Facial Plastic and Reconstructive Surgery: Rhinoplasty, Trauma, and Reconstruction
Scope
Facial plastic and reconstructive surgery tests nasal analysis and rhinoplasty, facial fracture management, local flaps, skin cancer reconstruction, and facial nerve anatomy. The exam favors functional and aesthetic diagnosis before operative planning.
Core rules
- Preoperative photographs and nasal analysis are mandatory. Assess dorsum, tip, alar base, and nasal valve. A positive Cottle maneuver suggests internal valve collapse.
- Spreader grafts widen the middle nasal vault and correct valve collapse after over-resection. Alar batten grafts support external valve collapse.
- Zygomaticomaxillary complex fracture causes malar flattening, trismus, and diplopia; assess the orbital floor and vision. Le Fort fractures are classified I, II, and III by level.
- Facial nerve branches: temporal, zygomatic, buccal, marginal mandibular, and cervical. Marginal mandibular injury causes lower lip depressor weakness.
- Local flaps: bilobed flap for small nasal defects, nasolabial flap for larger defects, and paramedian forehead flap for major nasal reconstruction.
- Skin cancer excision requires margin control; Mohs surgery is useful in cosmetically sensitive areas.
Worked example
A patient has a pinched middle third and nasal obstruction after prior rhinoplasty. Cottle test is positive. The diagnosis is internal nasal valve collapse. Treatment is spreader grafts to widen the middle vault; further alar resection would worsen obstruction.
Traps
Operating without photographs; missing orbital floor injury in midface trauma; failing to check vision after facial fracture; over-resecting the alar base; and ignoring the marginal mandibular nerve during neck surgery.