Dr. Alejandro Nogueira's Case #MWN2Q7N7

Such combination of Middle Eastern ethnic features and the posttraumatic deformities made of this case a challenge of very high difficulty.

It is a matter of highly experienced aesthetic judgment determining what is the right level of a dorsum; such a decision has to take into consideration the tip level, the frontal bone level, the overall facial profile balance and the final nasal size wished or planned.

The same perfect and straight profile can be set at different levels or heights, as long as the radix, the bony dorsum, the cartilaginous middle vault, the supratip and the tip are in the right alignment; deciding what is the adequate alignment line is important in many cases but in those like the one shown here it is extremely difficult to assess and much more to execute technically.

After a thorough reflection it was deemed, evident by the final outcome, necessary applying the principle of the two elevators, one ascending and the other descending in order to meet at the right level.

On one side there is an excessive hump at the upper dorsum, made up by oversized nasal bones which was aggravated by the multiple fractures happened leading to bone thickening; on the other side there is a sunken profile at the lower quarter of the dorsum or supratip, caused by multiple crushes of the supportive caudal septum which has collapsed; finally, the tip, in this specific case, was deemed lacking support, projection and too flat and undefined, considering the masculine facial balance of this patient.

With that said, the right neo level for the dorsal profile is somewhere between the bony hump and the sunken supratip; setting the right level at the bony hump would lead to a straight profile by means of massively raising the sunken part and significantly lengthening the tip, however this would entail an oversized nose; setting the right dorsum at the sunken supratip would force to perform an aggressive reduction scooping of the nasal bones and deproject the tip, ending in a disproportionately small and flat nose, like some ethnicities; this patient's nose needed both, lowering the upper three quarters of the dorsum and raising the lower quarter, with additional increase of tip length so that it balances the dorsum.

A complex revision rhinoplasty procedure was applied via open approach, featured by a initial stage of debridement or surgical cleansing of the massive posttraumatic fibrosis, an essential first step in every and each revision rhinoplasty procedure, which allows assessing the damage, indentifying the viable structures and those which are not and planning the surgical strategy.

The next stage was performing a dorsum narrowing by means of scalpel paramedial resection of the middle vault synchondrosis and a chisel resection of the osseous dorsum synostosis; subsequent osteotomies allowed roof closure and final effective narrowing of the nose at both dorsum and pyramid base, including a very successful medialization to correct the nasal deviation.

Tip work began with cephalic resection of the large ethnic excess of the lateral cruras of the alar cartilages, associated with axial trimming of the lateral cruras length to asymmetrically deproject and rotate upwards the tip; the domes received a transfixing scoring and suturing plasty to make them sharper and better projected; being the caudal septum unexpectedly firm and of good length, it was used to perform a tongue in groove maneuver by means of securing the medial cruras on that part of the septum, thus creating a new and horizontal nasolabial angle, achieving upwards tip rotation and working also as columellar strut to provide suitable support to the tip and to prevent its collapse tendency.

Finally cartilage graft was harvested from the ear concha bowl and shaped with two goals; on one side a custom graft was applied to raise the supratip posttraumatic depression, and on the other side the most challenging part of the procedure, which was shaping and applying with great refinement a custom tip graft, scored in a grid at its outer surface to achieve the optimal curvature and beveled at is edges to prevent its visibility; in literal terms the tip of the nose visible in this case is a result of a fully hand made construction.

Being the dorsal skin of the nose thick prevented the use of temporalis fascia grafting to camouflage the double dorsal work, shaving plus grafting; the final outcome is simply as seen in the images, a perfectly balanced dorsum level, straight, not too high and neither too low, with good tip support and complying with the patient's goals.