1. Babak Saedi Associate Professor Tehran University of Medical sciences Dr.babaksaedi.com

5.  Access for the osteotomy Short stab incisions just anterior to anterior attachment of the anterior turbinate Directed deep and laterally toward the bony piriform aperture  +/- subperiosteal tunnels for osteotome

8.  Typically the osteotomy is created in a high-low-high fashion. performing the osteotomy high along the pyriform aperture, low along the ascending maxilla, and then high again along superiorly along the nasal bones.  For extra wide nasal bones, a low to high osteotomy will cause further narrowing of the facial width caudally.

11.  Asmaller osteotome (2.0 mm) will provide perforations along the ascending maxilla superiorly  A 2.0 mm osteotome is tapped once through the soft tissue envelope of the nasal tissues. Controlled perforating fractures are then placed along the nasal bones.  The percutaneous approach has been shown to have increased ecchymosis on the second day versus continuous internal techniques

17.  Most of the time, lateral and medial osteotomies are sufficient for narrowing of both the nasal and facial width of the nasal bones.  Excessively wide nasal width will sometimes require excision of a portion of medial nasal bone to allow for appropriate narrowing of the nasal bridge.  Median osteotomy

18.  The crooked nasal bony pyramid requires a cogitative approach from the surgeon.  Most deviated nasal bones can be straightened by osteotomies.  If there is an asymmetric facial width, creating a discrepancy in slant height, a unilateral intermediate osteotomy should be considered.  If the slant height discrepancy is large, the surgeon should consider excision of nasal bone to provide a more equivalent slant height.

19.  It allows great precision in the placement of the osteotomy,  The narrowing does not affect the nasal valve or compromise it.  The external percutaneous approach may also be used to make intermediate transverse osteotomies  it can be used to straighten sharply curved nasal bones.

22.  This anatomic study confirms our clinical experience that the external perforated osteotomy results in a more controlled fracture with less intranasal trauma Plast Reconstr Surg. 1997 Apr;99(5):1309-12; discussion 1313. Rohrich RJ, Minoli JJ, Adams WP, Hollier LH.

23.  the perforating internal method gave better results than the perforating external method (group C), neither of these differences was significant by either testing method.  Plast Reconstr Surg. 2004 Apr 15;113(5):1445-56; discussion 1457-8. Gryskiewicz JM, Gryskiewicz KM Plast Reconstr Surg. Gryskiewicz JMGryskiewicz KM

24.  The external osteotomy procedure produces an excellent cosmetic result at the puncture sites in the skin. Visibility of Puncture Sites After External Osteotomy in Rhinoplastic Surgery. Arch Facial Plast Surg. 2003;5:408-411

25.  Both the continuous and perforating osteotomy technique resulted in a decrease in the ventral nasal bone width.  No statistical difference was found between continuous and perforating osteotomy techniques in the amount of nasal bone narrowing  Quantitative Comparison Between Microperforating Osteotomies and Continuous Lateral Osteotomies in Rhinoplasty Arch Facial Plast Surg. 2010;12(2):92-96

26.  No difference concerning swelling is found between the percutaneous and endonasal osteotomy technique sides. With 3D stereophotogrammetry volumetric data can be acquired and compared to evaluate soft-tissue changes Rhinology, 49, 121-126, 2011

27.  Creating subperiosteal tunnels before lateral osteotomy statistically increased periorbital ecchymosis. Although there was no statistically significant difference, creating subperiosteal tunnels also increased development and severity of subconjunctival ecchymosis and edema.  J Oral Maxillofac Surg. 2005 Aug;63(8):1088-90

28. immediateDelayed edemacellulitis bleedingNasal cyst formation ecchymosisanosmia hematomaEpiphora Stair step deformityRocker deformity

29.  There were not any permanent obstructions after lateral osteotomy of rhinoplasty. Temporary obstructions in the 1st postoperative week improved to normal preoperative status by the postoperative 3rd month. American Journal of Rhinology 19, 388–394, 2005)