Rhinoplasty

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Rhinoplasty ( ??? rhis , nose ???????? < span lang = "el-Latn" title = "Greek text"> plassein , to form ), commonly known as nose job , is a plastic surgery procedure to repair and reconstruct the shape, restore function, and aesthetically improve the nose by resolving nasal trauma (blunt, penetrating, explosive), congenital defects, respiratory obstruction, or major nasal surgery failure. Most patients ask for lumps, narrow nostrils, altered angles between the nose and mouth, as well as true injury, birth defects, or other problems affecting breathing, such as a distorted nasal septum or a sinus condition.

In surgery - closed rinoplasty and open rinoplasty - otolaryngologist (ear, nose and throat specialist), maxillofacial surgeon (jaw, face, and neck specialist), or surgeon plastics create a functional, aesthetic, and face-proof nose by separating the skin of the nose and soft tissue from the osseo-cartilaginous nose framework, correcting them as necessary for shape and function, tailoring incisions, using glue tissue and applying either pack or stent, or both , to paralyze the corrected nose to ensure proper healing of the surgical incision.

Video Rhinoplasty

Histori

Treatment for repair of damaged nose plastic was first mentioned in Edwin Smith Papyrus, an ancient Egyptian medical text transcription, the oldest known surgical treatise, dated to the Old Kingdom from 3000 to 2500 BC. The rhinoplasty technique was performed in ancient India by the ayurveda doctor Sushruta (800 BC), which depicted nasal reconstruction in Sushruta samhita (around 500 BC), medico-compendium surgery. Doctor Sushruta and his medical students develop and apply plastic surgery techniques to reconstruct the nose, genitals, ears, etc., which are amputated as religious, criminal, or military punishments. Sushruta also developed a forehead flap rinoplasty procedure that remains a contemporary plastic surgery practice. In the compendium of Sushruta samhita, Doctor Sushruta describes the graft-free Indian rhinoplasty (modern) as Nasikasandhana.

During the Roman Empire (27 BC - 476 AD), the encyclopedia Aulus Cornelius Celsus (c. 25 BC - 50) published 8-tome De Medicina (Drugs, c) IK 14), described plastic surgery techniques and procedures for correction and reconstruction of the nose and other body parts.

In the Byzantine Roman palace of the Emperor Julian the Apostate (AD 331-363), the Oribasius royal physician (c 320-400 AD) published 70 volumes of Synagogue Medicae (Medical Compilation, AD 4th century), which describes facial-defect reconstruction featuring loose stitches that allow surgical wounds to heal without disturbing the flesh of the face; how to clean bone exposed to wounds; debridement, how to remove damaged tissue to prevent infection and accelerate wound healing; and how to use autologous skin flaps to repair the damage of cheeks, eyebrows, lips, and nose, to restore the patient's normal face.

Nonetheless, during the medieval centuries of Europe (5th-15th century AD) following the collapse of the Roman Imperial (AD 476), knowledge of Asian plastic surgery of the 5th century BC from Sushruta samhita unknown. to the West until the 10th century, with publication, in Old English, from the Anglo-Saxon physician manual Bald's Leechbook (c) AD 920 illustrates the improvement of cleft lip plastics; as a medical summary, Leechbook is renowned for categorizing diseases and treatments as internal medicine and as an external medicine, to provide herbal medical treatments, and to provide prayer spells, if necessary.

In the 11th century, in Damascus, the Arab physician Ibn Abi Usaibia (1203-1270) translated the Sushruta samhita from Sanskrit to Arabic. In time, the medical summary of the Sushruta traveled from Arabia to Persia to Egypt, and by the fifteenth century Western Western medicine had discovered it as a medical atlas Cerrahiyet-ul Haniye (Imperial Operation, 15th century) , by? erafeddin Sabuncuo? lu (1385-1468); among the surgical techniques featuring breast reduction procedures.

In Italy, Gasparo Tagliacozzi (1546-1599), professor of surgery and anatomy at the University of Bologna, published Curatorum Chirurgia Per Insitionem (Displaced Surgery by Implantation, 1597), a technico-procedural manual for repair and reconstruction of wounded faces face on soldiers. The illustrations feature rhinoplasty retrofitted with biceps spikes; graft attached at 3 weeks post-procedure; which, in 2 weeks post-attachment, the surgeon then formed into the nose.

In time, the 5th century BC Indian rinoplasty technique - which features a free flap graft - was rediscovered by Western medicine in the 18th century, during the Anglo-Mysore Third War (1789-1792) of colonial annexation, by the British against Tipu Sultan, when the East India Company surgeon Thomas Cruso and James Findlay witnessed the Indian rinoplasty procedure at the British Residency in Poona. In English Madras Gazette , the surgeon publishes a photo of the rinoplasty procedure and the results of his nasal reconstruction; later, in the October 1794 edition of London's Gentleman's Magazine in London, Cruso and Findlay doctors published a pictorial report depicting the rhinoplasty of the forehead swaps which is a technical variant of the free graft flap technique that Sushruta has explained about twenty three centuries earlier.

Pre-dating Indian Sushuta samhita is a medical summary of Ebers Papyrus (about 1550 BC), an ancient Egyptian medical papyrus that describes nose surgery as a plastic surgery operation for reconstructing Noses that are destroyed by rinectomy, such defections are imposed as criminal, religious, political, and military punishment at that time and culture. In the event, Indian rhinoplasty techniques continued on the treatment of Western Europe of the 19th century; in the United Kingdom, Joseph Constantine Carpue (1764-1846) published Successful Two Operating Accounts for Restoring the Missing Nose (1815), describing two rinoplasty: reconstruction of a wounded nose due to war, damaged arsenic. (Operation Carpue)

In Germany, the rhinoplastic technique was perfected by surgeons such as the University of Berlin professor Karl Ferdinand von GrÃÆ'¤fe (1787-1840), who published Rhinoplastic (Rebuilding the Nose, 1818) in which he described fifty-five (55) historic plastic surgery procedures (Indian rhinoplasty, Italian rhinoplasty, etc.), and technically innovative free graft reconstruction (with tissue flaps taken from the patient's arm), and surgical approaches for eyelids, cleft lip, and correction a crack in the ceiling. Dr. von GrÃÆ'¤fe's protà © Ã… © gà © Ã… ©, medical and surgical polymath Johann Friedrich Dieffenbach (1794-1847), who was one of the first surgeons to anesthetize patients before performing nose surgery, published Die Operative Chirurgie > (Operative Surgery, 1845), which became the text of medical and basic plastic surgery. (see strabismus, torticollis) In addition, Prussian Jacques Joseph (1865-1934) published Nasenplastik und sonstige Gesichtsplastik (Rhinoplasty and other Plastic Facial Surgery, 1928), which describes fine surgical techniques for nose-reducing. rinoplasty through an internal incision.

In the United States, in 1887, otolaryngologist John Orlando Roe (1848-1915) performed the first modern endonasal rhinoplasty (closed nose cover), which he reported in the article "The Deformity Termed 'Pug Nose" and its Correction, by Simple Operations "(1887 ), and about the management of saddle nose defects.

At the beginning of the 20th century, Freer, in 1902, and Killian, in 1904, each pioneered the resection procedure of septopus Submucous Resection (SMR) to correct a deviant septum; they lift the mucoperichondrial tissue flap, and resection of the cartilaginous and bone septum (including the vomer bone and the perpendicular plate of the ethmoid bone), retain the septal support with a 1.0 cm margin in the dorsum and a 1.0 cm margin at caudad, where the technical innovation becomes a procedure basic standardized septoplastik. In 1921, A. Rethi introduced an open rhinoplasty approach featuring an incision to the columella to facilitate modifying the tip of the nose. In 1929, Peer and Metzenbaum performed the first manipulation of the caudal septum, where it originated and projects from the forehead. In 1947, Maurice H. Cottle (1898-1981) endonasally completed the septal deviation with a minimalist hemi transverse incision, which retained the septum; thus, it advocates the practical advantage of a closed rinoplasty approach. In 1957, A. Sercer advocated the "Decortication des Nase" technique that featured open surgery of rhinoplasty columellar that allowed greater access to the nasal cavity and to the nasal septum.

Nevertheless, in the mid-20th century, despite the refinement of the open rhinoplasty approach, endonasal nose surgery was the usual approach to nasal surgery - until the 1970s, when Padovan presented his technical improvements, advocated an open rhinoplasty approach; he was seconded by Wilfred S. Goodman in the late 1970s, and by Jack P. Gunter in the 1990s. Goodman promotes technical and procedural progress with the article External Approach to Rhinoplasty (1973), which reports on technical improvements and popularizes the open rhinoplasty approach. In 1982, Jack Anderson reported improvements to his nose surgical technique in the article. [Open Rhinoplasty: An Assessment] (1982). During the 1970s, the main application of open rinoplasty surgery was for the first rinoplasty patient (ie, major rinoplasty surgery), not as a revision surgery (ie, a secondary rinoplasty operation) to repair failed nose surgery. In 1987, in the article External Approach to Secondary Rhinoplasty (1987), Jack P. Gunter reported the technical effectiveness of the open rhinoplasty approach for performing secondary nasal surgery; improved techniques improve the management of failed nasal surgery.

Therefore, contemporary rhinoplastic praxis is derived from ancient Indian rhinoplasty (c 600 bc) (nasal reconstruction through autologous forehead skin flap) and its technical variants: Carpue surgery, Italian nose surgery (reconstructed pedicle-fold, aka Tagliocotian rinoplasty); and closed endonasal rhinoplasty approach, featuring an exclusive internal incision that allows the plastic surgeon to feel (feel) the correction done on the nose.

Non-surgical nose surgery

Maps Rhinoplasty

Anatomy of the human nose

Embryological development

At four (4) weeks of pregnancy development, neural crest cells (nasal precursors) initiate caudad migration (from the posterior) toward the midface. Two symmetrical nose nodes (future olfactory epithelium) develop inferiorly, the nostrils then divided into the medial and lateral processes of the nose (front and nose upper lip). The medial process then forms the septum, philtrum, and nasal premaxilla; the lateral process forms the side of the nose; and the mouth is formed from stomodeum (the anterior ectodermal part of the gastrointestinal tract), which is inferior to the nasal complex.

The nasobukal membrane separates the mouth from the nose; respectively, the inferior oral cavity (mouth) and the superior nasal cavity (nose). As the olfactory hole deepens, the word development forms a choanae, two openings connecting the nasal cavity and nasopharynx (the top of a continuous pharynx with the nasal passages). Initially, primitive forms develop, which then develop further into secondary, permanent choanae.

At ten (10) weeks of pregnancy, cells differentiate into muscle, cartilage, and bone. If these important initial facial embryogenesis fails, it may cause anomalies such as choanal atresia (absent or closed sections), medial nostrils (gaps), or lateral nostrils, nasal aplasia (erroneous or incomplete development), and polyrrhinia (double nose).

This normal human embryological development is very important - because the newborn breathes through its nose during the first 6 weeks of life - thus, when a child has bilateral choanal atresia, posterior nasal blockage, either by abnormal bone tissue or by abnormal soft tissue , emergency repair measures are needed to ensure that the child can breathe.

Structure of the nose

For plastic surgical correction, the structural anatomy of the nose understands: A. soft tissue of the nose; B. aesthetic subunits and segments; C arteries and v. blood supply; D. the nasal lymphatic system; E. facial and nose nerves; F. nasal bone; and G. nasal cartilage.

A. The nasal soft tissue

• Nasal Skin - Like the osseo-cartilaginous framework that supports the nose, the external skin is divided into three thirds vertical (anatomic part); from glabella (the space between the eyebrows), to the bridge, to the tip, to corrective plastic surgery, the anatomical nasal skin is considered, as:

1. The third part above - the upper nose skin is thick, and relatively easy to digest (flexible and moving), but then smaller, firmly attached to the osseo-cartilage framework, and into a thin skin of the dorsal, bridge of the nose.
2. The third center - the skin on the bridge of the nose (the mid dorsal part) is the thinnest, least stained, nose skin because it most closely adheres to the support framework.
3. The bottom third - lower nose skin is as thick as the upper nose, as it has more sebaceous glands, especially at the tip of the nose.

• Nasal Layer - In the vestibule, the human nose is coated with a squamous epithelial mucous membrane, which transitions the tissue into column, pseudo-stratified, ciliated columar epithelium (similar- lashes) tissue with abundant seromucinous glands, which retain moisture of the nose and protect the respiratory tract from bacteriological infections and foreign bodies.
• Nose muscles - The movement of the human nose is controlled by groups of facial and neck muscles deep in the skin; they are in four (4) functional groups interconnected by the superficial aponeurosis nasal - superficial musculoaponeurotic system (SMAS) - which is a solid, fibrous collagen bonding network sheets, collagen covering, investing and forming a termination muscle.

The movement of the nose is affected by

1. elevator muscle group - which includes procerus muscle and levator labii superioris alaeque muscle rice.
2. depressor muscle group - which includes nasal and aliphatic muscle and depressor muscles.
3. muscle group of compressors - which includes the transverse nasalis muscle.
4. dilator muscle group - which includes the dilator naris muscles that expand the nostrils; in two parts: (i) the anterior muscle rice dilator, and (ii) the posterior muscle rice dilator.

B. Aesthetic nose - nasal subunit and nasal segment

To plan, map and perform surgical correction of defects or nose defects, the structure of the external nose is divided into nine (9) aesthetic nasal subunits, and six (6) aesthetic nasal segments , which provides plastic surgeons with a step - steps to determine the size, extent, and location of the topography of the nose defect or deformity.

Surgical nose as a nine (9) aesthetic nose subunit

1. subunit tip
2. the columellar subunit
3. the right root subunit
4. right alarit wall subarit
5. leave the subarit of the root wall
6. leaving the base subarit
7. dorsal subunit
8. the right dorsal wall subunit
9. the dorsal subunit of the left wall

In turn, nine (9) nasal aesthetic subunits are configured as six (6) aesthetic nasal segments; each segment understands a larger area of ​​the nose than is understood by the nasal subunit.

Surgical nose as six (6) aesthetic nose segments

1. the dorsal nose segment
2. lateral nasal-wall segment
3. segment hemi-lobule
4. the soft tissue triangle segment
5. segment alar
6. columellar segment

By using the subunit coordinates and segments to determine the location of the topography of the defect on the nose, the plastic surgeon plans, maps, and performs the rinoplasty procedure. The division of the unity of the nasal topography allows the closure of the corrective tissue to be minimal, but precise, sharp, and maximal, to produce a functional nose with size, contour, and proportional appearance for the patient. Therefore, if more than 50 percent of the subunit aesthetic is lost (damaged, damaged, destroyed) the surgeon replaces the entire aesthetic segment , usually with a regional tissue graft, harvested either from the face or head, or with tissue grafts taken from elsewhere in the patient's body.

C. The nasal blood supply - arteries and veins

Like the face, the human nose is also vascularized with arteries and veins, and thus filled with abundant blood. The main arterial blood supply to the nose is doubled: (i) branch of the internal carotid artery, the branch of the anterior ethmoid artery, the branch of the posterior ethmoid artery, originating from the ophthalmic artery; (ii) branches of the external carotid artery, sphenopalatine artery, larger palatine artery, superior labial artery, and angular artery.

the outer nose is given blood by the facial artery, which becomes the angular artery that leads to the superomedial aspect of the nose. The sellar region (sella turcica, "Turkish chair") and the nasal dorsal region are administered with blood by the branches of the internal maxillary artery (infraorbital) and the eye artery originating from the internal internal carotid artery system.

Internally, the nasal lateral wall is provided with blood by the sphenopalatina arteries (from the back and bottom) and by the anterior ethmoid artery and the posterior ethmoid artery (from the top and back). The nasal septum is also administered with blood by the sphenopalatine artery, and by the anterior and posterior ethmoid arteries, with additional circulatory contributions of superior labial arteries and larger palatine arteries. Third (3) the vascular supply to the internal nose is gathered in Kiesselbach plexus (small area), which is the region in the anteroinferior-one third of the nasal septum, (in front and below). Furthermore, nasal venous vascularization of the nose generally follows the arterial vascular pattern of the nose. The nasal blood vessels are biologically significant, since they lack the valves, and because they are direct, the circulation of communication to the sinus caves, allowing the potential of intracranial spread of bacterial infection in the nose. Therefore, due to the abundant supply of nasal blood, tobacco smoking is therapeutically harmful to post-operative healing.

D. The nasal lymphatic system

The corresponding nasal lymphatic system arises from the superficial mucosa, and flows posteriorly to the retropharyngeal (back), and anterior (front) nodes, either to the upper cervical nodes (in the neck), or to the submandibular (neck) gland. lower jaw), or to both the gland and the neck and jaw gland.

E. Nasal nose

The sensation enrolled by the human nose comes from the first two (2) branches the cranial nerve V , the trigeminal nerve (trigeminal nerve). The list of nerves shows the innervation of each (sensory distribution) branch of the trigeminal nerve within the nose, face, and upper jaw (upper jaw).

The nerves indicated serve the facial and nose anatomy areas named

The innervation of the ophthalmic division

• The laryngeal nerve - gives sensation to the skin area of ​​the lateral orbital region (except the lacrimal gland).
• The frontal nerve - gives sensation to the areas of the forehead skin and scalp.
• Supraorbital nerves - provide sensation in the areas of the skin on the eyelids, forehead, and scalp.
• Supratrochlear nerve - provides sensation to the medial area of ​​the eyelid skin area, and the medial area of ​​the forehead skin.
• Nasociliary nerves - provide sensation in the nasal skin area, and mucous membranes of the anterior nasal cavity (front).
• Anterior ethmoid nerve - gives the anterior (front) sensation half of the nasal cavity: (a) the internal area of ​​the ethmoid and frontal sinuses; and (b) the external area, from the tip of the nose to the rhinion: the anterior edge of the nose-bone end of the terminal.
• Posterior ethmoid nerve - serves a superior (upper half) of the nasal cavity, sphenoids, and ethmoids.
• The intratroklear nerve - provides sensation in the medial region of the eyelid, the palpebral conjunctiva, the nasion (nasolabial junction), and the bone dorsum.

Maxillary division grounding

• The maxillary nerve - gives sensation to the upper jaw and face.
• The infraorbital nerve - gives sensation to the area from below the eye cavity to the external nostrils (nostrils).
• Zygomatic nerves - through zygomatic bones and zygomatic arches, provide a sensation to the cheekbone region.
• Superior nerve of the posterior tooth - a sensation in the teeth and gums.
• Superior anterior dental nerve - mediates sneeze reflexes.
• Sphenopalatina nerves - splitting lateral branches and septum branches, and conveying sensations from the back and central areas of the nasal cavity.

The supply of the parasympathetic nerve to the face and upper jaw (maxilla) is derived from the superficial branch of petrosal (GSP) larger than cranial nerve VII , the facial nerve. The GSP nerve joins the deep petrosus nerve (from the sympathetic nervous system), originating from the carotid plexus, to form the vidian nerve (in the vidian canal) that crosses the pterygopalatina ganglion (the autonomic ganglion of the maxillary nerve), where only the parasympathetic nerve forms the synapses, lacrimal glands and nose and palate glands, through the upper (maxilla) maxillary division cranial nerve V , trigeminal nerve.

F. Anatomy of the nasal bone of the nose

At the top of the nose, the nasal bones are attached to the frontal bone. Above and to the side (superolateral), the pair's nasal bones are connected to the lacrimal bone, and below and to the sides (inferolaterally), they attach to the upper jaw (upper jaw) process. Above and back (posterosuperior), the bone nasal septum consists of a perpendicular plate of ethmoid bone. The vomer bone is located at the bottom and back (posteroinferiorly), and partially forms the choanal opening to the nasopharynx, (the top of the continuous pharynx with the nasal passages). The floor of the nose consists of the bone of the premaxilla and the bone palatin, the roof of the mouth.

The nasal septum is composed of rectangular cartilage, vomer bone (vertical plate of ethmoid bone), premaxila aspect, and palate bone. Each lateral nose wall contains three pairs of turbinates (nasal conchae), small, thin, shell bone: (i) superior konka, (ii) the central concha, and (iii) the inferior concha, which is the skeleton of the turbinate. The lateral to the turbinate is the medial wall of the maxillary sinus. Lower than the nasal conchae (turbinate) is the meatus space, with the name corresponding to the turbinate, eg. superior turbine, superior meatus, and others. The internal roof of the nose is constructed by a horizontal, hollow (ethmoid bone) cribriform plate through which it passes through the sensory filaments of the olfactory nerve ( cranial nerve I ); finally, below and behind (posteroinferior) a cribiform plate, tilting down at an angle, is the bony face of the sphenoid sinus.

G. Pyramid of cartilage nose

A spongy cartilage ( septum of rice ) extends from the bones of the nose in the midline (top) to the bone septum in the midline (posterior), then down along the reinforced floor. The rectangular septum; the upper half is flanked by two (2) triangular-to-trapezoid cartilages: the upper lateral cartilage, which integrates with the dorsal septum in the midline, and is laterally attached, with loose ligaments, to the edges of the pyriform bone (pear shaped), whereas the inferior ends of the cartilage lateral over free (unbound). The internal area (angle), formed by the upper septum and lateral-cartilage, is the internal valve of the nose; the adjacent cartilage adjacent to the upper lateral cartilage in fibroareolar connective tissue.

Below the upper lateral cartilage there is a lower lateral cartilage; lower lower lateral cartilage swings outwards, from the medial attachment, to the caudal septum in the midline (medial crura) to the intermediate crus (shank) area. Finally, the lower lateral cartilage bursts out, above and to the side (superolateral), as the lateral crura; This cartilage is mobile, unlike the upper lateral cartilage. Furthermore, some people provide anatomical evidence of nasal scrolling - that is, the outer curve of the lower border of the upper lateral cartilage, and the inward curvature of the cephalic border of the alveolar cartilage.

External nose

Anatomy of the external nose

The nasal-dorsum subunit form, side walls, lobules, soft triangles, alae, and columella - are configured differently, according to race and ethnic group of patients, so that nasal physiognomy is characterized as: Africa, platyrrhine (flat, broad nose); Asiatic, subplatyrrine (low, wide nose); Caucasian, leptorin (narrow nose); and Hispanic, paraleptorrhine (narrow-side nose). The external valves of each nose vary depending on the size, shape, and strength of the lower lateral cartilage.

Internal nose anatomy

At the midline of the nose, septum is a composite (osseo-cartilaginous) structure that divides the nose into two (2) equal parts. The lateral nasal and paranasal nasal walls, superior konka, central concha, and inferior concha, form the corresponding portion, the superior meatus, the middle meatus, and the inferior meatus, on the nasal lateral wall. Superior meat is the area of ​​drainage for the posterior ethmoid bone and sphenoid sinuses; the middle meatus provides drainage for the anterior ethmoid sinus and for the maxillary and frontal sinuses; and the inferior meatus provides drainage for nasolacrimal ducts.

The internal nasal valve consists of an area bounded by lateral-upper cartilage, septum, nasal floor, and anterior head of the inferior turbine. In the narrow nose (leptorin), this is the narrowest part of the nasal airway. Generally, this area requires an angle greater than 15 degrees for unimpeded breathing; for such a narrower correction, the width of the nasal valve may be increased by spreading grafts and flaring sutures.

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Nasal Analysis

Surgical management of nasal defects and deformities divides the nose into six (6) anatomic subunits : (i) dorsum, (ii) side walls (paired), (iii) hemylobules (pairs), (iv) soft triangle (pairs), (v) alae (in pairs), and (vi) columella. Surgical and reconstructive correction understands all anatomical subunits affected by defects (injuries) or deformities, so that all subunits are corrected, especially when defective resection (enclosures) cover more than 50 percent of subunits. Aesthetically, the nose - from the nasion (the midpoint of the nasofrontal junction) to the columella-labial junction - ideally occupies one-third of the vertical dimension of the person's face; and, from ala to ala, ideally should occupy one-fifth of the horizontal dimensions of the person's face.

The nasofrontal angle , between the frontal bone and the nasion is usually 120 degrees; The nasofrontal angle is more acute on the male face than on the female face. The nasofacial angle , the slope of the nose relative to the facial plane, about 30-40 degrees. The nasolabial angle , the slope between the columella and the philtrum, is approximately 90-95 degrees in a man's face, and about 100-105 degrees across a woman's face. Therefore, when observing the nose in the profile, it shows normal columella (the height of the visible nostrils) is 2 mm; and dorsum must be square (straight). When observed from below (eye-worm view), the base of the altar configures an equilateral triangle, with its peak in the infra-tip lobe, immediately below the tip of the nose. Projection projection of the tip of the nose (the tip of the nose from the face) is determined by the Goode Method, where the projection of the tip of the nose should be 55-60 percent of the distance between the nerve (nasofrontal junction) and the end point. Columellar double breaks may exist, marking the transition between the lower and lower crucibles of the lateral cartilage and the medial crucial.

The Goode method determines the extension of the nose from the surface of the face by understanding the distance from the groove to the tip of the nose, and then connecting the measurement (the projection of the tip of the nose) to its length from the nasal dorsum. The projection measurements of the nose are obtained by painting a right triangle with lines separating from the nasion (nasofrontal point) to the alar-facial-groove. Then, a second, perpendicular, crossing the endpoint determines the projection ratio of the tip of the nose; therefore, the range of 0.55: 1 to 0.60: 1, is the ideal nasal-tip-to-nasal-length projection.

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Patient Characteristics

To determine the patient's suitability for a rinoplasty procedure, the surgeon clinically evaluates him with a complete medical history ( anamnesis ) to determine his physical and psychological health. Prospective patients should explain to the surgical and functional aesthetic nose doctor. The surgeon asks about the symptoms of the disease and their duration, passing surgical interventions, allergies, drug use and drug abuse (prescription and commercial drugs), and a general medical history. Additionally, the addition to physical suitability is psychological appropriateness - the psychological motive of the patient to undergo nose surgery is crucial for the surgical preoperative evaluation of the patient's surgeon. In the case of men, the surgeon should identify prospective patients who exhibit mental characteristics symbolized by the psychotic acronym SIMON (single, immature, male, over-expectant, and narcissistic), which may indicate a man-assesses the results of rinoplasty.

A complete physical examination of the rinoplasty patient determines whether he is physically fit to undergo and tolerate the physiological pressure of nasal surgery. This examination understands every physical problem that exists, and consultation with an anesthesiologist, if guaranteed by the patient's medical data. Special facial and nose evaluations record the patient's skin type, existing surgical scar, and symmetry and asymmetry of the aesthetic nose subunit . External and internal nose checks concentrate on third anatomy from the nose - upper, middle, lower part - specifically note their structure; the size of the corner of the nose (where the external nose project from the face); and physical characteristics of bone and soft naso-facial tissue. Internal examinations evaluate the condition of the nasal septum, internal and external nasal valves, turbinates, and nasal lining, paying particular attention to the structure and shape of the nasal dorsum and tip of the nose.

Furthermore, when necessary, special tests - mirror tests, vasoconstriction examinations, and Cottle maneuver - are included in the preoperative evaluation of prospective rinoplasty patients. Established by Maurice H. Cottle (1898-1981), Cottle maneuver is a major diagnostic technique for detecting internal nasal valve disturbances; while the patient gently inspires, the lateral surgeon draws the patient's cheek, thus simulating the widening of the cross-sectional area of ​​the corresponding internal nasal valve. If the maneuver specifically facilitates the inspiration of the patient, the result is a Cottle sign - which generally indicates airflow correction performed by surgery installed. The correction will improve the internal angle of the nasal valve and thus allow unobstructed breathing. However, the Cottle maneuver sometimes produces a false positive Cottle sign, usually observed in patients suffering from collapsed altars, and in patients with injured nasal valve areas.

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Operation rhinoplasty

Open rinoplasty versus closed rinoplasty

Plastic surgical correction of congenital and acquired abnormalities restores functional and aesthetic properties by the manipulation of the nasal skin surgeon, the underlying cartilage-and-bone fracture (subcutaneous), and the mucous membrane layer. Technically, the plastic surgeon's incisional approach classifies nasal surgery either as open rhinoplasty or as a closed rhinoplasty procedure. In open rinoplasty surgery, the surgeon makes a small, irregular incision in the columella, the fleshy nasal septal portion of the nose; This columellar incision is in addition to a series of ordinary incisions for nasal correction. In a closed nose surgery, the surgeon performs any procedural incision endonasally (exclusively inside the nose), and does not cut the columella.

Procedural differences

Except for the columellar incisions, the technical and procedural approach of open rinoplasty and closed rhinoplasty are similar; features a closed rinoplasty procedure:

• Reduces dissection (cuts) of nose tissue - no columella incisions
• Reduced excessive cutback potential (cuts) from nose support
• Reduce post-operative edema
• Reduces visible scars
• Decreased iatrogenic damage (not accidental) on the nose, by surgeon
• Increased availability to affect in situ procedural and technical changes
• Palpation that allows the surgeon to feel the interior changes on the nose
• Shorter operating space time
• Faster post-surgical recovery and recovery for patients

"ethnic nose"

The open rhinoplasty approach gives plastic surgeons the advantage of the ease in securing graft (skin, cartilage, bone) and, most importantly, in looking at proper nasal cartilage, and thus making the right diagnosis. This procedural aspect can be very difficult in revision surgery, and in rhinoplastic correction of the thick "ethnic nose" of colored men or women. Research, Ethnic Rhinoplasty: The Universal Preoperative Classification System for Nasal Tip (2009), reported that the nasal-tip classification system, based on skin thickness, has been proposed to assist surgeons in determining whether open Rinoplasty or closed rinoplasty should repair the defect or deformity that occurs in the patient's nose.

Cause

Causes, open and closed approaches to resolving rhinoplastic correction: (i) nasal pathology (intrinsic disease and extrinsic disease of the nose); (ii) unsatisfactory aesthetic appearance (disproportionate); (iii) failed primary nose failure; (iv) the airway is blocked; and (v) defects and congenital nose deformities.

Congenital aberration

• Cleft lip and palate in combination; cleft lip (cheiloschisis ) and palate crevice ( palatoschisis ), individually.
• Nostril abnormalities
• Genetically-derived genetic nose abnormalities

Experiencing abnormalities like:

• Allergies and vasomotor rhinitis - inflammation of the nasal mucous membrane caused by allergens, and caused by impaired circulatory and nervous system.
• Autoimmune system diseases
• Bites - animals and humans
• Burns - caused by chemicals, electricity, friction, heat, light, and radiation.
• Connective tissue disease
• Inflammatory conditions
• Nasal fracture
• Naso-orbito-ethmoidal fracture - damage to the nose and eye socket; and damage to the bones and walls of the nasal cavity; it is the ethmoid bone that separates the brain from the nose.
• Malignant and benign neoplasms
• Septum hematoma - blood mass (usually) clumps in septum
• Toxins - chemical damage caused by inspired substances - eg. cocaine powder, aerosol antihistamine drugs, and others.
• Traumatic deformities caused by blunt trauma, penetrating trauma, and blast trauma.
• Genital infections - eg, syphilis

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Surgical procedure

Rhinoplastic correction may be performed on a person who is under sedation, under general anesthesia, or under local anesthesia; Initially, a local anesthetic mix of lidocaine and epinephrine is injected to turn off the area, and while reducing vascularization, thus limiting bleeding. Generally, the plastic surgeon first separates the skin of the nose and soft tissue from the osseo-cartilagenous nose framework, and then corrects (reshapes) them as required, afterwards, sews the incision, and then applies an external or internal stent, and tape, to paralyze the newly reconstructed nose, and facilitate the healing of the surgical wound. Sometimes, the surgeon uses an autologous cartilage graft or bone graft, or both, to strengthen or change the contours of the nose. An autologous graft is usually taken from the nasal septum, but, if the cartilage is insufficient (as may occur in revision rhinoplasty), the rib transcellular graft (from the rib) or auricularis cartilage graft (concha from the ear) is harvested from the patient's body. When rinoplasty requires a bone graft, it is taken from the skull, hip, or ribs; In addition, when no type of autologous graft is available, synthetic grafts (nasal implants) are used to enlarge the bridge of the nose.

Photographic recording

For the benefit of patients and surgeons, the history of photography of all rinoplastic procedures is established; starting at the preoperative consultation, continuing during surgical procedures, and ending with postoperative outcomes. To record the physiognomy "before and after" the patient's nose and face, the specific visual perspective required is the nasal photographs seen from the anteroposterior perspective (front-to-back); lateral view (profile), eye-worm view (from below), bird's eye view (overhead), and three-quarter profile views.

• Photo A. - Open rinoplasty: At the end of rinoplasty, after the plastic surgeon has sewed (closed) the incision, the newly corrected nose will be dressed, taped, and dissected immobile to allow uninterrupted healing from a surgical incision. The purple ink guide ensures accurate cutting of the defect correction plan.
• Photo B. - Open rinoplasty: A new nose is prepared with paper tape to receive the nose metal that will paralyze it to maintain its true shape as a new nose.

• Photo C. - Open rinoplasty: After the initial nose removal, custom-made, metal nasal-splint, designed, cut, and shaped by surgeons, paralyze and protect the new soft tissues of the nose during recovery.
• Photo D. - Open rinoplasty: Records, straightening of metal splints, and the installation of a new nose complete the rinoplasty procedure. The patient then recovers, and the wound dressing will be removed at 1 week post procedure.

• Photo 1. - Open rinoplasty: The incision is endonasal (in the nose), and thus hidden. The sash of the skin to the columella helps the plastic surgeon sew properly to hide the scar - except for a columellar (red-dot guideline) incision at the base of the nose. The columellar incision allows the surgeon to see the size, shape, and condition of the nasal and bone cartilage to be corrected.
• Photo 2. - Open rinoplasty: Nose section. Scissors show the lower lateral (blue) cartilage, which is one of the wing-shaped cartilages that adjust the tip of the nose. Jagged red delineation indicates the location of a column incision. After the skin is removed from the bone-and-cartilage skeleton, the surgeon performs the task of correction of the nose.
• Photo 3. - Open rinoplasty: To narrow the tip of the nose too wide, the surgeon first determines the cause of the excessive nasal width. The superimposed stitches will narrow the tip of the nose. Red delineation shows the tip of the nasal cartilage, which narrows as the surgeon tightens the folded cartilage apex. Stitches (light blue) end in needle (white); Tweezers (green) hold the nasal cartilage in place for suturing.
• Photo 4. - Nose excision: Black delineation shows the desired nose reduction: straight nose. The base of the nose is the bone (red) above the toothed gray line, and the cartilage (blue) below the toothed gray line. The surgeon cuts the hump's cartilage with a scalpel, and carves the bone with the osteotome (sculpture). After sculpting the main masses of the nose hump with osteotome, the surgeon then sculpts, refines, and smooths the bone of the nose that is cut with a hoarse (file).

Types of rhinoplasty - primary and secondary

In plastic surgical praxis, the term primary rinoplasty indicates the initial, first, functional, or aesthetic corrective procedure. The term secondary rinoplasty signifies a revision of a failed rinoplasty operation, an occurrence in 5-20 percent rinoplasty surgery, thus an improvement of rinoplasty . The usual correction for secondary nasal surgery includes the re-formation of nasal cosmetics due to functional respiratory deficits from overly aggressive rhinoplasty, asymmetry, curved or crooked nose, collapse area, hanging columella, pinch tip, curved nose and more. Although the most revised rinoplasty procedure is "open approach", such correction is technically more complicated, usually because the nasal support structure is either defective or destroyed in primary nasal surgery; so the surgeon must recreate the nose support with a transplant of cartilage either harvested from the ear (auricular cartilage graft) or from the ribs (grafk cartilage costa).

Nasal reconstruction

In the reconstruction of rinoplasty, defects and abnormalities experienced by plastic surgeons, and must return to normal function, shape, and appearance including damaged and displaced nose bones; disrupted and displaced nasal cartilage; the collapsed bridge of the nose; congenital defects, trauma (blunt, penetrating, explosive), autoimmune disorders, cancer, damage to intranasal drug abuse, and failure of primary rinoplasty results. Rhinoplasty reduces the spine, and re-aligns the nasal bone after cutting (dissected, resected). When cartilage is disturbed, suturing for re-suspension (structural support), or the use of a cartilage graft to disguise depression allows the re-formation of normal nasal contours for the patient. When the bridge of the nose collapses, cartilage, ear cartilage, or skull graft can be used to restore the integrity of anatomy, and thus the aesthetic continuation of the nose. To increase the dorsum of the nose, autologous cartilage and bone graft are preferred over artificial prostheses, due to reduced incidence of histologic rejection and medical complications.

Surgical anatomy for nasal reconstruction

The human nose is a sensory organ structurally composed of three types of tissues: (i) the supportive framework of osseo-cartilage (the nasal trunk), (ii) the mucous membrane layer, and (iii) the external skin. The anatomical topography of the human nose is an elegant convex, curve, and depression, a contour that shows the basic shape of the nasal skeleton. Therefore, this anatomical characteristic enables dividing the nose into nasal subunit : (i) the midline (ii) the tip of the nose, (iii) dorsum, (iv) soft triangle, (v) the lobule of the alar, and (vi) lateral wall. Surgically, the border of the nasal subunit is the ideal location for scars, where superior aesthetic results are produced, the nose is corrected with appropriate skin tone and skin texture.

Nasal skelet

Therefore, successful rhinoplastic results depend entirely on the maintenance or recovery of each of the nasal skeletal anatomy, comprising (a) the nasal bone and upper jaw rising process in the upper third; (b) top-side cartilages paired in the middle third; and (c) lower lower lateral cartilage in the lower third. Therefore, managing surgical reconstruction of damaged, defective, or defective noses requires that plastic surgeons manipulate three (3) layers of anatomy:

1. osseo-cartilagenous skeletons - Upper lateral cartilages firmly attached to the caudal (rear) edges of nasal bones and nasal septum; said attachment delaying them over the nasal cavity. The paired altar cartridge configures a tripod-shaped unit that supports the lower third of the nose. The paired medial crura adjusts the foot-center of the tripod, attached to the anterior spine and septum, in the midline. The lateral crura forms the second leg and the third leg of the tripod, and attaches to the opening of the pirriform (pear-shaped), the nostrils at the front of the skull. The nostrils dome defines the peak of the cartilage of the alar, which supports the tip of the nose, and is responsible for the light reflex tip.
2. the nasal layer - A thin layer of vascular mucosa that is firmly attached to the surface of the deep bone and nasal cartilage. Closely related to the interior of the nose limits the mobility of the mucosa, consequently, only the smallest mucosal defects (& lt; 5 mm) can be sewn primarily.
3. the skin of the nose - A tight envelope derived from glabella (sharpness between the eyebrows), which then becomes thinner and more inelastic (less distensible). The middle skin of one third of the nose covers the upper and lower cartilage cartilage and is relatively elastic, but, on the third end of the nose is far away, the skin is firmly attached to the cartilage of the alar, and slightly inflatable. The skin and soft tissues that underlie the lobe of the alar form a semi-rigid anatomical unit that maintains the graceful curves of the rim of the alar, and the patency of the nostrils (anterior nares). To maintain this shape of the nose and patency, lobe alteration should include a supportive cartilage graft - although the lobe of the alar does not contain cartilage; because the sebaceous glands are numerous, the nasal skin usually has a smooth texture (oily). In addition, regarding scarrification, when compared to other facial skin areas, the skin of the nose produces a rather unobtrusive fine line scar, allowing the surgeon to strategically hide a surgical scar.

The principle of rhinoplastic reconstruction

Principle

The technical principles for nasal surgical reconstruction are derived from the principle of important plastic surgery operations: that the procedures and techniques applied produce the most satisfactory functional and aesthetic results. Therefore, the rhinoplastic reconstruction of the new nasal subunit, from its normal appearance, may be performed in several procedural stages, using intranasal tissue to correct defects in the mucosa; cartilage of battens to strengthen against tissue contraction and depression (topographic collapse); Axial skin flaps are designed from three-dimensional (3-D) templates derived from the nasal topography subunit; and refinement of correction produced by bone sculptor, cartilage, and subcutaneous meat. Nevertheless, surgeons and rinoplasty patients must adhere to the fact that the nasal subunit is reconstructed instead of the right nose, but collagen-stunned collage - the skin of the forehead, the skin of the cheeks, the mucosa, the vestibular lining, the nasal septum, and the fragments of the cartilage of the ear - as the nose just because the contours, skin color, and texture of the skin is true to the original nose.

Recovery

In nasal reconstruction, the plastic surgeon's ultimate goal is to create shadows, contours, skin tones, and skin textures that define the patient's "normal nose", as felt at a distance of about 1.0 meters. However, such aesthetic results suggest the application of a more complex surgical approach, which requires surgeons to balance the rhinoplasty that patients need, with the patient's ideal aesthetic (body image). In the context of surgery reconstructing the patient's physiognomy, the "normal nose" is a three-dimensional (3-D) template to replace the missing part of the nose (aesthetic nasal subunit, aesthetic nose segment), which plastic surgeons recreate using powerful modeling materials , soft, such as bone, cartilage, and skin and tissue folds. In repairing partial nasal defects (injuries), such as the lobule of the alar (the dome above the nostrils), the surgeon uses the non-damaged, counter-contralateral side as a 3-D model to create an anatomical framework for creating a defective nasal subunit, by printing the soft print material directly on the anatomy of the normal and undamaged nose. To affect total nasal reconstruction, the template may come from quotidian observations of the "normal nose" and from the patient's photo before he suffered nasal damage.

The surgeon replaces lost parts with tissues such as quality and quantity; the nose layer with the mucosa, cartilage with cartilage, bone with bone, and skin with the skin that best suits the original skin color and skin texture of the damaged nose subunit. For surgical repair of this kind, the skin flap is preferable to the skin graft, since the skin flap is generally a superior remedy for matching the color and texture of the nasal skin, preferably inhibiting tissue contractures, and providing better vascularization of the nasal bone; thus, when there is enough skin to allow tissue removal, the nasal skin is the best source of nasal skin. In addition, despite having prominent scar tissue, the nasal skin flap is a major consideration for nasal reconstruction, because of its greater verisimilensity.

The nasal reconstruction most effective to repair a nasal skin injury, is to recreate all nasal subunits; thus, the wound is enlarged to understand the entire subunit of the nose. Technically, this surgical principle allows putting scars in topographic transition zones between and between adjacent aesthetic subunits, which avoid juxtaposing two different skin types in the same aesthetic subunit, where color and texture differences may prove too visible even when reconstructing the nose with a skin flap. However, in the final stages of nasal reconstruction - replicating the anatomy of a normal "nose" with subcutaneous sculpting, surgeons do have technical leeway to revise the scars, and make them (less) conspicuous.

Reasons for reconstruction

Rinoplasty reconstruction is indicated for correction of defects and defects caused by:

1. Skin cancer. The most common cause (etiology) for nasal reconstruction is skin cancer, especially lesions of the nose melanoma and basal cell carcinoma. This oncology epidemiology occurs more easily among parents and people living in a very bright geographical area; Although each skin type is prone to skin cancer, whites are the most vulnerable epidemiologically to developing skin cancer. In addition, concerning plastic surgery scars, patient age is an important factor in the timely post-operative recovery of a skin cancer defect (lesion); in terms of scarrification, the highly elastic skin of young people has a greater regenerative tendency to produce thicker (stronger) and more visible scars. Therefore, in young patients, the strategic placement (hiding) of rhinoplastic scars is a greater aesthetic consideration than in older patients; less elastic skin produces a narrower and less visible scar.
2. Traumatic nasal defect. Although trauma is a less common rhinoplastic occurrence, nasal defects or defects caused by blunt trauma (collision), penetrating (puncture) trauma, and blunt (blunt and penetrating) trauma require surgical reconstruction that adheres to conservative operating principles plastic, as in correction of cancer lesions.
3. Default abnormality. The unique plastic properties of bone, cartilage, and skin of patients suffering from congenital defects, and related anomalies, are considered separate.

Surgical technique

The effectiveness of rhinoplastic reconstruction of the external nose is derived from the contents of the expert skin flap surgeon applicable to repair the defects of the nasal skin and mucosal lining; some management techniques are Bilobed flap , Nasolabial flap , Paramedian forehead , and Septal mucosal flap .

I. The bilobed flap

The design of the bilobed flap originates from the creation of two adjacent random transposition flaps (lobes). In the original design, the leading flap was used to cover the defect, and the second flap, superimposed on the skin where it flexed more, and filled the site-donor cut (from where the first flap was harvested), which was then closed largely. , with stitches. The first flap is geometrically oriented, at 90 degrees from the long axis of the wound (defect), and the second flap is oriented 180 degrees from the wound axis. Although effective, bilobed flap techniques do create troublesome "dog ears" of overfed meat that require pruning and also result in large areas of skin donor that are difficult to confine to the nose. In 1989, J. A. Zitelli modified the bilobed flap technique by: (a) orientating a leading flap at 45 degrees from the wound length of the wound; and (b) orientate the second fold at 90 degrees from the wound axis. Its orientation and empiration eliminates the excessive "dog ears," and thus requires a smaller donor skin area; resultant, broadly bilobed-based flap is less susceptible to "trap doors" and common "pin bearing" abnormalities in skin-flap transposition procedures.

Surgical technique - bilobed flap

The design of the bilobed flap coordinates the lobes with the long axis of the nasal defect (wound); each flap lobe is superimposed at a 45-degree angle to the axis. Both lobes of the bilobed flap rotate along the arc, where all points are equidistant from the top of the nose defect.

• Based on the available nasal skin area, the surgeon chooses locally for a bilobed flap, and directs the flower handle. If the defect is in the lateral aspect of the nose, the pedicle is based on the medial. If the defect is at the tip of the nose, or in the nasal dorsum, the pedicle is based laterally. The ideal location for the second flap is along the junction of the nasal dorsum and the lateral nose wall.
• Nose cuts are cut and shaped to form teardrops, by cutting a lump of Burrow meat on the base of the pedicle. Cutting the Burrow triangle (subcutaneous skin and fat) enables moving the pedicle flap, locking it without bending the adjacent tissue with the graft.
• Using a 20 mm calliper as a protractor - one end at the end of the wound - the surgeon describes two semi-circles, semi-inner circles, and a semi-outer circle. Semi-outer circles define the required length of the two skin lobes. The inner semicircle divides the original wound center, and continues throughout the donor skin, setting the general pedicle size limit to the two flap lobes. The surgeon then drew two lines from the top of the wound; the first line drawn is at an angle of 45 degrees from the long axis of the wound, and the second line drawn is at an angle of 90 degrees from the wound axis. Two (2) lines represent the central axis of two bilobed flap lobes.
• The depiction of each of the two flap lobes begins and ends in a semi-inner circle, and extends to the semi outer circle, to the point where it intersects the central axis. The width of the first lobe is approximately 2 mm narrower than the width of the wound; the second lobe width is approximately 2 mm narrower than the width of the first lobe.
• After cutting from the tissue donor site, the bilobed flap is lifted into the area between subcutaneous fat and nasalis muscle. The wound is deepened, up to the nasal bone, to accommodate the tissue thickness of the bilobed flap. Technically, cuts the wound, magnifies it, is better, and safer, than trimming (closing) the cover to fit the wound.
• Destructing donor sites for the second lobe allows closing them primarily; it also removes the excessive "dog skin" in the donor site. Additionally, if the donor site can not be covered with stitches, or if the skin is pinched when stitched, usually due to overly tight stitches, the tension is reduced by reducing the size (length, width, depth) of the wound to the depth of the seam that will allow it to heal easier. â € <â € <

II. Nasolabial flap

In the 19th century, surgical techniques J.F. Dieffenbach (1792-1847) popularized the nasolabial flap for nasal reconstruction, which remains a basic nasal surgery procedure. The nasolabial flap can be either superior or inferiorly based; in which a superior-based flap is a more practical application of rhinoplastic, because it has a more versatile rotational arch, and an inconspicuous donor-site scar. Depending on how the defect in the nose, the base of the flap pedicle can be inserted only to nasal reconstruction, or it can be divided into a second-stage procedure. The blood supply for the flap pedicle is the transverse branch of the contralateral angular artery (arterial facial terminal parallel to the nose), and by the vascular encounter of the angular artery and of the supraorbital artery in the medial canthus, (the angle formed by the upper and lower eyelid encounters). Therefore, the incision to harvest the nasolabial flap does not progress superiorly beyond the medial canton tendon. The nasolabial flap is a randomized flap superimposed on the lateral proximal portion resting on the lateral wall of the nose, and the distal portion resting on the cheek, which contains the main angular artery, and so is diffused with retrograde arterial flow.

Surgical technique - nasolabial flap

The pedicle of the nasolabial flap rests on the lateral nose wall, and is diverted to a maximum of 60 degrees, to avoid the "bridge effect" of the flap superimposed across the nasofacial angle.

• The surgeon designs a nasolabial flap and sets the center axis at an angle of 45 degrees from the dorsum (long) axis of the nose. The shape of the skin fold is cut from the wound template made by the surgeon.
• The incision is made on the flap (without epinephrine anesthetic injection), which is then lifted and oriented, inferior-to-superior, between subcutaneous fat and muscle fascia.
• The cutting continues until the flapping skin can be freely transferred to the nasal defect. The Burrow Triangle is cut from the skin between the medial flap and dorsum nasal boundaries; triangles can be cut before or after the nasolabial elevation.
• The cover is then bent back (reflected), and can be thinned (cut) below the loupe enlargement; however, the nasolabial flap can not be attenuated as easily as the axial skin flap.
• Once the nasolabial flap is superimposed, the donor site wound taken is closed. For injuries to the lateral nose wall that are less than 15 mm wide, where the donor flap can be closed primarily, with stitches. For wounds wider than 15 mm - especially wounds that understand the lobes of the alar and

  Source of the article : Wikipedia