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RHINOPLASTY
HISTORY
500BC – Susruta nasal reconstruction (original text described cheek flaps)
1000AD – Indian Forehead flap
1800s - Von Graefe and Dieffenbach refined both the Indian and the Tagliacotian methods
of rhinoplasty.
1887 - John O Roe introduced intranasal approach
1898 - 1898 Jacques Joseph pioneered nasal reduction
ASSESSMENT
History
1. Establish what the patient wants.
2. Previous trauma or surgery to the nose.
3. Airway problems? Snoring?
Examination
 Inspection and palpation are important.
 Intranasal examination must be done.
 Examine the nose in relation to the face and the patient as a whole.
 Midface hypoplasia, chin relationships
 Go region by region:
1. Naso-frontal angle and bridge (radix)
2. Dorsum: excess or deficient, convex or concave
3. Tip: width and projection
4. Alae: width and shape
5. Deviation of the nose
6. Columella: shape, position and length
7. Skin cover: thin or thick and sebacceous
8. Nostril: size, shape, symmetry
9. Septum (straight or deviated, in groove or out)
10. Turbinates and nasal floor
11. Nasal valves and airway
Patient selection

This is important in all cosmetic procedures, especially rhinoplasty.
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
Beware the super-secretive, the one unable to identify his or her desires, who requests urgent operation, is
overly concerned with minor deformities, has secondary motivations, is excessively demanding, carries a
number of photographs describing his/her preferred nose, is extremely indecisive, and the male patient

SIMON acronym, which stands for Single, Immature Male, Overly expectant, and Narcissistic.

four anatomic variants that strongly predisposed to unfavourable results (Constantian)
1. low radix/low dorsum
2. narrow midvault,
3. inadequate tip projection
4. alar cartilage malposition. – normal lateral crura diverges away from tip about 15. If diverges more,
then tendency to transect crura during the infracartilagenous incision. Common to get tip deformities
and notching of the alar rims
ANAESTHESIA
 GA (hypotensive) plus topical application (coccaine) and local infiltration  preferable.
 LA plus sedation  if requested by patient, if partial rhinoplasty, if inexperienced anaesthetist.
 1% lignocaine with 1 in 50 000 to 1 in 200 000 adrenaline is the usual LA.
 Coccaine 4 to 5% is the usual topical anaesthesia used. (2-3mg/kg)
PRE-OP
 Patient 30o up with head extended and on a head ring.
 Trimming of vibrissae with blade (Freddie Nicolle) or scissors and double hook
SURGERY
Traditional rhinoplasty (Joseph) aimed for a retrousse (turned up) nose with a narrow bridge
consisted of
1) caudal upper lateral cartilage trim
2) aggressive dorsal reduction
3) lateral osteotomy
Lessons learnt from early rhinoplasty
1. aggressive dorsal reduction lead to internal nasal valve obstruction
2. reduced tip projection following standard rhinoplasty
MODERN TRENDS IN RHINOPLASTY (Rees and others)
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1. Less removal of tissue
2. More preservation of structures
3. Under-operate rather than over-operate
4. Incisions designed to preserve lining and soft tissue
5. Excision of only the bare redundancy of UL cartilages
6. Tip before dorsum
7. Preservation of the domes - avoid transection to maintain the ‘spring’
8. Maximum preservation of the caudal border of the septum
9. Nasal spine only resected in well defined, specific cases
10. Medial osteotomies less frequently done
11. Outfracturing rarely done
Male vs Female
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Surgical Considerations

4 aspects
1. Approach – open, closed
2. The osteocartilagenous vault - Rasping/osteotome; Blade/scissors; Infractures/osteotomies
3. The tip-lobule complex
4. The septum – septoplasty vs resection
APPROACH
INCISIONS:
1. Inter-cartilaginous - between UL and LL cartilages
2. Intra-cartilaginous (trans-cartilaginous/cartilage splitting) - through LL
3. Infra-cartilaginous - follows caudal border of LL
4. Marginal – Along rim
5. Transfixion - through membranous or cartilaginous septum, caudally
6. Basal - stab at piriform fossa for lateral osteotomy
7. Combination
i. Cartilage delivery – combined infracartilaginous or rim with intercartilaginous
ii. External approach – rim combined with transcolumellar incision
a. allows exposure of the tip-lobule complex without disturbing intercrural and alar-septal
attachments
.
Intracartilaginous
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Inter cartilaginous
Cartilage delivery
Closed vs Open Approaches
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Adv of open
1. Better exposure for tip-lobule correction, asymmetric tip, secondary rhinoplasty
2. does not disrupt scroll area
3. Better binocular visualization for teaching and studying deformed anatomy
4. Control of bleeding by electrocautery
5. More accurate diagnosis
6. More precise correction of deformities
Disadv of open
1. Separation and secondary healing of the transverse columellar incision
2. Additional edema of the nasal tip persisting for several months
3. Increased operative time for incision closure
4. Increased loss of tip projection with open versus closed approach (3.43 mm versus 1.98 mm)
a. Attributed to the increased ligamentous disruption and skin undermining inherent in the open approach.
SURGICAL APPROACHES TO THE TIP
1. Retrograde Technique ( Eversion technique of Converse)
 Single intercartilaginous incision to approach dorsum, inferior part of UL and cephalic part of LL.
 Indicated where minimal cephalad resection of alar cartilages and dome modification is to be done.
 Disadvantages are difficult dissection, less visibility and limited access.
2. Cartilage Splitting Technique
 Intracartilaginous incision used.
 best suited to symmetrical tips that require cephalad resection of the alar cartilages, with or without
cephalad rotation of the lobule complex, and to tips that require only minimal refinement.
 Advantages are:
1. one incision, therefore minimal trauma
2. no disruption or dissection of the residual caudal element of the alar cartilage
3. no incision in the nasal valve area (intercartilaginous)
 Disadvantages are:
1. limited visibility of dome and medial crus
2. asymmetry can result if the incisions are not precisely the same
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3. decreased tip projection if the incision at the dome is too far caudal, which alters the pivot
point of the lobule
4. possible collapse of the lateral crura and alar notching if the caudal rim is weakened by
overresection
3. Cartilage Delivery Technique
 Combined intercartilaginous and infracartilaginous incisions allow for direct visualisation of the alar
cartilages and tip.
 The entire LL cartilage with attached vestibular skin and mucosa is thus delivered and exteriorized as a
bipedicled, chondro-cutaneous flap.
 Advantages
1. better visibility of alar cartilages
2. dome can be manipulated under direct vision
3. better post-op symmetry
4. contour cartilages without resection.
 The technique is therefore best for the difficult nasal tip: one that is asymmetrical, twisted, bulbous, boxy,
bifid or overprojecting.
 Disadvantages:
1. although visualisation is better than with other closed methods, the cartilages are deformed once
delivered and retracted.
2. 2 incisions, therefore ed trauma of dissection and a worse scar
3. risk of injury to the caudal strip of the alar cartilage from the infracartilaginous incision
 Avoid injury to the soft triangle.
4. External Approach
 Bilateral rim or marginal incisions along the inferior border of the alar cartilages that are connected in the
midline by a transcolumella incision.
 This allows exposure of the tip-lobule complex without disturbing the intercrural and alar-septal
attachments.
 Rethi used a partial, high transverse columella incision but it failed to uncover the entire nasal skeleton.
Subsequently multiple other columella incisions have been described (stepped, V, gull wing, etc).
 Advantages are that because of better visualisation, anatomy is properly seen and can be taught, Dx is
more accurate, haemostasis is better, and deformities can be better corrected.
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 Disadvantages are that the tip-lobule complex is degloved and displacement can occur when the wounds
are closed. If the tip is normal, this method is therefore not recommended. There is also the disadvantage
of a possible  in operating time, extra (and external) scarring and prolonged post-op oedema.
 When should the open technique be used?
1) cleft nose rhinoplasty
2) difficult septal deviation in the context of cosmetic rhinoplasty (Nicolle)
3) long-standing, severe, post-traumatic nasal deformity (Anderson)
4) secondary rhinoplasty
 very controversial even amongst experienced rhinoplasts.
 Closed is the traditional way.
 There is, however a trend towards the ed use of open rhinoplasty as a primary procedure (The modern
procedure).
THE OSTEO-CARTILAGINOUS VAULT
 The dorsal hump is often more cartilaginous(60%) than bone(40%)
 Both the septal and the UL cartilages require trimming to reduce the cartilaginous hump and the bone
requires resection for its component.
Cartilage Resection
Composite resection or individual resection of cartilages?
 With small humps, composite resection of both dorsal septum and UL cartilages is often better as mucosal
integrity is maintained.
 Larger humps require separation and individual resection of cartilages. The UL and septal cartilages are
separated from each other and resected. Redundant mucosa is excised.
 Cartilage best excised with 11 blade
 McC method: A strip of cartilage from the free caudal border of the septum may also need removal (knife
is used). If the septal angle is not reduced, a polly tip (snoopy droop, parrot beak) appearance may result.
Resection of the bony hump
 Common rhinoplastic manoeuvre.
Before or after tip reduction?
 Rees, Peck and Anderson:  Tip first; dorsum then brought into line with tip.
 Sheen, Safian, McC:  Dorsum first; tip then brought into line with dorsum.
 Byrd argues - Big tip, start with the dorsum; small tip start with the tip.
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 If tip excessive or adequate and only a small dorsal hump resection is required, do this first and the tip
after.
 If tip marginal or inadequate then get the tip projection as good as possible first and then bring the dorsum
down in line with this.
Technical Pointers
 With rasp, osteotome or burr. (Rasp safest, burr most effective).
 Aesthetic illusions
1. Burring best to deepen nasion - gives appearance of widened intercanthal distance and longer nose.
2. Reduction of the nasal bridge makes the nose look wider on AP and rotates tip upward on lateral.
3. Augmentation of the bridge makes the nose look narrower.
4. Lateral infractures make base look wider
5. Resection of the alar base not only narrows the nostrils but also moves the alar rim caudally.
6. Reduction of the nasal spine increases upper lip length on profile and reduces tip projection by
reducing support of the medial crura.
 Sheen recommends oblique rasping to avoid avulsing the UL’s from the bone.
 Skoog technique: resection of whole dorsal unit, tailored and replaced as a composite osteo-cartilaginous
graft. The aim was to be able to disguise any lateral deviations caused by septal problems. Some use this
technique for all their rhinoplasties (Lejour). Most would only use it if the dorsum is very large with weak
structural support (ie short nasal bones). There is a risk of displacement or resorption of the dorsal graft.
 Use spreader grafts in high risk noses - noses with short bones, thin skin, weak cartilages
Soft tissue response to skeletal manipulation (Guyuron)
 After reduction of the skeletal support, 2 factors prevent soft tissue re-draping:
a) redundancy of soft tissue and skin
b) memory of soft tissue and skin
these are function of thickness of skin and patient’s age (skin elasticity)
 The more skeletal framework removed, the less the soft tissue response.
 over the nasion and nasal spine show the least effect of skeletal surgery (25% response).
 The nasal bridge had the best soft tissue and skin re-draping. (60%)
 The tip-lobule area (including the supra-tip) had an intermediate response (40%)
Dorsal augmentation
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Indications
1. increase dorsal projection
a. congenital
b. trauma
c. post tumor excision
d. post surgery
e. inflammatory – Wegeners granulomatosis
f. aesthetics
2. camouflage irregularities of the dorsum
3. to balance appearance of wide nasal base
Objective
On frontal: recreate two slightly curved, divergent (hourglass) lines that extend from the medial supraciliary
ridges to the tip-defining points
On lateral: Nasion at level of supratarsal fold. A relatively straight dorsum with a slight convexity at the
rhinion is most natural and pleasing.
Materials
1. Prosthetic: silicone, medpor, goretex, vicryl mesh  up to 50% extrusion rate, can become infected.

Advantages
1. readily available with an unlimited supply
2. easy to fashion into the desired shape
3. resist warping and resorption
4. no donor-site morbidity
2. Allograft: bovine or cadaver cartilage, cadaver sclera  resorb.
3. Autogenous tissue:
a) Cartilage:
1. septal – first choice, less likely to warp
2. auricular – higher tendency to warp, not good if need straight graft
3. rib – tendency to warp. Becomes ossified in older patients
b) Bone: iliac, rib, calvarial

endochondral bone sources have greater resorption than membranous bone

usually worse donor sites than cartilage

unnatural feel if used in lower third
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
temporalis fascia has been used alone or wrapped around bone graft
Technical points
 Bone grafts become incorporated but require solid bony contact in new site.
 Cartilage grafts will take without direct bone or cartilage contact, but cartilage has a tendency to curl and
bend.
 Graft can be placed as a cantilever strut (2 point fixation with wire or screw) or as an L-shaped graft.
 McC recommends 2 stage surgery for severe deformities (usually those with severe septal deviation
requiring SMR):
 septal, osteotomies and tip surgery done first
 dorsal nasal implant done as a second stage
 Augmentation is not only used for saddle nose deformity.
 Sheen and Constantian also uses it if the patient has a large nasal base. By augmenting the bridge the
illusion is created that the nose is in proportion and therefore looks smaller. Advantages:
 ability to create the illusion of reduction while preserving skeletal support.
 Less limited by soft tissue constraints
 limits the amount of nasal skeletal reduction necessary, decreases the potential for postoperative change
and soft tissue distortion,
 Ortiz-Monasterio prefers septal cartilage for augmentation, sometimes stacked 2-3 pieces deep and scored
longitudinally to conform to a better shape.
 Gunter and Rohrich use dorsal augments to correct an obtuse nasal-frontal angle or to raise a low radix
 Endo reviewed 1200 cases of dorsal augmentation. 40% were to replace silicone. The remainder were for
noses that were too short or too flat. Ear cartilage was used. The complication rate was 4%; the
commonest Cx was malposition and infection occurred in 0.5% of cases.
 Most bone grafts show partial resorption (insignificant to about 30%). The nose is a potentially greater
bone resorptive site than other areas of the face. Usually, excellent contour is attained and maintained.
 Complications of cartilage graft (4-10%) include:
1. infection (1-4%)
2. resorption (3-4%)
3. mobility (4%)
4. warping (3%)
Osteotomies
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 Medial osteotomy: Outfracture.
 3 reasons for medial osteotomy and outfracture:
i. to allow the high “transverse osteotomy”
ii. to ensure adequate loosening at the line of the osteotomy
iii. to allow insertion of the rongeur to remove the remaining bony web at top of dorsal hump
excision.
The trend is away from outfracture as it can produce a “rocker” deformity.
 Lateral osteotomy: Infracture
 Indications for infracture continue to be debated. There are 2 goals:
1. Closure of an open roof after dorsal hump resection
2. To narrow the base of the bony cartilaginous pyramid
 Dorsal hump resection does not necessarily open the roof (especially if the dorsal hump resection is
small). Infracture may not be required and may, in fact, result in narrowing of the nasal pyramid.
 One must therefore always ask 2 questions prior to infracture:
1) Is there an open roof giving a flat appearance to the dorsum?
2) Is the base of the nasal pyramid excessively wide and unattractive?
 Infracture can give a pinched tip appearance to the upper and middle 1/3 and can interfere with the
internal valves. It must therefore not be done as a routine.
Classification of osteotomies
Lateral
1. low to low either with a transverse greenstick fracture or extending the osteotomy to include the transverse
element.
2. low to high  Start low, finish high (Sheen). Extra~ or intra~ nasal.
3. high to high (Hilger)
Medial - medial: between the septum and the nasal bones.
Technical Pointers

Sheen and Rees both caution against the high osteotomy because it can cause a step deformity.

Saw cuts produce less comminution but rasping is the simplest method

closure of an open roof necessitates medial movement of the bony vault that is greater at its caudal end
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
usual infracture method is a lateral osteotomy with greenstick fracture at the cephalad portion of the
bones (easier with low-high) although direct transverse osteotomy with a small osteotome through a stab
incision is more precise

above intercanthal line bone is thick and narrowing requires rongeuring the bone

transverse fracture pass through the body of the nasal bones and not through the nasofrontal suture

potential disadv of low to low are incomplete osteotomy and spicule formation in the cephalad portion
(use 2mm osteotome through a stab incision to knock it off)
Instruments / methods

osteotome through stab incision at the piriform aperture intranasally

Joseph saw – reciprocating saw – causes least mucosal trauma

2mm osteotome through a stab incision in the skin
o Becker compared 2.5-mm, 3-mm, and 4-mm low-profile guarded osteotomes - the 4-mm
osteotome caused intranasal mucosal tears 95% of the time, the 3-mm osteotome - 34%, and
2.5mm osteotome in 4%.
THE TIP-LOBULE COMPLEX
 Considerations
1. tip projection – 1-2mm above dorsum
2. tip rotation – will affect both tip projection and columella-labial angle
3. distance between the tip-defining points
4. supratip break
5. columella-labial angle
6. alar lobules
 The primary factor determining the nasal tip outline is the shape and position of the alar cartilages.
 The most difficult aspect of rhinoplasty is to manipulate the tip-lobule complex so as to achieve
predictable results.
 The total effect of tip surgery may not become apparent until many yrs after surgery.
 Tip support must be preserved by maintaining:
1. the dense connection between the lateral crura and the sesamoid cartilages
2. the aponeurosis between the UL and LL cartilages
3. the interdomal ligament between the domes of the alar cartilages
4. the junction of the medial crura and the caudal septum
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5. a minimum of 5 mm of intact lateral crural cartilage to support the weight of the soft tissues and to
maintain tip projection
 Without augmentation, it is easier to loose tip projection than to gain it. Local anaesthetic injection falsely
projects the tip by 1.5 mm. Cartilage splitting or cartilage delivery techniques weaken the support of the
tip and result in loss of tip projection. Lowering the cartilaginous dorsum and shortening the caudal
septum also result in loss of tip projection.
 The most important components of nasal tip projection in the post-surgical nasal tip are:
1. the medial crura
2. the attachments of medial crura to caudal septum
3. the presence of additional cartilage grafts
 Without active steps to improve tip projection intra-operatively, the tip projection will be decreased
McC:
 The caudal part of the septal cartilage is trimmed if necessary.
 The alar cartilage is either delivered or via an intra-cartilaginous incision (requires more skill), the
cephalad (supero-medial) part of the lateral crus of the LL cart is excised. This allows the tip to narrow
and be more refined. Excess removal, however, will result in a pinched tip appearance and even collapse
of the alae on inspiration.
 If the tip is bifid, the fibro-areolar tissue between the domes of the alar cartilages can be removed and the
alar cartilages can be sutured in the midline.
 Cartilage scoring can also be done to allow the domes to ‘fold’ better.
 Precautions:
a) Avoid removing vestibular lining and leaving raw areas as the healing by scarring can cause
distortion.
b) Do not remove too much  pinched appearance to tip and a groove in the supra-tip area.
c) Avoid sharp angles and protuberances.
Methods of dealing with the Tip
1. suturing techniques
2. scoring or crushing techniques
3. resection techniques
4. tip grafts
Suturing Techniques

Early tip surgery consisted of a combination of resection and sutures which disrupted the supporting
structures of the nasal tip and led to numerous postoperative deformities
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
Tebbetts led the crusade to replace the resection and scoring philosophy with that of suture control.

Unlike cartilage scoring or resection, have the distinct advantage of being nondestructive,
incremental, and reversible

Addition of a columellar strut is essential for most underprojected nasal tips

Surgical principle of suture technique:
1. predict the effect of each suture before inserting it (fix the strut with a needle, pinch the domal
segment with forceps, approximate the domes)
2. insert the suture, tighten it until the desired effect is achieved, and then place a single knot as a
"test tie";
3. redrape the skin frequently, evaluate the effect of each suture and, when in doubt, take it out. Tip
sutures are extraordinarily flexible, effective, and reversable intraoperatively.

Techniques:
1. Intradomal sutures (transdomal) - dome-definition sutures (Daniel 1987)

Horizontal mattress sutures from the medial to lateral crus and tightening them until the desired
domal shape is obtained.

Best for those with a bulbous tip
2. Interdomal sutures

made by approximating the middle crura with a 4-0 nylon suture at a level that is approximately 3
to 4 mm posterior to the dome.

Ensure that there is 1-3mm separation at the level of the domes.

Used when
a) asymmetry of the height of the domes is noted,
b) a reduction in interdomal width is desired,
c) the domes feel weak and tend to splay apart easily when pressed with a finger (may need strut)
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3. Lateral crural mattress suture (Rohrich PRS 2002)

Best for a triad of a boxy, poorly projecting, and underrotated nasal tip, or to correct lateral alar
convexities.

Ideally, the lateral crus is flat in the posterior two-thirds and slightly concave in the anterior onethird

Suture reduces convexity of lateral crura
4. Lateral crural steal (Kridel 1989) done via an open approach.

The principle is to increase the length of the medial crural by stealing from the lateral.

A secure nasal base needs to be established by suturing the medial crura to each other and then
advancing upwards with mattress sutures towards the tip. If the medial crura are buckled or weak,
a columella strut of septal cartilage is placed.

LCS relocates the tip superiorly and anteriorly - increase in both nasal tip projection and rotation.
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5. Columella-septal suture (medial crura anchor suture)

five purposes of this suture:
i.
reestablish tip strength and integrity, which might have been lost with a
transfixion/intercartilaginous incision;
ii. to provide a little more tip projection than the patient had originally
iii. to provide some tip rotation;
iv. to help treat a hanging columella
v.
to reduce an overprojecting tip (deproject it).

domes should be 6 to 8 mm above the level of the septal angle

dorsal columella septal suture for rotation - transverse suture penetrating both middle crura at the
midpoint of the infralobule and then going through the dorsal septum just cephalic to the anterior
septal angle

transfixion-columella septal suture for projection - passes from the caudal surface of the
columella at the medial/middle crura junction point and goes through the caudal septum, either at
a higher or lower point, to achieve the desired projection or deprojection
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6. Medial footplate sutures (flare control) – Guyuron 1998

Footplates = posterior 5 to 6 mm of the medial crura

The angle between the medial crura and the footplate plays a significant role in the strength of the
medial crura and the tip support and also determines length of columella

Suture will strengthen the tip support, narrow the columella, and advance the columella caudally
in the posterior half

Best for those with a wide angle of divergence between the footplates, a dependent tip, a receding
posterior portion of the columella, and protrusion of the soft tissue into the nostrils medially
7. Tongue in Groove (Kridel 1999)

corrects excessive columellar show and maintains correction after straightening a caudally
deviated septum.

medial crura are advanced cephaloposteriorly and the denuded caudal septum is placed into a
surgically created space between them.
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8. Lateral crural overlay (Kridel 1990)

midportion of the lateral crus, on each side, is transected by a vertical incision extending from the
cephalic to the caudal crural margins

cut ends of the lateral crura are overlapped to the desired extent and fixed with 5-0 Prolene,
transcartilaginous, mattress-type suture


results in increased tip rotation and decreased tip projection.
Daniel uses 3 sutures (PRS 1999)
Domal definition, domal equalisation and strut sutures
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Columella-septal
1. a strut suture to fix the columella strut between the crura,
2. bilateral domal definition (intradomal) sutures to create tip definition,
3. domal equalization(interdomal) suture to narrow and align the domes

Daniel places his sutures at the caudal end of the dome (not posterior in the medial crura)

He found that the traditional interdomal suture resulted in excessive narrowing of the normally
divergent middle crura, which in turn produced a hanging columella postoperatively with
excessive length of the infralobule
4. sometimes adding a columellar-septal suture for rotation and/or projection.
2. Scoring or Crushing Techniques
 Lateral crus can be scored immediately lateral to the dome.
 The middle or intermediate crus just beneath the dome can be scored too.
 Suturing of the tip can be combined with scoring or crushing.
 Best indicated when the tip-lobule complex is broad and boxy when the excess width can be converted
into vertical projection.
3. Resection Techniques
The alar cartilages can be resected transversely or longitudinally.
The inferior rim of the alar cartilage should be kept intact, otherwise there is the risk of deforming the
smooth, unbroken, arched contour of the nostril.
Transverse resection
 Transverse resection of the domes or central part of the alar cartilage is no longer advocated as it can lead
to a pinched tip deformity (Goldman vertical dome division)
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
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
Transverse resections are apt to leave visible deformities in thin skin individuals.
Longitudinal resection
 Cephalic trim
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 Resection of the cephalad portion of the lateral crus is the usual method of refining the tip, reducing tip
fullness, increasing dome definition and allowing cephalad rotation of the tip.
 One must be careful to leave at least 5 mm (in width) of lateral crus to avoid nasal collapse and a
pinched tip. It may also decrease tip projection and to hitch up the alar margin.
 Variations:
 Standard technique is complete strip which only gives moderate rotation
 Weakened complete strip combines cephalic resection with scoring or crushing
 Interrupted strip releases spring tension and gives significant rotation but sacrifices major tip support
mechanisms and reduces tip projection– may be
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1. medial – may cause notching, loss of tip projection and visible tip irregularities
2. lateral – less visible scarring, notching

 Other adjunctive measures for tip rotation
A) Septal shortening
B) Upper lateral reduction
C) High septal transfixition
D) Reduction hanging medial crura
4. Grafts to the Tip
 When tip projection needs to be improved more than can be attained by manipulation of cartilages or
manipulation of cartilages has failed, tip grafts may be required to improve tip projection.
 Strut graft may be required – fixed or floating
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 The aims are:
i)  the columella-tip angle
ii)  projection and angulation (pointiness) of the tip
iii) support the medial crura-columella to prevent “settling”
iv) correct pinched tip deformity
 Cartilage grafts are used as bone tends to resorb.
 Nasal septum is the best donor site for tip grafts
 Ear grafts are a 2nd best option (shatters when crushed). Best as batten grafts for lateral crura
 Gruber (Tandem ear cartilage - PRS 2003) describes harvesting the entire cymba conchae and cavum
conchae of the ear; separating them and suturing them to each other in tandem fashion; filling the
underside concavity of the cymba conchae part of the graft with scraps of cartilage. Cymba=proximal
½ and Cavum=distal ½. To avoid warping, no crushing was done
 Rib cartilage is reserved for complex reconstructions of the entire nasal skeleton.
28
 Tip grafts usually 6-8mm wide with the lower half of the graft creating the middle crus contour and the
upper half of the graft creating the dome contour.
 Design types – molar tooth/shield shape (Sheen), rectangular only graft (Peck), umbrella graft (vertical
cartilaginous strut between the medial crura and a horizontal onlay graft overlying the alar domes – Peck).
 Crushing damages more cartilage cells than cutting; only 10% to 30% of cells survive, depending on the
severity of crushing. In contrast, cutting leaves most cells viable and able to proliferate
 Sheen favors multiple, crushed grafts avoid angularities and improve definition. He feels single grafts tend
to become visible, blanch the overlying skin, or migrate causing asymmetries and unsightly contours.
 Grafts can be placed in a small, tight pocket to keep them in place or they can be sutured to other
cartilages or sutured in place with a pull-out stitch.
 Complications of tip grafts:
1. malpositioned - over or under projection (difficult to gauge intra-operatively if it is right)
2. displacement
 upwards
 tip blanching or overprojection
 laterally
 asymmetry
 downwards  protrude from the columella
3. resorption
4. warping
5. visible irregularities
6. compromise of the vascular supply to lobule skin if graft too large
7. extrusion
8. infection
9. soft-tissue deformities
10.

soft-tissue atrophy
rhinoplasty with grafts is associated with a significantly higher revision rate than when no graft is
required (15% vs 4%)

Baker uses temporalis fascia onlay to cover the underlying osseocartilaginous framework or cartilage
grafts in patients with very thin skin
 Anderson and Millard prefers a strut graft between the medial crura to the premaxilla, but these may have
a number of disadvantages:
i) widened columella
i) “tent pole” effect with blanching of the nasal tip
ii) the “tent pole” can lean one way causing distortion (laterally, up or down)
29
iii) the graft may become visible through the skin
Alar spreader grafts
Alar contour grafts
 Alar spreader grafts (Gunther and Rohrich) have been proposed for correction of the pinched nasal tip or
lateral alar convexity. The grafts are inserted between and deep to the remaining lateral crura to spread
them apart.
 Alar contour grafts (Rohrich) - used primarily to reshape the alar rim by their nonanatomic placement in
the alar rim in patients with minimal lining loss.
30
 Infradome grafts (De Carolis PRS 1998) – avoids excessive pinching ensuring symmetry and stability. By
placing grafts more laterally, tip projection increases (lateral steal).

Hamra (PRS 2000) favours dome resection, side-side cartilage repair and covering the repair with
crushed cartilage overlay graft to improve tip asymmetry in those with underprojecting tip deformities. In
those with overprojecting tips, he repositions the lateral crus and advances the crura laterally to decrease
the tip projection
 Mersilene implants have been used by Fanous. Although mersilene is soft, pliable, easily shaped and
allows ingrowth of connective tissue, Byrd cautions against their use  scarring, rejection.
THE SEPTUM
The Deviated Nose
 Traumatic or congenital.
 Partial or total.
 C-shaped, S-shaped or generalised.
 The key to straightening the deviated nose is in correcting the septum.
The Septum
31
 Deformities of the nasal septum may result in either internal nasal airway obstruction, external deformity
or both.
 Correction must deal with the functional (airway) and aesthetic (deformity) considerations, but must be
balanced with maintaining dorsal support.
 The indications for surgery are:
simple mid-septal deflections (25%)  SMR
caudal dislocations of the septum (65%)  mostly require septoplasty
complicated deformities (10%)  mostly require septoplasty
 distortion of the upper cartilaginous vault
 tip deformity
 deformed bony vault
 The therapeutic options are
3. SMR (judicious)  preservation of dorsal and caudal portions (min 1 cm strip)
4. Septoplasty: scoring, morselisation or other conservative means
Submucous resection (SMR)
 First described by Killian (1905) for obstruction.
 Usually indicated for mid-septal obstruction of the airway.
 Principle is sub-perichondrial dissection and resection of obstructing cartilage.
 Need only to resect obstructive or thickened portion(s) of septum
 Must preserve at least:
1 cm of the dorsal margin
1 cm of the caudal portion
Septoplasty
 Realignment of the cartilage, either after conservative SMR or independently.
 Usually achieved by scoring.
 Gruber advocates closed septal osteotomy to realign the bony septum
Combined SMR and septoplasty
A timid surgical attach on the deviated septum may result in a persistent deformity.
 Johnson and Anderson recommend resection of an inferior strip of septum next to the nasal spine so that
the septum can swing freely to the midline.
32
 Byrd totally releases the cartilaginous septum from the lower lateral and upper lateral cartilages as well as
cartilaginous and bony septal resection to free the dorsal and caudal septum from extrinsic and intrinsic
deforming forces. Scoring is avoided if possible, and the curvature is corrected by repositioning and
control sutures, aided by batten and extended spreader grafts.
 Rees advocates extra-mucosal excision of the entire bony and cartilaginous septum and replacement as a
free graft. Risky.
 Sheen states that a midline septum is irrelevant to the aims, ie, a patent airway and a straight nose. He
therefore advocates careful removal of the obstructing portions of the nasal septum (SMR). The bits thus
obtained are replaced as grafts to camouflage deviations on the dorsum. Similar concept advocated by
Constantian – he advocates resecting the dorsum in the area of deviation
 Gunter and Rohrich advocate simultaneous correction of the septum and bony pyramid when both
structures are involved.
 Conservative approaches to septal deviation use onlay grafts to mask the deformity.
Subsequent
resorption or displacement of the grafts, may result in recurrent or other deviations.
 Radical operations for straightening the septum risk losing dorsal support, resulting in collapse of the
nasal bridge and the development of a saddle nose deformity.
POST-OPERATIVE CARE
1. Fowler’s
2. Analgesia
3. Soft diet
4. Ice compresses are soothing, but probably make little difference.
5. Nasal splint for 5-10 days. No blowing after removal.
6. Vaseline or cold cream soften blood clots and crusts in the vestibule.
7. Gentle washing BD
Guyuron looked at the role of nasal packing for septorhinoplasty.
Packing prevents recurrence of septal deviation and prevents the formation of nasal synechia. It prevents
recurrence of nasal airway obstruction in 96% of patients compared with only 64% in those who are not
packed post-op.
ADJUNCTIVE PROCEDURES
1. Modification (trimming) of the alar base (Initially described by Weir in 1892).
33
2. Sculpturing the alar margin to reduce the bulky rim or elevate a drooping ala.
3. Modification of the columella-labial triangle (the naso-labial angle) when the septal cartilage protrudes
into the upper lip (ie, the angle is obtuse), resection of a strip of caudal septum generally corrects the
problem. The nasal spine may need trimming.
4. Deepening the obtuse nasal frontal angle may require a small transverse skin incision to allow direct
approach of the osteotome. An alternative is to augment the dorsum.
5. Mentoplasty: implant or advancement. According to Millard, indicated in 15% of rhinoplasty patients.
Implants must be placed as low as possible over the point of the chin. If > 8-9 mm is required, then an
implant is unlikely to be sufficient and a mandibular osteotomy or sliding genioplasty is indicated.
DYNAMICS OF RHINOPLASTY (Guyuron)
 Nasion reduction  Appearance of ed intracanthal distance and of a lengthened nose.
 Nasal bridge reduction On frontal view the nose looks wider and on profile the tip rotates up.
 Augmentation of the dorsum  On frontal view the nose looks narrower and on profile the tip rotates
down.
 Resection of the alar base  Narrowed the nostrils, moved the alar rims caudally and reduced tip
projection.
 Reduction of the nasal spine  ed upper lip length and reduced tip projection.
 Rotation of nasal tip results in shorter nose
 To lift the tip the procedures that can be used are (in order of effectiveness):
a) resection of caudal septum
b) resection of the caudal borders of the medial crus
c) resection of cephalic portions of LL cartilages
PROBLEM NOSES
1. Bone
1. Obtuse naso-frontal angle  Augment dorsum or burr down.
2. Short nasal bones  Pre-op Dx nb as osteotomies are to be avoided to prevent collapse of the middle
nasal vault.
2. Tip
A) Over-projecting (Pinocchio) tip
34

Pre-op Dx nb: is the tip projecting or is the dorsum recessed?

Over-projecting tip is due to excessive length of both the medial and lateral crura.

Principles:
1. Retroprojection via reduction of tip support mechanisms
O Transfixtion suture
O medial rotation and resection of the foot plates of the medial crus (McC)
O dome division – discouraged in order to attempt to preserve the tip shape especially in thin
skin patients
O lateral rotation and resection of lateral part of lateral crus (Sheen). These procedures can
be combined with scoring.
2. Reduction of overdeveloped anatomic structures (tension nose deformity – resecting overgrowth
of caudal septum or using interrupted strip for overgrowth lower laterals)
3. Normalization of adjacent anatomic structures
O Grafting with morselized cartilages overlying areas of cartilage transection is encouraged
to avoid sharp edges and resultant contour abnormalities.
B) Inadequate tip projection
1. Distinguish if tip low or dorsum high.
2. Release of tip tethering by the columella often does the trick and allows the tip to rotate
(upwards): release of columella from nasal spine, resection of depressor septi nasi muscle, release
of septum from nasal spine can all be used (often in combination) to release the tip.
3. lateral crural steal, transfixition or transdomal sutures often combined with a columella strut (23mm elevation)
4. If more projection required - onlay tip grafting is used (single or laminated).
C) Excessively pointed tip/pinched tip
1. Resection of alar domes advocated by Aufricht, but no longer recommended.
2. Lateral rotation (with scoring)
3. Onlay tip graft
4. De Carolis infradome graft
5. In secondary rhinoplasty
i. Sheen uses either unmodified, bruised, crushed, or morselized, often in combination. A
combination of solid grafts for support and projection, and soft grafts for fill and contour,
is a versatile and effective solution to a variety of tip deficits
35
ii. Rohrich uses alar spreader grafts
iii. Menick advocates anatomic reconstruction of the alar cartilages where residual cartilage
remnants are not available for repositioning and repair
Menick PRS 1999
D) Broad or bulbous tip
1. Defined as a wide nasal tip associated with an increased width between the tip defining points
(>4mm) - increased angle of divergence and increased angle of domal definition
2. Gruber 4 suture technique (PRS 2002)
a. lateral crus cephalic resection leaving 6mm rim
b. transdomal suture - to narrow the dome, narrow the convexity of the lateral crus and
increase tip projection
c. interdomal suture – reduce angle of divergence leaving 1-3mm of separation between
domes
d. Lateral crural mattress suture – if convexity persists
e. Columella-septal suture – if tip height needs further adjustment
36
3. Results will be limited by skin thickness
E) Boxy Tip
1. broad, rectangular appearance of the tip lobule on basal view (usually just increased angle of
divergence or just increased angle of domal definition)
2. Rohrich’s algorithm (PRS 2001)
a. Cephalic trim
b. Combination of transdomal(if increased angel of domal definition) and interdomal
(increased angel of divergence) sutures
c. Lateral crural strut grafts or alar contour grafts for lateral crura or rim deformities
F) Bifid tip  Interdomal suture
G) Deviated tip
1. Determine if due to extrinsic(bony and cartilaginous septum, the nasal bones, the upper lateral
cartilages, and the maxilla) or intrinsic (lower lateral cartilages)
2. Most common due to deviated septum and treat by correcting septal deviation.
3. Intrinsic abnormalities are treated with combination of sutures, transection, columella strut and tip
graft (Rohrich PRS 2003)
H) Thick skin
1. characterised by thick dermis, abundant sebaceous gland, rich blood supply, dilated cutaneous
pores and thick fat pad
2. Resist aggressive debulking, which may compromise vascular perfusion and result in skin
sloughing. Complications of necrosis, oedema and hematoma more likely to occur in bulbous tip
37
3. Consider tip grafting instead of debulking, and improving the definition of the alar groove by
performing cephalic lateral crural trimming or even placing intercrural and intracrural stitches.
4. Avoid aggressive reduction as inability of thick skin to adapt will cause this skin to accumulate in
the supratip region post rhinoplasty – cutaneous polly beak deformitiy
I) Polly beak deformity
1. postoperative deformity associated with fullness in the supratip, leading to a disproportionate
relationship between the tip and supratip – most common deformity most rhinoplasty
2. Normal anatomy – allow 6mm height in supratip in thin skin, 10mm in thick skin
3. Causes
a. Overresection of the nasal bones
b. Underresection of the cartilaginous dorsal septum
c. Overressection of the cartilaginous dorsal septum
d. Overresection of the lower lateral cartilages (leading to loss in tip support)
e. Soft tissue (scar) excess in the region of the supratip
4. Management
a. (Byrd PRS 1997 - septal extension grafts): as an alternative to columellar strut grafts to
predictably control nasal tip projection and shape.
b. Fibrin glue to remove dead space (and thus scar formation) following primary rhinoplasty
c. triamcinolone injection into the subcutaneous space with 10 – 40 mg/mL solution at 4 week
intervals to cause soft tissue atrophy and resolution of the deformity.
38
Spreader type
Batten Type
Direct septal extension
J) Parenthesis Tip
1. Malpositioned lateral crura –aligned superiorly with lack of alar rim support. If not recognise, one
can cut thru lateral crura accidentally during a intracartilaginous incision
2. Treament (Sheen PRS 2000)
a. total resection of the lateral crura, then replacing them as free grafts along the alar rims –
difficult and not recommended for the inexperienced
b. tip graft as a compromise
c. do nothing if patient agrees
3. Daniel (PRS 1999) - Excision of cephalic lateral crura followed by tip sutures
K) Plunging/Drooping tip
1. Inferiorly rotated tip - increase in the length of the nose with an acute nasolabial angle.
2. May interfere with airflow as well as being unattractive
3. Causes
a. Intrinsic
i. Inferiorly oriented alar cartilages (85 percent) - excessively long lateral crura,
vertically oriented lateral crura with high abutment to the pyriform aperture, or
short, weak medial crura.
b. Extrinsic
i. inferiorly displaced by the effect of extrinsic forces.
ii. overdeveloped scrolls of upper lateral cartilages (73 percent)
iii. high anterior septal angle (65 percent)
39
iv. thick skin of the nasal lobule (56 percent).
v. overactive depressor septi muscle
4. Techniques (Foda PRS 2003)..in order of most to least rotation
a. lateral crural overlay technique increased tip rotation and decreased tip projection
b. lateral crural steal technique increased nasal tip rotation and projection
c. tongue-in-groove technique increased tip rotation without significantly changing the
amount of projection.
5. Adjunctive procedures
(i) excise caudal septum or lowering the anterior septal angle
(ii) excision of the caudal end of upper lateral cartilages
(iii) nasal ptosis of the aged  skin resection at radix.
(iv) Overactive depressor septi nasi muscles (Rohrich PRS 2000)

characterized by descent of the nasal tip, shortening of the upper lip, increased maxillary
gingival show and a transverse crease in the mid-philtral area.

Diagnose with smile test

Originates from medial footplates to interdigitate with orbicularis oris

Transect through upper buccal sulcus incision or transfixion incision. May need to transpose
or/and suture ends together to prevent reattachment. Muscle excision may lead to contour
irregularities

Complication: lip numbness (transient), smile asymmetry
3. Nostril

Best assessed on basilar view

Nostril to lobule ratio should be 60:40%(Guyuron) and 55:45%(Daniel)
40
Aesthetically pleasing nostril
a) Nostril flare  Alar base repositioning and resection or Millard’s alar cinch.
b) Thick alar rim  Re-sculpture
c) Large nostril, small tip(Daniel PRS 2001)
i. Problems
a. the alar cartilages are highly divergent,
b. the infralobular segment is short
c.
the domal segment is flat and ill defined.
ii. The operative technique combines a three-stitch tip procedure, including an interdomal suture over a
straight strut, plus combined nostril sill/alar wedge resections.
iii. critical step in the tip operation is to lengthen the infralobule from the columella break-point to the tip
defining point using a straight crural strut to support the suture-defined domes, which are brought over
the top of the strut with an interdomal suture
41
iv. trapezoid sill excision (usually 2.5 to 4.0 mm wide) with continuation into an alar wedge excision
measuring 2 to 4 mm wide. The alar wedge incision is placed 1 mm above the alar crease because
incisions in the crease destroy its natural curvature
v. Because of the combination of lateral crural resection, tip-suturing techniques, and nostril sill/alar
wedge resection, notching of the alar rim can occur. It is remedied by insertion of a small (7 × 2-mm)
alar rim graft.
d) Short nostril, large tip (Guyuron PRS 2005)
i. Components
a. Flat, divergent domes and an ill-defined, under-projected nasal tip – transdomal and interdomal
sutures with columella strut to increase projection. Approximation of footplates (with resection of
the lateral portion of the footplates, if indicated) controls the nostril angle and width, and
establishes nostril symmetry while slightly increasing its length.
b. Alar concavity may be due to alar retraction – treat with rim grafts (mild-moderate) or VY
advancement (severe)
c. Redundant soft triangle lining - A crescent-shaped piece of redundant soft triangle lining is
removed with a pair of Iris scissors usually done at the end
4. Columella
Classification of alar-columellar relationships.(Gunther 1996)
42
a) Hanging columella

distance from the long axis of the nostril to the columella is greater than 2 mm

achieved by resection and reapproximation of variable amounts of membranous and cartilaginous
nasal septum in most cases

If the medial crura have an increased width and are contributing to increased columellar show, direct
caudal margin excision of the medial crura is helpful

Occasionally it may be due to vertically orientated middle crus – resect and reapproximate

Total resection of the medial crura, as advocated by Armstrong, may lead to overcorrection of the
hanging columella and loss of tip projection and is not recommended
43
Caudal septum excision
Medial crura excision
Vertical middle crura
b) Retracted columella

characterized by a decreased distance between the columella and the nostril axis

Due to deficient caudal portion of septal cartilage (secondary to injury or previous rhinoplasty
scarring) or underdevelopment of the maxilla and nasal spine (Binder’s).

Treatment is with augmentation of the columella septum with a contoured cartilage strut carved so that
the widest portion is positioned at the area of greatest retraction. Also may be designed to alter the
columellar-labial angle, if desired. Others use silicone prostheses.
c) Retracted/notched ala

Characterised by alar rim to the nostril long axis line distance > 2 mm

Increased columella show but need to differentiate from hanging columella

Mild retraction/notching may be treated with
i. detachment of the lateral crus from the accessory cartilages and repositioning the lateral crus
inferiorly(Gunther)
44
ii. alar rim cartilage (Guyuron), Rohrich calls this the alar contour graft (PRS 2002)

Mild-mod retraction may be treated with a vestibular rim incision with inferior mobilization of the rim
and the resulting defect filled with a composite graft of septal cartilage and mucosa or a composite
conchal cartilage-skin graft (Gunther)
45

Severe notching – V-Y lining flap  rim cartilage graft (Guyuron PRS 2001)
d) Hanging ala

decreased columellar show due to narrowing of alar rim to the nostril axis distance (<1mm)

Treat with excision of a vestibular ellipse to raise the ala

Width of the resected ellipse should be slightly more than the desired amount of alar rise but should
not exceed 3 mm, since an abnormal rolled-in appearance of the rim may result

In thin-skinned individuals, judicious trimming of the caudal border of the lateral crus without mucosa
will elevate the alar rim.

Ellenbogen (PRS 1992) recommends direct excision for the hanging ala
e) Wide columella base  The medial crura/footplates are the problem. They are mobilised, can be divided
transversely and sutured in the midline. Intervening fibrofatty tissue should be excised.
5. Columella-lip (naso-labial) angle
 Critical to the aesthetic appearance of the nose.
46
 According to Aston and Guy, it should be 90-95o in men and 100o in women.
 According to Lewis, it should be 95-105o in men and 102-11 in women.
 Also, less “tilt up” in
a) tall patients
b) patients with long faces
c) patients with receding foreheads and chins
 According to Byrd (SRPS), nasal length (affected by tilt up) should be in proportion to chin height.
 The naso-labial angle is influenced by the configuration of the nasal spine and caudal septum.
 Smiling sharpens the angle by pulling the septum backwards and making the nasal spine more prominent.
 Avoid trimming caudal end of medial crura – leads to contour irregularities
Methods to raise the columella
Dorsal wedge resection of the caudal septum:
1. opens the columella-labial angle
2. does not affect lip length
3. shortens the nose
4. rotates the tip cephalad
5. increases nostril show
Caudal septal resection:
1. minimally changes columella-labial angle
2. lengthens the upper lip
3. shortens the nose
4. tip moves cephalad
 Over-resection of the caudal septum can result in a “pig nose”, “a witches nose” or a long lip (“ape
lip”).
Nasal spine resection:
1. narrows the columella-labial angle
2. lengthens the lip
3. retrudes the columella base
4. may  lip projection
The Short Nose
 Definition
1. decreased distance from the nasofrontal angle to the tip-defining points (nasal height should be
2/3rd midface height or = menton-stomium/chin height)
2. overly obtuse nasolabial angle with increased nostril show.
47
 Combination of severe overrotation with flat dorsum is called a pig nose.
 Often seen in combination with saddle nose deformity
 Causes:
1. trauma – most common cause. Severe frontal impact. Nasal bones and ULC splay open. Lower
laterals lose cephalic support and rotate upwards.
2. post rhinoplasty – over reduction of dorsum and septum
3. cocaine abuse
4. inflammatory – Wegeners, syphilis
5. congenital – Binders syndrome
 Gunter PRS 1989
 Release the tip by detaching the lateral crura from the UL cartilages, suspensory (interdomal) ligament
and septum.
 has the effect of rotating caudally the alar cartilage complex, lowering the dome, decreasing projection
of the tip, and lengthening the distance between the nasofrontal angle and the tip-defining points.
 Hamra PRS 2001
 two- or three-tier graft sutured to the caudal edge of the medial crura.
 Guyuron (Tongue and Groove technique - PRS 2003)
 Uses 2 spreader grafts, one on either side of the septum, and extended beyond the caudal septal angle
proportional to the planned nasal lengthening
 columella strut, with the cephalocaudal dimension equaling the combination of the width of the
existing medial crura plus the amount of planned nasal lengthening. Fixed to the medial crura
 If additional projection beyond what is achievable by mere placement of a columella strut is required,
the strut is fixed to the spreader grafts in a more projected position.
48

To overcome short noses with contracted skin envelope, tissue deficiency of cartilage and mucosal lining,
Lee (PRS 2000) uses a gull-wing concha composite graft(using anterior conchal skin) and a rib
costochondral dorsal onlay graft through a endonasal approach.
49
 In summary a combination of grafts are used but limiting factor is the skin, mucosal envelope
1. the flying buttress graft, which is made up of a single or paired spreader graft secured to the
columellar strut
2. caudal septal grafts
3. tip grafts of various shapes
4. radix grafts to elevate the nasion
5. interposition grafts(spacer grafts) between the upper and lower lateral cartilages
Saddle Nose Deformity (Pug nose, Boxers nose)
Features
50
1. Short nose
2. Depression of the middle vault and dorsum
3. Loss of nasal tip support and definition
4. Overrotation of the nasal tip
5. Retrusion of the nasal spine and caudal septum
6. Nasal obstruction
Causes of Saddle nose deformity
1. Traumatic (most common)
2. Inflammatory – Wegener’s, relapsing polychondritis
3. Cocaine use
4. Infective: syphilis, leprosy, leishmaniasis
5. Post-operative: loss of septum either as a result of excess resection or secondary to destruction following
haematoma and infection. (0.4% risk after SMR)
Classification (Tardy 1989)

Minimal - Supratip depression greater than the ideal 1-2 mm tip-supratip differential
a. demonstrates moderate tip-supratip differential.
b. Commonly, the bony nasal hump is consequently mildly accentuated.
c. Little if any columellar retraction is apparent, and the nose is over wide.
d. Minimal supratip augmentation with cartilage or fascia is required, or occasionally with contouring of
the bony hump without supratip graft placement

Moderate - Moderate degrees of saddling due to loss of dorsal height of the quadrangular cartilage,
usually with septal damage
a. demonstrate significant loss of quadrangular cartilage dorsal height due to septal collapse.
b. Tissue losses from necrosis or trauma commonly result in significant columellar retraction with an
increasingly acute nasolabial angle.
c. In addition, if the saddling is the result of blunt trauma, the bony pyramid is often typically
excessively broad and flattened, necessitating augmentation or osteotomy narrowing or both.

Major - More severe degree of saddling with major cartilage loss and major stigmata of a saddle-nose
deformity
a. demonstrate all of the stigmata of the moderate saddle nose, only to a greater degree. They are more
commonly associated with childhood or massive trauma and are associated with major nasal twist and
severe septal deformity.
51
Correction
1. Reducing the dorsal hump
2. Dorsal boat-shaped graft and columella support (L – shaped strut reconstruction)
3. Lateral wall osteotomy
4. May require skin and lining replacement
 According to Stuzin and Kawamoto, nasal lining is the forgotten link to successful reconstruction of the
saddle nose deformity post rhinoplasty. Wide sub-periosteal mobilisation is done to the piriform aperture
and sometimes mucosal advancement.
 Kazanjian (PRS 1948) described nasal lining reconstruction using both forehead and nasolabial flaps for
post-syphilis saddle nose.

Millard (PRS 1980) described using forehead flaps, skin grafts

Harii (PRS 1982) - iliac bone graft and nasolabial flaps.

Brent (PRS 1985) used TPF free flap for nasal lining

Okazaki (PRS 2003) uses nasomaxillary epithelial inlay skin graft held by a mold (originally described
by Gillies for treatment of post syphilis saddle nose)

Duffy and Probaz (PRS 1998) using bilateral retrograde facial artery musculomucosal (FAMM) flaps
with costal cartilage for support to reconstruct a saddle nose deformity due to Wegener’s granulomatosis.

Posnick emphasises the use of full thickness cranial bone grafts through a coronal incision and rigidly
fixed. The graft must extend to the tip and must not be too broad.
ORIENTAL AND BLACK NOSES

non-Caucasian nose is flat, broad, and short with an infantile dorsum lacking projection from the
nasal tip to the nasofrontal angle

Asian nose in between more severe Black nose and Caucasian nose.
Anatomy
1. nose appears short because the nasal tip tends to be rounded and the starting point of the nose (deepest
point of the nasofrontal angle) is frequently poorly defined
2. nasal tip rounded and poorly defined with less projection
3. columella is short, thick, and hidden, and tends to diverge superiorly and inferiorly
4. acute nasolabial angle partly from underdeveloped anterior nasal spine
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5. nostrils are round or horizontally ovoid
6. alae are thick, flaring, wide-based, and overhang the columella acting to hide it on lateral view
7. Ill defined septal angle
8. quadrangular cartilage is smaller, thinner, and shorter
9. pyriform aperture is wide and the ratio of bone-to-cartilage of the nasal vault is smaller
10. skin of the ala is thick, fatty and inelastic with numerous sebaceous glands
Surgical principle
Requires strengthening weak cartilaginous structures, dorsal augmentation, preservation of major support
mechanisms, and careful manipulation of the skin-soft tissue envelope
Considerations
Results are limited due to:
1) the thick, inelastic nature of the skin-soft tissue envelope
2) after the tip is augmented the thick, short columella may preclude closure of the columellar
incision.
Procedures used in Orientals
1. Dorsal augment: silastic, bone, cartilage
2. Narrowing of the dorsum
3. Alar base wedge excisions
Procedures used in Blacks
1. Dorsal augment: bone best.
2. Narrowing of the dorsum
3. Columella lengthening – strut graft
4.  tip projection: excision of fibrofatty tissue, scoring, dome suture, multilayer tip grafting
5. Alar resection, narrowing and medial advancement for alar flaring
 Theoretical risk of keloid not borne out in practice.
TREATMENT OF ENLARGED TURBINATES
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 Subtotal resection of the turbinates was previously thought to interfere with the air conditioning functions
and to result in rhinitis sicca. This has subsequently been shown to be untrue and the procedure is
therefore recommended in patients who have hypertrophic turbinates that impede nasal flow.
 Steroid injections, electrocautery, crushing and outfracture result in only short term improvement.
 Pollock and Rohrich (408 patients) resect the anterior ½ to 1/3 of the inferior turbinate without any long
term problems.
COMPLICATIONS
 Overall Cx rate is about 4-18%.
 These Cx’s usually have little or no effect on outcome and despite their development usually about 9095% of patients are happy with their result.
 Since the 1960’s, although the Cx rate has fallen, more patients are dissatisfied.
 Reoperation rate – 10%
 Can be classified:
1. Intraoperative
2. Immediate postoperative
3. Early
4. Late
Intraoperative
1. Haemorrhage
 usually minor
 more likely in those undergoing simultaneous septal and turbinate procedure
 May be primary or secondary (infection)
 Excessive intraoperative hemorrhage reportedly occurs in 0.3-1% of cases.
 Early post-op hemorrhage varies from 2-4%, usually after removal of splints
 Treatment
2. Traumatic Complications
i. Intracranial injury
o CSF leak, pneumocephalus, frontal lobe injury, carotid-cavernous sinus fistulas.
o Usual site is junction of cribriform plate with perpendicular plate of ethmoid
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o If recognised intraoperatively – repair immediately with temporalis fascia grafts, septal
mucosal flaps and grafts done intranasally. Immobilise grafts with microfibrillar collagen,
gel foam and antibiotic-impregnated gauze for 7 days.
o If recognised postop – treat conservatively, sit patient up avoiding physical strain.
Most(70%) resolve spontaneously. Some place a indwelling lumbar CSF catheter. If fails
this, the surgery – either intra or extracranial approach.
ii. Blindness
o secondary to vascular damage or direct trauma to optic nerve.
o Has been described after steroid injection to inferior turbinate and retrograde flow of
intraarterial LA injection
iii. Iatrogenic AVM
o treat with artiography, embolisation or excision
iv. Osteotomy complications
o Bony spur at transverse fracture site – need to rasp this smooth
o Rocker deformity - medial osteotomy creates a cephalic fracture higher in the thicker part
of the frontonasal junction. Repositioning the cephalic fracture lower on the nasal bone.
o Open roof deformity

Causes
i. Greenstick cephalic fracture during osteotomies (will return to its
preoperative position)
ii. Failure to adequately mobilize the fractured segments medially
iii. Excessive nasal packing
iv. Uncorrected deviated perpendicular plate of the ethmoid (may prevent
medialization of the lateral segments)

If neglected, the intranasal mucous membrane adheres to the overlying soft tissue
and may create a depression at the site.

If alignment failure is unilateral, the nose appears asymmetric.

Correction involves centralization of the septum and complete medial mobilization
of the lateral segments following osteotomy.
o Step deformity - lateral osteotomy is performed too far medial to the nasofacial groove,
with a visible ridge on the side of the nose. Correction involves repeating the osteotomy at
the correct level.
v. Septal perforation
o Result from bilateral mucoperichondrial tears
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o small ones are more symptomatic (whistle). Large ones result in loss of epithelium and
cilia dysmotility causing crusting and malodour
o small perforations (<1.5cm) require rotation, transposition or hinge flaps (the 1st 2 need
mucosal grafts to the raw surface of the flap)
o large perforations: labial mucosal flap
vi. Dental injury
vii. Buttonholing of skin
o Beware skin injury with osteotome or burr during dorsal reduction or lateral osteotomy
Immediate Postoperative
1. Airways obstruction

Postextubation aspiration of blood may cause laryngospasm

Nasal packing or intranasal splint aspiration has been reported – secure these well
Early Complications
1. Haemorrhage

Look for septal hematoma
2. Infection
 Increased risk with
1. active infection at time of surgery (acne, intranasal furuncle, sinusitis
2. hematoma
3. implant
4. packing material left in >24 hours - packing obstructs sinus drainage
 Worry is spread to orbit and cranium due to lack of valves in facial, ethmoidal, angular and ophthalmic
veins – cavernous sinus thrombosis, meningitis, brain abscess
 Toxic Shock syndrome

In the early 80’s, the incidence was 16.5 per 100 000 nasal operations

Caused by a staph aureus endotoxin (TSST-1)

More likely in those with nasal packs as well as splints

Mortality 5-10%)
3. Transient epiphora (13%)
56

usually lasts 1-2 weeks secondary to soft tissue oedema. Lacrimal sac injury has been described
with using saw lateral osteotomies with subperiosteal dissection. Safer to use osteotome without
subperiosteal dissection
4. Anosmia (5%)

usually transient from airways obstruction and mucous membrane injury. Avoid damaging
cribriform plate
5. Persistent oedema

Severity may be determined by difficult osteotomies, use of guarded instruments, long operating
times, excessive nasal packing, postoperative vomiting, or raised blood pressure.

Minimise by performing osteotomies just before application of the dressing, intraoperative
intravenous dexamethasone, postoperative head elevation, cold compresses to the nose, and blood
pressure monitoring can minimize edema
6. Tip numbness

Nearly universal, often improves

Need to warn patients preop
7. Skin necrosis

Caused by excessive undermining, injudicious cautery use, and overzealous skin thinning, dorsal
augmentation (more likely with alloplasts and bone than cartilage), tight dressings
LATE
1. Internal valve collapse – nasal obstruction
2. Nasal stenosis

related to circumscribed incisions with excessive lining removal.

Difficult to treat
3. Septal-turbinate synechiae
4. Septal perforation
5. Mucous cysts

Nasal mucosa displaced into the subcutaneous tissue (rare)

Treat with excision.
6. Persistent oedema or bruising
7. Excess scar
8. Altered sensation
9. Gustatory rhinorrhea
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
Parasympathetic and sympathetic cross excitation as a result of misdirected regeneration of nerve
fibers subsequent to the trauma of surgery may cause rhinorrhea during eating. The treatment of this
condition is difficult, but antihistamines may help some patients.
10. Psychological complications
11. Poor shape:
Disproportionate nose
Upper 2/3rd
i. Deep nasofrontal angle: Correction may be achieved by augmentation
ii. Shallow nasofrontal angle: The angle may be deepened by removal of the procerus muscle. If the
problem is bony, osteotome and/or burr remova
iii. wide bony dorsum
iv. under reduction
v. over reduction – saddle nose deformity, inverted V deformity (overressected upper laterals)
vi. asymmetry
Lower 1/3rd
i. Supra-tip deformity – polly beak deformity
ii. Tip asymmetry
iii. Tip projection deformities
iv. Pinched tip
v. Hanging alar
vi. Retracted/notched alar
vii. Alar collapse
viii. Hanging columella or "columella show"
ix. Retracted columella
x. Retracted nasolabial angle
xi. Protracted nasolabial angle
12. Complications related to grafts
i. Warping
a. disruption of protein polysaccharide complexes abolishes the interlocking stress within
cartilage (Fry 1967)
b. minimized by the use of balanced cross sections (Gibson 1958)
c. septal cartilage warps least
d. centrally cut pieces of cartilage in each group warped less than peripherally cut blocks
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e. delay insertion of cartilage grafts for at least 30 minutes to allow initial warping to occur,
Mowlem(1941) reported banking carved rib cartilage grafts in an abdominal pocket for 3
months before use for dorsal nasal augmentation.
f. Gunter (PRS 1997) uses internal stabilisation of costal grafts with k-wires
ii. Resorption
a. Worst with bone
iii. migration
iv. extrusion
v. infection
vi. granulomas
SECONDARY RHINOPLASTY
Incidence of post-surgical nasal deformities requiring secondary correction varies from 5% (the best
experienced rhinoplastic surgeons achieve, according to Rees) to about 12%.
Sheen’s 5 ground rules for the Mx of post-surgical nasal deformities:
1. Defer surgery until tissue oedema has settled (at least 1 year).
2. Have a well defined aesthetic concept
3. Make a proper Dx
4. Limit the dissection
5. Use only autologous material
In general, surgical correction of secondary deformities must be more conservative than the primary
operation. Do not over resect. In fact, grafting is often necessary.
Classification of secondary deformities

Classify as upper 1/3, middle 1/3 and lower 1/3.

most common deformity across studies was pollybeak, with other common deformities being saddling,
midnasal asymmetry, bossa, and columellar retraction.
1. upper 1/3rd

excessive removal with a low broad bony pyramid.- causes pseudohypertelorism, with a
washed out appearance due to less shadowing along the lateral nasal wall.

Others- dorsal irregularity, high dorsum, and shifted graft.

dorsal over-resection due to the attempt to match the nasal dorsal profile to the radix that
may in fact be deficient. The ideal starting point for the nasal dorsum is at the superior
59
palpebral fold; this point is lower in the patient with a deficient radix. Byrd and Hobar
recommend the plane of the cornea surface as a preferred reference point for radix
projection; from this starting point the radix projects 0.28 times the ideal nasal length. It is
also important to realize the affect of the nasion on overall nasal length and that a low
radix decreases apparent nasal length while a high radix lengthens it
2. middle 1/3rd

saddle nose - over resection of the cartilaginous and/or bony dorsum or overprojected tip

polly beak

Inverted V – deformity over resection of the upper lateral cartilages or failure to secure
the upper lateral cartilages to the septum following cartilaginous hump removal or twisted
nose repair with subsequent displacement of the cartilages medially and inferiorly. ead to
an overly narrow middle nasal vault and the inverted “V” deformity of the caudal edge of
the nasal bones. Additionally, this may lead to internal nasal valve collapse and nasal
obstruction.

Midnasal asymmetry (crooked) – if deviation of the attachment of the nasal septum and
upper lateral cartilage is not recognized. In order to correct this deformity during the
primary operation the dorsal septum must be straightened and the upper lateral cartilage
detached from the nasal septum and re-sutured. If persistent deviation occurs following
these maneuvers the remaining asymmetry may be camouflaged with cartilage on-lay
grafting or the placement of spreader grafts depending on nasal valve function.
Peck lists the deformities and their correction:
1. Lack of tip projection from lack of alar cartilage dome projection
Rx: Conchal cartilage tip graft.
2. Lack of tip projection from lack of septal support
Rx: Conchal cartilage inter-crural graft.
3. Saddle deformity
Rx: Reconstruction of the septum with a layered septal cartilage graft as first choice and, as second choice,
bone graft from either ilium, rib or calvarium.
4. Supratip deformity
 usually d/t high supratip septal cartilage
Rx: Lowering the cartilaginous dorsum as a unit by resection of septum and UL cartilages.
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 2nd commonest cause is inadequate removal of fibrofatty tissue
Rx: Remove more.
 3rd commonest cause is inadequate sculpting of the alar cartilages
Rx: Sculpt more.
 d/t overzealous lowering of nasal pyramid in the presence of thick rigid skin
Rx: Columella strut graft or dome tip graft.
5. Alar deformities (notching) usually d/t resection of vestibular lining or transection of the alar cartilages.
6. Deformities of UL cartilages and nasal bones
Rx: Onlay grafting of cartilage (septal or conchal) or bone.
7. Deformities of the columella and short nose
Rx: Grafting to  caudal projection and improve angularity or length of columella.
8. Deformities of the naso-labial angle
Rx: Most just require shortening of the septum.
9. Thick rigid tip
Usually d/t thick sebacceous skin that does not drape well.
Rx: Augment the tip.
10.Persistent Pinocchio tip
Rx: Amputate the cartilages and use an onlay cartilage graft.
11. Incorrect columella-alar relationship (the nostril rim should parallel the columella at a slightly higher
level.
Rx:
a) excising skin of the nose
b) trimming of the lateral crura along the cephalad or caudal border
c) resection of nasal lining