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Selected Readings in Plastic Surgery (ISSN 0739-5523) is published approximately 8 times per year by Selected Readings in Plastic Surgery, Inc. A volume consists of 30 numbers issued over 2 to 3 years. Subscriptions are for half a volume or 15 issues and cost $300 domestic, $350 outside the U.S. CDs of each half-volume are available for $200 domestic, $250 outside the U.S. CME quizzes are $60 for 15 issues. Study Modules that combine related issues are available for $200 domestic, $250 outside the U.S. Please visit us at www.SRPS.org for more information.

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30 Topics

Gra�s and FlapsWound Healing, Scars, and BurnsSkin Tumors: BCC, SCC, and MelanomaImplantation and Local AnestheticsHead and Neck Tumors and ReconstructionMicrosurgery and Lower Extremity ReconstructionNasal and Eyelid ReconstructionLip, Cheek, and Scalp ReconstructionEar Reconstruction and OtoplastyFacial FracturesBlepharoplasty and Brow Li�RhinoplastyRhytidectomySkin Care and Cosmetic InjectablesLasersFacial Nerve DisordersCle� Lip and Palate/VPICraniofacial I: Dx, and OrthognathicsCraniofacial II: SurgeryVascular AnomaliesBreast AugmentationBreast Reduction and MastopexyBreast ReconstructionBody Contouring and LiposuctionTrunk Reconstruction and Pressure SoresHand I: So� TissuesHand II: Peripheral NervesHand III: Flexor TendonsHand IV: Extensor TendonsHand V: Wrist, Joints, Congenital, and RA

INTRODUCTIONOptimal results in cosmetic rhinoplasty demand muchof the surgeon. A detailed knowledge of the complexthree-dimensional anatomy of the nose, familiarity withall the described techniques of rhinoplasty, and a well-developed aesthetic sense are essential.

Since the last Selected Readings in Plastic Surgery reviewof rhinoplasty, numerous articles have been written thatfurther help us achieve a predictable, aesthetically pleas-ing outcome from rhinoplasty. Nevertheless, many ofthe classic articles still form the basis for a safe and effec-tive procedure and are highly recommended.

HISTORYCosmetic rhinoplasty evolved from and has contributedto reconstructive nasal surgery. From its early originsas an augmentation (reconstructive) operation, rhino-plasty subsequently became a reduction (cosmetic) tech-nique and has progressed full circle to its current dualrole as both a reduction and augmentation procedure.Rogers1 and Eisenberg2 offer comprehensive reviews ofthe history of rhinoplasty.

Indian techniques for reconstructive rhinoplastybegan with Sushruta in 500 BC, continued and evolvedduring Alexander the Great’s invasion of India in 327 BC,and subsequently waned following the Mohammedanconquest in 997 AD. The Indian knowledge of rhinoplasty

is recorded in Sanskrit manuscripts, but Western schol-ars were not aware of it until the British entered India inthe 18th century. The legendary clay potters of Satra,India, practiced Sushruta’s methods for recreating noses,and when these ancient techniques were translated intoEnglish, rhinoplasty was finally introduced to the Euro-pean medical community.

Two German surgeons, von Graefe and Dieffenbach,contributed significantly to the advance of rhinoplastyin the early 1800s. In 1887 John O Roe introduced theintranasal approach to rhinoplasty, and in 1891 Roe3

described cosmetic reduction of an entire nose withremoval of the bony and cartilaginous hump throughan intranasal approach.

In 1898 Jacques Joseph4 of Berlin pioneered modernreduction rhinoplasty with the publication of his firstpaper. His technique removed a V-shaped segment ofthe nasal dorsum through an external incision;included in the excision were skin, bone, cartilage,mucosal lining, a full-thickness portion of ala, and awedge from the lower portion of the septum. Josephanalyzed and classified various nasal deformities andintroduced numerous operative procedures for theircorrection. His monumental two-volume textbook onplastic surgery of the nose5 was published between 1928and 1931, and a few years later his teachings werebrought to the English-speaking world by Joseph Safian6

and Gustave Aufricht.7

RHINOPLASTYRichard Y Ha MDRicardo A Meade MD

Dallas Plastic Surgery Institute411 North Washington Avenue, Suite 6000Dallas, Texas 75246

www.haplasticsurgery.comwww.doctormeade.com

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ANATOMYDingman and Natvig8 illustrate the general anatomy,skeletal elements, blood supply, and innervation of thenose (Fig 1).

The skeletal framework of the nose is highly vari-able and frequently asymmetrical. Natvig and associ-ates9 illustrate several cartilaginous configurations asreported by various authors (Fig 2). Bernstein10 andBroadbent and Woolf11 review the anatomy of theupper, middle, and lower third of the nose and its clini-cal application in rhinoplasty.

The nasal bone is widest at the nasofrontal suture(14mm), narrowest at the nasofrontal angle (10mm),and widens again to a maximum of 12mm some 9–12mm inferior to the nasofrontal angle.12 The nasalbone is thickest superiorly at the nasofrontal angle(avg 6mm) and thins progressively toward the tip.

Daniel and Lessard13 note the following:

1. The critical, fixed anatomic landmark of the nose isthe medial canthal ligament, which in many noses

Fig 1. General anatomy of the nose. (Reprinted with permission from Dingman RO, Natvig P: Surgical anatomy in aesthetic and correctiverhinoplasty. Clin Plast Surg 4:111, 1977.)

Fig 2. The alar cartilages as depicted by various sources.(Reprinted with permission from Natvig P, Sether LA, GingrassRP, Gardner WD: Anatomical details of the osseous-cartilaginousframework of the nose. Plast Reconstr Surg 48:528, 1971.)

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corresponds to the desired level of the transversefracture line.

2. The soft-tissue coverage consists of skin—thickestat the tip and thinnest at the rhinion; subcutane-ous tissue—most prominent in the supra-tip area;and muscles—ranging from 3.5–9.2mm in thick-ness.

3. The nasofrontal suture is 10.7mm above theintercanthal line (Fig 3) and the intervening solid“bony triangle” is virtually impossible to narrowby digital pressure or to deepen by rasping.

Fig 3. Critical landmarks and relationships of the nose.(Data from Daniel RK, Lessard M-L: Rhinoplasty: A gradedaesthetic-anatomical approach. Ann Plast Surg 13:436, 1984.)

4. The keystone area of nasal bone overlapping theupper lateral cartilage (ULC) extends farther alongthe septum (7.6mm) than laterally (3.8mm).

5. The dorsal hump is predominantly (57%) cartilagi-nous rather than bony (43%).

6. The dorsal border of the cartilaginous septumprogresses from a Y, with a supraseptal depres-sion at the keystone area, to a T and eventually toan I by the septal angle.

7. In most cases the alar domes project far above andcaudal to the septal angle, thus discounting directseptal support for the tip.

McKinney, Johnson, and Walloch14 confirm fusionof the ULC and nasal septum in the dorsal midline.Only at the level of the septal angle are these struc-

tures separate (Fig 4) and merely connected to eachother by fibrous tissue.

Accessory cartilages are interspersed in the apo-neurosis connecting the lateral crus to the piriformaperture.15,16 A continuous, supporting ring of carti-laginous and fibrous tissue circumscribes the nasallobule, with connections between the medial and lat-eral crura and the floor,16 as follows:

• the first accessory cartilage underlies the alarcrease

• the second accessory cartilage is attached to thepiriform aperture by the deep portion of the alarnasal muscle arising from the undersurface of themaxilla

• the third accessory cartilage has a definite fibrousattachment to the nasal spine and forms the inter-nal nostril fold on the floor of the nasal vestibule.

The ring consists of the caudal septum resting on thenasal spine of the maxilla, the medial and lateral crura,and a chain of three or four accessory cartilages. Danieland Letourneau16 found no deterioration of the cartilagewith age, and doubt that attenuation of the cartilage andfibrous supporting structures is responsible for thedrooping nasal tip seen in the elderly, but rather believeit is due to resorption of the maxillary alveolar crest.

Rohrich et al17 discuss their approach to the man-agement of the nose in the aging patient. With age, thelower third of the face decreases in height secondaryto muscle atrophy of the orbicularis oris, fatty tissueabsorption, and maxillary alveolar hypoplasia (fromtooth loss and subsequent bony resorption). Withadvanced age, the nose lengthens and the nasal dor-

Fig 4. Cross-section of the ULC-septal angle at three levels.(Reprinted with permission from McKinney P, Johnson P, WallochJ: Anatomy of the nasal hump. Plast Reconstr Surg 77:404, 1986.)

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sum becomes more convex as a consequence of down-ward rotation of the lobule and relative columellarretraction. The tip elongates and droops and the flow ofair shifts superiorly, often causing functional airwayobstruction. Osteotomies are not recommended due tothe fragile nature of the bony nasal pyramid.

Daniel18 emphasizes the importance of the three cruraof the lower lateral cartilage—the medial, middle, andlateral crus¯and of the three nasal tip angles—the angleof tip rotation, angle of dome definition, and angle ofdomal divergence (Fig 5). The anatomy of the ULC corre-lates strongly with tip aesthetics.

Fig 5. Angles in the nasal lobule relevant to rhinoplasticsurgery.

Histologically, the bulbous tip consists of collagenousfibrous tissue and skeletal muscle; the adipose tissuecomponent is far less than expected.19 The tissue makeup,blood supply, and lymphatic drainage are directlyrelated to postoperative edema and scar formation andinfluence the resection that is performed for tip modifi-cation.

Copcu et al20 describe the interdomal fat pad as a sepa-rate anatomic component not structurally attached tothe subcutaneous tissue. The fat pad consists purely ofadipocytes and varies in size from 1.2x2.4mm to 3.6x5.2mm. Ultrasonography shows larger pads occupying theinterdomal space.

Rohrich, Gunter, and Friedman21 studied the bloodsupply of the nasal tip before and after transcolumellarincision in a fresh cadaver model. The lateral nasal arterywas present in all specimens and was located in the sub-dermal plexus 2–3mm superior to the alar groove. Thecolumellar branch of the superior labial artery was vari-

able. Even after transcolumellar incision there was con-sistent crossover flow from the lateral nasal artery arcadeto the distal aspect of the transected columellar branches.The authors conclude that external rhinoplasty does notcompromise nasal tip blood supply unless extensive tipdefatting or extended alar base resection above the alargroove is performed.

Toriumi and others22 looked at the effect of externalrhinoplasty on the vascular anatomy of the nose. Thestudy involved pre- and postoperative clinical evalua-tion, cadaver dissection, lymphoscintigraphy, and his-tologic evaluation. The major arterial, venous, and lym-phatic vessels course in or above the musculoapo-neurotic layer of the nose. The authors suggest that “inthe external rhinoplasty approach, dissection in theareolar tissue plane below the musculoaponeuroticlayer will minimize tip edema and protect against skinnecrosis by preserving the major vascular supply tothe nasal tip.…There was loss of normal flow of tracerwith the external approach using dissection that dis-rupted the musculoaponeurotic layer with supra-tipdebulking.”22

To minimize injury to the external nasal branch ofthe anterior ethmoidal nerve, Han, Shin and Kim23 per-formed anatomic dissections in 10 fresh cadavers andconclude that dissection deep to the nasal SMAS is safe.They recommend keeping the dissection to within 6.5mmof the midline and limiting onlay graft widths at therhinion to 13mm.

Pitanguy24 describes a dermocartilaginous ligament thatmay influence dorsum-tip relationships. The ligament ismost significant in patients with a bulbous tip and in Afri-can noses where a convexity of the lower third of the noseis still apparent after classic modification of the osseocarti-laginous structures. Division and partial resection of thedermocartilaginous ligament releases the lower third ofthe nose and the nasal tip moves upward. In a follow-uparticle, Pitanguy25 confirms this subseptal tip-anchoringstructure and detaches it subcutaneously through an openbrowlift approach for the aged, drooping nose.

Figallo26 describes a dynamic structure in the nasaltip, neither osseous nor cartilaginous, which he believesis a digastric muscle linking the nose to the upper lip.This complex anatomic structure is joined through apulley to the anterior nasal spine and is felt to accountfor the plunging tip. A distinction between this “new”structure and the nasal depressor muscles is unclear.

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Figallo and Acosta27 provide a detailed update on themuscles of the nose.

Ozturan et al28 used EMG to study the intrinsic nasalmusculature as it relates to airway collapse before andafter rhinoplasty. They caution against inadvertent dis-ruption of the procerus, transverse nasalis, and dilatornasalis muscles during rhinoplasty, which will affectnasal movements postoperatively. The authors empha-size staying in the appropriate tissue plane beneath themusculature and over the perichondrium to achieve thebest functional result.

In a cadaver study, Ali-Salaam, Kashgarian, Davilaand Persing29 found the alar lobule to be an area wheredermis interdigitates with muscle throughout and downto the alar rim. The alar groove is defined by a differen-tial in fibrofatty bulging anterior and posterior to it. Theauthors also studied the soft triangle and described theanatomy of the insertion of the dilator naris muscle downto the nostril rim.30

PHYSIOLOGYBaker and Strauss31 review the physiology of the noseand note that septal deviation and spur formation areanatomic variants prevalent in normal populations. Thenasal cycle is a physiologic response characterized byalternate shrinkage and engorgement of the nasal turbi-nates that repeats every 30 minutes to 4 hours. While onone side of the nasal airway the turbinates are shrink-ing, and giving off secretions of serous fluid and mucus,on the opposite side the turbinates are engorging. Thiscycle occurs in 80% of individuals and its exact functionis unknown. Total airway resistance remains relativelyconstant despite continuous changes in the size of theturbinates. Baker and Strauss31 discuss the physiologicbasis of nasal obstruction relative to pathologic states ofthe nasal turbinates. Rhinitis is classified as allergic,vasomotor, atrophic, hyperplastic, medicamentosa, orpostrhinoplastic. The differential diagnosis and treat-ment of obstructive rhinitis are reviewed.

On the basis of his vast experience treating patientswith nasal obstruction, Canady32 offers a relativelysimple algorithm (Fig 6) to identify the causes and man-agement of nasal obstruction. “Of equal or greaterimportance, however, this algorithm may allow the sur-geon to recognize and avoid performing surgery onpatients who will not be satisfied, even with a techni-cally good result.”32

Jesson and Malm33 followed 67 patients who were con-sidered candidates for septoplasty because of nasalobstruction and deviated nasal septum. These patientsdid not have surgery because their nasal airway sys-tems were discovered to be normal on rhinometry. At 5and 10 years of follow-up, 20% and 36% of patientsrespectively showed relief of nasal symptoms. Theauthors conclude that the majority were in fact suffer-ing from vasomotor rhinitis, which tends to disappearwith time, and recommend careful evaluation to distin-guish between anatomic obstruction and physiologicobstruction.

Deron et al34 evaluated the influence of septal devia-tion on Eustachian tube function and conclude that sur-gical correction improved tubal opening pressure onboth the deviated side and the nondeviated side. Fomonand associates35 and Courtiss and others36 state: “Un-less the internal or external valves are adversely affectedor unless a simultaneous septal operation results in sep-tal perforation, aesthetic rhinoplasty does not affectnasal airflow.”36 Infracturing of the nasal bones takesplace cephalad to the internal nasal valves and presum-ably does not impair airflow.

Ford and coworkers37 studied the effects of variousosteotomy techniques on the size of the airway incadavers, and conclude that “an interrupted trans-periosteal osteotomy preserving intervening strands ofperiosteum results in a more stable nose with less com-promise of the airway.”

Guyuron38 studied the effect of osteotomy on the air-way of 48 patients (96 nasal bones). The length of thenasal bones and position of the inferior turbinates wererecorded preoperatively and correlated with the type ofosteotomy performed and extent of bone movement.Each side was assessed independently. The high-to-lowosteotomies produced the least narrowing of the nasalpassages. Patients with short nasal bones had less con-striction of the airway than patients with either normalor long nasal bones. Airway narrowing was more sig-nificant when the inferior turbinates were positionedanteriorly. The author concludes that nasal osteotomydoes constrict the nasal airway in most instances and toa degree varying with length of the nasal bones, extentof nasal bone repositioning, position of the inferior tur-binates, and type of osteotomy.

Grymer and colleagues39 studied the significance ofplacement of the lateral osteotomy at levels above and

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below the insertion of the inferior turbinates in 16cadavers and found no difference between noses thatreceived high lateral osteotomy and those that had lowlateral osteotomy. Both groups showed 12–16% decreasein mean cross-sectional area at the piriform apertureafter lateral osteotomies were performed. This reduc-tion was independent of osteotomy placement but wasprobably due to detachment of the bony box from theunderlying structures.

Becker et al40 developed a rationale for selecting thecorrect osteotome in endonasal lateral osteotomy. The

mean bony lateral wall thickness was measured by CTscan in 56 adult patients and found to be 2.47 ± 0.47mmin men and 2.29 ± 0.40mm in women. The 4mm osteotomecaused intranasal mucosal tears 95% of the time, the 3mmosteotome created tears in 34%, and the 2.5mm osteotomein 4%.

Malm41 introduced the concept of acoustic rhino-manometry, described the technical aspects of the pro-cedure, and listed clinical norms. Grymer42 used acous-tic rhinomanometry to measure the internal dimensionsof the nasal cavity in 37 patients before and after reduc-

Fig 6. Algorithm for managing nasal obstruction. (Reprinted with permission from Canady JW: Evaluation of nasal obstruction inrhinoplasty. Plast Reconstr Surg 94:555, 1994.)

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tion rhinoplasty. There was a 22% reduction in minimalcross-sectional area at the nasal valve and 11% reduc-tion in cross-sectional area at the piriform aperture.

The Vomeronasal OrganMoran and coworkers43 and Stensaas and colleagues44

independently investigated the vomeronasal (Jacobson’s)organ. Interest in this vestigial structure stems from itssimilarity to the vomeronasal system of other vertebratespecies, in which Jacobson’s organ plays a crucial repro-ductive role by detecting pheromones. The authors col-lectively evaluated 600 human subjects and foundpaired vomeronasal pits in the anterior third of the nasalseptum in all individuals who had no underlying septalpathology. The pits signified the presence of closed tubes,2–8mm long and lined by unique pseudostratifiedcolumnar epithelium unlike any other in the humanbody. Two potential receptors were identified in theepithelial lining. The function of Jacobson’s organ inhumans is still in question, but in any case it would seemto be immune from injury by submucoperichondrial dis-section of the septum.

AESTHETICS AND FACIAL ANALYSISImplicit in a surgeon’s ability to correct nasal deformi-ties is an understanding of aesthetic proportions of theface, not just the nose. Farkas and coworkers,45–49 Danieland Farkas,50 and Ricketts51 review modern standardsin facial aesthetics. Bernstein52 delineates relationshipsbetween facial shape and nasal width, discusses nose-chin proportions, and lists differences between the maleand female nose. According to these authors, the aes-thetically pleasing face is not divided into equal thirdsor fourths, but rather the lower face is longer than themidface, which in turn is longer than the upper face.

Greer and associates53 reviewed the importance of thesubmental region in improving the perceived appear-ance of the nose. They advocated neck-rejuvenating pro-cedures for improving results. Byrd and Hobar54 find aconsistent relationship between vertical dimensions andanteriorly projecting characteristics of the nose, lips, andchin. They propose a dynamic system of analysis thatdescribes key measurements of the nose relative to otherfacial features and that maintains an overall proportionbetween nose, chin, and rest of the face. According to

their system, for any individual the ideal nasal length(RTi) is determined by nonnasal facial measurements(Fig 7). Specifically, RTi is equal to 67% of the midfacialheight (MFH) and equal to the chin vertical measure-ment (SMes).

RTi = 0.67 % MFH or RTi = SMes

Fig 7. Ideal relations and proportions of the facial structureson lateral view; legends in text. (From Byrd HS: The dimensionalapproach to rhinoplasty: perfecting the aesthetic balance between thenose and chin. Presented at the 14th Annual Dallas RhinoplastySymposium. Dallas, Feb 28-Mar 3, 1997.)

Nasal tip projection equals 67% of the calculated ideallength. The nose–lip–chin plane (NLCP) is determinedby a line drawn through a point halfway down the idealnasal length and touching the upper lip vermilion. Inmen the chin projects to this line, but in women it is3mm posterior to it. Other details of their facial analysismethod are as follows:

1. The MFH is measured from glabella (G) to alar baseplane (ABP). The lower face height (LFH) is measuredfrom ABP to mentum (Me). MFH should be equal to orslightly less than (<3mm) LFH. If it is not, reaffirm occlu-

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sion and look specifically for the presence of long- orshort-face syndrome or microgenia.

MFH ≤≤≤≤≤ LFH (≤≤≤≤≤3mm)

2. Select the mid- or lower facial subunit as the stan-dard for determining ideal nasal length. When the man-dible is normal and MFH and LFH are nearly equal, nasallength should be planned on the basis of chin vertical asmeasured from stomion (S) to mentum, ie,

RTi = SMes

In cases of microgenia or maldevelopment of the man-dible, the ideal nasal length is determined from themidfacial height, ie

RTi = 0.67 x MFH

Similarly, when the midface is overdeveloped and is notto be corrected orthognathically, the nose should be pro-portional to the midface rather than to the smaller man-dibular segment.

3. With the ideal nasal length established, adjust-ments to the existing nasal length and possibly the chinvertical should approximate the ideal nasal length. Thetreatment plan is ultimately determined by safe andreliable surgical guidelines.

4. Multiply the ideal nasal length by 0.67 to deter-mine the ideal tip projection.

Ideal tip projection = 0.67 x RTi

If actual tip projection is equal to or greater than thecalculated value, then tip projection is adequate despiteits appearance in relation to the dorsum. If actual tipprojection is less than the calculated ideal, surgical stepsto increase tip support should be considered.

5. Measure the distance betwen corneal plane (CP)and radix plane (RP). The ideal radix projection shouldbe 28% of the ideal nasal length, or

Ideal radix projection = 0.28 x RTi (9–14mm)

If less than the calculated value and a dorsal hump ispresent, consider a radix graft. If greater than 0.28 RTi

and the radix breakpoint is poorly defined, consider ra-dix reduction.

6. Note any difference in nasal length when measuredfrom supratarsal fold R and visual radix breakpoint. Ifnasal length is normal as measured from R but the noseappears short because of a low breakpoint, it can be cor-rected with a radix graft to raise the visual break.

7. Mark a point on the dorsum of the nose equivalent toone-half the ideal nasal length as measured from R. Dropa line from this point tangential to the vermilion of theupper lip. The projecting point of the chin should touchthe line in men and lie ~3mm back of this plane in women.

Chin projection = NLCP (men)Chin projection = ~3mm NLCP (women)

The aesthetically pleasing female face has a midfacialheight that is equal to or slightly less than lower facialheight (avg 61mm). Nasal length equals chin verticaldistance and averages 41mm (Fig 8).

8. On lateral view, the mean distance between nasalroot plane (RP) and corneal plane (CP) is 11mm orapproximately 0.28 x RTi. The nose projects from theface at an angle of 30°–36°, while the nasolabial anglevaries from an average of 90° in men to 95°–110° inwomen. A 2–3mm segment of columella should be seenbelow the rim of the ala.

McKinney and Sweis55 sought to define the elementsof the ideally balanced Caucasian nose. Ideal dorsallength was 2X rhinion height and tip projection. Idealradix height was 0.75X tip projection + rhinion height.In his discussion of this paper, Daniel56 references theideal nasion relative to its surrounding anatomic land-marks: 15–20mm from medial canthus; 9–14mm ante-rior to corneal plane on profile; 4–6mm behind glabellarline; and at lower border of upper lid, among others.

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VISUAL DOCUMENTATION

PhotographyKrugman57 reviews photoanalysis and emphasizes theneoclassical facial proportions and holistic treatmentplanning. Guyuron58 points to the advantage of full-scale, life-sized photography as an adjunct to soft-tissuecephalometric analysis in rhinoplasty and describes hisfacial analysis system, which includes proportions,angles, measurements, and recommended profile tem-plate. Preoperatively the system is used to confirm thetreatment plan and to serve as a baseline; postopera-tively it can help identify shortcomings in the rhino-plasty technique. Schwartz and Tardy59 propose a stan-dardized system of photodocumentation in rhinoplastyand make specific recommendations with regard toviews, lighting, and equipment.

Galdino, DaSilva and Gunter60 list additional consid-erations for maintaining detail and consistency in digi-tal photodocumentation of the nose. Various printingmethods are discussed.

Anatomical DrawingsGunter61 suggests a pictorial system to graphicallyrecord intra-operative maneuvers in rhinoplasty. Into

every patient’s chart goes a worksheet that consists offour views of the nose and a checklist of possible surgicaldetails and steps. The type of rhinoplasty; surgicalapproach; operations on the tip, lateral crura, medialcrura, dorsum, and nasal bones; use of grafts or implants;and miscellaneous adjunctive procedures are allrecorded here. The actual events during rhinoplasty aredrawn in on the anatomical illustrations and marked onthe checklist. The value of this standardized graphicrecord lies in its objective correlation between what wasdone surgically and the operative outcome.

Computer ImagingComputer imaging is another graphic tool in the preop-erative evaluation of the rhinoplasty patient as well asfor postoperative assessment of the result. Sophisticatedhardware and software are available in both PC andMacintosh platforms. The more valuable systems canimport undistorted, life-size images and alter them byincremental differences in nasal length, tip projection,angles, width, and shadowing.

For computer representations to be realistic, usersmust project their true surgical skills. Computer imag-ing is controversial because it is so powerful: Used as amarketing tool, it can mislead patients into expecting asurgical result that is impossible to achieve. Used prop-erly, computer imaging can offer a precise record of thedeformity and its proposed correction, a scaled surgicalplan, and an exact surgical record.

Mattison62 reviews facial video image processing, withemphasis on image capture, software modification,development of a surgical plan, and comparison of pre-and postsurgical results. Schoenrock63 reports his 5-yearexperience with computer imaging. Bronz64 recountsthe predictability of surgical planning with a computerimaging system in 100 primary rhinoplasty cases.

Vuyk and colleagues65 used a patient questionnaire toassess the role of computer imaging in facial plastic sur-gery. Most patients (>80%) found computer imaginghelpful in communicating with the surgeon, both forexpressing their wishes and expectations and in facili-tating the decision for or against a particular surgicalchange. The majority also felt that computer imagingshould be a routine part of preoperative evaluation forplastic surgery. The predictive value of computer trac-ings was about 80%.

Fig 8. Ideal relations and proportions of the facial structureson frontal view; legends in text. (From Byrd HS: The dimensionalapproach to rhinoplasty: perfecting the aesthetic balance between thenose and chin. Presented at the 14th Annual Dallas RhinoplastySymposium. Dallas, Feb 28-Mar 3, 1997.)

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PATIENT SELECTIONSelection of the appropriate patient for rhinoplastydepends on communication. The surgeon must listenand understand the patient’s wishes and balance themagainst his/her estimate of what can be reasonablyachieved surgically.

Thomson66 lists criteria to be used in the selection andcounseling of patients for rhinoplasty and cautionsagainst certain recognizable types of individuals: thesuper-secretive, the ones unable to identify their desires,those who request urgent operation, are overly concernedwith minor deformities, have secondary motivations,are excessively demanding, carry a number of photo-graphs describing their preferred nose, are extremelyindecisive, and male patients. Tardy et al67 stress theimportance of preoperative interviews.

Goin68 discusses the psychology of rhinoplastypatients. Honigman and colleagues69 reviewed the lit-erature on psychological outcomes after cosmetic sur-gery and identified consistent predictors of a poor psy-chosocial outcome.

In a retrospective study of 150 secondary rhinoplastypatients, Constantian70 noted four anatomic variantsthat strongly predisposed to unfavorable results: lowradix/low dorsum, narrow midvault, inadequate tipprojection, and alar cartilage malposition. The triad oflow radix, narrow midvault, and inadequate tip pro-jection was the most common combination (40%) inpatients seeking secondary rhinoplasty. More recentlyConstantian71 reviewed 100 consecutive primary rhi-noplasties and reported inadequate tip projection in67%, cephalic malrotation of the lateral crura in 46%,and a too-prominent tip in 23%.

Male RhinoplastyDaniel72 acknowledges the validity of Gorney’s73

SIMON profile: Single, Immature Male, Overlyexpectant, and Narcissistic. These patients are psy-chologically unstable and poor candidates for rhino-plastic surgery, but constitute only about 15% of menseeking rhinoplasty in his practice. Men’s noses tendto be more variable in aesthetic measurements, withwide ranges in level of nasion, height of nasion, andrelation between endocanthus and nasal base. Daniel’s

goal in male rhinoplasty is a “strong” profile and nosupratip break.

Rohrich and colleagues74 describe male rhinoplastypatients as typically nonspecific regarding their com-plaints, more demanding, and less attentive during con-sultations. It is important to avoid excessive dorsalreduction or tip refinement in this cohort.

ANESTHESIAGeneral anesthesia is recommended when operating onan apprehensive patient, for procedures involving deepseptovomerine manipulation, and in some posttraumaticdeformities accompanied by intranasal scarring. Thelocal anesthetic of choice is 1% lidocaine with epineph-rine 1:200,000 to 1:50,000.

Moscona and associates75 compared sedation tech-niques for outpatient rhinoplasty in 859 cases. Patientswere assigned to one of two groups, those who receivedmidazolam and those who had midazolam+ketamine.Sedation scores showed both groups were adequatelysedated. The midazolam+ketamine group were lesslikely to remember the injections and were more satis-fied with their surgical experience.

Miller and associates76 recommend topical adminis-tration of 4–5% cocaine solution to enhance anesthesiaand induce vasoconstriction while avoiding high plasmaconcentrations of cocaine. Mixing cocaine with epineph-rine offers no advantage, and the toxic effects of “cocainemud” are well documented.

In a prospective, randomized study of 12 consecutivepatients, Liao and associates77 tried to identify factorsthat influenced the safe use of topical cocaine during rhi-noplasty. Group 1 received cotton pledgets soaked in4mL of 4% cocaine solution for 10 min; group 2 received4mL of 4% solution for 20 min; and group 3 received 4mLof 10% solution for 20 min. Serum cocaine concentra-tions were measured at intervals of 5, 10, 15, and 20 min-utes. Of the total cocaine applied, 35% was absorbedsystemically within 15 min of application. This absorp-tion rate was 4X higher than expected, and led theauthors to conclude that topical use of 10% cocaine wasto be avoided.

Metzinger and others78 recommend adding 1 partsodium bicarbonate to 5 parts local anesthetic to lessenthe pain and irritation of injections during rhinoplasty.

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SURGICAL TECHNIQUESThe classic concepts of Joseph’s4,5 “reduction rhino-plasty”, updated by Aufricht,79 have evolved signifi-cantly in the past 35 years. According to Rees,80

...the highly styled retroussé nose of the past hasgiven way to emphasis on a more natural look withhigher dorsal profile, less tip elevation, and lesssculpturing of the alar cartilages. The ‘operated look’is to be avoided at all costs.

Rees (1977)

In 1977 Rees80 listed the trends in rhinoplasty as

• less removal of tissue

• more preservation of structures

• a decided tendency toward ‘underoperation’ ratherthan ‘overoperation’

To these we can now add

• incisions designed to preserve lining and soft tissue

• resection of only the bare redundancy of the upperlateral cartilages

• correction of the nasal tip first, or at least early in theprocedure, before modifying the dorsum

• a tendency to avoid transecting the domes or other-wise avoid interrupting the spring of the alarcartilages

• maximum preservation of the caudal border of theseptum

• resection of the nasal spine only in well-defined, iso-lated cases

• less frequent medial osteotomies

• rare outfracturing

The techniques of Anderson,81–83 Peck,84 Rees,85 Sheen,86

and Goodman87 are representative of current conceptsin rhinoplasty. Peck88 describes the preferred basicapproach to rhinoplasty and emphasizes that the mostimportant aesthetic goal is to create a pleasing tip thatwill stand out gracefully from the straight nasal bridge.

Sheen’s original methods of nasal augmentation, alongwith his refinements of surgical techniques for the cor-rection of secondary nasal deformities,86,89–92 furtherexpand modern rhinoplastic alternatives. In a retro-spective titled “Rhinoplasty: Personal Evolution andMilestones”, Sheen93 reviews the milestones in this evo-lution, as follows:

• vestibular stenosis: diagnosis of a surgical consequence

• etiology and treatment of supratip deformity: thedynamic relationship of soft-tissue contour to skel-eton

• etiology and treatment of the tip with inadequateprojection: tip graft design

• practical aesthetics of balance: the augmentation-reduction approach to rhinoplasty

• support of the middle vault: functional and estheticeffects

• malposition of the lateral crura: recognition and man-agement

• significance of the middle crura: clinical and aes-thetic considerations

This paper and the techniques therein should be care-fully studied by all rhinoplastic surgeons.

Intranasal ApproachThe intranasal approach to rhinoplasty includes sev-eral routes of access to the nose (Fig 9), as follows:

Fig 9. Intranasal incisions in rhinoplasty. (Reprinted withpermission from Dingman RO, Natvig P: The infracartilaginousincision for rhinoplasty. Plast Reconstr Surg 69:134, 1982.)

• intercartilaginous incisions between the upper andlower lateral cartilages

• transcartilaginous (cartilage-splitting) incisions throughthe lower lateral cartilages

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• infracartilaginous incisions following the caudal bor-der of the lower lateral cartilages

• combinations of the above, with or without a trans-fixion incision through cartilaginous or membranousseptum caudally85,94

Deformities requiring wide exposure, such as tipasymmetries, high dorsal septal deviations, and severeposttraumatic deformities, are frequently approachedthrough cartilage-delivery methods using infracar-tilaginous or marginal incisions, singly or in conjunc-tion with an intercartilaginous incision. They may alsobe combined with a transcolumellar incision and con-verted to an external approach. If the nasal tip morphol-ogy is normal, one should avoid dissection of the tipstructures as part of the exposure.

External (Open) ApproachThe open approach to rhinoplasty consists of bilateralmarginal or rim incisions along the inferior border ofthe alar cartilages that are connected in the midline by atranscolumellar skin incision 5–7mm long (Fig 10); it doesnot include Joseph’s large skin incision. The main differ-ence between the external and internal approach is thatthe external approach allows exposure of the lobule com-plex without disturbing intercrural and alar–septalattachments.

Fig 10. Incisions used in the external approach to rhinoplasty.

Adams et al95 reviewed nasal tip support in open andclosed rhinoplasty. The mean loss of tip projection withthe open approach was 3.43mm versus 1.98mm for the

closed approach. The difference was attributed to greaterligamentous disruption and skin undermining with theopen approach. Septal manipulation was associated withdecreased tip support regardless of approach.

Rethi96 used a partial, high-transverse columellarincision that failed to uncover the entire nasal skeleton.Sercer97 extended Rethi’s incision to expose the entireosseocartilaginous framework of the nose. Padovan98

further expanded the open rhinoplasty concept andincorporated his treatment of the nasal septum.Goodman87 described his technique of external rhino-plasty and reported an experience with 74 patients.99

Wright and Kridel100 endorsed Goodman’s method andlisted the following advantages to the external rhinoplastyprocedure:

• better binocular visualization for teaching andstudying deformed anatomy

• control of bleeding by electrocautery

• more accurate diagnosis

• more precise correction of deformities

The external approach enjoys all the advantages ofthe cartilage-delivery technique plus simultaneousbilateral visualization of the lower lateral cartilages intheir resting state without retraction. This additionalexposure can be of benefit when dealing with an asym-metric tip or when correcting tip projection, where it isdesirable to maintain the soft-tissue attachments101 whilesimultaneously evaluating the unloaded support to thetip complex.

On the other hand, the external approach impliesunnecessary degloving of the tip–lobule complex whentip projection is normal. In this case, the increased expo-sure gained by the open approach must be balancedagainst the risk of altering tip support or tip definitionwhile dissecting the dome. Goodman102 notes the follow-ing limitations and potential complications of the open approach:

• separation and secondary healing of the transversecolumellar incision

• additional edema of the nasal tip persisting for sev-eral months

• increased operative time for incision closure

The indications for the external approach remainarguable even among current masters of rhinoplasty.

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Anderson103 expressed some concern about the resultingscar and suggested that the external rhinoplasty tech-nique may be most applicable in long-standing, severe,posttraumatic nasal deformities. Friedman andGruber104 adopted the open rhinoplasty techniquebecause of the increased exposure it affords, but con-clude that it is probably not necessary if the cartilagi-nous vault or tip do not need to be modified much.

Constantian105 reviewed 100 consecutive patients whounderwent secondary rhinoplasty and report 36% hadopen rhinoplasty at the previous surgery. These patients’symptoms related to an overresected dorsum or tip andinternal nasal valve collapse. Excessive columellarlength, hard columellar struts, alar/nostril distortion,narrow nose, and external valvular obstruction weremore common in this group.

Surgical Approaches to the TipMost surgical approaches to the nasal tip are variationsof (a) the retrograde technique; (b) cartilage-splitting tech-nique; (c) cartilage-delivery technique; or (d) the externalapproach.

The Retrograde Technique

The retrograde or eversion technique of Converse106 usesa single intercartilaginous incision for access to thenasal dorsum, the cephalic portion of the alar cartilage,and the inferior scroll of the ULC; it also preserves anintact caudal rim of alar cartilage after resection. Theretrograde technique is indicated for deformities requir-ing minimal cephalad resection of the alar cartilages,minimal dome manipulation or modification, and mini-mal cephalad rotation of the lobule complex. Relativedisadvantages of the retrograde technique are a diffi-cult dissection, less visibility, and limited access to thedome–medial crural areas.

Cartilage-Splitting Technique

Anderson81 and Webster and others107 used intracarti-laginous incisions paralleling the caudal border of thealar cartilages. At the lateral aspect of the lateral cruravariable amounts of cartilage are resected according toindividual anatomy and the degree of tip rotationdesired107 (Fig 11).

Fig 11. Tip reduction by resection of variable amounts of alarcartilage to produce cephalad rotation of the tip. A, completestrip excision. B, rim strip excision. C, lateral crural flap. D,complete, curved strip excision. (Reprinted with permission fromWebster RC, White MF, Courtiss EH: Nasal tip correction inrhinoplasty. Plast Reconstr Surg 51:384, 1973.)

The cartilage-splitting approach is best suited to sym-metrical tips that require cephalad resection of the alarcartilages, with or without cephalad rotation of the lob-ule complex, and to tips that require only minimalrefinement. If there is significant asymmetry or the domeneeds to be modified, it may be wiser to use a differentapproach to gain direct access to this area. Peck88,108 pre-fers the cartilage-splitting incision for routine rhinoplas-ties. The advantages of the cartilage-splitting techniqueare 1) one incision with minimal trauma to cartilage andsoft tissue; 2) no disruption or dissection of the residualcaudal alar segment; and 3) absence of an incision throughthe “nasal valve” area at the junction of the upper andlower laterals.

Disadvantages include 1) limited visibility of the domeand medial crura; 2) possible asymmetry if the incisions

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are not precisely equal bilaterally; 3) decreased tip pro-jection if the incision at the dome is too far caudal, whichalters the pivot point of the lobule (Fig 12); and 4) pos-sible collapse of the lateral crura and alar notching if thecaudal rim is weakened by overresection.

Fig 12. Cartilage-splitting incisions have changed the pivotpoint of tip rotation. A, before and B, after splitting the alarcartilages. (Reprinted with permission from Anderson JR: Newapproach to rhinoplasty. A five-year appraisal. Arch Otolaryngol93:284, 1971.)

Cartilage-Delivery Techniques

Techniques that deliver the alar cartilages for directvisualization have been described by Sheen,86 Becker,109

and Bernstein.110 Access to the lobule is by combinedintercartilaginous and infracartilaginous (alar margin) inci-sions that offer greater visibility of the alar cartilages;the entire lower lateral cartilage with attached vestibu-lar skin and mucosa is exteriorized as a bipedicledchondrocutaneous flap. It is easier to manipulate thedome areas under direct vision to correct secondary tipdeformities and there is better postoperative tip sym-metry because the surgeon can see the amount of carti-lage remaining and possibly contour the existing carti-lage without resection. The cartilage-delivery techniqueis most appropriate for difficult nasal tip deformitiessuch as asymmetries, twisted, bulbous, box, bifid, oroverprojecting tips.111

Disadvantages of the cartilage-delivery techniqueinclude increased trauma from the dissection; a worsescar from two incisions; and the risk of injury to thecaudal strip of the alar cartilage from the marginal inci-sion. One must be careful not to penetrate the soft tri-

angle, for, as Sheen86 puts it, “any incisions in the softtriangle may cause deformity of the tip.”

THE OSSEOCARTILAGINOUS VAULT

Dorsal ReductionThe nasal dorsum can be lowered either before or afterthe tip is modified. Rees,80 Anderson,82 and Peck112 preferinitial tip modification with subsequent lowering of thedorsum to a level appropriate for the revised tip. Safian113

and Sheen,86 on the other hand, prefer initial reduction ofthe dorsum followed by tip modification.

When tip projection is adequate or excessive and a smallhump removal is anticipated, dorsal reduction mightbest be done before tip modification. A conservative, con-trolled dorsal reduction using a sharp rasp is a safe wayto avoid overreduction according to Rees,80 Sheen,86 andPeck.112

When tip projection is marginal or inadequate, it seems logi-cal to maneuver the tip first to achieve as much tip projec-tion as possible and then lower the dorsum, instead offirst lowering the dorsum, perhaps excessively, in anattempt to achieve a dorsal line below the level of tipprojection. Constantian114 described a notch that tendsto appear “at the midpoint of the nasal dorsum whenthe bridge has been resected beyond the ability of thesoft tissues to contract. This notch, commonly seen insecondary rhinoplasty patients, occurs at the cephalicend of the supra-tip convexity and appears whether ornot the tip has been overresected.”114

Skoog115 performed composite resection of the bonyand cartilaginous dorsum, tailoring the removed unit,and replacing it as a dorsal osseocartilaginous compos-ite graft. The original indications for the operationincluded severely deviated noses in which extensive dor-sal reduction was anticipated; any residual septaldeformities could thus be camouflaged by the dorsalautograft.

Regnault and Alfaro116 further refined the procedure,and Lejour and colleagues117 used the Skoog techniqueroutinely when dorsal reduction was indicated.Although hump reinsertion may seem overly aggres-sive by current standards of practice, the techniqueshould be considered in patients with very short nasalbones, in whom lateral osteotomies are risky, and in

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select cases of septal deviation where septal modifica-tion could lead to total collapse of nasal support. Disad-vantage of the Skoog technique in routine rhinoplasty isthe potential for displacement and resorption of the dor-sal graft.

Often the dorsal hump deformity is more one of carti-lage than bone.13,80 The cartilaginous dorsum, includingthe septum and upper lateral cartilages, can be reducedby composite resection86 or by separating the ULC fromtheir junction with the septum dorsally and resectingeach separately.85

With small dorsal humps (most frequent), compositeresection maintains mucosal integrity without formalextramucosal tunnel dissection and avoids the risk ofnarrowing mucosal surfaces at the septal-upper lateralcartilage junction as a result of scar contracture.

In large hump deformities it is necessary to divide theULC from the septum extramucosally and to resect theattached and potentially redundant mucosa to keep itfrom heaping over the dorsal profile.

When ULC have to be separated from the dorsal sep-tum to correct a markedly deviated nose or for betterseptal exposure, submucosal tunnels or extramucosaldissection from the underside of the septal-ULC junc-tion preserves mucosal integrity.

Rohrich and associates118 advocate a gradualapproach to dorsal reduction so as to avoid complica-tions such as dorsal irregularities, overresection,inverted-V deformities, and excessive narrowing of themidvault. They list five critical steps: 1) separation ofthe upper lateral cartilage from the septum; 2) incre-mental reduction of the cartilaginous septum; 3) dorsalbony reduction with rasps; 4) verification by palpa-tion; and 5) final modification. Bilateral submuco-perichondrial tunnels are created before releasing theULC from the septum to preserve the cartilages andmucosa of the internal nasal valves.

Sheen86 recommends oblique rasping across the bonesto minimize pull on the upper lateral cartilages frombelow. This prevents accidental avulsion of the cephalicportions of the ULC from their junction with the nasalbones during rasp reduction of the bony dorsum.Guyuron119 recommends the use of a guarded power burrfor deepening the nasofrontal angle. In substantialreductions of the nasofrontal junction, the burr is moreeffective than a rasp, electric saw, or osteotome.

Mommaerts and colleagues120 describe a reductionosteotomy in which the osteotome enters the verticalfrontonasal suture behind the nasal bones and in frontof the nasal spine of the frontal bone. In our view,reduction of the nasofrontal junction presents twoproblems. One, the soft-tissue response to bonyremoval is approximately 50%. Two, as the nasofrontaljunction deepens, the intercanthal bridge lines visiblywiden. Successful bone removal in this area, there-fore, may be tempered by a compromise in nasal aes-thetics.

Sheen86 recommends spreader grafts for reconstruc-tion of the middle roof in patients who have a narrownose with visible depression of the lateral walls andabnormal valving on inspiration. Noses predisposed tomidvault collapse—eg, noses with short bones, thin skin,weak cartilages, or combinations of these—will be toonarrow following resection of the roof and may also ben-efit from spreader grafts.

Skeletal Manipulation and the Soft TissuesGuyuron121 studied the reaction of the soft tissues to skel-etal reduction over several zones of the nose, as follows:

Bony Reduction Soft-tissue Response (%)nasion and nasal spine 25proximal and midnasal bridge 60supratip 43tip–lobule angle and infratip 40

Guyuron121 combines data on soft-tissue response withpreoperative records of the soft-tissue outline to formu-late a plan for precise nasal reduction.

Two factors influence the response rate: the thick-ness of the skin and soft tissues overlying the skeleton,and patient age, which modulates the degree of move-ment of the soft tissues in several zones. Unfortunately,in the clinical situation the soft-tissue response to skel-etal reduction is not linear over the length of the nose;that is, a direct, regularly progressive soft-tissueresponse does not hold throughout. In fact, as the degreeof skeletal reduction increases, the soft-tissue responsedecreases because of redundancy and “memory” of thesoft-tissue envelop e. Some studies122,123 even indicatethat standard maneuvers in tip modification usuallydecrease tip projection.

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Statistical analysis of these changes led Guyuron124,125

to the following conclusions:

• Reduction of the nasion gives the appearance ofincreased intercanthal distance and a longer nose.

• Reduction of the nasal bridge results in a wider noseon frontal view and a tip rotated upward on profile.

• Augmentation of the bridge makes the nose look nar-rower.

• Resection of the caudal septum, caudal borders of themedial crura, or cephalic portions of the LLC pro-duces cephalad rotation of the tip, in decreasing orderof effectiveness.

• Resection of the alar base not only narrows the nos-trils but also moves the alar rims caudally andreduces tip projection when severe enough.

• Resection of the nasal spine increases upper lip lengthon profile and decreases tip projection by weakeningsupport for the medial crura.

Pessa and colleagues126 used 3D CT scans of patientsin two age groups to assess skeletal remodeling of thenasal profile after rhinoplasty. The authors report con-tinued, differential growth of the craniofacial skeleton,with the piriform aperture changing the most. Thisongoing posterior movement of the maxilla manifestedas a retruded nasal profile with age.

Dorsal Augmentation and theNasofrontal AngleThe higher the nasal dorsum, the smaller the nasal baselooks. Constantian127 raises the nasal bridge to offset theappearance of an augmented base. This strategy limitsthe amount of nasal skeletal reduction necessary,decreases the potential for postoperative change and softtissue distortion, and increases the surgeon’s control overthe results.

Ortiz-Monasterio and Michelena128 review techniquesfor nasal dorsal augmentation with autogenous carti-lage and bone grafts. Their preferred graft material isnasal septum, sometimes stacked two and three layersthick. The longitudinal graft pieces are scored length-wise on their external surface so they conform to thenasal bridge contour. When the septum is not availablein sufficient quantities, the authors use composite carti-

lage-bone grafts from the rib molded to the appropriateshape.

Gunter and Rohrich129 describe U- and A-shapedmodifications of septal cartilage grafts for nasal dorsalaugmentation to raise the nasofrontal angle. The indica-tions for and surgical technique of these tailored septalgrafts are described in the article.

Dorsal surface irregularities can occur followingalteration of the osseocartilaginous vault. McKinney,Loomis, and Wiedrich130 advocate use of a thin septalgraft to reconstruct the nasal dorsum followingosteotomy. The authors note that “nasal hump resec-tion converts a smooth, fused nasal ‘cap’ into five sepa-rate components. This may unmask a twist in the sep-tum, expose sharp irregular edges, evidence an open-roof deformity, and/or develop a pinched middle thirdas a result of removal of the spreader effect of thehump.”130 Their septal graft is durable enough to cam-ouflage contour irregularities yet thin enough not to raisethe dorsum. If septum is not available, they opt for adouble layer of temporalis fascia rather than syntheticmaterial.

Endo and colleagues131 review 1200 cases of augmen-tation rhinoplasty with ear cartilage grafts, includingreplacement of silicone prostheses in 40%. Complica-tions developed in 4%, the most common being graftmalposition. The infection rate in their series was 0.5%.Crushed cartilage grafts have also been recommendedfollowing reduction of the dorsum.

More recently, Gryskiewicz et al132 proposed the useof Alloderm for the correction of dorsal contour irregu-larities and minimal dorsal augmentation. Allodermwas found to be stable (non-shifting), soft, and natural-looking. A 2+ year follow-up of 20 patients disclosedpartial graft absorption in 45%; 3 patients requiredreoperation. The authors recommend slight overcorrec-tion in the nasal dorsum, which exhibits the highest rateof resorption. A subsequent article133 looked at second-ary rhinoplasty patients and confirmed 20–30% graftresorption over the dorsum and 10–15% resorption overthe tip.

Jackson and Yavuzer134 note excellent outcomes withAlloderm for camouflage of dorsal nasal irregularities.Alloderm blocks adhesions between the osseocartilagi-nous vault and overlying skin and helps conceal scars.The authors found no significant absorption or recur-

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rence of deformity in 15 patients followed for 6–24months postoperatively.

Erol135 described an adjunctive procedure for dorsalcamouflage or augmentation in primary and secondaryrhinoplasty. The technique, called “Turkish delight”,involves diced cartilage wrapped in Surgicel and shapedas a tube. The roll is inserted in the nasal dorsum andmolded to fit the desired contour after closure of inci-sions. He reports a 0.7% complication rate in 2365 rhi-noplasties, with overcorrection and partial resorptionin 0.5%.

Elahi, Jackson, and others136 used a modified Erol tech-nique for augmentation rhinoplasty in 67 patients andreport good retention of the graft material for up to 24months.

Subsequent studies by other authors using Erol’s tech-nique have yielded variable results. Daniel and Calvert137

examined the use of diced cartilage wrapped in Surgicel(group 1), wrapped in fascia (group 2), and with no wrap-ping (group 3). There was complete resorption of thecartilage in the Surgicel group and good survival of thecartilage grafts in the other two groups. The authorsbelieve the Turkish delight technique may be useful inminor camouflaging but question its utility in signifi-cant dorsal augmentation.

Brenner et al138 studied the survival of four kinds ofdiced cartilage grafts implanted in dorsal skin pockets ofrats: cartilage and Surgicel, cartilage and fascia, fasciaalone, and Surgicel alone. The lowest cartilage viabilitywas seen in the group wrapped with Surgicel, probablydue to the inflammatory response elicited by Surgicel.

Nasal OsteotomiesOutfracture involves levering the nasal bones laterallythrough a medial osteotomy to complete the cephaladportion of the fracture of the nasal bones. The currenttrend in rhinoplasty is away from this maneuver, as itcan produce a “rocker” deformity.

The indications for nasal bone infracture continue to bedebated. Infracture is useful in accomplishing either oftwo goals: closure of an open roof following humpremoval to narrow the apex or roof of the nose, and nar-rowing the base of the bony-cartilaginous pyramid.Depending on the thickness of the septum and the dorsalangle of the ULC–septal junction, a certain amount of

the nasal dorsum may be removed without creating aspace between the septum and nasal bones or septumand upper laterals—an open roof. Removal of a smalldorsal hump deformity does not necessarily produce anopen roof, and infracture of the nasal bones only nar-rows the base of the bony-cartilaginous pyramid, notits apex or roof.

Two questions should be asked before undertakingan osteotomy: (1) Is there an open roof giving a flatappearance to the nasal dorsum? And, (2) Is the base ofthe bony pyramid excessively wide on frontal viewsuch that the aesthetic lines at the base of the pyramiddo not parallel the aesthetic lines from superciliaryridge to nasal tip along the dorsum of the pyramid?Routine or unnecessary nasal bone infracture in theabsence of a significant open roof or when the nasalbones are not divergent may produce a pinchedappearance to the upper and middle third of the nose.

Osteotomies of the nasal bones are classified as fol-lows:

• low-to-low lateral osteotomy with greenstick frac-ture of the cephalic portion of the nasal bones at theirjunction with the frontal bones85

• low-to-low osteotomy along the frontal process ofthe maxilla and extending to connect the cephalicportion of the lateral osteotomy with the nasal dor-sum at the radix85

• low-to-high osteotomy beginning low at the frontalprocess of the maxilla caudally and curving upwardto pass lateral to the dorsum at the radix86

• high lateral osteotomy81 beginning along the base ofthe nasal bones at the frontal process of the maxillacaudally and curving toward the dorsum at the radix(Hilger139)

• medial osteotomies passing vertically between theseptum and the nasal bones and extending cephaladto the nasal process of the frontal bone

Sheen86 lists advantages of the low-to-high osteotomyas follows: (a) the residual cephalic nasal bone bridge isnarrow and can be fractured with minimal digital pres-sure; (b) bony continuity is maintained when the remain-ing cephalic segment is greensticked; and (c) outfracture,infracture, and disarticulation of the nasal bones areunnecessary.

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In cases where the bony pyramid has an excessivelywide base and bony apex but dorsal projection is nor-mal, a lateral osteotomy is indicated, taking care to cir-cumscribe the abnormally wide portion of the skeletonwith the osteotomy. Laterally, periosteal elevation andsoft-tissue undermining should be kept to a minimumto maintain soft-tissue attachments to the lateral por-tion of the nasal bones. These soft-tissue attachmentskeep the bones from collapsing into the piriform aper-ture when mobilized.36,88 Infracture alone will not suc-ceed in narrowing the apex, however, so that a medialosteotomy and frequently a medial ostectomy are neces-sary to displace the osteotomized segment medially.

Rees85 and Sheen86 caution that an excessively highosteotomy laterally along the nasal bone can produce avisible ridge or stair-step deformity at the base of thebony pyramid. To avoid this problem the authors pro-pose their technical modifications, which leave a nar-row residual cephalic segment that is reportedly easierto greenstick without direct or medial osteotomy.

Wright140 in 1961 and later Daniel and Lessard13 evalu-ated the effects of various types of hump removal,osteotomy, and nasal dorsal dissection using cadavers.The authors conclude that

• saw cuts produce less comminution than chisel cuts(but this seems to be more of a disadvantage than anadvantage)

• rasping is safest and simplest for hump reduction

• closure of an open roof necessitates medial movementof the bony vault that is greater at its caudal end

• the length of the hump, especially its cephalic extent,determines how medial movement will occur

• following excision of a hump that extends above theintercanthal line, medial fracture or osteotomy maybe required

• in smaller humps that end below the intercanthalline, a transverse fracture is required

• the most satisfactory infracture method is that ofBecker109 (lateral osteotomy with greenstick fractureat the cephalad portion of the bones); the small spuron the residual superior portion of the nasal bone atthe nasofrontal junction can be rasped

• the bony triangle above the intercanthal line is vir-tually impregnable, and narrowing it requiresrongeuring of the bony web

• medial osteotomy with outfracture of the superiorattachment of the nasal bones is not desirable, for itproduces an unintended angling of the open dorsumand curved fracture lines following a curvedosteotomy. If the fracture line at its cephalad enddoes not reach the nasal dorsum, a bony bridge maypersist to cause a rocker effect, levering outward afterthe nasal bones are moved inward

• with infracture of the nasal bones after lateralosteotomy without medial osteotomy, the bones donot spring back into their original position so long asthe site of greenstick fracture is the thin upper por-tion of the nasal bones and not the upper heavierportion. Transverse fractures pass through the bodyof the nasal bones and not through the nasofrontalsuture line

• potential problems of the low-to-low osteotomy withgreenstick fracture are incomplete fracture or spi-cule formation in the cephalad portion. If this doesnot fracture readily, a 2mm osteotome may beinserted through a stab incision in the glabellar orcanthal area to complete the fracture line

• should the low-to-low osteotomy leave a wide cepha-lic portion of nasal bone, direct transverse osteotomywith a small osteotome through a stab incision ismore precise than medial osteotomy and outfractureor greenstick fracture

Rohrich and coworkers141 found the external perfo-rated osteotomy technique produced consistent resultsin rhinoplasty with minimal postoperative complica-tions. The osteotomies should be designed to cut throughintermediate or transitional zones of bony thickness, suchas along the lateral nasal wall. A comparative, endo-scopic study in cadavers142 confirmed the superiority ofexternal osteotomies in minimizing intranasal trauma:mucosal tears were seen in 11% of external perforatedosteotomies versus 74% of internal continuous osteoto-mies.

Harshbarger and Sullivan144 studied the bony thick-ness and fracture patterns of the medial nasal osteotomy.They drilled 1mm holes along the left nasal bones in 17cadavers and found bone thickness gradually increasedfrom caudal to cephalic and from lateral to medial, leav-ing a natural cleavage plane. The right hemi-noses hadmedial osteotomies at 0° or 15° from the midline and

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were combined with low-to-low lateral osteotomies fol-lowed by digital greenstick infracture. The 0° osteoto-mies produced contour irregularities and rocker-likedeformities. The 15° medial osteotomy produced reli-able, controlled infracture with adequate narrowing.

Gryskiewicz and Gryskiewicz145 studied 75 rhinoplastypatients who required nasal osteotomy and comparedthe perforating method of nasal osteotomy with a 2mmstraight osteotome versus the continuous technique witha 4mm curved, guarded osteotome. Each patient receivedone technique on one side of the nose and the other tech-nique on the opposite side. The osteotomies were per-formed through an internal transnasal or an external per-cutaneous approach. On evaluation at 3, 7, and 21 days,ecchymosis and edema were less on the side with perfo-rating lateral osteotomies with the 2mm straightosteotome than on the side with the continuous osteotomywith the curved osteotome.

Gryskiewicz146 also found that scars resulting fromexternal percutaneous osteotomies were imperceptiblein 94% of patients, but on a few occasions a small visiblescar may be apparent. He stresses the importance ofthorough cleaning of the chisel between cases to avoidtraumatic tattooing.

Castro and associates147 recommend a modified Josephsaw on a reciprocating handpiece for basal and superiornasal osteotomies. A fixator anchors the saw on a singleaxis that allows sawing without resistance and avertsmultiple bone cuts. Giampapa and DiBernardo148 prefera dual-plane, curved reciprocating saw for low-to-highosteotomies, believing they can make precise lateraltransverse osteotomies and avoid a medial osteotomywhen using this instrument. Kim and Kim149 describetheir technique for endoscopically-assisted osteotomieswith a reciprocating saw through bilateral intraoralincisions in the gingival sulcus. Despite these advancesin instrumentation, most rhinoplastic surgeons still pre-fer to use osteotomes in the nose.

THE TIP-LOBULE COMPLEXThe size, shape and position of the alar cartilages rela-tive to the upper lateral cartilages, septum, and soft-tissue envelope determine the conformation of the tip–lobule complex. When the tip-defining points of thedome fall at or below the profile line of the nasal dor-

sum, analysis of the facial and nasal measurements isneeded to determine the status of the tip. When tipprojection is adequate, reduction of the dorsum satis-fies the aesthetic requirements. When tip projection isinadequate, attempts to increase tip projection areappropriate.

The most difficult aspect of rhinoplasty is to surgi-cally manipulate the tip-lobule complex so as to achievepredictable results. Primary deformities of the tip andsupratip area are formidable problems initially, and sec-ondary deformities resulting from inappropriate surgi-cal manipulations are even more difficult to correct.11

A carefully planned and executed operation preservesthe normal anatomy of the nose as much as possible.Techniques for the correction of various tip deformitiesare detailed by Rees,85 Sheen,86 Janeke and Wright,101

Peck,111 Petroff and colleagues,122 and Rich et al.123 Janekeand Wright101 stress the importance of preserving tipsupport during rhinoplasty by safekeeping

• the dense connective tissue between the lateral cruraand the sesamoid cartilages

• the junction of the medial crura with the caudal sep-tum

• the aponeurosis between the upper and lower lat-eral cartilages

• the interdomal ligament formed by a congregation ofdense connective tissue between the domes of thelower laterals

A minimum 5mm of intact lateral crural cartilage mustbe left in place at the caudal margin to support the weightof the soft tissues and maintain tip projection.150

The most important elements of nasal tip projectionare the medial crura, their attachments to the caudalseptum, and the presence of additional cartilage graftsbetween the medial crura themselves or beneath thecrural feet. Petroff and colleagues122 evaluated 51patients who underwent primary rhinoplasty. Tip pro-jection was measured preoperatively, intraoperatively,and 6 months postoperatively. Nasal tip projectionincreased an average 1.5mm following injection of localanesthetic solution. When either a cartilage-deliveryor cartilage-splitting approach was used, most of thesupport mechanism of the nasal tip was weakened ortotally disrupted. Lowering the cartilaginous dorsumand shortening the caudal septum also had a profound

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effect on the postoperative position of the nasal tip.Regardless of the preoperative goal, actual nasal tipprojection decreased postoperatively in most patientsunless steps were taken to increase the length andstrength of the medial crural segment. Of these, 70%had full transfixion with excision of various amounts ofcaudal septum. Disruption of the caudal septal attach-ments not only correlated with a higher incidence ofdecreased tip projection, but the quantitative loss was2.8mm, compared with an overall average of 1.8mm.When the preoperative goal was to maintain nasal tipprojection, the success rate was 28%. When the preop-erative goal was to increase nasal tip projection, the over-all success rate was 57%, but most had procedures thatincreased the strength of the medial crural segment.When the preoperative goal was to decrease tip projec-tion, the success rate was 87%.

Rich and others123 reviewed 100 cases of non-augmenting rhinoplasty to measure the effect of lowerlateral cartilage excision on nasal tip projection. Threetechnique variants were used: cephalic artery resectionwith and without vertical dome division +/– sutureapproximation of the medial crura (modified Goldmantip) when the cartilage was sectioned. Despite overall

good to excellent results, the authors noted a measur-able loss of tip projection in all but one patient.

Byrd and coworkers151 reported on a subset of patientswho were retrospectively identified as being at high riskof losing tip projection, shape, and rotation during rhi-noplasty. Their noses were characterized by a weakmidvault, a plunging tip with polly beak, retracted alae,and weak lower lateral cartilages. These patients hadbeen treated with a floating columellar strut, yet all butone (of 20) lost nasal tip projection. Armed with thisinformation, a second group of 20 patients who had simi-lar features were treated prospectively with septalextension grafts, and nasal tip projection was eithermaintained or increased in all but one. The authors rec-ommend anterior septal extension grafts for controllingprojection, shape, and rotation of the nasal tip duringopen rhinoplasty in these high-risk patients.

Hubbard152 reported similar techniques using directfixation of the medial crura to the septum or septalextension grafts to secure the nasal tip, and noted mini-mal variance postoperatively.

Rohrich and Griffin153 present a classification of asym-metric deformities of the columella and nasal tip and theirrecommended methods of surgical correction (Fig 13).

Fig 13. Algorithm for surgery of the asymmetric nasal tip. (Reprinted with permission from Rohrich RJ, Griffin JR: Correction of intrinsicnasal tip asymmetries in primary rhinoplasty. Plast Reconstr Surg 112(6):1699, 2003.)

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These reports prompt the following questions: Doesthe loss of nasal tip projection during rhinoplastyaccount for the poor correlation between dorsal resec-tion and overlying soft-tissue response? Can we createthe appearance of tip projection after rhinoplasty by low-ering the dorsum and rotating the tip (Rich) despite ameasured reduction of true projection? Are we reallyachieving the desired nasal tip projection or are we modi-fying the dorsum simply to create the desired tip-dorsalprofile line?

Suturing TechniquesMany of the supporting structures to the tip areinterrupted during standard rhinoplasty and it is fre-quently necessary to increase tip definition at the time ofthe surgery.150 Kridel154 reports a tongue-in-groove tech-nique in which the medial crura are advanced upwardand back and the denuded caudal septum is placed intoa surgically created space between them. This methodcorrects excessive columellar show and maintains cor-rection after straightening a caudally deviated septum.It is also indicated for controlling nasal tip rotation andprojection while preserving the integrity of the lobularcartilaginous complex. The technique may be combinedwith either the external or endonasal rhinoplastyapproach.

Kridel and colleagues150 show the value of sutures inenhancing nasal tip rotation and projection and illus-trate the correction of wide, bulbous, amorphous tips in50 patients using a suture technique they call “lateralcrural steal” (LCS) through an open rhinoplastyapproach. The concept behind LCS is to increase thelength of the medial crura at the expense of the lateralcrura. The suture technique depends on a stable nasalbase, which is created by securing the medial crura toeach other, proceeding from the base of the columella tothe nasal tip. If the medial crura are buckled or weak, astrut of septal cartilage is placed in the columella foradditional strength. Plumping grafts are inserted toachieve the desired nasolabial angle. Once the middlecrural complex is stabilized, the lateral crura areadvanced medially and each is sutured first to its medialcrus and then to its counterpart on the opposite sidewith a mattress suture across the tip complex (Fig 14).As the lateral crura are shortened, the tip is relocated

superiorly and anteriorly. If tip rotation is not desired,the lateral crus can be freed from its lateral fibrousattachments and vestibular skin so that it can moveindependently.

Fig 14. Suture technique for increasing projection of the nasaltip. (Reprinted with permission from Kridel RWH, et al: Advancesin nasal tip surgery. The lateral crural steal. Arch Otolaryngol HeadNeck Surg 115:1206, 1989.)

Foda and Kridel155 evaluated the effect of two carti-lage-modifying techniques on their effects on nasal tipprojection and rotation. In the lateral crural steal tech-nique, the lateral crura are advanced onto the medialcrura, resulting in an increase in length of the medialcrura and shorter lateral crura. In the lateral crural over-lay (LCO) technique, the lateral crura are shortened byvertically transecting them and overlapping the cutedges. Computer imaging was performed on 30 patientsseeking primary rhinoplasty mainly for nasal tip repo-sitioning. The external approach was used in all cases.LCS resulted in an increase in both nasal tip projectionand rotation. LCO resulted in significantly greater tiprotation but decreased tip projection. The authors con-clude that LCS is indicated when a moderate increase innasal tip projection and rotation is desired, and LCO isreserved for patients with severe tip underrotationassociated with overprojection.

Tardy and coworkers156 review long-term outcomesof transdomal suture techniques on the nasal tip. Thesetechniques preserve the integrity of the nasal tip—eg, anintact caudal segment or complete strip of alar carti-lage—while reorienting its elements. The transdomal

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suture is indicated in broad, trapezoidal nasal tips wherethe alar cartilages are typically firm and strong, with abroader than normal arch to the dome segment connect-ing the intermediate and lateral crura. The triad of ana-tomic findings—firm, broad, divergent alar cartilages; thinskin; and delicate alar sidewalls—should suggest theoption of transdomal suture for nasal tip sculpturing.

Tebbetts157,158 places sutures to shape and stabilize thetip by controlling the multiple “force vectors” thatinfluence the tip complex. He believes in maintainingthe structural integrity of the alar rim strips; shapingand positioning the lateral and medial crura in a revers-ible, nondestructive manner; minimizing variables bydecreasing the need for a visible graft to shape the tipcomplex; applying sutures judiciously and precisely; andfollowing specific sequences for every maneuver.

Regalado-Briz159 studied 52 patients who underwentopen rhinoplasty by a modification of Tebbetts’ suturetechnique. The cephalic portion of the lateral crus waspreserved and lateral crural resection was limited to themost medial aspect. Suture shaping was used to stabi-lize and control tip morphology. Byrd’s160 discussionstresses the importance of controlling the projection androtation of the domes so as to establish an aesthetic tip-dorsum relationship.

Daniel161,162 presents a two-part review of a simplified3-stitch, open-tip suture technique for primary and sec-ondary rhinoplasty. The technique consists of 1) a strutsuture to affix the columellar strut between the crura, 2)bilateral dome-creation sutures to create tip definition,and 3) a dome equalization suture to narrow and alignthe domes.

Hugo163 uses a suture technique for replanting themedial crura in the hooked nose. The medial crura aredetached from the septum and each other, the tip iselevated and rotated to increase projection, and themedial crura are reattached to the septum.

Behmand, Ghavami and Guyuron164 track the evolu-tion of the major tip suture techniques. Guyuron andBehmand165 discuss the sequencing and multiplanareffects of several suture techniques for the tip.

Daniel166 analyzes the large-nostril-to-small-tip dis-proportion “deformity”. He argues against the tradi-tional basal view and the “ideal” ratio of 2/3 to 1/3, pro-posing instead a lateral view analysis and a nostril–tiplength ratio of 55:45 or 60:40. Daniel recommends a 3-

suture tip technique with columellar strut graft and alarbase resections to restore this relationship. In his dis-cussion of this paper, Sheen167 prefers tip augmentationwith cartilage grafts to achieve the same end.

Scoring or Crushing TechniquesMcCollough and English168 discuss various modificationsof the alar cartilages designed to increase tip projection,all of which involve weakening by scoring or crushingthe portion of the lateral crus immediately lateral to thedome as well as the middle or intermediate crus imme-diately below the dome. A horizontal mattress suture isused to pull the tip-defining points centrally and to carrythe alar cartilages medially, narrowing the lobule andincreasing the vertical height of the tip-defining points.These maneuvers are most applicable when the tip-lobulecomplex is broad and the excess width can be aestheti-cally converted into vertical projection.

Resection TechniquesGoldman169 divides the lateral crus lateral to the dometo narrow the lobule and add projection to the tip. Themethod borrows from the lateral crus to augment theheight of the medial crus (Fig 15).

Fig 15. Effect on tip projection from resection of the lateralcrura at two points.

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In McLure’s170 modification, no vestibular skin isincluded with the segment of the lateral crus that is rolledmedially and a septal cartilage strut is added betweenthe medial crura for support. A small separation is main-tained between the repositioned lateral crura to simu-late a double nasal dome.

The effects on the nasal tip of resecting the alarcartilages in the dome, intermediate crus, and medialcrus are illustrated in Figure 16. These are radical solu-tions to the problem of the drooping nasal tip, and inthin-skinned individuals they are apt to leave visibleirregularities.

Kamer and Cohen171 excise a central horizontal stripof alar cartilage to elevate the tip, increase tip projec-tion, and rotate the tip superiorly while preservingstructural integrity of the arch. The defect createdduring the resection is closed by rotating the caudalsegment of the lateral crus cephalad and affixing it tothe still-stable cephalic margin. They recommend thetechnique for noses that have a wide dome and adrooping tip.

Massiha172 describes elliptical horizontal excisionand repair of the alar cartilage in open rhinoplasty tocorrect cartilaginous tip deformities. An ellipticalexcision is made in the central segment of the lowerlateral cartilage and the upper and lower edges of theremaining cartilage are repaired with 5-0 nylonsutures. This technique appears identical to Kamerand Cohen’s.

Figure 17 illustrates the potential effects on the nasaltip of resecting the cephalic border of the alar cartilagesand caudal septum.

Adamson and associates173 report on 116 consecu-tive patients who had open rhinoplasty and verticaldome division. Patients operated on early in the serieshad cartilage resection and suture reapproximation,while those operated later had dome division, over-lap, and suturing technique. Vertical dome division isrecommended for the correction of lobule asymmetry,retrodisplacement, wide domal arch, and a hanginginfratip lobule. An important consideration in the car-tilage-overlap technique is a reduction in nasal tip pro-jection. If a loss of tip projection is not desired, tipgrafts or other methods to enhance tip projection areneeded.

Grafts to the TipGrafts to the lobule complex can improve tip projectionwhen manipulation of the existing cartilage alone fails.A cartilage graft is inserted within a limited soft-tissuepocket under some degree of tension to produce angula-tion at the columella-lobule junction (Sheen), projection

Fig 16. Effect on tip projection from resection of A, the lateralcrura at the dome, B, the intermediate crura, and C, the medialcrura.

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and angularity at the dome area (Sheen, Peck), or sup-port of the medial crura-columella to prevent settling(Anderson).

Sheen174 reviewed his 20-year experience with graftsto the nasal tip, which he feels are best suited for pri-mary rhinoplasties. Sheen divides his experience intothree parts, paralleling the evolution of nasal tip graft-ing to current standards. Over the years, sources of graftmaterials have included the septum, ear, rib, vomer, andethmoid. Septal cartilage grafts have evolved from asingle columella-lobule contour graft to multiple smallseptal cartilage fill grafts, sometimes crushed or bruisedto avoid angularities and to improve definition. Ear car-tilage is a distant second choice to septal cartilagebecause of its tendency to shatter when manipulated.Sheen reserves rib cartilage grafts for cases involvingcomplex reconstruction of the entire nasal skeleton. (A5-year review shows good take with rib grafts and nochange in tip contour.) Because of progressive resorp-tion of vomer and ethmoid bone grafts for the tip, Sheennow uses them only as buttresses to hold overlying sep-tal cartilage grafts.

The most persistent complications of tip grafts inSheen’s series were malposition and undesirable angu-larities. Tip grafts can shift their position and cause anumber of problems. Grafts that are displaced laterally

cause asymmetry; those that migrate upward cause tipblanching or overprojection; and if displaced downwardthey protrude from the columella. Oversized grafts canalso compromise the vascular supply to the skin of thelobule. Sheen stresses the need for thorough prep andprecise wound closure to keep infections to a minimum.

Cardenas-Camarena and Guerrero175 report an 8-yearexperience with cartilage grafts in nasal surgery, encom-passing 83% from the nasal septum, 12% from the ear,3% from the alar cartilages, and 2% from rib. Graftswere placed between the medial crura in 64%; as Sheentip grafts in 28%; in the nasal dorsum in 19%; as spreadergrafts in 8%; as Peck grafts in 8%; and in the rim in 3%.Reoperation was required in 8% to achieve the desiredresult.

Bateman and Jones176 reviewed the outcome of aug-mentation rhinoplasty using autologous cartilage graftsin 103 patients followed for an average 3 years. Therevision rate over the follow-up period was 15.5%. Thesame surgeons’ revision rate in 311 rhinoplasties with-out grafts over the same period was 4%. The authorsconclude that rhinoplasty with cartilage graft is associ-ated with a significantly higher revision rate than whenno graft is required.

Constantian177 notes that 77% of primary rhinoplastypatients and 80% of secondary rhinoplasty patients inhis practice required grafting mainly to improve lobu-lar contour, not tip projection. He describes the distanteffects of dorsal grafts and tip grafts in rhinoplasty andoutlines his techniques for achieving these effects. Graftsaffect nasal length, symmetry, ethnicity, and dorsum–tip relations. Constantian178 subsequently elaboratedan alternative cartilage-bearing tip graft technique inwhich small amounts of autologous donor material areused to augment only those lobular segments that requireincreased contour or support. The technique evolved inresponse to the high number of patients with inadequatedonor cartilage for traditional shield type grafts and theobservation that, by enlarging the lobule, tip grafts cancreate undesirable postoperative disproportions in somepatients. The revision rate in 405 rhinoplasties (40%primary, 60% secondary) was 14%.

Peck179 uses rectangular onlay grafts of septal orauricular cartilage that are placed overlying the domes.A tight pocket helps keep the graft in position, but ifnecessary it can be stabilized with a pullout suture.

Fig 17. Effect on tip support/projection from resection of acephalis strip of lateral crura.

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Much like Sheen’s tip grafts, Peck’s onlay grafts can dis-place, distort, or partially resorb, and it is difficult tojudge intraoperatively the appropriate degree of projec-tion desired, with the result that the tip is often over- orundercorrected.

Peck and colleagues180 describe an 18-year experiencewith the umbrella graft in rhinoplasty. The graft con-sists of a vertical cartilaginous strut between the medialcrura and a horizontal onlay graft overlying the alardomes. The umbrella graft was used in 22% of 1252mostly secondary rhinoplasties. The revision rate forthe umbrella graft was 5%, and the most common com-plication was visible cartilage. In his discussion of thispaper, Rohrich181 states that nasal tip support usuallydepends equally on the length and strength of the pairedlower lateral cartilages, which in turn are supported bythe suspensory ligaments connecting the domes and thefibers that connect them with the upper lateral cartilages.

Baker and Courtiss182 note that parchment-thin skinis a common problem associated with secondary rhino-plasty, and believe that an onlay graft of temporalis fas-cia is the most satisfactory method to cover the underly-ing osseocartilaginous framework or cartilage grafts inpatients who exhibit this condition. The surgical resultsin 6 patients with temporalis fascia grafts are reviewed.A biopsy of the temporalis fascia and cartilage graft con-firmed the long term viability of the fascia and itsunderlying cartilage.

Anderson82 prefers a strut of cartilage from the sep-tum placed between the medial crura, from the level of

the upper border of the nostrils downward almost tothe premaxilla. Millard183 recommends anterior septum-columellar struts extending from the premaxillary areato the nasal tip. Dibbell184 describes the use of a Bowie-knife-shaped strut to increase tip angularity and projec-tion, particularly in cleft lip noses. The potential disad-vantages of strut grafts are a widened columella, a tent-pole effect with blanching at the nasal tip, leaning of thetent pole, and visibility of the graft through the skin.

Arden and Crumley185 review their clinical experi-ence with and indications for combined placement ofcolumellar struts, shield grafting, and caudal septalgrafts. Patients most likely to require combination graftsare those with lobular hypoplasia or tip under-projection. The authors advocate a columellar strutsutured to the medial crura and septal midline when atransfixion incision is required. They find shield graftsparticularly useful in highlighting tip architecture in theAsian, Hispanic, Mestizo, or African nose, as well as inrevision rhinoplasties where tip scarring or existing alarcartilage structures prohibit natural skin redraping. Forlengthening the nose, caudal septal grafts are used, butthe limiting factor is the amount of available lining. Por-ter, Tardy, and Cheng186 advocate a contoured auricularprojection graft for nasal tip projection in Asian andAfrican noses.

Orak and colleagues187 report an extrasupported tip graftfor the treatment of bulbous nasal tips. The techniqueinvolves an A-shaped tip graft supported with a columel-lar strut, both inserted into small separate pockets (Fig 18).

Fig 18. Extrasupported tip graft and columellar strut. (Reprinted with permission from Orak F, Yucel A, Aydin Y: A new extrasupportedtip graft in the treatment of bulbous nasal tip. Aesth Plast Surg 22:259, 1998.)

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Gunter and Rohrich188 introduced alar spreader graftsfor correction of the pinched nasal tip. The grafts areshaped like bars or flat triangles and are carved fromautogenous septal or auricular cartilage. The spreadergraft is inserted between and deep into the remaininglateral crura to force them apart, propping up the caved-in segment of the pinched tip.

De Carolis189 reports using an infradome graft toimprove dome reshaping in rhinoplasty. The techniqueplaces under the domes two parallel strips preparedfrom the resected alar cartilages. The grafted cartilagesblock the plication suture, which averts excessive pinch-ing of the domes and enhances stability.

McCollough and Fedok190 describe the technique of lat-eral crural turnover graft for correction of the concavelateral crus. Adham and Teimourian191 mobilize andadvance the lateral crura toward the alar rim; the alarcartilages are reshaped and the domes are grafted withstacked disks of cartilage—individual dome-projectinggrafts. Adham192 later modified the procedure by cam-ouflaging the stacked disk grafts with LLC trimmings(from the cephalic edge) to avoid a boxy look.

Hamra193 prefers crushed cartilage grafts over the alardomes following reduction rhinoplasty via the openapproach. The tip is reduced through dome division

and suture reconstruction. Contour deformities areavoided by overgrafting the divided domal segmentswith a crushed onlay graft.

Guyuron, Poggi and Michelow194 introduced asubdomal graft for management of the pinched nasaltip. The graft is placed into a subdomal pocket extend-ing from one dome to another (8–10mm long x 1.5mmwide x 1.5mm thick). The technique was used success-fully in 53 primary rhinoplasties and 8 secondary casesof pinched nasal deformity or asymmetric domes.

Hamra195 opts for dome excision, side-to-side carti-lage repair, and crushed cartilage overlay graft toimprove tip contour. This is a simple method to treat tipdeformities and reduce tip projection when the angle ofdivergence is normal.

Bujia196 studied the viability of chondrocytes in crushed,uncrushed, and cut cartilage grafts. More cartilage cells(70–90%) are damaged by crushing than by cutting, whichleaves most cells viable and able to proliferate.

Pereira and colleagues197 assessed the availability ofblock conchal cartilage for total reconstruction of the alain a cadaver model. “From the lamina tragi, isthmus,and cavum conchae, en bloc resection is possible withcharacteristics of form and dimension similar to those ofthe homolateral alar cartilage” (Fig 19).

Fig 19. The ear is incised and a segment isremoved from the intermediate part of thelamina tragi, isthmus, and cavum conchae.The incised piece corresponds to the medialcrus (A), the junction of the medial and lateralcrura (B), and the lateral crus (C). (Reprintedwith permission from Pereira MD, Marques AF,Ishida LC, et al: Total reconstruction of the alarcartilage en bloc using the ear cartilage: a study incadavers. Plast Reconstr Surg 96:1045, 1995.)

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Fanous and Webster198 recount their experience withMersilene tip implants for the correction of tip deformi-ties in 98 patients. Indications were recession, boxiness,asymmetry, thick or thin skin, upward or downwardturn, and a bifid tip. Mersilene mesh is soft, pliable, andeasily shaped, and can be invaded by surrounding con-nective tissue, which affixes the implant firmly in placeand prevents displacement.199

Despite this favorable report, readers should exercisecaution when using alloplastic materials in the nasaltip. Aside from the potential for tissue ingrowth andscar, an alloplast rejection reaction would have cata-strophic consequences in this critical area of the nose.Autogenous sources of tip grafts, such as nasal septumand ear cartilage, are undeniably superior in nasalreshaping.

Broad or Boxy TipA nasal tip that looks boxy or bulbous rather than trian-gular from the basal view is the product of either anincreased angle of divergence of the medial crura or a widearc in the dome segment of the lateral crura. Tasman andHelbig200 measured the distance between the domes andthe skin thickness over the LLC before and aftertransdomal suture tip-plasty. The distance between thecartilaginous domes correlated with tip width before sur-gery. After surgery, the degree of tip refinement corre-lated with preoperative skin thickness but not withinterdomal distance. These data are further evidence thattip definition surgery is limited by thick soft tissues.

Rohrich and Adams201 propose an algorithm for themanagement of nasal tips where the angle of divergenceis >30° (type I); the domal arc (between the tip-definingpoints) is >4mm (type II); or both conditions are present(type III) (Fig 20). Their technique involves limited domaland cephalic trimming followed by transdomal and/orinterdomal suturing. The endpoint is reached when thedistance between tip defining points is 5–6mm.

Gruber and Friedman202 discuss the rationale for theiruse of sutures in the correction of broad or bulbous tips:the transdomal suture (to narrow the individual domes);the interdomal suture (to bring symmetry, add tipstrength, and sometimes to narrow the tip complex); thelateral crural mattress suture (to reduce lateral cruralconvexity); and the columella-septal suture (to preventtip droop and adjust tip projection).

Division Techniques

Goldman169 narrowed the square tip by completelytransecting the lateral crura and vestibular skin. Amodification of this approach divides the lateral cruraoutside the dome area with or without division of ves-tibular skin.203 The medial crura can then be suturednear the dome or the lateral crura, rotated medially,and sutured to gain further projection anteriorly.McKinney and Stalnecker204 describe their modificationof the Goldman technique for bulbous tips in thick-skinned individuals with both normal and overly pro-jecting dome points.

Unless the skin of the nose is very thick, transectiontechniques produce a more triangular tip at the expenseof a single dome point, the distinct possibility of pinch-ing or kinking of the alar rim, and visible asymmetries.

Scoring Techniques

Unlike transection, scoring usually maintains the in-tegrity of the cartilage and hence support of the tip,with less visibility of the cut cartilage edges.McCollough and English168 discuss an alternative to theGoldman technique that consists of scoring the carti-lage medial and lateral to the dome and bringing thelateral crus medially with horizontal mattress sutures.This centralizes the dome segment while avoiding thebreak or step-off that typifies the Goldman tip. Thetechnique is recommended for use in wide, bulbous, orunderprojecting tips.

Peck111 achieves a triangular tip through wide mobi-lization of the lateral crura with resection of theirdistalmost segment and scoring of the dome area. Sheen86

narrows the broad or boxy tip by interdigitating partialscoring cuts in the dome and medial crura. Hamra205

modifies Sheen’s technique for repositioning the lateralcrus by creating a subcutaneous pocket and suturingthe medial crura together. The dissection is simpler,undermining is easier, and the procedure can be donethrough an open or closed approach. The technique isindicated for patients who have cephalically positionedlateral crura showing the “parentheses” deformity onfrontal view. In these cases the tip is frequently flat andbroad, the alar rim is notched, and the basilar view showsa square perimeter.

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The Overprojecting TipOverprojection of the nasal tip—the “Pinocchio nose”—results from excessive length of the medial and lateralcrura. Procedures designed to reduce the overprojectingtip involve full-thickness resection of either themedial206,207 or lateral6,86,111 crura or scoring of the dome–medial crura junction with or without resection of thelateral crura.86,111 Tardy and others208169 analyzed theoverprojecting tip and find that overdevelopment of thecaudal quadrangular cartilage “tends to ‘tent’ the tipaway from the face and may tether the upper lip, pro-ducing an indefinite nasolabial angle and, on occasion,creating abnormal exposure of the maxillary gingiva,

particularly upon smiling.” Correction begins by low-ering the cartilaginous profile, releasing the tip from thisabnormal influence. Almost every case required weak-ening tip support and overall reduction of the overde-veloped components. Following complete transfixingincision, the tip immediately settled back.

Any procedure that transects the rim of the alar car-tilage can alter the smooth arch of the nostril and pro-duce sharp edges, a notch or step deformity. To mini-mize this potential complication, it is essential to pre-cisely realign and suture the transected cartilage ends and tokeep intact as much of the nasal lining as possible.

Fig 20. Management algorithm for the boxy nasal tip. See text for details of domal reconstruction. (Reprinted witn permission fromRohrich, RJ, Adams, WP Jr: The boxy nasal tip: classification and management based on alar cartilage suturing techniques. Plast ReconstrSurg 107(7):1849, 2001.)

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Neu209 addresses the Pinocchio tip by rolling the lat-eral crura medially and creating new, less prominentdomes while preserving the natural bowing of the alararch. If necessary, any extra length can be excised at thefootplates, which causes caudal rotation of the tip.

Smith210 reduces the overprojecting tip through anopen rhinoplasty technique that transects and raises acolumellar flap which carries the crura of the alar carti-lage within. Tip sculpting is limited to cephalic trim-ming of the lateral crura.

Gryskiewicz211 resects columellar skin to avert aniatrogenic hanging columella after reducing an over-projected tip. The optimal indication for this techniqueis when tip setback is >3mm.

Surgery on the Columella, Nasal Spine,and LipThe columella–lip angle is critical to the aestheticappearance of the nose. According to Aston and Guy,212

the desired septolabial angle is 90–95° in men and 100°in women. Lewis,213 on the other hand, proposes thatthe ideal uptilt of the columella should be 5–15° (or 95–105°) in men and 12–25° (102–115°) in women. He sug-gests that tall patients, patients with long faces, and thosewith receding foreheads or chins should have less of a“tilt-up,” while patients with straight foreheads orprominent chins should have even wider columella–lipangles. We disagree. In our opinion, tilting-up of thenasal tip creates a shorter nose that becomes furtherdisproportionate with a prominent chin. Instead, nasallength should vary directly with chin vertical length.

The nasolabial angle is directly influenced by the con-figuration of the nasal spine and caudal septum. Onsmiling, the upper lip pulls back and the caudal borderof the septum and nasal spine appear to protrude down-ward, sharpening the columella–lip angle. Aston andGuy212 review techniques for resection of the caudal bor-der of the septum and the nasal spine. Figure 21 illus-trates the effects of these maneuvers on the columella–lip angle.

Overresection of the caudal septum or nasal spinemay produce an excessively obtuse septolabial angle(“pig nose”), an acute septolabial angle with a plungingtip (“witch’s nose”), a retracted columella, or a flat upperlip that seems excessively long (“ape lip”). Webster andassociates214,215 discuss the anatomy of the columella and

analyze the aesthetics of the nose with respect to surgi-cal techniques for correcting deformities of the lip-columella junction, including tissue subtraction, tissueaddition, and sliding procedures.

Cachay-Velasquez216 advocates a Rowen-Boyd resec-tion of the depressor septi nasi muscles to correct therhinogingivolabial syndrome: drooping nasal tip, shortupper lip, and increased exposure of the maxillary gums,particularly when smiling. Resection is carried outthrough an extension of the transfixion incision and is

Fig 21. Effect on the columella-lip angle of resection of thecaudal septum and nasal spine.

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frequently accompanied by partial resection of the cau-dal septum and nasal spine. The postoperative resultsreflect the change induced in the columella–lip angle andbetween the tip and upper lip.

Rohrich et al217 studied the role of the depressor septinasi muscle in rhinoplasty and describe three anatomicvariations. An active depressor septi muscle can accen-tuate a drooping nasal tip by shortening the upper lip onanimation. They recommend muscle release and trans-position through a sublabial intraoral incision duringrhinoplasty to improve the tip–upper lip relationship.

De Benito and Fernandez Sanza218 resect the columellaand nasal depressor muscles to improve the nose–liprelationship and the smile. The resection eliminates thedownward movement of the nasal tip with smiling.

Lawson and Reino219 describe reduction columella-plasty, which involves full-thickness excision of a dia-mond shaped piece of tissue from between the feet of themedial crura. The incision is carried down through theskin, depressor septi muscle, and adjacent soft tissue.When the defect is closed, the splayed medial crura arebrought together, increasing the nasolabial angle, modi-fying the shape of the nares, and increasing projection ofthe nasal tip.

Pessa220 suggested selective resection of the levatoralae (levator labii superioris alaqui nasi) muscle to cor-rect the acute nasolabial angle and prominent nasola-bial folds and to improve asymmetries in nasal baseposition. Cadaver studies illustrate the origins of thelevator alae muscles at the frontal process of the maxillaand their insertions into the lateral alae and orbicularisoris muscles. The angular artery and vein lie medial andsuperficial to the muscle and serve as a reliable guide toits position. The infraorbital nerve is lateral to the leva-tor alae muscle and lies beneath the levator labiisuperioris muscle, approximately 7mm below the orbitalrim. The principal action of the levator alae muscle is toelevate the alar base, producing a sneer or snarl. As thealar base is elevated, the nasolabial angle becomes acuteand the medial nasolabial fold becomes accentuated. Themuscle is approached through a subciliary incision, askin-muscle flap is elevated, the orbicularis oculi muscleis dissected inferiorly to free it from the orbital rim, anddissection proceeds medially to the groove between themaxilla and nasal bones where the levator alae muscleis located and identified. A 0.5–1cm-long segment of

muscle is resected. Alternatively, muscle resection maybe accomplished through a buccal sulcus incision.

Foda221 reviewed his results after a minimum of 1 yearin 360 consecutive “droopy tip” rhinoplasties using threealar cartilage modification techniques. He found lateralcrural steal to be most effective for underprojected tips;lateral crural overlay worked best in cases of over-projected tips; and the tongue-in-groove technique wasbest suited for tips with adequate projection.

Guyuron222 studied abnormalities of the footplateof the medial crura and how their surgical correctioninfluences the outcome of rhinoplasty. In a prospec-tive series of 20 consecutive primary rhinoplasties,the author found the distance between the medialfootplates to be 7.5–15mm (avg 11.4mm). The lengthof the footplates was 4–7.5mm (avg 5.8mm). In a ret-rospective review of 295 consecutive rhinoplasties,footplates were altered in 76. In cases of overprojectingtip and divergent footplates, the lateral portion of thefootplates was partially resected and then approxi-mated. If the tip was underprojecting or had normalprojection, the divergent footplates were approxi-mated without resection. When the subnasale andthe base of the columella protruded, the soft tissuebetween the footplates was removed. When thefootplates diverged, the columellar base and nasalspines were retracted but the soft tissues leftundisturbed so as to narrow the columella andadvance it caudally.

Lengthening the Short NoseThe short nose is characterized by lower-than-normaldistance from the nasofrontal angle to the tip-definingpoints and an overly wide nasolabial angle withincreased nostril show.223 Gunter and Rohrich223 describea technique that lowers the tip-defining points bydetaching the lateral crura from their attachments tothe ULC, suspensory ligament, and septum (Fig 22). Thisrelease effectively rotates the alar cartilages caudally,lowers the dome, decreases projection of the tip, andlengthens the distance between the nasofrontal angleand the tip-defining points. As tip projection decreases,the illusion of nasal length increases. The technique isbest suited for patients who have a short nose with anoverprojecting tip.

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Fig 22. Technique for lengthening the nose by rotating the tipdownward. (Reprinted with permission from Gunter JP, Rohrich RJ:Lengthening the aesthetically short nose. Plast Reconstr Surg83:793, 1989.)

Lee et al224 lengthen the postoperative short nose witha combination gull-wing conchal composite graft andrib costochondral dorsal onlay graft as a replacementfor the missing nasal lining and cartilage and to rein-force the framework, respectively. Wide degloving ofthe outer skin envelope is recommended to cover theentire nasal length without tension.

The problem with this method of reconstruction isthe failure to differentially project the nasal tip abovethe plane of the reconstructed dorsum. The outcome ofthis technique is a somewhat underprojecting tip with“Polly beak” fullness. A more aesthetic result can beobtained by incorporating columellar support to raisethe nasal tip above the plane of the dorsum.

Naficy and Baker225 illustrate five techniques forlengthening the short nose:

• the flying buttress graft—a single or paired spreadergraft(s) secured to the columellar strut

• caudal septal grafts

• tip grafts of various shapes

• radix grafts to elevate the nasion

• interposition grafts between the upper and lower lat-eral cartilages

Ha and Byrd226 revisit their experience with septalextension grafts: extended spreader grafts, paired bat-ten grafts (below the junction of the septum and ULC),and direct extension grafts (directly affixed to the ante-rior septal angle when cartilage supply is limited).Despite the grafts’ tremendous versatility in primaryand secondary rhinoplasty, the authors caution againstsupratip/midvault widening or excessive lengtheningfrom “over-extension.”

Guyuron227 lengthens the nose with a tongue-and-groove technique and three pieces of appropriatelyshaped septal cartilage. The technique combines bilat-eral spreader grafts beyond the septal angle with a col-umellar strut, and yet avoids rigidity of the tip. Theauthor reports 20 of 23 patients enjoying good to excel-lent results over 12.5 years, but warns that the tech-nique is labor-intensive and requires sufficient cartilage.

Juri228 recommends conchal cartilage grafts in thenasal tip in conjunction with wide undermining of skinand mucosa for the treatment of the iatrogenicallyretracted tip and short nose. The precise method of shap-ing the cartilage grafts is detailed in this paper.

Hamra229 treated 15 patients with surgically short-ened noses by means of infratip cartilage grafts. A two-or three-tier cartilage graft from septal or conchal donorsite is sutured to the caudal edge of the medial crura.According to the author, the success of this operation ispartly due to lack of skin elasticity among the olderpatients in this series.

To lengthen the nose, Gruber230 releases the septalmucoperichondrial lining and ULC from the LLC. A bat-ten graft is attached to the septum, which in turn holdsthe tip cartilages in a more caudal position. The mostcommon complication is inadequate lengthening.

Wolfe231 uses a nasofrontal osteotomy with mobiliza-tion of previous fractures for lengthening posttraumaticforeshortened noses. To lengthen congenitally shortnoses, Wolfe prefers a perinasal osteotomy. His experi-ence with 9 cases is presented.

The Tension NoseExcessive growth of the quadrilateral cartilage resultsin a high nasal dorsum with anterior and sometimesinferior displacement of the nasal tip cartilages—atension nose.232 Johnson and Godin232 reviewed 50 con-

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secutive primary rhinoplasty candidates and note 46%had some manifestation of tension deformity. They rec-ommend an open approach to reduce the excessive ele-ments of septal cartilage and anterior nasal spine. Car-tilage grafts and sutures are then used to reproject thedomes. Tardy208 offers a different perspective on the sameanatomical deformity.

THE PHYSIOLOGIC AIRWAYHoward and Rohrich233 summarize the nasal anatomyand physiology in nasal airway obstruction. Primary airflow is through the middle meatus (Fig 23). Resistance toair flow is structurally related to hypertrophic turbinates,valvular incompetence, septal deviation, or intranasalmasses. Constricted points along the way increase thevelocity of air flow and may generate negative pressuresthat collapse the internal and external nasal valves. Theappropriate treatment of the obstructed nasal airwaydepends on its etiology. Medical management is oftenrecommended for nonstructural rhinitis. Surgical treat-ment is required when the airway obstruction is due toturbinate disorders, a deviated septum, or incompetentinternal or external nasal valves.

Fig 23. The primary inspiratory current is an arched pathwaythrough the middle meatus. (Reprinted with permission fromHoward BK, Rohrich RJ: Understanding the nasal airway: principlesand practice. Plast Reconstr Surg 112(4):1071. 2002.)

THE TURBINATESJackson and Koch234 review controversies in the man-agement of hypertrophic inferior turbinates, withemphasis on surgical treatment.

Ophir235 analyzed the results of total inferior turbi-nectomy in 38 patients after 1–7 years: 84% reportedsubjective relief of nasal obstruction and 92% had wide,clean nasal airways on rhinoscopy. Objective airflowmeasurements in 32 patients showed increased patencyin all, including 3 patients who still complained of nasalobstruction. There was no atrophy of the nasal mucosaor chronic infection. The author recommends total infe-rior turbinectomy for patients with obstructing inferiorturbinates.

Courtiss and Goldwyn236 looked for undesirable long-term sequelae in 25 patients who had resection ofobstructing inferior nasal turbinates at least 10 yearsearlier. They found no incidence of dry nose syndromeand conclude that bilateral subtotal resection of theinferior turbinates is the treatment of choice for nasalobstruction due to hypertrophied turbinates.

Surgery on the inferior turbinates should be con-sidered along with septal straightening when attempt-ing to relieve nasal obstruction. Pollock and Rohrich237

report an experience in 408 patients with obstructedairways who were successfully treated with adjunc-tive inferior turbinate resection. Their favorite proce-dure is full-thickness excision of the anterior one-thirdto one-half of the inferior turbinate. Long-term fol-low-up revealed no evidence of atrophic rhinitis oruntoward sequelae.

Rohrich and colleagues238 now prefer submucousresection (SMR) of hypertrophic inferior turbinates,which in their series was associated with fewer compli-cations of bleeding, mucosal crusting or desiccation, orrecurrent obstruction. The anterior one-third to one-half of the bony segment is resected with this technique.No atrophic rhinitis was reported.

THE NASAL VALVESConstantian239 analyzed the functional effects of alar car-tilage malposition. Rhinoplasty with resection of thecartilaginous dorsal roof or alar cartilages is the mostcommon cause of acquired incompetence at the internaland external valves. The external nasal valve is pre-sumed to be the mobile nasal ala at the introitus of thevestibule that is normally supported by the lateral crus;external valvular incompetence ensues from malposi-tion of the alar cartilage. Graft support to the lateral

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wall of the nostril is recommended to minimize this com-plication.

Teichgraeber and Wainwright240 report on 27 patientswith nasal obstruction who were treated over a 3-yearperiod. Of these, 14 had involvement of the internal valveonly; 2 had involvement of the external valve alone; and11 had involvement of both valves. The cause of theobstruction was previous surgery in 13 patients, traumain 8, and a congenitally narrow nose in 4. Surgery con-sisted of nasal valve repositioning and cartilage graftingthrough an open approach. The valves were recon-structed with spreader grafts, lateral crural spanninggrafts, crural onlay and sidewall grafts, and columellarstruts used singly or in combination (Fig 24). Treatmentwas successful in 24 of 27 patients. The authors suggeststrategies to prevent nasal valve collapse during rhino-plasty.

Fig 24. Site and number of cartilage grafts used in reconstruct-ing the nasal valve area. (Reprinted with permission fromTeichgraeber JF, Wainwright DJ: The treatment of nasal valveobstruction. Plast Reconstr Surg 93:1174, 1994.)

Stucker and Hoasjoe241 review the treatment of 56patients who had nasal valve obstruction. Follow-upranged from 18 months to 13 years. Treatment consistedof open rhinoplasty with valve and sidewall stabiliza-tion with a dorsal conchal cartilage graft bridging theULC and alar cartilage (Fig 25). Rhinomanometry in 24patients showed objective improvement postopera-tively.

Fig 25. Nasal valve stabilization by conchal cartilage graft withposterior perichondrium attached being placed over thenasal dorsum. Dashed lines represent location of mattresssutures used to coapt mucosal lining, cartilage graft, anddorsal skin. (Reprinted with permission from Stucker FJ, HoasjoeDK: Nasal reconstruction with conchal cartilage. Correcting valveand lateral nasal collapse. Arch Otolaryngol Head Neck Surg120:653, 1994.)

Sheen242 notes that internal valvular incompetence isseen when the angle between the caudal edge of the ULCand the septum is <15°, such as following resection of themidvault roof. Sheen recommends the use of spreadergrafts placed submucosally between the dorsum andULC to widen the ULC–septal angle.

Schlosser and Park243 quantified changes in cross sec-tional area of the nasal valve after placement of spreadergrafts and flaring sutures in 6 cadaver heads. The aver-age minimal area increased by 5.4% with spreadergrafts, by 9.1% with flaring sutures, and by 18.7% withcombined spreader grafts and flaring sutures. On a scaleof 1 (complete obstruction) to 10 (complete patency), themean nasal patency scores improved from 3.4 to 6.5 withthe combination of spreader grafts and flaring sutures.A follow-up article by Park244 emphasized the clinicalapplication of flaring sutures to enhance the repair ofdysfunctional nasal valves.

Guyuron and associates245 introduced the upper lat-eral splay graft to widen a narrow internal valve. Thesplay graft spans the dorsal septum but is deep to theleft and right upper lateral cartilages. Excessive widen-ing of the caudal portion of the dorsum is possible withimprudent use of the technique.

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Al-Qattan and Robertson246 review acquired nostrilstenosis with related airway obstruction secondary to ashortage of vestibular lining and discuss techniquesdesigned to replace the vestibular lining and widen theintroitus.

THE NASAL SEPTUMDeformities of the nasal septum may produce internalnasal obstruction without external deformity; externaldeformity without airway obstruction; or internal air-way obstruction and external deformity. The surgicalcorrection of internal or external septal deformities muststrike a balance between preserving dorsal support ofthe nose on the one hand and obliterating the visible orfunctional abnormality on the other. The correction ofcomplex deformities often necessitates both submucousresection and some form of septoplasty.

Episodes of staphylococcal bacteremia resulting inmetastatic infection have occurred in association withnasal septoplasty, suggesting the possible need forantimicrobial prophylaxis. Silk and others247 reviewedthe records of 50 healthy patients who had blood cul-tures drawn before and during the procedure.Although 50% had colonization of the nasal mucosaby Staphylococcus aureus, none of the blood culturesshowed bacterial growth. The authors conclude thatstaphylococcal bacteremia during nasal septoplastyis a rare occurrence that does not warrant antimicro-bial prophylaxis.

Yoder and Weimert248 analyzed the infection rate in1040 patients who underwent septal surgery withoutprophylactic antibiotics. Minor nasal infections devel-oped postoperatively in 5 patients (0.48%), and allresponded to oral antibiotic therapy. The authors con-clude that the risk of infection after nasal surgery with-out antibiotic coverage is minimal.

Submucous Resection (SMR)Submucous resection of an obstructive septal deformitywas first described by Killian249 in 1905. Currently thebasic principles of subperichondrial dissection andresection of the obstructing cartilage remain largelyunchanged, but “the Killian submucous resection is sel-dom indicated. If done, it should preserve at least 1cm of

the dorsal margin and 1cm of the caudal portion of theseptal cartilage.”250

Bernstein251 lists indications for SMR, includingmidseptal obstructive deformities. After conservativeexcision of the most severely obstructing portions of theseptum by SMR, the remaining cartilage is usuallyrealigned by septoplasty techniques.

SeptoplastyEdwards252 reviews the rationale for septoplasty. Simplemidseptal deflections (which can be successfully man-aged by SMR) comprise only 25% of cases, while caudaldislocations account for about 65%. Complicated defor-mities make up the rest. According to Edwards, SMRresults in inadequate correction of these more compli-cated deformities, three-fourths of which are best treatedby septoplasty.

In 1950 Converse253 recommended vertical scoring ofthe residual dorsal strut of the septum to correct persis-tent deviations of the dorsum. Fry254 later described “in-terlocking stresses” in nasal septal cartilage that couldbe relaxed by scoring the cartilage. Numerous modifi-cations of scoring techniques have since evolved, alongwith procedures combining resection and scoring.

Gruber and Lesavoy255 advocate closed septalosteotomy to realign the bony septum (perpendicularplate of the ethmoid, vomer, and vomerine ridge). Anintranasal fracture is carried out with a long nasal specu-lum. All 32 patients in their series had fracture of thevomer and perpendicular plate of the ethmoid. Thevomerine ridge (premaxilla area) was fractured in 69%.This resulted in dramatic straightening of the bony sep-tum in 82% of patients.

Combined SMR and SeptoplastyNoting that a timid surgical attack of the deviated sep-tum may result in persistent deformity, Johnson andAnderson256 recommend a more aggressive approachconsisting of resection of an inferior strip of septum next to thenasal spine so that the septum can swing freely towardthe midline. The authors advocate total or near-totaltransection of the dorsal strut to correct a deviation whilepreserving intact mucoperichondrium on the convexside. The septal strut is stabilized with transseptal mat-

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tress sutures to prevent collapse after division. Medialand lateral osteotomies to reposition the nasal bonescomplete the procedure. Any residual deformities of thedorsum can be camouflaged with morcelized autogenouscartilage grafts.

Byrd et al257 proposed an algorithm for correction ofthe crooked nose through an open approach. Anatomiccorrection consists of total release of the cartilaginousseptum from the LLC and ULC as well as cartilaginousand bony septal resection to free the dorsal and caudalseptum. Scoring is avoided and the curvature is cor-rected by repositioning the septum and control suturesaided by batten and extended spreader grafts. The nasaltip is routinely secured with a combination of battenand spreader grafts to preserve tip projection. Osteoto-mies are modified to deal with specific deformities in thebony skeleton.

De la Fuente and Martin del Yerro258 prefer “bilateralmucoperichondrial–mucoperiosteal dissection of theseptum from its caudal edge to the most posterior devi-ated part, because it provides easy septal resection in agood surgical field.” A dorsocaudal L strut is preservedwhen possible, but if involved in the deviation, it can beresected and reconstructed with dorsal and columellargrafts.

Cannistrá and coworkers259 advocate an endonasaltechnique with full release of the septum from the upperlateral cartilages.

Rees260 notes that when a high bony deviation is asso-ciated with marked distortion of the cartilaginous sep-tum, the surgeon is hard-pressed to completely alleviatethe septal deformity and simultaneously correct theexternal bony vault deflection without totally excisingthe septum. For severely deviated noses he recommendstotal removal of the entire bony and cartilaginous septumextramucosally and replacement as a free graft. This is arisky procedure if the lateral osteotomy and infractureshould turn out to be less than perfect.

More recently Gubisch261 described complete removalof the septum with subsequent replantation after cor-rection of deformity in 1012 patients. All septal replantshealed primarily. The complication rate was 2.2%. Themain problem with the technique was difficulty inreconstructing the dorsum and stabilizing the replant.

Sheen86 notes that a midline septum may be totallyirrelevant to the objectives of septal surgery—ie, patent

airways and a nose that appears straight. Sheen optsfor a conservative approach involving careful resectionof portions of the obstructing septum, which are subse-quently crushed and replaced as camouflage grafts tomask the deviations. Constantian262 resects the dorsumin the area of deviation until the dorsal edge is closeenough to the midline to disguise the remaining asym-metry. The author suggests the following steps for sur-gical correction of the asymmetrical nose:

1. Determine preoperative nasal balance: Is thedorsum high or too low relative to nasal base size?

2. Resect the dorsum in the area of the externaldeviation until the dorsal septum edge is sufficientlyclose to the midline to allow camouflage of theremaining asymmetry.

3. Perform the septal resection necessary for theairway, preserving a continuous dorsal strut.

4. Augment according to (a) the support needed forthe dorsum, middle vault, columella, and tip and (b)the aesthetic balance that must be restored.

Constantian

Jugo263 advocates total septal reconstruction throughan external approach. He gains access to the septumbetween the alar cartilages along the nasal dorsum. Fol-lowing removal of the entire septum, the straight carti-lage from the center is used to reconstruct the ventral–caudal and ventral–cranial septum, while the deformedcartilage is straightened by crushing and replaced in theposterior septal space. Five girls and 19 boys aged 5 to14 years were treated this way, and the author reportsno alterations of growth necessitating reoperation.

Gunter and Rohrich264 review the management of thedeviated nose and advocate simultaneous correction ofthe septum and bony pyramid when both structuresare involved. The authors propose extensive alterationof the septum but a conservative approach to the exter-nal nasal framework. Total septal reconstruction entailsmobilization of all deviated structures, including theULC, and reconstruction of the deviated L strut alongthe dorsum if necessary. The mucoperichondrial attach-ments should be disturbed as little as possible to pre-serve dorsal support to the nose. Planned, preciseosteotomies are used on the nasal bones.

Rohrich et al265 group nasal deviations into three basictypes: caudal septal deviations, concave dorsal deformi-ties, and S-shaped dorsal deformities with deviation ofthe bony pyramid. Management includes open exposure

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of all deviated structures, release of all involved attach-ments, straightening the framework while maintaining asturdy L-strut, restoring long-term support with but-tressing septal batten or spreader grafts, turbinatereduction if necessary, and precise osteotomies (Fig 26).

Guyuron and Behmand266 discuss the diagnosis andmanagement of caudal nasal deviation by independentlyassessing the components of the caudal nasal structures:septal deviations, asymmetric growth of the lower lat-eral cartilages, anterior nasal spine tilting, and medialcrural footplate asymmetry. The authors recommend

specific techniques to address each of these potentialsources of deviation.

Boccieri and Pascali267 address the crooked nose withseptoplasty, full thickness incisions, and a unilateral car-tilage spreader graft referred to as a “crossbar graft”that splints the concave surface of the deviated septum.The surgeon must avoid degloving the contralateral sur-face or interrupting the anatomic continuity of the L-shaped septal strut.

Conservative approaches to septal deviation useonlay grafts to mask the deformity, but subsequent

Fig. 26. Algorithm for the management of a deviated cartilaginous vault. ULCs, upper lateral cartilages. (Reprinted with permissionfrom Rohrich RJ, Gunter JP, Deuber MA, Adams WP: The deviated nose: optimizing results using a simplified classification and algorithmicapproach. Plast Reconstr Surg 110(6):1509. 2002.)

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resorption or displacement of the grafts may producedorsal irregularities. In turn, radical procedures for sep-tal straightening risk losing dorsal support to the nose,with subsequent collapse of the nasal bridge and saddledeformity. A thorough knowledge of nasal anatomy andphysiology is the key to proper correction.

Septal PerforationsTeichgraeber and Russo268 describe the management ofseptal perforations in 25 patients, 22 of whom weretreated surgically. The perforations ranged from 1.5–2.5cm and were located on the posterior border of thequadrilateral cartilage near the vomer–ethmoid junc-tion. Operative correction included external rhinoplastywith septal and intranasal mucosal flaps and an autograftof mastoid periosteum or temporalis fascia, and wassuccessful in 19/22 (86%).

Kridel269 used acellular human dermal allograft in therepair of septal perforations in 12 patients; 11 had com-plete closure of the perforation. The repair was consid-ered successful if on examination 3 months later the rightand left mucoperichondrial flaps were entirely healed.The authors felt this technique yields satisfactory resultssimilar to those obtained with temporalis fascia, mas-toid periosteum, or pericranium.

Schultz-Coulon270 reports bilateral closure usingbridge flap techniques in 54 patients, with an overallsuccess rate of 93.7%. Closure was supplemented withautologous cartilage from residual septum, rib, or auricle.Morre et al271 report a similar technique with equallygood results. A “cross-stealing” technique for closure ofseptal perforations is reported by Mladina and Heinzel.272

The surgery consists of turn-in flaps based on the mar-gins of the septal perforation from either side of the sep-tum.

Romo and colleagues273 propose a graduated approachto the repair of nasal septal perforations tailored to thesize and location of the perforation:

• Perforations up to 2cm diameter were closed in 93%of patients by an extended external rhinoplasty andbilateral posteriorly based mucosal flaps.

• Larger perforations (2–4.5cm) were closed in 82% ofpatients by a two-stage technique and midfacialdegloving to immediately advance posteriorly based,expanded mucosal flaps. A 1 x 3cm tissue expander

was first inserted in a submucoperiosteal pocket onthe nasal floor.

Foda274 reports a one-stage repair of septal perfora-tions up to 4cm diameter which he used in 20 patients.The repair consisted of bilateral intranasal mucosaladvancement flaps bridged by a connective tissue inter-position graft through an external rhinoplasty approach.There was complete closure of the perforation in 90%and 80% had resolution of preoperative symptoms.

Guyuron and Michelow275 propose an algorithm forthe management of intraoperative nasal septal tears andperforations based on an experience with 98 patients.Small, nonopposing perforations are allowed to healspontaneously. Opposing tears ranging from 1–2+cmare repaired on one side by inserting a straight piece ofseptal cartilage and then repairing the mucoperi-chondrium on the other side.

THE ALAR RIMThe alar rim is a common site of patient dissatisfaction,either because of preoperative deformity or postopera-tive complication. Gunter, Rohrich, and Friedman276

describe the ideal alar–columellar relationship and clas-sify discrepancies in these proportions. In aestheticallypleasing noses the highest point of the alar rim is locatedmidway between the transverse levels of the columella–lobule angle and the tip-defining points. On lateral viewthe nostril is oval; the alar rim forms the superior nostrilborder and the roll of the columella forms the inferiorborder (Fig 27). Abnormal variants can have a hangingor retracted columella, a hanging or retracted ala, or acombination of these.

In profile the nostril rim should be cephalad and par-allel to the columella. When this balance is disturbed, orif raising the columella will shorten the nose excessively,the alar rim(s) may have to be raised too. Matarasso,Greer, and Longaker277 diagnose a hanging columellawhen the septal mucosa is visible on profile, with orwithout a retracted caudal alar rim and regardless ofthe nasolabial angle. When unusually wide medial cru-ral cartilages contribute to the deformity—as was thecase in 15% of their series—balance can be restored byexcising a C-shaped crescent of cartilage from the cra-nial border of the medial crura through a direct approach.

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McKinney and Stalnecker278 discuss three techniquesfor achieving a proper columella-alar relationship: (1)excising the skin of the nose; (2) trimming the lateralcrura along the cephalic or caudal border; and (3)resecting nasal lining. Decisions relating to these choicesare discussed in the article.

Ellenbogen and Blome279 advocate raising the highpoint of the alar rim by 3–5mm from the caudal marginof the columella. Indications for raising the alar rim area cleft nose with anterior webbing, asymmetric nostrils,small or round nostrils, and a hanging sigmoid ala. Inthe event of a hanging columella, the alar rim may haveto be lowered to correct the high-arched nostril.Ellenbogen280 also reintroduced the concept of loweringthe alar rim by incising the alar margin along its freelength and unfurling vestibular mucosa caudally. A graftof septal or auricular cartilage is placed between the twolayers of mucosa at the proposed new alar height andheld in place with through-and-through sutures.

Gunter and Friedman281 describe the lateral cruralstrut graft for use in patients with alar rim retraction,alar malposition, alar collapse, concave lateral crura, and/or boxy tip. This versatile cartilage graft is typicallyplaced in anatomic position between the lateral cruraand the vestibular lining (Fig 28). The authors describetheir technique and provide illustrative examples of theseclinical indications.

Fig 28. The lateral crural strut graft. The graft is sutured to thedeep surface of the lateral crus. (Reprinted with permission fromGunter JP, Friedman RM: Lateral crural strut graft: technique andclinical applications in rhinoplasty. Plast Reconstr Surg 99:943,1997.)

Rohrich, Raniere, and Ha282 review alar rim deformi-ties and the surgical options for their correction (Table1). The authors advocate the use of alar contour grafts ornonanatomic alar rim grafts (septal cartilage) for patientswith mild to moderate congenital alar retraction; pri-mary rhinoplasty patients with a propensity for alarnotching; secondary rhinoplasty patients with minimalor no vestibular lining loss; and patients with malposi-tion of the lower lateral cartilages. Details of the surgicaltechnique are presented (Fig 29).

Guyuron283 discusses his approach to various alar rimabnormalities such as convexity, concavity, retraction,and hanging ala. He utilizes lateral crural spanningsutures, posterior transection of the lateral crura, ortransdomal sutures to correct convexity. Concavitiesare corrected with lateral crural strut or alar rim grafts.Mild alar retraction is also corrected with alar rim grafts.Guyuron proposes an internal V-Y advancement flapfor severe retraction and gives technical details in the

Fig 27. In the ideal nose, the vertical distance between thecolumellar-lobular angle and the tip-defining points is dividedin half by a horizontal line adjacent to the highest point of thealar rim. The greatest distance from the long axis of the nostrilto either the alar rim or the columella should be 1 to 2mm, orAB = BC = 1 to 2mm. (Reprinted with permission from Gunter JP,Rohrich RJ, Friedman RM: Classification and correction of alar-columellar discrepancies in rhinoplasty. Plast Reconstr Surg 97:643,1996.)

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paper. For hanging alar deformity, the author prefersvestibular lining excisions.

Other authors suggest different methods for correc-tion of alar retraction. Tardy and Toriumi284 propose

composite grafting of the alar rim. Constantian285 alsoadvocates liberal use of composite auricular cartilagegrafting for alar rim deformities in secondary and ter-tiary rhinoplasty patients based on his experience in100 consecutive patients. In the same paper Constan-tian describes an “axially oriented” auricular cartilagegraft spanning the alar base and sill for the correctionof vestibular stenosis with alar collapse. Gruber286,287

describes the use of an intercrural batten graft thatextends from the caudal edge of the ULC to the cephalicmargin of the LLC to push the lateral crus and alar rimcaudally.

Tardy and colleagues288 describe a technique for alarreduction and sculpture that is based on a detailed analy-sis of the anatomy of the alae and nostril floor. Alarmodifications are indicated when there is flaring,bulbosity, or excessive width of the nasal base or whentip retroposition at surgery produces excessive alar flare.Of importance is the site and angle of insertion of thealae into the face. A cephalic location of the alar–facialjunction may create a high arched appearance to thealae, exposing an excessive amount of columella. Inextreme cases this variant produces a snarl-like appear-ance. Caudal insertions of the alae into the face createthe appearance of a disproportionately large and bul-bous lobule and sometimes alar hooding. The authorsgive indications for internal nasal floor reduction, alarwedge excision, alar flap, and sliding alar flap.

Millard289 discusses alar margin sculpturing tech-niques through external incisions. Planas and Planas290

review the use of external excisions for correcting varia-tions in the shape of the nostrils in rhinoplasty.Matarasso291 approaches alar rim excision through an“internal technique” to core out excess alar tissuethrough an alar base incision. Subsequently the author

TABLE 1Surgical Indications and Options for Alar Deformities

(Reprinted with permission from Rohrich RJ, Raniere J, Ha RY: The alar contour graft: correction and prevention of alar rim deformities inrhinoplasty. Plast Reconstr Surg 109(7):2495, 2002.)

Fig. 29. Gunter graphics demonstrating the operative proce-dure. (Reprinted with permission from Rohrich RJ, Raniere J, Ha RY:The alar contour graft: correction and prevention of alar rim deformi-ties in rhinoplasty. Plast Reconstr Surg 109(7):2495, 2002.)

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limited the indications for this approach to deformitiesof the lower third of the rim.292

SECONDARY RHINOPLASTYThe incidence of postsurgical nasal deformities requir-ing secondary correction varies from 5% (the best thatexperienced surgeons achieve, according to Rees293) to12% (Smith,294 reporting on 221 patients). Rogers295 offersa comprehensive discussion of postrhinoplasty defor-mities and the procedures for their correction. The readeris also referred to Webster’s296 review of techniques,Peck’s297 retrospective, and Sheen’s86 chapter on second-ary rhinoplasty. Sheen86 believes that the key to aneffective secondary rhinoplasty is accurate diagnosis ofthe deformity and lists five “ground rules” for the man-agement of postsurgical nasal anomalies, as follows:86,89

• defer surgery until there is final resolution of tissueedema (at least 1 year)

• have a well-defined aesthetic concept

• make a proper diagnosis

• limit the dissection

• use only autogenous material

In general, surgical correction of secondary deformi-ties must be more conservative than the primary opera-tion. The surgeon should resist the temptation to repeaterrors of overreduction. In Millard’s298 words, “once thenose goes wrong, too often an irreversible chain reactionis set in motion, as the surgeon frantically excises againand again.”

Sheen89 discusses the secondary correction of supratipfullness, total disharmony of all nasal parts, a dorsumthat is too low after grafting, a snub nasal tip fromoverresection of the dorsum and underresection of thecaudal septum, and residual high septal deviation.Sheen’s technique for grafting the nasal tip90 is also help-ful in secondary rhinoplasty. When the middle vaulthas been narrowed excessively and the caudal bordersof the nasal bones are visible through the skin, Sheen92

recommends spreader grafts to reestablish an open anglebetween the ULC and the dorsal septum. The authorcorrelates reconstruction of the middle nasal vault withimprovement in nasal physiology and enhanced airwaycapacity.

Peck297 discusses some common deformities in second-ary rhinoplasty, as follows:

• lack of tip projection from lack of alar cartilage–domeprojection

• lack of tip projection from lack of septal support ofthe nasal tip–pyramid complex

• saddle deformity

• supra-tip deformity

• alar deformities

• deformities of the upper lateral cartilages and nasalbones

• deformities of the columella and short nose

• deformities of the nasolabial angle

• a thick, rigid tip

• persistent Pinocchio tip

Peck297 uses a conchal cartilage tip graft when there islack of tip projection from inadequate dome projectionand a conchal cartilage intercrural graft when the lackof tip projection is due to insufficient dorsal support.Peck’s choices for reconstructing the septum in saddlenose deformity are first, a layered septal cartilage graftand, second, a bone graft harvested from the ilium, rib,or calvarium.

In Peck’s experience the supratip deformity is mostcommonly caused by a high supratip septal cartilage,and for correction he recommends lowering the dorsumas a unit to include the septum and the left and rightULC. The second most common cause of supratip defor-mity is inadequate removal of the fibrofatty tissues. Thethird most common cause is inadequate sculpting of thealar cartilages. A supratip deformity can also result fromoverzealous lowering of the nasal pyramid in the pres-ence of thick, rigid skin, in which case a columellar strutor dome–tip graft may be indicated.297

Guyuron and associates299 noted supratip fullness in9% of primary rhinoplasty patients and in 36% of sec-ondary rhinoplasty patients. In primary rhinoplastythe deformity was due to inadequate tip projection(pseudodeformity), an overprojecting caudal dorsum, acombination of both, or cephalically oriented LLC. Insecondary rhinoplasty the deformity was caused byunderresection or overresection of the caudal dorsum,overresected midvault, underprojected tip (pseudo-

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deformity), or any combination of these. The authorsconclude that it may be possible to prevent supratipdeformity by properly resecting the caudal dorsum,avoiding dead space, restoring adequate projection tothe nasal tip, and approximating the supratip subcuta-neous tissues to the underlying cartilage with a supratipsuture.

Alar notch deformities are most often secondary toresection of vestibular lining or transection of the alarcartilages. Deformities of the upper lateral cartilagesand bone are generally corrected by onlay grafts of sep-tum or conchal cartilage.296

According to Peck,297 the most common cause of acrowded lip is a septum that is too long and has literallygrown onto the upper lip. Resection of the caudal end ofthe septum is usually all that is needed for correction.

The recessed nasolabial angle is corrected by inser-tion of a septal or conchal cartilage graft to build up thebase and open the angle. A tight frenulum can be cor-rected by V-Y advancement of the frenulum.297

The thick, rigid tip is generally associated with seba-ceous skin that will not drape over the skeletal frame-work. In these instances Peck297 recommends augmen-tation of the tip. He corrects the persistent Pinocchio tipby amputation of the cartilages and reconstruction withonlay graft from the concha.

Parkes and others300 analyzed their experience with1221 consecutive rhinoplasties, of which 170 (13.9%) wererevision procedures. Most secondary problems occurredin the lower third of the nose: Polly beak (33%), bossa(26%), and excessive dorsal resection (24%).

On the basis of his experience with 56 cases of second-ary deformity following primary open rhinoplasty,Daniel301 recommends a closed technique when augmen-tation is the solution and an open approach when struc-tural correction is required. The risks of skin necrosisand poor scarring are similar with either technique. Thestigmata of open primary rhinoplasty include 1) adepressed and visible scar; 2) destruction of the soft-tissue facets in the nostril apices; 3) columellar deformi-ties with associated nostril asymmetry; and 4) excessivetip or supratip defatting. These can and should beavoided, and Daniel offers suggestions for eliminatingthem.

Neu302 describes a “segmental” approach to second-ary rhinoplasty for mild to complete loss of alar cartilages

and a treatment algorithm based on the severity of thedeformity. His technique of cartilage grafting in thesedifficult patients is detailed and illustrated in the article.

SADDLE NOSE DEFORMITYStuzin and Kawamoto303 use cranial bone grafts to cor-rect the postrhinoplasty saddle nose deformity. The sub-periosteal pocket extends well into the piriform aper-ture and along the lateral nasal walls and nasal floor.Mucosal advancement is sometimes indicated. In addi-tion, patients with nasal foreshortening often require astrong cantilever bone graft to augment the dorsum,lengthen the nose, increase tip projection, and supportthe columella.

Erol304 elevates the nasal dorsum with a pliable graftof diced cartilage wrapped in Surgicel. Although thegraft seems more suitable for fill than for structural sup-port, the author reports good results in 2365 patientsover 10 years.

In the event of end-stage deficiency of the nasal skel-eton, Posnick and colleagues305 recommend full-thicknesscranial bone grafts and rigid internal fixation through acoronal incision. The dorsal graft often must extenddown to the tip for a well-chiseled contour and good tipdefinition. The authors warn against grafts that are toowide and that excessively broaden the nasal dorsum,and urge care in sculpting the nasofrontal junction.

Powell and Riley306 analyzed the 4-year results of 850calvarial bone grafts to the nose in 170 patients. Mostgraft sites showed partial resorption ranging frominsignificant to 30%. Areas of maximum resorption andcontour change were at the nasal dorsum and lateralposterior mandible. Excellent contour was achieved andmaintained in all but a few cases. Although the authorsendorse the use of calvarial bone grafts in facial skeletalreconstruction and in the nasal dorsum, their studyshows the nose to be a site of potentially greater boneresorption than other areas of the face.

Jackson307 reviews the long-term outcome of 363 cra-nial bone grafts used in nasal reconstruction. Split-thickness grafts were used in 85% and full-thicknessgrafts in the remainder. Jackson reports satisfactoryresults in the vast majority of cases. Hodgkinson308 arguesthat bone grafts should not extend to the nasal tip butstop at the septal angle; augmentation of the nasal tip

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should be accomplished with cartilage grafts from othersites. We agree with this view, as differential support ofthe tip produces aesthetic projection of the tip above thedorsal plane.

Kridel and Konior309 reviewed the fate of 306 irradi-ated costal cartilage homografts to the nose of which 122were used on the nasal dorsum, 40 for primary rhino-plasty (PR) and 82 for revision (SR). Complicationsincluded infection around the graft in 3–4%, graftresorption in 3–4%, graft mobility in 4%, and cartilagewarping in 2.7%. The overall complication rate wasapproximately 10%. Four patients in the PR group even-tually needed revisional nasal surgery for additional aug-mentation. To date, this is the largest published series ofirradiated costal cartilage homografts specifically usedfor nasal reconstruction.

Daniel310 describes the use of an osseocartilaginousautologous rib graft for dorsal contour in combination witha rigid cartilaginous strut to support the tip and reinforcethe columella. The methods of harvest and reconstructionare well illustrated. In a discussion of Daniel’s article, Byrd311

describes his technique for carving portions of the 10thand 11th ribs as nasal grafts (Fig 30).

Fig 30. Technique for harvesting a portion of the 10th and 11thribs to serve as columellar and dorsal grafts in rhinoplasty.(Reprinted with permission from Byrd HS: Discussion of “Rhino-plasty and rib grafts: evolving a flexible operative technique” by RKDaniel. Plast Reconstr Surg 94:610, 1994.)

Waldman312 reports his experience with Gore-Tex foraugmentation of the nasal dorsum in 17 patients whenautogenous sources were not available. The Gore-Tex

grafts were inserted during open rhinoplasty, and allpatients received some type of columellar support. Onfollow-ups of 12–36 months, Waldman notes no opera-tive or postoperative complications. One implant wasremoved 5 months after insertion because of excessiveaugmentation.

Godin, Waldman, and Johnson313 analyzed the postop-erative course of 137 patients—69 primary rhinoplasties,68 revisions—who had augmentation with Gore-Texpatches. Follow-up was 6–80 months (avg 25mo). Theystate: “Three (2.2%) of 137 grafts became infected andwere removed. One graft was removed 5 months postop-eratively because of excessive augmentation. None of thepatients who underwent implant removal required sub-sequent augmentation. All 137 patients [were] pleasedwith their results.” Several technical points were felt tobe important to the success of the procedure, as follows:

• For dorsal grafts, boat-shaped implants are prefer-able.

• All implant edges must be carefully beveled and thegraft cut to the width of the nasal bones at the nasion,gradually widened toward the rhinion, and taperedto a sharp point at its caudal end.

• The dissected pocket should easily accept the graftwithout rolling or bunching.

• The graft should run the entire length of the dorsumto avoid steps or notches in profile.

• The graft is soaked in saline containing a broad spec-trum antibiotic and secured with 5-0 polypropylenesuture.

• Overcorrection is not necessary, as resorption ofGore-Tex implants has never been observed.

An update of Godin’s series of nasal dorsal augmen-tation with Gore-Tex comprised 309 consecutivepatients, 52% primary rhinoplasty (PR) and 48% sec-ondary rhinoplasty (SR) cases.314 In follow-up of 5mo to10y, the graft infection rate was 3.2% overall: 1.2% PR,5.4% SR. The grafts became infected in 3 patients withperforated nasal septums and had to be removed. Theauthors consider septal perforation a contraindicationto Gore-Tex implantation.

Owsley and Taylor315 reviewed their use of Gore-Texfor nasal augmentation in 106 patients (87 on the dor-sum), and state that “postoperative follow-up has

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revealed a stable implant material with no complica-tions relating to the graft material.” In his discussion ofthis paper, however, Daniel316 cautions against the use ofGore-Tex for soft-tissue augmentation on the basis thatit is not approved by the FDA for this purpose and themanufacturer itself does not recommend it.

Straith317 reviewed the long-term (average 15y) out-come of Silastic implants for the correction of saddle-nose deformity in 5 patients. A careful dissection,watertight closure, antibiotic irrigation, and implantdesign that avoids pressure on thin vestibular mem-branes are credited for the good results.

The forgotten element in successful correction of post-traumatic saddle nose is nasal lining. For an in-depthdiscussion of this topic, the reader is referred to SRPSvolume 10, number 12.318

ADJUNCTIVE PROCEDURES

Resection of the Alar BaseSheen86 classifies alar bases according to relative pro-portions of vestibular and external skin. Weir319 in 1892corrected excessively flaring or wide nostrils byresecting the alar bases. Sheen86 later modified Weir’stechnique by retaining a medial flap on the wedge exci-sion. This refinement provides for a more natural, con-tinuous nostril sill and reduces the alar notching pro-duced by the scar of the Weir procedure.

Paranasal AugmentationGuerrerosantos320 reviewed augmentation of theparanasal and anterior maxillary area with autogenousfascia and cartilage. Graft designs and positions weredetailed. The procedure is recommended as an adjunctto orthognathic surgery as well as in primary and sec-ondary rhinoplasties.

MentoplastyIn 1965 Millard183 discussed adjunctive procedures incorrective rhinoplasty, including wedge excision of thealar bases and resection of the alar margins to narrowthe width of the nose and correct alar flare; insertion of acolumellar strut graft of septal cartilage to elevate thetip; and introduction of a chin implant through an

intraoral approach. According to Millard, augmenta-tion mentoplasty is indicated in approximately 15% ofrhinoplasty patients.

Rish321 proposed a simple and effective method fordetermining who would benefit from chin augmenta-tion. Using photographs of the patient in profile withthe Frankfort line parallel to the floor, a vertical line isdropped perpendicular to the Frankfort horizontal andthrough the lower lip. If the chin does not reach this line,the patient is probably a candidate for augmentationmentoplasty.

Davis322 classified chin deformities as macrognathic,retrognathic, and microgenic. Microgenia and occasion-ally retrognathia are the only conditions in which chinaugmentation is appropriate. He uses primarily Silasticchin implants and stresses proper placement over thepogonion, as low as possible over the point of the chin,where the bone is dense and less likely to resorb than ifthe implant is placed higher on the mandible. If aug-mentation >8mm is required, a simple chin implant isunlikely to give satisfactory results, in which case amandibular osteotomy or sliding genioplasty is indi-cated.

Two studies323,324 document resorption of the man-dibular cortical surface after placement of solid chin im-plants. Although essentially a radiographic finding andusually self limiting, this cortical resorption neverthe-less has prompted the development of softer prostheses.

Simons325 reviews the history of mentoplasty,describes an extraoral surgical approach, and discussesother adjuncts to rhinoplasty including chin reduction,orthodontia, makeup, and hair styling.

COMPLICATIONSIn 1964 Klabunde and Falces326 surveyed 300 unselectedcases of cosmetic rhinoplasty and noted an overall com-plication rate of 18.3%, although 95% of patients weresatisfied with the results. Intraoperative or early post-operative complications in their series included the fol-lowing:

• operative hemorrhage

• septal perforation

• anesthesia-related problems

• postoperative hemorrhage

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• postoperative infection

Late complications consisted of the following:

• persistence of edema or ecchymosis

• excessive scar

• vestibular webbing

• hypesthesia

A later retrospective study of 200 rhinoplasties byMcKinney and Cook327 disclosed considerably lowerincidence of infection, hemorrhage, and secondaryrevisions in the intervening 17 years. The overall com-plication rate was approximately 6% (4% if chin com-plications were excluded), and 12% of patients requiredrevisions. Despite the improved surgical outcome,patient satisfaction declined to 90%. Dissatisfiedpatients were more likely to be female, in their 40s, andnot physician referrals.

Teichgraeber, Riley, and Parks328 reviewed 259 con-secutive rhinoplasties and noted a 5% incidence of seri-ous complications, defined as hemorrhage (5), perfora-tion (4), infection (3), and pneumocephalus (1). All thesepatients had concomitant septal or turbinate surgery.

Padovan and Jugo329 reviewed the complications ofexternal rhinoplasty in their practice over a 14-yearperiod. Intraoperative complications included excessivebleeding (>250mL) in 1.3%, and cuts on the caudal bor-der of the LLC and tears of the columellar skin, whichoccurred rarely but were annoying. The most commonearly postoperative complication was transient epi-phora occurring in 12.7%. Transient anosmia occurredin 4.6% and prolonged edema in 3%. The most commonlate postoperative complication was failure to achievethe desired aesthetic or functional goal in 5% of patients.Approximately half of these requested secondary cor-rection. The authors recommend the following measuresto avoid complications in open rhinoplasty:

• meticulous surgical technique

• proper set of instruments

• hypotensive anesthesia

• careful screening for coagulation disorders

• no surgery during the menstrual period or duringtimes of aspirin intake

• careful patient selection and increased caution inhypertensive patients

• routine use of broad-spectrum antibiotics and steroids

• careful placement of nasal packs only in the anteriorhalf of the nasal cavity

• no narrow, straight osteotomes

CorticosteroidsHoffman and associates330 note certain advantages to theuse of steroids during rhinoplasty. In a randomized,double-blind study of 29 patients, they documented lesspostoperative edema of the eyelids and nose and fewerecchymoses when steroids were administered. Patientswho received steroids also had less discomfort post-operatively.

In a randomized, double blind prospective study of20 male patients, all of whom had osteotomies as part oftheir rhinoplasty, Berinstein and coworkers331 measuredthe effect of a single preoperative dose of 10mg dexa-methasone on postoperative edema. Contrary to expec-tations, these patients showed more edema than thosewho did not receive the corticosteroid.

Shafir et al332 report the case of a 37-year-old womanwho underwent rhinoplasty, including septal correc-tion, with injection of small amounts of long-acting Depo-Medrol to either side of the nasal bridge. Within secondsof the last injection, the patient lost vision in the ipsilat-eral eye and had no pupillary reflex. A diagnosis of cen-tral retinal embolus and choroidal occlusion was madeand routine treatment for vascular occlusion of the bulbwas immediately given. Despite these measures, thepatient remained blind in that eye.

In a review of the literature in 1981, Mabry333 found10 cases of blindness following steroid injections, but in1994 reported zero visual complications in his own seriesof 13,000+ intranasal steroid injections. The patho-mechanism is believed to be microemboli occluding oneor more of the retinal or choroidal vessels.

Nasal Packing, Stents, Splints, and DressingsGuyuron335 assessed the role of nasal packing inseptorhinoplasty and concluded that patients who hadpacking were less likely to develop recurrent septaldeviation and synechiae and more likely to have an

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improved nasal airway postoperatively. Significantimprovement in airflow was documented in 96% ofpatients who had nasal packing compared with 64% ofthose who did not have nasal packing.

Reiter and colleagues336 disagree. On the basis of theiranalysis of 75 consecutive nasal procedures completedwithout packing, they recommend through-and-through suturing of the entire septal flap, small caliberosteotomy, meticulous closure of all intranasal incisions,and proper application of conforming dressings asalternatives to packing.

Camirand and colleagues337 reviewed the course of812 patients who had neither internal packing norexternal immobilization following rhinoplasty. Noneshowed early bone or septal displacement and there wasno increased swelling, bruising, pain, epistaxis, or syn-echiae over patients who had packing. [It is not clearfrom their report whether any patient in this series hadturbinate surgery, which will increase the risk of syn-echiae.] Submucosal hematoma and septal necrosiswere nonexistent. Nevertheless, most rhinoplasty sur-geons feel that external conforming dressings are of ben-efit in controlling postoperative edema.

A randomized, prospective trial by Lubianca-Netoand associates338 evaluated the time of nasal packing inrelation to hemorrhagic complications after nasal sur-gery. Of 104 patients in the study, half had packing for24 hours and the other half for 48 hours. No statisticaldifference was observed between the two groups interms of hemorrhagic complications. Hypertension wasthe only prognostic factor for postoperative bleeding.

Guyuron and Vaughan339 evaluated the efficacy of sep-tal stents for maintaining patency of the airway afterseptorhinoplasty. Subjective ratings of airway improve-ment were very similar whether patients had receivedstents or not. The number of patients in this small samplewho complained about discomfort was higher in thenasal stent group, as well as the rate of partial, residual,or recurring septal deviation.

Airway ChangesConstantinides and colleagues340 studied the long-termoutcome of open cosmetic septorhinoplasty and itseffect on nasal airflow in 27 patients. Plethysmo-graphic findings showed improvement in 23 andworsening in 4. Subjective impressions of nasal

patency did not correlate well with objective mea-surements. The authors conclude: “Patients with nor-mal nasal resistance values may suffer long term as-ymptomatic increase in nasal resistance values aftercosmetic open septorhinoplasty.”

Risk of Nasal FractureGuyuron and Zarandy341 note an incidence of nasal bonefracture after rhinoplasty of 0.624/y (24/1121 over 8years). In contrast, the National Center for Health Sta-tistics cites a 0.021% annual incidence of nasal bone frac-ture. Clearly, “the incidence of nasal bone fracture fol-lowing rhinoplasty … is higher than that of fracture inthe general population.”

Sense of SmellKimmelman342 evaluated the olfactory capacity of 93patients before and after nasal surgery—includingethmoidectomy, polypectomy, Caldwell-Luc, reductionof nasal fracture, and septorhinoplasty—and reportimprovement in 61 and decline in 32. There was nocorrelation with age, gender, type of operation, oranesthetic.

Toxic Shock SyndromeReports of toxic shock syndrome (TSS) after nasal sur-gery343–345 deserve special attention. Between 1980 and1983 the incidence of TSS after nasal surgery was 16.5/100,000 patients, which is proportionately higher thanfor the general population of menstruating women. Inall cases the onset of symptoms was rapid and consistedof fever, nausea, vomiting, diarrhea, erythroderma, andhypotension; the wound did not appear grossly infected.The causative organism was a species of Staphylococcuscapable of producing a potent exoprotein, toxic shocksyndrome toxin-1 (TSST-1). Topical and systemic anti-biotics did not seem to offer any protection against thedisease.343 No predisposing factors have been identifiedand there is only a weak correlation with surgical tech-nique.343–345 Patients who develop TSS tend to receivesplints more often and all have nasal packing, but so do98% of all patients. In short, to this day we do not knowwhy a few patients contract TSS after rhinoplasty andmost do not.

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THE NONCAUCASIAN NOSEThe basic approach to the noncaucasian nose involveselevation (augmentation) and narrowing of the dorsum,increasing tip projection and definition, and narrowingof the wide nasal base and alae.

Hoefflin346 reports his experience with geometricsculpting of the thick and poorly defined nasal tip com-mon to black, Hispanic, and Asian patients. Tip defini-tion and refinement to create the illusion of a thinnernose can be accomplished through 1) geometric tipdefatting on the central and lateral areas; 2) triangularalar cartilage reduction; 3) placement of an ultra-supportive, peapod-shaped graft in the nasal tip; and 4)alar base reduction.

The Asian NoseMost rhinoplasty surgeons find that their Asian andWestern patients share similar concepts of the ideal nose.Asian noses frequently lack adequate tip projection, na-sal length, and dorsal height/projection. Widened alarbases, caudal tip rotation, short columella, and thick-ened alae are also common findings. The following pointsshould be considered when contemplating rhinoplastyon an Asian patient:

• Thick, sebaceous nasal tip and columellar skin maylimit the amount of lobule refinement that can beachieved.

• Patients tend to prefer intranasal or closedapproaches.

• The scars of transcolumellar incisions may remainvisible, with notching or hypertrophy.

• Patients generally opt for procedures without graftsbecause of their aversion to external scars.

• Septal cartilage availability is questionable.

• Flat or absent nasal dorsums may require extensivedorsal augmentation.

Alloplastic augmentation through closed techniques hasbeen advocated over more traditional open rhinoplastytechniques with autogenous materials. The safety andefficacy of alloplastic materials remains controversial.Falces and coauthors347,348 review specific techniquesdesigned to create Western features in Asian and blacknoses. Flowers349 addresses rhinoplasty in Asian noses

and lists indications and limitations of alloplastic mate-rials for dorsal augmentation.

Parsa350 uses autogenous split calvarial grafts fornasal augmentation in Asian noses based on his experi-ence with 62 patients followed for up to 8 years. Mostnoses could be satisfactorily augmented with a single-layer split calvarial graft, but some required multiplelayers. The complication rate was 8%, including 3 minorseroma-hematomas at the graft donor site, one completebone resorption, and one overcorrection that necessi-tated secondary revision.

Endo and colleagues351 used ear cartilage grafts foraugmentation of the nasal dorsum in 1263 Japanesepatients. Follow-up ranged from 6–20 months. Compli-cations occurred in 4% of patients, and the most frequentand significant problem was graft malposition. Localinfection developed in 6 patients but was controlled withantibiotics. The authors conclude that ear cartilage graftis the best alternative for dorsal nasal augmentation inJapanese patients.

Deva, Merten, and Chang352 reported a 10-year expe-rience with silicone augmentation rhinoplasty. A dor-sal-columellar strut prosthesis was most used com-monly. Of 422 patients (412 of Asian ethnicity), 5.5%had major complications requiring the removal of theimplant within the first 30 days. The causes of implantremoval were displacement, hemorrhage, prominence,and supratip deformity. An additional 4.3% of patientsrequired later removal of the silicone implant, mainlyfor excessive prominence or displacement. Only 2patients (0.5%) had implants removed because of extru-sion. There were no infections. The satisfaction rate was84%, and those who were dissatisfied wanted furtheraugmentation of the nose. The authors believe the maincause of extrusion is overaugmentation; there is an aug-mentation threshold beyond which the complicationrate will rise dramatically. They discuss implant selec-tion in relation to nasal morphology and desired aug-mentation, and maintain that silicone nasal rhinoplastyis safe in selected patients.

Zeng et al353 report 406 cases of silicone augmentationrhinoplasty. Complications were related to depth ofimplantation and character of overlying tissue. Theauthors conclude that subperiosteal implantation issuperior to subfascial. The published complication ratesin other series of dorsal nasal augmentation with sili-cone implants vary.354–356

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Clark and Cook357 describe their technique of immedi-ate nasal reconstruction with irradiated homograft cos-tal cartilage after extrusion of alloplastic nasal implantsin 18 patients. One complication (warping) requiredgraft removal. The authors state that this proceduremay be a reasonable alternative to staged reconstruc-tion because it avoids soft-tissue scarring and contrac-ture. The typical site of extrusion for Silastic (nasal tip),Supramid, and Gore-Tex (nasal valves, nasal sidewall,rhinion) implants is discussed.

Jung and colleagues358 recommend autogenous carti-lage grafts from the seventh rib over alloplastic materi-als for dorsal augmentation >8mm. Other autogenousand alloplastic materials for dorsal augmentation arediscussed in the “Saddle Nose Deformity” and “DorsalAugmentation” sections above.

The Black NoseOfodile, Bokhari, and Ellis359 analyzed 201 black

American noses and noted three distinct groups on thebasis of anatomic features: the African (44%), the Afro-Caucasian (37%), and the Afro-Indian (19%). The nasaldorsal contour went from mostly concave in the Africangroup to predominantly convex in the Afro-Caucasianand Afro-Indian groups. African noses were shortestand widest, Afro-Caucasian narrowest, and Afro-Indianlongest. The alar cartilages tended to be small and thinin the African group and large and thick in Afro-Indiannoses.

Rees,85,360 Bernstein,361 Kamer and Parkes,362 Santana,363

and Song and others364 review techniques of rhinoplastyin blacks. Santana363 advocates correction of alar baseflaring without alar base excision. Through a Caldwell-Luc incision, the soft tissues in the middle one-third ofthe face are undermined subperiosteally and sutures areplaced across the alar line and tightened in the midline.This narrows the alar bases somewhat and elevates thecolumella. The authors report no recurrence of flaring.Song and coworkers364 discuss the use of cantileveredcostal cartilage grafts for nasal dorsal augmentation in19 black patients. They detail the techniques for graftharvest, design, and placement.

Rohrich and Muzaffar365 discuss the classic anatomicfeatures of African-American noses (Table 2). They rejectthe notion that the alar cartilages are smaller or weaker

than in caucasians, and attribute the lack of tip projec-tion to the relatively obtuse angle between the medialand lateral crura with underdevelopment of the nasalspine. The many techniques for increasing tip projec-tion, increasing tip definition, dorsal augmentation, andcorrection of alar base abnormalities are reviewed. Theauthors recommend liberal use of tip grafts, alar baseexcision, and dorsal augmentation, with cautious use ofnasal osteotomies.

TABLE 2Caucasian vs. African-American Noses

(Reprinted with permission from Rohrich RJ, Muzaffar AR: Rhino-plasty in the African-American patient. Plast Reconstr Surg 111:1322,2003.)

Porter and Olson366 offer an anthropometric analy-sis of the African-American female nose, with a classi-fication of nostril morphology and norms. For example,the columella-to-lobule ratio is 1.5:1, the nasolabialangle is 86°, and the alar width-to-intercanthal dis-tance ratio is 5:4.

The Hispanic NoseOrtiz-Monasterio367 described his approach to rhino-plasty in Mestizo noses, and later128 reviewed the use ofaugmentation techniques in noncaucasian noses. Hispreferred source of graft material for augmenting thedorsum is septal cartilage; rib cartilage is only a secondchoice. Septal cartilage is also favored over auricularconcha for grafts to the nasal tip. Most patients requireaugmentation of the dorsum, columella, and tip, as wellas alar base resection.

Daniel368 proposed a classification system for Hispanicnasal morphology, as follows:

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Type I (Castilian) — high radix and dorsum and rela-tively normal tip projectionType II (Mexican–American) — low radix and bony dor-sum, normal cartilaginous dorsum, and depressed tipType III (Mestizo) — low radix, normal dorsum, decreasedtip projection, and thickened nasal ala/tip

Daniel’s surgical approach to rhinoplasty varies withthe type of deformity: a functional reduction rhinoplastyfor Type I noses; a “finesse” rhinoplasty for Type II; anda “balanced” rhinoplasty for Type III noses (Table 3).The author also stresses conservative dorsal reductionfor Type II and III noses, radix grafting for Type II, andlobular soft-tissue reduction with alar base/sill excisionsfor Type III.

THE COCAINE NOSESlavin and Goldwyn369 noted the potential problem ofcocaine users presenting for rhinoplasty. In their seriesof 13 patients who had used cocaine, fewer than halfwere properly identified as cocaine users during the ini-

tial consultation. The preoperative rhinoscopic findingsthat should alert a physician to cocaine use are: visibleperforation, microscopic evidence of granulomas, inflam-mation, and necrosis. Surgical complications related tococaine use include localized septal collapse, delayedmucosal healing, and inadequate correction of septaldeflection. The authors conclude that submucous resec-tion and septoplasty should be avoided in patients witha known history of intranasal cocaine use.

Millard and Mejia370 discussed their approach toreconstruction of cocaine-damaged noses. Cocainecauses vasoconstricton of the intranasal mucosal bloodvessels and, with continuing ischemia, mucosal necro-sis ensues. The exposed cartilage can succumb to chon-dritis and septal perforation to varying degrees. Theauthors support the use of local mucosal flaps forsmaller perforations. For more severe deformities,including complete midvault/tip collapse, staged recon-struction is required. They recommended the use ofbilateral nasolabial flaps for soft-tissue reconstructionfollowed by staged rib cartilage grafting of the tip anddorsum 3 months later.

TABLE 3Anatomic Characteristics and Recommended Surgical Procedures for Hispanic Noses

(Reprinted with permission from Daniel RK: Hispanic rhinoplasty in the United States, with emphasis on the Mexican American nose. PlastReconstr Surg 112:244, 2003.)

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