Nasal Reconstruction Art and Practice E-Book_nodrm

673
The Composite Defect
A month to six weeks later, the facial platform is stable. The nose can now be repaired
(Figure 24–7). Exact templates are designed from the contralateral normal upper lip and
C
A
B
Figure 24–7

674
Chapter • 24 • Rebuilding the Composite Defect
ala. The upper lip template is used to mark the ideal position of the new alar base, sill,
and the nasolabial fold. Using the contralateral alar subunit template as a guide, the
outline of the left ala is marked and residual normal skin is excised within the subunit.
Some of the excess skin from the residual ala was also hinged over for lining. A primary
cartilage graft, based on the contralateral normal ala, is designed to support and shape
the reconstructed left ala. The same pattern is used to determine the dimension and
outline of a two-stage forehead fl ap. This was transferred to resurface the entire alar
subunit.
The forehead fl ap was divided 3 weeks later.
Four months later (Figure 24–8), slight fullness at the junction of the left dome and ala
was sculpted by reopening the anterior aspect of the alar unit border incision. The ideal
left nasolabial fold, based on a pattern of the contralateral normal nasolabial fold, was
marked and directly incised to allow subcutaneous sculpture. This helped to re-establish
a fl at upper lip surface, the defi nition of the nasolabial fold and the fullness of the adjacent
cheek.
A
B
Figure 24–8

675
The Composite Defect
Months later (Figure 24–9), the contours of the lip, cheek and nose junction are aestheti-
cally pleasing. The distracting scar of the cheek fl ap extension, which crossed the superior
aspect of the upper lip, has ‘disappeared’. The creation of a nasolabial crease, by direct
incision, re-established the expected facial contour even in the irradiated fi eld.
A
C
B
Figure 24–9

676
Chapter • 24 • Rebuilding the Composite Defect
Case 3
Full-thickness Loss of the Left Ala, Columella and Nasal Sill, One Half of
the Upper Lip and Medial Cheek with an Unstable Platform
(Lip Sphincter Ablated)
In this patient (Figure 24–10) a massive recurrent basal cell carcinoma, originating at the
right alar base and upper lip, required full-thickness excisions of the right cheek, two
thirds of the upper lip, the entire columella, and right ala and nasal sill. Cover, lining and
support for the nose, lip and cheek were missing.
Such an extensive composite defect must be reconstructed, in stages, with ideal materi-
als. First, the nasal platform of lip and cheek is re-established. Then, the nose can be
rebuilt on a stable platform.
An aesthetic reconstruction of a full-thickness upper lip defect requires that all missing
components be replaced — cover, lining, and muscular support. The lip must be replaced
with tissue that functions as a lip and cosmetically looks normal. Only the lower lip has
the surface appearance, form and muscular function to replace a major full-thickness
loss of the upper lip.
The nasolabial fold normally extends inferiorly, lateral to the alar groove, and passes later-
ally around the oral commissure and into the mental crease. The nasolabial and submen-
tal folds were marked and incised (Figure 24–11). The cheek was resurfaced with an
inferior-laterally based fl ap. It replaced the missing cheek skin, leaving its scar hidden
within the nasolabial fold and submental crease. The residual dog-ear at the upper end
of the rotation would be revised at a later stage. The lining defect of the cheek was closed
primarily.
Figure 24–10

677
The Composite Defect
Small, superfi cial defects of the lateral upper lip can be repaired with lip rotation skin fl aps
or with nasolabial skin from the cheek, transferred as a one-stage extension or as an
island fl ap. Missing subcutaneous bulk is replaced with a fat fl ip-fl ap. As long as the
inferior one half of the orbicularis muscle sphincter remains intact, the lip will function
adequately.
However, if the defect is large and deep and the inferior one half of the orbicularis muscle
is excised or the defect is full thickness, a skin fl ap will fail. Although successfully resur-
faced with skin, without a circumferential muscle sphincter, the lip will hang motionless
and appear long and fl accid.
Large, deep defects of the lateral upper lip subunit which include muscle or are full thick-
ness are best repaired with a subunit midline cross lip Abbe fl ap. Lateral defects up to
one half of the upper lip can be repaired by sharing ‘like’ tissue from the lower lip.
The lip itself can be divided into topographic units: a lateral subunit, bordered by the
philtrum column, nostril sill, alar base, and the nasolabial crease, and a medial topo-
graphic subunit, which is one half of the philtrum. In this case, slightly more than half of
the upper lip, as well as the alar base, nasal fl oor and columella were missing.
Figure 24–11
Lateral subunit
Medial subunit

678
Chapter • 24 • Rebuilding the Composite Defect
The original lip defect included the entire upper lip subunit. At operation (Figure 24–12)
no extra tissue was excised.
A precise pattern of the left hemilip was designed, as a guide, for the missing right
hemilip.
The upper lip defect must be replaced exactly — no more, no less.
However, the design of the lateral subunit replacement was enlarged to include additional
tissue to replace the adjoining nostril fl oor, alar base and columella.
The subunit cross lip Abbe fl ap was inked in the midline of the lower lip. This full-thickness
lower lip fl ap was incised and rotated 180 degrees. It was perfused on a 1 cm wide
pedicle, based on the posterior vermilion and mucosa.
Two weeks later, at the second stage, the lip pedicle was divided. The dog-ear at the
right infraorbital margin was also excised.
The subunit Abbe fl ap is unlike the traditional cross lip Abbe fl ap. Typically, an Abbe fl ap
is positioned to straddle the defect. A lateral upper lip defect is fi lled with lateral lower lip
tissue. Unfortunately, when lower lip is harvested off the midline, the remaining lower lip
is distorted on closure. The commissures are pulled asymmetrically and the vermilion
margin is mismatched. Normal midline vermilion is fuller centrally, than laterally. When
the donor site of an off-center Abbe is repaired, the vermilion does not match along the
vertical lower lip closure.
A
B
Figure 24–12

679
The Composite Defect
C
D
E
Figure 24–12, Continued

680
Chapter • 24 • Rebuilding the Composite Defect
Traditionally, an Abbe fl ap is designed to replace only one half of the defect. The missing
upper lip is replaced with a lower lip fl ap which is 50% of the size of the actual excision.
Hoping to minimize distortion of the lower lip by decreasing the size of the donor fl ap,
the surgeon tries to make up the difference by relying on lip elasticity. Unfortunately, this
means that the upper lip defect is inadequately replaced. The midline of the upper lip,
the philtral columns, the commissures, and the nasolabial fold are ‘pulled’ into the wound.
These important central landmarks become malpositioned toward the center of the origi-
nal defect. Concern for the lower lip leads to permanent distortion of the upper lip, as
well. The traditional Abbe fl ap has serious limitations.
The subunit cross lip Abbe fl ap is designed to exactly replace up to one-half of the upper
lip. In principle, the upper lip is replaced, using the subunit principle. The replacement
for hemi-upper lip is based on a pattern of the contralateral lip. The fl ap is harvested from
the midline of the lower lip, regardless of the size or site of the defect.
After wound closure, the dimensions of the upper lip are restored and its landmarks are
correctly positioned, because missing tissues are replaced exactly. The remaining lateral
elements of the lower lip are drawn, centrally on closure of the donor site. This maintains
symmetry of the lower lip commissures and vermilion match.
Cross Lip Abbe Flap Technique
As illustrated in Figure 24–13, the lateral and medial subunits of the upper lip are
outlined with ink. The topographic subunit, based on an exact pattern, is replaced
using a contralateral normal as a guide. This may be the lateral lip subunit, bordered
by the philtrum column, nostril sill, alar base and nasolabial crease or the combined
medial subunits (one half of the philtrum) and lateral subunit.
Figure 24–13
A
B
C
Inferior labial
artery
Inferior labial
artery

681
In smaller defects, the lateral border of the excision is, by necessity, arbitrary. The full
thickness of the upper lip is not excised to satisfy the subunit principle. The fl ap is
designed along a real or imagined wrinkle line, perpendicular to the orbicularis muscle.
It is not necessary to replace the entire lateral subunit out to the lateral extent of the
inferior nasolabial fold, near the commissure. Residual lateral upper lip can also be
rotated medially to decrease the size of the defect. Ideally most scars will lie, in the
midline or the philtrum column, along the nasal sill and within the superior nasolabial
fold, where they will be less visible.
First, residual normal skin is excised within the planned subunit replacement.
Remember that the swollen, gaping wound does not refl ect the true tissue loss. Missing
tissue must be replaced exactly, if the width and height of the normal upper lip are to
be normal and match the contralateral normal upper lip. A template, based on the
contralateral normal, is used as a guide to restore correct lip height, width and border
outline.
The template of the missing topographic upper lip unit is made, reversed, inverted and
transferred to the midline of the lower lip. An additional extension may be included
in the design to replace the nostril fl oor, alar platform, and even the columella. The
white roll is marked at the donor and recipient sites to allow perfect realignment of
the vermilion line on closure.
The full-thickness lip is incised, rotated 180 degrees, and sutured into the upper lip
defect in layers, based on an ipsilateral pedicle of posterior vermilion and muscle, at
least 0.5-cm wide. The marginal artery of the inferior labial artery and fi bers of the pars
marginalis of the orbicularis muscle are included.
The patient can eat with a straw or small spoon. The pedicle is divided in 11 to 14
days.
After fl ap division, edema resolves slowly. Lip sensitivity and motor reinnervation
return over one year. Frequently, a horizontal excision of posterior mucosa will be
needed to achieve upper lip symmetry. The midline vermilion of the lower lip fl ap is
too full laterally, where it approaches the commissure, when it is switched to the upper
lip. Perhaps due to gravity and edema prior to reinnervation, the lip may look too long,
despite an exact pattern design. It is shortened, secondarily, by a horizontal excision
under the nostril sill or by a direct excision along the upper lip white roll and red ver-
milion junction, if necessary.
The only tissue suitable for aesthetic restoration of moderate size defects of the upper
lip is the lower lip due to its similarity and skin quality, form, bulk and muscle func-
tion. This principle is shared by the Abbe, Estlander, Gillies fan fl ap, and Karapandzic
techniques. None supply new tissue. All simply share the loss between the upper and
lower lip to reconstruct the other. However, the Karapandzic, Gillies fan fl ap, and
Estlander fl aps have serious limitations when used to repair defects of the lateral upper
lip. All rotate tissue around the commissure. Each displaces the corner of the mouth,
even if reinnervation is maintained or returns.
These fl aps are best applied to midline defects, especially of the lower lip. They are
much less effective in a repair of large lateral upper lip defects.
The subunit midline cross lip Abbe fl ap is useful for moderate-size deep defects of the
lateral upper lip. The pattern is designed to exactly replace up to one half of the upper
lip with an Abbe fl ap based in the midline of the lower lip. Like tissue is replaced in
kind, border scars are well position, the orbicularis sphincter is restored and upper and
lower lip balance and symmetry are maintained.
Cross Lip Abbe Flap Technique

682
Chapter • 24 • Rebuilding the Composite Defect
The ala sits on the platform of the lip and cheek at a precise facial location and angle.
These characteristics must be precisely restored. So, in this operation no attempt was
made to reconstruct the right ala, initially. Six to eight weeks later, once the platform
was stable, the right ala was reconstructed, as an exact subunit, based on the contra-
lateral ala (Figure 24–14).
A right paramedian forehead fl ap was prelaminated with a skin graft. The skin graft
was partially re-elevated, at forehead fl ap transfer, to allow placement of a delayed
primary alar cartilage graft between the graft and the overlying fl ap.
A
C
B
Figure 24–14

683
Eight months after initial reconstruction (Figure 24–15), ‘like’ tissue — nose, cheek, lip
— are replaced in kind. Border scars are positioned aesthetically and the orbicularis
sphincter is reconstituted. Spontaneous reinnervation of both sensory and motor func-
tion occurred within one year. The quality and border outline of the upper and lower
lip are correct. The alar bases and nasolabial folds are appropriately positioned. The
oral commissures are symmetrical. The left nasolabial crease had been previously dis-
torted by past excisions. The right upper lip was reconstructed to match the somewhat
abnormal left lip.
A
C
B
Figure 24–15
Cross Lip Abbe Flap Technique

684
Chapter • 24 • Rebuilding the Composite Defect
Case 4
Massive Central Facial Loss
This 69-year-old man (Figure 24–16) presented 12 years after radical nasectomy, bilateral
partial maxillectomy, and total upper lip resection for a multiply recurrent squamous cell
carcinoma of the septum, unresponsive to previous radiation therapy, chemotherapy and
surgery. Bilateral fan fl aps poorly restored a soft tissue upper lip partition. His palate
remained unrepaired. His visible deformity, unintelligible speech, requirement for tube
feeding, and constant drooling motivated repair. Staged reconstruction employing local
and distant tissue was planned.
At the fi rst stage, the upper lip fan fl aps were split. A rib graft was positioned ‘in the
breeze’ from one maxillary tuberosity to the other to provide central facial support and
projection. This bony scaffold was covered with a free latissimus dorsi myocutaneous
fl ap, anastomosed to the left facial vessels. The nasal ‘palate’ surface was covered with
back skin and the ‘oral’ muscle surface with a split-thickness skin graft. This separated
the oral and nasal cavities and established a central midfacial platform.
At a second stage, soft tissue was sculpted by the excision of excess latissimus skin and
subcutaneous tissue to improve the contour of the cheek and upper lip. A scalp fl ap
based on the right superfi cial temporal vessels was passed under the right cheek fl ap to
resurface the upper lip with hair bearing scalp, allowing the later growth of a mustache.
Bilateral cheek fl aps were rotated and advanced to resurface the medial cheeks.
At a third stage, a free radial forearm fl ap, anastomosed to the right facial vessels, was
positioned skin inward to provide nasal lining. Its external raw surface was temporarily
skin grafted. Subsequently, the skin graft was excised, the free fl ap thinned for nasal
A
B
Figure 24–16

685
lining, and an osteocartilaginous dorsal rib graft and columella strut positioned to restore
central nasal support. This was covered with a left paramedian forehead fl ap.
At a later date, during an intermediate operation, the forehead fl ap was re-elevated,
underlying soft tissues were sculpted, and further rib and ear cartilage grafts positioned
to support the alae, sidewalls and tip. Hair-bearing scalp skin, which had been moved to
the normally ‘hairless’ triangle of the superior lip, medial to the ideal nasolabial fold, was
excised. Then the right and left cheek fl aps were further advanced to resurface the
expected hairless fl at triangle of the upper lip with glabrous skin.
Later, when the forehead fl ap pedicle was divided, the nasolabial folds were recreated
by direct incision and soft tissue sculpting at the position of the ideal fold, disregarding
old scars.
Postoperatively, the patient can speak clearly, maintain oral input, and no longer drools.
The oral and nasal cavities are separated, facial projection is restored, and the expected
contours and skin quality of the normal face had been re-established. He remains well 9
years after reconstruction. His repair is illustrated in Chapter 20 — The Use of Distant
Tissue for Facial Reconstruction — Microvascular Tissue Transfer for Nasal Lining.
An Approach to the Composite Wound
In summary, the fi rst prerequisite for facial reconstruction is a clear visualization of
the goal and a commitment to achieve it. The entire repair should be intellectually
planned, designed step-by-step and laid out in a series of coordinated steps. General
principles should be applied to successfully repair composite defects of the nose, lip
and cheek.
1. The alar base must be precisely positioned on a stable, newly reconstructed
platform.
2. Exact patterns, based on the contralateral normal, allow the correct positioning
of landmarks, proper placement of incisions, and the exact replacement of
missing tissue in dimension and outline.
3. Pre-existing scars can often be ignored. Contour is the primary determinative
normal and direct incisions — disregarding old scars — often permit more
precise subcutaneous sculpture.
4. Alter the wound and site, size, shape, and depth as necessary to re-create the
expected units.
5. Avoid the use of ‘one hole’ and ‘one fl ap’ when reconstructing composite defects
which encompass multiple facial units.
6. Use ‘like’ tissue for ‘like’. Use local tissue for facial resurfacing and distant tissue
for ‘invisible’ needs.
7. Use primary and delayed primary cartilage and bone grafts to create a hard tissue
architecture. Use subcutaneous excision to sculpt and shape soft tissues during the
intermediate operation of a three-stage forehead fl ap and during late revisions.
8. Build in units.
9. Use surgical staging to advantage.
10. Consider the requirements of individual subunits and select materials and
techniques that will satisfy the needs of anatomy and aesthetics.
11. Appreciate the unique needs of the composite defect and restore the quality,
outline, and contour of each unit by careful application of regional unit principles.
An Approach to the Composite Wound

This page intentionally left blank

The Interface of Cosmetic and
Reconstructive Rhinoplasty –
The Crucifi ed Tip, the
Saddlenose and the
Continuum of Reconstruction
and Cosmesis
C H A P T E R
25
Although seemingly opposite spectrums of nasal repair, both cosmetic and reconstruc-
tive rhinoplasty defi ne their aesthetic from the visual. Although the vocabulary may
be different, the ideal nasofacial angle, tip defi ning points, and other internasal rela-
tionships, outlined by Sheen, Gunter, and Byrd, for use in aesthetic rhinoplasty are not
unlike the dimension, position, symmetry, and projection which defi ne the quality,
outline and contour of regional units.
Both modern disciplines emphasize the re-establishment of contour. A structured
subsurface architecture controls the shape of the overlying skin. Both acknowledge that
the greater the damage to the underlying architecture and any associated cover, lining
and soft tissue alteration the greater the need for rigid support.
In the past, reduction was the purpose of cosmetic nasal surgery. Over excision of
support sometimes produced a shapeless amorphous skin sleeve and the classic sec-
ondary rhinoplasty deformities.
When tissue was missing after cancer excision or trauma, the goal of early reconstruc-
tive surgery was a healed wound. Defects were ‘fi lled’ and the wound was closed, but
normal contour was not restored.
Today, both the disciplines have a refi ned ‘aesthetic’ which emphasizes contour. Both
demand the recreation of a subsurface architecture to support and shape the overlying
skin envelope.
Traditionally, closed rhinoplasty was a reduction operation — the goal was a smaller
nose. It was an ‘all take and no give’ operation. Then Sheen realized that the cosmetic
deformity was often one of support defi ciency, malposition, or poor shape. He com-
bined augmentation with standard excisional techniques.
Recently, open rhinoplasty has become popular. Wide exposure improved visualiza-
tion of anatomy and allowed the surgeon to apply new suture modifi cation techniques
to shape the intrinsic cartilage and rigidly fi x additional cartilage grafts.
Reconstructive surgery was expanded by an improved understanding of normal
anatomy and blood supply and confi rmed the importance of individual shaped support
grafts in re-establishing nasal subunits and surface contour.

688
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
Implications
The technical approach to nasal deformity should be dictated by etiology, not disci-
pline. The cause of injury determines the site of damage and the severity of its
consequences. The question should be: What is injured — cover, support, or lining?
Then correct the problem with all your tools — whether cosmetic or reconstructive.
Cosmetic revisional rhinoplasty deals with abnormalities of the mid layer. If iatrogenic
misbehavior complicates the problem, injury may progress to cover and lining.
Cocaine and infectious disease primarily affect the intranasal lining, leading to loss of
support and possible skin contraction or necrosis.
Nasal trauma causes acute bone and cartilage fracture, soft tissue laceration and scar
contraction. Loss of support and possible secondary skin and lining injury follow.
Most cancers destroy the skin and progress, secondarily, into the underlying support
and lining.
Surgical techniques of cosmetic and reconstructive surgery are interchangeable and
should be applied to address specifi c problems within either discipline. However,
reconstructive surgeons, unlike cosmetic surgeons, have a distinct advantage. They can
control the skin and lining sleeves by altering the dimension, outline, and quality of
their transferred replacements. Reconstructive surgeons are not limited to only altering
the middle support layer to solve a clinical problem.
Anatomic Reconstruction of the Nasal Tip Cartilages in
Secondary and Reconstructive Rhinoplasty
The entire character of the nose — its refi nement, inclination, length and width — is
determined by the contour of the nasal tip. The size, shape and position of its alar
cartilages provide support and defi ne its aesthetics.
Ideally, during primary rhinoplasty, the tip cartilages are modifi ed by partial excision,
transection, repositioning, suture modifi cation, or augmentation. Hopefully, nasal aes-
thetics are improved.
When they are not, a revision may be required. Under such circumstances, normal
anatomy will be altered, distorted, or destroyed. The alar cartilages may be missing.
Their remnants may be fi xed by scar, or by sutures, in an abnormal position. The injury
must be undone. The desired characteristics of the tip lobule and of the columella,
nostril, alar rims, and airway must be restored. Restoration of the form and function
of the tip cartilages becomes vital in any reoperation.
Assuming that useful remnants of the tip cartilages remain or can be modifi ed, most
recommendations to repair the tip include:
1. The release, repositioning, and repair of residual alar cartilages. This may
include an alar spreader graft to push the tip remnants inferiorly and laterally.
2. Suture unifi cation of the residual right and left alar cartilages to equalize
projection.
3. A columellar strut to project the residual medial crura and support the tip
complex.
1

689
4. Onlay cartilage grafts to recreate tip defi nition, a lateral crural onlay graft to re-
establish the convexity of the missing lateral crura, and separate rim grafts to
support the soft tissue of the alar rim and external valves.
Unfortunately, often the alar cartilages are gone. The loss may be unilateral, bilateral,
partial, or complete. Frequently the lateral crus, middle crus, and part of the medial
crus are totally destroyed or ablated. The correction of such complex injuries is often
not addressed in the literature.
Fortunately, the techniques used in reconstructive rhinoplasty can be applied to severe
secondary cosmetic deformities. In fact, primary, secondary, and tertiary cosmetic rhi-
noplasty is a continuum with reconstructive rhinoplasty. A fabricated rigid framework
is designed to replace the missing medial, middle, and lateral crura. It restores the
normal alar tripod, shaping and supporting the entire lower one third of the nose. The
technique is useful regardless of the cause of injury.
As illustrated in Figure 25–1, it must be remembered, that the nasal tip is a three-
dimensional structure with curves and angles. The shape, size, and position of the
paired alar cartilages are refl ected onto the skin surface. Each alar cartilage consists of
a medial crus, a middle crus, and a lateral crus — each component infl uencing the form
and function of specifi c parts of the nose.
Figure 25–1
Anatomic Reconstruction of the Nasal Tip Cartilages in Secondary and Reconstructive Rhinoplasty
Nasal bone
Nasion
Sellion
Rhinion
Lateral crus
Middle crus
Medial crus
Medial crus
Medial genu
Middle crus
Fibrofatty
tissue
Lateral crus
Septum
Anterior
nasal spine
Fibrofatty tissue
Lateral
genu
Upper lateral
cartilage
Lower lateral
cartilage

690
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
The medial crus lies within the columella and ends at the medial genu (the columel-
lar-lobular junction or columella breakpoint), where it joins the middle crus. The
medial crus controls the columellar/lobular ratio and the cephalad and caudal position
of the columella.
The middle crus bridges the medial and lateral crura. Its length, confi guration, and
angularity determine the shape, height and protrusion of the infra-tip lobule. Its cepha-
lad angulation is the angle of rotation that forms the columellar/lobular junction. Its
lateral angulation from the midline (the angle of divergence) determines the intercrural
distance. The middle crus join the lateral crus (the lateral genu and domes).
The domes determine the projection and defi nition of the nasal tip. The lateral crura
then extend into and fi ll the tip lobule, abutting and partially entering the superior
aspect of the ala.
Thus, a tripod is formed by the paired medial crura (fi xed to each other within the
columella and to the caudal septum by fi brous tissue) that support the central leg of
tip. The lateral crura extend laterally to form its two other spanning legs.
As described by Sheen, the middle, medial and lateral crura determine the essential
landmarks of the refi ned tip — lateral projection of the right and left domes, the point
of tip differentiation from the dorsum (the supratip break) and the columella/lobular
junction (columellar break).
Less emphasized is the contribution of the alar cartilages to form and function of the
entire lower one-third of the nose. More than just tip aesthetics, the alar cartilages
defi ne tip/lobular contour; columellar length, width and position; nasal shape; alar rim
position; alar support and airway patency; and apparent nasal length. If missing,
reconstruction of the alar cartilages requires that all their functions be restored — not
just tip projection or defi nition.
Surgical Technique
Cartilage replicas, similar in shape, size and position to normal alar cartilages, are
fashioned from septal, ear or rib cartilage and fi xed to the residual medial crura and/or
to a columellar strut to restore a skeletal framework (Figure 25–2). This technique is
useful in secondary rhinoplasty and reconstructive rhinoplasty when the tip cartilages
are absent or unrepairable.
First, a preoperative evaluation of the columella, tip lobule, ala, and nostril margin is
completed. During open rhinoplasty — or prior to fl ap resurfacing during a reconstruc-
tive rhinoplasty — a precise anatomic diagnosis of the tip deformity is made and the
requirements of repair are verifi ed. If the middle and lateral crura are absent, then an
anatomic reconstruction is performed. Usually, some medial crural remnants remain
in the membranous columella.
Donor cartilage is harvested from the septum, ear, or rib. Septal cartilage is stiffer than
normal alar cartilage. It can be bent and scored, if necessary. Ear cartilage is usually
thicker and more friable, but its inherent curves can be used to advantage. Rib cartilage
is easily fractured, especially if calcifi ed with age, but thin strips of cartilage and
periosteum can be carved into useful grafts.
Two grafts, 5 to 6 mm wide × 3.5 cm long × 2 mm thick, are formed. A 35 degree angle
can be incorporated into the original design or carved into the fi nal graft to establish

691
Figure 25–2
an angle of rotation. It is often helpful to use a columellar strut, as a jig, to fi x the ana-
tomic tip grafts to the residual medial crura. Brown Adson forceps and 5-0 and 4-0
polypropylene sutures on a tapered needle protect the graft material from unnecessary
trauma. The two graft struts are sutured inferiorly along their future cephalic margins,
unifying the two pieces. Their slight caudal fl are simulates the normal fl are of the
medial crura. The unifi ed strips are then stabilized to the residual medial crura and
bent backward to simulate the medial and lateral genu and the medial, middle and
lateral crura. They are fi xed with suture to the nasal lining and abut and parallel the
caudal margin of the upper lateral cartilage. The underlying lining is fi xed to the car-
tilage grafts with sutures. These sutures resuspend the vestibular skin, reforming the
‘cupola’ of the vestibule. Any gap between the cartilage grafts and the scarred lining
can be fi lled with extra bits of cartilage to eliminate dead space, if desired.
If the alar margin is retracted by scar, fi brous soft tissue is excised and the lining mobi-
lized, prior to cartilage reconstruction. Even when the nostril rim seems rigidly fi xed
preoperatively, often the lining is retrievable. It is may not be irrevocably destroyed
by excision or scar contraction.
Surgical Technique
A
B
C
D
E
F
Tip cartilage deficient
Remnant of medial
crus remains
Remnant of
medial crus

692
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
Scar and cartilaginous remnants are excised from the superfi cial surface of the thick-
ened, stiff lining. The underlying lining is re-expanded. The lining is advanced inferi-
orly and fi xed with suture to the stabilized alar cartilage graft. The graft holds the lining
in its correct position.
In this fashion, a retracted alar margin can be permanently repositioned, inferiorly.
Because the rim is to be positioned correctly by release of the contracted vascular lining
and fi xed in place with cartilage, it is often unnecessary to use a composite lining skin
graft to lower a retracted nostril. The lining is released, the nostril margin repositioned,
and the rim braced with cartilage support.
Columella position is controlled by the width of the alar replacement grafts and the
columellar strut. They effectively reposition a retracted columella, caudally.
Dome spanning sutures and lateral crural spanning sutures can be used to further
defi ne nasal projection and defi nition. Careful cartilage scoring can control cartilage
bending. A shield-shaped tip graft can be sutured over the reconstruction to improve
bidomal defi nition or projection. If desired, projection control sutures can be applied
to increase or decrease projection. The fabricated cartilage complex can be advanced
up or down on the caudal septum, through a transfi xion incision.
At the completion of tip reconstruction, an anatomically correct replica of one or both
alar cartilages can restore all or part of the missing medial, middle and lateral crura.
Other nasal deformities are corrected with dorsal grafts, lateral spreader grafts, etc.
The form and function of this 24-year-old woman’s nasal tip was severely impaired
after several previous rhinoplasties (Figure 25–3). The bulbousness of her tip, postop-
eratively, had been attributed to her ‘thick’ skin.
Figure 25–3
A
B

693
A precise anatomic diagnosis of the deformity was made during her open rhinoplasty
(Figure 25–4). The right lateral and medial crura and the left lateral crus were missing.
Their cut edges have been inked.
Figure 25–4
A
C
B
D
Surgical Technique

694
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
First, the dorsal septal angle was lowered and lateral spreader grafts were placed.
26 mm × 3 cm × 2 mm septal cartilage grafts, with a 35 degree angle of rotation, were
sutured with 5-0 nonabsorbable sutures along their cephalic margins. These unifi ed
strips were then stabilized to the residual medial crura and bent backwards to simulate
the normal. They were positioned to parallel the caudal margin of the upper lateral
cartilages and fi xed with sutures to the nasal lining. The sutures suspended the ves-
tibular skin. Dome spanning sutures were used to further defi ne nasal projection and
tip defi nition, after careful cartilage scoring to control the bending of the septal ana-
tomic grafts. Projection control sutures were placed through a membranous incision to
securely position the complex tip reconstruction and minimize late settling of the tip.
An onlay tip graft was not employed.
Intraoperatively, the change in tip conformation is evident before and after the tip
reconstruction (Figure 25–5).
Two and a half years postoperatively (Figure 25–6), the surface anatomy refl ects the
underlying alar replicas, simulating the contour of the normal tip. No further surgery
was performed.
Figure 25–5
A
B

695
Figure 25–6
A
C
B
Surgical Technique

696
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
Figure 25–7
A
C
B
This 60 year old woman (Figure 25–7) underwent rhinoplasty at 40 years of age. Her
nose was overly reduced. A dorsal silicone implant was placed but extruded several
years later.

697
She presented with a pinched tip, retracted and collapsed alar rims, and an overly
reduced dorsum.
During open rhinoplasty (Figure 25–8), both alar cartilage domes were found to be
transected and severely scarred. The residual cartilage remnants were advanced
Figure 25–8
A
B
C
D
Surgical Technique

698
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
maximally to the level of the midcolumella on a rib cartilage columellar strut, which
lengthened the nostrils. However, adequate tip projection and form were not achieved.
Ear cartilage replicas, similar in shape, bulk and position to normal cartilages, were fi xed
to the columellar strut, anterior to the alar remnants. Scar tissue was excised from the
underlying contracted lining. The re-expanded lining was then advanced inferiorly,
repositioning the nostril margins to their proper position. The lining was then fi xed with
sutures to the stable tip cartilage replacement grafts. This secured the alar margin, inferi-
orly. An onlay tip graft was not placed. A dorsal osteocartilaginous rib graft was used.
Three and a half years postoperatively (Figure 25–9), the form and function of the tip,
alar rims, columella, and nostrils and airway patency have been restored. No further
surgery was needed.
Most discussions of secondary tip reconstruction assume that useful remnants of the
tip cartilages remain and can be repaired. However, few authors have addressed the
more signifi cant problems which occur when the cartilages are absent or destroyed.
Sheen recommended closed dome excision with en bloc ablation of scarred remnants
and the reconstruction of the tip with multiple solid, bruised and crushed grafts in
limited, closed pockets. Johnson recommended excising scarred lateral crural rem-
nants, sculpting of the residual scar, a columellar strut, a shield-shaped tip graft, and
separate lateral crural onlay grafts, if needed. Juri recommended excising the fi brotic
cartilage remnants of the dome, leaving only a vertical segment of the medial crura,
and camoufl aging the tip defect with a shield-shaped ear cartilage graft or an onlay
anchor-shaped graft, if alar collapse was present.
All these methods, using single and stacked onlay grafts, camoufl age the defect.
Although fi ller grafts may mold overlying skin and a buttress graft may brace unsup-
ported tissue, these techniques are not anatomic. They do not attempt to replace the
alar cartilages.
Plastic surgery is a practical profession. The end justifi es the means — if the technique
really works and restores appearance and function! Practically speaking, whatever
technique molds the overlying skin into a nasal shape and supports the soft tissues
will do. But the surgeon must ask: Can a non-anatomic approach to the replacement
of ablated tip cartilages satisfy all the requirements of form and function of the tip,
nostril margins, and columella, in a predictable and controlled fashion?
Although the results of many methods can be good, problems with graft visibility and
malposition continue to challenge the surgeon.
Sheen, in an attempt to decrease graft visibility and displacement, altered his closed
technique. He recommended a change from single or stacked rigid shield-shape grafts
to multiple smaller, softer, bruised and crushed grafts, confi ned within one or more
limited subcutaneous pockets within the nasal tip. This ‘stuffi ng’ technique can be
successful. But it can seem perplexing. If one believes that the nasal surface refl ects its
underlying architecture, it seems contradictory to attempt to increase nasal shape and
defi nition with less supportive and contoured materials, especially during a secondary
rhinoplasty when subcutaneous scar may limit both the re-expansion and reshaping
of the skin sleeve or underlying lining. Will the stiffer skin control the softer graft —
rather than the desired goal of the graft shaping the overlying skin? Closed tip grafting
also assumes that malleable shapeless material can be placed by the average surgeon,
under edematous skin, and manipulated into a nasal ‘shape’. Will the poorly defi ned
subcutaneous mound mold the overlying skin into an aesthetic shape, after fi broblastic
contraction is complete and the wound is mature?

699
Figure 25–9
A
C
B
Surgical Technique

700
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
It must be acknowledged that, as patient expectations grow and surgical techniques
become bolder, secondary rhinoplasty patients present with depleted donor sites. Pre-
vious septoplasty and ear cartilage harvests limit both the quality and quantity of car-
tilage donor material. Proponents of the closed approach suggest that bits and pieces
of crushed or otherwise modifi ed cartilage, which cannot be sutured in place during
open rhinoplasty, can be positioned successfully in a closed subcutaneous pocket.
However, the greater degree of crushing, the greater the loss of graft visibility and
viability and the greater the potential for reabsorption. Substantial solid grafts may be
more diffi cult to fi nd but may be preferable.
The developers of the open rhinoplasty technique approached the problems of dis-
placement by taking advantage of increased exposure and their ability to manipulate
and suture solid grafts to create rigid support and ensure graft immobility.
However, both the closed and open tip approaches are non-anatomic. Neither replace
the missing alar cartilages — both instead use onlay fi llers to camoufl age the anatomic
defi ciencies. Both are limited in design to the restoration of bidomal defi nition or
increased tip projection. They do not attempt to restore the form and function of lateral,
middle and medial crura or their volume, defi nition, width, projection, rotation, or
columellar shape and position.
This anatomic reconstruction of the alar cartilages in secondary reconstructive rhino-
plasty is designed to provide precise anatomic replicas of missing normal anatomy,
using septal, ear or rib grafts. In such cases, the skin is often deformed by scar. This
restored rigid framework effectively molds the overlying skin and braces the repair
against scar retraction.
If needed, a columellar strut can provide rigidity to the medial crura, restoring the
central alar tripod and permitting secure, jig-like fi xation between the residual medial
crura and the reconstructed middle and lateral crura. Once stabilized, the alar replace-
ments are bent backward to form the domes, genua, and the columellar and supratip
breaks. A shield-shape tip graft is added only to improve bidomal defi nition or to
modestly increase projection. This allows the surgeon to correct an imperfect fabrica-
tion intraoperatively, without reshaping a new anatomic graft again and again. This
simplifi es the sculpting and time requirements, while accepting limitations in donor
graft material and surgical skill.
Anatomic alar cartilage reconstructive grafts:
1. Create tip defi nition and projection.
2. Fill the lobule and restore the expected convexity of the lateral crus.
3. Position the columella and re-establish columellar length.
4. Support and position the alar rim and brace the external valve against collapse.
5. Support the vestibular lining.
6. Restore nostril shape.
Conceptually, the technique acknowledges that the alar cartilages control more than
tip projection or defi nition. They are integral to size, shape, position, and contour of
the tip lobule, columella, alar rim, and external valve function.

701
The essential elements of the technique are:
1. Exposure by open rhinoplasty.
2. Anatomic diagnoses.
3. Anatomic reconstruction.
4. Secure suture fi xation.
5. Controlled contouring by in-situ graft sculpture, tip suturing techniques, and
shield-shaped onlay grafting, if needed.
6. Forceful remodeling of the skin envelope by the underlying skeletal structure.
7. The release, repositioning, and reshaping of both cover and lining by wide
undermining and release of subcutaneous scar.
This anatomic tip technique is recommended when the alar cartilages are signifi cantly
destroyed or absent in secondary or reconstructive rhinoplasty and their remnants are
insuffi cient for repositioning and repair. It is useful when support is absent or severely
abnormal, lining has been excised or retracted, or when subcutaneous scarring limits
re-expansion of the skin sleeve or the underlying lining. Sheen has stated that the
‘shape, size and position (of the alar cartilages) manifest surface anatomy and therefore
should determine the surgical actions that will alter their surface appearance.’ Rather
than camoufl aging the loss of the alar cartilages by subcutaneous augmentation, it may
be better to rebuild their structure in its entirety.
Anatomic reconstruction replaces them anatomically and functionally and can impart
a normal aesthetic subunit outline to the nasal skin surface. These anatomically designed
replacements, positioned during open rhinoplasty, allow an aesthetic restructured
skeleton to positively infl uence the conformation of the overlying skin envelope.
A nose repaired with a shield-shape tip graft may look abnormal because the graft
does not have an anatomic shape. The solution to unnatural looking grafts is to design
them with a natural shape. When seen through covering skin, anatomic grafts ‘show’.
But because they replicate the normal, they appear to be the ‘normal’ underlying archi-
tecture. A rigidly supported framework with a nasal shape can mold a covering fore-
head fl ap or the scarred skin of the secondary rhinoplasty into the shape of the normal
nose.
Repair of the Saddle Nose
Each anatomic part of the nose contributes to function and aesthetics. The overall
strength and form of the septum, the upper lateral cartilages and the alar cartilages
determine dorsal height and width, nasal length and tip projection. The integrity of
the septum determines the position and function of the middle vault and of the lower
nose.
Repair of the Saddle Nose

702
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
Figure 25–10
The term ‘saddlenose’ implies a loss of dorsal height. (See Figure 25–10.) In practical
terms, it describes a progressive deformity. A saddle nose may vary from a modest
depression of the upper or middle vault to one in which there is complete collapse of
the dorsal and caudal septum with progressive secondary loss of tip support and pro-
jection. The tip over rotates and the nose shortens in length. The columella retracts and
the soft tissues of the upper lip retrude due to loss of the caudal support of the septum
and nasal spine. An acute columellar labial angle, caused by posterior displacement of
the superior upper lip due to this premaxillary retrusion, develops. It is sometimes
referred to as a ‘monkey lip’. As the middle vault collapses, progressive nasal obstruc-
tion develops due to narrowing of the internal valves and collapse of the external
valves.
The degree of deformity depends on the site, the degree of injury, etiology and the
associated cover and lining injury. When the septal lining is destroyed by cocaine,
infection or immune disease, adjacent structures may be progressively destroyed. The
adjacent soft tissues of the nose, the lip, and even the lateral bony nasal walls, hard
and soft palate, and facial sinuses can be lost due to desiccation, infection or the
primary disease process.
A saddlenose may be caused by:
1. Iatrogenic injury — during an overaggressive rhinoplasty, the nasal bones,
dorsal septum or upper lateral cartilages may be over reduced or weakened,
leading to collapse.
Septal cartilage can be safely removed for graft material or during a submucous resec-
tion performed to straighten the nose or improve breathing. But a strong dorsal and
A
Normal
E
Maxillary
retrusion
B
Dorsal cartilage loss
D
Tip rotation, nasal shortening,
retruded columella
C
Dorsal bone and cartilage loss

703
caudal ‘L’ strut, 10 mm in width, must remain to support the bridge and columella. If
the septum is overly weakened or its continuity is broken at its junction with the
ethmoid bone and nasal bones, it is unable to support the soft tissues. The dorsum
collapses inward.
2. Trauma — the septum is often fractured, along with the nasal bones, during
trauma. Both the upper and middle vaults may be inadequately supported. If a
septal hematoma is unrecognized or becomes infected, the septal cartilage may
dissolve, further weakening support.
3. Intranasal lining loss — destruction of intranasal lining, typically of the septum,
devascularizes the underlying cartilage. Exposure, desiccation and infection
destroy the exposed cartilage and create a septal fi stula. In everyday practice,
intranasal use of cocaine is the most common cause. More rarely, it is due to
infectious mucositis from syphilis, leprosy, leishmaniasis, yaws, actinomycoses
or tuberculosis or due to autoimmune diseases such as Wegener granulomatosis
or cancers such as killer ‘T’ cell lymphoma.
4. Congenital — maldevelopment may follow childhood injury or developmental
syndromes or can be an ethnic characteristic.
The diagnosis is determined by careful history and physical examination to evaluate
the nose for both local and systemic problems. Drug screening, culture and sensitivity
or biopsy may be indicated. Serology which includes a sedimentation rate, ANA, C —
ANCA, and rheumatoid factor may be helpful. In most cases, consultation with an
otolaryngologist and rheumatologist is useful. Obviously, the underlying cause must
be controlled — drug use ended, infection cleared or autoimmune disease in
remission.
Planning the Correction
The surgeon must plan his or her repair.
1. If the underlying central septal support remains intact, although depressed, a
platform remains onto which a septal, ear or rib graft can be onlayed. The
residual dorsum is augmented with a dorsal graft with the length, width and
thickness needed to restore the correct dimensions of the dorsal subunit. These
grafts may be single or layered. They may be placed in a closed or open tech-
nique. They are fi xed in position by the dimensions of a subcutaneous closed
pocket or with sutures, a screw or wire during an open rhinoplasty.
2. If intrinsic support is absent, an onlay graft will sink into the pyriform aperture.
So the dorsal graft must be cantilevered to support the soft tissues. Typically, the
visible deformity will be greater in these cases. When the central support is
destroyed, resistance to pressure on the dorsum is absent. The nasal soft tissues
can be pushed into the pyriform aperture and the nasal tip compressed against
the lip. Frequently, an associated septal fi stula (which is not repaired) is present.
3. The surgeon must evaluate the quality of the soft tissues. Is the injured lining
and covering skin signifi cantly elastic and mobile to be repositioned, if support
is re-established? Are the soft tissues so scarred, contracted or defi cient that
additional lining or external skin must be added? This can usually be deter-
mined, with experience, by analyzing the degree of deformity, the visual quality
of nasal skin and lining, and by the mobility and distractibility of the soft tissues
determined by palpation and the use of an intranasal Q-tip.
Planning the Correction

704
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
4. Prevent additional iatrogenic injury. Avoid the use of alloplastic implants. The
risk of tissue necrosis and infection is high in the compromised soft tissues of the
saddlenose. Scarring and additional soft tissue loss will complicate the repair
and may necessitate lining or external skin replacement, even though the initial
injury was limited to the nasal skeleton.
5. It is also important to understand the complexity of the problem. Do not attempt
halfway measures. They will fail and only complicate the repair in the future.
Minor closed cartilage grafting or small local fl aps are rarely helpful in the
diffi cult saddlenose. They will not repair a signifi cant deformity and may
increase soft tissue scarring and your ability to correct the problem later.
6. Intranasal lining must be healed, soft tissue injury healed and mature, and the
underlying cause resolved or in remission. Raw intranasal wounds and crusts
are controlled with normal saline intranasal washes, débridement and antibiot-
ics. The nose is surgically repaired only when the initiating process is stable and
controlled.
7. As the severity of injury to the framework and soft tissues increases, the greater
the scarring and the more rigid must be the support required to restructure the
nose.
The treatment of a saddlenose will include both aesthetic and functional repair.
Onlay dorsal grafting
If the dorsum is low but the central support base is intact and stable, an onlay dorsal
augmentation may be performed.
During an open rhinoplasty, each cosmetic and functional defi ciency is individually
addressed (Figure 25–11).
1. A dorsal graft is employed to re-establish bridge height, width and length. If
available, septal cartilage is the fi rst choice. Ear or rib cartilage can also be used.
The length, width and thickness of the dorsal defi ciency are identifi ed. The graft
is designed to re-establish the correct position of the radix (at the level of
the eyelash or supratarsal crease), the dorsal line and supratip. The width of the
graft will determine the width of the dorsal subunit and the position of the
dorsal lines. The thickness of the graft will establish the dorsal profi le and height
of the bridge. Frequently, a second narrower graft is fi xed to the anterior surface
of the primary dorsal graft to restore the normal roundness of the bridge and
avoid an abnormal ‘fl atness’.
The graft is positioned within a precisely placed pocket. Frequently, it is guided to the
superior aspect of the pocket with an absorbable suture which exits the skin in the
midline at the nasal root. Or it may be fi xed superiorly at the radix with a temporary
percutaneous absorbable suture. Its inferior aspect is sutured, at the septal angle, to
the dorsal septum and upper lateral cartilages.
2. Lateral spreader grafts are placed and fi xed with fi ne suture, between the remain-
ing dorsal septum and the dorsal edges of the upper lateral cartilages. Lateral
spreader grafts open up the internal nasal valves and widen the middle vaults.
They contribute to function and the external dimension of the dorsal subunit.

705
Figure 25–11
Both lateral spreader and dorsal onlay grafts act to open and maintain the internal
valve and a functional airway.
3. Extended lateral spreader grafts are fi xed to the dorsal septum and sutured to the
tip complex or a columellar strut. They are longer than traditional spreader
grafts and extend caudal to the septum, allowing their fi xation to the tip
complex. They push the tip inferiorly and rigidly fi x its position. They lengthen
the nose and can derotate the tip, inferiorly.
4. A columellar strut is sutured between the medial crura. It unifi es and supports
the tip complex, positions the columella inferiorly, and corrects columellar
retraction. A columellar strut can also increase tip projection.
5. Tip projection and defi nition can be further controlled by suture techniques
which include dome spanning sutures and tip grafts.
6. A projection control suture may be added. The medial crura and columellar strut
are fi xed, by direct suture, to the caudal septum through a membranous incision.
By altering the position and direction of the suture, anteriorly or posteriorly, tip
projection can be increased or decreased. The strength of the suture fi xation
between the caudal septum and tip and medial crura-columellar strut complex
minimizes the risk of late settling.
Planning the Correction
A
B
C
D
E
Dorsal midvault
excision
Spreader grafts
MIDVAULT COLLAPSE
Projection
control
suture:
Depresses tip
Elevates tip
Dome sutures

706
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
Secondary Rhinoplasty — the Over Reduced Dorsum
After previous rhinoplasty (Figure 25–12), this patient’s entire nose is over reduced
and overly narrow. The radix is low. The supratip is high. The tip is pinched. The
middle vault is collapsed due to resection of the dorsal septal roof. The septal ‘T’ had
been resected and the upper lateral cartilages have fallen inward narrowing the inter-
nal valve. Her breathing is obstructed.
Figure 25–12
A
C
B

707
Using an open rhinoplasty technique (Figure 25–13), the dorsum was exposed extra
mucosally. Septal cartilage lateral spreader grafts were sutured to the dorsal septal
edge to displace the upper lateral cartilages laterally. These grafts open the internal
valve. A dorsal graft has the same effect.
A
B
Figure 25–13
Secondary Rhinoplasty — the Over Reduced Dorsum

708
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
At operation (Figure 25–14) a columellar strut was sutured between the residual medial
crura. It strengthens the middle tripod. Anatomic tip replacements for the resected
right and left middle and lateral crura were fi xed to the remnants of the middle crura
Figure 25–14
A
C
B
D

709
A
B
Figure 25–15
and columellar strut. A Sheen tip graft was positioned over the anatomic tip reconstruc-
tion. It adds further projection and bidomal defi nition to the tip without additional
manipulation of the anatomic graft. The caudal septum was approximated to the
medial crura-columellar strut with a projection control suture to maintain the position
of the entire complex. The height, width and confi guration of an aesthetic tip was
restored.
A double layered septal dorsal graft was guided by a percutaneous suture to the nasal
root and fi xed at the septal angle with a suture. The dorsal graft restored the height,
width and length of the dorsum. It re-established the three-dimensional contour of the
dorsal unit (Figure 25–15).
Secondary Rhinoplasty — the Over Reduced Dorsum

710
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
Postoperatively (Figure 25–16), the aesthetics of a normal nose have been restored. The
nose looks natural.
Figure 25–16
A
C
B

711
In this patient (Figure 25–17), after three previous rhinoplasties, the radix starts at or
below the mid pupillary level. The most projecting point of the tip is at the level of the
alar crease. The nose appears short, turned up. The bridge and tip are wide and fl at.
Figure 25–17
A
B
Secondary Rhinoplasty — the Over Reduced Dorsum

712
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
Intraoperatively (Figure 25–18), the lateral crura of both alar cartilages were found to
be ablated. The residual medial crura were advanced on a columellar strut. Anatomic
tip grafts of ear cartilage were fi xed to each other and to the columellar strut. Their
contour was controlled with dome spanning sutures to improve projection and defi ni-
tion. Septal extended lateral spreader grafts were sutured along the dorsal septum. The
extended grafts pushed the upper lateral cartilages outward, opening the internal
valves. Their distal ends were sutured to the columellar strut and the anatomic replace-
ments. This displaced the tip inferiorly and lengthened the nose. Their fi xation to the
tip complex also securely stabilizes its projection.
A two layered onlay dorsal graft augmented the bridge and re-established the dorsal
profi le and radix (Figure 25–19). No infracture was performed.
Eight months later, an additional conchal cartilage tip graft was placed through a
closed approach.
The nose appears narrower and longer. It fi ts the mature male face. The stigmata of
previous rhinoplasty have been removed. (See Figure 25–20.)
A
C
B
D
Figure 25–18

713
Figure 25–19
A
B
Figure 25–20
Secondary Rhinoplasty — the Over Reduced Dorsum

714
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
The Cantilevered Dorsal Graft
If intrinsic central septal support is absent, it must be re-established. A rigid solid graft
must be cantilevered from the nasal bones to support and shape the dorsal subunit.
Whatever the cause of a saddlenose, the process must be stable and the soft tissues
mature, prior to attempting repair. In many cases, the process is limited to nasal
support. Although injured secondarily, the soft tissues are minimally scarred. Hope-
fully, they do not require replacement. If the external skin and internal lining are
injured but re-expandable, strong central support alone will re-establish the nasal
contour.
If the healed lining appears clinically stable, the risk of extrusion or infection, even
after cocaine abuse, is low. By defi nition, septal cartilage is unavailable or is insuffi cient
in bulk and rigidity, to re-establish the dorsal line, when a stable base does not
remain.
Illustrated in Figure 25–21:
1. An open rhinoplasty approach is employed to improve visualization and
manipulation.
2. The nasal bones are lowered with a motorized burr to create a fl at raw bony plat-
form. It serves as a base for a rib osseocartilaginous dorsal graft. The bony radix
is lowered to provide room for the dorsal graft and avoid over augmentation of
the nasal root. This rigid graft, fi xed superiorly over the nasal bones as a cantile-
ver, will provide strong dorsal support. Combined with a columellar strut, it
restores nasal length.
3. An osteocartilaginous graft from the fl oating ninth or tenth rib is shaped to re-
establish the height, width and length of the dorsum. The graft straddles the
Figure 25–21
Rib bone
Cartilage
Columella
Notch
Tongue and
groove
OR
Columella
strut
Tip graft
Dorsum
OR
Columella
Sidewall
Reduction of nasal bones
Nasal spine
Dorsum OR

715
osteocartilaginous junction of the rib and is approximately 50% bone and 50%
cartilage. It is approximately 3.5 to 4 cm in length, 8 mm in width and 4 to 8 mm
in thickness, depending upon the needs of the defect. The bony aspect of the
dorsal graft is placed superiorly over the nasal bones and positioned at the ideal
nasal root. Excellent bony consolidation can be expected. It is fi xed with a single
1 mm screw to the bony platform through a 5 mm transverse incision at the
radix. The incision heals inconspicuously. Because only a small component of
this rib graft is cartilage, warping does not occur.
4. A rib cartilage columellar strut is placed between the residual medial crura and
fi xed to the nasal spine. The end of the columellar strut is sutured to the perios-
teum or passed through a drill hole. A buccal incision provides exposure of the
pyriform edge. The anterior tip of the columellar strut lies in a notch at the distal
end of the dorsal graft or can be fi xed to the dorsal graft with suture.
5. The alar cartilages are advanced upward on the columellar strut and fi xed to it with
permanent sutures. This resupports the tip and shapes and lengthens the
nostrils. Dome spanning sutures can provide additional projection and tip
defi nition. Frequently, a Sheen or Peck tip graft is added in these very defi cient
noses.
6. A rib cartilage premaxillary graft may be placed through a nostril fl oor or buccal
incision to augment the premaxilla and alar bases. It corrects the lip retrusion
due to the loss of the caudal septum and nasal spine.
In this patient (Figure 25–22), after chemical injury to the lining and loss of septal
support, the distal nose is collapsed, the columella is retracted and the lip retruded. A
large septal fi stula is present. Fortunately, covering skin and lining were intact and not
rigidly fi xed by scar.
A
B
Figure 25–22
The Cantilevered Dorsal Graft

716
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
Through an open rhinoplasty (Figure 25–23), the nasal skin was elevated. The tip car-
tilages were normal, but unsupported.
A
D
B
C
Figure 25–23

717
The nasal bones were lowered, with a burr, to provide a raw bony platform. Space was
made to accommodate the increased thickness of the dorsal graft. The dorsal osteocar-
tilaginous graft was fi xed through a short transverse incision, with a single screw, to
the nasal bone platform. A rib columellar strut was placed in a pocket between the
medial crura and fi xed with suture through a drill hole at the nasal spine. The anterior
tip of the columellar strut was sutured to the distal end of the dorsal graft. The tip
cartilages were then advanced upward on the columellar strut and modifi ed
aesthetically.
The cephalic margins of the lateral crura were trimmed. Dome spanning sutures were
placed to narrow the tip. A Sheen tip graft was added to improve projection and
bidomal projection. A premaxillary rib graft was placed through a nasal fl oor incision.
It extended, across the premaxilla, from just lateral to each nasolabial fold in a soft
tissue pocket, anterior to the pyriform aperture.
Intraoperatively, the improvement in the dorsal line, tip projection, columella and
upper lip position was immediately visible (Figure 25–24).
A
B
Figure 25–24
The Cantilevered Dorsal Graft

718
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
Postoperatively (Figure 25–25), scars at the nasal root and columella are invisible. The
aesthetics of an attractive nose had been restored. The large septal fi stula, whose repair
was not addressed, remains but is asymptomatic.
After chemical injury to lining (Figure 25–26), the proximal nasal support from the
nasal bones remains intact but the distal nose has collapsed, the columella retracts, and
the upper lip retrudes. Loss of the dorsal and caudal septum, combined with intranasal
lining contracture, has distorted the nose.
Intraoperatively (Figure 25–27), a Q-tip passes through a large septal fi stula. The
unsupported tip collapses to the pyriform aperture on light fi nger pressure.
A
B
Figure 25–25

719
A
B
Figure 25–26
A
B
Figure 25–27
The Cantilevered Dorsal Graft

720
Chapter • 25 • The Crucifi ed Tip, the Saddlenose and the Continuum of Reconstruction and Cosmesis
A
C
B
At operation (Figure 25–28) the rib is harvested through a 3 to 4-cm incision over the
ninth and tenth rib. A rib graft is placed from one nasolabial fold to the other, under
the maxillary base of the nose, to reposition the upper lip. It can be notched in the
midline, allowing it to bend and better follow the curve of the maxilla. (A rolled Gortex
graft has also been used successfully but increases the risk of infection, especially if it
lies in contact with a columellar strut, fi xed at the nasal spine through a buccal
incision.)
A dorsal osteocartilaginous graft is fi xed through a short transverse nasal root incision
with a single screw. A columellar strut, fi xed through a buccal incision at the nasal
spine, allows the advancement of the alar cartilages. A tip graft provides further tip
defi nition, width and projection.
A lovely nose compliments a lovely woman (Figure 25–29).
Replacing Dorsal Support and Cover and Lining
The adjacent soft tissue may be compromised by the initial injury or by iatrogenic
complications due to alloplast extrusion, infection or failed repairs with inadequate
local fl aps or cartilage grafts. If nasal lining is grossly defi cient or the external covering
skin has been destroyed, it must be replaced. Any combination of cover, support and
lining may need replacement, depending on the site and degree of loss. Rigid support
will not make up for a defi ciency of lining.
Figure 25–28

721
A
B
Figure 25–29
Clinically, secondary soft tissue injury is diagnosed by evaluating the degree of defor-
mity, the severity of maxillary retraction, and the fi xation of the soft tissues to the bony
rim of the pyriform aperture, when manipulated preoperatively. The fi xed immobility
of the soft tissues and the centripetal scar contraction of injured lining and cover must
be appreciated.
When the lining injury is less severe, nasolabial turnover fl aps, as popularized by
Millard, or a FAMM fl ap can be used to line the midvault, permitting the displaced
distal nose to be positioned inferiorly. In more severe injury, hingeover lining fl aps,
based on the distal nostril margins, or a free fl ap may be necessary to lengthen the
nose. Replacing the lining of the midvault, alone, is not suffi cient.
In the most severe circumstances, the injury extends to the covering skin. A forehead
fl ap will be needed to resurface the nose after replacement of lining and support. These
techniques are illustrated in Chapters 15, 16 and 20 — Restoring Nasal Lining — Hinge-
over Flaps for Lining, Use of a Second Flap for Lining and The Use of Distant Tissue
for Facial Reconstruction – Microvascular Tissue Transfer for Nasal Lining.
Replacing Dorsal Support and Cover and Lining