2017-18 HSC Section 4 Green Book

Volume 139, Number 3 • Open Dorsal Approach to Rhinoplasty

Fig. 6. Preoperative ( left ) and postoperative ( right ) photographs demonstrating a patient who underwent a dorsal hump reduction and restoration of the dorsal aesthetic lines.

Access can be gained to the dorsum for graft placement, dorsal septal reduction, and correc- tion of dorsal septal deviation. Our technique preserves and/or restores the anterior septal angle as the forefront of the wide caudal and dorsal L-strut for primary support, and the car- tilaginous framework is reconstructed around it, and results in preservation of the internal nasal valve, which is key to nasal function preserva- tion in all rhinoplasties. Access to the posterior septum can be gained for cartilage harvest and septal reconstruction, and the caudal approach facilitates caudal septal resection, medial crural

repositioning, and manipulation of the depres- sor septi muscle. This concept becomes even more important when anatomical planes are not clear and are severely scarred or absent in secondary and tertiary rhinoplasty, where the anterior septal angle becomes the cornerstone on which one must clearly define and locate to begin to perform a successful second- ary rhinoplasty. The anterior septal angle exposure also delineates howmuch of the septum is left or how scarred it is. Once this is determined, the surgeon can rapidly move to another cartilage source such as the rib or ear in an expedient and safe manner.

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