After infiltration of local anesthetic attention is turned to the greater lip segment where the skin is incised taking care to remain perpendicular at all times with the blade. The M flap is then elevated and care is taken throughout the course of surgery to avoid any undue trauma to the skin edges and so a single hook is often utilized. The M flap will be used for later reconstruction of the nostril floor. The C flap is then raised taking care to start the dissection off fairly superficial and then to bring it right above the level of the musculature down to the anterior nasal spine. The muscle is incised in order to completely separate the lip from the nose. Once the C flap is elevated the anterior nasal septum is freed from the malpositioned ANS so that it can be repositioned to the midline. A small back cut is made in the upper bocal sulcus on the greater segment to allow for adequate rotation. In this case a phrenotomy was performed as well. A limited medium muscle dissection is performed simply to release the muscle from its attachments to the nose. Tension is then turned to the lesser lip segment where again the skin is incised taking care to remain perpendicular and also taking care to leave the tattooed markings. The incision is carried up creating an L flap. The L flap in this case will later be used to line the back cut that is made and continued up onto the inferior turbinate. The back cut is made within the upper bocal sulcus to allow for complete release and medial mobilization of the lesser lip segment. The back cut continues onto the inferior turbinate and the entire cheek and nostrils segment are released until they can be adequately mobilized to the midline. Again limited muscle dissection is performed mainly to release the lip from the nose. The L flap in this case is sutured into the defect left by that release. Forochromic is used for intranasal suturing and I find that the castor viejo needle driver is very helpful for many aspects of this repair. The lip is then advanced and the back cut is closed. M flap is sutured into place to allow for closure of the nostril sill. Intraoral incisions are closed using horizontal mattress sutures to allow for eversion. A heminasal cinch stitch is placed in order to medialize and set the alar base. After closure of the intraoral incisions, attention is turned to the muscle repair. This is done with a monofilament and either figure of eight sutures or horizontal mattress sutures. The c flap is then inset. In this instance the entire c flap is utilized. It can be trimmed if needed. The skin is closed using 5-0 monocryl very deep dermal sutures. Only a few 6-0 fast absorbing gut sutures will be used on the skin if needed. Attention is then turned to the rhinoplasty portion. An alar rim incision is made and a single skin hook is used to elevate the skin. The lower lateral cartilage at this level should be adherent to the intranasal skin and dissection is taken above the level of the lower lateral cartilage. The overlying soft tissue is completely freed so that it can be re-draped. Through and through sutures are used in order to tack down the soft tissue and to attempt to correct the intranasal webbing. Intranasally, the two suture ends should be one to two millimeters apart to allow for that soft tissue to be tacked down, but on the external nose the same exit and entry hole are used in order to camouflage. The last step before placement of the intranasal stents is a few 6-0 fast simple sutures.

surgical reconstruction

nasal and lip structures

flap elevation

rhinoplasty

cartilage alignment