Mastering Advanced Rhinoplasty

Mastering Advanced Rhinoplasty

Wolfgang Gubisch
Mastering Advanced
Rhinoplasty
With contributions by Helmut Fischer

Wolfgang Gubisch
Klinik für Plastische Gesichtschirurgie
Marienhospital Stuttgart
Stuttgart
Germany
ISBN 978-3-319-67536-7        ISBN 978-3-319-67537-4  (eBook)

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v
Dedicated to Reny, Simon and Philipp, without whose patience,
understanding and support, I might never had completed this project.

vii
Preface
The nose is a distinctive facial feature of immense
aesthetic importance in the center of the face.
Attention focuses on the eyes in an attractive
human face but quickly diverts to an unattractive
or unnaturally shaped nose. To achieve optimal
facial beauty, therefore, the nose must fit harmoni-
ously and inconspicuously into the face. The nose
is important to more than facial beauty, however;
it is also an important sensory organ vital to one of
the essential functions of life: breathing. For this
reason, the significance of the nose has been
respected in all cultures since ancient times—its
amputation has long been used as a severe form of
both physical and psychological punishments.
The ultimate objective of aesthetic rhinoplasty is to
create a harmonious and natural-appearing nose
that assimilates into the surrounding face with no
visible signs of previous surgery. Of course, the
functional aspects must also be respected, and the
patient needs to be able to breathe comfortably
and without restriction. Only then can the surgical
result be considered a success.
In the early years of aesthetic rhinoplasty, nasal
reduction procedures were the first improvements
patients sought. In all probability, the German sur-
geon Dieffenbach performed the first nose reduc-
tion, employing a direct surgical approach in which
he incised the whole dorsum to reduce the under-
lying skeletal framework. He was the successor to
Ferdinand von Graefe who first started nasal
reconstruction at a university clinic in Europe.
Even though the first closed rhinoplasty was per-
formed by Rowe who published this operation in
1887 in New York, in 1898 Jacques Joseph—today
accepted as the godfather of rhinoplasty on both
sides of the Atlantic—performed the first total
nasal reduction, not knowing about his colleague’s
prior operation in North America. Although these
colleagues were unaware of Dieffenbach’s opera-
tion in 1845, in the more than 100-year history of
standardized rhinoplasty, this procedure has
become the most common surgical procedure in
aesthetic surgery. Further, while a successful rhino-
plasty may have enormous beneficial impact, every
surgeon must be aware that a failed rhinoplasty
leaves the patient with a facial deformity that can-
not be concealed. For this reason, every rhinoplasty
surgeon bears an enormous responsibility for the
psychosocial well-being of the patient.
Unfortunately, there are now many surgeons who
lack sufficient training or experience in this chal-
lenging field and who perform cosmetic nasal sur-
gery primarily for economic gain. In 2009,
rhinoplasty was the number one aesthetic opera-
tion in men. Nearly 70,000 men in the United
States underwent the operation. In women, rhino-
plasty was the second-most common aesthetic
procedure after breast augmentation. Nearly
180,000 American women had their noses changed
by this surgical procedure. The same tendency can
be seen in Europe and elsewhere. It is therefore not
surprising that of all aesthetic procedures, rhino-
plasty has one of the highest rates of patient dis-
satisfaction. Indeed, according to the recent
medical literature, rhinoplasty failure rates are
estimated at 30 %, and future increases are likely.
There are already many books, some of them
excellent, on the market. However, only a limited
number of rhinoplasty textbooks deal with sec-
ondary rhinoplasty. Presently, complex secondary
rhinoplasty accounts for approximately 50 % of my
practice, and the demand for revision rhinoplasty
is increasing worldwide. A greater understanding
of the complex nuances of revision rhinoplasty is
needed.
I have been operating on noses since 1976. With
my medical background—double-boarded in
plastic surgery and ENT—I am highly specialized
in the field of rhinoplasty.
In 1980, I performed the first extracorporeal septal
reconstruction, developing this technique into a stan-
dard procedure for the severely deformed septum.
Over a period of about 20 years, I used the closed
approach for extracorporeal septoplasty, which I
had recommended for much of my early career. For
this reason, I was invited to several meetings, where
there was always considerable emphasis and contro-
versy regarding the preference for the open versus
closed rhinoplasty approach. Although I was always
invited as a representative of the closed approach,
thanks to these many discussions I slowly began to
appreciate arguments in favor of the open approach.
Ultimately, it was the influence of Gilbert Aiach, the
famous French rhinoplasty surgeon, that prompted
a complete change of mind in this regard. Now we
too almost exclusively use the open approach. This
procedure is more precise with regard to both the

viii
analysis and the surgical procedure itself, and it helps
to avoid problems that commonly arise with the
closed technique, such as an unexpected drooping of
the tip. Furthermore, precision increases safety and
enhances quality. I personally think that the open
rhinoplasty approach prevents numerous complica-
tions that would otherwise require revision surgery.
Furthermore, the open surgical approach enables
us to perform many other useful rhinoplasty tech-
niques with greater accuracy, such as the sliding
technique (which we published in 2004) or the
spreader flap technique for widening the inner
valve. Although the spreader flap technique can
also be used in a closed technique, as with the
extracorporeal septoplasty, the closed approach is
much less predictable and less reproducible rela-
tive to the open approach.
Finally, for many years, colleagues from all over the
world who attended our Stuttgart courses on func-
tional and aesthetic rhinoplasty have been encour-
aging me to publish our experience in this
challenging and complex field. So finally I present
this atlas, with a view to sharing our techniques and
to helping all interested colleagues master the ever-­
challenging demands of secondary rhinoplasty.
I would like to express my sincere thanks to Rollin
Daniel who encouraged me to start this project
and who greatly supported me in achieving this
goal. Furthermore, I am extremly grateful to Rick
Davis for translating my Suebian English into an
understandable American one without his sup-
port and help this book would not have been pub-
lished.
My deep thanks go to Helmut Fischer who wrote
chapters 3 and 4. He has been working with me for
many years and stimulated me with a lot of new
ideas. I am very grateful for the regular discussions
about rhinoplasty problems with him, which
increased the level of our work a lot!
Last but not least, I want to thank the many
patients who graciously permitted use of their
clinical photographs for publication in this rhino-
plasty atlas. Because of their generous support,
readers will undoubtedly gain a much clearer
understanding of this challenging and often vex-
ing operation. I will always be grateful for their
selfless and valuable contribution.
Wolfgang Gubisch
Stuttgart, Germany

Preface

ix
I
Internal Nose: Septum
1
Primary Septoplasty......................................................................................................................................................
3
1.1
Surgical Principles in Primary Septoplasty.................................................................................................................
4
1.2
Case Studies: Primary Septoplasty................................................................................................................................   12
1.2.1
Case 1: Technique: Fixation of the Caudal Septum to the Nasal Spine....................................................................   12
1.2.2
Case 2: Technique: Using Cartilaginous Splinting Grafts to Straighten the Septum............................................   15
1.2.3
Case 3: Technique: Partial Extracorporeal Septoplasty (Septal Exchange Technique).........................................   18
1.2.4
Case 4: Technique: Extracorporeal Septoplasty..............................................................................................................   21
1.2.5
Case 5: Extracorporeal Septal Reconstruction for Severe Anterior Septal
Angulation and Dislocation of the Caudal Septum.......................................................................................................   24
1.2.6
Case 6: Extracorporeal Septal Reconstruction for Building a L-Shaped Neoseptum...........................................   27
1.2.7
Case 7: Technique: Extracorporeal Septal Reconstruction Using Bone Graft for Splinting................................   30
1.2.8
Case 8: Extracorporeal Septal Reconstruction by Resection of the Deviated Anterior
Septum and Turning the Posterior Part 180°...................................................................................................................   33

Suggested Reading................................................................................................................................................................     35
2
Secondary Septoplasty................................................................................................................................................     37
2.1
Surgical Principles................................................................................................................................................................   39
2.2
Case Studies............................................................................................................................................................................   51
2.2.1
Case 1: Technique: Splinting of a Scored Septum with Ethmoid Bone....................................................................   51
2.2.2
Case 2: Technique: Septal Extension Graft.......................................................................................................................   54
2.2.3
Case 3: Technique: Suture Fixation of the Neoseptum to the ANS Using Osseous Drill Holes..........................   58
2.2.4
Case 4: Technique: Creation of a Neoseptum with PDS Foil, Restoration
of Strong Tip Support Using a Sandwich Graft from the Concha..............................................................................   61
2.2.5
Case 5: Technique: Straightening by Splinting with Thinned Perpendicular Plate...............................................   65
2.2.6
Case 6: Technique: Covering the Reconstructed Septum with Free Diced Cartilage (FDC)...............................   69
2.2.7
Case 7: Technique: Lengthening of the Septum by Extracorporeal Technique.....................................................   72
2.2.8
Case 8: Technique: Reconstruction of an Overresected, Deformed Anterior Septum.........................................   78
2.2.9
Case 9: Technique: Reconstruction of a Neoseptum with Ethmoid Bone Grafting..............................................   82
2.2.10 Case 10: Septal Correction with Ethmoid Splinting Graft, Septal Extension Graft
from Double-Layered Conchal (Sandwich) Graft, and Maxillary Augmentation..................................................   86
2.2.11 Case 11: Technique: Extracorporeal Septal Reconstruction with Double-Layered L-Strut.................................   92
2.2.12 Case 12: Technique: Extracorporeal Septal Reconstruction and Repositioning
of the Anterior Nasal Spine..................................................................................................................................................   99
2.2.13 Case 13: Technique: Reconstruction of the Inner Valve with PDS Foil...................................................................... 102
2.2.14 Case 14: Technique: Total Reconstruction of the Septum with Both Conchae...................................................... 106
2.2.15 Case 15: Technique: Total Septal Reconstruction with Both Conchae,
Reconstruction of the Dorsum with DC-F........................................................................................................................ 110
2.2.16 Case 16: Technique: Augmentation of the Maxilla with a DC-F Graft....................................................................... 115
2.2.17 Case 17: Technique: Reconstruction of the Septal Framework Using Rib Cartilage............................................. 119

Suggested Reading................................................................................................................................................................   123
3
Functional Aspects in Primary Rhinoplasty...................................................................................................   125
3.1
Physical Examination.......................................................................................................................................................... 127
3.2
Surgical Principles................................................................................................................................................................ 138
3.2.1
Septoplasty............................................................................................................................................................................... 138
3.2.2
Spreader Grafts and Upper Lateral Cartilage (ULC) Suture Techniques................................................................... 139
3.2.3
Spreader Flaps and Anatomic Details of the Nasal Dorsum........................................................................................ 144
3.2.4
Batten Grafts or Lateral Crural Strut Grafts...................................................................................................................... 148
3.2.5
Reduction of Columellar Width........................................................................................................................................... 151
3.2.6
Turbinate Reduction.............................................................................................................................................................. 153
Contents

x
3.3
Functional Aspects in Primary Rhinoplasty: Case Studies................................................................................... 154
3.3.1
Case 1: Spreader Grafts.......................................................................................................................................................... 154
3.3.2
Case 2: Spreader Grafts.......................................................................................................................................................... 158
3.3.3
Case 3: Spreader Flaps........................................................................................................................................................... 161
3.3.4
Case 4: Spreader Flaps........................................................................................................................................................... 164
3.3.5
Case 5: Functional Correction of Complex Alar Deformities....................................................................................... 167
3.3.6
Case 6: Functional Correction of Severe Deviation of the Anterior Nasal Spine (ANS)........................................ 172
3.3.7
Case 7: Balancing Airway Cross Section and Nasal Aesthetics................................................................................... 176

Suggested Reading................................................................................................................................................................   179
4
Functional Aspects in Secondary Rhinoplasty.............................................................................................   181
4.1
Diminished Side Wall Support......................................................................................................................................... 182
4.2
Surgical Principles................................................................................................................................................................ 182
4.3
Case Studies............................................................................................................................................................................ 183
4.3.1
Case 1: Spreader Grafts and Extended Alar Batten Grafts........................................................................................... 183
4.3.2
Case 2: Spreader Grafts and Alar Batten Grafts............................................................................................................... 188
4.3.3
Case 3: Bony Out-Fracture and Spreader Grafts............................................................................................................. 193
4.3.4
Case 4: Bony Out-Fracture.................................................................................................................................................... 197
4.3.5
Case 5: Underscoring the Importance of Septal Support to Nasal Valve Function............................................... 199
4.3.6
Case 6: Bony Out-Fracture and Dorsal Narrowing......................................................................................................... 201
4.3.7
Case 7: Spreader Grafts and Alar Batten Grafts............................................................................................................... 203
4.3.8
Case 8: Septal Reconstruction with Rib Cartilage, Cephalic Fold-Under Flap........................................................ 207

Suggested Reading................................................................................................................................................................   211
II
External Nose
5
Primary Reduction of the Dorsum........................................................................................................................   215
5.1
Surgical Principles................................................................................................................................................................ 216
5.2
Case Studies............................................................................................................................................................................ 225
5.2.1
Case 1: Minor Hump Reduction with Power Drill........................................................................................................... 225
5.2.2
Case 2: Hump Reduction with Compound Technique.................................................................................................. 227
5.2.3
Case 3: Major Reduction for Rhinomegaly with Chisel Combined with Lateral Sliding
Technique for Deprojection of the Tip.............................................................................................................................. 231
5.2.4
Case 4: Lowering the Dorsum Combined with Extracorporeal Septal Reconstruction....................................... 234
5.2.5
Case 5: Lowering the Dorsum Plus Spreader Flaps........................................................................................................ 236
5.2.6
Case 6: Reduction for Rhinomegaly Combined with Extracorporeal Septal Reconstruction............................ 240
5.2.7
Case 7: Widening of Internal Valves with Spreader Flaps............................................................................................. 244
5.2.8
Case 8: Overprojected Dorsum Combined with Underprojected Tip...................................................................... 247
5.2.9
Case 9: Rhinomegaly: Reduction Rhinoplasty Combined with Extracorporeal
Septal Reconstruction........................................................................................................................................................... 249
5.2.10 Case 10: Rhinomegaly with Hypoplasia of the Chin: Reduction Rhinoplasty Combined
with Lateral Crural Overlap (Sliding) Technique, Tongue-in Groove Technique,
Spreader Flaps, and Chin Augmentation......................................................................................................................... 253
5.2.11 Case 11: Reduction Rhinoplasty Combined with Extracorporeal Septal
Reconstruction Plus Shortening of the Nasal Spine...................................................................................................... 256
5.2.12 Case 12: Overprojected Dorsum and Overprojected Tip and Long Nose............................................................... 258
5.2.13 Case 13: Dorsal Reduction Combined with Chin Augmentation............................................................................... 261

Suggested Reading................................................................................................................................................................   264
6
Secondary Correction of the Dorsum Including Polly-Beak Deformity......................................   265
6.1
Surgical Principles................................................................................................................................................................ 266
6.2
Treatment of the Undersupported Nasal Tip............................................................................................................. 268
6.3
Case Studies............................................................................................................................................................................ 278
6.3.1
Case 1: Polly-Beak Deformity with Tip Ptosis and Deviated Nose in a Thin-Skinned Patient............................. 278
6.3.2
Case 2: Complex Deformity with Polly-Beak Parrot Beak from Incomplete Hump Reduction.......................... 281
6.3.3
Case 3: Polly-Beak Deformity Following Septal Overresection and Increased Scarring...................................... 285

Contents

xi
Contents
6.3.4
Case 4: Inverted-V Deformity Combined with Underresected Dorsum................................................................... 292
6.3.5
Case 5: Inverted-V Deformity Combined with Polly-Beak Deformity....................................................................... 297
6.3.6
Case 6: Insufficient Tip Support with Retracted Columella......................................................................................... 300
6.3.7
Case 7: Underresected and Overprojected Dorsal Septum with Underprojected Tip
(Sheep’s Nose Deformity)...................................................................................................................................................... 303
6.3.8
Case 8: Irregular Overprojected Dorsum with Overresected Septum...................................................................... 307
6.3.9
Case 9: C-Shaped Tension-Nose Deformity with Long, Displaced Septum............................................................. 310
6.3.10 Case 10: Polly-Beak Deformity in a Short Nose............................................................................................................... 313
6.3.11 Case 11: Polly-Beak Deformity After Total Resection of the LLC in a Thick-Skinned
Patient with Bad Scarring..................................................................................................................................................... 316
6.3.12 Case 12: Irregular, Overprojected Dorsum with Ptotic Nasal Tip and Severe Septal Deformity....................... 321
6.3.13 Case 13: Overresection of the Dorsum with Saddle-Nose Deformity Combined
with Inverted-V and Polly-Beak Deformity....................................................................................................................... 325
6.3.14 Case 14: Overresected Dorsum Combined with Polly-Beak Deformity................................................................... 328
6.3.15 Case 15: Overresected and Deviated Dorsum................................................................................................................ 331

Suggested Reading................................................................................................................................................................   336
7
Primary Augmentation of the Dorsum..............................................................................................................   337
7.1
Surgical Principles in Primary Saddle-Nose Deformity......................................................................................... 338
7.2
Case Studies............................................................................................................................................................................ 344
7.2.1
Case 1: Augmentation with Cephalic Portion of LLC..................................................................................................... 344
7.2.2
Case 2: Dorsal Reconstruction by Extracorporeal Septal Reconstruction with PDS Foil..................................... 346
7.2.3
Case 3: Dorsal Reconstruction by Extracorporeal Septal Reconstruction............................................................... 349
7.2.4
Case 4: Augmentation with Conchal Cartilage and Allogenic Fascia....................................................................... 352
7.2.5
Case 5: Reconstruction of the Anterior Septum with Double-Layered Conchal
Graft and Augmentation with DC-F from Allogenic Fascia and Diced Cartilage.................................................. 355
7.2.6
Case 6: Dorsal Reconstruction by Solid Graft.................................................................................................................. 359
7.2.7
Case 7: Dorsal Reconstruction with DC-F......................................................................................................................... 362
7.2.8
Case 8: Dorsal Reconstruction with DC-F......................................................................................................................... 366
7.2.9
Case 9: Dorsal Reconstruction with DC-F......................................................................................................................... 369
7.2.10 Case 10: Dorsal Reconstruction of Ethnically Low Dorsum......................................................................................... 371
7.2.11 Case 11: Dorsal Reconstruction of Ethnic Saddle Nose and Narrowing of Alar Base........................................... 374
7.2.12 Case 12: Dorsal Reconstruction with DC-F After Septal Abscess in Childhood..................................................... 379
7.2.13 Case 13: Complex Dorsal Reconstruction of Binder Syndrome Deformity............................................................. 383
7.2.14 Case 14: Augmentation of a Severe Congenital Saddle Nose with Simultaneous
Bulbous Tip Correction.......................................................................................................................................................... 387
7.2.15 Case 15: Augmentation of a Severe Idiopathic Saddle Nose and Simultaneous Tip Correction...................... 391

Suggested Reading................................................................................................................................................................   394
8
Secondary Augmentation of the Dorsum.......................................................................................................   395
8.1
Surgical Principles in Secondary Saddle-Nose Deformity.................................................................................... 396
8.2
Case Studies............................................................................................................................................................................ 400
8.2.1
Case 1: Overresected Dorsum Augmented with Multilayered Allogenic Fascia Lata.......................................... 400
8.2.2
Case 2: Augmentation with Free Diced Cartilage.......................................................................................................... 403
8.2.3
Case 3: Augmentation with Free Diced Cartilage.......................................................................................................... 405
8.2.4
Case 4: Augmentation with Conchal Cartilage and Simultaneous Reconstruction
of the Lateral Crura................................................................................................................................................................. 408
8.2.5
Case 5: Augmentation with Conchal Cartilage............................................................................................................... 411
8.2.6
Case 6: Augmentation with Conchal Cartilage............................................................................................................... 412
8.2.7
Case 7: Augmentation with Conchal Cartilage............................................................................................................... 414
8.2.8
Case 8: Augmentation of DC-F Graft from Concha, Complex Tip Reconstruction................................................ 416
8.2.9
Case 9: Augmentation of DC-F Graft from Concha and Simultaneous Deprojection of the Tip....................... 420
8.2.10 Case 10: Augmentation with DC-F from Rib Cartilage and Lengthening with Septal Extension Graft........... 423
8.2.11 Case 11: Replacing a MedporeR Implant with a DC-F Graft......................................................................................... 427
8.2.12 Case 12: Augmentation with DC-F from Rib Cartilage.................................................................................................. 430
8.2.13 Case 13: Augmentation with DC-F from Rib Cartilage.................................................................................................. 434
8.2.14 Case 14: Dorsal Reconstruction with DC-F from Rib Cartilage................................................................................... 436

xii
8.2.15 Case 15: Dorsal Reconstruction with Solid Rib Graft Covered with DC-F................................................................ 440
8.2.16 Case 16: Augmentation with Diced Cartilage from the Previous Rib Cartilage Graft ......................................... 444
8.2.17 Case 17: Augmentation with Diced Cartilage from a Previous Rib Cartilage Graft.............................................. 447
8.2.18 Case 18: Augmentation with Diced Cartilage from the Previous Rib Cartilage Graft.......................................... 453
8.2.19 Case 19: Total Septal Reconstruction with Concha Combined with DC-F Graft from Rib Cartilage................ 455
8.2.20 Case 20: Removal of Silicone Implants and Replacement of DC-F Graft................................................................. 460
8.2.21 Case 21: Removal of Silicone Implants and Replacement of DC-F Graft................................................................. 463
8.2.22 Case 22: Removal of Synthetic Implant and Replacement of DC-F Graft................................................................ 466
8.2.23 Case 23: Enlarging the Shrunken Skin Envelope by Continuous Manual
Stretching as Prerequisite for a Successful Augmentation with Solid Rib Graft.................................................... 470

Suggested Reading................................................................................................................................................................   472
III
Nasal Pyramid
9
Osteotomies in Primary Rhinoplasty.................................................................................................................   475
9.1
Surgical Principles................................................................................................................................................................ 476
9.2
Case Studies: Primary Nasal Pyramid Correction..................................................................................................... 481
9.2.1
Case 1: Wide Nasal Bridge..................................................................................................................................................... 481
9.2.2
Case 2: Wide Nasal Bridge..................................................................................................................................................... 484
9.2.3
Case 3: Wide Nasal Bridge Complicated by Fracture of the Septal Frame............................................................... 487
9.2.4
Case 4: Wide Nasal Bridge with Functional Problems................................................................................................... 489
9.2.5
Case 5: Narrow Nasal Bridge................................................................................................................................................ 492
9.2.6
Case 6: Narrow Nasal Bridge with Overprojected Dorsum.......................................................................................... 494
9.2.7
Case 7: Deviated Wide Nasal Bridge................................................................................................................................... 496
9.2.8
Case 8: Deviated Nasal Bridge............................................................................................................................................. 499
9.2.9
Case 9: Asymmetrical Nasal Bridge with Severe Septal Deviation............................................................................ 501
9.2.10 Case 10: Inverted-V Deformity............................................................................................................................................. 504

Suggested Reading................................................................................................................................................................   506
10
Osteotomies in Secondary Rhinoplasty...........................................................................................................   507
10.1
Surgical Principles of Osteotomies in Secondary Rhinoplasty........................................................................... 508
10.2
Case Studies: Secondary Nasal Pyramid Correction............................................................................................... 509
10.2.1 Case 1: Wide Nasal Bridge..................................................................................................................................................... 509
10.2.2 Case 2: Wide Nasal Bridge..................................................................................................................................................... 511
10.2.3 Case 3: Asymmetrical Wide Nasal Bridge.......................................................................................................................... 513
10.2.4 Case 4: Deviated Nasal Pyramid Combined with Inverted-V Deformity.................................................................. 516
10.2.5 Case 5: Deviated Nasal Pyramid.......................................................................................................................................... 519
10.2.6 Case 6: Wide Bony Pyramid.................................................................................................................................................. 522
10.2.7 Case 7: Crooked Nose with Asymmetrical and Deviated Nasal Pyramid................................................................. 525
10.2.8 Case 8: Narrow Nasal Pyramid with Inverted-V Deformity.......................................................................................... 528

Suggested Reading................................................................................................................................................................   530
IV
Tip
11
Tip Refinement in Primary Rhinoplasty............................................................................................................   533
11.1
Surgical Principles................................................................................................................................................................ 535
11.1.1 Nasal Tip Contour.................................................................................................................................................................... 536
11.1.2 Projection of the Tip............................................................................................................................................................... 542
11.1.3 Rotation of the Tip.................................................................................................................................................................. 549
11.2
Case Studies: Contour......................................................................................................................................................... 555
11.2.1 Case 1: Debulking of the Tip................................................................................................................................................ 555
11.2.2 Case 2: Debulking of the Tip................................................................................................................................................ 557
11.2.3 Case 3: Augmentation of the Soft Triangle...................................................................................................................... 562
11.2.4 Case 4: Contouring by Suture Technique......................................................................................................................... 564
11.2.5 Case 5: Contouring by Suture Technique After Lateral Crural Overlay..................................................................... 570
11.2.6 Case 6: Contouring by Lateral Crural Steal and Transposition.................................................................................... 573
11.2.7 Case 7: Contouring in a Thick LLC by Dome Division Technique............................................................................... 575

Contents

xiii
Contents
11.2.8 Case 8: Contouring in a Thick LLC by Dome Division Technique............................................................................... 577
11.2.9
Case 9: Technique: Contouring in a Thin-Skinned Patient with Suture Technique
and Additional Camouflaging with Allogenic Fascia Lata and Foot Plate Resection........................................ 579
11.3
Case Studies: Projection.................................................................................................................................................. 582
11.3.1
Case 10: Deprojection and Lengthening of the Nose by Modified Lateral
Sliding (Overlay) Technique............................................................................................................................................... 582
11.3.2
Case 11: Deprojection by Medial Sliding....................................................................................................................... 584
11.3.3
Case 12: Deprojection by Medial and Lateral Sliding................................................................................................. 586
11.3.4
Case 13: Deprojection......................................................................................................................................................... 591
11.3.5
Case 14: Technique: Reduction Rhinoplasty with Tip Deprojection and Correction of
Concave Lateral Crura Using the Lateral Crural (Sliding) Overlap Technique...................................................... 594
11.3.6
Case 15: Increasing the Projection by Grafting............................................................................................................ 598
11.3.7
Case 16: Increasing the Projection................................................................................................................................... 600
11.3.8
Case 17: Increasing the Projection by Grafting............................................................................................................ 604
11.4
Case Studies: Rotation...................................................................................................................................................... 606
11.4.1
Case 18: Lengthening: Derotation by Columellar Strut Combined with Extended
Spreader Grafts..................................................................................................................................................................... 606
11.4.2
Case 19: Lengthening: Derotation by Septal Extension Graft.................................................................................. 607
11.4.3
Case 20: Shortening: Cranial Rotation by Tongue-in-Groove Technique.............................................................. 610
11.4.4
Case 21: Shortening: Cranial Rotation by Modified Tongue-in-Groove Technique............................................ 612
11.4.5
Case 22: Shortening: Cranial Rotation by Suspension with Anterior Sling Plasty.............................................. 613
11.4.6
Case 23: Shortening: Cranial Rotation by Suspension with Anterior Sling Plasty.............................................. 617
11.4.7
Case 24: Shortening: Cranial Rotation by Suspension with Posterior Sling Plasty............................................. 621
11.4.8
Case 25: Identical to Case 2 in Primary Dorsum: Tip Correction with Fold-Under Flap
Technique, Transdomal Suture, Spanning Suture, and Tip Suspension with Posterior Sling.......................... 622
11.4.9
Case 26: Shortening: Cranial Rotation by External Nose Lift.................................................................................... 626
11.4.10 Case 27: Shortening: Cranial Rotation by Dome Division Combined with Internal Nose Lift......................... 628
11.4.11 Case 28: Tip Correction by Columellar Strut (Sandwich Graft), Lateral Crural Steal
Technique, Mattress Sutures Plus Double Layered Onlay Graft in Combination
with Premaxillary Augmentation (DC-F Graft) ............................................................................................................ 630

Suggested Reading..............................................................................................................................................................   634
12
Tip Refinement in Secondary Rhinoplasty...................................................................................................   635
12.1
Surgical Principles in Secondary Tip Correction.................................................................................................... 637
12.2
Case Studies......................................................................................................................................................................... 640
12.2.1
Case 1: Suture and Shield Grafts....................................................................................................................................... 640
12.2.2
Case 2: Alar Reconstruction with Septal Cartilage...................................................................................................... 643
12.2.3
Case 3: Fold-Under Flap Combined with Lateral Crural Overlay............................................................................. 646
12.2.4
Case 4: Combination Columellar Strut/Cephalic Fold-Under Flap/Suspension
Suture with Anterior Sling.................................................................................................................................................. 650
12.2.5
Case 5: Technique: Supratip Excision.............................................................................................................................. 653
12.2.6
Case 6: Reconstruction of the Lower Framework with Septum via Bending Technique.................................. 657
12.2.7
Case 7: Reconstruction of the Lower Framework with Septum via Bending Technique.................................. 661
12.2.8
Case 8: Reconstruction of the Lower Framework with Septum via Bending Technique.................................. 664
12.2.9
Case 9: Reconstruction of the Lower Framework with Septum via Bending Technique.................................. 667
12.2.10 Case 10: Reconstruction of the Lower Framework with Septum via Bending Technique................................ 670
12.2.11 Case 11: Reconstruction of the Lower Framework with Septum via Bending Technique................................ 673
12.2.12 Case 12: Reconstruction of the Lower Framework with Septum via Bending Technique................................ 677
12.2.13 Case 13: Reconstruction of the Lower Framework with Septum via Batten Graft Technique......................... 681
12.2.14 Case 14: Reconstruction of the Lower Framework with Septum via Batten Graft Technique......................... 683
12.2.15 Case 15: Reconstruction of the Lower Framework with Septum via Batten Graft Technique......................... 686
12.2.16 Case 16: Reconstruction of the Lower Framework with Septum via Batten Graft Technique......................... 690
12.2.17 Case 17: Reconstruction of the Lower Framework with Septum via Batten Graft Technique......................... 692
12.2.18 Case 18: Reconstruction of the Lower Framework with Septum via Batten Graft Technique......................... 695
12.2.19 Case 19: Reconstruction of the Lower Framework with Septum via Batten Graft Technique......................... 698
12.2.20 Case 20: Reconstruction of the Lower Framework with Septum via Batten Graft Technique......................... 701
12.2.21 Case 21: Correcting the Lower Framework with Septum via Batten Graft Technique...................................... 704

xiv
12.2.22 Case 22: Reconstruction of the Lower Framework with Septum via Batten Graft Technique......................... 707
12.2.23 Case 23: Reconstruction of the Lower Framework with Rib Grafts......................................................................... 712
12.2.24 Case 24: Reconstruction of the Lower Framework with Rib Grafts......................................................................... 716
12.2.25 Case 25: Reconstruction of the Lower Framework with Rib Grafts......................................................................... 720
12.2.26 Case 26: Reconstruction of the Lower Framework with Rib Grafts......................................................................... 723
12.2.27 Case 27: Reconstruction of Tip Projection by Sandwich Graft, Combined with
Lateral Crural Steal Technique........................................................................................................................................... 728
12.2.28 Case 28: Increasing Projection by Grafting.................................................................................................................... 731
12.2.29 Case 29: Reconstruction of Tip Support with Conchal Graft (Sandwich).............................................................. 734
12.2.30 Case 30: Deprojection with Simultaneous Correction of Dysplastic LLCs by Medial
Crural Overlap (Medial Sliding)......................................................................................................................................... 738
12.2.31 Case 31: Deprojection by Medial Crural Overlap (Medial Sliding).......................................................................... 739
12.2.32 Case 32: Deprojection by Medial Crural Overlap (Medial Sliding).......................................................................... 740
12.2.33 Case 33: Deprojection by Medial Crural Overlap (Medial Sliding).......................................................................... 742
12.2.34 Case 34: Deprojection by Medial Crural Overlap (Medial Sliding).......................................................................... 744
12.2.35 Case 35: Deprojection by Lateral Crural Overlap (Lateral Sliding).......................................................................... 748
12.2.36 Case 36: Complex Tip Reconstruction with Deprojection and Lengthening by Sandwich
Graft, Combined with Push Down, Reconstruction of the Missing Dome with Ear Cartilage......................... 751
12.2.37 Case 37: Deprojection by Lateral Crural Overlap (Lateral Sliding) and Setback
by Septal Extension Graft................................................................................................................................................... 755
12.2.38 Case 38: Deprojection Combined with Cranial Rotation by Septal Extension Graft.......................................... 757
12.2.39 Case 39: Deprojection Combined with Cranial Rotation and Total Reconstruction of the
Lower Framework................................................................................................................................................................. 761
12.2.40 Case 40: Deprojection by Lateral Crural Overlap Combined with Sandwich Graft
Working as a Septal Extension Graft............................................................................................................................... 765
12.2.41 Case 41: Lengthening by Columellar Strut and Extended Spreader Grafts,
Reconstruction of the Lower Framework with Septal Cartilage.............................................................................. 769
12.2.42 Case 42: Lengthening by Septal Extension Graft......................................................................................................... 773
12.2.43 Case 43: Lengthening by Combination from Sandwich Graft and Septal Extension Graft.............................. 777
12.2.44 Case 44: Lengthening by Two Doublelayered Sandwich Grafts from both Conchae........................................ 779
12.2.45 Case 45: Shortening by Tip Suspension Suture with Anterior Sling, Additionally
Columella Shortening......................................................................................................................................................... 783
12.2.46 Case 46: Shortening by Sandwich Graft for Tip Support........................................................................................... 786
12.2.47 Case 47: Shortening by Combination of Different Techniques................................................................................ 790
12.2.48 Case 48: Shortening by Combination of Different Techniques................................................................................ 793
12.2.49 Case 49: Correction of Hanging Columella with Columellar Strut from Double-Layered
Conchal Cartilage (Sandwich Graft) Plus Double-Layered Shield Graft and Soft-Tissue Graft....................... 797
12.2.50 Case 50: Correction of Hanging Columella with Columellar Strut and Extended Spreader Grafts,
Total Reconstruction of the Lower Framework............................................................................................................ 801

Suggested Reading..............................................................................................................................................................   805
V
Malformations
13
Malformation...................................................................................................................................................................   809
13.1
Surgical Principles.............................................................................................................................................................. 810
13.2
Case Studies......................................................................................................................................................................... 815
13.2.1
Primary Cases........................................................................................................................................................................ 815
13.2.2
Secondary Cases................................................................................................................................................................... 837

Suggested Reading..............................................................................................................................................................   868
VI
Complex Revision
14
Complex Revisions.......................................................................................................................................................   871
14.1
Case 1: Long-Term Result of Complex Tip Reconstruction (12-Year Follow-Up)........................................ 872
14.2
Case 2: Complex Reconstruction with Extracorporeal Septal Reconstruction,
Cartilage Grafts from Ear and Rib and Dorsal Reconstruction with DC-F Graft........................................ 878

Contents

xv
Contents
14.3
Case 3: Complex Nose Reconstruction in a Patient with Partial Necrosis of the Columella................. 882
14.4
Case 4: Reconstruction of Tip and Dorsum with Rib Grafts............................................................................... 886
14.5
Case 5: Complex Tip Reconstruction.......................................................................................................................... 890
14.6
Case 6: Severe Psychological Problems After Minor Surgical Deformity
with 15-Year Follow-Up.................................................................................................................................................... 894
14.7
Case 7: Scar Correction After a Failed Open Approach....................................................................................... 899
14.8
Case 8: Complex Tip Reconstruction.......................................................................................................................... 902
14.9
Case 9: Complex Reconstruction of the Nasal Framework in Severely Scared Skin................................ 905
14.10
Case 10: Complex Tip and Dorsal Reconstruction Including Extracorporeal
Septal Reconstruction...................................................................................................................................................... 911

Suggested Reading..............................................................................................................................................................   916
VII
Software
15
New Software for Rhinoplasty Documentation and Record Keeping........................................   919
15.1
Case 1: Overprojected Dorsum with Bulbous Tip and Thin Skin..................................................................... 921
15.2
Case 2: Overprojected, Hourglass-Shaped Narrow Dorsum............................................................................. 926
15.3
Case 3: Primary Rhinoplasty in a Thin-Skinned Patient...................................................................................... 930
15.3.1
Technique: Camouflaging with Allogenic Fascia......................................................................................................... 930
15.4
Case 4: Secondary Rhinoplasty After Overresection of the Dorsum and the LLCs.................................. 934

Suggested Reading..............................................................................................................................................................   938

1
I
Internal Nose: Septum
Contents
Chapter 1
Primary Septoplasty – 3
Chapter 2
Secondary Septoplasty – 37
Chapter 3
Functional Aspects in Primary Rhinoplasty – 125
Chapter 4
Functional Aspects in Secondary Rhinoplasty – 181

3
© Springer International Publishing AG 2018
W. Gubisch, Mastering Advanced Rhinoplasty,
1
Primary Septoplasty
1.1
Surgical Principles in Primary Septoplasty – 4
1.2
Case Studies: Primary Septoplasty – 12
1.2.1
Case 1: Technique: Fixation of the Caudal Septum
to the Nasal Spine – 12
1.2.2
Case 2: Technique: Using Cartilaginous Splinting Grafts to Straighten
the Septum – 15
1.2.3
Case 3: Technique: Partial Extracorporeal Septoplasty (Septal Exchange
Technique) – 18
1.2.4
Case 4: Technique: Extracorporeal Septoplasty – 21
1.2.5
Case 5: Extracorporeal Septal Reconstruction for Severe Anterior
Septal Angulation and Dislocation of the Caudal Septum – 24
1.2.6
Case 6: Extracorporeal Septal Reconstruction for Building
a L-Shaped Neoseptum – 27
1.2.7
Case 7: Technique: Extracorporeal Septal Reconstruction Using Bone
Graft for Splinting – 30
1.2.8
Case 8: Extracorporeal Septal Reconstruction by Resection of the
­Deviated Anterior Septum and Turning the Posterior Part 180° – 33
Suggested Reading – 35

4
1
1.1
Surgical Principles in Primary
Septoplasty
The septum is the central part of the framework of the nasal
skeleton. It is partially cartilaginous, partially bone. It is also
perhaps the most underestimated and neglected structure of
the nose. In a review of 469 of our own rhinoplasties per-
formed in 2009, 198 procedures were found to be revision
cases. One hundred and fifty-three of these revision cases
(77.2 %) required surgical correction of a residual septal
deformity that created a negative functional and aesthetic
outcome. And whereas the functional importance of the
nasal septum is often appreciated, its importance to the aes-
thetic outcome of surgery is often greatly underappreciated.
As a consequence, failed cosmetic and functional surgeries
are increasingly common.
Only a straight septum will permit the nose itself to
remain straight. This is particularly true for the so-called sep-
tal “L-strut,” the L-shaped outer septal perimeter composed of
both the dorsal and caudal segments. Unfortunately, the tech-
nical solutions and advice given in textbooks for septoplasty
are often difficult to translate into reliable clinical results. For
example, the scoring technique as well as the expectation that
the scoring technique will keep a septum straight by releasing
the unbalanced tension lines often does not work. Therefore,
in addition to straightening the septum, it must also be prop-
erly supported and secured after scoring. For this reason, in
all cases in which we release the septum from the premaxilla,
for example, to take out a spur or to shorten the vertical length
of the caudal septum, we make a drill hole through the ante-
rior spine (. Fig. 1.1a) and fix the caudal septum with at least
three stitches to keep the cartilage anchored to different parts
of the spine (. Fig. 1.1b). Moreover, if we feel that scoring will
help to straighten the septum, we always apply a splint of eth-
moid bone to keep the scored cartilage straight during the
healing process (. Fig. 1.2).
Following the classification of Bahman Guyuron, the ulti-
mate objective is a straight septal framework. If the central
part is bent but the L-strut is still straight, it is relatively easy
to remove the deviated segment, straighten it, and put it back.
However, if the dorsal strut is straight but the caudal septum
is deflected (i.e., the L-strut is bent), it may be difficult to
achieve a completely straight septum without reconstructing
the L-strut. There are two options to solve this problem: a less
difficult one that preserves the straight part and takes out
only the deformed segment (. Fig. 1.3; see Case 3) or a more
complicated procedure that involves taking out the entire
septal framework, called an extracorporeal septal reconstruc-
tion (. Fig. 1.4). The latter option means that the whole sep-
tum is removed, preferably with the bony and the cartilaginous
segments in one piece. By measuring the original length of
the dorsum as well as of the anterior border of the septum,
straight segments with the required dimensions can be
sought for reconstruction. Frequently, there is a straight seg-
ment located at the bony cartilaginous junction that mea-
sures between 30 and 35 mm. This can be used as the new
dorsum. Typically, the anterior border measures between 18
and 20 mm, and a separate straight replacement piece can
also be found. However, if a straight segment with the
required dimensions is unavailable, the remaining bent seg-
ments can be straightened by “laminating” reciprocally bent
pieces to balance the deflection. In all cases of an extracorpo-
real septoplasty, spreader grafts are inserted to keep the dor-
sal septum straight and to simultaneously support the
internal nasal valve (. Fig. 1.5).
A precise fixation of the replanted septum is essential for
the success of the procedure. First, it is essential to suture the
reconstructed septum to the upper lateral cartilages (. Fig. 1.6)
and in most cases to the nasal bones as well (. Fig.  1.7).
However, in noses with long upper lateral cartilages, it is often
sufficient to only fix the replant to the upper lateral cartilage.
Conversely, in cases with long nasal bones and short upper
lateral cartilages, fixation to the nasal bones is a must
(. Fig. 1.7). This first requires drilling perforations in the nasal
bones to permit placement of mattress sutures.
Recently we developed two additional techniques for
securing the reimplanted septum back to the bony vault.
With our previously described technique, it was sometimes
difficult to find the opposite drill hole when passing the
suture through the reimplanted septum. Therefore, we now
use what we call the “crisscross” technique. With this method,
we drill a hole through the distal nasal bone on the right side
and then pass the suture obliquely through the reimplanted
septum until it emerges from the contralateral ULC. We then
drill a hole through the distal left nasal bone and repeat the
process. In this manner, the reimplanted septum is securely
fastened at the keystone area with a crisscrossing mattress
suture where we begin the suture fixation (. Fig. 1.8).
If the nasal bones are too short to permit access for drill
hole placement, my collegue Sebastian Haack suggested to
create osseous drill holes using a percutaneous technique
called the “transcutaneous-transosseous-cerclage technique”
(TTC-technique). The drill holes are created by mounting
the hub of an 18-gauge needle over a cylindrical drill bit and
then penetrating the skin with the needle before drilling
through both nasal bones and the reimplanted septum with a
single pass (. Fig. 1.9). The needle is then left in position but
disconnected from the drill, and a 4-0 PDS suture is fed ret-
rograde through the needle tip until it emerges from the
needle hub. The needle is then removed leaving the suture in
place, and a small hook is passed subcutaneously to retrieve
the suture tails from beneath the skin flap. The suture is then
tied over the bony dorsum to immobilize the reimplanted
septum leaving the suture buried subcutaneously.

Chapter 1 · Primary Septoplasty

5
1
After secure fixation of the septum to the nasal dorsum,
the caudal septum is stabilized in a longitudinal groove,
which is drilled to the anterior spine. Before fixation, precise
adaptation of anterior septal length is established by trim-
ming excess cartilage from the base of the caudal septum.
Only then is the septum fixed to the anterior spine through a
transverse drill hole placed through the nasal spine, resulting
in safe and reliable immobilization (. Fig. 1.1).
Before fixation of the replanted septum to the anterior
nasal spine is performed, it must be confirmed that the spine
rests in the anatomic midline. If this is not the case, treatment
depends on whether the spine is wide and broad enough to
permit partial resection on one side so that the remnant is
positioned in the midline (. Fig. 1.10). If so, the caudal sep-
tum can be successfully secured to the spinal remnant. In
cases where the anterior spine is dislocated by more than
2–3  mm, we amputate the spine with a Lindemann burr,
reposition the bony fragment onto adjacent bony structures,
and secure the fragment with microscrews and microplates
(. Fig. 1.11). However, in such cases it is often difficult to fix-
ate the caudal septum to the repositioned nasal spine, mak-
ing it necessary to fix the septum directly to the microplate
(. Fig. 1.12).
In severely deformed noses, there can be problems with
minor dorsal irregularities because concurrent osteotomies
are often needed to straighten the bony nasal pyramid.
Camouflage can be accomplished with different onlay grafts
such as reinsertion of a modified dorsal hump (. Fig. 1.13),
morselized cartilage (. Fig. 1.14), free transplanted diced car-
tilage (FDC) (. Fig. 1.15), or a fascia graft, either autogenous
or allogenic (. Fig. 1.16). The graft should cover the whole
dorsum to create a smooth and uniform surface.
a
b
.
. Fig. 1.1  (a) Drilling a hole through the anterior nasal spine (ANS) with a Lindemann fraise. (b) Fixation of the septum to the anterior nasal spine
via a transverse bony drill hole
.
. Fig. 1.2  Splinting of the scored septum using the perpendicular
ethmoid plate
1.1 · Surgical Principles in Primary Septoplasty

6
1
a
b
.
. Fig. 1.3  (a, b) Endonasal septal correction with reinsertion of straight segment
a
c
b
.
. Fig. 1.4  (a–c) Explanted severely deformed septum

Chapter 1 · Primary Septoplasty

7
1
a
b
.
. Fig. 1.5  (a, b) Creation of L-shaped neoseptum fixing spreader grafts
.
. Fig. 1.6  Suture fixation of neoseptum to the upper lateral cartilage
1.1 · Surgical Principles in Primary Septoplasty

8
1
.
. Fig. 1.7  Suture fixation of the neoseptum to the nasal bones using
bony drill holes

Chapter 1 · Primary Septoplasty

9
1
.
. Fig. 1.8  Crisscross technique for reconstruction of the keystone area
.
. Fig. 1.9  TTC technique to fix the septal replant to the bony ­pyramid
.
. Fig. 1.10  Partial resection of the anterior nasal spine
1.1 · Surgical Principles in Primary Septoplasty

10
1
.
. Fig. 1.12  Fixation of the septum to a microplate
.
. Fig. 1.11  Fracturing and fixation by osteosynthesis of the anterior
nasal spine
a
b
.
. Fig. 1.13  (a) Removed hump after using compound technique. (b) Molding the hump with a cylindrical drill for dorsal grafting
.
. Fig. 1.14  Dorsal graft from morselized cartilage

Chapter 1 · Primary Septoplasty

11
1
a
b
.
. Fig. 1.15  (a, b) Camouflaging dorsal irregularities with free diced cartilage (FDC)
.
. Fig. 1.16  Dorsal graft from allogenic fascia lata (Tutoplast)
1.1 · Surgical Principles in Primary Septoplasty

12
1
1.2
Case Studies: Primary Septoplasty
1.2.1 Case 1: Technique: Fixation
of the Caudal Septum to the Nasal
Spine
Through the open approach, the nasal spine is bluntly dis-
sected from the soft-tissue attachments using scissors or a
round knife. This dissection is carried out between the two
medial crural segments of the lower lateral cartilage to expose
the spine along the bony floor of the nasal cavity, where it
continues as the maxillary crest. The relation to the caudal
septum and the shape of the spine can be clearly seen, and its
central location can be confirmed. A power-driven
Lindemann burr is used to drill two or three transverse holes
across the nasal spine for firm fixation of the caudal septum.
An anteroposterior oriented midline groove is then burred
into the nasal spine to receive the relocated septum. It is nec-
essary to adequately mobilize the septum from the maxillary
crest to allow it to return to the midline for fixation. This
technique is also used in the replantation of the septum in an
extracorporeal septoplasty. A nonabsorbable 4.0 suture such
as a Prolene suture is used to achieve firm fixation with mul-
tiple passes through cartilage and bone.
A 28-year-old male presented with breathing problems
and a nose that was slightly deviated to the right. In profile, a
small hump was seen. The columella was oblique rather than
vertical, and the caudal septum was displaced into the left
nasal vestibule. Endonasal examination also revealed a wide
spur on the left side.
Intraoperatively, the septum was found to be too tall and
was dislocated off the premaxilla into the left nasal vestibule
(. Fig. 1.17). The base of the septum was subsequently short-
ened and mobilized from the maxillary crest to permit mid-
line repositioning, where it was seated into the predrilled
groove (. Fig. 1.18). Firm suture fixation to bone was then
possible through the drill holes in the nasal spine.
Postoperatively, the axis of the nose is seen to be straight
with a vertical columella and near symmetrical nostrils. In
profile, the dorsum was straight (. Figs. 1.19, 1.20, and 1.21).
.
. Fig. 1.17  The dislocated septum, drilling a groove into the anterior nasal spine (ANS)

Chapter 1 · Primary Septoplasty

13
1
.
. Fig. 1.18  The shortened septum is fixed in the midline
.
. Fig. 1.19  Front view pre-op/post-op
1.2 · Case Studies: Primary Septoplasty

14
1
.
. Fig. 1.20  Profile view pre-op/post-op
.
. Fig. 1.21  Base view pre-op/post-op

Chapter 1 · Primary Septoplasty

15
1
1.2.2 Case 2: Technique: Using Cartilaginous
Splinting Grafts to Straighten
the Septum
Once the septum has been returned to the midline or scored
to correct its convexity, grafts of septal cartilage or perpen-
dicular plate bone can be applied to maintain the shape and
ensure a durable result.
These grafts are not used for straightening of the dorsum,
where spreader grafts are favored.
A septal cartilage graft is obtained during submucous
resection of a deviated central portion of the septum. This
cartilage is applied to the caudal septal strut using its inher-
ent convexity to flatten the deviated segment and render the
preserved septum straight. The two opposing cartilages are
united with a 5-0 Prolene suture. A modified Aiach clamp
helps to hold the cartilages straight and closely opposed
while the suture is placed.
A 23-year-old woman presented with a crooked nose,
deviation of the dorsal lines, and deviation of the columella
and the nasal tip to the right.
An open rhinoplasty was planned. At operation the dor-
sal septum was noted to be straight and was therefore pre-
served. However, the deformed caudal septum was
straightened endonasally by scoring the deformed sections
and splinting the caudal septum with a cartilage graft har-
vested from the posterior septum (. Figs. 1.22 and 1.23). The
residual quadrangular septum extending to the bony carti-
laginous junction was then removed. A sagittal groove and
transverse suture hole were drilled into the anterior nasal
spine (ANS) for suture fixation of the caudal septum in the
midline. The dorsum was then lowered using the component
technique allowing both overprojected upper lateral cartilage
to be used as spreader flaps. The deviated nasal pyramid was
then straightened using parasagittal medial osteotomies, fol-
lowed by percutaneous low-to-low lateral and transverse
osteotomies. After placing a columellar strut fabricated from
excised septal cartilage, the tip was contoured using both
transdomal and spanning sutures followed by placement of a
shield graft also made from septal cartilage. Alar rim grafts
were then placed for alar rim contouring and support
(. Figs. 1.24, 1.25, and 1.26).
.
. Fig. 1.22  Splinting of the scored septum and drilling a hole through the anterior nasal spine (ANS)
1.2 · Case Studies: Primary Septoplasty

16
1
.
. Fig. 1.24  Front view pre-op/post-op
.
. Fig. 1.23  The straightened septum is fixed on top of the anterior nasal spine (ANS)

Chapter 1 · Primary Septoplasty

17
1
.
. Fig. 1.25  Profile view pre-op/post-op
.
. Fig. 1.26  Base view pre-op/post-op
1.2 · Case Studies: Primary Septoplasty

18
1
1.2.3 Case 3: Technique: Partial
Extracorporeal Septoplasty (Septal
Exchange Technique)
There are two options for treating a deviated anterior septum.
The first is removal of the entire septum with replantation of
a reconstructed, straight septum (extracorporeal septo-
plasty). When the dorsum is straight and only the anterior
septum is deviated, a dorsal strut can be maintained while
the deviated anterior portion is removed with the central car-
tilaginous septum (partial extracorporeal septoplasty).
Second, through the open approach, the septum is dis-
sected free from the perichondrium in its entirety. A straight
dorsal strut of at least 1 cm in width is marked, and the pro-
jection of the desired anterior septum is measured. The
remaining central septum and deformed anterior portion are
removed as one large piece, often including a segment of per-
pendicular plate, vomer, and maxillary crest. The piece is
studied to identify the straightest portion. This is invariably
located at the posterior bony cartilaginous junction of the
explanted septum. An anterior septal strut is fashioned from
this, using the already measured projection as a guide to the
length of the anterior border. The graft is designed to be large
enough to also provide a straight dorsal border. This allows
fixation to the already preserved dorsum and simultaneously
serves as a unilateral spreader graft.
The graft is re-placed into the nose between the intact lay-
ers of perichondrium, and it is fixed to the cartilaginous dor-
sum with 5-0 Prolene sutures. Firm bony attachment is
achieved by suturing the graft to drill holes in the nasal spine.
A 25-year-old female patient presented with a crooked
nose. The columella was oblique and the nostrils asymmetric.
An S-shaped deformity was palpable within the caudal septum.
An open rhinoplasty was planned. At operation, the dor-
sal septum was found to be straight and was therefore pre-
served (. Fig. 1.27). The deformed anterior septum, including
the residual central septal cartilage up to the bony cartilagi-
nous posterior junction, was removed (. Fig. 1.27). This large
graft was flipped 180° to allow the straight posterior portion
adjacent to the bony cartilaginous junction to become the
anterior border. The incised superior border was applied to
the dorsal strut for fixation and as a spreader graft. A second
spreader graft was applied to the opposite side (. Fig. 1.28).
The postoperative result showed a straight dorsum and a
straight columella with symmetric nostrils (. Figs. 1.29, 1.30,
and 1.31).
.
. Fig. 1.27  Septal exchange technique, preserving a dorsal strut, turning the explanted septum 90°

Chapter 1 · Primary Septoplasty

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1
.
. Fig. 1.28  The replant is fixed to the dorsal strut, for balancing a spreader graft is put to the opposite side
.
. Fig. 1.29  Front view pre-op/post-op after exchange technique
1.2 · Case Studies: Primary Septoplasty

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1
.
. Fig. 1.30  Profile view pre-op/post-op after exchange technique
.
. Fig. 1.31  Base view pre-op/post-op after exchange technique

Chapter 1 · Primary Septoplasty

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1
1.2.4 Case 4: Technique: Extracorporeal
Septoplasty
Through an open rhinoplasty approach, the entire bony and
cartilaginous septum can be removed. In cases of a severely
deformed septum, this may be the best means of achieving a
straight nose.
Once the soft tissue has been elevated via a mid-columella
incision, the anterior septal border is identified. Meticulous
subperichondrial dissection is necessary to ensure that intact
mucosal flaps are preserved. The correct plane is found using
the pointed tips of a scissors to “scratch” the perichondrial
edge free. A size 15 blade can also be used to incise the peri-
chondrium at the anterior border and allow access. Upper
tunnels are created on either side of the septum, and the
upper lateral cartilages are separated from the septum with a
straight sharp scissors. This again preserves the mucosal lin-
ing and the pocket into which the reconstructed septum will
eventually be returned. With the help of a nasal speculum,
the lower tunnels can be approached and dissected under
direct vision. The strong fibrous attachments at the junction
of the septum and maxillary crest need to be carefully released
to access the lower tunnels. With the lower tunnels dissected,
the nasal spine, maxillary crest, and vomer are visible.
Complete mobilization of the septum requires fracturing
through the perpendicular plate using pressure from a small
5-mm osteotome. The same osteotome is also used to break
the attachment to the maxilla. Paramedian osteotomies of
nasal bones dorsally complete the dissection, and the septum
can be removed as one large piece. Before removal, septal
length and projection are measured as a guide to reconstruc-
tion. These dimensions are usually 35–40 mm for the length
and 25–30 mm for projection.
The anatomy of the septum can now be fully appreciated
with all fractures and deviations in plain view. Careful plan-
ning is necessary to design a straight septal framework,
spreader grafts, and ideally a columellar strut from the
explanted septum. The straightest portion usually lies in the
bony cartilaginous region of the septum. This serves as the
anterior border. A straight dorsal border is then cut to meet
the new anterior one. The dimensions are guided by the mea-
surements made before removing the septum but sometimes
are limited by the size of the available cartilage. Spreader
grafts are cut from the remaining septum and fixed to the
neoseptum before replantation. The three cartilage compo-
nents are held with a modified Aiach forceps and fixed with a
horizontal mattress suture of 4-0 Prolene applied with a
straight needle. The application of spreader grafts at this stage
is also an opportunity to eliminate any remaining minor
deviations of the neoseptum caused by their splinting effect.
The key to replantation of the septum is firm fixation in
the true midline. Anteriorly, this is achieved via drill holes in
the nasal spine as previously described for septal relocation.
It is critical to ensure that the nasal spine is truly midline.
Dorsally, drill holes are made in the nasal bones for firm fixa-
tion. In this situation a 4-0 Prolene permanent suture or a 4-0
slowly resorbable PDS suture is used to hold cartilage to
bone. Fixation is completed by suturing the neoseptum to the
upper lateral cartilage.
In the situation in which the nasal bones are too short to
allow drill holes and sutures to be placed, fixation is adequate
to just the comparatively long upper lateral cartilages and
nasal spine.
After completion of any tip refining and supporting
maneuvers, a 4-0 polydioxanone (PDS) suture is used to inte-
grate the columellar strut, medial crura, and anterior septum;
at the same time the mucosa is applied to the neoseptum, and
dead space is eliminated. This suture is placed in a running
caudal-to-cranial quilting pattern. After closure of the colu-
mella incision, silicone splints are applied to both sides of the
septal mucosa and fixed with a 4-0 Prolene suture. The knot
is tied in the left vestibule according to convention. These
splints remain in place for 2 weeks. Invariably, osteotomies
have been performed as part of the total rhinoplasty; how-
ever, a plaster nose splint is always applied to control posi-
tion, shape, and swelling. This may be changed after one
week, but removed after two weeks.
A 16-year-old girl presented with a wide, deviated nose
and obstruction of the right nostril as the result of a bike acci-
dent several years previously. Although she initially was seen
at the age of 12, we opted to postpone surgery because extra-
corporeal septoplasty was required to repair the deformity
and we prefer to wait at least 2 years after menarche (or the
change in voice) before performing this procedure. We
believe that delaying surgery until after the adolescent growth
spurt avoids adverse effects upon facial skeletal growth.
Open rhinoplasty was planned, and at the time of surgery,
the septum was found to be severely deformed. Extracorporeal
septoplasty was indicated to identify a straight cartilaginous
area for reconstruction of the septum. The area was located in
the posterior septum behind the fracture line in the cartilage.
This piece was rotated 90° to achieve adequate dorsal length
and anterior projection (. Fig. 1.32).
From the deformed anterior septal remnant, two spreader
grafts could be fashioned and attached to the new septum.
The straight “neoseptum” with attached spreader grafts was
returned to the nose and fixed to nasal bones, upper lateral
cartilage, and the nasal spine. Low-to-low and transverse
osteotomies were performed to narrow the dorsum. Suture
techniques of placing intradomal, interdomal, and spanning
sutures were used to refine the tip.
Postoperatively, the nose was straight with acceptable
dorsal lines and a symmetrical narrow tip (. Figs. 1.33, 1.34,
and 1.35).
1.2 · Case Studies: Primary Septoplasty

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1
.
. Fig. 1.32  Extracorporeal septal reconstruction by turning the septum 90° and putting on spreader grafts
.
. Fig. 1.33  Front view pre-op/post-op after extracorporeal septal reconstruction by turning the septum 90° and putting on spreader grafts

Chapter 1 · Primary Septoplasty

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1
.
. Fig. 1.34  Profile view
pre-op/post-op after
extracorporeal septal reconstruc-
tion by turning the septum 90°
and putting on spreader grafts
.
. Fig. 1.35  Base view
pre-op/post-op after
extracorporeal septal
reconstruction by turning the
septum by 90° and putting on
spreader grafts
1.2 · Case Studies: Primary Septoplasty

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1
1.2.5 Case 5: Extracorporeal Septal
Reconstruction for Severe Anterior
Septal Angulation and Dislocation
of the Caudal Septum
A 26-year-old girl presented with a nasal deformity resulting
from trauma. Her nose was deviated to the right, and the left
nasal bone was depressed. Palpation of the anterior septum
demonstrated significant bending.
Open rhinoplasty was performed, and owing to the severe
deformity of the anterior septum, an extracorporeal septoplasty
technique was used. A straight posterior segment was found
with adequate dimensions and cut to size to create the neosep-
tum. The inferior border was rotated 180° to become the new
dorsum, while a straight anterior border was cut just behind the
deviation in the original septum (. Fig. 1.36). Spreader grafts
were harvested from the anterior deformed cartilage and
applied to the new dorsum, acting as splints to hold the septum
straight once it was sutured in place.
Tip sutures were used to refine the domes, and then
the nose was closed in the usual manner. Using this proce-
dure, a permanently straight nose with a straight septum
was achieved allowing normal function (. Figs. 1.37, 1.38,
and 1.39).
.
. Fig. 1.36  Extracorporeal septal reconstruction in a transverse dislocated anterior septum with resection of the deformed anterior part and
straightening by spreader grafts

Chapter 1 · Primary Septoplasty

25
1
.
. Fig. 1.37  Front view pre-op/post-op
.
. Fig. 1.38  Profile view pre-op/post-op
1.2 · Case Studies: Primary Septoplasty

26
1
.
. Fig. 1.39  Base view pre-op/post-op

Chapter 1 · Primary Septoplasty

27
1
1.2.6 Case 6: Extracorporeal Septal
Reconstruction for Building a L-Shaped
Neoseptum
A 19-year-old boy presented with an extremely deviated nose
following trauma in childhood. The anterior septal border
was dislocated into the left nostril. The posterior septum had
suffered a multidimensional deformation with sharp edges,
indicating multiple previous septal fractures.
Open rhinoplasty was performed, and the entire septum
was removed. A bigger piece was straightened by shaping and
scoring, and a further straight piece of posterior septal carti-
lage was used as a splint to maintain the shape of the con-
struct (. Fig. 1.40). The result was a straight neoseptum that
could be replanted and fixed to the nasal bones, upper lateral
cartilages (ULCs), and anterior nasal spine (ANS). Tip
sutures were used to stabilize the domes. A columellar strut
and a shield graft were placed to provide a well-supported
lobule (. Fig. 1.41). The nose was closed in the usual manner.
Follow-up after 1 year demonstrated a straight nose with
a straight columella, symmetrical nostrils, and open func-
tional airways bilaterally (. Figs. 1.42, 1.43, and 1.44).
.
. Fig. 1.40  Extracorporeal septal reconstruction with splinting of the bended parts by posteriorly harvested cartilage
1.2 · Case Studies: Primary Septoplasty

28
1
.
. Fig. 1.41  The straight neoseptum in the front view, tip contouring with shield graft, which is horizontally incised for more natural shape
.
. Fig. 1.42  Front view pre-op/post-op

Chapter 1 · Primary Septoplasty

29
1
.
. Fig. 1.43  Profile view pre-op/post-op
.
. Fig. 1.44  Base view pre-op/post-op
1.2 · Case Studies: Primary Septoplasty

30
1
1.2.7 Case 7: Technique: Extracorporeal
Septal Reconstruction Using Bone
Graft for Splinting
During submucous resection of the quadrangular septum, a
portion of the bony perpendicular plate can also be harvested
to create a splinting graft for more effective straightening of a
deformed caudal septum. The graft can be fabricated from an
osseous specimen or from a composite specimen consisting
of perpendicular plate with the attached septal cartilage. In
both cases, a straight donor specimen is selected and thinned
with a powered burr to a final thickness of 1–2 mm. Multiple
small perforations are then made with a drill to facilitate
suture fixation and tissue in-growth. A modified Aiach clamp
is used to temporarily stabilize the construct while a 5-0
Prolene suture is used for fixation.
A 31-year-old female presented for surgery with a severe
post-traumatic deviation of the nose. Examination revealed a
wide nasal tip and extreme rightward deviation of the caudal
septum (. Fig.  1.45) causing deviation of the outer nasal
framework. An extracorporeal septal reconstruction was
indicated because of severe deformity of the L-strut.
Using the external rhinoplasty approach, paramedian
osteotomies were used to release the upper bony septum, and
the entire septal partition was removed. After scoring and
splinting the deviated cartilage segments with perforated
ethmoid bone grafts (. Fig. 1.46) and placement of bilateral
spreader grafts, the septal construct was rotated 90° and rein-
serted so that the bony cartilaginous junction became the
new dorsal septum and the dorsum became the new caudal
septum. Suture fixation to the nasal spine, ULC, and nasal
bones was performed for stabilization, and the newly rebuilt
dorsum was then augmented with three layers of allogenic
fascia lata. Prior to reinsertion of the new septal construct,
osteotomies were performed to straighten the bony pyramid
(. Figs. 1.47, 1.48, and 1.49).
.
. Fig. 1.45  C-shaped deviation of the anterior septum

Chapter 1 · Primary Septoplasty

31
1
.
. Fig. 1.46  Extracorporeal septal reconstruction with splinting of the bended parts by thinned ethmoid bone
.
. Fig. 1.47  Front view pre-op/post-op after straightening by splint from the ethmoid bone and spreader grafts
1.2 · Case Studies: Primary Septoplasty

32
1
.
. Fig. 1.48  Profile view pre-op/post-op after extracorporeal septal reconstruction and covering the dorsum with four layers of alloplastic fascia;
tip suspension with posterior sling
.
. Fig. 1.49  Base view pre-op/post-op after extracorporeal septal reconstruction with splinting of the bended parts by thinned ethmoid bone

Chapter 1 · Primary Septoplasty

33
1
1.2.8 Case 8: Extracorporeal Septal
Reconstruction by Resection
of the Deviated Anterior Septum
and Turning the Posterior Part 180°
A 32-year-old female presented for primary surgery with a
post-traumatic nasal deformity. Examination revealed devia-
tion of the external nose, an overprojected nasal dorsum, and
deviation of the septum to the patient’s left side with oblique
misalignment of the columella. The patient also reported
nasal airway obstruction. Using the external rhinoplasty
approach, the deformed quadrangular septum was removed
(. Figs.  1.50, 1.51, and 1.52). The deviated anterior segment
then was excised and used for spreader grafts (. Fig. 1.53).
The septal remnant was turned upside down and reinserted so
that the septal base became the new dorsal septum reinforced
with spreader grafts. The septal construct was then sutured to
the ULC, nasal bones, and the anterior nasal spine after drill
holes were created in the nasal bones and nasal spine. The
deviated bony pyramid was then straightened using percuta-
neous osteotomies. The tip was refined using both transdomal
and spanning sutures (. Fig. 1.54, 1.55, and 1.56).
.
. Fig. 1.50  Side view of the explanted severely bended septum
.
. Fig. 1.51  Front view of the explanted severely bended septum
.
. Fig. 1.52  View from above to the explanted severely bended
­septum
.
. Fig. 1.53  Extracorporeal septal reconstruction of a severely
C-shaped bended cartilage by turning the septum 90° and putting on
spreader grafts from the anterior deformed part
1.2 · Case Studies: Primary Septoplasty

34
1
.
. Fig. 1.54  Front view pre-op/post-op after extracorporeal septal reconstruction
.
. Fig. 1.55  Profile view pre-op/post-op after extracorporeal septal reconstruction

Chapter 1 · Primary Septoplasty

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1
.
. Fig. 1.56  Base view pre-op/post-op after extracorporeal septal reconstruction
Suggested Reading
Boenisch M, Nolst Trenité GJ. Reconstruction of the nasal septum using
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Ballenger’s otolaryngology head and neck surgery. 17th ed. Shelton:
BC Decker/People’s Medical Publishing House; 2009. p. 633–9.
Gruber RP, Nahai F, Bogdan MA, Friedman GD. Changing the convexity
and concavity of nasal cartilages and cartilage grafts with horizontal
mattress sutures: part I.  Experimental results. Plast Reconstr Surg.
2005a;115:589–94.
Gruber RP, Nahai F, Bogdan MA, Friedman GD. Changing the convexity and
concavity of nasal cartilages and cartilage grafts with horizontal mattress
sutures: part II. Clinical results. Plast Reconstr Surg. 2005b;115:595–605.
Gubisch W. The extracorporeal septum plasty: a technique to correct dif-
ficult nasal deformities. Plast Reconstr Surg. 1995;4:218–26.
Gubisch W. Twenty-five years experience with extracorporeal septoplasty.
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Gubisch W. Treatment of the scoliotic nose with extracorporeal septo-
plasty. Facial Plast Surg Clin North Am. 2015;23:11–22.
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Gunter JP, Rohrich RJ, Adams WP. Dallas rhinoplasty. Nasal surgery by the
masters. St. Louis: QMP; 2002.
Guyuron B. Rhinoplasty. Philadelphia: Elsevier; 2012. p. 307–9.
Kantas I, Balatsouras DG, Papadakis CE, Marangos N, Korres SG, Danielides
V. Aesthetic reconstruction of a crooked nose via extracorporeal sep-
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Suggested Reading

37
© Springer International Publishing AG 2018
W. Gubisch, Mastering Advanced Rhinoplasty,
2
Secondary Septoplasty
2.1
Surgical Principles – 39
2.2
Case Studies – 51
2.2.1
Case 1: Technique: Splinting of a Scored Septum with Ethmoid
Bone – 51
2.2.2
Case 2: Technique: Septal Extension Graft – 54
2.2.3
Case 3: Technique: Suture Fixation of the Neoseptum to the ANS Using
Osseous Drill Holes – 58
2.2.4
Case 4: Technique: Creation of a Neoseptum with PDS Foil, Restoration
of Strong Tip Support Using a Sandwich Graft from the Concha – 61
2.2.5
Case 5: Technique: Straightening by Splinting with Thinned Perpen-
dicular Plate – 65
2.2.6
Case 6: Technique: Covering the Reconstructed Septum with Free Diced
Cartilage (FDC) – 69
2.2.7
Case 7: Technique: Lengthening of the Septum by Extracorporeal Tech-
nique – 72
2.2.8
Case 8: Technique: Reconstruction of an Overresected, Deformed Ante-
rior Septum – 78
2.2.9
Case 9: Technique: Reconstruction of a Neoseptum with Ethmoid Bone
Grafting – 82
2.2.10
Case 10: Septal Correction with Ethmoid Splinting Graft, Septal Exten-
sion Graft from Double-Layered Conchal (Sandwich) Graft, and Maxil-
lary Augmentation – 86
2.2.11
Case 11: Technique: Extracorporeal Septal Reconstruction with Double-
Layered L-Strut – 92
2.2.12
Case 12: Technique: Extracorporeal Septal Reconstruction and Reposi-
tioning of the Anterior Nasal Spine – 99
2.2.13
Case 13: Technique: Reconstruction of the Inner Valve with PDS
Foil – 102
2.2.14
Case 14: Technique: Total Reconstruction of the Septum with Both
Conchae – 106

2.2.15
Case 15: Technique: Total Septal Reconstruction with Both Conchae,
Reconstruction of the Dorsum with DC-F – 110
2.2.16
Case 16: Technique: Augmentation of the Maxilla with a DC-F Graft –
115
2.2.17
Case 17: Technique: Reconstruction of the Septal Framework Using Rib
Cartilage – 119

Suggested Reading – 123