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Flashcards in Rhinoplasty Deck (166):
1

A 55-year-old woman comes to the office because she is dissatisfied with the appearance of her nose, specifically the scars left by acne as a young adult. She has undergone scar revision by punch biopsy and closure as well as dermabrasion by four different physicians but has never been satisfied with the results. She spends approximately 1.5 hours per day putting makeup on her face before leaving the house. She has never married and feels embarrassed to be seen in public because she feels that everyone is staring at her nose. Which of the following most accurately represents the prevalence of this diagnosis in patients who undergo plastic surgery?
A) Less than 1%
B) 2 to 4%
C) 7 to 15%
D) 22 to 25%

C) 7 to 15%

The patient described has body dysmorphic disorder (BDD), which affects 7 to 15% of all plastic surgery patients. In

2

What percent of plastic surgery patients are affected by body dysmorphic disorder?

7 to 15% of all plastic surgery patients.

3

Body dysmorphic disorder

In this disorder, the patient’s degree of concern is far greater than the degree of actual deformity. This perception may involve the entire body or just one area. The patient is generally unaware that his or her concerns are excessive. BDD can be associated with other diagnoses, including depression, substance abuse, social phobia, and/or obsessive-compulsive disorder. The patient is preoccupied with his or her appearance so much that a significant amount of time is spent trying to camouflage or change the outward appearance with makeup.

4

Demographic of patients with body dysmorphic disorder

Most patients with BDD are single (70% never married), and up to 50% have suicidal ideation.

The prevalence of BDD has been shown to be significantly higher in the plastic surgery population than in the general population (1 to 3%). It does not appear to have a gender or cultural predilection.

5

Operating on a patient with body dysmorphic disorder

Operating on these patients almost never leads to a satisfied patient; therefore, preoperative diagnosis is essential.

6

A 21-year-old woman comes to the office because of difficulty breathing through the right nostril and dissatisfaction with the appearance of a “bump” in her nose and a wide tip. History includes three untreated nasal fractures and intermittent seasonal allergic symptoms. Functional septorhinoplasty with spreader grafts and a reduction of the nasal tip and dorsum are performed. One week postoperatively, a fluid collection that tests positive for MRSA infection is noted along the nasal dorsum. Drainage is performed, and oral antibiotics are administered. The patient comes to the office for follow-up 4 weeks postoperatively, and she says she is dissatisfied with the appearance of her nose despite significant functional and cosmetic improvement. Which of the following is the most appropriate strategy to avoid further patient dissatisfaction?
A) Ask the patient to return weekly for the next 6 weeks
B) Explain to the patient that this is a normal postoperative course and ask her to return in 4 months
C) Offer to revise her surgery, explaining that she will have to pay the facility and anesthesia charges
D) Transfer care to another surgeon

A) Ask the patient to return weekly for the next 6 weeks

Patient dissatisfaction following aesthetic surgery has many origins, including unrealistic patient expectations, inappropriate motivation for surgery, poor patient choice on behalf of the surgeon, and underlying psychopathology.

7

Most common reasons for dissatisfaction with aesthetic rhinoplasty

Aesthetic septorhinoplasty cases comprise avery large portion of the dissatisfied patient population. The most common reasons include unsatisfactory results, visible irregularities or scars, continued breathing difficulty, asymmetry, "emotional distress," and the cost of revision surgery.

8

Patients to avoid in aesthetic surgery

Several groups of patients with certain characteristics should be avoided. These include patients with unrealistic or overly idealized expectations, excessively demanding patients, indecisive patients, immature patients, secretive patients, patients motivated to seek surgery by others, patients with unstable personalities, patients with body dysmorphic disorder, patients you simply do not like, and "surgiholics," or "doctor shoppers."

9

Key to dealing with dissatisfied patients postoperatively

Proper communication and frequent contact with the patient postoperatively.

Successful communication requires empathy, compassion, and reflective listening to make sure the patients understandthat their concerns are valid and important. The common denominator of litigation in plastic surgery is poor communication.

10

Preoperative considerations for potential needs for later revision surgery

It is important to establish a revision fee structure prior to embarking on the initial surgery.

11

The principal blood supply to the nasal tip is provided by which of the following arteries in a patient who undergoes open rhinoplasty via a transverse columellar incision?
A) Columellar
B) Lateral nasal
C) Posterior ethmoid
D) Sphenopalatine
E) Superior labial

B) Lateral nasal

12

Principal blood supply to the nasal tip following division of the columellar skin

The principal blood supply to the nasal tip following division of the columellar skin is the lateral nasal artery, a branch of the anterior ethmoid artery (internal carotid circulation).
When rhinoplasty is conducted via stepped incision in the external approach, the columellar artery, a branch of the superior labial artery (external carotid circulation) component, may be abolished by division or cautery.

13

Blood supply to the upper lip

superior labialartery

14

Blood supply to the posterior nasal septum

sphenopalatine artery

15

Blood supply to the upper central nasal septum

posterior ethmoid artery

16

Blood supply to the nasal tip

We conclude that nasal tip blood supply is derived primarily from the lateral nasal arteries, with a variable contribution from the columellar arteries. - Rohrich, 1995

17

A 45-year-old man comes to the office because of a chronic “stuffy nose” that is worse in the mornings than in the evenings. After decongestion, examination shows a slight posterior bony septal deviation, internal nasal valve angle of 12 degrees, and bilateral inferior turbinate hypertrophy. After a failed course of medical management, which of the following is the most appropriate single treatment?
A) Alar batten grafts
B) Flaring sutures
C) Inferior turbinate reduction
D) Septoplasty
E) Spreader grafts

C) Inferior turbinate reduction

18

Most common cause of nasal airway obstruction

bilateral inferior turbinate hypertrophy

19

The normal internal valve angle is:

The normal internal valve angle is 10 to 15 degreesThe normal internal valve angle is 10 to 15 degrees

20

Commonest cause of nasal obstruction

Rhinitis is the common cause of nasal obstruction. Medical treatment should be instituted for turbinate hypertrophy before committing to surgery.

21

Pathogenesis of rhinitis

The most common type, infectious rhinitis, is nearly always caused by a virus (rhinovirus, or the common cold).
Another common cause of nasal obstruction is allergic rhinitis, which is an antigen-antibody reaction mediated by immunoglobulin E.

22

Treatment of allergic rhinitis

Another common cause of nasal obstruction is allergic rhinitis, which is an antigen-antibody reaction mediated by immunoglobulin E.

Many medication options are available for conservative medical management, each having its own specific indications for use. The most useful classes of medications include decongestants, second-generation antihistamines, cromolyn sodium nasal spray (mast cell stabilizer), nasal topical corticosteroids, ipratropium bromide nasal spray (anticholinergic), and corticosteroid injection of the inferior turbinate.

23

___________________ help with internal nasal valve collapse, but are not the most beneficial in this instance.

Spreader grafts and flaring sutures help with internal nasal valve collapse, but are not the most beneficial in this instance.

24

A 45-year-old woman is being evaluated because of discrete, red, facial capillaries that she would like to have removed. Which of the following lasers is most appropriate to ablate the vessels?
A ) KTP (532-595 nm)
B ) Q-switched ruby (694 nm)
C ) Nd:YAG (1064 nm)
D ) Er:YAG (2940 nm)
E ) Carbon dioxide (10,600 nm)

A ) KTP (532-595 nm)

The 532-595 nm wavelength is the most appropriate choice, as it has the highest affinity for the vessels and can be more effective with the appropriate settings.

25

A 32-year-old man with no drug allergies is scheduled to undergo rhinoplasty with cartilage grafting. Which of the following is the primary prophylactic antibiotic of choice for this patient?
A ) Cefazolin
B ) Levofloxacin
C ) Linezolid
D ) Trimethoprim and sulfamethoxazole
E ) Vancomycin

A ) Cefazolin

26

Primary periop antibiotic of choice for plastic surgery patients

Currently, 1 g of cefazolin administered 30 to 60 minutes prior to incision is the primary antibiotic choice in nonallergic patients for most plastic surgery procedures. For beta-lactam allergic patients, clindamycin is recommended as the prophylactic antibiotic of choice. For long (greater than 3.5 hours) or excessively bloody procedures, the recommendation is to consider an intraoperative (second) dose of cefazolin or clindamycin, respectively, not to administer vancomycin.

27

Indication for perioperative Vanc in plastic surgery patients

Vancomycin should be used only when absolutely indicated (high methicillin-resistant Staphylococcus aureus rate, one dose only)

28

A 36-year-old woman is scheduled to undergo secondary rhinoplasty to correct an inverted-V deformity. Which ofthe following operative steps is most likely to correct this deformity?
A ) Infracturing of the frontal processes of the maxilla
B ) Nasal bone rasping
C ) Placement of a spreader graft
D ) Resection of the caudal septum
E ) Weir excisions

C ) Placement of a spreader graft

In the scenario described, spreader grafts fashioned from septal cartilage can be used to correct this deformity. Spreader grafts can also restore an open roof deformity after aggressive hump reduction and recreate the dorsal aesthetic lines while simultaneously maintaining patency of the internal valve.

29

Cause of nasal inverted-V deformity

The inverted-V deformity is often attributed to avulsion of the upper lateral cartilages. It can also be caused by excessive removal of the transverse portion of the upper lateral cartilage during dorsal septal resection. When the transverse portion of the upper lateral cartilage is over-resected, collapse of the nasal sidewalls occurs with retraction of the upper lateral cartilage and exposure of the shape of the nasal bones in the keystone area.

30

Nasal hump deformity is usually corrected with:

Nasal hump deformity is usually corrected with nasal bone rasping.

31

Weir excisions

Weir excisions are resections of the alar bases used to reduce wide or flaring nostrils.

32

Resection of the caudal septum is used to:

Resection of the caudal septum is used to correct the hanging columella.

33

Osteotomy of the frontal process of the maxilla helps:

Osteotomy of the frontal process of the maxilla helps reduce or narrow a wide nasal bridge.

34

A 26-year-old man is referred for evaluation for nasal surgery. He is satisfied with the appearance of the nose, but he has difficulty breathing through it. A Cottle maneuver significantly improves the patient’s breathing. On examination, an anterior rhinoscopy is performed using a nasal speculum. No marked anatomic abnormalities are noted. Which of the following is the most appropriate management?
A ) Placement of a columellar strut
B ) Placement of a lateral crural strut
C ) Placement of a spreader graft
D ) Septoplasty
E ) Submucous resection of inferior turbinate

B ) Placement of a lateral crural strut

35

The Cottle maneuver test for:

The Cottle maneuver is performed by placing lateral traction on the cheek skin. This displaces the lateral nasal wall, thus opening the internal nasal valve.

36

Treatment for narrowed internal nasal valve

The most appropriate management for a narrowed internal nasal valve is the placement of a spreader graft to increase this angle.

37

Treatment for obstruction at external nasal valve

Lateral crural strut

38

Anterior rhinoscopy

An anterior rhinoscopy is the inspection of the anterior portion of the nasal cavity with or without the aid of a nasal speculum.

39

A 25-year-old man undergoes primary rhinoplasty and develops a septal hematoma. Which of the following is the most likely resulting nasal deformity?
A ) Midnasal asymmetry
B ) Pollybeak
C ) Retracted columella
D ) Saddle nose

D ) Saddle nose

40

Deformation following septal hematoma

Saddle nose deformity

41

Columella retraction after rhinoplasty

Columella retraction may result from over-resection of the caudal end of the septal cartilage and/or the nasal spine along with caudal rotation of the cartilaginous septum following overmobilization and/or vertical shortening.

42

A 45-year-old man is scheduled to undergo submucous resection septoplasty to correct left-sided nasal airway obstruction. Which of the following complications is most likely to occur if the surgeon uses a full-transfixion incision instead of a Killian (hemi-transfixion) incision?
A ) Bilateral alar notching
B ) Decreased tip projection
C ) External nasal valve collapse
D ) Middle nasal vault collapse
E ) Saddle nose deformity

B ) Decreased tip projection

43

A full-transfixion incision can lead to:

A full-transfixion incision can lead to decreased tip projection, especially if dissected down over the anterior nasal spine. Support for the nasal tip is lost. A columellar strut can help add support.

44

Alar notching results from:

Alar notching results from over-resection of the lower lateral cartilages

45

External nasal valve collapse results from:

External nasal valve collapse results from weak or narrow lowerlateral cartilages and is addressed by the use of batton grafts

46

Middle nasal vault collapse is prevented by:

Middle nasal vault collapse is prevented by the use of spreader grafts.

47

How much caudal septum should be preserved in a submucous resection septoplasty.

Saddle nose deformity is created by over-resection of the dorsal septum. At least 10 mm of dorsal septum and 10 mm of caudal septum should be preserved in a submucous resection septoplasty.

48

A 35-year-old man has persistent numbness of the nasal tip three years after undergoing cosmetic rhinoplasty through an endonasal approach. Injury to which of the following nerves is the most likely cause of the numbness?
A ) Anterior ethmoidal
B ) Infraorbital
C ) Infratrochlear
D ) Supraorbital
E ) Supratrochlear

A ) Anterior ethmoidal

49

The anterior ethmoidal nerve

The anterior ethmoidal nerve is particularly vulnerable to damage during endonasal rhinoplasty procedures. The nerve emanates from between the nasal bone and the lateral nasal cartilage, supplying sensation to the skin at the distal nasal dorsum and tip.

50

What provides sensation to the skin at the distal nasal dorsum and tip?

The anterior ethmoidal nerve

51

The infraorbital nerve - sensation to the nose

The infraorbital nerve supplies sensory enervation to the lower lateral half of the nose and columellar skin

52

The infratrochlear nerve - sensation to the nose

The infratrochlear nerve supplies the cephalic portion of the nasal sidewalls and the skin overlying the radix.

53

An open rhinoplasty that includes Weir resection for alar flare and tip modification is planned. Which of the following will decrease the risk of columellar flap necrosis?
(A) Limited lateral dissection above the alar groove
(B) Minimal dissection of the septal cartilage
(C) Minimal superior dissection of the osseocartilaginous framework
(D) No use of epinephrine in local anesthetic
(E) Use of only bipolar cautery during dissection

(A) Limited lateral dissection above the alar groove

54

Minimizing risk of loss to the nasal tip and columella

Limited dissection above the alar groove will spare injury to the lateral branch of the angular artery, which is one of five vessels contributing to the blood supply for the nasal tip and columella. However, it is the one source that could contribute to tissue loss if injured.

55

A 22-year-old woman undergoes an open tip septorhinoplasty. Which of the following arteries is the terminal blood supply to the skin envelope?
(A) Angular
(B) Columellar
(C) Facial
D) Lateral nasal
(E) Superior labial

D) Lateral nasal

56

Lateral nasal artery

The lateral nasal artery, which is a branch of the angular artery, supplies the vascular arcade that keeps the nasal tip viable during an open tip septorhinoplasty

57

A 24-year-old man comes to the office because he has had difficulty breathing through the nose, particularly on forced inspiration, for the past six months. He underwent cosmetic rhinoplasty one year ago. He does not have seasonal allergies or sinus problems. Physical examination shows a small dorsal hump; the nose is otherwise aesthetically pleasing and well proportioned. Intranasal speculum examination shows the septum minimally deviated anteriorly to the left. Cottle maneuver is positive on the right. Which of the following is the most appropriate management?
(A) Placement of alar graft
(B) Placement of radix graft
(C) Placement of spreader graft
(D) Reduction of the component dorsal hump
(E) Resection of the submucous septum

(C) Placement of spreader graft

The patient described requires placement of a spreader graft to stent the right internal nasal valve. The Cottle maneuver confirms the presence of internal nasal valve pathology.

58

Treatment for collapse of internal nasal valve causing breathing problems (post-rhinoplasty)

spreader graft

59

Post-rhinoplasty treatment of overresection of the lower lateral cartilages/inspiratory collapse

The patient described requires placement of a spreader graft to stent the right internal nasal valve. The Cottle maneuver confirms the presence of internal nasal valve pathology.

60

A 35-year-old man comes to the office for consultation about a white spot on the tip of the nose. He first noticed it three months ago, and it has gradually become more prominent since then. He underwent rhinoplasty one year ago. Physical examination shows a 3-mm-diameter white area on the nasal tip between the medial crura. Gentle pressure on the surrounding skin makes the white area more prominent. Which of the following is the most likely diagnosis?
(A) Devascularization of the skin as a result of surgery
(B) Displacement of the caudal septum
(C) Fungal infection of the epidermis
(D) Growth of a squamous cell carcinoma
(E) Pressure on the skin of the nasal tip from a graft

(E) Pressure on the skin of the nasal tip from a graft

Although devascularization might show some skin discoloration, it is unlikely to be localized to a small spot.

Displacement of the caudal septum is not an appropriate response, because this usually causes problems with the columella, not the tip.

61

A 30-year-old woman comes to the office for consultation regarding aesthetic improvement of the nasal tip. Examination shows a narrow angulation of the lateral genu (dome) and a 90-degree angle of divergence of the middle crura with an intercrural distance of 8 mm. Which of the following is the most appropriate description of this variation?
(A) Boxy tip
(B) Lateral crus malposition
(C) Narrow lobule
(D) Nostril-lobular disproportion
(E) Supratip deformity

(A) Boxy tip

The boxy tip has been described as a square perimeter of the nasal base that is caused by the position of the lower lateral cartilage. The angle of divergence of the middle crura (and their length) determines the intercrural distance. A wide angle of divergence results in the lateral positioning of the domes appearing like the corners of a box. An angle of divergence of 90 degrees would give a long intercrural distance and a boxy tip. The optimal angle of divergence is approximately 30 to 60 degrees, depending on the literature.

62

Optimal angle of divergence (nose)

30 to 60 degrees

63

A wide angle of divergence results in: (nose)

A wide angle of divergence results in the lateral positioning of the domes appearing like the corners of a box.

64

What determines intercrural distance?

The angle of divergence of the middle crura (and their length) determines the intercrural distance.

65

Type I boxy tip

- increased intercrural angle of divergence (greater than 30 degrees)
- normal domal arc (4 mm or less)

^^ manifesting as the tip-defining points

66

Type II boxy tip

- normal angle of divergence (30 degrees or less)
- a widened domal arc (greater than 4 mm)
- increased angulation of the domes of the lower lateral segments of cartilage

67

Type III boxy tip

- increased angle of divergence (greater than 30 degrees)
- widened crural domal arc (4 mm or greater)

68

A supratip deformity

A supratip deformity describes the fullness in the supratip area, often found after aggressive reduction rhinoplasty.

69

A 36-year-old woman comes to the office because she has persistent difficulty breathing through the nose two years after having rhinoplasty. Examination shows a deviateddorsum and an open roof deformity. Which of the following is the most appropriate method of reconstruction?
(A) Alar batten graft
(B) Columellar strut
(C) Dorsal onlay graft
(D) Lateral nasal wall graft
(E) Spreader grafts

(E) Spreader grafts

70

Placement of spreader grafts

Spreader grafts are placed between the dorsal septum and the upper lateral cartilages in a submucoperichondrial pocket.

71

What are spreader grafts used for?

Spreader grafts are used to restore or maintain the internal nasal valve, straighten a deviated dorsal septum, improve the dorsal aesthetic lines, and reconstruct an open roof deformity

72

What are Alar batten grafts / what is their use?

Alar batten grafts are nonanatomic grafts placed in a pocket extending from the piriform aperture to a paramedian position in the alar sidewall at the site of maximal, lateral, nasal wall collapse during inspiration.

73

What are dorsal sidewall onlay grafts / what are they used for?

Dorsal sidewall onlay grafts are placed along the lateral side of the nose and are different shapes and sizes depending on the indications. They are used to combat localized lateral depressions or asymmetries of the body of the nose and especially to camouflage collapse of the upper lateral cartilages.

74

What are nasal wall grafts / what are they used for?

The lateral nasal wall graft is placed in an undermined pocket between the undersurface of the lateral crus and the vestibular skin; it is stabilized by suturing it to the crus. It is used to correct alar retraction, alar rim collapse, and concave, convex, or malpositioned lateral crura

75

A 35-year-old woman comes to the office for consultation regarding correction of the bulbous appearance of the tip of the nose. She says she would like the nasal tip to be more defined. On physical examination, the lateral crus of the lower lateral cartilage points toward the medial canthus. A cephalic trim of the lower lateral cartilages is planned. Which of the following interventions is most likely to maintain external nasal valve competence?
(A) Addition of an alar rim graft
(B) Low to low lateral osteotomies of the nasal bones
(C) Transection of the medial crura and cephalic repositioning of lateral crura
(D) Use of spreader grafts
(E) Use of transdomal sutures

(A) Addition of an alar rim graft

76

When the lateral crus is malpositioned and a cephalic trim is planned, what can result?

When the lateral crus is malpositioned and a cephalic trim is planned, external valve incompetence can result. Adding support to the alar rim improves external valve competence. Transdomal suturing is used to treat wide domal arches.

77

Transdomal suturing is used to treat what?

Transdomal suturing is used to treat wide domal arches. This often mandates the use of alar rim grafts to support the external nasal valve from the concavity that can occur with the sutures

78

When referring to nasalanatomy, the angle of divergence is made between which of the following structures?
(A) Lateral crura of the lower lateral cartilages
(B) Middle and lateral crura of the lower lateral cartilages
(C) Middle and medial crura of the lower lateral cartilages
(D) Middle crura of the lower lateral cartilages
(E) Septum and upper lateral cartilage

(D) Middle crura of the lower lateral cartilages

79

The angle of divergence:

The angle of divergence refers to the middle crura of the lower lateral cartilages. The angle of divergence is the angle between the right middle crus and the left middle crus running from the medial genu to the lateral genu, while looking at the nose from the anteroposterior view. T

80

A more obtuse angle will cause:

A more obtuse angle produces a long intercrural distance and a more boxy tip.

81

A very acute angle of divergence will cause:

A very acute angle of divergence makes a shorter intercrural distance and a narrow lobule.

82

A shorter or absent middle crus will cause:

A shorter or absent middle crus will cause the tip to appear stubbed with inadequate projection.

83

Tip defining point

The angle from the middle and medial crura refers to the angle of rotation as the tip gently bends cephalad from the columella to the tip-defining point.

84

What forms the angle of the internal valve?

The septum and the upper lateral cartilage form the angle of the internal valve and relate to issues of occlusion of the airway.

85

What forms the lateral genu?

The middle and lateral crura form the lateral genu.

86

A 23-year‑old man comes to the office for follow-up examination four months after undergoing rhinoplasty and horizontal sliding osseous genioplasty with miniplate fixation. He says he has noticed increasing show of his lower teeth since the surgery. Physical examination shows ptosis of the lower lip and a deep inferior gingivobuccal sulcus. Which of the following is the most likely cause of these findings?
(A) Excessive traction by the digastric muscle
(B) Inadequate fixation of the osteotomy segment
(C) Inadequate repair of the mentalis muscle
(D) Injury to the marginal mandibular nerve
(E) Injury to the mental nerve

(C) Inadequate repair of the mentalis muscle

The patient described has a witch’s chin deformity as a complication of a lower buccal sulcus incision for access during an osseous genioplasty. In making this incision, the mentalis muscle is divided. Leaving a cuff of muscle superiorly is helpful because it provides a good tissue base for suturing the muscle when closing the incision. This closure of the muscle helps to resuspend the soft tissue of the chin and prevents ptosis of the lower lip and soft tissues

87

Witch's chin deformity

A witch’s chin deformity is a complication of a lower buccal sulcus incision for access during an osseous genioplasty: In making this incision, the mentalis muscle is divided. Leaving a cuff of muscle superiorly is helpful because it provides a good tissue base for suturing the muscle when closing the incision. This closure of the muscle helps to resuspend the soft tissue of the chin and prevents ptosis of the lower lip and soft tissues.

With inadequate repair, the lower lip becomes ptotic and there is a deep inferior gingivobuccal sulcus.

88

A 25‑year‑old woman is scheduled to undergo rhinoplasty using lateral nasal osteotomy using an external perforating technique. Which of the following arteries is most susceptible to injury during this procedure?
(A) Angular
(B) Anterior ethmoidal
(C) Dorsal nasal
(D) Infraorbital
(E) Lateral nasal

(A) Angular

An external perforating osteotomy is performed at the nasofacial junction. When performing this osteotomy, care must be taken to avoid the angular artery. This artery arises from the facial artery and makes its way toward the nose. Once on the nose proper, the angular artery becomes the lateral nasal artery. The lateral nasal artery provides blood supply to the nasal tip and is not located in the region where the osteotomy is performed.

89

Reason for care during an external perforating osteotomy (nasal)

An external perforating osteotomy is performed at the nasofacial junction. When performing this osteotomy, care must be taken to avoid the angular artery. This artery arises from the facial artery and makes its way toward the nose. Once on the nose proper, the angular artery becomes the lateral nasal artery. The lateral nasal artery provides blood supply to the nasal tip and is not located in the region where the osteotomy is performed.

90

In a worm’s eye view of the Caucasian nose, which of the following is the most common ratio of the lobular portion of the nose to the columella?
(A) 3:1
(B) 2:1
(C) 1:1
(D) 1:2
(E)1:3

(D) 1:2

91

Ideal worm's eye view of the Caucasian nose

The lobular portion of the nose from the worm’s eye view should be in a 1:2 ratio with the columella and nasal apertures. The lobular portion comprises one third and the collumellar portion comprises two thirds of the total distance from the tip to the base. The nostrils should have a teardrop configuration with the diameter of the base slightly larger than the diameter of the apex. The long axis of each nostril points in a slight medial direction.

92

A 32-year-old woman comes to the office because she has persistent paresthesia of the lower lip three weeks after undergoing alloplastic chin augmentation via the submental approach. Which of the following is the most appropriate management?
(A) Gentle external massage
(B) Oral administration of a corticosteroid
(C) Surgical readjustment of the prosthesis
(D) Surgical release of the mentalis muscle fibers
(E) Observation

(C) Surgical readjustment of the prosthesis

Paresthesia of the lip after insertion of an alloplastic chin prosthesis should be resolving or decreasing by two to three weeks postoperatively. If not, the prosthesis should be removed and trimmed superiorly at the level of the mental nerve foramen, or the implant wing should be positioned lower to prevent continued impingement of the mental nerve. Leaving a prosthesis in situ for eight weeks or longer with persistent numbness of the lip may result in some permanent loss of sensation. It is best to adjust prostheses as early as possible—or by four weeks at the latest—for satisfactory results.

93

Timeline for recovery of the mental nerve after insertion of an alloplastic chin prosthesis

Paresthesia of the lip after insertion of an alloplastic chin prosthesis should be resolving or decreasing by two to three weeks postoperatively. If not, the prosthesis should be removed and trimmed superiorly at the level of the mental nerve foramen, or the implant wing should be positioned lower to prevent continued impingement of the mental nerve. Leaving a prosthesis in situ for eight weeks or longer with persistent numbness of the lip may result in some permanent loss of sensation. It is best to adjust prostheses as early as possible—or by four weeks at the latest—for satisfactory results.

94

Latest time by which an alloplastic chin prosthesis should be adjusted postoperatively for mental nerve sensation loss

4 weeks at the latest

95

A 45-year-old man with microgenia is evaluated before undergoing augmentation genioplasty using an alloplastic prosthesis. A lateral cephalogram shows horizontal deficiency of 5 mm. A prosthesis of which of the following thicknesses is most appropriate for correction of this patient’s deformity?
(A) 3 mm
(B) 6 mm
(C) 9 mm
(D) 12 mm

(B) 6 mm

The ratio of soft-tissue response to augmentation genioplasty is approximately 0.8 to 1.0. Therefore, a 5-mm deficiency would best be corrected with a slightly thicker, 6-mm implant.

96

The ratio of soft-tissue response to augmentation genioplasty is :

The ratio of soft-tissue response to augmentation genioplasty is approximately 0.8 to 1.0.

97

A 36-year-old woman comes to the office for consultation regarding surgical augmentation of the chin. Which of the following postoperative outcomes is most likely to occur in this patient if a porous polyethylene prosthesis is used instead of a solid silicone prosthesis?
(A) Capsular contracture
(B) Infection
(C) Ingrowth of tissue
(D) Migration of the prosthesis
(E) Resorption of the prosthetic material

C) Ingrowth of tissue

The pore size (100-to 250-_m diameter) of porous polyethylene prostheses used in facial augmentation procedures is sufficient to allow fibrous tissue ingrowth and, thus, relative incorporation of the prostheses. Smooth surface prostheses, such as solid silicone, inevitably become encased in a fibrous tissue capsule through the host/foreign-body response.

98

A 20-year-old woman has pollybeak deformity of the nose 18 months after she underwent primary rhinoplasty for reduction of a dorsal hump. Which of the following procedures is most appropriate for correction of this patient’s deformity?
(A) Injection of a corticosteroid into the soft tissue of the supra tip
(B) Rasping of the radix
(C) Weir excisions
(D) Resection of the caudal septum
(E) Placement of nasal tip grafts

(E) Placement of nasal tip grafts

99

Pollybeak deformity

The pollybeak deformity, also known as a supratip deformity, is a convexity of the region just superior to the nasal tip (the supratip) when viewed in profile. The nasal tip lacks projection relative to the dorsum. The most common causes are overprojection of the caudal nasal dorsum and inadequate preservation of tip projection. This can be corrected by increasing nasal tip projection using cartilage grafts.

100

When is injection of corticosteroids indicated for correction of a supra tip deformity

Injection of corticosteroids can be used to correct a supratip deformity when given within three months of the primary rhinoplasty and when the deformity is due to formation offibrous tissue in the deadspace between the over-resected dorsum and remaining nasal skin envelope. Injection of corticosteroids is not indicated for any type of supratip deformity more than three months after the primary rhinoplasty

101

A 40-year-old woman undergoes rhinoplasty for correction of boxy tip deformity. Which of the following is the primary purpose of a transdomal suture during this procedure?
(A) Decrease in tip projection
(B) Improvement of columellar projection
(C) Narrowing of the domes
(D) Rotation of the tip
(E) Strengthening of the tip

(C) Narrowing of the domes

102

The purpose of transdomal sutures

The primary purpose of the transdomal suture is to narrow the domes. The secondary purpose of the transdomal suture is to narrow the convexity of the lateral crura. At times, the transdomal suture may also have a tertiary effect of slight increase in tip projection.

103

A 34-year-old man undergoes rhinoplasty using local anesthesia. During resection of the nasal spine, the patient tells the surgeon that he feels pain. Inadequate anesthesia of which of the following nerves is the most likely cause?
(A) Anterior ethmoid
(B) Infraorbital
(C) Internal nasal
(D) Lesser palatine
(E) Nasopalatine

(E) Nasopalatine

104

What does the nasopalatine nerve innervate?

The nasopalatine nerve branches from the pterygopalatine ganglion to innervate the inferior septum and travels through the incisive foramen to join the greater palatine nerve from the palate

105

What does the anterior ethmoid nerve supply?

The anterior ethmoid nerve supplies sensation to the tip of the nose and the lateral nasal vault.

106

What does the internal nasal nerve supply?

The internal nasal nerve is a branch of the anterior ethmoid nerve supplying the anterior nasal lining

107

What does the lesser palatine nerve supply?

The lesser palatine nerve supplies sensation to the soft palate.

108

A 38-year-old man who plays ice hockey undergoes rhinoplasty for correction of a deformity caused by repetitive injury to the nose. During the procedure, spreader grafts are placed. This intervention is most appropriate to achieve which of the following?
(A) Decrease the angle of the internal valve
(B) Narrow the mid vault
(C) Recreate the dorsonasal line
(D) Rotate the nasal tip
(E) Stabilize the external valve

(C) Recreate the dorsonasal line

Spreader grafts are a very useful adjunct in rhinoplasty procedures because they can recreate the dorsonasal line. The dorsonasal line extends from the eye to the nasal tip, making its aesthetics of special concern during rhinoplasty. The graft can be placed above the septal plane to be visible or below the septal plane to be more concealed. When placed above the septal line, the graft will more aggressively define the dorsal aesthetic line. Spreader grafts can be sutured to theseptum and to the upper lateral cartilages at the level of the apex of the internal valve. Spreader grafts can also reconstruct the dorsonasal roof, widen the internal nasal valve, or straighten and buttress a high dorsally deviated septum.

The spreader grafts would make the internal valve angle more obtuse and open the airway; they would not narrow the mid vault but make it more augmented as well as prevent or treat the inverted V deformity

109

Where is the dorsonasal line?

The dorsonasal line extends from the eye to the nasal tip, making its aesthetics of special concern during rhinoplasty.

110

A 68-year-old man comes to the office for consultation regarding rhinoplasty. Examination of the nose shows drooping and elongation of the tip complex. The primary cause of these findings is age-related loss of intrinsic support of which of the following structures?
(A) Columella
(B) Lower lateral cartilage
(C) Nasalis muscle
(D) Septum
(E) Upper lateral cartilage

(B) Lower lateral cartilage

111

Most significant age related changes to the nose

The most significant and distinctive changes in the patient with advancing age occur in the nasal tip. Therefore, it is usually the area that needs the most refinement. This manifests as a drooping, elongated tip complex.

112

Cause of age related change to the nose

Drooping, elongated tip complex:
- Primarily due to loss of intrinsic lower lateral cartilage support.
- Weakening or loss of suspensory ligament support withloss of medial crural support
- Thickening and possible ossification of cartilages, leading to greater prominence
- Thickening of the overlying skin and subcutaneous tissue with concomitant increased vascularity, leading to increased bulkiness and weight of the tip
- Maxillary alveolar hypoplasia with resultant divergence of the medial crural feet and columellar shortening

113

A 28-year-old man comes to the office for consultation regarding a “small” chin. Which of the following is most likely to be achieved with implantation of a silicone prosthesis in this patient’s chin?
(A) Addition of height to the lower face
(B) Correction of asymmetries of the anterior mandible
(C) Effacement of the labial mental fold
(D) Enhancement of sagittal projection to the pogonion
(E) Increase in the bigonial distance

(D) Enhancement of sagittal projection to the pogonion

Modest augmentation of the sagittal projection is the key advantage to a silicone prosthesis. Silicone prostheses cannot reliably improve asymmetries.

114

Optimal genioplasty for patient with significant vertical deficiency and deep labial mental fold

A patient with a significant vertical deficiency and deep labial mental fold would be better served with an osseous genioplasty, or a rigidly fixed porous polyethylene (Medpor) prosthesis, to vertically lengthen the chin, efface the labial mental fold, and add sagittal projection.

115

Advantages of silicone prosthesis for genioplasty

Modest augmentation of the sagittal projection is the key advantage to a silicone prosthesis.

116

Prosthesis to increase biogonial width

Porous polyethylene (Medpor) prostheses can also increase the bigonial width when used to augment the mandibular ramus.

117

Two months after cosmetic rhinoplasty, a patient has numbness of the nasal tip. The most likely explanation is injury to which of the following nerves?
(A) Descending branch of the infraorbital
(B) Descending branch of the lesser palatine
(C) External branch of the anterior ethmoidal
(D) Medial branch of the infratrochlear
(E) Medial branch of the nasopalatine

(C) External branch of the anterior ethmoidal

118

The anterior ethmoidal nerve anatomy

The anterior ethmoidal nerve enters the nose near the crista galli and has two branches. The external branch emerges between the nasal bone and the lateral nasal cartilage and supplies the skin of the nasal tip and alae. It is vulnerable during tip cartilage dissection. The internal branch of the anterior ethmoidal supplies sensation to the septum and the internal nasal walls

119

Anatomy of the nasopalatine

The nasopalatine runs anteroinferiorly on the nasal septum in a groove in the vomer. It supplies sensation to the septum and the hard palate.

120

What does the lesser palatine innervate?

The lesser palatine innervates the uvula, tonsil, and soft palate.

121

A 19-year-old man has numbness of the left lower lip four weeks after undergoing transoral placement of a Silastic chin implant. Physical examination shows superior displacement of the left wing of the implant. Which of the following is the most appropriate management?
(A) Injection of a corticosteroid
(B) Massage
(C) Observation
(D) Reoperation
(E) Taping

(D) Reoperation

122

Concern related to superior displacement of chin implant w/ numbness

Pressure on the mental nerve - and In a patient with numbness, leaving an implant in place for eight weeks or more may lead to permanent loss of sensation due to fascicular pressure and may require nerve repair.

123

A 25-year-old woman comes to the office for postoperative follow-up 10 days after undergoing aesthetic rhinoplasty with rasping of a dorsal hump without the performance of cartilage grafts or osteotomy. Physical examination shows dorsal prominence with erythema but no fluctuance. Which of the following interventions is the most appropriate initial management?
(A) Needle aspiration and irrigation
(B) Observation
(C) Open excision
(D) Oral administration of an antibiotic
(E) Topical administration of an antibiotic

(D) Oral administration of an antibiotic

Because this patient has periostitis of the nasal dorsum, the most appropriate initial management is oral administration of an antibiotic to treat the infection. After the erythema resolves, the dorsal prominence can be surgically excised in 8 to 12 months. Studies show that shavings retained after dorsal rasping or saw osteotomy provide a nidus for periostitis. To reduce the risk of periostitis, all debris should be evacuated from the dorsum at the conclusion of dorsal rasping or saw osteotomy.

124

Periostitis after nasal dorsal rasping or saw osteotomy

Studies show that shavings retained after dorsal rasping or saw osteotomy provide a nidus for periostitis. To reduce the risk of periostitis, all debris should be evacuated from the dorsum at the conclusion of dorsal rasping or saw osteotomy.

The most appropriate initial management is oral administration of an antibiotic to treat the infection. After the erythema resolves, the dorsal prominence can be surgically excised in 8 to 12 months.

125

Resection of the cephalic borders of the alar cartilages and caudal septum during rhinoplasty is most likely to have which of the following effects?
(A) Decrease the alar flare
(B) Lengthen the nose
(C) Lower the columella
(D) Move the tip cephalad
(E)Shorten the nasal bones

(D) Move the tip cephalad

126

Cephalad resection of the lateral alar crus does what?

Cephalad resection of the lateral alar crus moves the tip of the nose cephalad, decreases its fullness, and increases the definition of the projecting points of the dome.

127

A 21-year-old man comes to the office for consultation regarding rhinoplasty because of a large dorsal hump. Effective surgical interventions to eliminate this patient’s deformity include each of the following EXCEPT
(A) augmentation of a saddle-nose deformity
(B) augmentation of the radix with a dorsal implant
(C) rasping of the hump
(D) resection of the hump, followed by osteotomy and infracturing of the nasal bones
(E) separation of the upper lateral cartilages from the nasal septum using a transmucosal incision

(E) separation of the upper lateral cartilages from the nasal septum using a transmucosal incision

128

How much of the nasal dorsal hump is cartilaginous versus bony?

The nasal dorsal hump is predominently cartilaginous (57%) rather than bony (43%).

129

Treatment of a nasal dorsal hump

Humps are classically resected by osteotomy. If an open-roof deformity is created, infracture should be additionally performed. Some surgeons prefer rasping the hump for fine control and shaping.

130

The cartilaginous portion of the nasal dorsal hump is composed of:

The cartilaginous portion of the hump consists of the nasal septum and the upper lateral cartilages. These structures can be resected as a unit sharply. Separating the upper lateral cartilages from the septum is not necessary and can compromise the support of the nose.

131

When should a nasal dorsal hump be treated with additional height?

Some humps are prominent due to lack of height at the radix or the supratip area. For patients with a low caudal nasofrontal junction, a dorsal implant can give the illusion of a reduced hump. Similarly, if a patient has a saddle nose, correction of this defect will make a hump less conspicuous.

132

Each of the following is a general characteristic of the Asian nose EXCEPT
(A) alar flare
(B) bulbous nasal tip
(C) columellar show
(D) thick subcutaneous tissue
(E) wide flat dorsum

(C) columellar show

133

Common anatomic characteristics among Asian patients

Common anatomic characteristics among Asian patients include alar flare, a bulbous nasal tip, a short retracted columella, thick subcutaneous tissue, and wide flat nasal dorsum.

134

Base view of the Asian nose (commonly)

The base view of the nose commonly shows a flat columella-alar triangle with hanging ala and a poorly projecting nasal tip.

135

Upper, middle, lower vaults of the nose

Upper vault: nasal bones, ethmoid, vomer, cephalic septal border

Middle vault: upper lateral cartilages, septum, maxila

Lower vault: alar cartilages and inferior septum

136

Which of the following is the most likely adverse effect of performing infracture of the nasal bones?
(A) Development of an open roof deformity
(B) Development of a supra tip deformity
(C) Narrowing of the internal nasal valve
(D) Narrowing of the nasal tip
(E) Retraction of the columella

(C) Narrowing of the internal nasal valve

Infracture of the nasal bones is performed to narrow the nasal dorsum. However, because the upper lateral cartilages are attached to the nasal bones, this technique may lead to an excessively acute angle (less than 10 degrees) between the upper lateral cartilages and the septum. Narrowing and occlusion of the internal nasal valve can result, causing breathing difficulties.Infracture is also a method of correcting an open roof deformity.

137

The internal nasal valve is comprised anatomically of the septum and which of the following structures?
(A) Caudal edge of the upper lateral cartilage and pyriform aperture
(B) Inferior turbinate and nasal floor
(C) Nasal floor and caudal edge of the upper lateral cartilage
(D) Pyriform aperture and vomer
(E) Vomer and inferior turbinate

(C) Nasal floor and caudal edge of the upper lateral cartilage

138

Anatomy of the internal nasal valve

The internal nasal valve is a triangular shaped passage that is comprised of the septum, the nasal floor, and the caudal portion of the upper lateral cartilage. The normal angle of the internal nasal valve is 10 to 15 degrees; if the angle is less than 10 degrees, airway occlusion at the internal nasal valve may result.

139

A 40-year-old woman is to undergo rhinoplasty to increase projection of the nasal tip. In addition to tip grafting, which of the following techniques will provide the greatest tip projection?
(A) Resection of the lateral crura
(B) Resection of the lower lateral cartilages
(C) Resection of the nasal spine
(D) Suturing of the medial crura
(E) Transfixion incision

(D) Suturing of the medial crura

140

Techniques to increase tip projection

Projection of the nasal tip can be increased by applying a cartilage graft to the tip, suturing the medial crura, and placing a strut graft between the medial crura. In addition, the caudal margin of the septum and cephalic alar rim can be resected to rotate the nasal tip and increase its projection subtly.

141

Techniques to decrease tip projection

Tip projection is decreased by resecting the lateral and medial crura and the nasal spine. Complete transfixion incision ultimatelydecreases projection because it weakens nasal support

142

If the procedures used to correct tip projection lead to a broad-based appearance of the nose:

It should be noted that procedures to correct tip projection can lead to a broad-based appearance of the nose. Weir-type alar resection or nasal sill resection is appropriate for rectifying this problem

143

A 30-year-old man is undergoing evaluation for rhinoplasty. He has a 20 pack/year history of cigarette smoking and says that he has difficulty breathing through his nose. Evaluation of this patient’s breathing difficulties should address each of the following anatomic structures EXCEPT the
(A) dorsal nasal hump
(B) internal nasal valve
(C) nasal septum
(D) nasal vestibule
(E) turbinates

(A) dorsal nasal hump

The dorsal nasal hump is a bony and cartilaginous prominence that does not affect internal nasal air flow

144

Most common cause of nasal airway obstruction in a patient who has had no trauma or previous surgery

Chronic hypertrophy of the inferior turbinate is the most common cause of obstruction in a patient who has had no trauma or previous surgery.

145

In a patient with functional nasal airway obstruction secondary to nasal valve collapse, findings on a Cottle test are negative. To relieve this patient's airway obstruction, which of the following grafts is most appropriate?
(A) Batten graft
(B) Lateral crural strut graft
(C) Septal extension graft
(D) Spreader graft

(D) Spreader graft

This patient has negative findings on the Cottle test, thereby localizing the obstruction to the external nasal valve. To correct the nasal valve collapse, a lateral crural strut graft should be inserted between the vestibular lining and the lateral crus of the lower lateral cartilage.

146

Cottle test

A Cottle test pinpoints the site of collapse. This test can be performed by placing lateral traction on the paranasal skin of the leftcheek, which will distract the upper lateral cartilage away from the septum and open the angle of the internal nasal valve. Any improvement in airflow is considered a positive finding and will confirm the diagnosis of obstruction of the internal nasal valve

147

A 35-year-old man is undergoing surgical correction of a hanging columella. After trimming of the caudal margin of the nasal septum, which of the following is the most appropriate procedure for correction of this deformity?
(A) Caudal resection of the medial crura of the lower lateral cartilage
(B) Placement of a cartilage graft at the nasal spine
(C) Placement of a cartilage strut in the columella
(D) Resection of excess columellar skin
(E) Transposition of an alar cartilage flap into the columella

(A) Caudal resection of the medial crura of the lower lateral cartilage

148

The hanging columella typically results from:

The hanging columella deformity typically results from prominence of the caudal margin of the septum or marked convexity of the caudal margin of the medial crura of the lower lateral cartilage.

149

Management of a hanging columella

Trim the caudal margin of the nasal septum

Although resection of the caudal margin alone is often sufficient for correction of this deformity, additional trimming may be required if the medial crura is excessively large. Following exposure of the medial crura, the excess cartilage and a portion of the mucosal lining may be removed.

150

A 19-year-old man has nasal obstruction on the left. Physical examination shows hypertrophy of the inferior turbinate. (The coronal CT scans shown above depict hypertrophy of the left inferior turbinate in a patient who has a mild septal deviation.) Which of the following is the most appropriate next step in management?
(A) Cottle test
(B) Evaluation for deviated septum
(C) Cephalography
(D) Needle biopsy
(E) Secretory IgA assay

(B) Evaluation for deviated septum

The most appropriate next step in the management of this 19-year-old man with turbinate hypertrophy is evaluation for septal deviation. Because turbinate hypertrophy is also associated with nasal allergies, it is important to determine the underlying cause of the condition in order to appropriately treat it without causing excessive drying of the nasal mucosa and hemorrhage.

151

Which of the following maneuvers performed during rhinoplasty is most likely to result in a saddle nose deformity?
(A) Alar wedge resection
(B) Comminution of nasal bones during in fracture
(C) Displacement of spreader grafts
(D) Excessive resection of the upper lateral cartilages
(E) Onlay grafting of the dorsal septum

(B) Comminution of nasal bones during in fracture

152

Causes of saddle nose deformity

Causes of the saddle nose deformity include excessive resection of the nasal dorsum leading to a loss of dorsal support, excessive resection of the septum, fracture of the perpendicular plate of the ethmoid, or comminution of the nasal bones during infracture that results in their displacement in the piriform aperture.

153

Prevention / management of postoperative saddle nose deformity

Limiting the amount of dorsal hump that is resected will preserve the periosteal attachments over the nasal bones. A minimum of 1 cm of septal cartilage should remain in the dorsum, and its attachment to the perpendicular plate should not be disrupted. The surgeon should be conservative when reducing the dorsal nose, and infracture should be performed to minimize comminution. Onlay grafting of cartilage or bone is the recommended treatment of saddle nose deformity.

154

Which of the following anatomic structures marks the path of the primary inspiratory nasal current?
(A) Inferior turbinate
(B) Middle meatus
(C) Middle turbinate
(D) Superior meatus
(E) Superior turbinate

(B) Middle meatus

155

Through what structure does the main flow of air within the nasal airway pass?

The middle meatus marks the path of the primary inspiratory nasal current; the main flow of air within the nasal airway occurs through this structure.

156

Functions of the nose

Functions of the nose include respiration, humidification, modification of temperature, filtration of particulate matter, olfaction, and phonation.

157

A 25-year-old woman has numbness of the nasal tip two years after undergoing cosmetic rhinoplasty through an endonasal approach. Which of the following is the most likely cause of the numbness?
(A) Division of the descending branches of the infratrochlear nerve
(B) Division of the supratrochlear nerve
(C) Injury to the external nasal branch of the anterior ethmoidal nerve
(D) Injury to the external nasal branch of the supraorbital nerve
(E) Retraction injury to the branches of the infraorbital nerve

(C) Injury to the external nasal branch of the anterior ethmoidal nerve

158

A 37-year-old man has partial airway obstruction on inspiration and a "caved-in" alar rim after undergoing cosmetic rhinoplasty for correction of a bulbous deformity of the nasal tip. Which of the following is the most appropriate management?
(A) Placement of transdomal sutures anchored to the caudal septum
(B) Septoplasty
(C) Use of alar grafts
(D) Use of cranial bone grafts, morselized and placed subcutaneously
(E) Use of middle nasal vault spreader grafts

(C) Use of alar grafts

In this patient who has a pinched nasal tip, the most appropriate surgical technique is insertion of alar grafts. A pinched nasal tip can result from excessive resection of the lower lateral alar cartilages and may lead to airway obstruction secondary to compromise of the external nasal valve. To correct the deformity, alar cartilage can be obtained from the auricle or nasal septum and then placed between and deep to the remaining lateral crura to oppose the forces leading to nasal valve collapse.

159

In addition to the septal cartilage, which of the following structures should be examined carefully in the evaluation oftraumatic deviation of the nasal septum?
(A) Ethmoid and maxilla
(B) Ethmoid and vomer
(C) Nasal bones and sphenoid
(D) Sphenoid and vomer
(E) Vomer and nasal bones

(B) Ethmoid and vomer

The osseous component of the septum, which lies posterior to the cartilaginous component, is comprised primarily of the ethmoid bone in its superior portion and the vomer bone in its inferior portion. Because nasal septal deviation can be either developmental or traumatic (associated with fracture of the nasal bones and/or ethmoid complex), any person with obstruction of nasal airflow should beevaluated for deviation after other causes have been ruled out.

160

In a patient who has just undergone open rhinoplasty, perfusion of the nasal tip depends primarily on which of the following arteries?
(A) Angular
(B) Columellar branch of the superior labial
(C) Dorsal nasal
(D) External branch of the anterior ethmoidal
(E) Lateral nasal

(E) Lateral nasal

161

The facial artery arises from the __________ and then divides into the _______________

The facial artery arises from the external carotid artery and then divides into the angular and labial arteries.

162

Origin of the lateral nasal artery

The lateral nasal artery, which is located in the subdermal plexus at a point 2 mm to 3 mm superior to the alar groove, usually arises from the angular artery.

163

The above photographs are of a 34-year-old woman who is disappointed with the aesthetic result 18 months after undergoing primary rhinoplasty. She says that her lower nose looks pointy and that she has nasal obstruction with deep breathing. On examination, she has alar collapse with inspiration.Which of the following is the most appropriate operative management?
(A) Cartilage grafting to increase tip support
(B) Cephalic trimming of the lower lateral cartilages to increase nasal projection
(C) Osteotomies to narrow the upper nose
(D) Weir resections to decrease alar flare
(E) Trimming of the dorsal septum to correct the polybeak deformity

(A) Cartilage grafting to increase tip support

164

A 26-year-old woman who desires cosmetic rhinoplasty is scheduled to undergo rasping of the nasal hump and reshaping and grafting of the nasal tip followed by Weir excisions. Which of the following factors, if present, will decrease the likelihood of an optimal result in this patient?
(A) Mediterranean heritage
(B) Presence of a bony rather than cartilaginous hump
(C) Smoking history of one-half pack of cigarettes daily
(D) Thickened skin with prominent sebaceous glands
(E) Use of an open technique

(D) Thickened skin with prominent sebaceous glands

A patient who primarily desires a smaller or defined nasal tip but has thick skin and prominent sebaceous glands will not experience the postoperative shrinkage necessary to fit the altered nasal cartilage framework; consequently, the nasal tip may still be larger than is desired by the patient. Consequently, the skin thickness should be assessed during preoperative evaluation and discussed with this patient in order to ensure that her expectations are appropriate.

165

Mild to moderate smoking history and rhinoplasty

A mild-to-moderate smoking history has not been shown to affect rhinoplasty, most likely because of theexcellent blood flow within the nasal plexus.

166

Pros and cons of open rhinoplasty

Open rhinoplasty offers better visualization of the tip cartilage but is associated with greater postoperative edema and the potential development of an external scar. However, the type of exposure should not affect the outcome of the rhinoplasty