Basic Principles of Rhinoplasty

CHAPTER 65
Basic Principles of Rhinoplasty

James Koehler, DDSy MD
Peter D. Waite, MPH, DDS, MD
For many cosmetic surgeons rhinoplasty is

one of the most challenging surgical procedures. A clear understanding of nasal anatomy is critical in order to provide an esthetic
result that does not compromise nasal frxnction. Developing a pattern of analysis of the
nose is vital for proper diagnosis and for
determining the most appropriate treatment plan. Numerous rhinoplastic techniques have been described. Some surgeons
favor an endonasal approach whereas others
believe that an external approach is more
desirable. Each surgeon must become familiar with all technique options in order to
address the wide variety of challenges of
rhinoplasty surgery.
The goal of this chapter is to give a
broad overview of the diagnosis and treatment of nasal deformities. It is by no means
exhaustive since multiple textbook volumes
have been written on this subject. The reader should gain an understanding of nasal
anatomy and determine how to systematically analyze the nose. Both endonasal and
external rhinoplasty will be described.
Nasal Anatomy
A clear understanding of nasal anatomy is
important to successfully perform nasal
procedures and decrease the incidence of
complications.
Surface Anatomy
The terms used to describe the surface
anatomy of the nose are important in
nasal form analysis and for treatment plan

formulation (Table 65-1). For descriptive
purposes the spatial relationships are
described as cephalic, caudal, dorsal, basal,
anterior, posterior, superior, and inferior
(Figure 65-1).
Skin and Soft Tissue

The soft tissue that overlies the bone and
cartilage may influence the final result of
rhinoplasty. The thickness of the skin
will determine how it will re-drape after
performing a rhinoplasty. The skin
thickness varies along the dorsum of the
Table 65-1
nose. The skin is fairly thick and mobile

in the region of the nasion. It quickly
thins over the nasal dorsum and is generally thinnest and most mobile in the
mid-dorsal region (rhinion). In the distal third of the nose the skin tends to be
more thick and adherent and has an
increased sebaceous content.
A patient with thin skin will show dramatic changes with alteration of the
underlying bone and cartilage, and this
limits room for error since little is camouflaged by the thickness of the skin. Conversely for thick-skinned individuals more
Surface Anatomy of the Nose
Giabella: the most forward projecting point of the forehead in the midline at the level of the
supraorbital ridges
Radix: the junction between the frontal bone and the dorsum of the nose
Rhinion: the anterior tip at the end of the suture of the nasal hones
Dorsum: the anterior surface of the nose formed by the nasal bones and the upper lateral
cartilages
Supratip break: the slight depression in the nasal profile at the point where the nasal dorsum
joins the lobule of the nasal tip
Infratip lobule: the portion of the tip lobule that is found between the tip-defining points
and the columellar-lobular angle
Tip-defining points: there are four tip defining points, which include the supratip break, the
columellar-lobular angle, and the most projected area on each side of the nasal tip formed
by the lower lateral cartilages
Alar sidewall: the rounded eminence forming the lateral nostril wall
Alar-facial junction: the depressed groove formed on the face where the ala joins the face
Columella: the skin that separates the nostrils at the hase of the nose
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Part 9: Facial Esthetic Surgery
Superior
Inferior
FIGURE 65-1 Spatial descriptors. In describing

the relationship of one anatomic unit to another
many terms are used. The standard relationships
are anterior, posterior, superior, and inferior. The
nose is also described in terms of dorsal, basal, caudal, and cranial (or cephalic) positions. Adapted
from Austermann
K. Rhinoplasty: planning
techniques and complications. In: Booth PW,
Hausamen JE, editors. Maxillofacial surgery.
New York: Churchill Livingstone; 1999. p. 1378.
beneath the SMAS. Violating the SMAS

will often result in increased bleeding,
scarring, and postoperative edema.
Tbe muscles of the nose can be divided into four categories: the elevators, tbe
depressors, tbe compressors, and tbe dilators (Figure 65-2). The muscles of significance are tbe paired depressor septi nasi.
Tbese muscles can result in drooping of the
nasal tip during smiling. This added tension on tbe nasal tip must be recognized
preoperatively and addressed by resection
in order to achieve a cosmetic result.'
Blood Supply
Tbere is a ricb blood supply to tbe subdermal vascular plexus of the nose that
arises from branches of both tbe internal
and external carotid arteries. The blood
supply from the internal carotid artery
that supplies the external nose includes
the dorsal nasal artery and the external
nasal artery. The dorsal nasal artery is a
branch of the ophthalmic artery. The
aggressive sculpturing of tbe nasal skeleton must be performed in order to effect

significant cbanges. Altbougb thick skin
may mask imperfections it does not redrape as well and can result in underlying
fibrosis and formation of a polybeak
deformity (supratip scarring). Better
results are possible with thin-skinned
patients, however tbe margin for error is
smaller. The surgeon must sometimes
modify the technique depending on the
type of skin of the patient.
Superficial Musculoaponeurotic
System and Nasal Musculature
The muscles of the nose are encased in the
nasal superficial musculoaponeurotic system (SMAS). This is a fibromuscular layer
that separates tbe skin and subcutaneous
tissue from the nasal cartilage and bone.
Tbe SMAS of the nose is in continuity
with the SMAS of the face. During rhinoplastic surgery the dissection is performed
external nasal artery is a branch of the

anterior ethmoid artery.
The external nose is also supplied by
branches of tbe facial artery and tbe internal maxillary artery, which originate from
the external carotid artery. Tbe facial artery
branches include the angular artery, lateral
nasal artery, alar artery, septal artery, and
superior labial artery (Figure 65-3).
i
Tbe internal nose is supplied by tbe
internal and external carotid branches.
The ophthalmic artery, a branch of the
internal carotid, brancbes into the anterior
and posterior ethmoidal arteries. The
anterior ethmoidal artery suppbes tbe
anterosuperior part of tbe septum and tbe
lateral nasal wall. Tbe posterior ethmoid
artery supplies the septum, lateral nasal
wall, and the superior turbinate.^
The internal maxillary artery brancbes
include the sphenopalatine artery and tbe
greater palatine artery. Tbe spbenopalatine
artery supplies most of tbe posterior part
of tbe nasal septum, lateral wall of the
Procerus muscle
Transverse
nasaiis muscie
Diiator naris
anterior muscle
Levator labii superioris
alaeque nasi muscle
Compressor
narium minor muscie
Alar nasalis muscie
Depressor septi nasi

muscle
Orbicularis
oris muscie
FIGURE 65-2 Nasal musculature. The muscles of the nose are grouped into the elevators (light blue),
the depressors (dark blue), the compressors (light gray), and the dilators (dark gray). Adapted from
fewett B. Anatomic considerations. In: Baker SR, editor. Principles of nasal reconstruction. St. Louis
(MO):Mosby: 2002. p 17.
Supraorbital artery
Supratrochlear
artery
Dorsal nasal artery
External nasal branch

of anterior ethmoidal
artery
Infraorbital artery
Angular artery
Lateral nasal artery
Bone and Cartilage
Columellar branch
The structure of the nose consists of the

paired nasal bones as well as the frontal
process of the maxilla. The bone is thickest near the junction with the frontal
bone and tapers as it joins with the upper
lateral cartilages.
The upper lateral cartilages are in intimate contact with the nasal bones and
underlie the nasal bones for approximately
6 to 8 mm. The connection between the
Septal branch
Superior labial artery
Facial artery
FIGURE 65-3 Arteries of the external nose. The arterial supply of the external nose comes from
branches of the external carotid artery (dark blue) and the internal carotid artery {light h\ue). Adapted from Jewett B. Anatomic considerations. In: Baker SR, editor. Principles of nasal reconstruction. St.
Louis (MO): Mosby; 2002. p. 18.
nose, roof, and part of the nasal floor. The

greater palatine artery supplies a portion of
the anterior and inferior portion of the
nasal septum (Figure 65-4).^
The surgically significant area for
internal nasal bleeding is known as Kiesselbach's plexus (also termed Little's area).
This is the area in the anteroinferior part of
the nasal septum which is a common site of
expistaxis. It is where the sphenopalatine,
greater palatine, superior labial artery, and
anterior ethmoid arteries anastamose (Figure 65-5).^ The venous drainage of the
nose is primarily from the facial and ophthalmic veins.
One concern during nasal surgery is
the possibility of compromised blood
flow to the nasal tip if the surgeon performs an external rhinoplasty. The blood
supply to the nasal tip has been analyzed
by lymphoscintigraphic studies, cadaver
dissections, and histologic sections.^''* The
conclusion is that the primary blood supply to the nasal tip comes from the bilateral lateral nasal arteries that course in a
plane superficial to the alar cartilages in
the subdermal plexus approximately 2 to
3 mm above the alar groove. Thus a columellar incision does not compromise tip
blood supply. Also there are no significant
veins and minimal lymphatics in the columellar region.-''' Some surgeons believe
that external rhinoplasty remains more
edematous for longer postoperative periods than an endonasal rhinoplasty.
Lateral Internal nasal branch of

anterior ethmoidal artery
artery
Lateral branch of
posterior ethmoidal artery
Sphenopalatine
artery
DesQending
palatine artery
Lesser
palatine artery
Greater
palatine artery
Branch of
angular artery
FIGURE 65-4 Arteries of the lateral nasal wall. The arterial supply of the lateral nasal wall arises from
branches of the external carotid artery (black) and the internal carotid artery (blue). Adapted from
Jewett B. Anatomic considerations. In: Baker SR, editor Principles of nasal reconstruction. St. Louis
(MO): Mosby; 2002. p. 23.
1347
1348
Medial internal nasal branch

o( anterior ethmoidal artery
Septal branch of
posterior ethmoidal artery
Nasal septal
cartilage
Posterior septal
branch ot
sphenopalatine
artery
Kiesselbach's plexus
Septal branch of
superior labial artery
FIGURE 65-5 Arteries of the nasal septum. The arterial supply of the nasal septum arises from
branches of the external carotid artery (black) and the internal carotid artery (blue). Kiesselbach's
plexus is formed by the sphenopalatine artery, greater palatine artery, superior labial artery, and anterior ethmoid arteries. It is a common site ofepistaxis. Adapted from Jewett B. Anatomic considerations. In: Baker SR, editor. Principles of nasal reconstruction. St. Louis (MO): Mosby; 2002. p. 23.
52%
20%
17%
11%
Various configurations of the scroll

FIGURE 65-6 Configurations of the scroll. The
relationship of the upper lateral and lower lateral cartilages is termed the scroll. Anatomic studies have identified four common confrgurations:
interlocked (52%), overlapping (20%), end to
end (17%), and opposed (11%). Adapted from
Lam SM and Williams EF ilL^
nasal bones and upper lateral cartilages

should not be violated since this may disrupt
the internal nasal valve causing nasal
obstruction and asymmetry. The internal
nasal valve is formed by the junaion of the
upper lateral cartilages and the nasal septum.
The lower lateral cartilages comprise
the lower third of the nose and connect to
the upper lateral cartilages in a union
described as the scroll. There are various
configurations of the scroll.^'' The scroll is
described as interlocked (52%), overlapping (20%), end to end (17%), or opposed
(11%) (Figure 65-6). The scroll provides
significant support to the nasal tip. When
performing an endonasal rhinoplasty this
area is violated by the intercartilaginous
incision (Figures 65-7-^5-9). The lower
lateral cartilage is divided into medial and
lateral crura. The medial crura are in intimate contact with the nasal septum and
provide tip support. The lateral crura

extend superiorly and form dense
fibroareolar tissue attachments with the
pyriform aperture. The intermediate crus
is the diverging of the medial crus before
turning to become the lateral crus proper.
The highest point of the intermediate crus
is an important surgical landmark known
as the tip-defining point (Figure 65-10).
The nasal septum is formed by both
bone and cartilage. The ethmoid and
vomer provide bony support posteriorly.
The quadrangular cartilage provides support anteriorly (Figure 65-11).
|
Support for the nasal tip is classified into major and minor divisions.
The major tip support comes from the
size, shape, and strength of the lower
lateral cartilages, the attachment of the
medial crura of the lower lateral cartilage to the caudal septum, and the
fibrous attachment of the lower lateral
cartilage to the upper lateral cartilage.
The minor tip support comes from the
nasal spine, the membranous septum,
the cartilaginous dorsum, the sesamoid
complexes, the interdomal ligaments,
and the alar attachments to the skin
(Table 65-2).5
Nerves
The sensory nerve supply to the skin of
the external nose is supplied by the ophthalmic and maxillary divisions of the
FIGURE 65-7 Partial transfixion. The partial

transfrxion incision through the membranous
septum and short of the medial crural foot pads.
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Cribriform plate
Perpendicular
plate of
ethmoid
bone
Nasal bone
Septal
cartilage
Upper lateral
cartilage
Vomer
Alar cartilage
Nasal crest of
maxilla
FIGURE 65-8 Intercartilaginous incision. The

intercartilaginous incision, between the upper
and lower cartilage, allows access to the nasal
dorsum. Note the incision does not violate the
nasal valve.
FIGURE 65-11 Anatomy of the nasal septum. The nasal septum is composed of the perpendicular plate
of the ethmoid, the vomer, and the quadrangular cartilage. Adapted from Jewett B. Anatomic considerations. In: Baker SR, editor. Principles of nasal reconstruction. St. Louis (MO): Mosby; 2002. p. 22.
FIGURE 65-9 Connecting

intercartilaginous
and partial transfixion incisions. The intercartitaginous incision extends along the upper edge of
the lateral crus to connect with the transfixion
incision. This will provide access for a septoplasty during internal rhinoplasty.
trigeminal nerve. Branches of the supratrochlear and infratrochiear nerves supply the skin in the region of the radix and
rhinion. The lower half of the nose is
supplied by the infraorbital nerve and
the external nasal branch of the anterior
ethmoidal nerve (a branch of the
nasociliary nerve that arises from the
ophthalmic branch of the trigeminal
nerve) (Figure 65-12).
The main sensory nerve supply to the

nasal septum comes from the internal nasal
nerve (a branch of the anterior ethmoidal
nerve) and the nasopaiatine nerve (Figure
65-13). The lateral nasal wall sensation is
supplied by the anterior ethmoidal nerve,
branches of the pterygopalatine ganglion,
branches of the greater palatine nerve, the
infraorbital nerve, and the anterior superior alveolar nerve.
intermediate crus:
lobular segment
domal segment
Lateral crus
intennedrate crus:
domal segment
lobular segment
Lateral crus
Intermediate crus
Medial crus
{columellar
segment)
Medial crus
(footplate
segment)
Lateral crus
Medial crus
B
Medial crus
FIGURE 65-10 A-C, Anatomy of the lower lateral cartilages. The lower lateral cartilages are often described as having a lateral crus, medial crus, and an intermediate
cms. Tlie intermediate cms is the most projected portion of the lower lateral cartilages and these form two of the tip-defining points seen on nasal tip analysis. Adapted
from Jewett B. Anatomic considerations. In: Baker SR, editor. Principles of nasal reconstruction. St. Louis (MO):Mosby; 2002. p. 21.
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Table 65-2
Tip Support Mechanisms
The three major tip support mechanisms include

1. The size, shape, and strength of the lower lateral cartilages
2. The attachment of the medial crura to the caudal septum
3. The attachment of the lower lateral cartilages to the upper lateral cartilages
The minor tip support mechanisms include
1. The interdomal ligament
2. The sesamoid complex extending the support of the lateral crura to the piriform
aperture
3. The attachment of the alar cartilages to the overlying skin
4. Cartilaginous septal dorsum
5. Nasal spine
6. The membranous septum
appearance in the supra-alar region. The

Cottle test is used to evaluate obstruction
at the internal valve by using a fmger to distract the check and lateral wall of the nose
thereby opening the valve. If nasal airflow
is dramatically improved, then the internal
valve may require correction. These
patients often have symptomatic relief by
the use of external taping devices. Surgical
correction involves the placement of
spreader grafts between the septum and
upper lateral cartilages to increase the
angle at this junction.^""^
'
Cosmetic Evaluation
Parasympathetic innervation is derived
from branches of the pterygopalatine ganglion which are derived from cranial nerve
VII. Some sympathetic branches reach the
nasal cavity via the nasociliary nerve.^'''
Nasal Valve
The airflow through the nose is regulated
by the internal and external nasal valves.
The external nasal valve is comprised of
the lower lateral cartilage and the nasal
septum and floor. Collapse of the external
nasal valve can sometimes be noted when
the nares become occluded on even gentle
inspiration. This problem is seen in
patients with narrow nostrils, a projecting
nasal tip, and thin alar sidewalls. External
nasal valve collapse is usually seen in
patients who have had previous rhinoplasty surgery and excessive trimming of
the cephalic portion of the lower lateral
cartilages. It is also seen with increased
age and in facial nerve paralysis. The
external nasal valve collapse can be corrected by deprojecting the overprojected
nose, realigning the lateral crura into a
more caudal orientation, and placing alar
batten grafts to provide structural support
and prevent collapse.^
The internal nasal valve is formed by
the junction of the septum with the upper
lateral cartilages. The angle formed should
be a minimum of 10 to 15 to maintain
patency. Deviation of the nasal septum or

separation of the upper lateral cartilages
from the nasal bones can lead to obstruction. This problem is also seen after rhinoplasty if the patient has had weakening of
the upper and lower lateral cartilages.
These patients often have a pinched
Supraorbital nerve
The cosmetic evaluation begins in the

same way as with any examination, by eliciting the chief complaint of the patient.
The patient should be given a mirror and
cotton-tipped applicator to point out specific cosmetic concerns. Following this a thorough medical history should be obtained.
Specific attention should be directed toward
Supratrochlear
nerve
Infralrochlear nerve
Infraorbital nerve

nerve
FIGURE 65-12 Sensory nerves of the external nose. The sensory innervation of the nose is derived
from the V] (ophthalmic: colored hlackj and from 16 (maxillary: colored bluej divisions of the
trigeminal nerve. Adapted from Jewett B. Anatomic considerations. In: Baker SR, editor. Principles of
nasal reconstruction. St. Louis (MO): Mosby; 2002. p. 19.
Internai nasal
(anterior
ethmoidai)
1351
and its proportions should be done. Refer

to Cbapter 54, "Database Acquisition and
Treatment Planning," for additional information on facial analysis in ortbognatbic
surgery.
Nasal Analysis
FIGURE 65-13 Sensory nerves of the

nasal septum. The main sensory
nerve supply comes from the internal
nasal nerve (a branch of the anterior
ethmoidal nerve Vi (black) and the
nasopalatine nerve V2 (blue). Adapted from Jewett B. Anatomic considerations. In: Baker SR, editor. Principles of nasal reconstruction. St. Louis
(MO): Mosby; 2002. p. 19.
Mediai
posterior
superior
Nasopaiatlne
obtaining a history of nasal trauma, nasal

obstrucfion, previous nasal surgery, and
medications (including over-tbe-counter
and herbal medications).
I
Psychiatric Stability
In addition to analyzing tbe nose the surgeon needs to assess if the pafient is psychologically prepared for a cosmetic procedure.
Patients should have realistic expectations
and motivations. A patient who is internally
motivated (eg, wishes to improve their selfesteem) to have the procedure is a better
candidate tban one who desires the procedure for external reasons (eg, spouse wants
them to have it
The surgeon should beware of patients

wbo are indecisive, rude, uncooperative,
depressed, have unrealistic expectations, or
have significant personality disorders
because they may never be satisfied. Other
warning signs of poor patients are those
who overly flatter, are talkative, consider
themselves to be a very important patient,
have minimal or no deformity, are surgeon
shoppers, price hagglers, or involved in litigation. Most importantly, do not operate on
a patient that you do not like.""'*
General Facial Analysis

Prior to performing a specific analysis of
the nose, a global assessment of the face
The nasal examination should be performed in a systematic manner so that the

proper diagnosis is attained (Figures 65-14
and 65-15).
General Assessment
Skin
The skin sbould be assessed for its tbickness, mobility, and sebaceous gland content. Any pigmentations or scars sbould
also be noted. Thick skin does not redrape well after rhinoplasty.
Symmetry
Any gross asymmetries in all views sbould
be noted.
Lateral View Nasofrontal Angle Tbe
nasofrontal angle is defined as the angle
formed from lines that are tangential to
the glabella and tbe nasal dorsum and
intersect tbrougb the radix as seen on a
profile view. The normal angle is between
125 and 135 (Figure 65-16).
'HA
A
FIGURE 65-14 Preoperative rhinoplasty. A, Preoperative frontal view shows the width of the nose and alar base. B, Preoperative lateral view shows the nasal profile and dorsum in relation to the nasofrontal angle and nasolabial angle. C, Preoperative three-quarter, or oblique view, is most natural and often revealing for
harmony of the orbital rims and gull wings that flow into the nasal dorsum. D, Preoperative basal view is either taken from above or below the patient and is a
good view of tip and base morphology.
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FIGURE 65-15 Postoperative rhinoplasty A, Postoperative frontal view shows the change in the width of the nose. This is the patient's most critical analysis. B,
Postoperative lateral view shows the change in dorsal reduction and tip position. C, Postoperative three-quarter, or oblique view, demonstrates the symmetry and
graceful balance of the nose with the face. D, Postoperative basal view shows the width of the nose and any tip deviation from the dorsal midline.
The postion of the radix should then

be assessed in terms of its anteroposterior
and vertical positions from a profile view.
The radix should lie in a vertical plane
Radix
FIGURE 65-16 Position of the nasal dorsum and radix.

The nasal dorsum is typically 2 mm behind a line drawn
from the radix to nasal tip in women. In men the nasal
dorsum typically lies on this line. The radix should lie
between the upper eyelid margin and the supratarsal folds
in a vertical plane and approximately 4 to 9 mm anterior
to the corneal plane. Adapted from Austermann, K.,
Rhinoplasty: planning techniques and complications. In:
Booth PW, Hausamen }E, editors. Maxillof'acial surgery.
New York: Churchill Livingstone; 1999. p. 1380.
somewhere between the lash line and the

supratarsal folds. In addition it should be
4 to 9 mm anterior to the corneal plane
(see Figure 65-16).
Nasal Dorsum In women the nasal dorsum should lie approximately 2 mm posterior to a line drawn from the radix to the
nasal tip. In males the nasal dorsum
should lie on this line or slightly in front of
it (see Figure 65-16).
The length of the nose (radix to tip)
can be measured clinically or on photographs taken during the initial examination. The ideal nasal length should approximate the distance from stomion to
menton if the lower facial height is proportionate to the middle facial height
(glabella to subnasaie). If the lower face
height is not proportionate it is best to
estimate the nasal length as 0.67 times the
middle facial height.
Nasal Tip Definition The nose should
have four tip defining points which when
drawn on the nose in the frontal view
appear as two equilateral triangles (Figure
65-17). These points include the supratip
break, the columellar-lobular angle, and
the two tip-defming points (the most projected portion of the nasal tip)
Nasal Tip Projection Nasal tip projection can be defined as the distance that
the tip (pronasale) projects anterior in
the facial plane.'"^ Perception of nasal tip
projection can be influenced by may factors: upper lip length, nasolabial angle,
nasofrontal angle, dorsal hump, and
FIGURE 65-17 Nasal tip-defining points. A nose

should have four tip-defining points. These are
defined by the supratip,
columellar-lobular
angle, and the tip-defining points of each intermediate crus of the lower lateral cartilages.
chin projection. There are several methods to determine if the nasal tip projection is adequate. Most cosmetic rhinoplasty procedures are designed to
preserve tip projection.
The simplest method to remember is
Simons' method, which states that the lip-totip ratio is 1:1. Essentially the length of the
upper lip (from subnasale to labrale superioris) should equal the nasal projection
(measured from subnasale to pronasale).
This method may be invaUd because of the
wide variation in lip lengths.'^
The Goode method is another way of
determining nasal projection. Using the
Goode method a line is drawn from the
radix to the nasal tip. A second line is drawn
from the radbt to the alar columellar junction. A third line is drawn perpendicular to
this and passes through the nasal tip.
Goode's analysis states that if the nasofacial
angle is between 36 and 40, then the length
of the perpendicular line passing through
the nasal tip should be 0.55 to 0.6 of the
length ofthe nasal dorsum (Figure 65-18)."^
Rohrich describes another technique
of assessing nasal tip projection. If the
nasal dorsal length is appropriate, the tip
projection should be 0.67 times the ideal
nasal length. The ideal nasal length should
be equal to the distance from stomion to
menton or 1.6 times the distance from the
nasal tip to stomion. The tip projection is
measured from the alar facial junction to
the nasal tip.''' This method is subject to a
great deal of facial variation.
Additionally a vertical line drawn
from the most projected portion of the
upper lip should divide the nose in two
equal halves between the alar facial groove
and the nasal tip. If the anterior portion is
greater than 60%, then the nose is likely to
be overprojected (Figure 65-19).'''
Nasal tip Rotation The nasal tip rotation
is evaluated by the nasolabial angle and the
columellar-lobular angle. Nasolabial angle is
defined as the angle formed by lines that are
tangential to the columella of the nose
and the philtrum of the lip and intersect at

the subnasale. In women this should be
approximately 95 to 110, whereas in
men this should be 90 to 95. Lip position
may be dependent on tooth position. The
columellar-lobular angle is defined as the
angle formed by the intersection of a line
tangential to the columella and a line tangential to the infratip lobule. This angle is
normally between 30 and 45.
Tip Support The strength ofthe cartilage
in the tip of the nose is apparent when one
presses on the tip. A nose with poor support may require cartilaginous struts to
counteract the inherently weakened tip
from the rhinoplasty. The effect of facial
animation should also be noted. Some
patients have overactive depressor septi
nasi muscles, which result in a drooping
nasal tip on smiling. The columella show
on a lateral view should be 3 to 4 mm
below the inferior alar ri
Frontal View Width of Nasal Dorsum
The width of the nasal body and tip
should be approximately 80% of the alar
base width. This is assuming that the alar
base is in proper anatomic proportions.
The alar base width should approximate
the intercanthal distance. If the width of
the nasal dorsum is significantly greater
than 80%, then lateral nasal osteotomies
should be considered. The eyebrows
should gracefully flow into the nasal dorsum analogous to a gull wing in fiight.
The alar rims and columella should
also be a gently curving line that appears
as a bird in flight.
36-40'
FIGURE 65-18 Goode method of nasal projection. This method is sometimes used to determine adequacy of nasal projection. If the
nasofrontal angle is between 36 to 40, then the
length of a perpendicular line through the nasal
tip should be 0.55 to 0.6 the length ofthe nasal
dorsum. x - nasal length. Adapted jrom Austermann, K., Rhinoplasty: planning techniques and
complications. In: Booth PW, Hausamen JE, editors. Maxillofacial surgery. New York: Churchill
Livingstone; 1999. p. 1380.
Alar Width The alar base width should

approximate the intercanthal distance. Seldom is the nasal width less than the intercanthal dimension.
Basal View From a basal view the
columella-to-lobule ratio should be 2:1.
Nostril size and shape should also be
noted. An esthetic nostril is teardrop
1353
FIGURE 65-19 Nasal projection. A vertical line

through the most projected part of the upper lip
should divide the nose into two equal parts. If the
nasal tip comprises > 60%, then the nose may be
overprojected.
1354
shaped, but there is a great amount of ethnic variation (Figure 65-20).

Oblique View The oblique view is most
natural and sometimes more revealing than
standard photographs. It demonstrates the
flow of subunits and facial harmony. The
three-quarters view is how we usually see
each other in routine interaction.
Functional Considerations
Although the patient desires cosmetic correction of their nose, the functional significance of the nose should be closely considered. Nasal airflow through both the
internal and external nasal valves should be
evaluated. The septum should be evaluated
for deviation and perforations. The septum
is often a good site for harvesting autogenous cartilage for grafting. The turbinates
should be evaluated for hypertrophy.
Rhinoscopy with a nasal speculum can be
performed both before and after the
administration of a topical decongestant.
Photographs
The examination is not complete without
standardized facial photographs. The
standard facial photographs should
include frontal, right, and left lateral
views; right and left oblique views; and a
high and low basal view. Close-up views
are taken if warranted. The photographs
are beneficial from a medicolegal standpoint, and they also allow the surgeon to
study the nose in more detail and to

develop a surgical plan.
Anesthesia
Proper anesthesia of the nose is important
to ensure minimal distortion of the tissues
as well as to provide adequate hemostasis.
Prior to injecting the nose, cottonoids or
cotton-tipped applicators soaked in 4%
cocaine or oxymetazoline are placed in
each nostril to constrict the mucous membranes of the turbinates. If the rhinoplasty
is to be performed under sedation, then
cocaine is preferred because of its anesthetic properties. If the procedure is performed under general anesthesia, then
oxymetazoline is sufficient.
Three cottonoids are placed in each
nostril: one along the middle turbinate,
one along the superior nasal vault, and
one along the inferomedial septum.
Local anesthesia is achieved with 2%
lidocaine with 1:100,000 epinephrine. In
an endonasal rhinoplasty the following
areas are injected:
0.5 cc deposited at the junction of
each upper and lower lateral cartilage
(intercartilaginous area)
0.5 cc deposited in the region of each
marginal incision
3 cc along the nasal dorsum and lateral nasal bones (hugging periosteum)
1 cc along the nasal septum
0.5 cc at each alar base
1 cc at each infraorbital nerve
1 cc at the nasal tip
For external rhinoplasty the following
additional area is injected:
1 cc to the coiumeila
Incisions/Sequencing
There are multiple incision techniques
used to gain access to the cartilage and
bone support of the nose.
Complete Transfixion
FIGURE 65-20 Columella-to-lobule ratio. The
columella-to-lobule ratio should be 2:1.
This incision provides access to the caudal

septum, medial crura, and nasal spine.
The incision is made with a no. 15 blade,

beginning just caudal to the superior caudal end of the nasal septum. The incision
extends inferiorly through the membranous septum, following the cephalic margin of the medial crura (see Figures 65-7
and 65-21A). It results in ptosis and
deprojection of the nose.
Partial Transfixion
This incision is similar to the complete
transfixion incision except that it stops at
the level of the medial footpads of the
lower lateral cartilages. The advantage of
this incision is that the attachments of the
medial footpads of the lower lateral cartilages to the caudal septum are not disrupted (see Figures 65-7 and 65-21B).
Hemitransfixion
This incision is a complete transfixion incision that is performed on only one side of
the membranous septum. It does not traverse both mucosal surfaces and therefore
some attachments of the medial crura to
the caudal septum are maintained. Access
to the nasal septum is good with this incision; however, delivery of the lower lateral
cartilage on the side opposite to the incision
is difficult (see Figures 65-7 and 65-21C).
Killian Incision
This incision is seldom used in rhinoplasty.
It is a useful incision to gain access to the
nasal septum if only a septoplasty is to be
performed. The incision is made several
millimeters cephalad to the caudal edge of
the septum. It can be extended onto the
nasal floor if needed.
Intercartilaginous Incision
This incision is made at the junction of the
upper and lower lateral cartilages. The
nare is elevated superiorly with a double
skin hook. A no. 15 blade should pass
below the lower lateral cartilage and above
the upper lateral cartilages. This incision is
typically made after a transfixion incision.
The intercartilaginous incision is then
Rim/Marginal Incision
Complete transfixion
This incision parallels the caudal edges of

the lower lateral cartilages. The incision is
used in combination with an intercartilaginous incision in an endonasal rhinoplasty. The two incisions allow the lower
lateral cartilage to be delivered and visualized. This allows the surgeon to more
accurately trim the cartilage if needed. In
an open rhinoplasty this incision is combined with a transcolumellar incision in
order to gain access to the lower lateral
cartilage and nasal dorsum (Figure 65-23).
Transcolumellar Incision
Partial transfixion
Hemitransfixion
This incision is made through the thinnest

portion of the columella at a level just
superior to the flaring of the medial crura.
The incision can be made with a notched
V in the center of the columella or as a
"stair step." This will break up the scar and
assist in closure. This incision is connected
with a marginal incision bilaterally for
open rhinoplasty (see Figure 65-23).
The two principle techniques are the
endonasal and external rhinoplasty. Each
of these techniques will be described in
general terms, in the order in which the
authors perform them. Other surgeons
may perform the sequence in a different
order (Tables 65-3 and 65-4).
Septoplasty
In rhinoplasty surgery there are several rea-
FIGURE 65-21 Transfixion incisions. A, A complete transfixion incision is made caudal to both the
medial crura and through the membranous septum. B, A partial transfixion incision is similar exceptsons to access the nasal septum: (1) to corthe incision stops short of the medial foot pads of the medial crura. C, A hemitransfixion incision is a rect nasal airflow obstruction, (2) to assist
complete transfixion incision that is performed only on one side, therefore the other medial crura andin the correction of asymmetries, and (3)
footpad is not violated.
connected to the translEixion incision (see

Figures 65-8, 65-9, and 65-22).
Intracartilaginous Incision
This incision is made through hoth the
vestibular nasal mucosa and a portion of
the lower lateral cartilages. This incision is
similar to the intercartilaginous incision
except that it is made 3 to 5 mm posterior
to the junction of the upper and lower lateral cartilages. This incision in effect performs a complete cephalic strip of the
lower lateral cartilages without the need
for delivering the cartilage. The disadvantage is that the lower lateral cartilage is not
directly visualized and it may therefore be
difficul to achieve symmetry between the
right and left sides.
to harvest cartilage for tip grafting.

Access to the nasal septum in an
endonasal approach is through a partialtransfixion incision, which is connected to
bilateral intercartilaginous incisions. The
partial-transfixion incision can he extended to the nasal floor on the side on which
the septoplasty is to be performed. After
completing the incisions the caudal aspect
of the nasal septum is exposed by dissecting the mucoperichondrium from one
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Table 65-3 Surgical Sequence for

Endonasal Rhinoplasty
The general sequence is
FIGURE 65-22 Intercartilaginous

incisions. The intercartilaginous
incision is made at the junction of
the upper and lower lateral cartilages. The blade should pass below
the lower lateral and above the
upper lateral cartilage. Adapted
from Alexander R. Fundamental
terms, considerations, and approaches in rhinoplasty. In: Waite
PD, editor. Atlas of the oral and
maxillofacial surgery clinics of
North America:
rhinoplasty.
Philadelphia (PA): W.B. Saunders; 1995. p. 19.
1.
2.
3.
4.
5.
6.
7.
FIGURE 65-23 Marginal incision.

This incision is made parallel to
the caudal edge of the lower lateral cartilage. This incision can be
combined with bilateral intercartilaginous incisions for a cartilage
delivery technique in endonasal
rhinoplasty or combined with a
transcolumellar incision for an
external rhinoplasty. Adapted
from Alexander R. Fundamental
terms, considerations, and approaches in rhinoplasty. In: Waite
PD, editor. Atlas of the oral and
maxillofacial surgery clinics of
North America:
rhinoplasty.
8.
9.
!0.
11.
Table 65-4 Surgical Sequence for

External Rhinoplasty
The general sequence is
1.
2.
3.
side. Two tunnels will be developed, one

superior and the other inferior, which will
ultimately be joined so that wide exposure
of the septum is obtained.'^ Intially sharp
dissection is done witb a no. 15 blade or
scissors to expose a portion of the caudal
septum. The pericbondrium is gently
scored using a no. 15 blade. A dental amalgam condenser is then used in a sweeping
motion to develop a plane between the
perichondrium and tbe nasal septum (Figure 65-24). Once tbis plane of dissection is
started a Freer or Cottle elevator can be
used to complete the septal envelope (Figure 65-25). The mucoperichondrium is
Local anesthesia
Partial transfixion incision
(see Figure 65-7)
Intercartilaginous incision
(join with partial transfudon)
(see Figures 65-8, 65-9, 65-21,
and 65-22)
Septoplasty (if needed)
(see Figures 65-24 and 65-25)
Dorsal reduction (see Figures
65^28-65-30)
Lateral nasal osteotomies
(see Figure 65-31)
Marginal incision
(see Figure 65-23)
Delivery of lower laterai cartilages
(see Figure 65-37)
Tip modification (ie, cephalic
strips/cartilage grafting/suture
techniques)
Alar base modification
(see Figure 65-41)
Closure, taping, and splinting
tightly bound at the junction of the septum and the maxillary crest.
Once tbe septum is exposed it can be
treated in four ways: (1) resection, (2)
morselization, (3) segmental transection,
and (4) swinging door flaps.'^ Submucosal resection allows a significant portion of
cartilage to be barvested for grafting. At
least 1 cm sbould be maintained superiorly and anteriorly in an L-shaped configuration to provide support for the nose
(Figure 65-26). In order to resect the cartilage a Cottle elevator is used to cut the cartilage. Fomon scissors may be used to
make tbe superior and inferior cuts
4.
5.
6.
7.
8.
9.
10.
11.
12.
Local anesthesia
Bilateral marginal incisions
(see Figure 65-23)
Columellar incision
(see Figure 65-23)
Skeletonization of upper and lower
lateral cartilages and nasal dorsum
Dorsal reduction
Dome division if access is needed
to the septum for septoplasty or
graft harvest
Septopiasty (if needed)
Turbinate reduction
Lateral nasal osteotomies
Tip modification (ie, cephalic
strips/cartilage grafting/
suture techniques)
Alar base modification
Closure, taping, and splinting
1 cm
L-shaped strut
Removal of deviated
septum or cartilage
obtained for grafting
FIGURE 65-24 Identifying perichondrium. The

perichondrium is elevated with a dental amalgam condenser. One will notice a slight bluegray cartilage and a distinct plane of dissection.
FIGURE 65-26 Resection of cartilage/bone from the nasal septum. This may be done to harvest cartilage
for grafring procedures or for removal ofgrossly deviated septum. It is important to maintain 1 cm dorsally and caudally for nasal support.
Septum
FIGURE 65-25 Elevation of mucoperichondrium. The Cottle elevator is specifically designed to

elevate the nasal envelope without perforation.
through the bony septum. The cartilage

can also be removed with a Ballenger swivel blade. If no cartilage is needed for the
rhinoplasty, the resected cartilage can be
morselized and replaced. Morselization
can be performed in situ. Another technique for aligning the septum is through a
segmental transection. In this technique
the mucoperichondrium is elevated on
one side of the septum. Cross-hatching
with a no. 15 blade is performed to weaken the cartilage (Figure 65-27). The
mucoperichondrium on the other side of
the septum provides support. 4-0 gut mattress sutures can he positioned through
the septum to assist in realignment. A septal splint is placed for 1 week. Finally a
swinging door type flap can be used to
reposition a large segment of flat cartilage
Scoring on concave side
Section of crest and

septum removed
FIGURE 65-27 Septal repositioning. A deviated nasal septum can be repositioned by removing the
obstruction inferiorly (A) and cross-hatching the cartilage to allow the deviated portion to he repositioned (B). Adapted from Robinson RC. Functional septorhinoplasty. In: Waite PD, editor. Atlas of the
oral and maxillofacial surgery clinics of North America: rhinoplasty. Philadelphia (PA): WB. Saunders; 1995. p. 35.
that is improperly angulated. The

mucoperichondrium is elevated on one
side. Through and through incisions are
made on either side of the deviated cartilage. The cartilage is also separated from
the maxillary crest so that it can hinge into
a more normal position. Septal splints may
be required for 1 week. In all septal procedures a 4-0 gut on a straight needle is routinely used to perform a mattress suture
through the septum and mucosa. This
decreases the likelihood of a septal
hematoma formation and circumvents the
need for nasal packs.
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Tears in the septal mucosa are not

uncommon. However, it is not problematic as long as the tears are only on one side
of the septum. Unilateral tears require no
elaborate closure. If the tear is through
and through, at least one side should be
closed. This is best done with a 5-0
chromic gut suture.
Turbinectomy
Although the focus of this chapter is the
cosmetic rhinoplasty, some mention needs
to be made on maintaining function. Inferior turbinate hypertrophy is a problem
that can result in nasal obstruction after
cosmetic rhinoplasty, if the problem is not
recognized preoperatively. Hypertrophy of
the inferior turbinates is the most common cause of nasal airway obstruction.'^'^"
Hypertrophy can be caused by numerous
factors. Most commonly it is related to
allergic symptoms. Hypertrophy caused by
allergy should be managed medically with
antihistamines and topical corticosteroids.
If this fails, then surgical management can
be considered.^' In cases of a deviated
nasal septum the turbinate on the side at
which the nasal passage is enlarged can
become hypertrophic with time. In
patients with anatomic enlargement ofthe
turbinate, the problem needs to be recognized so that the nasal passage does not
become obstructed when the septum is
straightened.
Management of inferior turbinate
hypertrophy is controversial and outside
the scope of this chapter. The surgical procedures used to treat this problem have
included corticosteroid injection, turbinate
out-fracture, electrocautery, cryosurgery,
laser reduction, partial turbinate resection,
total turbinate resection, submucous
turbinate resection, and vidian neurectoj^y 20-24 g(-|^ Qf these procedures has various advantages and disadvantages and the
procedure chosen depends on the patient.
The most common complications from
turbinate surgery are hemorrhage, atrophic
rhinitis, and ozena.
Nasal Dorsum
Reduction
One of the most dramatic changes that
can be achieved in rhinoplasty surgery is
correction of a dorsal hump. There are
many ways to remove the hump. Some
surgeons use a scalpel and osteotome,
whereas others use rasps, and a few use
power rasps. The authors recommend to
first incise the cartilaginous convexity
below the nasal bones and then to use a
Rubin osteotome to remove the bony
hump (Figures 65-28-65-31). Care must
be taken to keep the osteotome directed
superficially, since it can defiect downward and result in over-reduction. After
removing the gross hump, sequential
rasping can be used for refinement. After

removal of any significant dorsal hump,
the patient is left with an open roof deformity. This must be closed with lateral
nasal osteotomies (see Figure 65-31).
Augmentation
Augmentation is indicated when there has
been excessive reduction from previous
rhinoplasty or from a post-traumatic
defect. Several techniques are used to augment the nasal dorsum.
Autogenous Augmentation In the setting of acute trauma, cranial bone grafts
can be used to provide support. These are
cantilevered off the frontal bone with a
miniplate. The graft must be properly
Nasal bones
Upper lateral
cartilages
FIGURE 65-28 Removal of a dorsal hump. A, Vie dorsal hump is removed by first using a scalpel to incise
through the upper lateral cartilages. B, Next, a Rubin osteotome is used to reduce the bony prominence.
Care is needed to keep the osteotome from being directed too far posteriorly thereby over-reducing the dor
sum. AdaptedfromAustermann, K., Rhinoplasty: planning techniques and complications. In: Booth PW,
Hausamen JE, editors. Maxillofacial surgery. New York: Churchill Livingstone; 1999. p. 1389.
shaped so that it provides support but

does not distort the shape of the
nose,''^"^^Rib cartilage can also be harvested for augmentation of the nasal dorsum. Silicone sizers can be used to estimate the size and shape of graft needed.
Once the graft is harvested, a 0.035 inch
K-wire can be placed in the center of the
graft to stabilize it. Rib grafts have a tendency to distort with time and the K-wire
may help limit this tendency.'*^
FIGURE 65-29 Dorsal reduction. An Aufricht
retractor lifts the dorsal drape and can protect
the skin during hump reduction. A no. 15 blade
is used to incise the cartilaginous dorsum. Working through this incision, an osteotome or rasp is
used to reduce the bone of the dorsum.
FIGURE 65-30 Dorsal reduction. The dorsum

should be about two-thirds of the cartilage and
one-third of the bone.
For a less aggressive augmentation,

autogenous cartilage harvested from the
nasal septum can be used. This can be
layered and sutured together. It is then
placed through traditional rhinoplasty
mcisions. 29-31
Alloplastic Augmentation Another technique is to use cadaveric dermis along the
nasal dorsum. The advantage here is that
no harvesting is required and the material
is pliable. However, the resorption of
this material is unpredictable. Other
implantable materials include silicone
and expanded polytetrafluoroethylene
(ePTFE) implants. These can be contoured
to the appropriate size intraoperatively.
The issue with implants is that the grafts
can extrude or become infected. Meticulous placement is essential.^ ^"^''
Osteotomies
FIGURE 65-31 Lateral nasal

osteotomies.
Removal of a large dorsal hump will often leave
a flat open roof deformity, and this can be
reduced by lateral nasal osteotomies with an
invert chisel, saw, or rasp.
Osteotomies are performed after the nasal

reduction has been performed. The purposes of lateral nasal osteotomies include
reduction of the open nasal roof, correction
of deviated nasal bones, and narrowing of a
wide nasal base (see Figure 65-31).
There are two principal types of nasal
osteotomy: lateral and medial. The lateral
nasal osteotomy can be performed at different levels. It typically begins low on the
piriform rim and can end either high or
low in its relationship to the nasal bones.
Thus the osteotomy is often termed as a
low-to-low osteotomy or a low-to-high
osteotomy. These osteotomies can be performed via an internal or external tech-
nique. Regardless of which technique is

used, limited periosteal dissection is
favored so that support is provided to the
nasal bones. Medial osteotomies are seldom needed but can be used to obtain a
controlled fracture in patients with thick
nasal bones or when a low-to-low technique is used. Also, regardless of the
osteotomy technique, the osteotomies
should not be carried above the intercanthal line. The bone above this point
becomes much thicker and mobilization
becomes difficult. Care should be taken
when performing medial osteotomies,
since the thicker portion of the nasal bone
can be included in the lateral osteotomy
segment and result in widening of the
upper nasal dorsum. This is termed a rocker deformity.
,
Lateral nasal osteotomies are not
always required to close an open roof
deformity after dorsal hump reduction.
Some surgeons believe it is better to place
spreader grafts in those patients with short
nasal bones so that compromise of the
internal nasal valve does not occur. If an
osteotomy is performed in a patient with
shorter nasal bones, then a low-to-high
technique is preferred.
Nasal Tip
Understanding the mechanisms of nasal
tip support is critical when performing
rhinoplasty. The surgeon must understand both the desired and undesired
changes that occur from the surgical
approach or technique.^^
The three major tip support mechanisms include the following:
1. The size, shape, and strength of the
lower lateral cartilages
2. The attachment of the medial crura to
the caudal septum
3. The attachment of the lower lateral cartilages to the upper lateral cartilages
The minor tip support
include the following:
mechanisms
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1360
1. The interdomal ligament

2. The sesamoid complex, extending the
support of the lateral crura to the piriform aperture
3. The attachment of the alar cartilages
to the overlying skin
4. The cartilaginous septal dorsum
5. The nasal spine
6. The membranous
Certain surgical procedures can
affect tip support. For example a complete transfixion incision will disrupt the
fibrous attachments of the caudal septum to the medial crura thus leaving little support for the nasal tip. Suturing
techniques and cartilage strut grafts may
be necessary to reestablish support if this
incision is performed. Intercartilaginous
incisions, which are useful to gain access
to the nasal dorsum, interrupt the ligamentous connections of the upper and
lower lateral cartilages. This can result in
cephalic tip rotation, which may or may
not be desirable. A cephalic strip procedure creates even further disruption and
rotation of the lower lateral cartilages.
Most often tip rhinoplasty is designed to
refine and decrease the tip lobule while
maintaining or even increasing rotation
and projection.
The cartilaginous support of the nasal
tip is often described in terms of a tripod
concept.^**'^^ The medial crura of both the
lower lateral cartilages together form one
strut of the tripod, and each of the lateral
crura of the lower lateral cartilages forms a
strut. By selectively shortening or lengthening any of these struts, the tip position
can be altered.
The tip position changes are referred
to in terms of both projection and rotation. Tip projection is the distance from
the tip of the nose to the alar-facial junction. Increasing tip projection is one of the
most difficult procedures to perform in
rhinoplasty surgery. Nasal tip projection
can be increased by both grafting and nongrafting techniques.
Tip Projection
Increasing Tip Projection Nongrafting techniques to increase
nasal projection include the following:
1. Suturing of divergent medial crura: For
this technique to be effective there must
be diverging medial crura. Intervening
soft tissue may require excision prior to
suturing with mattress sutures.*'
2. Lateral crural steal: The lower lateral
cartilage is skeletonized and the lateral
crura cartilages are sutured with a
mattress suture so that the lateral
crura now contributes to the medial
crura (Figure 65-32). This results in
increased projection and some rotation as
Grafting techniques to increase projection
include the foUowing:
1. Collumellar strut: This technique
involves the placement of a strut of septal cartilage between the feet of the
medial crura and abutted against the
nasal spine. The medial crura are elevated superiorly with double skin hooks
and the cartilage strut is sutured to the
medial crura via mattress sutures. Only
a minor amount of tip projection can
be increased with this method.
2. Peck graft: This is an onlay graft in the
region of the nasal tip. Layers of cartilage are placed in the domal region to
increase projection. The graft material

is either conchal or septal cartilage. The
cartilage is secured to the dome by
sutures. This technique can increase
projection by 2 to 6 mm (Figure 65-33).
3. Umbrella graft: This technique involves
the creation of a cartilaginous structure
that resembles the appearance of an
umbrella. It is useful when both tip
projection and support of weak medial
crura are required. The umbrella graft
is constructed from harvested septal,
ear, or rib cartilage. It is then sutured in
position so that the "handle" of the
umbrella is between the medial crura
and the "canopy" of the umbrella rests
atop the dome. The canopy portion can
be modifled to incorporate the Peck
graft technique by stacking layers of
cartilage (Figure 65-34).^^
4. Shield graft: This graft was first
described by Sheen.^" A piece of septal
cartilage is shaped to form a trapezoidal configuration measuring 6 to
8 mm superiorly and 5 mm inferiorly.
The graft is usually 10 to 12 mm long
and is beveled so that the corners are
blunted. The graft is placed in a pocket through an endonasal approach or
sutured in position via an open
approach. The superior and lateral
aspect of the graft forms the tipdefining points (Figure 65-35).^
FIGURE 65-32 Lateral crural steal A, B, A horizontal mattress suture is placed in the lateral crura in
order to increase nasal projection and narrow the nasal tip. Adapted from Taylor CO. Surgery of the
nasal tip. In: Waite PD, editor. Atlas of the oral and maxillofacial surgery clinics of North America:
rhinoplasty Philadelphia (PA): W.B. Saunders; 1995. p. 61.
FIGURE 65-33 Peck graft. This involves the placement of layers of cartilage grafts in the region of the
nasal tip to increase nasal projection. Adapted from
Taylor CO. Surgery of the nasal tip. In: Waite PD,
editor. Atlas of the oral and maxillofacial surgery
clinics of North America: rhinoplasty. Philadelphia (PA): W.B. Saunders; 1995. p. 62.
Decreasing Tip Projection Decreasing

tip projection involves reduction of tbe
tip supporting mechanisms. Acbieving
acceptable results when decreasing projection can be difficult since nasal definition can be lost.''' If tbe nasal projection
needs to be decreased, be certain to first
confirm tbat the problem is not the result
of an optical illusion caused by a low
radix position. If the problem is a low
radix, then a dorsal radix graft is the
appropriate treatment.
Methods to decrease projection include
the following:
1. Complete transfixion incision: As discussed above, a complete transfixion

incision will decrease tip support.
Intercartilaginous incisions or cephalic strips will also weaken tbe tip support but will increase tip rotation.
2. Lower the septal angle: If tbe septum
is providing significant support for the
nasal tip, then the septal angle must be
lowered. This is done by excision of a
portion of the caudal septum. Additionally the medial crura can be separated from tbe caudal septum to
decrease projection.
3. Crural excision: To dramatically
decrease tip projection the medial and
lateral crura may need to be sectioned,
overlapped, and sutured into a new
position witb less projection. Tbis
tecbnique maintains the natural shape
of the tip at the domes (Figure 65-36).
Excision of a segment cartilage in the
domes and suturing them back
togetber can be done, but it will
cbange the shape of the nasal tip.
Sometimes, after decreasing the nasal
projection, the patient may have flaring of
the ala and increased infratip columellar
show. This can be treated with an alar base
resection but should be used judiciously.
Tip Rotation Increasing Tip Rotation

Understanding the tripod concept and tip
supporting mechanisms is important
wben determining wbich of the following
methods to use to increase tip rotation.
1. Removal of dorsal hump: A subtle way
to increase rotation of the tip is to
reduce a dorsal hump if present.
2. Resection of the caudal septum: A
small triangular piece of caudal septum
can be removed. Tbe base of this triangular shape is at the nasal dorsum.
3. Cephalic strips from lower lateral cartilages: A complete strip of cephalic cartilage from the lower lateral cartilages will
result in increased tip rotation. Even an
intercartilaginous incision will result in
some tip rotation (Figure 65-37).
4. Shorten the lateral crura
5. Shield graft: A shield graft gives the
illusion cf increased tip rotation.
6. Augmentation of premaxiila: Placement of cartilage or ePTFB in the premaxiila region below the anterior
nasal spine will also give the illusion of
increased tip rotation.
Decreasing Tip Rotation Decreasing tip
rotation is done by two methods:
6-8 mm
10-12 mm
FIGURE 65-34 Umbrella graft. This is essentially

a columellar strut graft placed between the medial crura, combined with a tip graft. This technique
improves support of the medial crura as well as
increases nasal projection. Adapted from Taylor
CO. Surgery of the nasal tip. In: Waite PD, editor. Atlas of the oral and maxillofacial surgery
clinics of North America: rhinoplasty. Philadelphia (PA): W.B. Saunders; 1995. p. 61.
FIGURE 65-35 Shield graft. A, B, This is a grafting technique used to redefine the tip-defining points
of the nose. The graft is typically 6 to 8 mm wide superiorly, 5 mtn wide inferiorly, and 10 to 12 mm
long. Adapted from Taylor CO. Surgery of the nasal tip. In: Waite PD, editor. Atlas of the oral and maxillofacial surgery clinics of North America: rhinoplasty Philadelphia (PA): W.B. Saunders; 1995. p. 62.
1361
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1. Trim the caudal septum near the anterior nasal spine

2. Augment the nasal dorsum: this creates
the illusion of decreased tip rotation.
Tip Shape In addition to changing the tip
position, the tip shape must also be considered. Historically changes to the nasal tip
were performed by selective cartilage excision and reapproximation. The Goldman
tip is an example of such a technique. The
current trend is to preserve and re-orient
existing cartilage and place cartilaginous
grafts if required.**^ Excessive grafting can
be unpredictable in the long run.
Although cartilage preservation is
emphasized there is stiU sometimes a need
to remove cartilage. There are three principal techniques of cartilage excision in the
nasal tip region: a complete strip technique,
a weakened complete strip technique, and
an interrupted strip technique. A greater
Overlapped cartiiage
FIGURE 65-36 Crural excision. This is used when

the nasal tip needs dramatic deprojection. A portion of the lateral crura is excised and the ends are
sutured back together.
resection generally results in more dramatic tip narrowing and rotation.

Complete strip techniques involve the
removal of a complete piece of cartilage
from the cephalic end of the lower lateral
cartilages (see Figures 65-37 and 65-38).
This procedure is thought to be more stable since it leaves an intact strip of the
inferior border of the lower lateral cartilage. Aggressive resection can result in loss
of tip support, alar notching, alar retraction, and the appearance of increased collumellar show. Most surgeons feel that a
minimum width of 6 mm is required to
maintain the structural integrity of the
lower lateral cartilage.
The weakened complete strip technique
involves the removal of a complete cephalic
strip followed by weakening of the cartilage
by selective morselization of the medial and
lateral crura with a scalpel blade.
An interrupted strip involves division
of the lateral crura from the dome (Figure
65-39). This technique provides greater
rotation than a complete strip but can also
result in complications, including loss of
tip support, alar notching, and alar retraction. In addition the nasal tip can develop a
pinched appearance. The classic Goldman
tip is an example of an interrupted strip
FIGURE 65-37 Delivery of lower lateral cartilage. The lower lateral cartilage is best delivered
by a marginal incision or exposed through an
open rhinoplasty for direct visualization and
surgical manipulation.
Tip refinement
is
improved in this case by complete tip reduction
to reduce the volume of the tip.
Maintain
6 mm width
FIGURE 65-38 Complete strip technique. This

involves the excision of a strip of cartilage on the
cephalic portion of the lower lateral cartilage. This
will result in increased tip rotation. It is important
to maintain a minimum oj 6 mm width of cartilage for structural support of the nose. Adapted
from Taylor CO. Surgery of the nasal tip. In:
Waite PD, editor. Atlas of the oral and maxillofacial surgery clinics of North America: rhiiioplasty.
technique (Figure 65-40). In this technique

the lateral crura are divided lateral to the
tip-defming points. The medial segments
are sutured together, which results initially
in increased tip projection. The lateral
crural segments are left alone as independent units. This procedure is no longer
commonly used because of problems with
tip asymmetry, pinched appearance of the
nasal tip, and long-term tip ptosis.
For patients with a broad nasal tip,
transdomal suturing techniques are often
used to narrow the tip. Volume reduction is
performed first if needed by cartilage excision as described above. Next, excision of
excessive interdomal soft tissue is performed. A 4-0 polydioxanone transdomal
suture is placed in a horizontal mattress
fashion to narrow and re-orient the alar
cartilages. The advantage of this technique
is that the suturing can be done multiple
times until the surgeon is satisfied with the
result. Additionally the long-term results of
this technique have been favor able.'
Excised
cartilage
Area of skin
to be excised
FIGURE 65-39 Interrupted strip technique. This

is similar to the complete strip except the remaining cartilage is also divided in a vertical fashion.
This allows for even greater tip rotation, as indicated by the arrow; however, it can result in a
pinched nasal tip and functional problems. The
cartilage can be weakened by scoring it in a vertical fashion and this is termed a weakened complete strip technique. Adapted from Taylor CO.
Surgery of the nasal tip. In: Waite PD, editor.
Atlas ofthe oral and maxitlofacial surgery clinics
of North America: rhinoplasty. Philadelphia
(PA): W.B. Saunders: 1995. p. 59.
FIGURE 65-40 Coldman tip. This is an interrupted strip technique in which the lateral crura
are divided lateral to the tip-defining points. Tlic
medial segments are then sutured together to
increase nasal tip projection and to narrow the
nasal tip. Adapted from Willis AE, Costa LE. Surgical management of the nasal base. In: Waite
PD, editor. Atlas of the oral and maxillofacial
surgery clinics of North America: rhinoplasty.
and skin. The angulation can be adjusted

so that greater reduction of the outer
perimeter of the ala is reduced and only
limited reduction ofthe internal perimeter
is performed.^^ The excision should be
conservative and will rarely be greater than
3 mm in width (Figure 65-41).
Postoperative Management
Nasal Base Alar Reduction
The alar base should approximate the
intercanthal distance and be no more than
1 to 2 mm wider than this. The nostrils
should have a symmetric appearance.
Asymmetry of the nostril is often due to a
deviated nasal septum and this should be
reevaluated prior to consideration of an
alar base resection.
The primary procedure to reduce the
alar base width is an alar base resection.
Alar modification is often considered in
cases where the nose has to be deprojected or to balance the anatomy in certain
ethnic types. It is mandatory to be conservative when performing alar reduction
since it is difficult to correct an overreduction. If there is any doubt, the surgeon should delay the alar base reduction
until a later date.^^
The procedure is performed by excising a small wedge of vestibular mucosa
After performing the rhinoplasty the

surgeon must decide whether intranasal
stents or packing is necessary. We generally do not place nasal packing. If the
septum requires additional support during healing, then silicone stents are
placed. These stents are also used if there
are mucosal tears or if a turbinectomy
was performed. The stents help reduce
the incidence of synechiae formation.
The stents are secured to each other by a
3-0 silk suture passed through the columella and are typically left in place for
1 week.
Next the nasal dorsum is splinted. Benzoin or mastisol is painted on the nasal dorsum and l/i inch brown paper tape is
applied. After placement of the tape the
sphnt is applied. A metal Denver splint or
thermoplastic splint is contoured and
applied. Additional paper tape can be
placed over the splint.
FIGURE 65-41 Alar base reduction (Weir's excision). A, This is med to narrow an overly wide
nostril. B, A small amount of vestibular mucosa
and skin is excised and sutured together. The
excision is usuaUy 1 to 2 mm wide
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CHAPTER 65