2017-18 HSC Section 4 Green Book

Plastic and Reconstructive Surgery • March 2017

the anterior septal angle. The approach begins with a transcolumellar step incision connected to bilat- eral infracartilaginous incisions. The key element here is it keep deep and hug the perichondrium of the lower lateral cartilage at all times to stay in the proper plane. The columellar skin is dissected meticulously from the medial crura, and the nasal skin and subcutaneous tissue are reflected in the subperichondrial plane. This exposes the anterior septal angle and the nasal tip and midvault. The dissection continues cephalad on the cartilaginous dorsum to the keystone area, and then the rest of the area is dissected over the bony dorsum in the subperiosteal plane to free the skin over the nasal bones using a Joseph periosteal elevator. The upper lateral cartilages and lower lateral cartilages are then released from each other using curved sharp scissors by means of the component dorsum approach. 4,5 This maneuver allows adequate retraction of the lower lateral cartilages for anterior septal exposure. The genua of the lower lateral car- tilages are retracted from each other and the inter- domal ligament is divided sharply, which exposes the anterior septal angle. ( See Video, Supplemental Digital Content 1 , which demonstrates the proper exposure of the anterior septal angle, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, available at http://links.lww.com/PRS/C55 .) The anterior septal angle is palpated and the thin mucoperichondrium is incised sharply on each side of the septum at the level of the anterior septal angle. The septum is dis- sected in the submucoperichondrial plane using a no. 15 blade and the Cottle periosteal elevator over the cartilaginous septum going first high and poste- rior, then inferior to the perpendicular plate, and

sweeping inferior and forward to clear the septum off the often deviated vomerine bone. The upper lateral cartilages are sharply released from the dor- sal septum using a no. 15 blade in the submucoperi- chondrial plane, and the remaining septal dissection is completed. This will begin the dorsal component exposure of the nose. Caudally, the dissection continues from the anterior septal angle along the caudal septum between the medial crura down to the anterior nasal spine. This reliably exposes the caudal sep- tum, medial crura, and depressor septi muscle for manipulation of the caudal region of the nose. The anterior septal angle should be reattached or sta- bilized to ensure adequate support to the L-strut. Secondary Rhinoplasty Attention to the exact anatomical position of the anterior septal angle becomes important, especially in revision rhinoplasty, as the surgeon is often met with severely scarred planes with indistinct anatomy in and around the tip and supratip areas. The opera- tive notes are often inadequate andmisleading, offer- ing little information regarding what was previously performed. Palpation of the anterior septal angle (below the scarred interdomal ligamentous region) is the first maneuver once the skin envelope is dis- sected. The lower lateral cartilages are preserved as one proceeds, making sure to use the power of the scar tissue for structural support for later nasal tip refinement. All scar tissue should be kept intact unless it contributes to the deformity, as this is the sta- ble portion of the nasal base for nasal reconstruction. Dissection proceeds cautiously until ana- tomical relationships are clearly elucidated and

Video. Supplemental Digital Content 1 demonstrates the proper exposure of the anterior septal angle, available in the “Related Vid- eos” section of the full-text article on PRSJournal.com or, for Ovid users, available at http://links.lww.com/PRS/C55 .

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