained intact. Small segments of nasal bone were removed at the pyriform aperture to allow for let down of the dorsal hump.

Next, a modified through and through dorsal cartilage z plasty incision was performed along with an osteotomy through the perpendicular plate of the ethmoid bone to allow for let down of the dorsal hump. At this point, the nasal dorsum was fully let down. A 5-0 prolene was placed around the excised septal cartilage segment to hold the let down dorsal hump in position. An inferior oblique incision is then carried caudally through to the anterior septal angle to level of cartilaginous dorsum.

Inferior septal cartilage was harvested in one piece with care taken to maintain greater than 1.5 cm L strut. The anterior left upper lateral cartilage was released from the septum. Cephalic trims were performed leaving 8mm wide lower lateral cartilages and releasing the scroll. A septal extension graft was fashioned from the harvested septal cartilage and secured to the maxillary crest and left side of the native septum with 4-0 PDS and 5-0 prolene. 5-0 prolene dome spanning and lateral crural tensioning sutures were placed to create new domes and increase rotation, securing the lower lateral cartilages to the septal extension graft. The skin was elevated off the medial crura. A tongue-and-groove procedure was performed and the medial crura were sutured to the caudal septum with 5-0 prolene. Medial crural fixation sutures were placed to secure the medial crura together and narrow the columella. We placed a crushed dorsal onlay graft, a midvault butterfly graft and a left batten graft. They were secured with 5-0 chromic suture.