Rhinoplasty Dissection Manual

Rhinoplasty
Dissection Manual
DEAN M. TORIUMI DANIEL G. BECKER
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~ L1PPINCOTf WILLIAMS & WILKINS
Rhinoplasty Dissection
Manual
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Rhinoplasty
Dissection Manual
Dean M. Toriumi, M.D.
Associate Professor
Division of Facial Plastic and Reconstructive Surgery
Departm ent of Otolaryngology-Head and Neck Surgery
University of Illinois at Chicago
Daniel G. Becker, M.D.
Assistant Professor
Division of Facial Plastic and Reconstructive Surgery
Department of Otolaryngology-Head and Neck Surgery
Universi ty of Pennsylvania
Illustrated by Devin M. Cunning, M.D.
4 ~ LIpPINCOTT WILLIAMS & WILKINS
A Wolters Kluwer Company
Phi ladelphi a Baltimore New York London
Buenos Ai res Hong Kong Sydney Tokyo
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Acquisitions Editor: Danette Knopp
Developmental Editor: Sara Lau ber
Production Editor: Patri ck Carr
Manufacturing Manag er: Tim Reynolds
Cover Designer: Christine Jenn y
Compositor: Maryland Composi tion
Printer: Couri er Westford
1999 by LIPPINCOTT WILLIAMS & WILKINS
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of ficial duties as U.S. government empl oyees are not covered by the above-me ntioned copyri ght.
Illust rations Dani el G. Becker.
Photograph s Dean M. Toriumi.
Printed in the Unit ed States of America
Library of Congress Cataloging-in-Publication Data
Toriurni, Dean M.
Rhinopla sty dissection manu al/Dean M. Toriumi, Daniel G. Bec ker ;
illustrated by Devin M. Cunning.
p. em,
Includes bibliographical references and index.
ISBN 0-7817 -1783-3
I . Rhinopl asty Handbooks, manuals, et c. 2. Nose-Surgery
Handbooks, manuals, etc. I. Becker, Dani el G. II. Title.
[DNLM: 1. Rhinopla sty-methods Handbooks. WV 39 T683 r 1999]
RDII 9.5.N67T67 1999
617.5' 230592---dc21
DNLMIDLC
for Library of Congress 99-26058
CIP
Care has been take n to confirm the accuracy of the information pre sented and to descri be generally
accepted practi ces. However, the authors, editors, and publisher are not responsibl e for errors or
omis sions or for any consequences from application of the information in this book and make no
warranty, expresse d or impli ed, with respect to the currency, completeness, or accuracy of the contents
of the publicati on. Appli cation of this information in a particular si tuation remains the professional
respon sibility of the practitioner.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage
set forth in this text are in accordance with current recommendations and practi ce at the time of
publ ication . Howe ver, in view of ongoing research, changes in government regul ation s, and the constant
flow of information relat ing to drug therapy and drug reaction s, the reader is urged to check the package
insert for each drug for any change in indic ation s and dosage and for added warnings and preca utions.
Thi s is particularly i mportan t when the recommended agent is a new or i nfrequently employed drug.
Some drugs and medical devices present ed in this publication have Food and Drug Administration
(FDA) clearance for limit ed use in restricted rese arch settings. It is the responsibil ity of the health care
provi der to asce rtain the FDA status of each drug or device planned for use in their clinical practice.
10 9 8 7 6 5 4 3 2
To my ever supportive wife, Colleen, and our two daughters, Hannah and
Olivia, and to my parents who gave me encouragement to practice
medicine.
With special appreciation and love for my family-my parent s Bill and
Merle, and my brothers and sisters-in-law, Richard and Rachel, Paul, Sam,
and Jen.
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Contents
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Preface xiii
Acknowledgments xv
Chapter 1: Anatomy . 1
Chapter 2: Rhinoplasty Analysis . 9
Landmarks for Analysis . 9
Lab Exercise: Nasal Analysis . 11
Surface Angles, Planes, and Measurements-
Definitions . 12
Rhinoplasty Analysis . 16
Chapter 3: Injection . 25
Infiltrative Anesthesia Technique . 25
Chapter 4: Septoplasty . 31
Nasal Dissection: Septoplasty with
Cartilage Harvest . 31
Chapter 5: Incisions and Approaches . 37
Transcartilaginous or Cartilage-Splitting
Approach . 37
Delivery Approach . 40
The External (Open) Rhinoplasty Approach . 43
Chapter 6: Removal of Bony-Cartilaginous Hump . 59
: Osteotomies . 67 Chapter 7
Medial Osteotomies . 67
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viii CONTENTS
Chapter 8:
Chapter 9:
Chapter 10:
Chapter 11:
Chapter 12:
Chapter 13:
Appendix A:
Appendix B:
Appendix C:
Appendix D:
Appendix E
Appendix F:
Appendix G:
Appendix H:
Appendix I:
Appendix J:
Appendix K:
Lateral Osteotomies and Infracture 67
Intermediate Osteotomies 68
Spreader Grafts 71
Surgery of the Tip 81
Exercises 81
Alar Base Resection 113
Internal Nostril Floor Reduction 113
Wedge Excision of Nostril Floor and Sill . .. 114
Alar Wedge Excision 114
Sliding Alar Flap 114
Other Maneuvers . . . . . . . . . . . . . . . . . . . . . .. 117
Plumping Grafts 117
Caudal Extension Grafts 118
Deviated Caudal Septum 122
Rib Cartilage Graft Reconstruction of
Saddle Deformity 130
Harvest of Autogenous Tissue 139
Harvesting Conchal Cartilage 139
Harvesting Ethmoid Bone 143
Harvesting Rib Graft 143
Harvesting Calvarial Bone 144
Incision Closure, Nasal Splint, Post-Operative
Considerations 149
Closure of Midcolumellar Incision 149
Closure of the Marginal, Intercartilaginous,
or Transcartilaginous Incision 152
Placement of Intranasal Packs, Nasal
Splint 152
Postoperative Care 152
Tripod Concept 155
Guide to Nasal Analysis 156
Aesthetic Analysis 157
Surface Angles, Planes, and
Measurement: Definitions 158
Tip Support, Incision, and Approaches 160
Achieving Surgical Goals: Selected Options . . 161
Selected Complications of Rhinoplasty 163
Adjunctive Procedures 165
Cleft Lip Nasal Deformity 167
Photography Setup 169
Indications for External Rhinoplasty
Approach 170
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Contents ix
Appendix L:
Appendix M:
Suggested Surgical Instruments for
Rhinoplasty
List of Selected Companies with
AddresseslPhone Numbers
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171
172
Appendix N: Selected Recommended Literature . 174
Index 177
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Foreword
Exce llent surgical outcomes in rhinoplasty derive from two interrelated factors: (1) a de
tailed understanding of the multiple nasal anatomic varian ts encountered, and (2) an ac
qui red knowledge of the ulti mate long-term effects of surgical altera tions of these anatomic
components-the evolution of healing.
The first ski ll can be learned by detailed observation, enhanced by cadaver dissection;
the second skill onl y by careful foll ow-up of operated patients over time.
The general concepts of nasal anatomy have been fundamentall y clear for centuries , but
only in recent decades have surgeons appreciated the finely det ailed nuances of nasal
anatomic dynamics that influence the surgical crea tion of a natural, pleasing rhinopl asty re
sult, free of surgical stigmata. A det ailed comprehension of nasal anatomy must therefore
transcend knowledge of basic anatomic relationships. The surgeo n must j udge, by inspec
tion and palpation, the character of the ski n and subcutaneous tissues as they vary from
nasal region to region, the influences of faci al mimetic musculature, the relative strength
and support of the carti laginous and bony framework and substruct ure, and the limitations
imposed by the int err elationship of all these struc tures upon the ultimat e favorable result.
As important as the evaluation of what can reasonably be accomplished during rhi noplasty
is the acqui red knowledge and ski ll to assess what canno t be acco mplished.
This judgment is largel y predicated on the critical ana lysis of each pat ient's indivi dual
anatomy, coupled with technical refinements guided by experie nce, and generally requires
years of personal surgic al result evaluati on to become keen.
In this dissection manual, Drs. Becker and Toriumi have created a unique study guide
and cadaver dissection manual dedicated to guiding the learner in a disciplined manner.
They admirably extend the tradit ion of the Universi ty of Illinois Department of Otolaryn
gology's leader ship in teaching anatomy and surgery in rhinoplasty. Cadaver dissection
cons titutes a privil ege not available to all, and, as such, this precious material must be
wise ly and conservatively approached. Experie nce teaches that a discipl ined, structured ap
proach to dissecti on of the nose produces the best educational outcome.
An important favorable develop ment in cont empo rary rhinopl asty is the appropria te con
cern for conservative and subtle anatomic changes that by defi nition derives from a preser
vative attitude toward nasal tissues. Commonly, rather than excisional sacrifice of large
segments of cartilage or bone, a phil osophy of preservation and restoration oftissues is de
veloping that precludes crea tion of unnecessary tissue voids which may heal and scar un
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xii FOREWORD
predictably. Wise surgeons recognize that even a larger nose, well balanced to the sur
rounding facial features, is always aesthetically preferable to a nose made over-small by
radical surgery. Conservation surgery thereby further extends the surgeon's control over
the final surgical result, as an appropriate equilibrium between the corrected nasal skeleton
and soft tissue covering is more reliably achieved. Conservative sculpture and volume re
duction of the alar cartilages clearly produce more favorable results, generally avoiding
major resections and vertical interruprion of the intact residual strip of lateral and medial
crus. Notching, pinching, alar cephalic retraction, over-rotation, and asymmetries are all
almost entirely eliminated in long-term healing when this conservative philosophy is em
braced. A further striking example of conservatism is the preservation of a strong , high pro
file in many patients, a distinct contrast to the dramatic retrousee pro files created in
decades past by sacrifice of over-generous segments of nasal bony humps.
Finally, thoughtful nasal surgeons, through accurate anatomic diagnosis, discern which
portions of the nasal anatomy are pleasing and satisfactory, striving to avoid disturbing
these structures and areas when correcting (or gaining access to) anatomic components in
need of correction. Thi s philosophy further extends the surgeon 's favorable control over ul
timate healing. Thoughtful cadaver dissection provides the learner with visual pathways to
gain access to structures to be modified, while preserving normal tissues and relationships.
Important tissue planes, vital in live surgery, can be appreciated best when viewed at leisure
in the dissection laboratory.
Thi s well-conceived work, properly employed, contributes substantially to shortening
the steep learning curve characteristic of rhinoplasty.
M. Eugene Tardy, Jr., M.D., F.A.C.S.
Profes sor of Clinical Otolaryngology
Director, Division of Facial Plastic and
Reconstructive Surgery
University of Illinois Medical Center
Chicago, Illinois
Professor of Clinical Otolaryngology
Indiana University School of Medicine
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Preface
The successful rhinoplasty surgeon' s operative plan is based on a clear understanding of
the patient's desired changes, a careful and accurate diagnosis of the patient's anatomy , and
a wide armamentarium of surgical techniques. Prior techniques and the surgeon's personal
experiences with the array of surgical techniques are also primary factors in the decision
for a particul ar operative approach. The successful surgeon's applicatio n of surgical tech
niques is designed to accommodate differences in anatomy and to account for varia nt
anatomy. For example, noses with thin skin and noses with thick ski n each present specific
problems that must be considered when choosing techniques for altering nasal structure.
Also, the effects of scar contract ure vary from patient to patient and can significantly affect
the ultimate aesthetic and functional outcome . The rhinoplasty surgeon must recognize that
the healing process may distort the changes made at the time of surgery, however expert ly
they were accomplished. The surgeon's only recourse is to build a structurally sound nasal
architecture that can withstand the force s of scar contracture and provide an acceptable suc
cess rate.
The importance of experience in rhinopl asty cannot be overemphasized. The experi
enced rhinoplasty surgeon can anticipate the likelihood of a favorable outcome based on his
or her experience using certain techniques with a specific deformi ty. Selection of the proper
technique for each circumsta nce should provide the opportunity for a high success rate.
The purpose of this dissec tion manual is to provide practical infor mation about a wide
range of surgical techniques in rhinopl asty. The dissection manual guides the reader
through a step-by-step dissection. It focuse s on the execution of basic and advanced rhino
plasty techniques and seeks to provide practical information that can be readily applied in
surgery. The text is intended to be a procedurally oriented dissection manual and is orga
nized to allow easy reference to a wide array of basic and advanced rhinopl asty techniques.
Illustrations and intraoperative photographs, along with detailed text, guide the reader
through the step-by-step dissection. Important technical and cl inical "pearls" are high
lighted in each section. A programmatic cadaver dissection videotape accompanies the text.
Before beginning the nasal dissection, review the chapter on nasal anatomy (Chapter 1)
and the chapter on pre-operative rhinoplasty analysis (Chapter 2). Chapter 3 outlines local
anesthesia injection techniques; the dissector is instructed to practice the injections prior to
commenci ng the programmatic dissection.
The dissection manual guides you through the following dissect ions: septoplasty, trans
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xiv PREFACE
cart ilag inous or int er-cart ilaginous approach, de livery approac h and an external rhinopl asty
approach. The remainder of the programmatic nasal dissection detai ls a number of rhino
plasty techniques and addresses a number of specific rhinopl asty problems. The manual fo
cuses primarily on the external rhinopl asty approach; however, all approaches are covered
and ca n be performed sequentially, or the dissector may choose to foc us on a specific ap
proach. Appropriate targeted references for further readi ng are also provided.
We recommend that the diss ector proceed with Chapters 1- 6 with the ski n-soft tissue en
velope intact. For the remai ni ng chapters, the dissector may wish to split the ski n down the
midl ine for better exposur e. In this fashi on, the dissection can be performed without an as
sistant, and (except for a complete septopl asty) without a headlight.
The cadaver laboratory is the plac e to sharpen one ' s sur gical skills. This manual seeks to
provide the di ssector with the opportunity to obtai n maximum benefit from performing this
complex opera tion on cadaver specimens. The di ssecti on manual was "field tested" at the
Unive rsity of Pen nsyl vania Rhinoplast y Course: Aesthetic & Funct ional Rhinopl ast y. Par
ticipants, many of whom professed relativel y limited rhinopl asty experience, undertook the
stepwise, programmatic dissection and worked through the manual (with the except ion of
rib or clav arial bone harvest) in a single five-hour period.
Rhinopl asty is an operation that requires constant thought , assimilation of information,
and reac tion to unexpected fi ndi ngs . With this in mind, the authors strongly recomme nd in
volvement in as many advanced teaching encounters as possible. This may invol ve readi ng
time ly literature, attending advanced rhinoplasty courses, observi ng other experienced sur
geons, or sharpening one's skills in the cadaver laboratory. We hope that use of this di s
section manual will stimulate thought and inci te both the enthusiasm of the beginner as well
as experienced rhinopl asty surgeons seeki ng to broaden their surgical armamentariu m,
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Acknowledgments
We wish to thank the following friends, colleag ues, and mentors for their encouragement,
support, and guidance .
Dr. M. Euge ne Tardy, Jr., has been an inspirational mentor and friend , whose advice and
encouragement were instrumental in this project ' s development.
Our mentors in Otolaryngology- Head & Neck Surgery and in Facial Plastic & Recon
structive Surgery are a continuing source of inspiration and guidance.
Depar tment Chai rmen, Ed Appl ebaum at the University of Illinois at Chicago, and David
Kennedy at the University of Pennsylvania, deserve special thanks for supporting and fa
cilitating this undertaking.
Devin M. Cunning deserves much appreci ation. His medical illustrations speak for them
selves, but do not tell of the countl ess hour s of collaboration, hard work, and multiple re
visions.
Danett e Knopp of Lippincott Wi lliams & Wi lkins provided publishing leadership from
the very conception of the proj ect to its completion.
Sara Lauber of Lippincott Willi ams & Wil kins played an instrumental role in guiding the
manuscript through its final, critical stage.
Patrick Carr deserves thanks for his outstandi ng work as Production Edit or.
xv
Rhinoplasty Dissection
Manual
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1
Anatomy
Although the anatomy of the nose has been fundamentally understood for many years, only
relatively recently has there been an increased understanding of the long-term effects of
surgical changes on the function and appearance of the nose. A detailed understanding of
nasal anatomy is critical for successful rhinoplasty. This chapter reviews the surface and
structural anatomy of the nose, with an emphasis on important surgical anatomy.
Accurate assessment ofthe anatomic variations presented by a patient allows the surgeon
to develop a rational and realistic surgical plan. Furthermore, recognizing variant or aber
rant anatomy is critical to preventing functional compromise or untoward aesthetic results.
This chapter presents a limited diagrammatic overview of nasal anatomy. More detailed
study of nasal and facial anatomy is recommended (1) (Figs. 1-10).
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2 RHINOPLASTY DISSECTION MANUAL
4
Figure 1. Surface anatomy of the nose: Frontal view. 1,
Figure 2. Surface anatomy of the nose: Base. 1, Infratip lob
Glabella; 2, nasion; 3, tip-defining points; 4, alar-sidewall ; 5,
ule; 2, columella; 3, alar sidewall; 4, facet or soft-tissue trian
supraalar crease; 6, philtrum.
gle; 5, nostril sill; 6, columella-labial angle or junction; 7,
alar-facial groove or junct ion; 8, tip-def ining points.
Figure 3. Surface anatomy of the nose: Lateral. 1, Glabella; 2, nasion, nasofrontal angle;
3, rhinion (osseocartilaginous junction) ; 4, supratip; 5, tip-defining points; 6, infratip lobule;
7, columella; 8, columella-labial angle or junction; 9, alar-facial groove or junction .
Figure 4. Surface anatomy of the nose: Oblique. 1, Glabella;
2, nasion, nasofrontal angle; 3, rhinion; 4, alar sidewall; 5,
alar-facial groove or junction; 6, supratip; 7, tip-defining
points; 8, philtrum.
Figure 6. Nasal anatomy: Lateral (rotated slightly obliquely) .
1, Nasal bone; 2, nasion (nasofrontal suture line); 3, inter
nasal suture line; 4, nasomaxillary suture line; 5, ascending
process of maxilla; 6, rhinion (osseocartilaginous junction) ; 7,
upper lateral cartilage; 8, caudal edge of upper lateral carti
lage; 9, anterior septal angle; 10, lower lateral cartilage, lat
eral crus; 11, medial crural footplate; 12, intermediate crus;
13, sesamoid cartilage; 14, pyriform aperture.
,
13
Figure 5. Nasal anatomy: Oblique. 1, Nasal bone; 2, nasion
(nasofrontal suture line); 3, internasal suture line; 4, naso
maxillary suture line; 5, ascending process of maxilla; 6, rhin
ion (osseocartilaginous junct ion); 7, upper lateral cartilage; 8,
caudal edge of upper lateral cartilage; 9, anterior septal an
gie; 10, lower lateral cartilage, lateral crus; 11, medial crural
footplate; 12, intermediate crus; 13, sesamoid cartilage; 14,
pyriform aperture.
Figure 7. Nasal anatomy: Base. 1, Tip-defining point; 2, in
termediate crus; 3, medial crus; 4, medial crural footplate; 5,
caudal septum; 6, lateral crus; 7, naris; 8, nostril floor; 9, nos
tril sill; 10, alar lobule; 11, alar-facial groove or junction; 12,
nasal spine.
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Figure 8. Nasal septum. 1, Quadrangular cartilage; 2, nasal
spine; 3, posterior septal angle; 4, middle septal angle; 5, an
terior septal angle; 6, vomer; 7, perpendicular plate of eth
moid bone; 8, maxillary crest , maxillary component; 9, maxil
lary crest, palatine component.
Figure 9. Nasal musculature. A: Elevator muscles: 1, pro
cerus; 2, levator labii alaequae nasi; 3, anomalous nasi. B:
Depressor muscles: 4, alar nasal is; 5, depressor septi nasi.
C: Compressor muscles: 6, transverse nasal is; 7, compres
sor narium minor. D: Minor dilator muscles : 8, dilator naris an
terior . E: Other: 9, orbicularis oris; 10, corrugator.
B
2
A
Figure 10. Nasal vasculature. 1, Dorsal nasal artery; 2, lateral
nasal artery; 3, angular vessels; 4, columellar artery.
5 Anatomy
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Figure 10, continued.
PEARLS
o The nose may be thought of in anatomic thirds. The upper third roughly corre
sponds to the bony dorsum; the middle third roughly corresponds to the cartilagi
nous dorsum; and the lower third generally corresponds to the tip.
o When describing relationships of one structure to another in the nose, use the well
. defined anterior/posterior or caudal/cephalic. (Fig. II). .
o The nasal bones are usually small; the ascending process of the maxilla provides
a significant contribution to the bony anatomy of the nose.
o The alar lobule contains fat and fibrous connective tissue, but it contains no carti
lage. The lateral crus of the lower lateral cartilage takes on a more cephalic posi
tion as it extends laterally and is not found in the alar lobule.
o The lobule, alar lobule, and the infratip lobule are terms that designate three dis
tinct anatomic areas of the nose. The lower third of the nose may be referred to as
the lobule or tip. The alar lobule is a fibrofatty nasal subunit that is devoid of car- .
tilage and composes a portion of the lateral nasal sidewall . The infratip lobule
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PEARLS, continued
should comprise one third of the vertical length of the nose on base view (i.e., 2:1
columellar/lobule ratio).
The nasal valve area includes the cross-sectional area described by the nasal valve"
and is affected by the inferior turbinate; the caudal septum, and the tissues sur
rounding the pyriform aperture. The nasal valve proper is bounded by the nasal
septum, the caudal margin of the upper lateral cartilage, and the floor of the nose,
and is considered to be the location of the least cross-sectional area in the nose. In
lateral osteotomies, care is taken to preserve a small triangle of bone at thepyri
form aperture to prevent medialization of the inferior turbinate, which can corn
, promise the cross-sectional area of the nasal valve area.
Scroll region: The upper lateral cartilages and lower lateral cartilages interrelate
in three different configurations. Most commonly, the cephalic edge of the lower
lateral cartilage overlaps the caudal edge of the upper lateral cartilage in the scroll '
region. Less commonly, the cephalic edge of the lower lateral cartilage abuts the
caudal edge of the upper lateral .cartilage. Rarely the cephalic edge of the lower
lateral cartilage is overlapped by the caudal edge of the upper lateral cartilage. .
Internasal suture line: The nasal bones are fused inthe mid\ine at the internasal su
ture. Whenelevating the skin-softtissue envelope, decussating fibers must be di
vided (typically with scissors) from their attachment at the midline internasai su- .'
ture to achieve the desired exposure. '
The caudal margin of the nasal septumhas a defined posterior septal angle, a mid
dle septal angle, and an anterior septalangle. This anatomy plays a significant role
in the shape of the nasal tip, including the infratip lobule, double-break, and
supratip region . The surgeon attempting to create or allow for tip rotation by con
servative excision of a superiorly based triangle of caudal septum must be aware
of this anatomy, .', ' ,
The septum is composed of contributions from a number of anatomic structures
(see Fig. 8).
In performing septoplasty, great care must be taken to preserve a generous L 'strut
to maintain support for the lower two thirds of the nose. Generally, it is recom - ;
mended that at least 15 mm caudally and 15 mm dorsally (after accounting for any '
removal of dorsal hump) be preserved.
Rhinion versus sellion: The rhinion is the soft-tissue correlate of the osseocarti
, laginous junction of the nasal dorsum. The sellion corresponds to the osseocarti
laginous junction the nasal dorsum. ' .'' ' . ' ,' .
Osteotomies should not extend into"the bone. When osteotomies
, extend too far cephalically into this thick, hard bone, a rocker deformity may re
suit. In a rocker deformity, infracture of the bone may displace this excessive, '
cephalic portion laterally. .
Vascular supply and lymphatics are found superficial to the nasal musculature (2).
The soft-tissue layers in .the nose are epidermis, dermis,subcutaneous [this plane
contains blood vessels and lymphatics; and also a (typically) thin layer of fat);
muscle and fascia (musculoaponeurotic) plane, areolar tissue plane, and perichon
drium/periosteum. Dissection during rhinoplasty in the proper tissue planes [are
olar tissue plane (i.e., submusculoaponeuroticj] preserves nasal blood supply and
minimizes postoperative edema. ' . .
The astute surgeon will be able to anticipate' the contour of the upper and lower
lateral cartilages by studying the surface topography of the nose.
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7 Anatomy
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Figure 11. Nasal relationships.
REFERENCES
1. Tardy ME, Brown R. Surgical anat omy of the nose. New York: Raven Press, 1990.
2. Toriu mi DM, Mueller RA, Grosch T, Bhatt acharyya TK, Larrabee WF. Vascular anatomy of the nose and the
external rhinoplasty approach. Arch 0101Head Neck Surg 1996; 122:24-34.
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Rhinoplasty Analysis
Development of an oper ative plan that will achieve the desired outcome requires an under
standing of the patient' s wishes and selection of appropriate surgical maneuvers to effect
the propo sed changes. The surgeon must be abl e to identify anatomic constraints that will
limit the ability to change contour (thick skin, weak cartilages, etc. ). Experi ence with rhino
plasty over time has shown that det ailed anatomic analysis of the nose is an essential first
step in achi eving a successful outc ome. Failure to recogni ze a particular anatomic point
preoperatively will often lead to a less than ideal long-term result.
After you have identified the vari ous anatomic landmarks in Chapter 1, undertake a pre
operative rhinoplasty analysis of your patient (cadaver specimen) . In this programmatic
dissection, you will perform a number of incisions, approaches, and surgic al techniques,
but it is also important to develop your skills in rhinoplasty analysis. Repeated practice of
rhinoplasty-analysis skills will improve your preoperative diagnostic abilit y. Therefore, in
this exercise, determine what the best approach and techniques would be in your specimen.
Follow the simplified rhinoplasty-analysis algorithm provided as you examine the face and
nose.
Also provided is a more detailed description of terms and a more detailed review of
rhinoplasty analysis.
LANDMARKS FOR ANALYSIS (FIG. 1) (Appendix C)
Points
Trichion: Anterior hairline in the midlin e
Glabella: Most prominent midline point of forehead, well appreci ated on lateral view
Nasion: Most posterior midline point of forehead, typically corresponds to nasofrontal su
ture
Rhinion: Soft -tissue correlate of osseocartilaginous junction of nasal dorsum
Sellion: Osseocartilaginous junction of nasal dor sum
Supratip: Point cephalic to the tip
Tip: Ideally, most anteri orly projected aspect of the nose
Subnasale: Junction of columella and upper lip
9
Figure 1. Nasal analysis: Landmarks.
Stomion
Glabella
Menton

Nasion
\
J
--+-------J.../I----4--- Rhinion
. \
I --'--------AAf-..-----I-- Supratip

- - - - - - F- - - I--Subnasale
Labrale superius
/ ---- -
------- I
A
Glabella
1----- Nasion
/L--jl'----,f.---_ Trichion
_ _ Rhinion
Supratip
(
Tip
Subnasale
Labrale Superius
Stomion
1----- Mentolabial Sulcus

Pogonion
Menton
B Cervical Point
c
11 Rhinoplasty Analysis
Labrale superius: Border of upper lip
Stomion: Central portion of interlabial gap
Stomion superius: Lowest point of upper-lip vermilion
Stomion inferius: Highest point of lower-lip vermilion
Mentolabial sulcus: Most posterior midline point between lower lip and chin
Pogonion: Most anterior midline soft-tissue point of chin
Menton : Most inferior point on chin
Cervical point: Point of intersection between line tangent to neck and line tangent to sub
mental region
Gnathion: Point of intersection between line from subnasale to pogonion and line from cer
vical point to menton
LAB EXERCISE: NASAL ANALYSIS
General
Skin quality: Thin, medium, or thick
Primary descriptor (i.e., why is the patient here): For example, "big," "twisted," "large
hump"
Frontal View
Twisted or straight: Follow brow-tip aesthetic lines
Width: Narrow, wide, normal, "wide-narrow-wide"
Tip: Deviated, bulbous, asymmetric, amorphous, other
Base View
Triangularity: Good versus trapezoidal
Tip: Deviated, wide, bulbous, bifid, asymmetric
Base: Wide, narrow , or normal. Inspect for caudal septal deflection
Columella: ColumelJarllobule ratio (normal is 2: 1 ratio); status of medial crural footplates.
Lateral View
Nasofrontal angle: Shallow or deep
Nasal starting point: High or low
Dorsum: Straight, concavity, or convexity; bony, bony-cartil aginous, or cartilaginous (i.e.,
is convexity primarily bony, cartilaginous, or both)
Nasal length: Normal, short, long
Tip proj ection: Normal, decreased, or increased
Alar-columellar relationship: Normal or abnormal
Naso-labial angle: Obtuse or acute
Oblique View
Does it add anything, or does it confirm the other views?
Many other points of analysis can be made on each view, but these are some of the vital
points of commentary.

--=-'''''::1
. -.
_- :1,
':::::1..1
SURFACE ANGLES, PLANES, AND MEASUREMENTS: DEFINITIONS (FIG. 2)
(1-5) (Appendix D)
Facial thirds
Upper third : Trichion to glabella
Middle third: Glabella to subnasale
Lower third: Subnasale to menton (Fig. 2A)
Horizontal fifths: Five equally divided vertical segments of the face (Fig. 2B)
Frankfort plane: Plane defined by a line from the most superior point of auditory canal to
most inferior point of infraorbital rim (Fig. 2C)
Nasofrontal angle: Angle defined by glabella-to-nasion line intersecting with nasion-to-tip
line. Normal, 115 to 130 degrees (within this range, more-obtuse angle more favorable
in female , and more acute angle in male patients ; Fig. 2D)
Nasofacial angle : Angle defined by glabella-to-pogonion line inter secting with nasion-to
tip line. Normal, 30 to 40 degrees (Fig. 2E)
1/5 1/5 1/5 1/5 1/5
A
1/3
1/3
1/3
B
Figure 2. Surface angles, planes, and measurements. A: Horizontal facial thirds. B: Vertical facial fifths.
c
Figure 2, continued. C: Frankfort plane. D: Nasofrontal angle.
E
Figure 2, continued. E: Nasofac ial angle . F: Nasomental angle.
G
Figure 2, continued. G: Relationship of lips to subnasale-to-pogonion line. H: Relationship of lips to na
somental line.
Figure 2, continued. I: Mentocervical angle. J: Legan's angle of facial convexity.
- --,
, I ~
-, ~ l
K
Figure 2, continued. K: Nasolabial angle. L: Nasal projection: method of Goode.
PEARL
Normal projection with a "3-4-5" triangle described by Crumley (see later) gives a
riasofacial angle of 36 degrees .
Nasoment al angle : Angle defined by nasion-t o-tip line intersecting with tip-to-pogoni on
line. Normal , 120 to 132 degrees (Fig. 2F)
Relation ship of lips
To nasomentalline: Upper lip, 4 mm behind; lower lip, 2 mm behind line from nasal tip
to menton (Fig. 2H)
To subnasale-t o-pogonion line: Upper lip, 3.5 mm anterior; lower lip, 2.2 mm anterior
(Fig.2G)
Mentocervical angle: Angle defined by glabella-to-pogonion line intersecting with men
ton-to-cervical point line (Fig. 21)
Legan faci al-con vexity angle: Angle defined by glabella-to-subnasale line intersecting
with subnasale-to-pogonion line; normal , 8 to 16 degree (Fig. 21)
PEARL
Useful in assessing chin deficiency, candidacy for chin implant, chin advancement,
or other chin alteration
Nasolabi al angle: Angle defined by columell ar point-t o-subnasale line intersecting with
subnasale-to-Iabrale superius line; normal , 90 to 120 degrees (within this range, more
obtuse angle more favorable in female, and more acute in male patient s; Fig. 2K)
Columell ar show: Alar-columellar relationship as noted on profile view; 2 to 4 mm of col
umell ar show is normal
Nasal projection: Anterior protrusion of nasal tip from face (Fig. 2L)
Goode's method : A line is drawn through the alar crease, perpendicular to the Frankfurt
plane. The length of a horizontal line drawn from the nasal tip to the alar line (alar
point-to-nasal tip line) divided by the length of the nasion-to-nasal tip line. Normal,
0.55 to 0.60 (2,3)
Crumley's method: The nose with normal projection forms a 3-4-5 triangle [i.e., alar
point-to-nasal tip line (3), alar point-to-nasion line (4), nasion-to-nasal tip line (5)]
(4).
Byrd's method: Tip projection is two-thirds (0.67) the planned postoperative (or the
ideal) nasal length . Ideal nasal length in this approach is two-thirds (0.67) the midfa
cial height (5)
POWELL AND HUMPHRIES "AESTHETIC TRIANGLE"
Nasofrontal: 115 to 130 degrees
Nasofacial: 30 to 40 degr ees
Nasomental: 120 to 132 degrees
Mentocervical: 80 to 95 degrees (3)
RHINOPLASTY ANALYSIS
A thorough physical examination and accurate preoperative anal ysis are critical to
achieving the desired long-term postoperative rhinoplasty result. Some degree of mental
organization assi sts in the execution of the physical examination. Visual examination and
finger palpation are equally important in the nasal evaluation. Throughout the evaluation,
a mental image of the potential outcome and surgical limitations inherent in every individ
ual should be visualized. In effect, the potential rhinoplasty operation is rehearsed even as
the physical examination proceeds (1,6).
Study of the standard preoperative photographic images for rhinoplasty (frontal , base,
lateral, oblique) allows a systematic, detailed anatomic anal ysis that complements the phys
ical examination process. Thi s chapter focuse s on analysis of the four standard rhinoplasty
photographic views (frontal, base, lateral , oblique). Emphasis is placed on anatomic de
scriptions of structures and their relationships to other structures.
Analysis begins by examining all four view s and making an assessment of the overall
stature of the pati ent , the facial skin quality , and the symmetry of the face. The principle of
dividing the face into horizontal thirds and vertical fifths is a useful tool to obtain a general
sense of any incongruent areas of the face that may playa key role in nasal appearance and
the outcome of nasal surgery. It is essential that these incongruent areas or asymmetries be
recognized and discussed with the patient. Thickness and quality of the facial skin-subcu
taneous tissue complex must be determined, as it plays a critical role in dictating the limi
tations of what can and cannot be accompli shed with aesthetic nasal surgery (1,6,7).
After completing the general assessment, note and highlight the most striking character
istics of the nose. These are typically the characteristics that bring the patient for rhino
plasty , such as excessive size, deviation, or a dorsal hump. These primary patient concerns
must be recognized, highlighted, and addres sed above all else.
As the surgeon reviews each photographic image, the major aesthetic and technical
points that can be evaluated on a given view are noted first. Subtleties in analysis are then
addressed. It is important to recognize both the characteristics of greatest concern to the pa
tient and the more subtle findings. The patient may not notice these other subtle abnormal
ities if they are left unaddressed by the surgeon. Postoperatively, the scrutinizing patient
may notice and point out these abnormalities. Stepwise, methodical analysis of the patient
and the photographic views allows the well-trained surgeon to identify significant anatomic
and aesthetic point s.
"""''''
.
. 'Il
'" ,ill
Frontal View
On frontal view, the observant surgeon first notes nasal width, any deviation from the
midline , and characteri stics of the nasal tip. Nasal width can be assessed in the upper, mid
dle, and lower third of the nose. It is important to recognize that a saddle deformity of the
bony or cartilaginous dorsum will contribute to the appearance of an overwide dorsum on
front al view, whereas a hump will give the impression of a narrow dorsum. Simil arly, a low
bony dorsum will create an illusion of a relatively wide upper third of the nose and wide in
tercanthal distance or pseudohypertelorisrn (7). This appearance can be significantly im
proved by augmenting the nasal dorsum. The width of the nasal base on frontal view should
approximate the interc anthal distance.
The contour of the curved aesthetic lines that follow the eyebrows, traverse the radix, and
continue down along the lateral nasal dorsum to end at the tip-defining points (the brow-tip
aesth etic lines) should be followed, and any asymmetries, twists , or deviation s noted.
These brow-tip aesthetic lines should be smooth, unbroken, gentl y curved, and symmetric
(1,6) .
The nasal tip should be characterized on frontal view with regard to symmetry and def
inition. Concavity or other anatomic findings of the alar sidewall are noted. Vertical and
horizontal aspects of bulbosity should be recognized when present. Bifidity of the nasal tip
may be visible on this view (but is typically best appreciated on base view) . The gentle
"gull-in-flight" relationship of the nasal alae to the infratip lobule should be followed , and
any asymmetry should be noted. Exaggeration of this curve is suggestive of alar retraction
and/or a dependent infratip lobule. If the columella is not visible ("hidden columella") on
frontal view, this also may indicate a retracted columella. The vertical position and sym
metry of the alar insertions should be described on the front al view.
Base View
On base view, special attention should be given to triangularity, symmetry, columella/lob
ule ratio, and width and insertion of the alar base. The nasal base should be configured as an
isosceles triangle with a gently rounded apex at the nasal tip and subtle flaring of the alar
sidewalls (Fig. 3) (4,8,9). Poor triangularity or trapezoidal configuration with broad domal
angles may suggest abnormal divergence of the intermediate crura. The presence of asym
metry of the tip may best be appreciated on this view. Often one can visualize the outline of
Figure 3. Nasal analysis: Base view. Give special attention
to triangularity, symmetry , columellar/lobule ratio, and width
and insertion of the alar base.
. - -
. .
. -
--
. . \,,--:..:
"':il
! - : ; - = - ~
the lower lateral cartilages beneath the thin skin of the columella and alar rim, and asym
metries or buckling can be noted . Overlong or short medial crura may be apparent; a wide
columella and flaring of the medial crural footplates should be noted when present. One
should look into the nasal vestibule to identify possible recurvature of the lateral aspect of
the lower lateral cartilage (lateral crura), which on occasion contributes to nasal obstruction
or correlates with an alar concavity seen on frontal view. This recurvature of the lateral crura
can be accentuated with application of dome-binding sutures (transdomal sutures, etc.), re
sulting in nasal airway obstruction. The caudal septum may be seen protruding into a nos
tril. Asymmetric nostrils or protruding medial crural footplates may be a clue of subtle cau
dal septal deviation or asymmetry. Asymmetric orientation of the nostril apices may be
indicative of underlying abnormalities of the domal region of the lower lateral cartilages.
The width of the alar base should be noted, with normal width generally being within a
vertical line dropped from the medial canthi. Variations in the appearance of width on the
base view may be due to the variation in horizontal position of the alar insertions on the
face or in the flare of the alar sidewalls. The alar sidewalls themselves are characterized
with regard to thickness and flare. Alar base insertions are described by degree of recurva
ture, with straight insertions going directly into the face (i.e., no nostril sill) , and extremely
recurved alae inserting directly into the columella (4,8,9) .
The ratio of the columella to lobule should approximate a 2:1ratio, and the beginning of
the flare of the medial crural footplates should divide the alar base into halves. The nostrils
are commonly oriented 30 to 45 degrees toward the midline and are pear-shaped and elon
gated. The facets or external soft-tissue triangles are attractive when they are well defined
but can detract if they are overly conspicuous (4,8,9).
Lateral View
The lateral view offers important information on tip projection, nasal length, dorsal profile,
and alar-columellar relationship.
The nasal tip should ideally project strongly from the the face and gracefully lead the
supratip dorsum, creating a modest supratip break. An identifiable but not overly exagger
ated columellar double break typically marks the junction of the medial and intermediate
crus . Nasal tip projection is consistentl y assessed by using the method described by Goode
(see Fig. 2) (2,3). If the length of a line drawn from the tip-defining point perpendicular to
a tangent to the alar-facial junction is greater than 0.55 to 0.60 of the line drawn from the
nasion to tip-defining point, then the nose may be overprojected. However, when assessing
tip projection, relationships between the nose and other aesthetic facial features (chin pro
jection, forehead contour, ethnic background, etc.) must be considered.
Nasal length is complicated to define. The nasal length is compared with the horizontal
thirds of the face and the overall stature of the patient to determine whether the nose is of
appropri ate length. However, the factors contributing to the appearance of nasal length are
complex. The nose can be considered to have three lengths, with nasion to tip being the cen
trallength, and nasion to alar margin being the lateral lengths. A short or long lateral length
may reflect a retracted or hooded ala, respectively, whereas a ShOl1 or long central length
may reflect an obtuse or acute nasolabial (columellar-labial) angle, respectively. Further
more, a deep nasofrontal angle contributes to the illusion of a short nose, and a shallow na
sofrontal angle adds apparent length to the nose (10). In Fig. 4A, three diagrams identical
except for the nasofrontal angle illustrate the effect of the nasofrontal angle on the appear
ance of nasal length. Another three diagrams (Fig. 4B), identical except for the nasolabi al
angle, illustrate the effect of the nasolabial angle on the appearance of length.
The nature of the columellar-labial confluence and columellar-lobular angle (double
break) also must be assessed. Webbing or tenting of the columellar-labial confluence
should be noted. An overly obtuse columellar- labial angle and/or an exaggerated double
break will make the nose appear ShOI1, whereas the converse (acute columellar-labial an
gle and/or absent double break) will add apparent length. A posteriorly inclining lip or de
ficiency of the premaxilla may confound accurate measurement of the columellar-labial
A,B
c
D,E
Figure 4. A deep nasofrontal angle and/or an obtuse nasolabial angle contributes to the ap
pearance of a short nose , whereas a shallow nasofrontal angle and/or an acute nasolabial
angle adds appa rent length . In the first three line drawings (A) , the nasolabial angle is the
same, whereas the nasofrontal angle is altered to illust rate the effect of the nasofrontal an
gie on the appearance of nasal length. In the next three drawings (B), the nasofrontal angle
is constant , whereas the nasolabial angle var ies.
angle. The rel ationship of the nose to other facial structures also will influence nasal length;
for exampl e, a flat forehead will give the illusion of increased nasal length (l0).
Byrd (5) described a useful method for determining appropriate aesthetic proportions for
tip projection, nasal length, and radix projection. "Ideal" nasal length is two thirds of the
midfacial height and is equal to chin vertical. Tip projection is ideall y two thirds of this
planned or ideal nasal length. Radix proj ect ion may be measured from the junction of the
nasal bones with the orbit and ideally should be one third of the calculated nasal length.
. . - ~ ' I - ' ~
['I
~ J 1 i i
,-
~
~
20
RHINOPLASTY DISSECTION MANUAL
Byrd recommended 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. In
Byrd's report , the radix projected 9 to 14 mrn from the plane of the cornea surface (5).
One should be famili ar with the aesthetic angles applied in facial analysis as gener al
guidelines for standards of facial aesthetics and facial harmony. Powell and Humphri es
aestheti c triangle (nasofacial, nasofrontal, nasomental, and ment ocervical angles) and the
nasolabial angle or confluence are a few of the more commonly cited measurements (3).
Assessment of the dorsal contour should identify any concavity, convexity, or irregul ar
ity. A high dorsum with a slight concavity at the rhinion is generall y considered the aes
thetic ideal in the white female nose. A high dorsum that is straight or with a small hump
is ideal in a white male nose. Other notable components of the dorsum include the nasal
start ing point , which is ideally positioned at the level of the superior palpebral fold, and the
tip-supratip relationship, as previousl y mentioned.
The ala is anal yzed in detail on the lateral view. Insertion of the ala on the face 2 to 3 mm
above the columella in the horizontal plane, as described by Crumley (4), is judged to be
normal. The contour of the alar rim in profile ideally approximates a "lazy S" shape: one
should note if this is normal, exaggerated, or straight. The size of the alar lobule is classi
ficd as small , normal , or large. The alar-columellar relationship should be precisely de
scribed. The range of normal columellar show is generally considered to be 2 to 4 mm. The
complexities of the alar- columellar relationship were categorized by Gunter et al. (11),
who identified abnormal positioning of the ala and the columella in relationship to a line
drawn through the long axis of the nostril. All patient s have a hanging, normal , or retracted
ala and a hanging, normal , or retracted columella. Thus nine possible anatomic combina
tions make up the alar-eolumellar relati onship (Fig. 5).
On lateral view, the long axis ofthe nostril should rise at approx imately 10 to 30 degrees
from a plane horizontal to the Frankfurt plane. This is a reliable determinant of the need for
operative rotation of the nasal tip (7).
Oblique View
Although it offers the least amount of objective data, this is an important aesthet ic view be
cause the nose is most often seen at oblique angles. Several aspect s of nasal contour are high
lighted on this view and should be assessed. The brow-tip aesthetic lines and the soft-tissue
facets are especi ally prominent and should be carefull y assessed, as irregulariti es may be
highlighted on this view. Furthermore, abnormalities of the lateral aspect of the nasal bones,
nasal length, dorsal height, and tip project ion also may be highli ghted on the oblique view.
Overview
There is no "standard" rhinoplasty. Each operation is unique in that it must be tailored to
the specific anatomic components involved and the desires of the patient. By developing a
consistent, meticulous routine in which the patient' s nose is analyzed with regard to its
anatomic components and their complex interrelationships, the surgeon can select the best
incisions, approaches, and techniques to achieve the desired surgical outcome.
.,
,,- '.
PEARLS
The soft-tissue point correlating to the of the nasal
. dorsum is the rhinion , The skin at this location is relatively thin compared with the
thicker skin of the nasion. This is importantto recognize when planning dorsal
hump reduction. After hump reduction, this area must be very smooth to avoid vis
ible or palpable irregularities (see Appendix G): .
The nasal starting point typically corresponds to the nasion. In female patients, it
is ideally situated at the same level as the superior palpebral fold. .
n _ . __
- .
-

Normal
Retracted Hanging
Columella
Columella Columella
Normal
Ala
-,
Retracted
Ala
\
Hanging
Ala
Figure 5. Nine possible anatomic combina
tions making up the alar-columellar relation
ship.
~ ~ - -
"} ~
, ~ - ~ - : ;
PEARLS, continued
The nasaltipshouid be the most anteriorly projecting portion oftbe nose. The nasal
tip should ideally lead the supratip dorsum, creating a modest supratip break. .
A "pollybeak" is a postoperative situation in which the supratip leads the tip.
Causes for a pollybeak include underresection of cartilaginous dorsum at the ante
rior septal angle, excessive scar tissue formation, and inadequate u p p o ~ t of the tip,
causing postoperative loss oftip projection. . . .. . .. .
. . ..
An identifiable but not overly exaggerated columellar double break usually marks .
the junction of the medial and intermediate crus. . .
Nasal-tip projection may be consistently assessed by using the method described .
by Goode. If the length of a line drawn from the tip-defining point perpendicular to
a tangent to the alar-facial junction is greater than 0.55 to 0.60 of the line drawri
from the nasion to tip-defining point , then the nose may appear overprojected.
Thickness and quality of the facial skin-subcutaneous tissue complex must be de
termined, as it plays a critical role in dictating the limitations of what can and can
not be accomplished with nasal surgery. .
Thin skin, strong cartilages, and bifidity: an important anatomic triad. The surgeon .
must recognize the need to approximate the tip-defining points to improve tiptri
angularity. The surgeori must recognize the risk of bossa formation if excessive lat
eral crura is excised (see Appendix G). . . .
Facial analysis can describe vertical facial thirds: trichion-to-glabella, glabella-to
subnasale, and subnasale-to-menton.However.the hairline is variable, and at times
the glabella is not always precisely identifiable. Another method considers the
lower two thirds of the face from the nasion to the menton. The.nasion-to-subriasale
distance is 47% of the total, whereas subnasale to menton is53% (Fig. 6). . .
The astute surgeon will be able to anticipate the contour of the lower lateral carti
lages by studying surface topography of the nasal tip; . .
The basal view provides information about the shape of the lower lateral cartilages.
A trapezoidal nasal base indicates a wide domal angle and indicates the need for a
tip technique that will create a more acute dome angle (dome-binding suture, etc.). .
Cephalic positioning of the lateral crura is indicated by the "parenthesis" deformity
and lack of lateral wall support.
The "narrow nose syndrome" is noted in patients with a projecting nose, short nasal
bones, and long upper lateral cartilages. These patients are at high risk for inferome
dial collapse of the upper lateral cartilages after dorsal-hump excision. These patients
frequently need spreader grafts. The contour of the caudal margin of the medial and .
intermediate crura canfrequently be assessed by close examination of the nasal base.
I'
II ILLUSIONS IN RHINOPLAS.TY . . . .
.A dorsal convexity or hump frequently gives the appearance of narrowness on
frontal view. It also provides the illusion of relative decreased projection. That is,
changing the relationship between the dorsum and tip can improve the appearance.
of projection. .. .
A low dorsum gives the appeaiance of increased nasal width due to less shadow"
ing along the lateral nasal wall.
A saddle deformity of the bony or cartilaginous dorsum will contribute to the ap
. pearance of an overwide dorsum on frontal view, whereas a hump will give the im
pression of a narrow dorsum. Similarly-a low dorsum will create an illusion ofa
relatively wide upper third of the nose or pseudohypertelorism. This appearance
can be significantly altered by augmeriting the nasal dorsum .
A deep nasofrontal angle lends the appearance of a short nose, as does an obtuse
nasolabial angle or an accentuated double break.
I
47%
53%
Figure 6. Relationship of the lower two-thirds of the face.
REFERENCES
I. Tardy ME. Rhinopl asty: the art and the science. Philad elphia: WB Saunders, 1997.
2. Tardy ME, Walter MA, Patt BS. The overprojecting nose: anatomic component analysis and repair. Facial
Plast Surg 1993;9:306- 316.
3. Ridley MB. Aestheti c facial proport ions. In: Papel ID, Nachl as NE, eds . Facial plastic and recons tructive
surgery. Philadelphia: Mosby Year Book, 1992:99-109.
4. Crumley RL, Lanser M. Quantitative analysis of nasal tip project ion. Laryngoscope 1998;98:202-208.
5. Byrd HS, Hobar Pc. Rhinoplasty: a practical guide for surgical planning. Plast Reconstr Surg 1993;91:
642-656.
6. Tardy ME, Brown R. Surgical anatomy ofthe nose. New York: Raven Press, 1990.
7. Johnson CM, Toriurni DM. Open structure rhinoplasty. Philadelphi a: Saunders, 1990.
8. Tardy ME, Pan BS, Walter MA. Alar reduction and sculpture: anatomic concepts. Facial Plast Surg 1993;9:
295-305.
9. Becker DG, Weinberger MS, Greene BA, Tardy ME. Clini cal study of alar anatomy and surgery of the alar
base. Arch Otolaryngol Head Neck Surg 1997;123:789- 795.
10. Tardy ME, Becker DG, Weinberger MS. Illusions in rhinoplasty. Facial Plast Surg 1995; 11:117-138.
I I. Gunter JP, Rohrich RJ, Friedman RM. Classification and correct ion of alar-columellar discrepan cies in
rhinoplasty. Plast Recon str Surg 1996;97:643- 648.
3
Injection
INFILTRATIVE ANESTHESIA TECHNIQUE
Proper local anesthesia is critical to allow atraumatic dissection with minimal bleed
ing and edema. A total volume of less than 3 ml of 1% lidocaine with 1:100,000
epinephrine is typically used to attain anesthesia for rhinoplasty alone. When performing
septorhinoplasty, as much as 10 ml of local anesthetic may be used. The anesthetic is al
lowed to take effect for at least 15 minutes to maximize the vasoconstrictive effect of the
epinephrine.
To become familiar with a method of injection of local anesthetic agent, saline can be in
jected with a 5-ml syringe and 27 gauge (1.5 ern) needle along the site of injection in your
cadaver specimen. Injection varies in some respects, based on the surgical approach se
lected; for example, the subdermal columellar injection may be omitted in an endonasal ap
proach. A generalized approach to injection is described below. For a septoplasty, multiple
0.5-ml to 1.0 rnl injections are made in the subperichondrial and subperiosteal plane along
the entire area of anticipated dissection. Injections also should be placed along the site of the
proposed incision (Killian, hemitransfixion, etc.). Both sides of the septum should be in
jected if the surgeon plans to elevate mucosa bilaterally. The injection will aid in the dis
section if placed in the subperichondrial plane . It is helpful to place an injection on the pos
terosuperior septum bilaterally to minimize bleeding from the sphenopalatine blood vessels.
Inject local anesthetic into the subdermal plane in the midline of the columella from tip
defining points to the nasal spine in preparation for the external approach (Fig. I). This in
jection is limited to < 0.3 ml to prevent distortion of the columella or nasal base. For either
endonasal or external approach, inject < 0.3 ml of local anesthesia into the soft-tissue be
tween and around the domes of the lower lateral cartilages (Fig. 2). The injection extends
up to the region of the anterior septal angle. After completing this injection, gently massage
the domal region between the thumb and index finger of both hands to disperse the anes
thetic throughout the tip region. Place multiple injections of 0.1 ml of local anesthetic along
the caudal margin of the lateral and intermediate crura (along the planned marginal inci
sion; Fig. 3). Overinjection will result in distortion of the nostril rim and soft-tissue trian
gle. Inject <0.1 ml to raise a small bleb in the vestibular skin along the lateral aspect of the
25
\
Figure 1. Inject < 0.3 ml of local anesthetic into the
subdermal plane in the midline of the columella from
tip-defining points to the nasal spine in preparation
for the external approach. This injection of the col
umella is necessary for the external approach but
may not be necessary for most endonasal ap
proaches.
Figure 2. Inject < 0.3 ml of local anesthetic into the soft tissue be
tween the dome s of the lower lateral cartilages . Injection of the
supratip is illustrated here as a percutaneous injection but also may be
performed endonasally.
~ \ )
'1 I
Figure 3. Place multiple injections of 0.1 ml of local anesthetic along the caudal margin of the lateral
and intermediate crura (along the planned marginal incision).
Injection 27
Figure 4. Inject < 0.3 ml along the planned incision site for the columellar flap of the exter
nal rhinoplasty approach.
medial crura, at the planned incision site for the columellar flap of the external rhinoplasty
approach (Fig. 4).
For an intercartil aginous, transcartilaginous, or delivery approach, place similar injec
tions of 0.1 ml intranasally along the respective incision sites (Fig. 5).
After inserting the needle between the upper and lower lateral cartilages (intercartilagi
nous), inject local anesthetic along the lateral wall of the nose approximately 1 ern off the
midline (Fig. 6). The line of injection is along the lateral aspect of the nose and extends
from the nasofrontal suture line to the cephalic margin of the lateral crura. Use <0.5 ml for
this injection to prevent distortion of the tissues. Perform no injections along the dorsum of
the nose to prevent distortion of the soft tissue that may inhibit accurate evaluation of the
contour of the dorsum. In preparation for lateral osteotomies, inject on the outside and in
side of the nasal bones just above the periosteum. After completing these injections, mas
sage the injection sites to help disperse the local anesthetic and prevent tissue distortion.
PEARLS
Subperichondrial and subperiosteal injections of local anesthetic will make dis
section of the septal flap easier by hydrodissecting the flap. This is particularly
. ~ ~ ~ ~ ~
- ::; 1 ' 1 ; 1
:i'll'
- ~ ~ ~
-1'
Figure 5. For an intercartilaginous , transcartllaqlnous, or delivery approach, place injec
tions of 0.1 ml intranasally along the incision site.
PEARLS, continued '
helpful when dissecting over fractures in the cartilage, bone, or along the maxillary
crest.
Injection of the osteotomy sites s hould be performed on the i nside and outside of
the ascending process of the maxilla. .
Avoid excessive injection of local anesthetic into the columell a; otherwise the
lation between the ala and columella may be altered.
In cases in which dorsal hump excision must extend into the region of the nile
sofrontal angle, additional injections of local can be placed along the
path of the supratrochlear artery and just medial to the medial canthus.
If the surgeon plans to use lateral crural strut .grafts, injections of local anesthetic
can be placed in the vestibular skin on the undersurface of the lateral crura where
the vestibular skin will be dissected. '

"':'TI:
i

::;It Ill
Injection 29
_..
- --=
A
Figure 6. A. Injection of local anesthetic along the lateral wall of the nose. B. Injection for
lateral osteotomies.
REFERENCES
1. Beeson WH. The nasal septum. Otolaryn gol Clin North Am 1987;20:743-767.
2. Kasperbauer JL, Facer GW, Kern EB. Reconstruct ive surger y of the nasal septum. In: Papal!D, Nachlas NE,
eds. Facial plast ic and reconstructive slIrgely. Philadelphia: Mosby Year Book, 1992:337- 343.
4
Septoplasty
NASAL DISSECTION: SEPTOPLASTY WITH CARTILAGE HARVEST
Hemitransfixion Incision with Anterior Septal Tunnels
1. Retract the columella with a small nasal speculum, multi toothed Brown-Adson forceps,
large two-prong hook, or another suitable instrument. Thi s maneuver exposes the cau
dal margin of the septum ( 1,2).
2. Make a hemitran sfixion incision along the caudal borde r of the cartilaginous septum
with a no. 15 blade or no. 15-C blade. In this exercise, a hemitransfixion incision ex
tending from the anteri or septal angle to the posterior septal angl e is used to gain access
to the caudal septum. A Killian incision can be used if access to the caudal septum is not
necessary (Fig. IA).
3. In rare cases, the nasal spine should be exposed .
4. With a no. 15 blade, small , sharp-pointed scissors, or other suitabl e instrument, incise
the perichondrium of the septum adj acent to the caudal septum on one side.
5. Perform a subperichondrial dissection along the lower half of the septum to allow har
vesting of septal cartilage. Do not extend this dissection too high, so that later in the dis
section a precise pocket tunnel can be made to place a spreader graft via an endon asal
approach.
6. Repeat maneuver 5 on the opposite side of the septum.
7. If the septum needs any shortening, now may be a good time to perform selective exci
sion of the caudal aspect of the septum (Fig. IB-D). If rotat ion of the nasal tip is neces
sary, a superiorly based triangle of caudal septum can be excised (Appendi x F). For an
obtuse nasolabial angle, the posterior septal angle can be trimmed . For a tension nose
deformity (3) or hanging-columell a deformity, the entire caudal septum may need to be
trimmed. Instead of resection, an overly long midlin e caudal septum can be sutured be
tween the medi al crura to provide support, increase projection, and set tip-rotation and
alar-columellar relation.
.;f,.,..
'" --;T,
. . ,I
;
.
. -
31
B
"
"
C
o
Figure 1. A: A hemitransfixion incision (short dotted lines) or a Killian incision (longer dotted lines) may
be used to perform septoplasty. B: Conservative excision in an overlong septum of a thin wedge of cau
dal septum to decrease columellar show or shorten the nose. C: Excision of a wedge of caudal septum
with the base of the excised wedge anterior, for increased rotation. D: Excision of excessive septum at
the posterior septal angle to decrease fullness of the nasolabial angle.
Septoplasty 33
Figure 2. A generous L-strut of :2: 15 mm must be preserved to maintain adequate nasal
support. If a dorsal-hump excision is planned, this must also be accounted for in preserva
tion of an adequate L-strut.
Septal Surgery with Harvesting of Cartilage
Carry out a routine septoplasty or submucous-resection operation. To harvest septal car
tilage, disarticulate the cartilaginous septum from its bony attachment (osseocartilaginous
junction), leaving an ample attachment superiorly (dorsally) at the "Keystone" area . Incise
the cartilage dor sall y and caudally, preserving 2 15 mm anteriorly to support the nasal tip,
and being sure that 215 mm will remain dorsaJly after hump removal (Fig. 2). Preserve this
harvested septal cartilage for use as struts or grafts later on in this exercise. If inadequate
septal cartilage is available, plan to harvest auricular cartilage for grafting purposes.
Note: We have described septoplasty via a hernitransfixion or a Killian' s incisi on. A vi
able alternative is to approach the caudal septum directly by performing an extern al rhino
plasty approach and separating the medial crura, thereby coming upon the caudal septum
(Fig . 3). Septoplasty may then proceed as described earlier. Although this approa ch avoids
the need for a septal mucosal incision, it is a more complex approach and carries with it a
higher risk of loss of tip support if appropriate supportive maneuvers (e.g., columellar strut ,
caudal extension graft) are not undertaken. This approach is ideal in patients who have an
overly long midline caudal septum (tension nose deformity). In these cases, the medial
crura can be dropped back and sutured to the midline caudal septum. Thi s maneuver will
allow shortening of the nose, deprojection of the nasal tip, or correction of the hanging col
umella deformity.
PEARLS
Special care must be taken .to be sure the dissection is in the subperichondrial
plane. If there is any blood-tinged tissue over the surface of the cartilage, there .
may be a layer of perichondrium left on the cartilage.
To correct aspur along the floor, a subperiosteal tunnel can be dissected along the
floor and connected to the dissection above the junction of the septum and maxil
"lary crest. This method of dissection will minimize the chance of tearing the mu
cosal flap along the maxillary crest. . ' . .
If-the surgeon plans to apply spreader grafts into precise submucosal tunnels, a
bridge ofmucosa should be left on the dorsal septum. This will allow the surgeon
to create tunnels under the junction of the upper lateral cartilages and septum to
accept the grafts.
If the surgeon plans to approach the caudal margin of the septurri to correct defor
A
B
"
c D
"
E F
Figure 3. To perform septorhinoplasty, a viable approach to the septum is to perform an external rhino
plasty approach and separate the medial crura, thereby coming upon the caudal septum, and then pro
ceeding with elevation of mucoperichondrial and mucoperiosteal flaps in standard fashion. Before dis
section, local anesthetic should be injected between the medial crura and into the vestibular skin caudal
to the caudal septum. While an assistant holds the lower lateral cart ilages laterally (A) , the surgeon dis
sects between the medial crura (B) until the caudal septum is identified (e). Special care must be taken
to remain in the proper plane between the crura. The mucoperichondrial flaps are next further developed
with an elevator (D). The dorsal septum can be divided from the upper lateral cartilages in an anterior
to-posterior direction (E) after both mucoperichondrial flaps have been elevated to the junction of the up
per lateral cartilage and septum (extramucosal dissect ion). This will allow preservation of continuity of
the intranasal mucosa while dividing the upper lateral cartilages from the dorsal septum. Bilateral mu
coperichondrial flaps are developed for wide access to the septum (F). Appropr iate support ive maneu
vers (e.g., columellar strut, caudal extension graft) are undertaken because of the risk of loss of tip sup
port. With an overly long caudal septum, the medial crura can be sutured back on a midline caudal
septum to provide support and set tip position.
- - "
~ I
. "ill
Septoplasty 35
0- _
PEARLS, continued
, mity or to shorten the septum, the septum can be approached through the external
. rhinoplasty approach . .
0 ' After dissecting between the medial crura to approach the septum, the medial can
be dropped back ~ n d sutured to an overly long midline caudalseptum. This ma
neuver will create a more rigid nasal tip without normal tip recoil.
o If significant bleeding is noted, the surgeon can reinject the mucosal flaps and place
neurosurgical pledgers bilaterally to compress the mucosal flaps.
. .
REFERENCES
I . Tardy ME. Rhinoplasty: the art and the science. Philadelphia: WB Saunders, 1997.
2. Beeson WHo The nasal septum, Otolaryngol Clin North Am 1987;20:743-767.
3. Johnson Clvl Jr, Godin MS. The tension nose: open struc ture rhinoplasty approach. Plast Reconstr Surg 1995;
95:43- 51.
5
Incisions and Approaches
Incisions are methods of gaining access to the bony and cartil aginous structures of the nose
and include transcartilaginous, intercartilaginous, marginal, and transcolumellar incisions.
Approaches provide surgical exposure of the nasal structures including the nasal tip and in
clude cartilage-splitting (transcartilaginous incision), retrograde (intercartilaginous inci
sion with retrograde dissection), delivery approach (intercartilaginous, marginal incisions),
and external (transcolumellar and marginal incisions). Based on an analysi s of the individ
ual patient's anatomy, appropriate incisions, approaches, and tip-sculpturing techniques are
selected (I) (Appendix E).
, In this section , a transcartilaginous incision is performed on one side. Then an intercar
tilaginous and marginal incision is made on the other side to deliver that cartilage. Next,
proceed with the external rhinopl asty approach. Following these instructions will allow an
experience with several incisions and approaches in a single specimen.
TRANSCARTILAGINOUS INCISION OR CARTILAGE-SPLITTING
APPROACH
As demonstrated in the accompanying figures, use a two-prong retractor and the middle
finger of the nondominant hand to expose the lower lateral cartilage (LLC).
Locate the caudal and cephali c margins of the lateral crura. (The surgeon must identify
the cephalically positioned lateral crus when it is present before executing this incision.)
Make an incision through vestibular skin only 5 mm to 8 mm cephalic to the caudal mar
gin of the lateral crus of the LLC incision . Figur e I illustrates the site of a transcartilagi
nous incision and the more cephalic location of an intercartilaginous incision. With scis
sors, dissect free the vestibular skin in a cephalic direction to just beyond the cephalic edge
of the lateral crus (Fig. 2). Then incise the lateral crural cartilage and free the cephalic por
tion (to be removed) from its remaining soft-tissue attachments by dissecting superficial to
it in the supraperichondrial plane . Use a skin hook to retract the caudal vestibular skin and
another skin hook to retract the nostril margin. An assistant may hold the skin hook that re
tracts the nostril margin, while the surgeon grasps the cartilage to be removed and com
pletes the excision by dividing any last soft-tissue attachments with scissors (Fig. 3) (1,2).
37
Figure 1. Retraction with a wide two-prong retractor and the middle finger of the nondomi
nant hand exposes the transcartilaginous incision site and also the more cephalically lo
cated intercartilaginous incision site.
Figure 2. In a cartilage-splitting approach, dissect the vestibular skin in a cephalic direction
to just beyond the cephalic edge of the lateral crus. Then assess how much lateral crus
should be removed, and incise the lateral crural cartilage . Be sure to leave mm to 9 mm
of intact strip.

[III

.

39 Incisions and Approaches
A B
c
Figure 3. A: Use a skin hook to re
tract the caudal vest ibular skin and
the nostril margin. Free the cephalic
portion (to be removed) from its re
maining soft-tissue attachments by
dissecting superficial to it in the
supraperichondrial plane. Grasp the
cartilage to be removed, and com
plete the excision by dividing any
last soft-tissue attachments with
scissors . B: The carti lage incision
must come far enough medially to in
clude the cephalic lateral crus at the
dome region, or else supratip full
ness may persist. However, it is im
portant not to incise too far infero
medially, or the cartilage (which is
typically narrow at this region) may
be excessively weakened or divided.
C: A 3D-gauge needle placed percu
taneously at the dome can help
guide the medial aspect of the tran
scartilaginous incision in selected
cases.
DELIVERY APPROACH (PERFORM ON SIDE OPPOSITE CARTILAGE
SPLITTING APPROACH)
Intercartilaginous Incision
By using a two-prong retractor , evert the caudal margin of the nostril and, by applying
pressure with the middle finger of the nondominant hand, reveal the gap between the cau
dal margin of the upper lateral and the cephalic margin of the lower lateral cartilages. With
a scalpel, make an intercart ilaginous incision in this location (Fig. 4) (1,2).
A,S
f
o
E
Figure 4. A-C: Intercartilaginous incision. D: For an intercartilaginous approach, bilateral
intercartilaginous incisions are connected in the midline over the anterior septal angle, and
the incision extends anterior to the caudal septum as a high partial-transfixion incision. Ex
posure of the middle and upper nasal vault proceed as described in the text. E: After com
pletion of the intercartilaginous approach, a Converse retractor (or other appropriate retrac
tor) may be inserted through the incisions, beneath the skin/soft-tissue envelope, to provide
exposure of the upper two thirds of the nose.
41 Incisions andApproaches
Marginal Incision
By using a two-prong retractor, evert the caudal margin of the nostril in which an inter
cartilaginous incision was made and, by applying pressure with the middle finger of the
nondominant hand, define the caudal margin of the lower lateral cartilage. Pressing cepha
lad on the nasal dome will cause the caudal margin to appear laterally. Remember that the
non-hair-bearing area is a guide to the caudal margin of the lateral crus. Furthermore, pal
pation of the cartilage edge with the handle of the scalpel can be helpful before cutting. By
using the two-prong retractor to obtain proper exposure, make the marginal incision just
caudal to the caudal edge of the lower lateral cartilage (Fig. 5). Great care must be taken as
the lateral incision nears the midline. Make sure that the incision follows the cartilage edge
and does not take a "short-cut" along the alar rim, which can damage the facet area. Great
care must be taken not to cut across a narrow dome or intermediate crus (1,2).
Delivery of lower lateral cartilages
At this stage, an intercartilaginous incision and marginal incision on one side and a
transcartilaginous incision on the other side have been made. Reinsert the two-prong re
tractor into the nostril with the intercartilaginous and marginal incisions and present the
caudal margin of the lower lateral cartilage with the aid of pressure from the third finger of
the nondominant hand.
Use a slightly curved, fine-pointed dissecting scissors to lift and dissect the soft tissues
from the surface of the lower lateral cartilage (Fig. 6). Perform this dissection by inserting
scissors into the marginal incision laterally and then separate the perichondrium of the
lower lateral from the overlying external skin and soft tissue with a spreading motion. If
this is difficult, caudal traction on the vestibular skin underlying the lower lateral cartilage,
with a fine two-prong hook, will facilitate this maneuver (Fig. 7) by pulling the lateral crus
into the vestibule and thus opening up the potential dissecting plane. Avoid damaging the
overlying muscle and nasal vasculature (1,2).
A B
Figure 5. Marginal incision. The nondominant hand is critical to obtain proper exposure.
Figure 6. Dissect the soft tissues from the superficial surface of the lower lateral cartilage.
Do not work too far laterally. The latera l one fourth of the lower lateral cartilage should
be avoided by the surgeon in near ly all cases.
Place the hook end of a Nievert retractor through the inter carti laginous incision and draw
the now-free later al cr us down , like a visor. until it appears outside of the vestibule. It can
be held in this position by the Nievert or by another suitable instrument (Fig. 8).
Examine the lower lateral cartil ages for unique anatomic feat ures and asymmetries.
Figure 7. Caudal traction on the vestibular skin underlying the lower lateral cartilage with a
fine two-prong hook pulls the lateral crus into the vestibule and opens the potential dissect
ing plane.
Figure 8. Delivery of lateral crus of lower lateral cartilage.
THE EXTERNAL (OPEN) RHINOPLASTY APPROACH
Background
The external rhinoplasty approach to the nose provides maximal exposure of the lower
lateral cartilages, upper lateral cartilages (Ul.Cs) , middl e nasal vault, and bony nasal vault.
These supportive structures can be manipulated in a precise and symmetric fashion . The in
creased exposure facilitates accurate suture placement and fixation of cartilage grafts. The
external rhinoplasty approach also facilitates diagnostic capability and is a tremendous aid
in teaching rhinoplasty (3-10) (Appendix K).
The incisions used in this approach include a transcolumellar incision connected to bi
lateral marginal incisions. The actu al configuration of the transcolumellar inci sion is not as
critical as the placement of the inci sion . The incision should be made at the level of the mid
columella where the caudal margins of the medial crura lie close to the skin and can sup
port the incision to help prevent a depressed scar. An inverted-V incision, or some other
broken-line incision, is used to break up the scar and lengthen it to minimize scar contrac
ture. The surgical dissection must be performed in the proper areolar tissue planes to min
imize tissue damage and scarring, maintain hemostasis, and maximize redraping of the
skin/soft-tissue envelope. Dissection in proper tissue planes will help preserve vascular
structures of the flap , ensure flap viability, and minimize bleeding, postoperative edema,
and scarring ( I I) .
NASAL DISSECTION: EXTERNAL (OPEN) RHINOPLASTY APPROACH
Marking the Transcolumellar Incision
Begin the dissection by outlining the transcolumellar incision used in the external rhino
plasty approach with a marking pen . Mark an inverted-V transcolumellar inci sion at the
level of the midcolumella (Fig. 9). The midcolumellar incision should be marked midway
between the top of the nostril and the base of the columella, where the caudal margin of the
medial crura lie just beneath the skin, to provide support for the incision. The midcolumel
lar incision will be connected to bilat eral marginal inci sions, which are placed just caudal
to the caudal margin of the lateral crura (Fig. 10). The marginal incision should not be made
along the rim of the nostril (rim inci sion). The marginal incision may be marked with a
marking pen as well.
A B
c
Figure 9. A-C: Inverted-V incision on the midcolumella,
at a level where the margin of the medial crura lies just
beneath the skin.
A
B
Figure 10. A, B: Marginal incisions are placed just caudal to the caudal margin of the in
termediate and lateral crura .
I I I
I I
Midcolumellar Incision
By using a no. 11 blade with a "sawing" motion, follow the midcolurnellar markin gs to
compl ete the midcolumellar incision (Fig. 11). Proceed medial to lateral on one side of the
columella and then the other. Take special care to keep the blade perpendicular to the skin
edges, thereby preventing beveling of the skin edges. (Beveling of the skin edges may lead
to a "trapdoor" deformity with eventual unacceptable scar). While incising laterally, be
careful to stay superficial to avoid damage to the caudal margin of the medial crura . Use a
no. 15 blade to make the columellar extension of the marginal incision on both sides of the
columella, 1 to 2 mm behind the leading edge of the columell a (Fig. 12). This incision is
made along the caudal margin of the medi al and intermedi ate crura. By minimi zing the dis
section over the medial crus, damage to this cartilage can be avoided.
Figure 11. A-C: Midcolumellar ' incision
made by using a no. 11 blade with a sawing
motion. Keep the blade perpendicular to the
skin edges, and stay superficial to avoid dam
age to the caudal margin of the medial crura.
A
B
c
A B

I
E
C
F
Figure 12. A: Columellar extension of marginal incision. 8-0: Columellar extension of
marginal incision in a patient. E, F: Marginal incision.
Marginal Incision
Beginning laterall y, make a light incision throug h vestibu lar ski n 1 to 2 mm caudal to the
caudal margin of the lateral crura. Follow the caudal margin of the lateral crura as the inci
sion is extended medi ally. (The dissector has already made the marginal incision on one
side; here simpl y make a marginal incision on the other side .)
Define the Columellar Flap
By using angled Converse scissors, or another suitabl e dissecti ng scissors, elevate the thin
vestibular skin of the flap that covers the medial crura. Insert the scissors beneath the col
umellar extension of the marginal incision and dissect medially in the correct plane of dis
section, below the musculoaponeurotic layer (Fig. 13). The scissors should then pass super
ficial to the caudal margin of the ipsi lateral and then contralateral medial crus (Fig. 14). Guide
the scissors through the oppos ing columellar extension of the marginal incision (Fig. 15).
During this dissection, take special care to avoid damaging the flap or the caudal margin of
the medial crura. Use the scissors to spread the tissues in the plane of dissection (Fig. 16). If
not positioned properly, the dissector may cut through the cauda l margin of the medial crura.
To avoid this, the dissector must remain caudal to the medial crura and dissects very carefully.
Flap Elevation
Use the Converse scissors to compl ete the midcolumellar incis ion without beveling the
inci sion or damaging the medi al crura (Fig. 17). Take specia l care to avoi d beveling this in
cision. Use a narrow double-prong hook to retract the flap. The paired columellar arteries
may be seen, and typic ally must be cauteri zed with bipolar cautery.
Figure 13. To elevate the thin vestibular skin of the flap that covers the medial crura, insert
the scissors beneath the columellar extension of the marginal incision and dissect medially
in the correct plane of dissection, below the musculoaponeurotic layer. If one meets resis
tance, they can alternate dissection to the contralateral side of the columell a.
- -
Figure 14. The scissors pass superficial to the caudal margin of the ipsilateral and then
contralateral medial crus.
Figure 15. Guide the scissors through the opposing columellar extension of the marginal
incision.
- T ~

'"
,!I'
n
A
Figure 16. A, B: Spread the tissues in the plane of
dissection.
B
Figure 17. A, B: Complete the midcolumellar inci
sion. Do not bevel the skin edges, or an unaccept
A
able scar (due to a trapdoor deformity) may result.
B
Three-Point Countertraction
To elevate the ski n/soft-tissue envelope over the nasal tip, (a) place a wide doubl e-prong
hook along the margin of the nostril rim caudal to the lateral crus, (b) place a small double
prong hook on the columellar flap, and (c) place a small double-prong hook on the vestibu
lar skin side of the intermediate crus (Fig. 18). Then use Converse scissors to dissect the
columellar flap from the caudal margin of the medial and intermed iate crus, as the coun
tertraction acts to expose the areolar tissue plane. The scissors are used to expose the cau
dal aspect of the lateral crus as well. Then the dissection advances cephalica lly over the sur
face of the lateral crus. As the dissection continues along the surface of the lateral crus, soft
tissue is elevated, leaving only perichondrium on the carti lage . As dissection proceeds lat
erally along the lateral crus, cut the vestibular skin along the caudal mar gin of the lateral
crus, thereby completing the marginal incision. Make small, calibrated cuts under direct vi
sion to avoid inadvertently cutting through the lateral crus . Limit dissection of the lateral
crus to the areolar tissue plane deep to the muscle. A cotton-tip applicator can be used to
comp lete the dissection of the lateral crus once the deep aerolar tissue plane has been iden
tified. A portio n of the dissection on the opposite side was performed with the cartilage de
livery approac h; nevertheless, repeat these maneuvers on the oppos ite side to complete el
evation of the ski n/soft-tissue envelope over the nasal tip.
[An alternative approach to this dissectio n is to begin dissection through the marginal in
cisions (retrograde dissection) (12).] In this approach, identify the proper tissue plane , and
elevate the skin/soft-tissue envelope off the lateral crus . Then proceed medially with scis
sor dissection toward the domes and intermedia te crura. This maneuver is performed bilat
erally to achieve elevation of the skin/soft-tissue envelope.
This retrograde dissection is helpful if the surgeon is having difficult y followi ng the cau
dal margin of the intermediate and lateral crus. This is not unusual in cases in which there
is buckling of the intermediate crus or domes. Retrograde dissection generally is not the ap
proac h of choice for seco ndary rhinopl asty, as the lateral crura may have been exci sed or
previously dissecte d.]

[Examine the lateral crura on the side of a transcartilaginous incision and cephalic trim.
Eval uate the excision of cephalic cartil age. Was it stopped too short, leaving cephalic lat
eral crus at the dome region? Did the incision go too far; was the dome inadvertently di
vided? Was too much cartilage taken? Measure the amount of lateral crus remaining; there
should be at least 7 mm to 9 mm.]
A B
Figure 18.
C
D
E F
G
Figure 18. A, B: With three-point countertraction exposing the areolar tissue plane, use
Converse scissors to dissect soft tissue from the caudal margin of the intermediate and lat
eral crus. Dissection of the skin/ soft-tissue envelope proceeds in the deep areolar plane be
low the muscle, leaving only perichondrium on the cartilage. C: As dissection proceeds lat
erally , follow the caudal edge of the lateral crus and cut the marginal incision . Make only a
very small cut at a time, and take great care to avoid cutting the cartilage. D: As dissection
continues laterally, the marg inal incision is extended laterally as described above . E: When
dissecting the proper tissue plane , a cotton -tip applicator can be used to sweep soft tissue
off of the lateral crus. F: Completed exposure of the left lateral crus via the external ap
proach . G: Dissection has been completed of both the left and right lateral crus, and atten
tion will now be directed toward the midline.
Midline Dorsal Dissection
Di vide fibrous connections in the midline near the surface of the domes to release the
flap and allow dissection cranially (Fig. 19). Do not dissect tissue from between the domes;
otherwise a midline band of tissue may be left on the flap. Shift the dissection to the mid
line, where the anterior septal angle is identifi ed with a spreading action of the Converse
scissors or other suitable dissecting scissors. Once the blue hue of the cartilaginous middl e
third of the nose has been identified, create a midline tunnel over the cartilaginous middl e
vault. Then use a cott on-t ip appli cator to dissect bluntl y the soft-ti ssue envelope cranially
and laterall y (Fig. 20). This maneuver will frequentl y expose sizable blood vessels that can
be spared, as they are dissected laterally. Depending on the degree of exposure that is
needed, some fibrou s connections may need to be cut near their attachment to the carti
laginous nasal vault (Fig. 21). Muscle and vessels can be spared by dividing tissues close
to the surface of the cartil ages.
A B
c o
' I I I I ~
, ~ "
"
53 Incisions andApproaches
E F
Figure 19. A-C: Shift the dissection to the midline, and divide fibrous connections in the
midline near the surface of the domes to release the flap and allow dissection cranially. Do
not dissect tissue from between the domes ; otherwise, a midline band of tissue will be left
on the flap . With a spreading action of the Converse scissors or other suitable dissecting
scissors (D, E), identify the blue hue of the cartilaginous middle third of the nose, and cre
ate a midl ine tunnel over the cartilaginous middle vault (F).
A B
Figure 20. A: If dissection proceeds in the proper tissue plane, a cotton-tip applicator can
assist in the exposure. B: Divide the decussat ing fibers (apply bipolar cautery first ) to con
nect the dissected spaces over the middle vault and lateral crura .
____ _ ______0 _
A B
Figure 21. A, B: Exposure of the middle nasal vault.
Exposure of Cartilaginous and Bony Dorsum
Exposure ofthe Cartilaginous Vault
The cartil aginou s vault , typically corresponding to the middle third of the nose, can be
exposed as described earlier. Alternatively, as with a cartilage-splitting, retrograde, or de
livery approach, the skin/soft-tissue envelope can be exposed either by using sharp scalpel
dissection or by scissor dissection in the supraperichondrial plane .
Use a scalpel (no. 15 blade) or long , slightly cur ved dissecting scissors to elevate the soft
tissues in the midline, working up toward and just beyond the rhinion, inserting and open
ing, but not cutting, with the blades under the skin.
Lay bare the perichondrium of the ULC in the midline but do not extend too far laterally
at this stage. Take special care not to follow the ULC below the caudal margin of the nasal
bones . Such a maneuver may result in disarticulation of the ULCs from the nasal bones.
Elevation of Periosteum/Exposure of Bony Vault
Under direct vision by using an Aufricht or Converse retractor, use a Joseph periosteal
elevator or other appropriate instrument to cut through the periosteum 2 mm cephalad and
parallel to the caudal margin of the nasal bones (Fig. 22) .
Alternatively, palpate the junction between the nasal bone and ULCs with the Joseph el
evator beneath the skin/soft-tissue envelope by gently allowing the Joseph to "fall" off the
nasal bone onto the ULCs as it is withdrawn. The Joseph elevator can then be seated 2 mm
above this junction with certainty, and the periosteum incised. Elevate the periosteum off
the bony nasal vault up to the nasion. Then elevate in the subperiosteal plane over the bony
dorsum toward the midline and laterally (Fig. 23). Execute these maneuvers bilaterally
(Fig. 24) . Do not extensively undermine over the side walls of the bony nasal pyramid at
,
.
Figure 22. Subperiosteal dissection over bony nasal vault up to the nasion.
Figure 23. Cross section at level of nasal bones, illustrating dissection in subperiosteal
plane. Lateral and medial motion of the elevator achieves this elevation in the subperiosteal
plane.
Figure 24. After bilateral elevation , the midline decussating fibers remain undivided. These
generally are severed with scissors .
this stage. Next , sever the midline internasal suture attachments; this can be accomplished
with scissors or sharp elevator. Make sure that the nasal skeleton is completely freed from
the overlying skin. Pass an elevator or similar instrument from side to side over the bony
cartilaginous dorsum . This completes the execution of the external rhinoplasty approach.
[The dissector now has exposure via the external rhinoplasty approach. When achieving
exposure via an endonasal approach, the intercartilaginous or transcartilaginous incisions
are typically connected caudally in the midline and continue over the caudal septum as a
high partial-transfixion incision, as described previou sly (see Fig. 4D and E). Direct visu
alization of the nasal dorsum is thus achieved with the aid of an Aufricht or Converse re
tractor inserted through the intercartilaginous or transcartilaginous incision.
[Note: If the dissector wishes to place spreader graft s via a precise pocket endona sal ap
proach, it should be undertaken now. The technical steps are described in Chapter 8. Later ,
after hump removal (Chapter 6) and osteotomies (Chapter 7), the dissector will place
spreader grafts via the external rhinoplasty approach.
PEARLS
If the surgeon plans to place a dorsal graft or radix graft, a precise pocket can be
made over the upper dorsum and/or radix. This will allow the surgeon to place the
graft into a precise pocket and minimize the chance of graft migration.
If the surgeon plans to place an alar batten graft, the lateral extent of the dissection
should be minimized. .
During the extermil rhinoplasty approach, elevation of the skin/soft-tissue enve
lope from the underlying supportive structures of the nose results in disruption of
the minor tip-support mechanism provided by the attachment of the skin/soft-tis
sue envelope to the lower lateral cartilages. To help offset this loss oftip support,
a columellar strut cartilage graft can be 'sutured in a pocket between the medial
crura . Such a strut is used to support the medial crura to preserve tip projection and
not necessarily to increase tip projection (Appendix F).
The columellar extension of the marginal incision should beplaced only 1 to 2 mm .
behind the face of the columella to minimize dissection of vestibular skin and to
avoid damage to the caudal margin of the medial crura,
When advancing the converse scissors across the .columella to the opposite
marginal incision, special care should be taken to remain caudal to the medial
crura .
Dissect in the tissue plane just above the perichondrium. Avoid violating the mus
cle layer. .
DUling dissection; follow the caudal margin ofthe lower lateralcartilages. Ifthe
caudal margin is lost sight of, move laterally to pick up the lateral crus, and dissect '
retrograde to avoid cutting across a buckled intermediate crus or deformed dome.
Precise closure of the midcolurnellar incision, with meticulous alignment of the
skin edges, is critical to prevent an unsightly scar. Principles ofskin-edge eversion
and tension-free closure will also help prevent a visible scar. Vertical mattress-
suture closure aids in skin-edge eversion. ' . ' .
REFERENCES
1. Tardy ME, Tor iumi OM. Philosophy and prin ciples of Rhinopl ast y. In: Cummings CW, Fredri cks on JM,
Harker LA, et aJ. Otolaryngology -head & neck surgery. 2nd ed. SI. Louis : Mosby Year Book, 1993:278-294.
2. Tardy ME. Rhinoplasty : the art and the science. Philad elphi a: WB Saunders, 1997.
3. Johnson CM Jr , Toriumi OM. Open structure rhinoplasty. Philad elphia: Saunders, J990 .
4. Adamson PA. Open rhinoplasty. In: Papel 10, Nachl as NE, eds. Facial plast ic & reconstruct ive surgery. SI.
Louis: Mosby Year Book, 1992:295-304.
5. Larrabee WF Jr. Open rhinoplasty and the upper third of the nose. Facial Plast Surg Clin North Am J993 ; I:
23- 38.
6. Toriumi OM, Johnson Clvl. Open structure rhinopl asty featured technical poi nts and long- term follow-up . Fa
cial Pla st Surg Clin North Am 1993;1:1- 22.
7. Tori urni OM. Management of the middle nasa l vault. Oper Tech Plast Reconstr Surg 1995;2: I6-30.
8. Toriumi OM, Ries WR. Innovative surgical management of the crooked nose. Facial Plast Surg Clin North
Am 1993;1:63-78.
9. Toriumi OM, Johnson Clvl. Management of the lower third of the nose: ope n structure rhinopl asty technique.
In: Pape1!D, Nachlas NE, eds. Fac ial plastic & reconstructive surgery. St. Louis: Mosby Year Book, 1992:
305- 313.
10. Gunt er JP. The merit s of the open approach in rhinop lasty. Plast Reconstr Surg 1997;99:863- 867.
11. Tori umi OM, Mueller RA, Grosch T, Bhattacharyya TK, Larrabee WF. Vascular anatomy of the nose and the
externa l rhinoplasty approach. Arch Otol Head Neck Surg 1996; 122:24-34.
12. Thomas JR. Externa l rhinop lasty: intact colume llar appr oach . Laryngo scope J990; 100:206-208.
6
Removal of
Bony-Cartilaginous Hump
In this exercise, the car tilagi nous and bony hump are removed en bloc. Be conservative!
Plan to take a small amount of the hump off at first and thereby avoid incising the mu
coperichondrium, which provide s import ant support. Later, after the bony-cartilaginous
hump has been removed, be prepared to make multiple fine adj ustments of both the septum
and dorsal margins of the upper lateral cartilages. When lowering the dorsal septum, keep
in mind the importance of allowing for the thicker ski n over the lower one third of the nose.
Also, recognize that inadequate resection at the supratip may result in a polly-beak defor
mity. (Appendix G)
[Note: The dissector may wish to incise the skin/soft-tissue envelope down the midline
either now or subsequent to this chapter. The hump excision may be done first, and then
split the skin to exami ne the result and allow easy exposure for subsequent maneuvers. If
the dissector intends to augment the dorsum with a cartilage graft, this may be done first,
and then split the skin for easy exposure during the remaining dissection. The skin in the
midline can be sutured back together as desired at any time.]
Expose the cartilaginous dorsum with a Converse retractor, and use a no. 15 blade to in
cise lightl y any remaining soft tissue overlying the cartilaginous dorsum. Reflect this tis
sue laterally on both sides. Next, beginning at the osseocartilaginous junction and pro
ceeding caudally, incise the cartilaginous dorsum at the planned level of initial excision
(Figs. 1 and 2). Try to keep this incision even on both sides, but remember that there will
be additio nal "fine-tuning" modifi cations after initial hump excision.
Under direct vision, place an osteotome agai nst the bony hump at the osseocartilaginous
junction (Fig. 3). Use the incised but attached cartilaginous dorsum to help seat the os
teotome at this locat ion. With a gentle, controlled two-t ap technique, incise the bony hump
with the osteotome (Fig. 4). Take care not to overresect the bony hump , as the osteotome
will tend to cut deeper into the bone. Remove the hump with a hemostat or simi lar instru
ment , and examine its features (1,2).
When exec uting hump excision, preserve the underlying nasal mucoperichondrium. The
nasal mucoperi chondr ium provides support to the upper lateral cartilages and helps de
crease the risk of inferomedi al collapse of the upper lateral cartilages after hump excision
(Fig. 5). [Inferomedi al collapse of the upper lateral cart ilages and inadequate infracture of
59
, .
Figure 2. At this stage, the cartilage remains attached at the
Figure 1. Beginning at the osseocartilaginous junction and
osseocart ilaginous junction.
proceeding caudally, incise the cartilaginous dorsum at the
planned level of initial excision. This amount of excision is
larger than normally performed. Most patients would require
smaller dorsal hump excisions.
Figure 3. Under direct VISion, insinuate an osteotome
against the bony hump at the osseocartilaginous junct ion.
Use the incised but attached cartilaginous dorsum to help
seat the osteotome at this location.
Figure 4. A,S: With a gentle, controlled, two-tap technique , incise the bony hump with the
osteotome . Careful examination of the excised hump can help guide additional calibrated
excision of remnant cartilage or bone. Assess whether the nasal mucoperichondrium was
successfully avoided. C,D: Patient underwent dorsal hump excision and application of radix
graft. E.F: Conservative dorsal hump excision leaving high profile.
B
c L ~ _
D
F
61
- - - - - - - ~ - - - - - - - - - ~ ~ - --- ------ --
A
Figure 5. Cross-section at the
level of the cartilaginous vault
(A). The nasal mucoperichon
drium provides support to the up
per lateral cartilages and helps
decrease the risk of inferomedial
collapse of the upper lateral car
tilages after hump excision (B,
e). When the nasal mucoperi
chondrium is violated, inferome
dial collapse of the upper lateral
cartilages may occur (D, E).
B
E
the nasal bones can lead to an "inverted V deformity," in which the upper lateral cartilages
collapse inferomedially, and the caudal edges of the nasal bones are visible in broad relief,
creating an unacceptable appearance.] (3,4) (Appendix G)
Now make additional fine-tuning modifications to the cartilaginous dorsum as indi cated.
Examination of the excised hump may guide any additional excision. Trim the anterior
(dorsal) margins of the upper lateral cartilages such that they lie on a level with or ju st be
low that of the trimmed border of the septum. Additional modification of the bony dorsum
also may be required.
An "open roof" may be created by hump removal. The bony margin s should now be
smoothed with a rasp by using few but firm strokes (Fig. 6). Any bony fragments should be
removed, making sure that all obvious particles are removed from under the skin/soft
tissue envelope.
An alternative to the manual rasp is a powered reciprocating rasp or sheathed burr (Figs.
7 and 8) (5). These instruments can be used wherever a manual rasp would be used , but with
less soft-tissue trauma. The site to be treated can be directly visualized. The powered in
struments are especially useful to smooth the bony marg ins of the open roof. They also are
useful to correct isolated bony irregularities that may be encountered, for example, in sec
ondary rhinoplasty. It appears that a more reproducible result can be obtained with a lower
incidence of visible or palpable bony dorsal irregularities. After rasping or burring, bone
particles should be irrigated from the surgical site.
63 Removal oj Bony-Cartilaginous Hump
Figure 6. Smooth the bony margins with a rasp by using few
but firm strokes, cutting only on the downstroke.
Figure 7. The powered reciprocating rasp is an alternat ive to the manual rasp.
Figure 8. The powered sheathed suction bur is an alternative to the manual rasp.
[Note: This is one approach to hump excision. Another approach is described here. In
some cases, the surgeon may wish first to separate the upper lateral cartilages from the dor
sal septum. This is accomplished in the submucoperichondrial plane and can be readily ac
complished through the hemitransfixion incision or external rhinoplasty approach (Fig. 9).
Then rather tban excising the entire cartilaginou s hump, only a strip of dorsal septum is ex
cised. The remainder of the hump excision proceeds as described earlier; tbe upper lateral
cartilages are then shaved down individually so that they are at the same level as the dorsal
septum.] This method is good for excision of large dorsal humps where preservati on of mu
cosal cont inuity may be otherwi se difficult.
PEARLS
Two-tap technique: Overzealous force on the osteotome may lead to loss con- .
trol and undesired under- or overresect ion of the dorsal hump . A controlled exci
sion of the bony dorsum is best with a careful , repeated 'two-tap tech
nique designed to advance the osteotome only a short distance at a time.
The surgeon should be sure that theosteotomesare sharp to allow precise bone .
cuts. . .
.In cases with large dorsal humps, an extramucosal reduction can be performed by
dissecting mucosa off the undersurface of the middle and upper vaults. . .
The beginning surgeon may wish to premark the proposed hump excision on the '
nasal skin. .
If the surgeon feels uncomfortable using an osteotome for dorsal-hump removal ,
a sharp rasp will be effective with less risk of overresection.
The periosteum must be cleared f rom the bone prior to rasping to insure effective
lowering of the bone.
Most dorsal humps are primar ily cartil aginous. Therefore, the dissector should
limit excision ofthe bony vault : .. . '.
-
,'''Ifil
...
1
1
11

,I
65 Removal oj Bony-Cartilaginous Hump
A B
c D
Figure 9. A-E: Division of the upper lateral cartilages from their attachment to the dorsal septum in the
submucoperichondrial plane. Great care should be taken to preserve an intact mucoperichondrium.
E
F
G
Figure 9, continued. F: Division of the upper lateral cartilage from the attachment to the dor
sal septum , with dissection of a submucoperichondrial flap, may be accomplished from
above, as shown here via the external rhinoplasty approach . G: This dissection begins at
the anterior septal angle, and then subperichrondrial dissect ion is performed .Completed di
vision of upper lateral cartilages from septum.
REFERENCES
I. Tardy ME . Rhinoplasty: the art and the science. Philadel phia : WB Saunders, 1997.
2. Larrabee WF Jr. Open rhinoplasty and the upper third of the nose. Facial Plast Surg Clin North Am 1993;1:
23-3 8.
3. Johnson CM Jr , Toriumi DM. Open structure rhinoplasty. Philadelphia : WE Saunders, 1990.
4. Toriurni DM. Management of the middle nasal vault. Oper Tech Plast Reconstr Surg 1995;2:16- 30.
5. Becker DG, Toriumi DM. Gross CW, Tardy ME. Powered instrumentation for dorsal nasal reduction. Facial
Plast Surg 1997 ;13:291-297 .
7
Osteotomies
MEDIAL OSTEOTOMIES
To perform medial osteotomies, insert the osteotome at the junction between the nasal
bone and septum. With the two-tap technique, advance the cutting edge cephalad and fade
laterally as the frontal bone is reached (Fig. 1). Control the sharp leading edge of the chisel,
as it moves under the skin, with the forefinger of the nondominant hand. Thi s fading me
dial osteotomy avoi ds the thick frontal bone. Medial osteotomies are usually not necessary
in cases in which large dorsal humps are excised, leaving an open-roof deformity .
LATERAL OSTEOTOMIES AND INFRACTURE
[Note: The dissector may wish to mark the site of the proposed osteot omy on the skin be
fore proceeding. Perform the lateral osteotomy on one side, and then reflect the skin/soft
tissue envelope laterally to examine it. Is it in proper position? Is the periosteum intact, or
has it been violated? Is the mucoperiosteum intact?
After assessing the first lateral osteotomy, the skin of the opposite side may be reflected
before the osteotomy. This will allow observation of the osteotomy under direct vision.]
The lateral osteotomi es run from the most lateral point of the pyriform aperture to a point
medial to the inner canthus of the eye, taking a high to low to high path. In practice, this
means a starting point 3 mm to 4 mm above the base of the pyriform aperture and adja cent
to the head of the inferior turbinate. The high-to-low lateral osteotomy preser ves a small
triangle of bone at the base of the pyriform aperture (Fig. 2). Use a 2-mm (unguarded) or
3-mm (guarded or unguarded) curved or flat osteotome. Use a guarded or unguarded os
teotome based on preference.
Make a small incision near the base of the pyriform apertur e. Althou gh it is not essen
tial, many surgeons create a short subperiosteal tunnel along the path of the proposed lat
eral osteotomy . Seat the osteotome on the bone 3 mm to 4 mm above the base of the pyri
form aperture, and use a gentle two-tap technique to advance the osteotome gradually.
Angle the osteotome in a posterior and cephalic direction initi ally, and then adjust the os
teotome so that the cutting edge travels toward a point medi al to the inner canthus of the
eye. Thi s creates the typical high-to-low-to-high lateral osteotomy . Control the cutting edge
by palpation with the thumb or fingers of the nondominant hand as the osteotome travels
toward the inner canthus. When the osteotome approaches the level of the inner canthus,
67
Figure 1. Fading medial osteotomies. Place an osteotome
Figure 2. Lateral osteotomies should be started from a point
flat against the septum with the edge facing laterally . Control 3 mm to 4 mm above the base of the pyriform aperture to a
the sharp leading edge of the chisel , as it moves under the
point adjacent to the inner canthus of the eye. Some rhino
skin, with the forefinger of the nondominant hand. Avoid the plasty surgeons find it helpful to mark the proposed line of the
thick frontal bone. osteotomy on the skin before executing this maneuver.
rotate the osteotome clockwise on the patient' s right side and counterclockwise on the left
side. This will normally fracture the nasal bone inward creating a controlled backfracture.
It may be necessary to complete the fracture with thumb pressure.
INTERMEDIATE OSTEOTOMIES
An osteotomy between the medial and lateral osteotomies is occasionally indicated. Spe
cific indicat ions include the abnormally contoured nasal bone that is either excessively con
vex or concave. Intermediate osteotomies are most effective for decreasing the curvature of
an excessively convex nasal bone. The intermediate osteotomy allows recontouring of the
nasal bone for correction of the severely deviated bony vault. This osteotomy is performed
before the lateral osteotomy. A 2-mm transcutaneous osteotomy performed midway up the
nasal bone is typically used to complete the intermediate osteotomy .
PEARLS .
Medial osteotomies are performed to control the backfracture of the nasal bones
after lateral osteotomies. If a large dorsal-hump removal was performed, leaving
an open roof, it may not be necessary to perform medial osteotomies.
High-to-low-to-high lateral osteotomies are performed to leave a small triangle of
bone at the base of the pyriform aperture and. prevent medialization of the inferior
turbinate. "
The dorsal nasal septum at the level of the bony vault must be midline to allow
symmetric medialization of the nasal bones; If there is difficulty medializing the
nasal bones, a blade handle can be used to shift the bony septum to the midline
with the nasal bones: . '
If agreenstick fracture is noted, a transcutaneous 2-mm osteotome can be used to
complete the backfracture and infracttire the nasal bone,
Greenstick fractures are acceptable in older patients .
.
I
__ ~ m
~ III
...1" I
Osteotomies 69
REFERENCES
I. Tardy ME. Rhinoplasty: the art and the science. Philadelphia: WB Saunders, 1997.
2. Larrabee WF Jr. Open rhinoplasty and the upper third of the nose. Facial Plast Surg Clin North Am 1993; 1:
23-28.
3. Johnson CM Jr, Toriumi DM. Open structure rhinoplasty. Philadelphia: WB Saunders, 1990.
4. Murakami CS, Larrabee WF. Comparison of osteotomy techniques in the treatment of nasal fractures. Facial
Plast Surg 1992;8:209-219.
5. Farrior RT. The osteotomy in rhinoplasty. Laryngoscope 1978;88: 1449.
6. Thomas JR, Griner NR, Remmler DJ. Steps for a safer method of osteotomies in rhinoplasty. Laryngoscope
1987;97:746-747.
8
Spreader Grafts
Spreader grafts may be placed endonasally or via the external rhinoplasty approach. If en
donasal placement of spreader grafts is done in this dissection, undertake this before hump
reduction and osteotomies.
Through a small (5-mm) mucosal incision near the anterior septal angle, develop a pre
cise subperichondrial pocket along the length of the cartilaginous dorsum near the junction
of the dorsal septum and upper lateral cartilage (Fig. 1). A Cottle or Freer elevator can be
used to elevate the subperichondrial tunnels. Special care must be taken to get into the sub
perichondrial plane; otherwise, the mucosa may tear. Additionally, avoid pushing the ele
vator through the septum to the other side. Fashion rectangular spreader grafts that extend
from the osseocartilaginous junction to the internal nasal valve where the upper lateral car
tilage meets the dorsal septum. Appropriate thickness can be determined to achieve the de
sired functional effect without causing excessive widening, usually I mm to 3 mm in thick
ness. Experience is required to develop reliable surgical judgment regarding the
appropriate width and length of spreader grafts. Insert the grafts into the precise subperi
chondrial tunnels, taking great care to preserve the mucosa (see Fig. 1).
[Note: After placing endonasal spreader grafts, return to Chapter 6 and perform hump
excision and then osteotomies. To exam.ine the precise pocket that was made before hump
removal, separate the upper lateral cartilage from the septum, as described below and il
lustrated in Fig. 2.]
Division of the upper lateral cartilages from their attachment to the dorsal septum is un
dertaken in the submucoperichondrial plane (see Fig. 2). This may be done before hump
excision, or in cases in which no hump excision is necessary. Alternatively, this maneuver
may be undertaken after hump excision. Again, great care should be taken to preserve an
intact mucoperichondrium.
The accompanying figures (Figs. 2 through 6) illustrate placement of spreader grafts
through the external rhinoplasty approach. At this point, the dissector should have under
taken hump reduction and osteotomies. (If hump removal has not been completed, return
to Chapter 6). Spreader grafts are placed into pockets between upper lateral cartilage and
dorsal septum (Figs. 3 and 4). A typical graft extends from the osseocartilaginous junction
to the anterior septal angle. The spreader grafts are secured with absorbable suture [we rec
ommend 5-0 polydioxanone suture (PDS), Monacryl, or other similar suture]. The spreader
71
A
C
B
D
Figure 1. A-D: Placement of spreader grafts via endonasal approach. A: Mucoperichondrial incision
down to the cartilage. B: Careful elevation of subperichondrial tunnel. C: Spreader grafts . D: Insertion
of spreader grafts .
73 Spreader Grafts
D
E,F G
Figure 2. Division of the upper lateral cartilages from their attachment to the dorsal septum in the sub
mucoperichondrial plane. Great care should be taken to preserve an intact mucoperichondrium.
A
B c
Figure 3. A: Spreader grafts are placed into a pocket between upper lateral cartilage and dorsal septum.
A typical graft extends from the osseocartilaginous junct ion to the anterior septal angle. 8, C: A spreader
graft has been carved and is positioned between the dorsal septum and upper lateral cartilage.
B,
Figure 4. A-C: Bilateral spreader grafts in submucoperichondrial pocket between upper lateral carti
lage and septum.
~ ~ - ~
i
I,
I
, ,; ~ ~ I
I
75 Spreader Grafts
Figure 5. Spreader grafts may be secured first with ab Figure 6. Spreader grafts sutured into position. Several hor
sorbable suture to the septum to stabilize them in position. izontal mattress sutures secure the spreader grafts and up
(We recommend 5-0 PDS, or other similar suture). per lateral cartilages. A needle of adequate size (such as a
PS-2) facilitates engaging all structures (upper lateral carti
lage-to-spreader graft-to-septum-to-spreader graft-to-upper
lateral cartilage) in a single pass. Note how this suture
passes through the dorsal edge of the upper lateral cartilage.
grafts may be secured first to the septum to stabilize them in position (Fig. 5). Alternatively
(and commonly), simply engage all structures (upper lateral cartilage-to-spreader graft-to
septum-to-spreader graft-to-upper lateral cartil age) with a single mattress suture (Fig. 6).
An additional horizontal mattr ess suture may be necessary to secure the spreader grafts and
upper lateral cartilages in position . A needle of adequate size (such as a PS-2) facilit ates en
gaging all structures in a single pass (Fig. 6). Do not cinch down the mattress sutures too
tightly or inferiorly, or else the upper lateral cartila ges may actually be forced mediall y.
SPREADER GRAFTS
In the absence of other causes of nasal obstruction, the nasal valve and nasal valve area
constitute the flow-limit ing segment of the nose. The nasal valve is bounded by the caudal
border of the upper lateral cartilage and the nasal septum, which join at an angle of 9 de
grees to 15 degree s in the normal Caucasian nose (Fig. 7). A valve fulfills the definition of
a movable structure that regulates the flow of gas or fluid. The nasal valve area includes
the cross-sectional area described by the nasal valve and is affected by the inferior
turbinate, the caudal septum, and the tissues surrounding the pyriform aperture (Fig. 7). The
nasal valve area is considered to be the location of the least cross-s ectional area in the nose
and is believed to regulate significantly both nasal airflow and resistance and the velocity
and shape of the air stream. The nasal valve area is the major flow-resisti ve segment of the
nasal airway (I ).
An overnarrow nose in the middle third, whether congenital or (more commonly) the
consequence of previous surgery or trauma, requires cartilage graft augmentation to im
prove the airway and restore aesthetic balance. Examinati on may reveal an overnarrow an
Figure 7. Nasal valve and nasal valve area.
gle at the nasal valve area, medi al coll apse of the valve on even modes t inspi ration, or col
lapse of the upper lateral cartilage against the septal wall , effecti vely compromising the air
way. Spreader graft s act as spacers between the upper lateral cartilage and septum, cor
recting an overnarrow middl e vault and internal nasal valve or preventing excessive
narrow ing in the high-risk patient (2-10).
A submucoperichondrial tunnel on one or both sides of the dorsal aspect of the septum
may be prepared by elevating the mucoperichondrium bridging the upper lateral cartilages
to the septum. Thi s dissection provides a space to be filled by a cartilage graft insinuated
into the pocket, lateralizing the upper lateral cartil age(s), improving the airway and effec
tivel y widenin g, when indic ated, the appearance of the middle third of the nose. In our ex
perience, spreader grafts are more effect ive when the fibrous connections between the dor
sal septum and upper lateral cartilage are left intact. Applicati on of the spreader grafts
creates a cantilever effect and aids in lateralizing the upper lateral cartilage to provide max
imal airway improvement.
Whereas spreader graft s may be comfortably carried out through traditional endonasal
techniques (2), in more complex recon structi ons, particularly complicated by multiple ab
normalities, an external rhinopl asty approach may facilitate accurate dissection and graft
suture fixation (6) .
When the T-shaped configuration (horizontal extension) of the nasal septum is resected
with dorsal-hump remov al, narrowing of the middle nasal vault may be problematic in the
high-ri sk pati ent. Identifying the high -risk patient during initial preoperative analysis is es
sential to the prevention of excessi ve narrowing of the middle nasal vault with internal
nasal valve collapse. An anatomic vari ant referred to as the "narrow-nose syndrome" has
been described (2,6). Short nasal bones, long weak upper lateral cartilages, thin skin, and
a narrow projecting nose predispose to middle vault collapse. A large en bloc hump re
moval should be avoided, as the T-shaped horizontal support of the nasal septum is elimi
nated and the intran asal mucosa (which provides support to the upper lateral cartilage) is at
risk of injury . Regardles s of the approach to the middle vault, keepin g the intrana sal mu
cosa intact with execution of profile alignment (dorsal-hump removal) helps maintain im
portant support of the upper lateral cartilages (see Chapter 6, Fig. 5). This can be achieved
by dissecting submucosal tunnels and freeing the upper lateral cartilages from the septum
before cartil aginous hump remov al. Alternativel y, conservative hump excision followed by
millimeter-by-mill i meter shaving of the upper later als under direct vision preserves the in
tranasal mucosa.
Coll apse of the middle nasal vault may highlight the caudal edges of the nasal bones to
produce the characteristic "inverted V" deformity (Appendix G) .
When the dorsal hump has been taken down and the upper lateral cart ilages appear desta
bilized , such as in the high-risk patient, suturing the upper lateral cartilages back to the sep
tum can be helpful to prevent middle nasal vault collapse. Spreader graft s applied between
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77 SpreaderGrafts
the nasal septum and upper lateral cartilages prevent excessive narrowing of the nose and
preser ve an adequate nasal val ve. An external rhinopl asty approach may faci litate accurate
graft-suture fixa tion in this setting. These precautionary maneuvers are not necessary in all
cases but may prevent problems in the high-risk pati ent (6) .
Commo nly performed surgical maneuvers can result in loss of support to the midd le vault.
Cephalic him (volume reduct ion) of the lateral crura disrupts the scro ll (rec urvature) and
frees the caudal margi n of the upper lateral cart ilage . Lateral osteotomies may further medi
alize the upper lateral cart ilages . The upper lateral car tilages can fall toward the narrowed
dorsal sept al edge, producing narr owing of the middl e vault and internal valvular collapse.
In the majority of patients, the combi nation of these maneuvers will not result in a problem;
however, in high-ri sk patients (narrow-nose syndrome), this combination of maneuvers may
contri bute to excessive narr owin g of the middle vault with internal valve collapse.
When spreader grafts are used, appropria te spreader-graft thickness will achieve the de
sired functional effect wi thout causi ng overwidening. Great care should be taken to avoid
overwideni ng if poss ible. Experi ence is required to develop reliable surgical judgment re
garding the appropriate width and length of spreader grafts. Careful palp ation of both up
per lateral cart ilages can aid in ver ifying symmetry of the middle nasal vaults.
Spreader grafts are usually 1 mm to 3 mm in thickness. It is generally better to use thin
ner spreader grafts because if the middle vault is too wide, revision surgery wi ll be neces
sary. After spreader grafts are secured in pos ition via the externa l approach, or if they are
placed endonasally after dissect ion of the soft-tissue envelope , the middl e-vaul t width can
be assessed by inspect ion and palpa tion . The middle vault should be no wider than the bony
vault and nan-ower than the nasal tip. If excessive width or asymmetry is noted, the grafts
should be repositi oned or narrowed, Over time, thi s area of the nose tend s to nalTOW as
edema resolves and sca r contracture pulls the upper lateral cartilages mediall y.
Asy mmetry of the middle nasal vau lt may at times be addressed with the placement of a
unilateral spreader graft , or alterna tively, with the placement of sprea der grafts of unequ al
thickn ess (Fig . 8) ( 10). In most cases, we prefer to use bilateral spreader grafts to splint de
viations of the dorsal septum and prevent worsening of the dorsal septal deviation.
A variety of other maneuvers are at the surgeon ' s disposal in addressing the middle
nasal vault. Onlay cartilage wafer grafts, derived from the septum or ear, effectively ef
face and imp rove mi ddle-third depressions, but may be used to i mprove aes thetics only
when airway blockage does not exist as a consequence of mi ddle-vault collapse . Ca reful
preoperati ve analysis should determine the need for ot her supportive and reco nstruc tive
B
Figure 8. Spreader grafts may be applied unilaterally or asymmetrically to camoufl age
asymmetry of the middle nasal vault.
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Figure 9. Coronal sinus computed tomography scan in a patient with nasal obstruction, il
lustrating obstructing concha bullosa.
maneu vers, such as conchal cartilage grafts to restore support to a collapsed lateral nasal
wall. External val ve collapse and the potential need for alar batten grafts also should be
evaluated.
PEARLS
If there is difficulty in spreader-graft placement by using an external approach;
check the expo sure. A common mistake is a failure to carry the marginal incision
and dissection over the lateral crura laterally enough, limiting exposure. Extend
ing this incision and dissection appropriately will improve exposure of the middle .
nasal vault and greatly facilitate spreader-graft placement.
Double check middle-vault width and symmetry after applying spreader grafts.
Careful palpation will allow preci se assessment of middle-vault width.
Spreader grafts applied into preci se submucosal tunnels iritroduce bulk under the
intact connection between the upper lateral cartilage and dorsal septum. The
spreader graft creates a cantilever effect and effectively .lateralizes the collapsed
upper later al cartil age.
When securing spreader graft s via suture fixation, gently stretch the upper lateral
cartilage toward the anterior septal angle to ensure that they are not buckled. The
suture will place gentle traction on the upper lateral cartilages to prevent buckling.
After completing suture fixation, inspect the upper lateral cartilages to be sure that
they are not buckled (6) . . .
. In considering nasal obstruction, acomplete evaluation is critical. Causes of nasal
obstruction include allergic rhinitis, chronic sinusitis; rhinitis med icamentosa,
nasal pol yps, deviated septum, internal and external nasal-valve collapse, and oth- .
ers. One commonly overlooked cause of nasal obstruction is a concha bullosa, or'
aerated middl e turbinate (Fig. 9), which can be most easily recognized on nasal en
d o s ~ o p y or coronal computed tomography scan. .
REFERENCES
I. Tardy ME. Surgical anatomy of the nose. New York: Raven, 1990.
2. Sheen JH. Spreader graft: a method of reconstructing the roof of the middle nasal vault followi ng rhinoplasty.
Plast Reconstr Surg 1984;73:230-237.
79 Spreader Grafts
3. Goode RL. Surger y of the incompetent nasal valve. Laryngoscope 1985;95:546-555.
4. Johnson CM, Toriumi DM. Open structure rhin oplasty. Philadelphi a: WB Saunders, 1990.
5. Toriumi DM, Johnson CM. Open structure rhinoplasty: featured techni cal point s and long-term follow-up.
Facial Plast Surg Clin North Am 1993 ; I: 1-22.
6. Toriumi DM. Management of the middl e nasal vault in rhinoplasty . Oper Tech Plast Reconst r Sur g 1995 ;2:
16-30.
7. Constantian MB, Clardy RB. The relative importanc e of septal and nasal valvular surgery in correcting air
way obstruction in primary and secondary rhinopl asty. Plast Reconstr Surg 1996;98:38-54.
8. Teichgrae ber JF, Wainwri ght DJ. The treatment of nasal valve obstructi on. Plast Reconstr Surg 1994;93:
1174-11 84.
9. Aiach G. Atlas de rhinopl astie. Paris: Masson , J 989:74-85.
10. Toriurni DM, Ries WR. Innovativ e surgical management of the crooked nose. Facial Plast Surg Clin North
A/11 1993;1:63-78.
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9
Surgery of the Nasal Tip
EXERCISES (Appendix F)
Placement of Columellar Strut
The placement of a rectangul ar cartil age strut between the medial crura can improve tip
support and augment tip projection. A columellar strut also can be used to correct buckled
medi al or intermediate crura or to increase columellar show. The strut may be placed by us
ing the externa l approach or into a precise pocket via the endonasal approach.
Placement of Columellar Strut via an External Rhinoplasty Approach
The area between the medial crura is dissected to create a pocket to place the strut. The rect
angular cartilage strut typically measures 8 mm to 12 rnm in length, 3 mm to 4 mm in width,
and 1 mm to 2 mm in thickness. The strut is most typically fashioned from harvested septal
cart ilage, but also, when necessary, from auricul ar cart ilage, and at times from rib cartil age.
The strut is positioned so that it sits above (without extending to) the nasal spine (Fig. 1). It is
preferable to leave a small soft-tissue pad between the strut and the nasal spine. The strut
should not extend above the intermediate crura. It is secured to the medi al crura with several
absorbable mattress sutures (e.g., 4-0 plain gut, Keith needle) placed through the vestibular
skin. Asymme tries of the lower lateral cartilage (LLC) may be improved with placement of
the strut (Fig. 2). Asymmetry of the tip may be created if the medial crura are asymmet rically
sutured to the strut (Fig. 3), or if an overlong strut extending beyond the nasal spine shifts to
the side of the nasal spine, thereby causing a deviated nasal tip (Fig. 3) ( 1,2).
Placement of Columellar Strut via an Endonasal Approach
A small incision is made through the vestibular skin and ipsilateral medial cr us (Fig. 4).
Scissor dissecti on creat es a precise pocket through this small incision (Fig. 5). The col
81
c D
E F
Figure 1. Placement of columellar strut. A, B: The strut sits above (without extending to) the nasal
spine, and it should not extend above the intermediate crura. C-F: A columellar strut may be placed via
the external rhinoplasty approach . With proper exposure achieved (C), dissection of a pocket between
the medial crura is undertaken (0) . The carved columellar strut is placed in the pocket, as described ear
lier (E) and secured with interrupted 4-0 plain gut on a straight septal (Keith) needle (F).
82
83 Surgery oj the Nasal Tip
c
D
Figure 2. A-D: Asymmetries of the lower lateral cartilage may be improved with placement of the strut.
A
B
Figure 3. Asymmetry may be created if the medial crura are Figure 4. Placement of columellar strut via an endonasal ap
asymmetrically attached to the strut (A), or if an overlong strut proach. First, an incision is made through the vest ibular skin
extending beyond the nasal spine "slips" to the side of the and ipsilateral medial crus.
nasal spine, thereby causing a deviated nasal tip (8).
\
Figure 5. Scissor dissection creates a precise pocket.
Figure 6. The columellar strut is inserted into the precise
pocket.
umellar strut is inserted into the preci se pocket (Fig. 6) and is manipulated into proper po
sition (Fig. 7). A 5-0 chromic mattress suture can be used to fix the strut between the me
dial crura . The incision is closed with a single absorbable suture (3).
Identify the Dome
Identify the dome and approximate the lateral and medial crura at the dome with a pair of
multitoothed Brown-Adson forceps. The line of the dome should be at approximately 30
degrees to the sagittal plane.
Figure 7. Completed placement of columellar strut via an endonasal approach.
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Reduce the Crural Volume and Rigidity: Complete Strip
Identify the scroll region, the cephalic border of the LLC (Fig. 8). Excise the cephalic por
tion of the LLC by making an incision parallel to the caudal margin with the 15 blade and
then peeling off the cephalic portion , leaving the vestibular skin behind. The line of inci
sion parallel s the caudal margin of the LLC. Leave at least 7 mm to 9 mm of intact carti
lage. This preserves an intact strip of cartilage from the feet of the medial crura to the most
lateral part of the lateral crus. This will produce conservative narrowing of the nasal tip.
B
c
o
Figure 8. Cephalic resection of lateral crura of lower lateral cartilages.
Accentuate the Tip
Now apply domal/transdornal sutures as outlined.
Place Individual Horizontal Mattress Domal Sutures
For domal sutures (Fig. 9), a mattres s suture of 5-0 polydiox anone suture (PDS) or other
appropriate suture is passed through each dome, and the knot of each mattress suture is tied
between the domes. As the sutures are secured, narrowing of the tip is accomplished. An
interdomal suture sets the width between the domes. If stiff nasal-tip cartilages are en
countered, the surgeon should use 5-0 clear nylon instead of PDS (4-6).
Place Single Transdomal Suture
Alternatively, a single transdomal suture that traver ses both domes may be placed, in lieu
of two individual domal sutures and an interdomal suture (Fig. 10) (1-3). The caudal pass
should be slightly longer than the cephalic pass of the mattress suture. When the mattress
suture is placed in this fashion, the caudal edge will tend to lead the cephalic edge as the
suture is tightened. This creates a more favorable tip-supratip relation . If the cephalic edge
leads the caudal edge of the lateral crus despite proper placement of the domal suture, a
small cephalic wedge of the cartilage may be excised and the edges sutured, which reposi
tions the cephalic edge lower in relation to the caudal edge (Fig. 11).
A,B c
Figure 9. Individual horizontal mattress domal sutures. The caudal pass is slightly longer than the
cephalic pass of the mattress suture . As the sutures are secured, narrowing of the tip is accomplished.
An interdomal suture is placed between the two domes, securing the interdomal distance.
87 Surgery oj theNasal Tip
B
C
D
Figure 10. A, B: A single transdomal suture may be placed in lieu of two individual domal sutures and
an interdomal suture. C-J: Patient with trapezoidal tip and broad domal angles. Transdomal suture tech
niques were used to improve the patient's tip triangularity as seen in preoperative (G, E, G, I) and post
operative (0, F, H, J) photographs. K-Z: Patient with trapezoidal asymmetric nasal tip. Columellar strut
and transdomal suture techniques were useful to improve tip symmetry and triangularity. K, L: Preop
erative frontal and base view. M, N: Graphic operative worksheet (Gunter diagram) . O-Q: Intraopera
tive photographs illustrating placement of columellar strut and suture techniques. R-V: Preoperative (R,
T, V, X) and postoperative (S, U, W, V) photographs.
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Figure 11. If the cephalic edge leads the caudal edge of the lateral crus despite proper
placement of domal suture , a small cephalic wedge of the cartilage may be excised , and the
edges sutured, which repositions the cephalic edge lower in relation to the caudal edge. In
this figure, one lower lateral cartilage illustrates the wedge excised, and the other illustrates
the edges resutured (A). B: The effect of this maneuver on the relationship between the
cephalic and caudal edge is illustrated.
A
c
E
D
F
Figure 12. A, 8 : Lateral crural steal. When the horizontal mattress domal sutures take a larger bite of
lateral crus, a portion of the lateral crus is "borrowed" by the medial crus. The "medial crural " 1eg of the
tripod is lengthened, whereas the "lateral crural" legs of the tripod are shortened (see Appendices A and
F). This results in increased projection and rotation. Tip refinement also is achieved, as with a standard
domal suture. C-F: Rotation of this patient's nasal tip was achieved by using the lateral crural steal tech
nique and by suturing medial crura back on overly-long midline caudal septum .
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94
Lateral Crural Steal
Lateral crural steal (Fig. 12) is an effective method for increasing tip projection and rota
tion (7). When the horizontal mattress domal sutures take a larger bite of lateral crus, a por
tion of the lateral crus is shift ed mediall y. The " medial crura]" leg of the tripod is length
ened , where as the "lateral crural" legs of the tripod are shortened (see Appendices A and
F); the result is increased proj ection and rotation. Tip refinement also is achiev ed, as with
a standard domal suture.
Further Refinement with Dome Division with Intact Vestibular Skin and Suture
Reconstitution
We rarely divide the domes, but when this technique is performed, it is usually in the thick
skinned patient. In most cases, we use some form of dome-binding suture to change tip con
tour (8).
Remove the transdomal sutures to perform this maneuver. Di viding the dome by verti
cal incision allows further narrowing of the nasal lobule. Projection also can be altered by
removal of a superiorly based triangle of cartilage lateral or medi al to the vertic al incision.
By excising a larger amount of car tilage along the cephalic margin of the later al crus, the
cephalic dome can be positioned below the caud al dome (Fig. ]3).
B
Figure 13. Divide the dome by vertical incision. Reapproximate the divided cartilages with
suture (e.g ., 6-0 PDS) to secure the position of the cartilage and reconstitute the intact strip.
/
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Figure 14. Suture reappro ximation of divided lower lateral cartilages is undertaken with
simple interrupted stitches. Mattress stitches in this situation may result in overnarrowing .
Reapproximate the divided cartilages with 6-0 PDS suture (Fig. 14). The placement of
sutures to reapproximate the divided cartilages after dome division secures the position of
the cartilage and contributes to increa sed tip stability. Simple interrupted sutures are pre
ferred to a mattress suture, because a mattr ess suture may excess ively narrow the tip (Fig.
14).
Note: We rarel y perform dome di visi on because we find less- aggressive techniques
(dome-binding suture) very effective for mod ifying tip contour. We try to avoid dome di
visi on in patients with thin skin.
Lateral Crural Overlay
When the patient's anatomy calls for rotation and deproj ection, lateral crural overlay is
one possibl e techn ique (Fig. 15) (7, 9). The lateral crura are incised lateral to the domes. The
vestibular mucosa is elevated from the undersurface of the lateral crus, and the medial por
tion is overlapped over the later al and secured in place with sutures. When undert aking this
maneuver, great care must be taken to perform it symmetrically.
F
E
c
B
D
A
G
J
Figure 15. (left and above) A-J: Lateral crural overlay. Great care must be taken
to perform this technique symmetrically.
97
Tip Graft
Sutured in place, shield-shaped tip grafts typically are used to increase tip projection and
change tip contour (1,2). They also can be used to camouflage tip asymmetries. Tip grafts
should be avoided in patients with thin skin.
Carve a shield-shaped tip graft from the harvested septal cartilage. The width generally
varies from 8 mm to 12 mrn at the leading edge. The length varies from 8 mm to 15 mm,
and thickness typically varies from I mm to 3 mm (Fig. 16). The graft is thicker at the lead
ing edge and thinner at the base. One may consider cutting the graft larger at the leading
edge to allow in situ carving once the graft is secured in position. The graft is sutured to the
caudal margins of the medial/intermediate crura that have been stabilized by the sutured
in-place columellar strut. An excessively thick tip graft will increase fullness in the infratip
lobule .
Secure the tip graft with 6-0 PDS or Monacryl sutures (Fig. 17). Four to six sutures are
usually applied. Place the lower sutures first.
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Figure 16. A-E: Tip graft width generally varies from 8 mm to 12 mm at the leading edge. The length
varies from 8 mm to 15 mm, and thickness typically varies from 1 mm to 3 mm.
B
Figure 17. A: The tip graft is sutured to the caudal margins of the medial/intermediate crura. Four to six
6-0 PDS sutures are typically placed . Place the middle sutures first. B, C: Intraoperative photographs il
lustrating placement of tip graft.
c
D E
. I ,
F G
Figure 17, continued. D-K: Preoperative (D, F, H, J) and postoperative (E, G, I, K) photographs of a
patient who underwent application of a tip graft . The tip graft was used to increase tip projection and pro
vide a bidomal shape to the nasal tip. Please refer to text for a more detailed discussion of tip grafts.
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When placing a tip graft in a patient whose domes have been divided (and suture recon
stituted ), apply the tip graft so that it camoufl ages the caudal aspect of the cut domes (Fig.
18), decreasing the risk that this point will be palpable or visibl e after surgery.
Figure 18. If a tip graft is applied in a patient with divided domes, the caudal aspect of the cut
domes should be hidden behind the tip graft to decrease the risk of a palpable or visible point
after surgery.
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Cap or Buttress Graft
Typically, a tip graft should be projected 1 mm to 2 mm above the existing domes. In pa
tient s with thick skin and an underpr ojected tip, a longer tip graft can be projected 2 mm to
4 mm above the existing domes. In these and other appropriate cases, a cap or buttress graft
placed behind the leading edge of the tip graft may be useful to support the graft (particu
larly softer, pliable auricul ar cartilage tip graft s) and to prevent excessive cephalic rotation
of the graft under the tension of closure of the skin/soft-tissue envelope. Buttre ss grafts are
sutured to the tip graft and both domes by using 6-0 PDS or Monacryl suture (Fig. 19). The
buttress grafts should creat e a smooth transition from the edge of the tip graft to the caudal
margin of the lateral crura (2).
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Figure 19. A-D: Buttress or cap graft.
F E
G H
Figure 19, continued. E-L: Preoperative (E, G, I, K) and postoperative (F, H, J, L) pho
tographs of two patients who had tip grafts with cap-graft placement. Cap grafts were placed
to support the leading edge of the grafts , prevent cephalic rotation of the graft, and ensure
a smooth transition from the edge of the graft to lateral crus.
J
K L
Figure 19, cont inued.
M N
Figure 19, continued. M, N: Intraoperative photograph illustrating tip graft with cap graft.
Alar Batten Graft
The external nasal valve is composed of the cutaneous and skeletal support of the mobile
alar side-wall. Overaggressive resection of the lateral crura during rhinoplasty and the sub
sequent postoperati ve soft-tissue contraction may lead to internal and/or external nasal
valve compromise. Ceph alic positioning of the lateral crura also will leave suboptimal
structural support in the mobile alar side-wall (external valve collapse).
Alar batten grafts , typically of curved septal or auricul ar cartilage, placed to support the
alar rim, can correct internal or external nasal-valve coll apse (Fig. 20) (l0-12).
Create a precise pocket for an alar batten graft. The graft is typically placed caudal to the
lateral crura at the point of maximal lateral nasal wall collapse. Fashion a graft from har
vested auricular or septal cartilage, and insert it into the precise pocket. The pocket is sub
cutaneous and is placed at the point of maximal supr aal ar collapse. Auricular cartilage is
preferred becau se of the curvature of the cartilage. The convex side of the graft is oriented
laterall y to correct the supraalar pinching. If this pocket is too superficial, the graft may be
palpable or visible . When placed via an external rhinoplasty approach, secure the graft with
a suture applied medially from the graft to adjacent soft tissue or lateral crus.
Figure 20. A: Alar batten graft .
B
c
Figure 20, continued. B, C: Intraoperative photographs illustrate location of alar batten graft placement,
centered around the point of greatest weakness and concavity of the alar sidewall. The alar batten graft
in this case has been fashioned with autogenous auricular cartilage.
D E
Figure 20, continued. D, E: Alar batten grafts may be placed via a precise pocket endonasal rhinoplasty
approach .
F
H
Figure 20, continued. F-T: Prima ry rhinoplasty patient
with cephalic positioning of the lateral crura requiring alar
batten graft s. Preoperative photographs (F-I).
G
J
Figure 20, continued. As demon
strated on base view (J), gentle inspi
ration results in valve collapse .
K
M N
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Q
R
S
T
Figure 20, continued. The rhinoplasty worksheet (K-L) illustrates that this patient underwent septo
plasty with cartilage harvest. She underwent conservative cephalic resection. She received a columel
lar strut , plumping grafts , dorsal onlay grafts , spreader grafts , and alar batten grafts. Preoperative (M, 0,
Q, S) and postoperative (N, P, R, T) photographs are seen here. Note the improvement in the nasal
valve, best seen on base view.
Lateral Crural Grafts
Lateral crural grafts are anatomic grafts that replace excessively reduced or deformed lateral
crura. These grafts are shaped like lateral crura and measure approximately 5 mm in verti
cal height. Auricular cartilage has the ideal curvature for lateral crural grafts. The grafts are
sutured to the vestibular skin and medial or intermediate crura . Care is taken so the caudal
margins of the grafts are placed symmetrically; otherwise, there may be asymmetry of the
alar rims. Grafts that are too large or curved may create a bulbous tip (2) (Fig. 21) .
Figure 21. Intraoperative photograph illustrating lateral cru
ral grafts and a shield graft. The grafts are sutured to the
vestibular skin and medial or intermediate crura.
-
PEARLS
Complete Strip
Although many surgeons perform cephalic trim of the lateral crura as a routine ma
neuver during rhinoplasty, some patients have flat or concave lateral crura that do
not contribute to tip bulbosity. Many of these patients do not need to undergo '
cephalic trim of the lateral crura. Cephalic trim should be performed when there is
fullness (bulbosity) in the supratip or supraalar region due to protrusion ofthe
cephalic margin of the lateral crura. :
The surgeon should leave 7 mm to 9 mm of lateral crus. This determination is
made on a patient-to-patient basis. The strength of the lateral crura and alar side
walls should be considered. With strong cartilages, more cartilage can be excised,
and with weak cartilages, more cartilage should be preserved. . ..
Complete strip is illustrated here via the external rhinoplasty approach but was il- ' .
lustrated earlier in this text via the cartilage-splitting approach (Chapter 5, Figs.
1-3). In a cartilage-splitting approach, the attachments of the lateral crura to the
skin/soft-tissue envelope are undisturbed, and a complete strip of 6 mm to 8 mm
should be preserved. Cephalic resection of lateral crus may also be accomplished '
via the retrograde dissection approach and via the delivery approach;
Minimize lateral resection of the cephalic margin of the lateral crura. Change iri tip
contour is primarily effected by niedial excision, and .lateral excision can con
tribute to valve collapse and supraalar pinching,
I' Thin skin, strong cartilages, and bifidity is a cornmon triad that should be recog
nized. These patients are at higher risk for bossa formation if excessive cartilage
is excised from the cephalic margin of the lateral crura (Appendix G).
. .
.PEARLS, continued
Transdomal Sutures .
Tran sdomal suture placement can create excessive fullness in the infratip lobule.
The infratip lobule should be assessed after transdomal suture placement. Addi
tionally , the lateral aspect of the lateral crura may medialize into the airway with
. placement of a transdomal suture. If this occurs, it may be necessary to apply lat- . .
eral .crural strut grafts to straighten the lateral crura . On rare occasions, the lateral- ;
most aspects of the lateral crura may need to be trimmed. .
.Separate dome binding sutures are better able to correct asymmetric domes . ..
Tip Grafts
Before closure, all edges of the tip graft should be rounded off to prevent visibility
ofthe edges of the graft.
Excessively stiff tip grafts should be crosshatched on the caudal surface to allow
cephalic bending and a good double break.
o Surgeons tend to make shield grafts too narrow. Most grafts should be approxi
.. matelyB mm to 10 mm in width at the leading edge: In male patients, the tip grafts
are generally wider, and typically measure 10 mm to 12 mm in width at the leading
edge: . .
Most cadaver specimens have thin, atrophic skin, so the tip graft will tend to be more
. noticeable. Indeed, we try to avoid the use of tip grafts in patients with thin skin.
Tip grafts are ideal for camouflaging subtle tip asymmetries.
Alar Batten Grafts
. Alar batten grafts may be placed via anextemal rhinoplasty approach or into apre
cise pocket made through an endonasal incision. This graft is nonanatomic and is
typically placed caudal to the lateral crura where there is maximal collapse of the
lateral nasal wall and supraalar pinching.
. If alar batten grafts are placed too far cephalic, excessive fullness over the middle
vault will be noted.
Patients should be told that there will be temporary fullness in the area of the graft.
This fullness will typically decrease over a 2- to 3-month period. .
. o For maximal support, the alar batten graft should extend over.the bone of the pyri
form aperture. .
REFERENCES
1. Johnson CM, Toriumi DM. Open structure rhinopl asty. Philadelphia: WB Saunders, 1990.
2. Toriumi OM, Johnson CM. Open structure rhinoplasty: featured technical point s and long-term follo w-up .
Facial Plast Surg CUll No rth Am 1993; I : 1-22.
3. Tardy ME. Rhinoplasty : the art and the science. Phil adelphia: WB Saunders, 1997.
4. Tardy ME, Cheng E. Tran sdomal suture refinement of the nasal tip. Facial Plast Surg 1987;4:317-326.
5. Tardy ME, Patt BS, Walter MA. Transdoma1 suture refinement of the nasal tip: long-term outcomes. Facial
Plast Surg 1989;9:275-284.
6. Toriumi OM, Tardy ME. Cartil age suturing techniques for correction of nasal tip deformities. Oper Tech 010
lary ngol Head Neck Surg 1995;6:265- 273.
7. Konior RJ, Kridel RWH. Controlled nasal tip positioning via the open rhinoplasty approach. Facial Plast
Surg CUn No rth Am 1993; I:53- 62.
8. Simon s RL. Vertical dome di vision in rhinopl asty. Otolaryngol Clin Nor th Am 1987;20: 785-796.
9. Kridel RWH , Konior RJ. Cont rolled nasal tip rotati on via the lateral crur al overlay technique. Ar ch Otol Head
NeckSurg 1991;117:411-415 .
10. Toriumi OM, Josen J, Weinberger MS, Tardy ME. Use of alar batten graft s for correction of nasal valve col
lapse . Arch Otol Head Neck Surg 1997;123:802-808.
II . Constanti an MB. The incompetent external nasal valve: pathoph ysiolo gy and treatment in primary and sec
ondary rhinoplasty. Plast Reconstr Surg 1994 ;93:919-933.
12. Constanti an MB, Clardy RB. The relative importance of septal and nasal valvular surgery in correcting air
way obstructi on in primary and secondary rhinoplasty. Plast Reconstr Surg 1996;98:38-54.
.... ~
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10
Alar Base Resection
Foll ow the accompanying figures and text to perform alar base resections (1,2).
The site of incisions and the amount , deg ree, and geometry of alar reducti ons depend on
a host of anatom ic variations predetermined before and durin g surgery. Alth ough the sur
geon's aesthetic j udgment will ultimately determine the site and degree of resection, a more
precise surgical approach may be determined if several anat omic guidelines are assessed
and integrated. Conservatism is mand atory to avoid overreduction and asy mmetry, condi
tions that are difficult to correct satisfactorily.
As the need for reduction increases, both the incision and excision become more exten
sive. Alar redu ction is a compromise operation, in which greater reductions exa ct the
penalty of a larger scar. The surgeon must balance this compromi se with experienced aes
theti c j udgment and prov en scar-camouflage techniques.
Skin sutures placed across the alar-faci al juncti on often lead to permanent suture marks.
Effective camouflage at the alar- facial junction may be facilit ated by positioning incisions
I mm to 2 mm above the alar- facial junction. Skin clo sure can be performed with a
cyanoa crylate adhes ive (oc tyl-2-cyanoacrylate, Dermabond; Ethicon, Somervill e, NJ ,
U.S.A.).
INTERNAL NOSTRIL FLOOR REDUCTION
In patients requiring minimal alar redu ction, excision of a wedge of epithelium and soft
tissue from the nostril floor only (Fig. I) will slightly reduce the alar flare by reducing the
dimension of the internal (medial) border. Although the outward curve of the ala is altered,
no medial repo sitioning of the alar-facial junction is effected. The scar is effectively hid
den within the nostril floor if the nostril sill is not violated. At times , the shape of the nos
tril sill will determine whether this approach is appropriate. Subtle, conservative , but ef
fect ive improvements are possible with this approach . The dimension of the lateral alar
border remains unchanged.
113
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=- ~ ~ I
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A B
Figure 1. Internal nostril floor reduction will slightly reduce alar flare.
WEDGE EXCISION OF NOSTRIL FLOOR AND SILL
Further reduction of alar flare is accompli shed by carrying the incision across the sill into
the alar- facial junction I mm to 2 mm above the alar-facial crease. Reduction of flare as
well as slight reduction of the alar bulk is effect ed (Fig. 2).
ALAR WEDGE EXCISION
If the alar development is excessive and bulbous , excision of a wedge of ala at the
alar-facial junction 1 mm to 2 mm above the alar-facial crease will reduce the overall bulk
iness of the alar anatomy (Fig. 3). Some medi al repositioning of the alae may be effected
with this maneuver. Reduction of the overall length of the alar sidewalls occurs when gen
erous wedges are excised, ideal in the reduction of the alar flare created when correcting
the overprojecting tip.
SLIDING ALAR FLAP
More substantial alar reduction with medi al repositioning is effected with a generous in
cisi on above the alar- facial jun ction with various degrees of alar exci sion (Fig. 4). Reduc
tion of the volume, curve, and flare of both the internal and external alar margins will re
sult from this procedure, the extent of each dependent on the angulation of the alar incision.
A backcut placed 2 mm above the alar-facial j unction allows the alar flap to slide medially,
narr owing the alar base signifi cantly.
A B
Figure 2. Wedge excision of nostril floor and sill conservatively reduces flare as well as alar
bulk.
--
115 Alar Base Resection
A B
Figure 3. Excision of a wedge of ala at the alar-facial junction 1 mm to 2 mm above the
alar-facial crease will reduce the overall bulkiness of the alar anatomy. Some medial repo
sitioning of the alae may be effected with this maneuver.
A B
Figure 4. Sliding alar flap typically incorporates a backcut to allow the alar sidewall to ad
vance medially.
PEARLS
. ' When performing alar base reduction, the surgeon should err onundercorrecting
. the deforrnityto prevent resection of excessive tissue. Once too much tissue is ex
cised, it is very difficult to correct ; be particularly conservative in male patients.
Internal alar base excision can significantly decrease the internal diameter of the
nostril and should be performed in a conservative manrier. When performed, usu- .
ally <2 mm of tissue is removed.
Ifan incision is made on the lateral surface of the ala, the incision should be made
,
above the alar crease to minimi ze scarring. A cyanoacrylate adhesive (Der
maborid; Ethicon, Somerville, NJ, U.S.A.) can be used to close the lateral alar in
cision.
In the incision, the skin edges can be favorably beveled to maximize skin-edge
eversion and avoid a depressed scar.
REFERENCES
1. Tardy ME, Patt BS, Walter MA. Alar reducti on and sculpture: anatomi c concepts. Facial Plast Surg 1993;9:
295-305.
2. Becker DG, Weinberger MS, Greene BA, Tardy ME. Clinical study of alar anatomy and surgery of the alar
base. Arch Otolaryngol Head Neck Surg 1997; 123:789-795.
. .
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11
Other Maneuvers
PLUMPING GRAFTS
Plumping grafts may be used to open up an acute nasolabial angle, improve a retracted
columella, and support a deficient nasal base. Dissect a midcolumellar precise pocket to
just above the nasal spine. Place multiple small pieces of cartilage (I rom to 2 mm), har
vested from the septum or ear, in the pocket. These grafts will augment the deficient area
(Fig. 1) (1,2). Plumping grafts placed below the medial crural footplates will increase sup
port of the nasal base (Appendix F)
A,B c
Figure 1. Plumping grafts may improve a retracted columella.
117
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CAUDAL EXTENSION GRAFTS
Caudal extension grafts have been described for use in corr ecting a retracted columella,
overrotated tip, short nose, or to increase tip support and projection (3) (Appendix F). Thi s
graft is sutured to the caudal margin of the nasal septum and is secured between the medial
crura in the midline with 5-0 buried polydi oxanone suture (PDS) (Fig. 2). When suturing
the caudal extension graft to the caudal septum, the caudal margin of the graft must be in
the precise midline. Devi ation off the midlin e will result in a deviation of the nasal base or
tip. It is critical to assess nasal proj ection, length, tip rotation, and alar/columellar relation
when positioning a caud al extens ion graft. Patient s should be told preoperati vely that their
nasal tip will be stiffer, with loss of the norm al tip recoil.
A
B F
OtherManeuvers 119
c
o
G
H
Figure 2. A caudal extension graft may at times be useful to correct retraction of the colum
ella (A) . In this patient example (preoper ative, B-E; postoperative, F-I) , a caudal extension
graft, harvested from the patient's posterior septal cartilage, was used to address the re
tracted columella .
~
.
.
.
.
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< .;a
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E
J K
Figure 2, continued. This intraoperative sequence illustrates placement of the graft, ex
tending beyond the caudal septum (J, K). The caudal septum in this patient was deviated
toward his left, so the graft was placed to take advantage of the slight curvature of the graft
to achieve a midline position.
,
, ,
. 1 ~
OtherManeuvers 121
L M
Figure 2, continued. With the graft in place (L), the medial crura were secured to the cau
dal aspect of the graft to achieve proper tip projection and to address the retracted columella
(M). Special care was taken to set appropriate projection , rotation, length, and columellar
show. It is critical that the caudal extension grafts be placed in the precise midline .
DEVIATED CAUDAL SEPTUM
A number of maneuvers are at the surgeon' s disposal in the treatment of a caudal septal
devi ation (4,5) . Traditional approaches include scoring the septal cartilage on the concave
side, thereby relaxing the "spring" of the cartilage. This may be done as a solitary maneu
ver, or in conjunction with a so-called "swinging door maneuver." As illustrated in Fig. 3,
a wedge of cartilage excised along the maxillary crest releases the caud al septal attach
ments and allows the septum to swing to the midline. The midline position may be secured
with a 4-0 PDS attached to the periosteum adjacent to the opposite side of the nasal spine.
Ethmoid bone splinting grafts or sandwich grafts also may be of benefit in this situation
(6). A straight piece of bone is harvested; a large straight Keith needle may be used as a del
icate hand-held drill to make holes in the bone graft. The deviated portion of cartilaginous
septum may be addressed by scoring on the concave side, and the bone graft or grafts may
then be used to splint the septum in a straighter orientation. However, use of the ethmoid
bone graft in this location thickens the caudal septum and can contribute to nasal obstruc
tion. The ethmoid bone sandwich grafts may be used to address a deviation of the dorsal
septum, where the additional septal thickness caused by this graft is well tolerated (Fig. 4).
In cases of a severely deviated caudal and dorsal septum, the offending portion may be
exci sed and replaced with a straight piece of cartilage, typically harvested from the septum
more posteriorly (Fig. 5) (4). Suture fixation to a stable segment of cartilage attached at the
osseocartilaginous junction and nasal spine will allow recon struction of an intact L-strut to
support the lower third of the nose. The recon structed caudal segments can be sutured be
tween the medial crura to set nasal length, projection, rotation, and the alar/columellar re
lation .
A,B
Figure 3. Deviated caudal septum, "SWinging door" maneuver.
Figure 5. A, B: Septal replacement for severe cases of deviated caudal and dorsal septum.
C-T: In the first case example (preoperative photographs, C-F), a segment of caudal sep
tum is removed (G, H) and replaced with a straight piece of septal cartilage harvested pos
teriorly (I, J) .
Figure 4. A splinting graft of ethmoid bone may help main
tain the septum in a straighter orientation.
A
, i
B
c D
123
_ __ F
E
G H
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- m
, I I
, "
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OtherManeuvers 125
K
J
L
Figure 5, continued. As illustrated. the replacement cartilage is extended caudally and se
cured between the medial crura as well (K) . In this case, a tip graft also was applied (L).
_______........ N
M
0 ..... _
p
Other Maneuvers 127
R Q
s T
Figure 5, continued. Preoperative (M, 0, Q, S) and postoperative (N, P, R, T) comparison .
U-BB: This series of intraoperative photographs illustrates total replacement of the severely
deviated caudal septum.
u
. ... -.. X
w
v
OtherManeuvers 129
......_---" z
Y
AA
Figure 5, continued. The severely deviated component (U-W) is removed, along with pos
terior septum (X). The deviated septum is replaced with straight septal cartilage (Y-Z) har
vested posteriorly. A tip graft also was applied (AA).
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RIB CARTILAGE GRAFT RECONSTRUCTION OF SADDLE DEFORMITY:
INTEGRATED DORSAL GRAFT/COLUMELLAR STRUT
The severe saddle-nose deformity may be treated by using autogenous rib cartilage (8,9).
Harvest of rib is . escribed later. The rib graft is carved into a dorsal graft and a columellar
strut, which are interdigitated to recreate an intact L-strut (Fig. 6). This type of structural re
construction is particularly useful when there is complete loss of septal support . If an intact
nasal septal L-strut is present, onlay dorsal grafting will be sufficient to correct the deformity.
Great care must be taken to adhere to the principle of "balanced cross-sectional carving" to
minimize the risk of graft warping. Once in position, the domes can be sutured over the graft
with a transdomal suture. An external rhinoplasty approach allows exposure for facile place
ment of these grafts. A tip graft allows improved tip projection and definition.
Figure 6. A, B: Severe saddle-nose deformity. Rib graft is
fashioned into a columellar strut (secured to the medial
crura) and a dorsal onlay graft that interdigitates with the
columellar strut. C-EE: (slides) Preoperative (C-F) pho
tographs of a patient with a severe saddle-nose deformity.
She underwent application of an iliac bone graft to her
nasal dorsum in the past. Lack of an intact L-strut and in
adequate middle vault support resulted in descent of the
graft, airway obstruct ion, and referral to our office for re
construction . Base view reveals the bone graft in the left
nostril and a widened columellar scar.
OtherManeuvers 131
c D
E F
. ,

--;r-r,
I'
-
_
G H
J
Figure 6, continued. Graphic operative worksheet (G, H) illustrates the surgical high points. Rib graft was
harvested (I, J), and exposure was achieved via the external rhinoplasty approach (K, L). A sutured-in
place columellar strut fashioned from rib graft was secured between the medial crura (M, N). A dorsal-on
lay graft was carefully carved (0, P) with a notch, allowing it to interdigitate with the columellar strut.
r1j
'Iii
-'
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Other Maneuvers 133
M
N
...... ...;:;;;::::
L
o
p
:!'Oo
. I
- . ~ ~
L ~ I I
. .. .... IT
Q
s
R
T
--
Other Maneuvers 135
u
v
w
Figure 6, continued. The dorsal graft was placed and se
cured (0-T). Example from another patient illustrating in
terdigitation of strut and dorsal onlay graft (U). A tip graft
was placed and covered with a layer of perichondri um to
camouflage and soften the leading edge of the tip graft.
(V, W).
.'.
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.,
. .. .. :
x
z
y
AA
. 11'1
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III
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Other Maneuvers 137
BB
cc
DD
EE
Figure 6, continued. Preoperative (X, Z, BB, DO) and postoperative (Y, AA, CC, EE) side-by-side com
parison.
PEARLS
When placing plumping grafts, the surgeon should overcorrect because the grafts
tend to settle over time. Additionally, the pocket can be gently irrigated with an
tibiotic solution to minimize the incidence of infection.
When performing a caudal extension graft, the surgeon must take special care to
set appropriate tip projection, rotation, length, and alar/columellar relation. Addi
tionally, the caudal margin of the graft must be in the precise midline.
The inferior border of the caudal extension graft should be stabilized on the pos
terior septal angle, soft tissue, or other supporting tissues to avoid postoperative
counterrotation of the extension graft. .
Deviations of the caudal septum can usually be corrected by crosshatching the car"
tilage and other conservative maneuvers described in the text. Many cases can be .
corrected by accounting for excessive length of the L-strut. Inrare cases, subtotal
septal replacement may be necessary.
When using an integrated columell ar strut/dorsal graft, the surgeon must take spe
cial care to stabilize the columellar strut in the midline to avoid shifting or tilting
of the columella . Placement of the dorsal graft into a preci se dorsal pocket or su-: .
ture fixation of the dorsal graft to the middle nasal vault will miriimize the chance .
of the graft shifting to one side.
Symmetric carving of the costal cartilage graft will minimize the chance of the
graft warping over time:
REFERENCES
I . Tardy ME, Becker DG, Weinb erger MS. Il lusions in rhinopl asty. Facial Plast Surg 1995; 11: 117-1 38.
2. Tardy ME. Rhinoplasty: the art and the sc ience. Philadelphi a: WB Saunders, 1997.
3. Tor iurni OM. Caudal septal extension graft for correction of the retracted colume lla. Opel' Tech Otolary ngol
Head Neck Surg 1995;6:3 11-318.
4. Beeson WH. The nasal septum. Otolaryngol Clin North Am 1987;20:743- 767.
5. Toriurni DM, Ries WR. Innovati ve surgical manageme nt of the crooked nose. Facial Plast Surg Clin North
Am 1993;1 :63-78.
6. Met zinger SE, Boyce RG, Ri gby PL, Joseph JJ, Anderson JR. Ethmoid bone sandwich grafting for caudal sep
tal defect s. Arch Otolaryngol Head Neck Surg 1994;120 : 1121-11 25.
7. Toriurni DM. Subtotal reconstruction of the nasal septum: a preliminary report. La ryn goscope 1994 ; 104:
906-9 13.
8. Daniel RK. Rhinopl asty and rib grafts : evo lvi ng a flexible operati ve techni que. Plast Reconstr Surg 1992 ;94:
597-6 11.
9. Wang TO. Aestheti c struct ural nasal augmentation. Opel' Tech Otolaryngol Head Nec k Surg 1990.
12
Harvest of
Autogenous Tissue
HARVESTING CONCHAL CARTILAGE: ANTERIOR APPROACH
Auricular cartilage can be harvested using the anterior or posterior approach (1-6). In
most cases, we prefer the anterior approach because we believe it is less traumatic, and the
incision heals well if vertical mattress closure is used. If smaller cartilage grafts are needed,
then we use the posterior approach.
With a marking pen, outline an incision that follows the outer edge of the cavum and
cymba concha. This incision should be placed along the portion of the concha that is verti
cally oriented in relation to the lateral aspect of the skull (Fig. I). Use a syringe with 1% li
docaine (Xylocaine) solution with 1:100,000 epinephrine (or for the lab demonstration, wa
ter) to "hydrodissect" the skin of the concha cavum and cymba from the underlying
cartilage.
Make the incision with a no. 15 blade, and elevate the skin and perichondrium from the
underlying cartilage. Dissection proceeds by using appropriate scissors, and also bluntly
with cotton-tip applicators. Care should be taken not to damage the soft auricular cartilage,
which can tear. The dissection should stop short of the cartilage of the external auditory
canal. The radix helicis should be preserved if preservation of ear position is critical. If the
entire conchal bowl in excised, the auricle will usually settle closer to the head.
Dissect out the desired piece of cartilage, and leave the underlying muscle behind (peri
chondrium will remain adherent to the posterior surface of the cartilage), Avoiding deep
dissection into the soft tissue minimizes bleeding.
Suture the circumferential incision with a 6-0 nylon running mattress suture. Alterna
tively, the incision may be closed with interrupted vertical mattress sutures. Special care
must be taken to avoid overlap of the skin edges. Place a bolster dressing of Telfa, dental
roll, or other suitable material into the concha, and suture it into position to decrease the
risk of hematoma. No residual deformity of the pinna is expected with this approach.
139
A
c
E
B
o
F
Figure 1.
--
141 Harvest oj Autogenous Tissue
G
K
H
J
L
Figure 1, continued. A-T: Injection hydrodissects the skin of the concha cavum and cymba
from the underlying cartilage (A). The incision follows the outer edge of the cavum and
cymba concha and is placed along the portion of the concha that is vertically oriented in re
lation to the lateral aspect of the skull (B, C). Dissection proceeds by using appropriate scis
sors, and also bluntly with cotton-tip applicators (D-G). The dissection stops short of the car
tilage of the external auditory canal. Incise the cartilage (H, I) and dissect out the desired
piece of cartilage (J, K). Achieve perfect hemostasis before closure (L). The cartilage should
be handled gently to avoid tearing or damaging the soft auricular cartilage.
Il
, ; ~ ,
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M
o
Q
s
N
p
R
T
143
C
Harvest oj Autogenous Tissue
HARVESTING ETHMOID BONE
The perpendicular plate of the ethmoid bone and/or the vomer may be used as a splint
ing graft in the treatment of a deviated cartilaginous septum. Ethmoid bone may be har
vested via a standard septoplasty approach.
HARVESTING RIB GRAFT
Cartilage is typically harvested (Fig. 2) from the eighth and ninth ribs or the confluence.
If additional cartilage is requi red, the tenth rib also may be harvested. Bone may be har
vested with the ninth rib if desired .
A B
Figure 2. Rib cartilage harvest. Cartilage is typically
harvested from the eighth and ninth ribs. A 4 cm to 6 cm
incision overlying the eighth rib allows adequate expo
sure (see also Chapter 11, Fig. 6). Dissection proceeds
to and then through the rib perichondrium . Dissection
around the rib is undertaken subperichondrially; the
pleura is typically closely adherent to the perichondrium .
With the donor rib completely separated from surround
ing soft tissue, the graft is incised and delivered under di
rect vision. The surgeon may place a malleable retractor
beneath the rib as it is incised.
...
Figure 1, continued. Suture of the circumferential incision is shown here with a 6-0 nylon
running vertical mattress suture (M-P). Alternatively, one may close the incision with in
terrupted mattress sutures . Place a bolster dressing of Telfa, dental roll, or other suitable
material into the concha and suture it into position (0-T) to decrease the risk of
hematoma.
.- --,
. . . " ~
- ~
~ " 3 ! '
A 4-cm to 6-cm incision overlying the eighth rib allows adequate exposure. Dissection
proceeds to and then through the rib perichondrium. The muscle fibers can be separated in
stead of cut to minimize postoperative pain. Dissection around the rib is undertaken sub
perichondrially; the pleura is typically closely adherent to the perichondrium. With the
graft completely separated from surrounding soft tissue , the graft is incised and delivered
under direct vision. The surgeon may elect to place a malleable retractor beneath the rib as
it is incised. Saline is placed in the surgical site and Valsalva or positive pressure applied
to check for a pleural leak . If a pleural tear is identified, a pursestring suture closure is un
dertaken around a red-rubber suction catheter. The surgeon then requests a "Val salva " from
the anesthesiologist. The red rubber is then removed and the suture tightened. Saline may
be placed in the wound and another Valsalva undertaken while the surgeon carefully in
spects for air bubbles. A standard, layered soft-ti ssue closure without a drain is accom
plished. Skin edge eversion can be accomplished with everting subcutaneous sutures.
A chest radiograph is obtained in all patients after rib harvest. In the rare instance of a
difficulty, the surgeon may wish to consult the appropriate surgical colleague.
HARVESTING CALVARIAL BONE
Parietal bone may be harvested (Fig. 3) through a horizontal incision (typically, 4 em to
6 em) superior to the temporal line. Typically the nondominant side is chosen. Incision to
and through the periosteum, followed by subperiosteal undermining, provides proper ex
posure. A drill is used to outline the proposed graft (typical graft size, 1 em to 1.5 em by 4
em to 4.5 em) . A trough is drilled through the outer table to the diploe; this allows the
proper angle for application of a chisel or powered oscillating saw to harvest the grafts care
fully. Short controlled taps on a sharp osteotome allow increased precision and help de
crease the risk of inner-table penetration and dural tear.
Patients must be cautioned preoperatively of the risk of possible dural tear and possible
brain injury. Any dural entry should elicit an immediate neurosurgical consultation.
The donor site can be contoured with hydroxyapatite cement or any other biocompatible
bone substitute material. The incision is typically closed in a multilayer fashion .
A
' f
B
Harvest of Autogenous Tissue 145
o C
E F
Figure 3. Calva rial bone harvest. Parietal bone may be harvested through a horizontal incision (typi
cally, 4 cm to 6 cm) superior to the temporal line. Typically the nondominant side is chosen (A). A drill is
used to outline the proposed graft (typical graft size, 1 cm to 1.5 cm by 4 cm to 4.5 cm) . A trough is drilled
through the outer table to the diploe (B , 0, E). A chisel or powered oscillating saw may be used to har
vest the grafts carefully (C, F-I). Narrower grafts are safer and easier to harvest.
- ~
l- T ~ ! l J !
'. . . i l -
G
H
Figure 3, continued. Short , controlled taps on a sharp os
teotome (H) allow increased precision and help decrease
the risk of inner table penetration and dural tear.
PEARLS
When harvesting auricular cartilage, the surgeon can simplify the dissection by
performing local anesthetic injections in the subperichondrial plane. This will act
to hydrodi ssect the flap and allow blunt dissection to elevate the flap.
Special care must be taken to evert the skin edges when performing the skin clo
sure. There will be a tendency for the dissected flap to overlap the skin on the side
that was not dissected. Vertical mattress sutures are most effective for aligning the
skin edges. . " . . " "
If lateral ear position is a concern, the radix helicis can be left'intact to support the
auricle and preserve lateral ear position.
Perichondrium can be dissected off the posterior surface of the cartilage and used
as tissue for camouflage or to cushion a tip graft.
If small cartilage grafts are needed, the posterior approach can be used to harvest
ear cartilage. . "" "
If the patient has one ear that protrudes more than the other; then the cartilage
should be harvested from that side: If the' patient sleeps on one side 'of the head,
. then the cartilage should be removed from the contralateral side.
. .
- -
147 Harvest oj AutogenousTissue
PEARLS, continued
. Harvesting Costal Cartila ge
Palpate appropriat e-shaped cartilage, and place the incision over the rib to be har
. vested. In female patient s, the incision should be placed in the proximity of the in
framammary crease .
Postoperative pain can be minimi zed by cutting as little muscle as possible when
dissecting over the costal cartilage . The muscle fibers can be bluntly dissected to
expose the costal cartilage and .then retracted to perform the dissection.
Postoperative pain can be significantly decreased by keeping the inferior ribs intact
to support the rib cage. With the inferior ribs intact, the patient will have much less
pain on inspiration.
Dissect perichondrium off cartilage, taking special care to elevate perichondrium
off the inferior surface of the costal cartilage. By leaving the perichondrium intact
over the pleura, there will be minimal chance of pneumothorax.
The incision should be closed in multiple layers. After closing the muscle, fascia,
. and subcutaneous tissues, evert the dermal sutures [4-0 polydioxanone suture
(PDS)] to provide prolonged support to the skin edges: The wound will remain
everted for several months; however, the scar camouflage will be excellent.
Patients should be informed of the temporary excess eversion of the skin edges.
With costal cartilage for grafting, symmetric carving is essential to avoid postop
erative warping.
Harvesting Ethmoid Bone
. AVOId resecting ethmoid bone high near the cribriform plate !o prevent cere
brospinal fluid leak. Use atraumati c instruments and techniques when removing
the bone. .
. The bone graft can be shaped with a burr.
Harvesting Cal varial Bone .
Examine the curvature of the skull to determine the 1TI0st favorable shape to the
.bone to harvest the bone graft. The parietal or occipital areas are the most common
areas where calvarial bone grafts are harvested. - .
Create a bone trough down to the diploic layer to allow a curved osteotome to ele
vate the external table gently off an intact inner table. Generous irrigation is nec
essary to avoid damage to the bone. . .
Narrower I 'ern to 2 ern strips of bone are easier to elevate off the inner table.
The bone defect can be filled witha bone substitute material.
REFERENCES
I. Tard y ME, Denn eny J, Frit sch MH. The versat ile cartilage autograft in reconstructi on of the nose and face .
Laryngoscope 1985;95:523- 532.
2. Met zinger SE, Boyce RG, Rigby PL, Joseph JJ , Ande rson JR. Ethmoid bone san dwich graf ting for caudal sep
tal defects. Arch Otol Head Neck Surg 1994; 120: 1121-11 25.
3. Dani el RK. Rhin oplasty and rib gr afts: evolvin g a flexible operative technique. Plast Recon str Surg 1992;94:
597--6 11.
4. Wan g TD. Aesth etic structural nasal aug mentat ion. Opel' Tech Otol aryngol Head Neck Su rg 1990.
5. Tardy ME. Rhinoplasty: the art and the scie nce. Philadelphia: WB Saund ers, 1997.
6. Chen ey ML, Glicklicb RE. The use of calvari al bone in nasal reconstruction. Arch Otolaryng ol Head Neck
Surg 1995; 121 :643-648.
. -ii
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13
Incision Closure, Nasal
Splint, Postoperative
Considerations
CLOSURE OF THE MIDCOLUMELLAR INCISION
A single, subcutaneous 6-0 polydioxanone suture (PDS) can be positioned in the dermal
tissues to enhance skin-edge eversion and take tension off of the closure (Fig. I). This su
ture should provide skin-edge alignment and slight eversion . Excessive eversion will cre
ate a deformity that may require many months to resolve. The level of the skin edges must
be preci sely aligned with this suture; otherwise, an unsightly scar may result. If there is no
tension on the closure, a subcutaneous suture may not be necessary.
To close the skin, five 7-0 nylon vertical mattres s sutures are used. The first suture lines
up the apex of the inverted V. The next two sutures are angled from medial on the lower
flap to lateral on the upper flap to align the closure properly. A 6-0 chromic suture is used
to line up the vestibular skin at the corner of the columellar flap. This corner suture is im
portant because aberrant healing of this corner can result in a visible notch defect.
149
, I
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1111
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RHINOPLASTY DISSECTION MANUAL 150
\8
A
D
151 Incision Closure, Nasal Splint, Postoperative Considerations
E
G
F
H
Figure 1. A-D: Closure of external columellar incision . Note how the two sutures placed
just off the midline are angled from medial on the lower flap to lateral on the upper flap. This
will recruit redundant skin medially and prevent lateral notching of the columellar incision.
Intraoperative photographs (E, F) highlight proper suture placement. When the columellar
flap is elevated properly , and then closed meticulously, it should be inconspicuous, as illus
trated in this preoperative (G) and postoperative (H) base view.
-
.
.

- -_ I

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Figure 2. Closure of endonasal incisions.
CLOSURE OF THE MARGINAL, INTERCARTILAGINOUS,
OR TRANSCARTILAGINOUS INCISION
This incision is closed with one or two 5-0 chromi c sutures located laterally that act to
advance the lateral crura slightly toward the domes (Fig. 2) This suture advancement will
negate the need for an additional suture placed in the region of the domes. All sutures used
to close the marginal incision must be exami ned to make sure there is no distortion of the
nostril rim or domal region. If the nostril rim is notched, then the suture should be repl aced,
taking a smaller bite.
PLACEMENT OF INTRANASAL PACKS, NASAL SPLINT
Intranasal Pack
When extensive septoplasty is undertaken, or when partial turbinectomy or turbinoplasty
is performed, the surgeon may wish to place a temporary intranasal pack. The goal is to pro
vide some compression of the septal flaps and, in the case of turbin ate surgery, to decrease
the risk of postoperative bleeding. There are a number of commercially available packs. An
intran asal pack is typically left in place at most overnight and removed the next morning.
External Splint
A great variety of splints are commercially available. In general, after placement of an
appropriate adhesive, a small rectangular strip of Telfa is placed over the nasal dorsum to
facilitate removal of the splint in 5 to 7 days. Tape is applied over the dorsum and the nasal
tip. A splint is carefully applied.
POSTOPERATIVE CARE
The sutures should be removed from the columellar inci sion after 5 days. At that point,
the incision may be supported with flesh-colored steri-strips for several week s to act as an
titension taping. Persistent postoperative supratip edema can be treated with subdermal in
153 Incision Closure, Nasal Splint, Postoperative Considerations
jections of triamcinolone acetonide (Kenalog; 10 mg/ml , 0.1 ml ) injected into the supratip
region of the nose. These subdermal injections should not be used in any region othe r than
the supratip and should not be used more frequentl y than once every 8 weeks. Superficial
injections or excessi ve use can result in subdermal atrophy.
PEARLS
Closure of external rhinoplasty incisions; ,
If there is any tension on the closure, a midline 6-.0PDS suture can be applied to
evert the skin edges . Special care must be taken to align the skin edges properly.
If the subcutaneous suture is not placed properly, the result wili likely be avisible
.scar.
The columellar incision is closed with the first 7-0 nylon vertical mattress suture
' : placed in the precise midline. The next two sutures are placed just off midline and ,'
, are angled from medial on the lower flap to lateral on the upper flap. This maneu
ver will minimize the chances of creating a notch at the lateral aspect of the col
umellar flap.
After closing the marginal iricision , the surgeon should check the alar margin to
ensure that there is no notching of the margin . Thi s occurs if too much mucosa is
taken and acts to deform the alar rim.
' " The surgeon Should examine the columellar extension of the columellar incision.
In mostcases , no suture IS needed in this regi on because the vestibular skin is ad
equately aligned. In some cases, the vestibular skin is not aligned properly, and a
6-0 chromicsuture should be used to align the incision properly. '
Application of the Cast
' . A strip of Telfa can be applied over the dorsum to allow the cast and tape to bere
moved without lifting the dorsal skin off the underlying nasal skeleton, with l'e
suIting edema.
, The nose should be loosely taped to avoid vascular compromise. The tissues will
become edematous, and if taped tootight, the tissues may become compromised,
An Aquaplast cast can be loosely applied to the nose and left in place for 5 days .
At,the time of cast removal, adhesive remover applied through the holes in thecast
will loosen the tape. A blunt instrument can be used to lift the cast and tape care- .'
fully off the nose. '
Postoperative Care , "
At the time of cast removal, the tape should be loosened with adhesive remover '
that is applied through the holes in the Aquaplast cast and allowed to work for 5 to
10 minutes. ' ,
, Digital exercisescan be used in the patient who has adeviated nose. These patients
,can perform digital exercises on the nasal bones to avoid postoperative shifting of
the bony nasal vault. This must be done within 10 days after surgery; otherwise,
the bones wiil have started to fixate . '
Postoperative steroid injections can be' used to correct subtle aSYrrllnetries of the
nose . Triamcinolone acetonide (Kenalog; 10 mg/ml ) can be injected into the sub
dermal region where excessive asymmetric edema is noted. ' ,
" ', ' . ,'" "
REFERENCES
1. Toriumi OM, Johnson Cvl. Open structure rhinoplasty featured technical points and long-term follow-up, Fa
cial Plast Surg Clin North Am 1993; I :1-22,
2. Johnson eM Jr, Toriumi OM, Open structure rhinoplasty. Phi ladelphia: WB Saunder s, 1990.
3. Tardy ME, Rhinoplasty: the art and the science. Philadelphi a: WB Saunders, 1997.
-..

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Appendix A:
Tripod Concept
TRIPOD CONCEPT
When considering the effect of surgical techniques on the nose, one may think of the tip
as a tripod, with each lateral crus composing one leg of the tripod , and the paired medial
crura composing the third leg (l ,2). Shortening the two "lateral crura!" legs will cause the
tripod to fall in that direction, thereby "rotating and deprojecting" the tripod . Weakening
these two legs (as with cephalic resection) is also said to have the same effect (although less
so), as the healing forces applied to these weakened legs of the tripod will cause the tip to
rotate and deproject slightly over time. Similarly, a columellar strut will strengthen the
"medial crural " leg of the tripod. Use of a columellar strut to correct buckled medial or in
termediate crur a may increase tip projection and rotation. Even though the tripod concept
oversimplifies the dynamics of the nasal tip, it provides those with little experience in
rhinoplasty with a method of predicting the effects of specific techniques.
REFERENCES
I. Ander son JR. A reasoned approach to nasal base surgery. Ar ch Otolaryngol Head Neck Surg 1984;110:
349-358.
2. McCollou gh EG. Surgery of the nasal tip. Otolaryngol Clin North Am 1987 ;20:769-784.
155
Appendix B:
Guide to Nasal Analysis
NASAL ANALYSIS
General
Skin quality: Thin, medium, or thick
Primary descript or (i.e., why is the patient here): For example , "big," "twisted," "large
hump "
Frontal View
Twisted or straight: Follow brow-tip aesthetic lines
Width: Narrow, wide, normal , "wide-narrow- wide"
Tip: Deviated, bulbous, asymmetri c, amorphous, other
Base View
Triangularity: Good versus trapezoid al
Tip : Deviated, wide, bulbous, bifid, asymmetric
Base: Wide, narrow, or normal. Inspect for caudal septal deflecti on
Columella: Columellarllobule ratio (normal is 2: 1 ratio); status of medial crural footplates.
Lateral View
Nasofrontal angle: Shallow or deep
Nasal starting point: High or low
Dorsum: Straight, concavity, or convexit y; bony, bony-cartilaginous, or cartilaginous (i.e.,
is convexity primarily bony, cartilaginous, or both)
Nasal length: Normal, short, long
Tip projection: Normal, decreased, or incre ased
Alar-columellar relationship: Normal or abnormal
Nasa-labial angle: Obtuse or acute
Oblique View
Does it add anything, or does it confirm the other views?
Many other points of analysis can be made on each view, but these are some of the vital
points of commentary.
Appendices 157
Appendix C:
Aesthetic Analysis
LANDMARKS FOR ANALYSIS: POINTS
See figures on page 10.
Trichion: Anterior hairline in the midline
Glabella: Most prominent midline point of forehead, well appreciated on lateral view
Nasion : Most posterior midline point of forehead, typically corresponds to nasofrontal su
ture
Rhinion: Soft-tissue con-elate of osseocartilaginous junction of nasal dorsum
Sellion: Osseocartilaginous junction of nasal dorsum
Supratip: Point cephalic to the tip
Tip: Ideally, most anteriorly projected aspect of the nose
Subnasale: Junction of columella and upper lip
Labrale superius : Border of upper lip
Stomion: Central portion of interiabial gap
Stomion superius: Lowest point of upper-lip vermilion
Stomion inferiu s: Highest point of lower-lip vermilion
Mentolabial sulcus: Most posterior midline point between lower lip and chin
Pogonion: Most anterior midline soft-tissue point of chin
Menton: Most inferior point on chin
Cervical point: Point of intersection between line tangent to neck and line tangent to sub
mental region
Gnathion: Point of intersection between line from subnasale to pogonion and line from cer
vical point to menton
-
.
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Appendix D:
Surface Angles, Planes,
and Measurements:
Definitions
Facial thi rds
Upper third: Trich ion to glabella
Middl e third: Glabella to subnasale
Lower third : Subnasale to menton
Horizont al fifths: Five equally divided vertical segments of the face
Frankfort plane: Plane defined by a line from the most superior point of auditory canal to
most inferior point of infraorbital rim
Nasofrontal angle: Angle defined by glabella-to-nasion line intersect ing with nasion-to-tip
line. Normal, 115 to 130 degrees (within this range, more-obtuse angle more favorable
in female, and more acute angle in male patients)
Nasofacial angle: Angle defined by glabella-to-pogonion line intersecting with nasion-to
tip line. Normal , 30 to 40 degrees
PEARL
. . .
Normal projection with a "3-4-5" triangle described by Crumley (see below)
give s a nasofacial angle of 36 degrees. .
Nasomental angle: Angl e defined by nasion-t o-tip line inter secting with tip-to-pogonion
line. Normal , 120 to 132 degrees
Rel ationship of lips
To nasomental line: Upper lip, 4 mm behind; lower lip, 2 mm behind line from nasal tip
to menton
To subnasale-to-pogonion line: Upper lip, 3.5 mm anteri or; lower lip, 2.2 mm anteri or
Mentocervical angle: Angle defined by glabella-to-pogonion line intersecting with men
ton-to-cervical point line
Legan faci al-convexit y angle: Angle defined by glabella-to-subnasale line intersecting
with subna sale-t o-pogonion line; normal, 8 to 16 degrees
PEARl;
Useftil in assessing chin deficiency, candidacy for chin implantchin
or other chin alterati on
Nasolabi al angle: Angle defined by columellar point-to-subnasale line intersecting with
subnasale-to-labrale superius line; normal , 90 to 120 degr ees (within this range, more
obtuse angle more favorabl e in female, and more acute in male patient s)
Columellar show: Alar-columellar relat ionsh ip as noted on profile view; 2 to 4 mm of col
umell ar show is normal
Appendices 159
Nasal projection: Anterior protrusion of nasal tip from face
Goode' s method: A line drawn through the alar crease, perpendicular to the Frankfurt
plane. The length of a horizontal line drawn from the nasal tip to the alar line divided by
the length of the nasion-to-nasal tip line. Normal , 0.55 to 0.60 (2,3)
Cruml ey' s method: The nose with normal projection forms a 3-4-5 triangle (i.e., alar
point-to -nasal tip line (3), alar point-to-nasion line (4), nasion-to-nasal tip line (5) (4).
Byrd's method : Tip projection is two-thirds (0.67) the planned postoperative (or the ideal)
nasal length. Ideal nasal length in this approach is two-thirds (0.67) the midfacial height
(5)
Powell and Humphries "Aesthetic Triangle":
Nasofrontal: 115 to 130 degrees
Nasofacial: 30 to 40 degree s
Nasomental : 120 to 132 degree s
Ment ocervic al: 80 to 95 degrees
REFERENCES
1. Tardy ME, Walt er MA, Patt BS. The overprojecting nose: anatomic component analysis and repair. Facial
Plast Surg 1993;9:306-3 16.
2. Ridley MB. Aesthetic facial proportions. In: Papel ID, Nachlas NE, eds. Facial pla stic and reconstructive
surgery. St. Louis : Mosby Year Book, 1992:99-109.
3. Crumley RL, Lanser M. Quantitative analysis of nasal tip projection. Laryngoscope 1998;98:202- 208.
4. Byrd HS, Hobar Pc. Rhinoplasty: a pract ical guide for surgical planning. Plast Reconstr Surg 1993;91:
642-654.
Appendix E:
Tip Support, Incisions,
and Approaches
MAJOR TIPSUPPORT MECHANISMS
1. Size, shape, and strength of lower lateral carti lages
2. Medial crural footpl ate attachment to caudal septum
3. Attachment of caudal border of upper lateral cart ilages to cephal ic border of lower lat
eral cartila ges
[Nasal septum also is considered a major support mechanism of the nose.]
MINOR TIPSUPPORT MECHANISMS
1. Ligament ous sling spanning the domes of the lower lateral cartilages (i.e., interdomal
ligament)
2. Cartilaginous dorsal septum
3. Sesamoid complex of lower lateral cartilages
4. Attachment of lower lateral cartilages to overlying skin/soft-tissue envelope
5. Nasal spine
6. Membranous septum
INCISIONS: METHODS OF GAINING ACCESS
I. Intercartilaginous
2. Transcartilaginous
3. Marginal (NOT to be confused with rim incision)
4. Transcolumellar
APPROACHES: PROVIDE SURGICAL EXPOSURE
1. Cartilage-splitt ing
2. Retrograde
3. Delivery: Marginal + intercartilaginous incision
4. External approach: Marginal + transcolumellar incision
SCULPTING TECHNIQUES: SURGICAL MODIFICATIONS
I. Complete strip (i.e., cephalic resection) or volume reduction of lateral crur a
2. Incompl ete strip (dome division)
3. Transdomal/dornal sutures
4. Augmentation grafting
5. Tip graft
6. Other
REFERENCES
I . Tardy ME. Rhinoplasty: the art and the science. Philadelphia: WB Saunders, 1997.
2. Tardy ME, Toriumi DM. Philosophy and principles of rhinoplasty. In: Cummings CW, Fredri ckson 1M,
Harker LA, et al., eds. Otolaryngology: head & neck surgery. 2nd ed. St . Louis: Mosby Year Book, 1993:
278-294 .
Appendices 161
Appendix F:
Achieving Surgical Goals:
Selected Options
INCREASE ROTATION
Lateral crural steal
Transdomal suture that recruit s lateral crura mediall y
Base-up resecti on of caudal septum (variable effect)
Cephalic resection (variable effect)
Lateral crural overlay
Columell ar strut (variable effect)
Plumpin g grafts (variable effect)
Illusions of rotation: increased doubl e break, plumping grafts (blunting nasolabi al angle)
DECREASE ROTATION (COUNTERROTATE)
Full transfixion incision
Double -layer tip graft
Shorten medial crura
Caudal extension graft
Reconstruct L-strut , as in rib graft reconstruction (integrated dorsal graft/columellar strut)
of saddle nose
INCREASE PROJECTION
Lateral crural steal (increas ed projection, increased rotation)
Tip graft
Plumping graft s
Premaxillary graft
Septocolumell ar sutures (buried)
Columell ar strut (vari able effect)
DECREASE PROJECTION
High parti al, or full transfixi on incision
Lateral crural overlay (decreased projecti on, increased rotation)
Nasal spine reduction
Vertical dome division with excision of excess medial crura, with suture reattachment
INCREASE LENGTH
Radix graft
Double-layer tip graft
Reconstru ct L-strut
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DECREASE LENGTH
See increas e rotation
Also, deepen nasofrontal angle
Set-back and suture medial crur a to midline caudal septum
TIP REFINEMENT
Cephalic resection (volume reduction)
Dome-binding sutures
Vertical dome division, with suture reconstitution
Tip graft
REFERENCES
1. Tardy ME. Rhinoplasty: the art and the science. Phil adelphia: WB Saunders, 1997.
2. Johnson CM Jr, Toriumi OM. Open structure rhinoplasty. Philadelphia: WB Saunders, 1990.
3. Tardy ME, Toriumi OM. Phil osophy and pri ncipl es of rhinoplasty. In: Cummin gs CW, Fredrickson Jlvl,
Harker LA, et al., eds. Otolaryngology: head & neck surgery. 2nd ed. St. Louis: Mosby Year Book, 1993:
278- 294.
Appendices 163
Appendix G:
Selected Complications
ofRhinoplasty
Bossae: A knuckling of lower lateral cart ilage at the nasal tip caused by contractural heal
ing forces acting on weakened cartilages. Patients with thin skin, strong cartil ages, and
nasal-tip bifidity are especially at risk. Exce ssive resection of lateral crus and failure to
eliminate excessive interdomal width may play some role in bossae formation .
Polly beak: Postoperative fullnes s of the supratip, with an abnormal tip-supratip relation.
This has several etiologies: Failure to maintain adequate tip SUpp0l1 (postoperative loss
of tip projection), inadequate cartilaginous hump (anterior sept al angle) removal, and/or
supratip dead space/scar formation .
Treatment depends on anatomic cause. If the cartilaginous hump was underresected,
then resect additional dorsal septum. One also must ensure adequate tip support. Ma
neuvers such as placement of a columellar strut may be of benefit. If the bony hump was
overresected, consider a graft to augment the bony dorsum. If a polly-beak is from ex
cessive scar formation, consider triamcinolone (Kenalog) injection or skin taping in the
early postoperative period, before any consideration of surgical revision.
Inverted V deformity: Inadequate support of the upper lateral cartilages after dor sal-hump
remov al can lead to inferomedial collapse of the upper lateral cartilages and an "inverted
V deformity." In this deformity, the caudal edges of the nasal bones are visible in broad
relief. Inadequate infracture of the nasal bones is also a frequent cause. When executing
hump excision, it is helpful to preserve the underlying nasal mucoperichondrium (extra
mucosal dissection), which provides significant supp ort to the upper lateral cartilages
and helps decrease the risk of inferomedial collapse of the upper lateral cartilages after
hump excision. When undertaking osteotomies after hump excision, appropriate infra c
ture and narrowing of the bony vault must be achieved.
Rocker deformity: If osteotomies are taken too high, into the thick frontal bone , the supe
rior aspect of the osteotomized nasal bone may project or "rock" laterally when the bone
is infractured. This is a "rocker" deformity. A 2-mm osteotome may be used percuta
neously to create a more appropriate superior fracture line and correct the rocker defor
mity.
Dorsal irregularities: After creation of an "open roof" by hump removal, the bony mar
gins should be smoothed with a rasp. Any bony fragments should be removed, making
sure that all obvious particles are removed from under the skin/soft-tissue envelope. Fail
ure to remove all fragments may lead to a visible and/or palpable dorsal irregularity.
Nasal valve collapse: The surgeon should recognize the existence of the internal and ex
ternal nasal valve . The internal nasal valve area is bounded by the caudal margin of the
upper lateral cartilage, septum, and floor of the nose. The external nasal valve refers to
the area delineated by the cutaneous and skeletal support of the mobile alar wall. Exces
sive narrowness in either of these locations may cause nasal obstruction. Weakness at ei
ther of these locations may result in collapse with the negative pressure of inspiration,
resulting in nasal airway obstruction. Nasal valve collapse is seen most often as a sequela
of overresection of lateral crura or middle vault collapse. Overaggressi ve resection of the
lateral crura and the subsequent postoperative soft-tissue contraction frequently leads to
nasal valve compromise.
-
. "'"
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,
/
REFERENCES
J. Simons RL, Gallo JF. Rhinoplasty complications. Facial Plast Surg cu Nor th Am 1994;2:52 1-529.
2. Kamer FM, Pieper PG. Revision rhinoplasty. In: Bailey B, ed. Head and Ne ck Surge ry Oto laryngolo gy.
Philadelphi a: Lippincott, 1998:2663- 2676.
3. Tardy ME, Kron TK, Younger RY, Key M. The cartilaginous pollybeak: etiology, prevention, and treatment.
Facial Pla st Surg 1989;6: 113-1 20.
4. Larrabee WF Jr. Open rhinoplasty and the upper third of the nose. Facial Plast Surg Clin No rth Am 1993;I:
23-38 .
5. Toriumi DM. Management of the middle nasal vault. Oper Tech Pl ast Reconstr Surg 1995;2: 16-30.
6. Becker DG, Toriumi DM, Gross CW, Tardy ME. Powered instrumentation for dorsal nasal reduction. Facial
Plast Surg 1997; 13:291-297.
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Appendices 165
Appendix H:
Adjunctive Procedures
Chin implant (Fig. 1)
~ ~
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A B
Figure 1. Chin augmentation can be a useful adjunctive procedure to create facial balance
in the patient with an underdeveloped chin, In this illustration, only the chin differs between
these two line drawings.
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Submental lipectomy (Fig. 2)
A B
Figure 2. In the selected patient seeking nasal surgery, submental lipectomy is another
useful adjunctive procedure to create facial balance .
REFERENCE
1. Tardy ME, Thomas JR. Facial aesthetic surgery. Philadel phia : Mosby, J995.
Appendices 167
Appendix I:
Cleft Lip Nasal Deformity
UNILATERAL CLEFT (Fig. 3)
Nasal tip:
Medi al crus of LLC shorter on cleft side
Lateral crus of LLC longer on cleft side (total length of cleft and noncleft side LLC are
the same)
Tip-defining point on cleft side is flat and laterally displa ced
Columella:
Short on cleft side
Columellar base directed to noncleft side (unopposed orbiculari s muscle )
Nostril:
Hori zontal orientation on cleft side
Alar base:
Laterally , inferi orly, and post eriorly displaced on cleft side
Nasal floor:
Usually absent
Septum:
Caudal deflect ion to noncleft side
Posterior deflection to cleft side
BILATERAL CLEFT
Figure 3. Cleft-lip nasal deform ity. Typical anatomic findings characteristic of unilateral
cleft-lip nasal deformities.
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Nasa l tip:
Medial cr ura short bilatera lly
Lateral crura short bilaterally, caudally displaced
Tip-defining points poorly defined and widely separated
Columella:
Short, with a wide base
Nostri ls:
Horizontal orientation bilaterally
Alar base :
Laterally, inferiorly, and posteriorly displaced bilatera lly
Nasal floor:
Usually abse nt bilaterally
REFERENCE
J. Sykes 1M, Senders CW, Wang TD. Cook TA. Use of the open approach for repai r of secondary cleft lip nasal
defo rmity . Facial Plast Surg ChI! North Am 1993 ; 1: 111- 126.
Appendices 169
Appendix J:
Photography Setup (1)
(Fig. A-4)
Camera: 35-mm SLR (single light refl ex camera) with 105-mm macro lens
Lighting: dual elect ronic flash units; overhead kicker light adds a backlighting effect that
improves picture quality and sof tens or eliminates background shadows
Background: Nassau blue no. 25
Film: Kodak Ektachrome ASA 100
STANDARD RHINOPLASTY VIEWS
1:7, front al, base, lateral, oblique
1:5 and 1:3, close-up, base view
Background
~ Overhead Kicker Light
/ I \ \
8
Light Source Light Source
Camera
Figure 4. Schematic photography setup.
REFERENCE
I. Tardy ME. Brown R. Principles ofphotography inf acial plastic surgery. New Yor k: Th ieme Publishers. 1992.
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Appendix K:
Indications For External
Rhinoplasty Approach
(1,2)
Asy mmetric nasal tip
Crooked-nose deformity (lower two thirds of nose)
Sadd le-nose deformity
Cleft- lip nasal deformity
Secondary rhinoplasty requiring complex structural grafting
Septal -perforation repair
REFERENCES
I. l ohnson CM 1r, Toriumi DM. Open structure rhinoplasty. Philadelphia: WB Saunders. 1990.
2. Toriumi DM, l ohnson CM. Open structure rhi noplasty: featured technical point s and long-t erm follow -up. Fa
cial Plast Surg Clin North Am 1993; I: 1-22.
Appendices 171
Appendix L:
Suggested Surgical
Instruments for
Rhinoplasty
1. Needle holder
2. Bayonet forceps
3. Mallet
4. Takaha shi forceps
5. Siegel retractor
6. Converse retractor
7. Hemostat (curved)
8. Hemostat (straight)
9. Small nasal speculum
10. Large nasal speculum
I I. Small single skin hook
12. Small double skin hook
13. Small double skin hook
14. Medium double skin hook
15. Wide double skin hook
16. Freer/Cottle elevator
17. Joseph elevator
18. Converse scissors
19. Fomon scissors
20. Straight Stevens scissors
21. Curved Stevens scissors
22. Curved Iris scissors
23. Scalpel handle
24. Scalpel handle
25. Brown-Adson forceps
26. Brown-Adson forceps
27. Bishop-Harmon forceps
28. Bishop-Harmon forceps
29. 2.0-mm unguarded osteotome
30. 3.0-mrn straight unguarded osteotome
31. 3.0-mm straight guarded osteotome
32. 2.5-mm straight guarded osteotome
33. Medical grade sharpening stone
34. Dorsal (Rubin) osteotomes : small, medium, large
35. Rasps with tungsten-carbide inserts: 1/2, 3/4, 5/6
36. Aiache cartilage crusher
37. No. 10 Frazier tip suction
. -II.
-=?i:
=- -4-
U1
I -".
Appendix M:
List of Selected
Companies with
Address/Phone Numbers
RHINOPLASTY INSTRUMENT SETS
Anthony Products, Inc., Indianapolis, IN 800 428-1610
Ell is Instruments, Inc., Madison, NJ 800 218-9082
Instruments Unlimited, Quakertown, PA 800 818-0094
Invotec, Jacksonville, FL 800 998-8580
Lorenz Sur gical , Jacksonville, FL 800 874-7711
MicroFrance, St. Aubin, France 800- 874-5797
Smith-Nephew-Richards, Madi son, WI 888 395-8060
Snowden Pencer, Tucker, GA 800 843-8600
Stor z Instrument s, St. Louis, MO 800 325-9500
Xomed Surgical Produ cts, Jacksonville, FL 800 874-5797
ALLOPLASTIC CHIN IMPLANTS
Allied Biomedical, Paso Robles, CA 800 276-1322
Hanson Medi cal, Inc., Kingston, WA 800771-2215
Porex Surgical, Inc ., College Park, GA 800521-8145
W. L. Gore & Associ ates, Inc., Flagstaff, AZ 800 528-8763
Xomed Surgical Products, Jacksonville, FL 800 874-5797
ALLODERM
LifeCell Corporation, The Woodlands, TX 800367-5737
DERMABOND (OCTYL-2-CYANOACRYLATE)
Ethi con, Somerville, NJ 800 888-9234
RHINOPLASTY POWER INSTRUMENTATION
LinvatecIHall Surgical Products Group, Largo, FL 800 925-4255
United American Medical, McMinnville, TN 800 521-5002
NASAL SPLINTS
Invotec, Jacksonville, FL 800 998-85 80
Shippert Medical Technologies (Denver Splints), Englewood, CO 800 888-8663
Appendices 173
Vision Medical (Thermoplast), Peoria, AZ 800 874-5797
INTRANASAL PACKS
- - - _ J ~
. :. ~
-t-:
. '. ~ ,
Appendix N:
Selected Recommended
Literature
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Surg 1997;13:291-297.
Becker DG, Weinber ger MS, Greene BA, Tardy ME. Clinical study of alar anatomy and surgery of the alar base.
Arch Otolaryngo l Head Neck Surg 1997;123:789-795. '
Beeson WHoThe nasal septum. Otolaryngol Clin North Am 1987;20:743-767.
Byrd HS, Andochick S, Copit S, Walton KG. Septal extension grafts: a method of controlling tip project ion shape.
Plast Reconstr Surg J998; I00:999-1 0 IO.
Byrd HS, Hobar Pc. Rhinoplasty: a practical guide for surgical planning. Plast Reconstr Surg 1993;9 I:642-654,
discussion 655-656.
Cheney ML, Glicklich RE. The use of calvarial bone in nasal reconstruction. Arch Otola ryngol Head Neck Surg
1995; 121:643-648.
Constantian ME. The incompetent external nasal valve: patbophysiology and treatment in primary and secondary
rhinoplasty. Plast Reconstr Surg 1994;9 3:919-933.
Constantian MB, Clardy RB. The relative import ance of septal and nasaJ valvular surgery in correcting airway ob
struction in primary and secondary rhinoplasty. Plast Reconstr Surg 1996;98:38-54.
Crumley RL, Lanser M. Quantitative analysis of nasal tip projection. Laryngoscope 1998;98:202-208.
Daniel RK. Rhinoplasty and rib grafts: evolving a flexible operative technique. Plast Reconstr Surg 1992;94:
597-61 I.
Farrior RT. The osteotomy in rhinoplasty. Laryngoscope 1978;88: 1449.
Goode RL. Surgery of the incompetent nasal valve. Laryngoscope 1985;95:546-555 .
Gunter JP. The merit s of the open approach in rhinoplasty . Plast Reconstr Surg
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rier to cartilage warping. Plast Recons tr Surg 1998; I00: 161-1 69.
Gunter JP, Clark CP, Friedman RM. Internal stabilization of autogenous rib cartilage grafts in rhinoplasty: a bar
rierto cartilage warping. Plast Reconstr Surg 1997; J00: J6 1-169.
Gunter JP, Friedman RM. Lateral crural strut graft: technique and clinical applications in rhinoplasty. Plast Re
constr Surg 1997;99:943-955.
Gunter JP, Rohri ch RJ. Management of the deviated nose: the importance of septal reconstruct ion. Clin Plast Surg
1988;15:43-55.
Gunter JP, Rohrich RJ. Augmentati on rhinoplasty: dorsal onlay graft ing using shaped autogenous septal cartilage.
Plast Reconstr Surg 1990;86:39--45.
Gunter JP, Rohrich RJ, Friedman RM. Classification and correc tion of alar-columellar discrepancies in rhino
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Johnson CM Jr, Godin MS. The tensi on nose: open structure rhinoplasty approach. Plast Reconstr Surg 1995;95:
43- 51.
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Johnson CM Jr, Tor iumi DM. Open structure rhinoplasty . Phil adelphi a: WB Saunders, 1990.
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Facial plastic and reconst ruct ive surg ery. Philadelphia: Mosb y Year Book, 1992:337-343.
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1981; J07: 12- 16.
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Murakami CS, Larr abee WF. Comparison of osteot omy techniques in the treatment of nasal fractures. Facial Plast
Surg 1992;8:209-21 9.
Rohri ch RJ, Hollier LH. Rhinoplasty with advancing age: characteristics and management. Clin Plast Surg 1996;
23:281-296.
Appendices 175
Schwartz MS, Tardy ME. Standardized photodocumentation in facial plastic surgery. Facial Plast Surg 1990;7:
1-1 2.
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Pl ast Reconstr Surg 1984 ;73:230--237.
Sheen JH. Tip graft: a 20 year retrosp ect ive. Plast Reconstr Surg 1993;91:48- 63.
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Tardy ME. Rhinopla sty in midlife. Ot olaryngol Clin North Am 1980;13:289-303.
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11:111-1 15.
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Toriumi DM, Sykes JM, Johnson CM. Open structure rhinoplas ty for management of the non-caucasian nose.
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Toriumi DM, Tardy ME. Cartilage suturing techniques for correction of nasal tip deformitie s. Oper Tech Ot o
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Wang TD. Aestheti c structural nasal augmentation. Oper Tech Ot olaryngol Head Neck Surg 1990 .
.
- r. - ~
III '
:- ~ l I j l
~ ~ _ ' I , .'__
- - -
Subject Index
1'"
,11,,1
_U-'
{ , ~ .' '"
Subject Index
A page number followed by f indicates a figure.
A
Aesthetic analysis, I I, 157
Aesthetic/cosmetic issues
alar base reduction, 113
closure of midco lumellar inci sion, 149, 150f- 15 1f
Aesthetic triangle, 16, 20
Airway obstruction. See Nasal obstruction
Ala, rhinoplasty analysis, 20
Alar base
cleft lip-nasal deformity
bilateral, 168
unilateral, 167
resect ion, 113-115
alar wedge excision, 114, I ISf
internal excis ions, 115
internal nostril floor reduction, 113, 114f
pearl s, l iS
sliding alar flap, 114, 115f
wedge excision of nostri l floor and sill, 114, 114f
rhinoplasty analysis, 18
Alar batten graft, 105, 106f-I09f
Alar-columella relationship, 20, 21f
Alar-facial groove (junct ion), 2f, 3f
Alar flare
internal nostril floor reduction, 113, 114f
wedge excision of nostril floor and sill, 114, 114f
Alar lobule, 3f, 5, 20
Alar nasalis muscle, 4f
Alar sidewa ll, 2f
Anatomy of nose, 1- 7
musculature, 4f
nasal relationships, S, 7f
nasal valve area , 6
pearls, 5-6
scroll region, 6
septum, 4f
soft tissue layer, 6
surface anatomy, 2f-3f
basal view, 2f
front al view, 2f
lateral view, 2f
oblique view, 3f
surgical anatomy, 3f-5f
basal view, 3f
lateral view, 3f
oblique view, 3f
vasculature, 4f- 5f
Anesthesia, infilt rative injecti on technique, 25-29
columella injection, 25, 26f, 28
intercartilaginous, transcartilaginous, or delivery approach, 27, 28f
lateral wall of nose, 27, 29f
mul tiple injections along margi nal incision area, 25, 26f
for osteotomy, 27, 28
pearls, 27-28
soft -tissue, domal regi on, 25, 26f
Anomalous nasi, 4f
Anterior septal angle, 3f
Aquaplast cast, application and removal, 153
Artery(ies), nasal, 4f-5f
Auricular carti lage
alar batten graft , 105
harvesting, 139, 140f-1 42f, 146-147
B
Beveling of skin edges, 45
Bifidity, nasal tip, 17
Bleeding, septoplasty, 33
Blood vessels, 4f-5f
Bone infarction, 6
Bones, nasal, 3f, 5
infracture during osteotomy, 67-68
medializati on, 68
postoperati ve margins, smoo thing with rasps, 62, 63f
postoperati ve shi fting, digital exercises for, 153
Bossa for mation, 22, 110, 163
Brow-tip aesthetic lines, 17
Bulbosity, 17
Buttress graft, 102, 102f-105f
Byrd' s method, nasal projection, 16, 19, 159
C
Calvari al bone, harvesting, 144, 144f-1 46f, 147
Cap graft, 102, 102f- I05f
Carti lage
harvesting. See Tissue harvesting
lower lateral (LLC). See Lower lateral cartilage
quadrangular, 4f
-
. ,:,_. ~ - i
179
180 SUBJECT INDEX
Cartilage tcontd.i
sesa moid,3f
upper lateral (ULC). See Upper lateral cartilage
Cartilage-splitti ng approac h, 37, 38f-39f
Cephalic trim, 77,11 0
Cervi cal poi nt, IOf, I I, 157
Chin altera tions
augment ation, 165f
alloplastic imp lant manufac turers, 172
Legan faci al-convexity angle, 15
Cleft lip- nasal deformity, I67f, 167- 168
bilateral , 167f, 168
unilateral, 167, 167f
Col umell a, 2f
cleft lip-nasal deform ity
bilateral, 168
unilat era l, 167
hanging columella deformity, septoplasty, 31
infilt rati ve anesthetic injec tion technique, 25, 26f, 28
retr acted, 17
caudal extension grafts, 118, 118f-12lf
plumpi ng graft , 1l7, 117f
rhino plasty analysis, fron tal view, l7
Columella-labi al angle (junc tion), 2f
Col umell ar artery, 4f
Columellar flap, 47, 47f-49f
elevation of, 47, 49f
infiltrat ive anesthetic inject ion technique, 27f
Columell ar-labi al confluence, 18
Columellar -lobular angle, 18
Columell ar show
normal value, 15, 20
rhi noplasty analysis, 15, 158
Col umell ar strut cartilage graft, 56, 81-84
dorsal onlay graft interdigit ating wit h. See Saddle nose deformity
placement, 81- 84
endonasal approach, 8 1, 83f-84f
external rhi noplas ty approach, 81, 82f
tripod concept, 155
Complications, 163
Compressor muscl es, 4f
Com pressor narium minor , 4f
Computed tomography (CT scan), concha bullosa, 78, 78f
Co ncha bullosa, 78, 78f
Co nchal carti lage . See Auri cu lar cartilage
Converse scissors, nasal dissection, 5 Jf
Corrugat or muscle , 4f
Crumley' s method, nasal projecti on, 16, 159
Crus/crura, 3f. See also specific area
Cyanoacrylate ad hesive
man ufactur er, 172
skin closure, 113
D
Del ivery approach, 40-43
deli very of LLC, 41-42, 42f-43f
intercarti laginous incision, 40, 40f
marginal incision, 4 1, 4 lf
Depressor muscles, 4f
Depresso r septi nasi, 4f
Derma bond. See Octyl-2-cya noa cry late
Digital exercises, postoperat ive, 153
Dil ator muscles, 4f
Dilator naris anterio r, 4f
Dissection
auricular cartilage harvest ing, 139, 140f-1 41f
deli very of LLC, 41-42, 42f-43f
external rhinop lasty approach. See Externa l rhinoplasty approac h, nasal
dissecti on
retrograde, 50
rib cartilage harvesting, 144
septoplasty, 31, 32f, 33
Dome
divided, tip graft in, 101, 10If
divis ion. See Nasal tip, surgery
iden tification , 84
Dorsal nasal art ery, 4f
Dorsum of nose
cartilagi nous, exposure and i ncision for hump removal, 59, 60f
contour assessment, anes thetic inj ection and, 27
irregularities, pos toperative, 163
rhi noplasty analysis, 11,20
Double break , 18-19
Dur al tear , parietal bone harvesting, 144
E
Edema, per sistent postoperative supratip edema, 152-1 53
El evator mus cles, 4f
Endonasal approach
alar batten graft placement, 106f
columellar strut cartilage graft placement, 8 1, 83f- 84f
incision closure, 152, 152f
nasal dissecti on, 56
spreader grafts, 7 1, 72f
Ethmoid bone
harve sting . 143, 147
perpendicular pla te, 4f
splinting (sand wich) gra fts, 122, 123f
External rhinoplasty approach, 43-56
anes thesia injection techn ique, 25- 29, 26f-29f
bac kgrou nd, 43
columel lar strut carti lage graft placement, 81, 82f
dissecti on, 43
incisions for, 43
indications for , 170
integrated dorsal graf t-co lumellar strut for saddle nose deformity, 133f
marg inal inci sion, 43, 44f
colume llar extension, 45, 46f, 56
nasal dissection, 43-47
defi ning columell ar flap, 47, 47f-49f
elev atio n of per iosteum and exposure of bony vault, 54-56, 55f
exci sion of cephalic car tilage, 50
exposure of cartilaginous middle nasal vault, 54, 54f
flap elevati on, 47, 49f
incision marking, 43, 44f
lateral crus, 50, 5 1f
marginal incision, 43, 44f, 47
mi dcol umellar incisio n, 43, 44f, 45, 45f
midline dorsal dissecti on, 52, 52f- 53f
retrograde dissect ion , 50
three-poi nt counter traction, 50, 50f
pearl s, 56
septoplasty, 33, 34f
spreader graft placeme nt, 7 1, 72f-75f
transcolumellar (mi dcolu mella r) incision, 43
closure , 56
marking for, 43, 44f
F
Face
Frankfort plane, 12, 13f, 158
hori zontal faci al thirds, 12, 12f, 158
surface measurement s, 22, 23f
Legan faci al-conv exity angle, 14f, 15
Subject Index 181
mentocervica l angle, 14f, 15
nasofaci al angle, 12, 13f, 158
nasofrontal angle, 12, 13f, 158
nasolabi al angle, 15, 15f
nasomental angle, l3f, 15, 158
surface angles, plane s, and meas urements, 12 16, 158-159
vertical facial fifths, 12, 12f, 158
Facet ,2f
Fl ap, columellar, 47, 47f-49f
G
Glabella, zr, 9, 10f, 157
Gnathion, 10f, 11, 157
Goode's method, nasal projec tion, 15f, 16, 18,159
Grafts/grafting
alar batt en graft, 105, 106f-l09f
cap or buttress graft, 102, I02f-1 05f
caudal extension grafts, 118, 118f-1 21f, 138
columellar strut cartilage graft, 56
ethmoid bone spli nting (sandwich) grafts, 122, 123f
harvest of autogenous tissue, 139-147
calvarial bone, 144- 146
conchal (auricular) car tilage, 139-1 42
ethmoid bone, 143
rib graft , 143-144
integrated dorsal graft -col umellar strut for saddle nose deformity,
130-137
lateral crural grafts, I 10, II Of
nasal tip, 98- 101
onlay cartil age wafer grafts, 77
plumping grafts, 117, 1l7f, 138
shield-shaped tip graft, 98 10I
spreader grafts, 7 1-79
Greenstick fracture, in osteotomy, 68
H
Hanging columella deformity, septoplasty, 3 1
Hemitransfixion incision, septoplasty, 31, 32f
"Hidden columella, " l7
Hump, 17
Hump excision, 59- 66
excision of bony hump, 59, 61f
expo sure and incision of cartilaginous dorsum, 59, 60f
extramucosal reduction, 64
fine-tun ing modifications, 62
in high-risk patient , 76
in "narrow nose syndrome, " 76
nasofrontal angl e in, anesthesia considerations, 28
"open roof," 62
preoperative and postoperati ve views, 61f
separation of ULC from dorsal septum, 64, 65f
septoplasty and, 33
smoothing bony margins, 62, 63f, 64f
Hydrodissection, auricul ar cartilage harvesting, 139, 140f
I
Illusions, 22
Incisions, 160
alar base reduction surgery, 113
auricular cartilage harvesti ng, 139, 140f
closure. See Wound clos ure
external rhinoplasty approach, 43-47
intercartil aginous, 38f, 40, 40f
closure, 152, 152f
marginal, 41 ,41f
clos ure, 152, 152f, 153
columell ar extension, 45, 46f, 153
external rhinoplasty appro ach, 43, 44f
midco lumellar
closure, 149, 150f-151f, 153
external rhinoplasty approach, 43, 44f , 45, 45f
suture removal, 152
parietal bone harvesting, 144
rib cart ilage harvesting, 144
septoplasty, 31, 32f
transcartila gi nous, 37, 38f
closure, 152, 152f
Infratip lobule, 2f, 5
transdornal sutur e placement and, III
Injection. See Anesthesia
Instrumentat ion
rasps, 62, 63f
suggested surgical instrument s for rhinopl asty, 171
manufacturers' address/ phone numbers, 172
Intermediate crus, 3f
anesthetic inject ion, 25, 26f
Internasal suture line, 3f, 6
Int ranasal pack, 152
manufacturers, 173
"Inverted V" deformit y, 76, 163
K
Kenalog. See Triamcinolone aceto nide
Killian incision, septoplasty, 31, 32f
L
Labrale superiu s, 10f, II, 157
Lateral crus , 3f, 5
anesthetic inj ection, 25, 26f
cephalic trim, 110
grafts, 110, II Of
lateral crural over lay, 96, 96f-97f
reduction of volume and rigidity, 85, 85f
transcartilagi nous incision, 37
Lateral nasal artery, 4f
Lega n facial-convexity angle, definit ion, 14f, 15, 158
Length of nose
central, 18
definiti on, 18
"ideal," 19
illusions, 22
lateral, 18
rhinoplasty analys is, 11, 18-1 9, 19f
surgical goals and options for achieving, 161-1 62
Levator labii alaequae nasi, 4f
Lidocaine , infiltrative anesthesia techniqu e, 25-29
Li pectomy , submental, 166f
Lips, rhinoplasty analysis , 14f, 15, 158
Literature recommendati ons, 174-175
LLC. See Lower lateral cartilage
Lobule, 5
Lower lateral car tilage, 3f
asymmetries, columellar strut for, 83f
cephalic resecti on of lateral crura, 85, 85f
L-strut
integr ated dorsal graft-c olumellar strut , 130-137
in septoplasty, 33, 33f
M
Mattress sutur es
closure of auricular cartil age harvest site, 139, 142f
closure of midcolumell a incision, 149, 150f-15If
spreader graft stabilization, 75, 75f
Maxilla, ascendng process, 3f
-
::-.::::c::""
. -'r,-I
r ; ' ~ - ~ ~
182 SUBJECT INDEX
Maxillary crest, 4f
Medial crural footpl ate, 3f
Medial crus, 3f
Mentocervical angle
definition, 14f, IS, 158
Powell-Humphries "aesthetic triangle," 16
Mentol abial sulcus, 10f, II , 157
Menton, 10f, II, 157
Midcolumellar incision. See Incisions
Mucoperichondrium, support funct ion, 59, 62f
Muscles, nasal, 4f
N
Naris, 3f
"Narrow nose syndrome," 22
hump removal in, 76
Nasal analysis. See Rhinoplasty analysis
Nasal floor, cleft lip-nasal deformity
bilateral, 168
unilateral, 167
Nasal obstruction, 18
causes, 78
concha bullosa, 78, 78f
spreader grafts for, 75-78
Nasal septum. See Septum
Nasal spine, 3f, 4f
Nasal splint
external, 152
application and removal, 153
manufacturers, 172-1 73
Nasal starting point , 20
Nasal tip, 9, IOf, 157
acce ntuating
cephalic edge leading caudal edge of lateral crus, 86, 93f
dome division with intact vestibular skin and suture reconstitution,
95f , 95-96, 96f
individual horizontal mattress domal suture technique, 86, 86f
lateral crural overlay, 96, 96f-97f
lateral crural steal, 94f, 95
single transdomal suture technique, 86, 89f-93f
tip grafts, 98-101
transdomal surgical techniques for, 86-95
trapezoidal asymmetric tip, 89f-93f
trapezoida l tip and broad doma l angles, 87f-89f
anterior protrusion. See Rhinoplasty analysis, nasal projection
asymmetry, 81, 83f
bifidit y, 17
cleft lip-nasal deformity
bilateral, 168
unilateral, 167
deviated, 8I , 83f
grafts
alar batten graft, 105, 106f- 109f, J II
cap or buttress graft, 102, I02f-1 05f
caudal extension grafts, 118, 118f-1 21f
in divided domes, 101, IOIf
lateral crural grafts, 110, I I Of
pearls, II I
shield-shaped tip graft, 98- 101
narrowing, transdomal surgical techniques for, 86
projection, surgical goals and options for achieving, 161. See also
specific procedures
rhinoplasty analysis, I I
frontal view , 17
lateral view, 18
rotation
lateral crura l steal, 94f, 95
surgical goals and options for achieving, 161. See also specific
procedures
support
columellar strut cartilage graft. 56, 81- 84
major support mechanisms, 160
minor support mechanisms, 160
surgery, 81-1 11. See also specific procedure
accentuate tip, 86-95
alar batten graf t, 105, 106f-I 09f, II I
cap or buttress graft, 102, 102f-J 05f
caudal extensi on grafts, 118, 118f-1 21f
columellar strut cartilage graft placement, 81-84
dome division with intact vest ibular skin and suture reconstitution ,
95f, 95-96, 96f
dome identi fication, 84
lateral crural grafts, 110, 1JOf
lateral crural overlay, 96, 96f-97f
pearls, 110-1 11
reduction of crural volume and rigidity, 85, 85f
refinement, 162
sculpting techniques , 160
shield-shaped tip graft, 98-10I
placeme nt, 98, 99f
preoperative and postoperative views, 100f-IOlf
size of, 98, 98f, I II
tip grafts, 98- lOI
tip-defining points, zr, 3f
tripod concept, ISS
Nasal valve, 75, 75f
collapse, 163
ajar batten graft, 105
Nasal valve area, 6, 75, 75f
Nasal vault
bony, postoper ative shifting, 153
middle
asymmetry, 77, 77f
collapse, 76-77
excessive narrowing , 77
exposure, 54-56
width, assessment, 77
Nasion, 2f, 3f, 9, 10f, 157
Nasofacial angle
definition, 12, 13f, 158
normal values, 12
Powell-Humphries "aes thetic triangle," 16
Nasofrontal angle, 2f
aesthetic analysis, II
definition, 12, 13f, 158
in hump excision, anesthesia considerations, 28
length of nose and, J8, 19f
normal values, ]2
Nasofrontal bone, osteotomy, 6
Nasofrontal suture line, 3f
Nasolabial angle
aesthetic analysis, 11
definition, IS, 15f, 158
length of nose and, 18, 19f
normal values, 15
obtuse, septoplasty, 31
Nasomaxi llary suture line, 3f
Nasomental angle
definition, 13f, IS, 158
Nasomental line, lip relat ionships, 14f, 15, 158
Subject Index 183
Nostri l(s)
cleft lip-na sal defo rmi ty
bilateral , 168
uni lateral , 167
rhinop lasty ana lys is, 18
Nostri l floo r, 3f
intern al nostril floor redu ction , 113, 114f
wedge exci sion, 114, 114f
Nostr il sill, 2f
wedg e excision, 114, 114f
Notch defe ct, 149
o
Octyl-z-cyanoacrylate (Derrnabond)
man ufac ture r, 172
ski n closure, 113
Onlay cartilage wafe r grafts, 77
Ope rati ve worksheet
integrated dorsal graft -columellar strut for saddle nose deformi ty, 132f
secondary rhinoplasty patient requiri ng alar batten graf ts, I08f
trapezoidal asymmetric nasal tip, 90f
Orbicularis or is muscle, 4f
Osseocart ilagino us j unction, 2f, 3f , 6
Osteotomy, 67-69
anestheti c injection , 27, 28
inter mediate, 68
lateral, 67-68, 68f
high-to-low, 67, 68f
high-to-low-to-high, 67
inf racture of nasal bone, 67-68
med ial, 67, 68f
nasofrontal bone, 6
pearls , 68
p
Packs/ pack ing, intranasal, 152
man ufactu re rs, 173
Pain, postoperati ve, rib cartilage har vesting, 147
"Parenthesis" de formity, 22
Pari etal bone, harvesting, 144, 144f- 146f, 147
Perichondri um, rib cartilage barves ting, 147
Phi ltrum , 2f
Photograp hy setup, 169f
Pleural leak (tear), rib carti lage harvesti ng, 144
Pl umpi ng grafts, 117, 117f, 138
Pne umo thorax, rib carti lage harves ting , 147
Pogon ion, 10f, II , 157
Pollybeak defor mi ty, 22, 59 , 163
Pol ydioxanone suture
inci sion clos ure, 149
spreader graft fixa tion, 7 1
Postope rative care, 152-1 53
digital exercises, 153
per si sten t supratip edema, 152-153
suture remova l, 152
Powell-Humphries "aesthetic triangle," 16,20
Procerus muscle , 4f
Pseudohypertelorism, 17, 22
Pyriform aperture, 3f
in osteotomy, 67 '.,
Q
Quadr angular cartilage, 4f
R
Radi x projection, 19- 20
Rasps, 62, 63f
Rhinion, 2f, 3f, 9, 10f, 157
sellion vs. , 6
Rhi noplasty analysis, 9-23
base view, 17f, 17-18
guide lines, II , 156
co lume llar show, IS, 158
facial planes, 12, 12f, 158
horizo ntal facial thirds, 12, 12f, 22, 23f
lower two thirds surface measurements, 23f
vertical facial fifths, 12, 12f
frontal view, 17
guidelines, II, 156
general assessment, 16
guidelines, I I, 156
guide to, 11, 156
lab exercise: nasal analysis, II
landmar ks, 157
points,9-1 1,I Of
surfac e ang les, plane s, and measur ements, 12- 16
lateral view , 18- 20, 19f, 2 lf
guidelines , II , 156
Legan facial-conve xit y angle , 14f, IS, 158
length of nose, 18-1 9, 19f
lip relationships, 14f, 15, 158
me ntocerv ica l angle, 14f, IS, 158
nasal proj ection, 15f, 16, 159
asse ssment, 22
Byrd's meth od, 16, 19, 159
Crumley's method , 16, 159
Goode's method, 15f, 16, 18, 22,159
normal values, 16
nasofacial angle, 12, 13f, 158
nasofrontal angle
definitions, 12, 13f, 158
guidelines, 11, 156
nasolabial angle
definitions, IS , 15f, 158
guidelines , 11, 156
naso me ntal angl e, de finitions, 13f, IS, 158
obliq ue view , 20
gui delin es, I I, 156
pear ls, 20, 22
photographic analysis, 16
physica l examination and anatomic analysis, 16-21
Powell- Humphries "aes thetic triangl e," 16
ski n qu alit y, 11, 156
surface angles , planes, and measurement s, defini tions, 12- 16, 158- 159
Rib carti lage (gra ft)
harvesti ng, 143f, 143-144, 147
pos tope rat ive pai n, 147
integrated dorsal graft-columellar strut for sadd le nose deformity,
130-1 37
Rocker deformity, 6, 163
Rotation. See Nasal tip
S
Saddle nose deformity, 17,22
integrated dorsal gra ft-colu mellar stru t for, 130-137
dorsal onlay graft , 133f
external rhino plasty approach, 133f
graft placement , 134f
graft shifting, 138
operative workshee t, 132f
pearls, 138
preoperat ive and postoperative views, 136f- 137f
preoperative views, 13 lf
-
.: ~
-" ~ ,
, ' : ~ - '
184 Subject Index
Scars/scarring. See Aesthetic/cosme tic issues
Scr oll region, 6, 85
Sculpting techniques, 160. See also Nasal tip, surgery
Sell ion , 6, 9, 10f, 157
Sept al angle(s) , 4f, 6
Septal devi ation
caudal, 18, 122-129
et hmoid bone splinti ng (sandwich) graft s, 122
scoring septal cartilage for, 122
"swingi ng door" maneuver for, 122, 122f
dorsal, ethmoid bone splinti ng (sandwich) grafts, 122, 123f
septal repl acement , 122, 123f-1 29f
parti al, 122, 123f-1 27f
total, l2 8f-129f
Septoplasty, 6, 31-34
anesthesi a injection technique, 25, 27
harvest ing of cartil age, 31, 33
hernitran sfi xion inci sion with anterio r septal tunnel s, 31, 32f, 33
pearJs,33
Septorhin oplasty, 33, 34f
Septum , 6
anatomy, 4f
caudal, 3f
cleft lip-nasal deformity, 167
deviated . See Septal deviation
Sesamoid cartilage, 3f
Skin
at rhinion, 20
rhinoplasty analysis, 11
thickness and quality, 22
Skin edges, beveling, 45
Skin marking
for osteotomy, 67
transcolumellar (midcolume llar) incision, 43, 44f
Skull , parietal bone harvesting, 144, 144f-146f, 147
Sliding alar flap, 114, j 15f
Soft tissue layer, 6
--
Spl ints/spl inting
external nasal spl int, 152, 153
manufactur ers, J72- 173
Spreader grafts, 7 1- 79
bilateral,74f / .
cli nical indications, 76-78
endonasal approach, 7 1, 72f
external rhinoplasty approac h, 7 1 _ _ _
ove rwidening, 77 '
pearl s, 78
placement ',. ,
endonasal approach, 71, 72f, 76
exposure of middl e nasal vault , 78
external rhinoplasty appro ach, 71, 72f- 75f, 76
rationale, 76
size, 71
suture fixation, 78
suture fixation (stabilization), 75, 75f
Stornion, 10f, II , 157
inferiu s, 10f, 11, 157
superius, 10f, II, 157
Subnasale, 9, 10f, 157
Sub nasale-to-pogoni on line, lip relationships, 14f, 15, 158
Suction drill , postoperative smoothing of bony margins, 62, 64f
Supraalar crease , 2f
Supr atip, 2f, 9, ior, 157
anest hetic injec tion, 25, 26 f
persistent postoperative edema, 152-,153
Sur gical exposu re, approaches, 160. See also specific approaches
Suture lines, 3f
Sutures/suturing
auricular cartilage graft site, 139, l4 2f
buttress grafts, 102, 102f
domal suture techniques
individual hor izont al mattress dornal suture technique, 86, 86f
infrat ip lobul e after transdornal suture placement, III
singl e transdornal sutur e technique, 86, 89f-93f
suture reapprox irnation of LLC after dome di vision, 95f, 95-96, 96f
incision closure, 149-152
spreader grafts, 7.1 , 75, 75f, 78
T
Tensi on nose deformity , septoplasty, 31
Ti ssue harve sting
auricular cartilage, 139, 140f-142f
calvarial bone, 144, I44f-146f, 147
ethmoid bone , 143
pearls, 146-1 47
rib cartilage , 143f, 143-J44
septal cartilage, 31, 33
Tr ansverse nasali s muscle, 4f
Triamcinolone acetonide (Kenalog), for persistent postoper ative supratip
edema, 153
Trichion , 9, lOf, 157
Tripod concept, 155
Tunn els
septal, 3 1, 33
subperiosteal, proposed osteotomy path, 67
Two-tap technique
hump excision, 59, 6lf
osteotomy, 67

JLC. See Upper lateral cartilage
.Jpper lateral cartil age, 3f
disarti cul ation, 54
di vision from dorsal septum, spreader graft place ment, 73f, 74f
inferomedial collapse, 59, 62f
separ ation from dorsal septum, 64, 65f
V
Vascul atur e,4f-5f
W
Wedge resection
accentuating nasal tip, cephalic edge leading cauda l edge of lateral cr us,
86,93f
alar, 114, 115f
nostr il floor and sill, lJ4, 114f
Width of nose
illusions , 22
rhinoplasty anal ysis, 11, 17
Wound clos ure
auricular cartilage har vesting, 142f
closure of margin al , intercartila ginous, or transcartil aginous incision,
152, 152f
closure of midcolumella incision, 149, 150f--15If
pearls, 153
rib carti lage harvest ing, 147

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