Orthognathic Surgery

• Figure 37-16  A woman in her early 50s requested an evaluation of a “weak chin,” deep perioral creases, mild ptosis of the brow and upper
eyelids, and unfavorable nasal aesthetics. Examination confirmed mild drooping of the brow and mild excess skin of the upper eyelids. A devel­
opmental mandibular deficiency was unchanged over the years, and she had a functional occlusion. She agreed to a limited incision brow lift, but
as a result of dryness of the eyes, decided against the removal of the skin of the upper lid. She also agreed to an osseous genioplasty that included
vertical lengthening and horizontal advancement with interpositional bloc hydroxyapatite grafting. Her rhinoplasty included nasal osteotomies
(in-fracture); dorsal reduction (bone and cartilage); and tip maneuvers (modification of lower lateral cartilages and septal cartilage caudal strut graft­
ing). All procedures were carried out simultaneously. A, Oblique facial views before and after surgery. B, Profile views before and after surgery.
Orth
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Orth
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1592 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
• Figure 37-17  An African-American man in his early 40s underwent evaluation for a “weak chin” and laxity of the neck soft tissues. There was
a degree of procumbency to the maxillary and mandibular dentition but with a stable occlusion. He also planned to undergo cosmetic modification
of the anterior dentition. A treatment plan was agreed to that included osseous genioplasty (vertical lengthening with interpositional grafting and
minimal horizontal advancement) and an anterior approach to the soft tissues of the neck (cervical flap elevation, neck defatting, and vertical
platysma muscle plication). A, Profile views before and after surgery. B, Oblique facial views before and after surgery.
Orth
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1593
CHAPTER 37  Aesthetic Alteration of the Chin: Evaluation and Surgery
D
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C
C, Frontal views before and after surgery. D, Lateral cephalometric radiographs before and after surgery.
• Figure 37-17, cont’d

1594 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
• Figure 37-18  A 17-year-old high school student was referred by his orthodontist for surgical evaluation. His maxillary deficiency and mandibular
excess Class III negative overjet anterior open-bite malocclusion required orthodontics and jaw surgery. Because the patient had a lifelong history
of nasal obstruction and consistent physical findings, intranasal procedures were also required. With orthodontic dental decompensation complete,
the patient’s surgery included maxillary Le Fort I osteotomy (horizontal advancement, anterior vertical lengthening, and clockwise rotation); sagittal
split ramus osteotomies (set-back); osseous genioplasty (vertical reduction); and septoplasty and inferior turbinate reduction. A, Frontal views
before and after treatment. B, Profile views before and after treatment.
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1595
CHAPTER 37  Aesthetic Alteration of the Chin: Evaluation and Surgery
C
D
Maxillary
advancement
and clockwise
rotation
C, Articulated dental casts that indicate analytic model planning. D, Lateral
cephalometric radiographs before and after treatment.
• Figure 37-18, cont’d 
ramus osteotomies are also carried out with limited or no
set-back at the incisors but with clockwise rotation to
diminish projection at the pogonion. In this case, lower-
face aesthetics are often further enhanced via an osseous
genioplasty with vertical reduction and minimal sagittal
change.
A second frequent pattern of presentation is an indi­
vidual with a chin that appears prominent in profile because
the mandible is overly closed (i.e., short face growth pattern).
In these patients, the vertical height (in millimeters) from
the mandibular incisal edges to the menton is deficient.
With this dentofacial deformity, both horizontal and verti­
cal deficiency of the maxilla and the mandible (i.e., decreased
lower anterior facial height and limited facial projection) are
present (see Chapter 23). A “pseudoprotrusion” of the chin
will result. A patient who asks for a chin set-back only to
manage his or her short face (i.e., maxillomandibular defi­
ciency) is unlikely to be pleased with the aesthetic result if
this request is honored. In this case, reestablishing the pre­
ferred vertical and horizontal dimensions of the face requires
a Le Fort I osteotomy with horizontal advancement, vertical
lengthening, and, often, clockwise rotation. The mandible—
which is also horizontally and vertically deficient—requires
sagittal split ramus osteotomies and reorientation to match
the new maxillary position. The chin region also benefits
from a change in shape. This is accomplished through an
oblique osteotomy of the chin with clockwise rotation (i.e.,
downward and backward positioning of the pogonion)
while maintaining contact and pivoting at the posterior
osteotomy line. The interpositional gap is grafted with
allograft, autograft, or bone substitute, and the chin segment
is fixed in place with plates and screws (see Figs. 37-6
and 37-7).
All of these facial aspects must be considered before
embarking on any treatment of the chin region if a favorable
result and a satisfied patient are to be expected.

1596 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
• Figure 37-19  A 16-year-old boy who had sustained a fracture of the right condyle of the mandible
during his early childhood presented with resulting facial asymmetry. He previously underwent
years of orthodontics to neutralize the occlusion, which also resulted in loss of labial bone along the
anterior mandibular teeth. He then underwent an orthognathic approach that included Le Fort I oste­
otomy (cant correction); left sagittal split ramus osteotomy; reconstruction of the right condyle–
ascending ramus with a costochondral graft; and an osseous genioplasty (correction of vertical and
horizontal asymmetry) (see Fig. 35-8). A, Frontal facial views with smile before and after reconstruction.
B, Oblique facial views before and after reconstruction. A, from Posnick JC: Management of facial
fractures in children and adolescents, Ann Plast Surg 33:442-457, 1994.
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Chin Asymmetries
Asymmetries of the chin relative to the face are most fre­
quently encountered in association with specific syndromes
and other conditions such as hemifacial microsomia, hemi­
mandibular elongation, hemimandibular hyperplasia, or a
condyle fracture sustained during childhood with resultant
ipsilateral mandibular undergrowth (Fig. 37-19). For indi­
viduals who present with the chin shifted to one side, aes­
thetic assessment of the entire face, including the soft tissues
and the skeletal structures, should be undertaken. Consid­
eration is given to both the lower facial skeleton (i.e., the
maxilla, the mandible, and the chin region) and the upper
facial skeleton (i.e., the cranial vault, the zygomas, the
orbits, and the nasal bones). The chin region may be asym­
metric or disproportionate, or it may simply appear to be
so as a result of maxillary or mandibular malposition. In
several of the conditions mentioned, the extent of actual
chin asymmetry is much less than that of the mandible and
maxilla. When indicated, a Le Fort I osteotomy and sagittal

1597
CHAPTER 37  Aesthetic Alteration of the Chin: Evaluation and Surgery
cuspid region, stopping just short of the visualized
mental nerve on each side (Fig. 37-20, A). The center
two thirds of the incision is next extended down to bone.
A full cuff of mucosa and muscle is maintained adjacent
to the attached gingiva of the anterior teeth; this should
allow for adequate layered wound closure of the muscle
and mucosa without periodontal sequelae.
• Dissection with an elevator exposes the anterior surface
of the chin although not completely to the inferior
border of the central chin. The dissection continues later­
ally and remains inferior to the mental nerve, with lateral
exposure to the inferior border of the mandible. There is
no need to dissect above the mental nerve on either side.
If 360-degree dissection around the nerve is completed,
it is more likely that the nerve will be excessively stretched
or avulsed.
split ramus osteotomies of the mandible with three-
dimensional repositioning will greatly improve the chin
symmetry. A separate osteotomy to reposition the chin
region is also generally required to simultaneously correct
disproportion of the lower third of the face.
Osseous Genioplasty: Surgical
Technique (
Videos 11 and 12)
• Attention is turned to the facial vestibule of the chin.
The lower lip is stretched outward to allow for visualiza­
tion of the mental nerve through the mucosa on each
side. In the depth of the vestibule, an incision is made
with a Bovie electrocautery device or a knife (no. 15
blade) just through the mucosa from cuspid region to
B
A
• Figure 37-20  Illustrations of standard osseous genioplasty. See the text for descriptions of
the techniques depicted.
Continued

1598 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
D
C
• Figure 37-20, cont’d

E
G
F
• Figure 37-20, cont’d

1600 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
With the chin secured in its new location, the position­
ing screw is removed.
• If significant vertical lengthening of the chin is planned,
an interpositional graft (e.g., autograft, allograft, bloc
hydroxyapatite) is crafted and placed in the gap. The
graft fills the central gap between the fixation plates. I
do not find it necessary to place graft in the lateral aspect
of the gaps. An additional plate and screws are generally
placed vertically in the midline across the osteotomy
site and directly over the graft (see Chapter 18 and
Fig. 37-20, G ).
Achieving Favorable Chin Aesthetics
Establishing preferred aesthetics in the chin region is heavily
dependent on the surrounding structures. The variables
include the following: 1) maxillomandibular morphology;
2) the position of the teeth within each arch; and 3) the
soft-tissue envelope that overlies the skeletal structures.
Preferred maxillomandibular morphology is primarily
dependent on the following: 1) facial height; 2) sagittal
projection; and 3) A-point–to–B-point relationships when
viewing the facial profile and the natural head position.
Ideally, the positioning of the teeth within the alveolar bone
establishes the preferred incisor inclination, which is an
important component of perioral aesthetics. The overlying
soft-tissue envelope will be distorted by either maxilloman­
dibular skeletal or dental disharmony. Common patterns of
soft-tissue distortions may include either lip strain with
labiomental effacement (i.e., long face growth pattern) or a
full flaccid lower lip with a deep labiomental fold (i.e.,
mandibular deficiency growth pattern).
Morphology of the chin aesthetic unit is an important
aspect of facial aesthetics. The essential components of chin
morphology include vertical height, horizontal projection,
and the surface contour of the pogonion. When considering
the chin aesthetic unit, an assessment of the individual’s
lateral cephalometric radiograph is useful. As stated, if the
vertical height of the chin is too long, lip incompetence and
an overly effaced lip–chin soft-tissue drape will result. If the
vertical height of the chin is too short, there will be a flaccid
lower lip, a deep labiomental curl, and a “button” appear­
ance to the soft tissues.
Riolo’s table of normative cephalometric values con­
firms that the mean vertical height of the chin (i.e., the
mandibular incisal edge to the menton) is approximately
42 mm (±2.7 mm) for females and 49.4 mm (±2.9 mm)
for males.83A These measurements are a useful benchmark
from which to judge the preferred vertical height of the
individual’s chin.
The extent of preferred horizontal chin projection at the
pogonion should be with reference to the B-point. When
viewing an individual’s lateral cephalometric radiograph
taken in the natural head position and with the incisors
upright (with or without the need for orthodontics) and
with the maxillomandibular vertical height and horizontal
projection being proportionate (with or without the need
• A small S-shaped Tessier chin retractor is placed on each
side inferior to the mental nerve and laterally to the
inferior border. A sterile pencil is used to mark the loca­
tion of the oblique osteotomy ((see Fig. 37-20, B). This
should be planned sufficiently below the dental roots and
the mental foramen on each side. The exact location of
the osteotomy will depend on the presenting chin mor­
phology and the planned reconstruction (i.e., vertical
reduction or lengthening and the extent of horizontal
advancement).
• With the use of an oscillating saw (i.e., a thin fan blade
on a long shaft), a vertical groove is made in the midline
across and perpendicular to the proposed horizontal
osteotomy. This will help to maintain vertical orientation
after the osteotomy and before fixation (see Fig. 37-20,
C ).
• A drill hole is placed in the midline within the distal chin
(see Fig. 37-20, C ). Later, a screw (1.7 mm in diameter
and 8 mm in length) will be partially inserted and used
as a retractor. The screw is usually not placed in the distal
chin until the osteotomy is completed. It will then be
held with a wire twister that is used as a retractor to
facilitate the repositioning and orientation of the distal
chin unit.
• The oblique osteotomy of the chin is initiated in the
central portion with the use of an oscillating saw (i.e.
wide fan blade on a short shaft). The use of this saw and
blade to initiate the osteotomy helps to maintain orienta­
tion and to limit canting (see Fig. 37-20, D).
• Using a reciprocating saw with a short blade and then
with a longer blade is helpful to complete the lateral
aspects of the osteotomy and to go through the depth of
the bone on each side (see Fig. 37-20, E ). An osteotome
may be inserted with a twisting motion to complete the
osteotomy separation (see Fig. 37-20, E ).
• When vertical shortening of the chin is planned, there
are two options. If only limited shortening is required in
combination with horizontal advancement, it may be
preferred to use a rotary drill with a watermelon bur to
remove bone height at the osteotomy line. If a more
significant vertical reduction is planned, a second parallel
osteotomy (for ostectomy) is completed through the
proximal chin (below the dental roots) using a recipro­
cating saw with a straight blade on a long shaft. Any
lateral–inferior bony irregularities are also removed using
a rotary drill with a watermelon bur to limit palpable or
visible step-offs.
• The distal chin is held in the desired position by the
assistant to the surgeon with the use of the wire twister
secured to the positioning screw. The surgeon contours
each titanium plate across the osteotomy site and then
secures each with screws (1.7 mm in diameter and
4 mm in length). Typically, either a three- a four-hole
straight plate is contoured with the ends placed on
either side of the osteotomy. The superior screw is
usually placed in between and inferior to the lateral
incisor and canine on each side (see Fig. 37-20, F).

1601
CHAPTER 37  Aesthetic Alteration of the Chin: Evaluation and Surgery
2. The experienced surgeon will rely heavily on the
direct visual examination to evaluate overall facial
proportions and any notable mirror-image asym­
metries that involve (but are not limited to) the chin
region. Without protractors or rulers, the absence of
Euclidean proportions can usually be discerned.
Confirmation of the clinician’s aesthetic impressions
may then be clarified through either anthropometric
surface measurements or cephalometric radiographic
analysis, as indicated.
3. The theoretic advantage of an alloplastic (chin
implant) genioplasty is that it is a procedure that is
seemingly easier to execute and often considered less
invasive by the patient. It has the disadvantage of
being primarily effective only for a mild anteropos­
terior deficiency of the chin, and it generally requires
an external facial scar. It will have a higher incidence
of infection than a chin osteotomy, and such an
infection may even occur years later.34,35,41,49,82,121,125
In addition, there may be underlying bony erosion
from the implant over time, and the individual can
never be without at least some concern about trauma
to the chin. Alternatively, the osseous genioplasty is
versatile in all three planes and has proven and long-
lasting results without concerns about infection,
bony erosion, a shift in position, or the need for
limited physical activities after initial satisfactory
healing has occurred.
4. When completing the intraoral incision and the
soft-tissue dissection to expose the surface of the
bony chin, avoid subperiosteal dissection above
the mental neurovascular bundle to limit the extent
of nerve contusion and stretching and the chance
of avulsion from the mental foramen. The mucosal
incision should be deep in the vestibule to leave a
full cuff of mucosa and muscle for ease of two-layer
closure and to limit periodontal sequelae.
5. When lengthening the chin, an oblique osteotomy
with the interpositional placement of a graft (e.g.,
allogenic or autogenous bone, porous bloc hydroxy­
apatite) is generally preferable to the placement
of a chin implant (as mentioned in point 3; see
Fig. 37-20, G).
6. When vertical reduction and posterior set-back
are indicated, the vector of reduction and set-
back should generally follow the long axis of the
chin prominence. This will avoid step-offs at the
junction of the chin osteotomy and the inferior
border of the mandible and limit suboptimal aes­
thetics as a result of the “bunching” of the soft
tissues (see Fig. 37-18).
7. When using a reciprocating saw to complete the
posterior (lateral) aspect of the oblique chin oste­
otomy, the inferior border may unknowingly remain
partially intact. When this happens, there is a ten­
dency for the uncontrolled fracture of the chin to
be more posterior than desired. This can result in an
for orthognathic surgery), the pogonion should not project
more than 3 mm to 5 mm anterior to the B-point. If the
pogonion projects too far in front of the B-point, the overly
prominent chin is unattractive. If the pogonion does not
project enough in front of the B-point, then a “weak” chin
will be apparent in profile.
At times, the surface contour of the anterior bony chin
will be unattractive. Two common patterns of chin-surface
dysmorphology include either an overly pointed pogonion or
bifid bony morphology (i.e., prominent lateral tubercles).
Direct recontouring of the exposed chin surface with a bur
on a rotary drill can be carried out to improve either of these
surface irregularities. When indicated, this is accomplished
simultaneously with an inferior border osteotomy to also
alter the vertical height and horizontal projection of
the chin.
In review, errors concerning chin aesthetics are more
likely when maxillomandibular morphology and incisor
inclination are not fully considered. Attempting to compen­
sate for the unfavorable positioning of either the maxillo­
mandibular complex or the teeth is responsible for much of
the observed patient dissatisfaction after a chin procedure.
The common error in these circumstances is to either use an
osseous genioplasty to project the pogonion too far in front
of the B-point or to place a “too-large” chin implant with a
resulting unnatural look. Either of these techniques is likely
to be more unattractive than the presenting “weak” chin.
Avoiding Pitfalls during Chin Surgery
The chin is one of the most visually prominent facial fea­
tures, and its role in facial appearance has been recognized
since antiquity. It may seem to be an easy structure to alter,
but focusing on the chin without fully considering the
associated facial dysmorphology (e.g., the skeleton, the
dental and soft tissues) may have unexpected and unwanted
effects on overall aesthetics. The basic surgical technique of
osseous genioplasty is reviewed earlier in this chapter. It is
also illustrated in Figure 37-20 and can be seen on
(
  Videos 11 and 12). Avoiding pitfalls during the aes­
thetic evaluation of the patient’s chin and during the surgi­
cal execution of an osseous genioplasty is essential to the
achievement of a favorable outcome.*
1. When assessing a chin that is considered to be either
retrusive or protrusive, place the patient in the
natural head position and the mandible in the rest
position (i.e., with the condyles seated and with
normal freeway space between the teeth in each
arch). The lips should be relaxed and separated. By
assessing the face in this way, you are likely to
unmask any baseline dentofacial deformity (e.g.,
short or long face growth pattern) and to gain a more
accurate impression of any true chin disproportion.
*References 5, 12, 15, 19, 35, 38-40, 42, 47, 48, 55, 58, 62, 63, 71, 74,
76, 78, 81, 93, 94, 96, 102, 103, 110, 111, 119, 122, 134

1602 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
13. Adequate fixation of the distal chin across the oste­
otomy site is reliably carried out with a limited
volume of small titanium plates and screws. The
type and extent of screws and plates used will vary
in accordance with patient-specific fixation needs
and surgeon preferences (see Fig. 37-20, F and G).
Complications and Unfavorable Results
Although the majority of patients who have undergone an
osseous genioplasty state that they would do it again, com­
plications and suboptimal results will always occur in a
minority of cases.*
Infection
Infection occurs among less than 1% of patients who have
undergone an osseous genioplasty. The routine use of pro­
phylactic antibiotics to cover both oral flora and skin organ­
isms is useful to limit this complication. When an avascular
implant is placed to augment the chin (rather than a chin
osteotomy being performed), a higher rate of infection
would be expected. This is especially true for non-porous
implants that are not stably fixed to the underlying bone.
Altered Sensibility
The mental nerve is at risk of injury in association with an
osseous genioplasty. The mental nerves will always be
stretched when the soft-tissue dissection and retraction is
carried out for exposure of the chin. The observed loss of
sensibility to the lip–chin region early after surgery is usually
temporary. The potential for cutting the mental nerve
during the soft-tissue vestibular incision is limited by taking
care during the lateral aspect of the incision. The nerve can
also be avulsed from the mental foramen during retraction
at the time of osteotomy. When determining a location for
the osteotomy, remember that the nerve dips below the
mental foramen posteriorly. According to the literature, as
many as 10% of patients may experience a degree of per­
manent loss of sensibility in the distribution of the mental
nerve on one or both sides as a result of genioplasty.
Wound Complications
The osseous genioplasty is completed through an intraoral
vestibular incision. To limit wound-healing complications,
the incision is made in the depth of the vestibule. Mainte­
nance of the attached gingiva and a full cuff of mucosa and
muscle adjacent to the cervical margins of the teeth best
ensures a relaxed wound closure in two layers (i.e., the
muscle and the mucosa). This will minimize wound dehis­
cence, muscle dysfunction, and chin ptosis and limit muco­
gingival problems. Placing the soft-tissue incision too close
uneven aesthetic result, and it is avoided by carefully
completing the lateral and posterior osteotomy
before the “splitting” of the chin (see Fig. 37-20, E).
8. When completing a vertical reduction and advance­
ment genioplasty, limit significant step-offs at the
junction of the chin osteotomy and the inferior
border of the mandible to avoid a palpable ridge or
an unattractive “hourglass” appearance to the infe­
rior border of the mandible. A continuous inferior
border of the mandible is less likely to accentuate
jowling. A significant ridge at the osteotomy site
may be prevented by extending the chin osteotomy
more posterior (i.e., as far back as first molar); by
not “overadvancing” the chin (i.e., in profile, the soft
tissue of the chin should not be anterior to the lower
lip); and by recontouring any significant step-offs
using a rotary drill with a watermelon bur before
securing the chin in its new location.
9. When an alloplastic chin implant has failed and
requires removal (i.e., as a result of suboptimal aes­
thetics, infection, bony erosion, or a shift in implant
position), chin morphology is generally best restored
with a vascularized osseous genioplasty rather than
another avascular implant. Unfortunately, the
implant will have stretched the overlying soft tissues,
resulting in ptosis and possible muscle dysfunction
when it is removed. If the chin implant was com­
posed of non-porous material (e.g., Silastic), then
a fibrous capsule will have formed, which adds to
the residual soft-tissue deformity. Reassessing the
overall maxillofacial morphology is essential before
proceeding with further chin surgery. A baseline
maxillo-mandibular dysharmony may be present
and require reconstruction to best achieve patient
satisfaction (see Figs. 37-1, 37-7, 37-9, and 37-10).
10. When the surface contour of the chin is severely
dysmorphic (i.e., overly pointed or bifid), direct bur
recontouring using a rotary drill with a watermelon
bur is the preferred approach. This does not negate
the simultaneous completion of an oblique osteot­
omy for the three-dimensional repositioning of the
remaining chin unit. Adequate circulation to the
distal chin is maintained through the genioglossus
and geniohyoid muscle attachments to the genial
tubercle.
11. When completing an oblique osteotomy of the chin,
the temporary placement of a screw in the distal
chin (i.e., one that is only halfway screwed in) that
is then clamped with a wire twister (i.e., to be use
used as a handle or retractor) is helpful for ease of
positioning of the chin before osteotomy fixation
(see Fig. 37-20, C and F).
12. Marking the midline of the bony chin with a small
vertical notch perpendicular to the proposed hori­
zontal osteotomy helps with the maintenance of
chin symmetry before the placement of plate and
screw fixation (see Fig. 37-20, C).
*References 7, 10, 11, 17, 18, 20, 24, 25, 29, 32, 34, 49, 53, 54, 65, 72,
73, 75, 80, 82, 85, 98, 100, 113, 114, 117, 121, 133, 136, 137

1603
CHAPTER 37  Aesthetic Alteration of the Chin: Evaluation and Surgery
• Figure 37-21  An oblique osteotomy of the chin was carried out (vertical lengthening and horizontal advancement)
with interpositional hydroxyapatite grafting. Postoperative radiographs indicate the closeness of the screw fixation to
the lateral incisor (1.7-mm diameter and a 4-mm length). Darkening of the crown indicates pulpal injury. Root canal
therapy and internal bleaching of the involved tooth were carried out.

R
L
1
After root
canal treatment
surgeon, the dentist, and the patient are essential, because
root canal therapy or other forms of treatment may be
indicated (Fig. 37-21).
Patient Dissatisfaction
Patient dissatisfaction after an osseous genioplasty will gen­
erally revolve around facial aesthetics. This is best avoided
via the following means:
1. Accurate preoperative facial and dental assessment by
the surgeon and then discussion with the patient of
the following: 1) the surgeon’s findings; 2) the patient’s
goals; 3) any patient-specific biologic limitations
(e.g., soft tissues, skeletal, dental); 4) any baseline
head and neck dysfunction that may be related to the
to the teeth can negatively affect wound healing and result
in scar bands and periodontal sequelae (e.g., mucogingival
pull).
Injury to the Teeth
The location of the chin osteotomy should be based on
the patient’s chin morphology. The review of the patient’s
radiographs (e.g., lateral cephalometric, Panorex) will
confirm the anatomy of the anterior teeth and the location
of the mental foramen. Injury to the teeth at the time of
osteotomy is not common, but it can occur. Dental injury
may also occur as a result of the placement of the fixation
screws, but this is also not common. If dental injury is
suspected, evaluation by the patient’s dentist or referral to
an endodontist is recommended. Discussions among the

1604 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
chin (e.g., breathing, lip competence); and 5) the
surgeon’s overall recommendations
2. A clear understanding among all parties of the opera­
tive objectives and any compromises in treatment
that have been jointly agreed upon
3. The meticulous execution of the procedures by the
surgeon with the patient under controlled anesthesia
and with proper instrumentation and assistance
4. At set time intervals after surgery, a discussion with
the patient about the results achieved and any short­
comings perceived
Alloplastic Chin Augmentation
Successful chin implants are primarily placed to address
mild deficiencies in the sagittal dimension at the pogonion
and any limited hypoplasia immediately lateral to the sym­
physis.128,129 Depending on the philosophy and skill of the
surgeon, some vertical lengthening may also be possible.130
Complaints after alloplastic chin augmentation are not
infrequent, which may explain their decreased use by board-
certified surgeons over a recent 10-year time frame.* Avail­
able statistics from the American Society of Aesthetic Plastic
Surgeons confirm an 85% drop in the number of chin
implants that were placed between 1997 and 2009 (i.e.,
11,000 implants were placed in 1997, whereas 1700 were
placed in 2009).101 Although individuals often present with
the specific complaint of a “weak chin” and with a seemingly
simple request for a “chin implant,” they frequently have a
combination of microgenia, mandibular deficiency, and
additional associated maxillofacial dysmorphology. A com­
plete systematic soft-tissue and skeletal facial evaluation is
required. The surgeon may choose not to discuss associated
baseline maxillomandibular skeletal deformities either as a
result of a lack of knowledge (i.e., an incomplete diagnosis)
or because the patient or family “only requested a chin
implant.” In either case, after sagittal chin augmentation, a
dissatisfied patient may express bewilderment with the
result and at a minimum demand implant removal (see Figs.
37-1, 37-7, 37-9, and 37-10). When indicated, counseling
the patient about the preferred orthodontic and orthogna­
thic approach versus camouflage genioplasty alone is
advised.
When the facial aesthetic analysis indicates that an
implant is an acceptable alternative, a customized porous
polyethylene chin augmentation with screw fixation is gen­
erally preferred.104,128-130 Silicone (i.e., Silastic) implants heal
with a surrounding fibrous capsule. Porous polyethylene
implants heal with fibrous tissue in-growth into the open
pores. The placement of an appropriately shaped implant
with stable fixation will limit the risk of displacement, infec­
tion, and erosion of the underlying bone. The obliteration
of dead-space gaps (i.e., between the implant and the skel­
eton) by custom contouring the implant and when applying
compressive fixation screws before wound closure is essen­
tial. To review, experienced surgeons generally recommend
the following: 1) placing a chin implant through a submen­
tal incision without intraoral exposure; 2) using an implant
of porous material that is customized; and 3) applying stable
screw fixation to increase success and limit complications.128-130
Despite the apparent technical ease of placing an allo­
plastic implant, a disproportionate number of repetitive
problems seem to occur after a chin implant.11,24,57,97 A
common clinical scenario involves sagittal augmentation
with an implant that is excessive in size and that does not
address vertical aspects or associated jaw deformity. In these
cases, it is generally not just the patient who perceives that
the implant is too big; it is hard for the surgeon and other
observers at conversational distance to deny the unfavorable
aesthetic result, and thus surgeons are forced to honor
their patients’ request for implant removal. Unfortunately,
depending on the material used, the implant may have
caused capsule formation, splaying of the mentalis muscles,
and stretching of the overlying soft-tissue envelope. After
removal of the “too-large” implant, soft-tissue contracture
may occur, which looks even worse with dynamic function
(i.e., the soft-tissue “balling up” effect). If mentalis muscle
dysfunction remains, there may be unattractive sagging
(ptosis) of the soft tissues. Removing the implant and
simply placing a smaller one has a low probability of satisfy­
ing the patient’s concerns. Facial reassessment may clarify
other skeletal deformities (e.g., primary mandibular defi­
ciency, maxillomandibular deficiency, long face growth
pattern) that account for the suboptimal result. Many
times, after implant removal, a chin osteotomy with three-
dimensional repositioning with or without combined
orthognathic procedures will give the best result.
Frequent sequelae include improper initial positioning
of the chin implant (i.e., not directly over pogonion) and
inadequate fixation with lateral or superior shifting. These
conditions may result in suboptimal aesthetics, erosion of
the underlying bone, or compression of the mental nerve
with dysesthesia of the lip–chin region. A late trauma event
involving an otherwise initial satisfactory implant may lead
to swelling and then infection. Late infection as a result of
either bacteremia with secondary implant seeding or an
adjacent dental infection can also occur. Management gen­
erally requires drainage, the removal of the implant, and the
use of antibiotics. After resolution, further reconstructive
options can be considered.
Conclusions
An osseous genioplasty can be a useful technique for the
enhancement of facial aesthetics. Before an isolated genio­
plasty procedure can be considered, a thorough facial aes­
thetic and head and neck functional assessment—followed
by a frank discussion with the patient and the family about
*References 8, 11, 14, 21, 24, 26, 27, 37, 41, 46, 50, 56, 57, 67, 68, 70,
72, 84, 86, 87, 97, 107-109, 115, 132

1605
CHAPTER 37  Aesthetic Alteration of the Chin: Evaluation and Surgery
the ideal treatment and any compromised treatment agreed
to—is essential. A review of the risks, possible complica­
tions, and hoped-for benefits of a chin reshaping procedure
should result in a high degree of patient satisfaction. To
limit the occurrence of a dissatisfied patient outcome, the
setting of realistic and agreed-upon objectives is essential.
The meticulous execution of the procedure by the surgeon
with the patient under controlled anesthesia and with
proper instrumentation and assistance further ensures
success.
Patient Education Materials
Osseous Genioplasty (Chin Reshaping) Surgery
Many people are motivated to alter their chins when they see themselves in profile. For example, when the chin is
small, it may undermine the entire face and make the nose look larger and more conspicuous. An osseous genioplasty
is a procedure that is often carried out to reshape or change the size, projection, or appearance of the chin. The chin
region may be surgically changed with regard to its length, projection, or symmetry.
An osseous genioplasty may balance your profile by enhancing or diminishing chin prominence in relationship to the
nose, jaws, and lips. Strengthening the chin will tend to tighten the skin of the neck and generally maintain or restore a
more youthful appearance. The surgical reshaping of the chin is carried out either as an isolated procedure or as part
of other facial surgery (e.g., orthognathic procedures, rhinoplasty, neck lift). The procedure usually requires 1 hour and
is carried out with the patient under anesthesia. The incision that is used to gain access to the chin is made on the
inside of the lower lip. Depending on other procedures that are carried out simultaneously, most people return to work
after 1 week.
INSTRUCTIONS FOR OSSEOUS GENIOPLASTY SURGERY
The purpose of these instructions is to help you prepare for and recover from your operation with as little discomfort
and inconvenience as possible.
Preoperative Instructions
1. Do not take any aspirin, aspirin-containing, or aspirin-like products (e.g., Advil) for at least 2 weeks before surgery.
Aspirin and aspirin-like products tend to increase bleeding during surgery and bruising postoperatively.
2. Be sure that you do not smoke and that there are no nicotine products in your bloodstream for at least 3 weeks
before and 2 weeks after surgery. Nicotine in the bloodstream jeopardizes wound healing. Smoke that is chronically
ingested by the lungs may also result in pulmonary complications that will hinder optimal healing.
3. Do not eat or drink anything after midnight the night before surgery, not even a sip of water. You may brush your
teeth, but do not swallow the water.
4. Starting 2 days before surgery, we request that you shampoo your hair and shower at least once per day. The
morning of surgery, you may also shower and shampoo your hair again.
5. We will give you a prescription for pain control and another for antibiotics. You may wish to fill them before the date
of surgery.
6. Be sure to make arrangements for someone to accompany you home after surgery, because you will not be
allowed to drive.
Postoperative Instructions
1. A cold compress applied in the neck and chin region should reduce swelling and discomfort for the first 24 to 36
hours after surgery. However, this is of little value after that time.
2. Keep the head of your bed elevated when resting and sleeping for the first week after surgery.
3. You may shower and shampoo your hair the day after surgery. Do not be afraid to wash your face and neck.
4. After discharge from the hospital, eat lightly (mostly liquids) and advance to a soft diet during the first week until
further instructions are given.
5. You should begin brushing your teeth the day of surgery. Brush your upper teeth in the regular way and your lower
teeth (including the anterior teeth) carefully and slowly. Do not brush the incision.
Continued

1606 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
6. Keep your level of physical activity to a minimum, get lots of rest, and do not do anything that requires more than
limited physical exertion during the first week after surgery. You will gradually increase your activity level, but no
sports or exertional exercise are allowed for 5 (five) weeks from the date of surgery. Ask your surgeon for specific
instructions with regard to physical activity.
7. Do not consume beverages that contain alcohol or drive a motorized vehicle while taking prescription pain
medications.
8. When you are at home, you should take the prescribed pain medication as needed. Tylenol may be substituted
when your pain has diminished. Avoid taking aspirin or aspirin-like products for an additional 2 weeks after surgery.
Take the antibiotic medication as directed until the supply is exhausted.
9. Call the office for an appointment to see your surgeon on the date specified on your discharge instructions. If there
are any concerns, contact your surgeon’s office at any time, day or night. After hours, the answering machine will
advise you about how to proceed.
Jeffrey C. Posnick, DMD, MD
Director, Posnick Center for Facial Plastic Surgery
Consent for Osseous Genioplasty Surgery
_______
INSTRUCTIONS
Initial here
This is a document that has been prepared to help your surgeon educate and inform you about your chin
reshaping (genioplasty) surgery and its risks as well as alternative treatment options. It is important that
you read this document carefully and completely. Please initial each section on each page to indicate
that you have read and understand it. In addition, please sign the consent for surgery on the last page
as proposed by your surgeon.
_______
INTRODUCTION
Initial here
Many people are motivated to alter their chins when they see themselves in profile. For example, when a
chin is small, it may undermine the entire face and make the nose look larger and more conspicuous.
Genioplasty is a surgical procedure that is often carried out to reshape or change the size, projection,
or appearance of the chin.
Under anesthesia, in an operating room, a small incision is made on the inside of the lower lip. Then, with
the use of specialized instruments, the bone of the chin is cut and then repositioned or reshaped in
accordance with your specific needs as discussed with your surgeon.
Genioplasty can balance your profile by enhancing or diminishing chin prominence in relationship to the
nose, jaws, and lips. Strengthening the chin may tighten the skin of the neck and generally result in a
more attractive appearance. The surgical reshaping of the chin is carried out either as an isolated
procedure or as part of other facial surgery (e.g., orthognathic procedures, rhinoplasty, neck lift). The
surgery usually requires about 1 hour to complete. Most people return to work 1 week after surgery.
_______
ALTERNATIVE TREATMENT
Initial here
Alternative forms of management include not doing anything to your chin at all. Some individuals may
consider a chin implant option; this involves the placement of artificial material (i.e., a chin implant)
directly over the surface of your bone. Risks and potential complications are also associated with this
and other alternative forms of treatment. These are all issues to consider in detail before you select the
approach that best suits your overall needs.

1607
CHAPTER 37  Aesthetic Alteration of the Chin: Evaluation and Surgery
_______
RISKS OF SURGERY
Initial here
Every surgical procedure involves a certain amount of risk. An individual’s choice to undergo a specific
procedure is based on the comparison of the risk to potential benefit. Although the majority of patients
do not experience the complications detailed below, you should discuss each of these items with your
surgeon to be sure that you understand the risks, potential complications, and consequences of the
chin reshaping surgery planned for you.
_______
SURGICAL ANESTHESIA
Initial here
The use of both local and general anesthesia involve risk. Complications and injuries are possible with all
forms of anesthesia and sedation.
_______
INFECTION
Initial here
Infection is not common after chin reshaping surgery. Treatment with antibiotics will begin just before
surgery and is continued afterward surgery. If an infection does occur, additional treatment (e.g., a
change in antibiotics, drainage, other procedures) may be necessary.
_______
SCARRING
Initial here
Although good wound healing after the procedure is expected, abnormal healing or unattractive scars
may occur within the skin, the deeper structures, and the mucous membranes. Additional treatment or
procedures may be helpful to treat scarring or gingival (gum) problems.
_______
ALTERATION OF FACIAL SENSIBILITY
Initial here
With a genioplasty procedure, the mental nerve is at risk for injury. Such an injury may result in diminished
sensation of the lower lip, the skin of the chin, the gums around the anterior teeth, and the anterior
teeth themselves. Gradually over the course of 6 to 12 months, the feeling improves and generally
returns to close to normal. Approximately 10% of the time, a degree of permanent sensory loss in the
lower lip, chin, gums, and teeth remains.
_______
INJURY TO ADJACENT TEETH
Initial here
During the genioplasty procedure, injury to the roots of the anterior teeth or interference with the
circulation (blood flow) to the dental and bone segments can occur. Devitalization (nerve damage) of
the teeth, which may then require a root canal procedure, can occur. Infrequently, the teeth may be
injured by the fixation screws. It is possible (but unlikely) that the loss of teeth may occur and later
require additional treatment. These are not common events, but they must be mentioned as possible
occurrences.
_______
DISSATISFACTION WITH FACIAL APPEARANCE
Initial here
An individual’s dissatisfaction with his or her facial appearance after genioplasty surgery is not common,
but it can occur. Despite your surgeon’s best efforts, on occasion, this type of surgery may result in
visible deformities, asymmetries, or structural malposition. You may be disappointed if the results of the
chin surgery do not meet your expectations. Additional treatment and procedures may be possible
should the results be considered unsatisfactory.
Continued

1608 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
_______
FACIAL ASYMMETRY
Initial here
The human face is normally asymmetric. There can also be variation from one side of the face to the
other with regard to the results achieved with a chin reshaping procedure. Additional surgery may be
possible should the extent of asymmetry be of concern.
_______
MEDICATIONS
Initial here
Medications, prescription drugs, and anesthetics, may cause drowsiness and a lack of awareness and
coordination, which can be increased by the use of alcohol or non-prescription drugs. Your surgeon
advises you not to operate any vehicles, automobiles, or other potentially hazardous devices while
taking such medications and until you have achieved full recovery from the effects of these substances.
We ask that you not drive yourself home after discharge from the hospital or to and from office
appointments initially after surgery.
_______
HEALTH INSURANCE
Initial here
Most health insurance companies exclude coverage for changing the shape of the chin (genioplasty) or
for any complications that may arise from this surgery. Please carefully review your health insurance
subscriber-information to clarify these issues.
_______
FINANCIAL RESPONSIBILITIES
Initial here
The cost of surgery involves several charges for the services provided, including the fees charged by your
surgeon (i.e., surgeon’s fees); the cost of surgical supplies, laboratory tests, and the use of the
operating room (i.e., hospital charges); and the cost of anesthesia (i.e., anesthesiologist’s fees).
Depending on whether the cost of surgery is covered by your medical insurance plan, you will be
responsible for necessary copayments, deductibles, and all other charges that are not covered.
Additional costs may occur should complications or an unfavorable result develop from the surgery.
Any secondary surgeries and all charges involved with revision procedures (i.e., surgeon’s fees, hospital
charges, and anesthesiologist’s fees) would also be your responsibility.
_______
DISCLAIMER
Initial here
Informed-consent documents are used to communicate information about the proposed surgery and to
disclose risks and alternative forms of treatment. The informed-consent process attempts to define
principles of risk disclosure that should generally meet the needs of most patients in most
circumstances.
Since every patient is unique, this informed-consent document should not be considered all-inclusive with
regard to defining methods of treatment and potential risks encountered. Your surgeon will provide you
with additional written and verbal information that is based on all of the facts of your particular case
and the current state of medical knowledge.
Informed-consent documents are not intended to define or serve as the standard of medical care.
Standards of medical care are determined on the basis of all of the facts involved in an individual case
and are subject to change as scientific knowledge and technologic advances and practice patterns
evolve.
It is important that you read the above information carefully and have all of your questions
answered by your surgeon before signing the consent form on the next page.

1609
CHAPTER 37  Aesthetic Alteration of the Chin: Evaluation and Surgery
CONSENT FOR OSSEOUS GENIOPLASTY SURGERY
1. I hereby authorize my surgeon, __________, and such assistants as may be selected by my surgeon to perform the
following procedure(s):
_________________________________________________________________________________________
_________________________________________________________________________________________
2. I have received, read, and understand the following information sheets:
• Osseous Genioplasty Surgery
• Book Chapter about Genioplasty
• Consent for Osseous Genioplasty Surgery
3. I recognize that, during the course of the operation, unforeseen conditions may necessitate different procedures then
those listed above. I therefore authorize my surgeon, __________, and my surgeon’s assistants or designees to perform
such other procedures that are in the exercise of professional judgment necessary and desirable. The authority granted
under this paragraph shall include all conditions that require treatment and that are not known to my surgeon at the
time the procedure is begun.
4. I acknowledge that no guarantee has been given by anyone with regard to the results that may be achieved by the
procedures to be carried out.
5. I agree not to use alcoholic beverages and unprescribed drugs and to avoid all sports and water activities for at least 5
(five) weeks and then to resume them only after approval by my surgeon.
6. I consent to the photographing of me (head and neck region) before, during, and after surgery. These photographs
may be used by my surgeon for medical, scientific, or educational purposes now and in the future.
7. I agree to cooperate completely with the recommendations of my surgeon and to provide all medical and dental
information about myself while I am under my surgeon’s care. I realize that a lack of same could result in less than
optimal care.
8. I consent to the disposal of any body tissues or medical devices that may be removed.
9. THE FOLLOWING INFORMATION HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:
• THE PREVIOUSLY DESCRIBED PROCEDURES TO BE UNDERTAKEN
• ALTERNATIVE PROCEDURES AND METHODS OF TREATMENT THAT I HAVE DECIDED AGAINST
• THE SPECIFIC RISKS AND POTENTIAL COMPLICATIONS OF THE PROCEDURES THAT I PLAN TO
UNDERGO
I CONSENT TO THE PROCEDURES AND THE ABOVE LISTED ITEMS (1 THROUGH 9). I AM SATISFIED WITH
THE EXPLANATION GIVEN TO ME.
________________________________________
___________________________
Patient (or Person Authorized to Sign for Patient)
Date
________________________________________
_____________________________
Witness
Date

1610 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
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56. Matarasso A, Elias AC, Elias RL: Labial
incompetence: A marker for progressive bone

1611
CHAPTER 37  Aesthetic Alteration of the Chin: Evaluation and Surgery
resorption in Silastic chin augmentation.
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59. McCarthy JG: Microgenia: A logical surgical
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60. McCarthy JG, Kawamoto HK, Grayson BH,
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61. McCarthy JG, Ruff GL: The chin. Clin Plast
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62. McCarthy JG, Ruff GL, Zide BM: A
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63. McDonnell JP, McNeill RW, West RA:
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64. McKinney P, Rosen PB: Reduction
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65. Mercuri LG, Laskin DM: Avascular necrosis
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66. Michelow BJ, Guyuron B: The chin: Skeletal
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67. Millard DR: Chin implants. Plast Reconstr
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68. Millard DR: Adjuncts in augmentation
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69. Millard DR, Pigott R, Hedo A: Submental
lipectomy. Plast Reconstr Surg 41:513, 1968.
70. Mole B: The use of Gore-Tex implants in
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71. Mommaerts MY, Van Hemelen G, Sanders
K, et al: High labial incisions for genioplasty.
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72. Newman J, Dolsky RL, Mai ST: Submental
liposuction extraction with hard chin
augmentation. Arch Otolaryngol 11:454,
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73. Nishioka GJ, Mason M, Van Sickles JE:
Neurosensory disturbance associated with the
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J Oral Maxillofac Surg 46:107, 1988.
74. Obwegeser H: The surgical correction of
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75. Omnell ML, Tong DC, Thomas T:
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76. Ousterhout DK: Sliding genioplasty,
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77. Peterson RA: Correction of the senile chin
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78. Polido WD, de Clairfont RL, Bell WH:
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79. Posnick JC: Aesthetic alteration of the chin:
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81. Putnam JM, Donovan MG: Modified
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83. Ricketts RM: Esthetics, environment, and
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84. Rish BB: Profile-plasty. Report on plastic
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85. Ritter EF, Moelleken BRW, Mathes SJ,
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88. Rosen HM: Surgical correction of the
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89. Rosen HM: Porous, block hydroxyapatite as
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90. Rosen HM: Aesthetic refinements in
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91. Rosen HM: Aesthetics in facial skeletal
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93. Rosen HM: Aesthetic guidelines in
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128. Yaremchuk MJ: Mandibular augmentation.
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129. Yaremchuk MJ: Facial skeletal reconstruction
using porous polyethylene implants. Plast
Reconstr Surg 111:1818, 2003.
130. Yaremchuk MJ: Improving aesthetic
outcomes after alloplastic chin augmentation.
J Plast Reconstr Surg 112:1422–1432, 2003.
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134. Zide BM, Boutros S: Chin surgery: III.
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135. Zide B, Longaker MT: Chin surgery: II.
Submental ostectomy and soft-tissue
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136. Zide BM, McCarthy JG: The mentalis
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1999.

1613

38
Aesthetic Alteration of the Nose:
Evaluation and Surgery
JEFFREY C. POSNICK, DMD, MD
• Nasal Surface Anatomy
• Classic Rhinoplasty Maneuvers
• Facial versus Nasal Proportions and Effects
on the Aesthetic Perspective
• The Nasal Airway: Anatomy and Physiology
• Anatomic Locations and Causes of Nasal
Obstruction
• Evaluation of the Nasal Airway
• Surgical Approach to Open the Nasal Airway
• Outcome Assessment of Surgery to Improve
Nasal Breathing
• Initial Rhinoplasty Consultation
• Definitive Rhinoplasty Planning
• Open versus Closed Approach to the Nose
• Complications Associated with Rhinoplasty
• Primary Septorhinoplasty: Step-by-Step
Approach
• Cleft Nasal Deformities
• Congenital and Posttraumatic Saddle-Nose
Deformities
• Cocaine-Related, Autoimmune and Iatrogenic
Saddle-Nose Deformities
• Conclusions
• Patient Education Materials
and the nasal process of the maxilla) and the cartilaginous
vault (the upper lateral cartilages [ULCs] and the dorsal
aspect of the cartilaginous septum). The transition from
bony to cartilaginous dorsum is called the keystone area.49
The caudal aspects of the nasal bones overlap the cephalic
portions of the ULCs in the keystone area. The width of
the nasal bones and ULCs is greater in the keystone area
than at either the radix or the supratip regions.
Aesthetically, the dorsum of the nose is analyzed with
regard to its height or anterior projection and its width
and shape. Ideally, the dorsum of the nose, when viewed
in profile, should be straight or slightly concave. The naso­
facial angle is a soft-tissue measurement from the nasion
to the tip and from the nasion to the glabella and should
be approximately 34 to 36 degrees. The width of the dorsal
lines of the nose should be roughly equal to that of the
philtral columns. The maximum width of the bony vault
(i.e., the dorsal width) of the nose is ideally less than that
of the medial intercanthal width.
The lobule of the nose encompasses the entire area that
overlies the lower lateral cartilages (LLCs), whereas the
intrinsic nasal tip represents the area between the nasal-tip–
defining points and the area between the infratip breakpoint
and the supratip breakpoint. The ideal tip-defining points are
approximately 6 to 8 mm apart in females and 8 to 10 mm
apart in males. The LLCs are key anatomic points of refer­
ence that define the nasal tip. They are subdivided into the
medial crus, the middle crus, and the lateral crus.
Of aesthetic importance are the angles formed by the junc­
tion of the crura; these include the columella infratip break­
point (i.e., the middle crura–medial crura angle) and the
dome tip-defining points (i.e., the middle crura–lateral crura
angle).
The columella is a critical region and component of the
nose. It must be in balance between the adjacent alar rims
and the medial crura. It should also form an attractive angle
with the upper lip (i.e., the nasolabial or columella–labial
angle). If the columella is either retracted or demonstrating
excessive show, it will be less attractive and benefit from
change (i.e., augmentation versus reduction).
Nasal Surface Anatomy
The external nose may be described as consisting of three
parts: the osseocartilaginous vault, the lobule/tip, and the
base (Fig. 38-1).
The osseocartilaginous vault consists of the bony vault
(the nasal bones, the nasal process of the frontal bones,

1614 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
quadrangular cartilage or from another source (e.g., the
conchal floor, the rib cartilage).201 A caudal strut graft
remains the workhorse for the addition of support to weak
LLCs and for the control and maintenance of the nasal tip
position. The caudal strut graft also functions as a central
scaffold on which the tip structures can be unified. When
a shield tip graft is used, it is placed over the domes with the
inferior margin extending to the mid columella. A shield
graft is effective for increasing infratip lobular definition
and projection. Columellar tip grafts extend superiorly and
are often secured to the ULC above and the caudal margin
of the medial crura below. They are more useful in thick-
skinned individuals in whom there is an additional need to
improve tip definition beyond the usual rhinoplasty maneu­
vers. In thin-skinned individuals, tip grafts are only used
cautiously, because they may result in visible irregularities.
Interdomal sutures are placed in mattress fashion in the
region of the middle crura.89,98,199 This suturing technique
is effective for reducing interdomal distance and thereby
increasing tip projection and refinement. Medial crural fixa­
tion sutures are placed to unify the medial crura beneath the
domes of the LLC and to reduce flaring. These sutures are
typically placed after a caudal strut graft is secured. Trans­
domal sutures are placed in a horizontal mattress fashion and
then across the dome of the middle crura. All of these suture
techniques can be effective to alter the tip position, to
narrow the distance between the tip-defining points, and to
correct domal asymmetries.
Spreader grafts may be either horizontal or vertical, and
they are used to correct deficiencies of the cartilaginous
vault.24,38,46,87,88,92,95,97,208,209,255 Vertical spreader grafts are gen­
erally paired and extend from just deep to and then flush
The thickness and quality of the soft tissues over the nasal
skeleton have a significant impact on the appearance and will
also affect the final result of a rhinoplasty. In most individu­
als, the skin is thickest in the supratip region; it thins over
the domal area.
To the experienced clinician, the appearance of the exter­
nal nasal anatomy will give an indication of the anatomic
causes of subjective nasal airway obstruction.249 Middle-
vault collapse, pinched nasal sidewalls, asymmetric nostrils,
and a crooked dorsum are all outward indications of
obstructions to nasal airflow; this is discussed later in this
chapter.
Classic Rhinoplasty Maneuvers
Classic rhinoplasty maneuvers include the following 1) nasal
osteotomies (i.e., to reduce the nose’s width, to straighten a
crooked nose, and to close an open roof) 2) dorsal reduction
(bone and cartilage) 3) the selective removal of cephalic
portions of the lower lateral crura (maintenance of 6 mm
of caudal rim) 4) suturing of the LLCs (i.e., interdomal and
transdomal areas) and 5) augmentation with cartilage grafts
(i.e., caudal strut graft, alar contour grafts, lateral crural strut
grafts, shield tip graft, columellar tip graft, spreader grafts,
dorsal strut graft).47,51,69,93,138,142-144,182,207,219,237
Grafts are indicated when other lesser maneuvers to
improve the projection and definition of the nasal tip are
not adequate.* When indicated, a graft that will be used to
alter the nasal tip can be fashioned from removed
•  Figure 38-1  A, Illustration of the soft tissues and skeletal anatomy of the nose as seen in profile view.
B, Illustration of the skeletal anatomy of the external nose and the lower lateral cartilages as seen in three-quarter
and worm’s-eye views.
A
B
*References 6, 21, 23, 36, 46, 48, 53, 70, 79, 90, 96, 99, 100, 108, 135,
156, 169, 174, 235, 239, 241

1615
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
the nasal aesthetic unit, but the patient may express displea­
sure with the results. This will more frequently occur in the
individual with either a long face growth pattern, a short
face growth pattern, or an isolated sagittal mandibular defi­
ciency growth pattern who perceives that he or she still has
a “big” nose, even after rhinoplasty (Fig. 38-3). The patient
may have initially sought out a cosmetic surgeon and
requested a rhinoplasty with the goal of achieving a “smaller”
nose. The surgeon may create a well-proportioned nasal
aesthetic unit, but the nose may still remain “big” in pro­
portion to the rest of the face. The surgeon may then be
asked to revise the rhinoplasty to create a “smaller” nose.192,193
When the surgeon further reduces the nasal bones and
cartilage beneath the soft-tissue envelope, an “operated”
look may result, and the overall facial proportions may
move even further out of balance.
The Nasal Airway: Anatomy
and Physiology
Symptomatic nasal obstruction is a condition in which
the individual feels that he or she has inadequate nasal
airflow. Although it is a subjective feeling, it should have a
foundation in objective anatomic and physiologic findings
(Fig. 38-4). Knowledge of both nasal anatomy and physiol­
ogy is required for the accurate diagnosis and treatment of
the subjective sensation of obstructed nasal breathing.*
Bony Anatomy
The anterior (pyriform) aperture generally represents the
narrowest bony aspect of the nasal airway.123 Its anatomic
boundaries include the paired nasal bones (i.e., the nasal
pyramid), which join to the ascending process of the maxilla
laterally. The bony floor of the nose is formed by the superior
aspect of the premaxillary alveolus anteriorly and the
secondary palate posteriorly. The anterior nasal spine is
in the anterior midline of the nasal floor, and the posterior
nasal spine is in the posterior midline of the nasal floor.
These spines provide the anterior and posterior limits of
the inferior aspect of the cartilaginous and bony septum,
respectively.
The posterior (choanae) aperture has a medial wall that is
formed by the vomer, which is the posterior aspect of the
nasal septum. The floor of the choanae is formed by the
posterior aspect of the hard palate. The lateral walls of
the posterior aperture are formed by each lateral maxillary
process.
The posterior inferior septum is composed of the vomer,
and it is contiguous with the perpendicular plate of the
ethmoid superiorly. The anterior septum is composed of the
with the nasal bones. They are secured on each side of the
dorsal septum and then generally to the ULCs with sutures.
The caudal end of each vertical spreader graft may continue
beyond the septal angle and below the LLCs to elongate the
nose and to derotate the tip. They are typically 15 to 20 mm
in length and approximately 2 to 4 mm in width. A hori­
zontal spreader graft is a single dorsal graft that is inset
between the ULCs and that forms a “T” with the dorsal
septum. Spreader grafts are used as a technique to prevent
or correct the narrowing of the internal nasal valve, to pre­
serve or correct the nasal dorsum or dorsal aesthetic lines,
and to correct and stabilize a “crooked” dorsal septum.
There are four aspects of the nasal base that may be con­
sidered for surgical modification5:
1. Selective reduction of the caudal aspect of the quad­
rangular cartilage (septum) may be completed to
limit columella show in profile. Augmentation of the
deficient caudal septum may be required after over­
aggressive rhinoplasty or to reconstruct congenital
deficiencies (e.g., Binder syndrome).
2. Modification of the anterior nasal spine may be
carried out to alter the nasolabial angle or to augment
a congenital deficiency (e.g., Binder syndrome).
3. Deepening of a high nasal floor and widening of
narrow pyriform apertures by recontouring (e.g.,
using a rotary drill with a bur) may be indicated to
improve the airway and to enhance aesthetics (i.e., in
those with a long face growth pattern). Augmentation
of this region may also be carried out to reconstruct
a deficiency (e.g., Binder syndrome, alveolar
clefting).
4. A cautious approach to excision of the alar rims (i.e.,
Weir excisions) may be performed to achieve a pre­
ferred interalar width (i.e., just less than the intercan­
thal width). It is preferred to accept a slightly increased
interalar width rather than to end up with an “oper­
ated” look from either overresection of the rims or
resulting scarring.
Facial versus Nasal Proportions and
Effects on the Aesthetic Perspective
The surgeon must distinguish between the aesthetics of the
nose (i.e., nasal proportions) and the aesthetics of the face
(i.e., overall facial proportions) (Fig. 38-2).* Establishing
the Euclidean proportions of the full face represents a differ­
ent aesthetic objective than simply establishing pleasing
proportions of the nose as an isolated aesthetic unit. The
individual who is seeking rhinoplasty often perceives that
his or her aesthetic objectives can be met by addressing
the nose only. In these circumstances, after cosmetic rhino­
plasty, the surgeon may be pleased with improvements in
*References 1, 9, 11, 15, 17, 27, 29, 30, 34, 39, 40, 44, 45, 55, 57, 62,
80-82, 85-87, 94, 101, 105, 110, 121, 124-126, 131, 139, 141, 146,
161, 162, 179, 197, 206, 213, 231
*References 163-165, 186, 192, 203, 205, 211, 248
Text continued on p. 1620

1616 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 38-2  A, Frontal and B, profile views of a well-proportioned face, including the underlying skeletal
anatomy, are illustrated.
Superion
Glabella
Naso-facial angle (radix)
Dorsum
Supratip break
Nasal tip
Collumella
Naso-labial angle
Labio-mental angle
Pogonion
Nasal bones
Upper lateral cartilage
Dorsal aspect of quadragular cartilage
Lower lateral cartilage
A
B

1617
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
B
•  Figure 38-3  The clinician must distinguish between the aesthetics of the nose (i.e., the nasal aesthetic proportions) and the aesthetics of the
face (i.e., the facial aesthetic proportions). Establishing the Euclidean proportions of the overall face represents a different aesthetic objective than
simply establishing pleasing proportions of the nose as an isolated aesthetic unit. The individual who is seeking rhinoplasty often perceives that his
or her objectives can be met by addressing the nose only. Errors in aesthetic judgment are especially frequent when viewing an individual with the
following uncorrected issues: 1) a long face growth pattern (see Chapter 21); 2) a primary mandibular deficiency growth pattern (see Chapter 19);
3) a short face (maxillomandibular deficiency) growth pattern (see Chapter 23); or 4) a maxillary deficiency with a relative mandible excess growth
pattern (see Chapter 20). Four case examples are shown to illustrate the importance of aesthetic perspective. A, A woman in her mid 20s with a
long face growth pattern is shown before and after undergoing successful orthognathic surgery to correct facial disproportion. Before surgery, the
nasal aesthetic unit was reasonably well proportioned but appeared “big” when viewing the face in profile. After successful orthognathic surgery,
the same nose appears well proportioned with respect to the rest of the face. The procedures performed included Le Fort I osteotomy, sagittal
split ramus osteotomies, and osseous genioplasty (see Fig. 21-5). B, A woman in her late 20s requested the evaluation of a “big” nose and a
“small” chin. After successful orthognathic correction, which included sagittal split ramus osteotomies and osseous genioplasty the nose appears
well proportioned with respect to the rest of the face (see Fig. 19-7).
Continued

1618 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
C
D
C, A teenage girl with a short face growth pattern (maxillomandibular deficiency with excess
overjet) had previously undergone orthodontics to neutralize the occlusion. She complains of a “big” nose and a “small”
chin. She is shown before and after successful orthognathic surgery that included Le Fort I osteotomy (horizontal advance­
ment, vertical lengthening, and clockwise rotation), sagittal split ramus osteotomies (horizontal advancement, and clock­
wise rotation), and osseous genioplasty (vertical lengthening). After surgery, the nose no longer appears big and is well
proportioned with respect to the rest of the face (see Fig. 23-2). D, A 20-year-old college student with a maxillary defi­
ciency and a relative mandibular excess growth pattern arrived for a surgical evaluation with complaints of a “big” nose
and “prominent” chin. He is shown before and after successful orthognathic surgery. The patient’s procedures included
Le Fort I osteotomy (arch expansion, horizontal advancement, vertical lengthening, and clockwise rotation) and sagittal
split ramus osteotomies (clockwise rotation). After surgery, the nose no longer appears to be prominent, and the chin
region of the lower jaw assumes improved proportions within the face (see Fig. 20-4).
• Figure 38-3, cont’d

1619
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
•  Figure 38-4  A, A three-dimensional computed tomography (CT) scan view of a mixed-dentition skeleton with a deviated septum. B, A coronal
CT view through the nasal cavity and maxilla demonstrates a deviated septum and enlarged inferior turbinates. C, A sagittal section through the
nasal cavity and the maxilla is illustrated. The anatomy of the septum is highlighted. D, A CT scan through the nasal cavity (coronal cut) demon­
strates a deviated septum. E, A sagittal section through the nasal cavity and the maxilla is illustrated. The anatomy of the turbinates is highlighted.
F, A coronal CT view through the nasal cavity demonstrates a deviated septum and enlarged inferior turbinates.
A
B
Vomer
C
D
Perpendicular plate
of ethmoid bone
Quadrangular
cartilage
Septal deviation
Supreme turbinate
Inferior turbinate hypertrophy
Superior turbinate
Middle turbinate
Inferior turbinate
E
F

1620 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
of the columella medially, and the nasal sill and bony floor
inferiorly. The size of the opening is variable and dependent
on the shape, location, and strength of the bordering
structures.
Generally, the site of greatest resistance to the entrance
of air into the entire human airway is the internal nasal
valve. Anatomically, the internal nasal valve is bordered
superiorly by the ULC, medially by the cartilaginous nasal
septum, laterally by the anterior aspect of the inferior
turbinate, inferiorly by the nasal floor, and also laterally
by the anteromedial aspect of the maxilla (i.e., the pyri­
form rim).
Mucosal Anatomy
The lining of the nasal cavity is composed primarily of
epithelium. Along the superficial aspect of the external nasal
valve, keratinized stratified squamous epithelium (i.e., skin)
is present. Within the nose, the mucosal lining transitions
from respiratory epithelium with goblet cells that secrete
mucin to basal cells, columnar cells (ciliated and non-
ciliated), and granule cells. Mucin glands are scattered
throughout the nasal airway. The sinuses, in combination
with the nasal cavity mucosa, produce between 1 and 2
liters of mucin each day. In the superior aspect of the nasal
cavity are located specialized neuroepithelial cells that
contain bipolar olfactory receptor neurons and mucin
glands.
Nerve Supply
In addition to general sensory nerve supply through the first
and second divisions of the trigeminal nerve, there is auto­
nomic and sympathetic innervation to the nasal cavity.
Nasal Physiology and Function
The five major functions of the nose are respiration, filtra­
tion, humidification, protection, and temperature regulation.
Filtration is accomplished through the vibrissae (located in
the vestibule) and the mucosal cilia, which line the airway.
Humidification and temperature regulation of the air are con­
trolled by specialized vascular tissues that are regulated by
sympathetic and parasympathetic nerve fibers. The capillary
system is supplemented by venous sinuses that may con­
strict and result in enlargement, especially of each inferior
turbinate.103 Protection from bacteria and viruses is both
mechanical and chemical. Chemical protection is provided
by immunoglobulin A and muramidase, which are found
in the mucus on the membranes of the nasal cavities.
Mechanical clearing of trapped organisms is provided by the
beating cilia, which move the mucous blanket into the
nasopharynx every 20 minutes. During respiration, the nose
resists the inspiration of air by providing almost 50% of the
total airway resistance.
Airflow in the nasal cavity is very much related to
resistance. The airflow resistance in the nasal cavity is
quadrangular cartilage, which is contiguous with the bony
septum.
Attached to the lateral nasal walls are three paired “scroll-
like” bones that are known as the turbinates. The superior,
middle, and inferior turbinates are composed of conchal
bones that support the erectile mucosal tissue of the turbi­
nates. Just inferior to each turbinate is a space called a
meatus. Each of the paired sinus cavities drains into either
the superior or the middle meatus region. The inferior
meatus drains the nasolacrimal duct. The middle meatus
provides the drainage pathway for the anterior ethmoid,
maxillary, and frontal sinuses. The superior meatus is the
drainage region for the posterior ethmoid and sphenoid
sinuses. The majority of the air that passes through the nose
is at a line below the middle turbinate.
Cartilaginous Anatomy
The cartilaginous septum joins to the bony portion of the
septum (i.e., the vomer and perpendicular plate of the
ethmoid) and the nasal crest of the maxilla inferiorly.
The caudal aspect of the cartilaginous septum that joins to
the maxillary crest does so through densely interwoven
fibers of periosteum and perichondrium. The cartilaginous
septum is called the quadrangular cartilage because of its
geometric shape. Even small deviations or deflections of the
septum can significantly alter nasal airflow. A frequent sur­
gical procedure involves the removal of portions of the
quadrangular cartilage that are obstructive to nasal airflow
or for the purpose of grafting either the nasal tip or vault.
During this procedure, it is important to maintain adequate
dorsal and caudal struts of the quadrangular cartilage, which
are responsible for the strength and support of the cartilagi­
nous vault.
The cartilaginous anatomy of the nose also includes
the paired ULCs, the paired LLCs, and the variable sesa­
moid cartilages (see Fig. 38-1). The ULCs are trapezoidal
in shape and articulate with the nasal bones superiorly,
with the quadrangular cartilage over the midline dorsum,
with limited connections laterally to the bony pyriform
aperture, and also to small sesamoid cartilages inferiorly.
The LLCs connect to the ULCs superiorly via fibrous
tissue. The LLCs are responsible for much of the form
and shape of the nasal tip and the ala. Components of
the LLC include the medial, middle, and lateral crura
(see Fig. 38-4).
Intranasal Anatomy
Within the nose, sites of obstruction tend to occur at spe­
cific locations, including the external nasal valves, the inter­
nal nasal valves, the turbinated cavities, and the posterior
nasal (choanae) apertures (see Fig. 38-4).
The external nasal valve is described as the area bounded
by the caudal edge of the ULC superolaterally, the nasal ala
and attachment of the lateral crus of the LLC laterally, the
caudal aspect of the cartilaginous septum and the soft tissue

1621
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
deformity requires cartilage support grafts that are applied
to the LLCs.
Posterior Nasal (Choanae) Apertures
Obstruction of the posterior nasal apertures may result from
the skeletal structures that compose the choanae (i.e., the
vomer and the palatine bones) or from the overlying soft
tissues (i.e., polyps, adenoids, and turbinates).210 Choanal
atresia may also be associated with congenital anomalies
such as CHARGE syndrome, Treacher Collins syndrome,
and Apert syndrome.
Middle Turbinate Concha Bullosa
It is known that the majority of airflow through the nose
enters the middle meatus, which is directly beneath the
middle turbinate. A pneumatized middle turbinate (i.e.,
concha bullosa) is a common anatomic variation that occurs
in approximately 25% of the population. If the concha
bullosa is extremely large and associated with septal devia­
tions, it may contribute to nasal obstruction.
Physiologic Causes of Nasal Obstruction
Both benign and malignant neoplasms may occur anywhere
in the sinonasal tissues and should always be ruled out.
Inflammation of the nasal mucosa is a common multifacto­
rial process that results in edema and congestion of the nasal
soft tissues. For example, nasal polyposis is thought to be
triggered by a combination of factors (e.g., inflammation,
asthma, allergy). If they are large enough, polyps may
obstruct the nasal airway and the sinus ostium and result
in blockages and sinus infections. Allergies are a common
cause of sinoatrial inflammatory disease leading to turbinate
hypertrophy, which further exacerbates ongoing complaints
of nasal obstruction. Hormonal changes associated with
pregnancy, menopause, and hypothyroidism are also known
to have effects on the nasal mucosa and vasculature, with
resulting obstructive nasal breathing. In an attempt to
improve the symptoms of nasal obstruction, the overuse of
prescription and over-the-counter medications (e.g., drugs
from the imidazoline class, sympathomimetic amines) can
also cause significant problems. The “rebound nasal conges­
tion” phenomenon is well known and typically occurs with
chronic use.
Evaluation of the Nasal Airway
Among the pertinent findings that require clarification from
the patient are a history of nasal obstruction, sinusitis, or
inflammatory sinonasal disease and the presence of a limited
sense of smell or taste. A history of environmental or sea­
sonal allergies, nasal surgery, or trauma should be correlated
with physical findings.
With regard to the nasal airway, a complete external and
internal nasal examination should be undertaken. Direct
somewhat artificially divided into regions that include
the external nasal valve, the internal nasal valve, the tur­
binated cavity, and the posterior nasal (choanae) aperture.
The nasal valves comprise the major areas of resistance
in the nasal cavity. The internal nasal valve is generally
the “flow-limiting” segment of the nasal airway. According
to Poiseuille’s law, even small changes in the size of the
internal nasal valve can have exponential effects on the
airflow resistance. The size of the nasal airway is also
governed by the physiologic alternating pattern of conges­
tion and decongestion called the nasal cycle. This pattern
of vascular engorgement of the capillaries involves the
nasal lining in general and the vessels of the inferior
turbinates specifically.
Anatomic Locations and Causes of
Nasal Obstruction
The etiology of nasal airway obstruction is often multifacto­
rial and may include both anatomic aspects and physiologic
effects of the nasal and sinus mucosa.
Internal Nasal Valve
The internal nasal valve is typically the site of maximum
resistance and frequently the cause of subjective complaints
about obstructive nasal breathing. Obstruction that worsens
during inspiration (i.e., dynamic obstruction) is usually
caused by a weakening of the cartilaginous vault (i.e., the
collapse of the ULCs and the LLCs) that is unable to with­
stand the inspiratory pressures. Static obstruction of the
internal nasal valve occurs as a result of encroachment by
the boundary structures of the valve. This is often the result
of enlargement or hypertrophy of the inferior turbinates;
deflection (i.e., thickening) of the nasal septum; medially
located lateral nasal walls (i.e., maxillary constriction); an
elevated nasal floor (i.e., long face growth pattern); or thick­
ened and scarred nasal mucosa (i.e., as a result of allergies).
During rhinoplasty, internal nasal valve collapse is pre­
vented by avoiding the resection of the ULCs or the over­
resection of the LLCs. When either of these conditions is
the cause, secondary reconstruction via the placement of
spreader grafts is generally helpful.
External Nasal Valve
Common causes of static narrowing of the external nasal
valve include alar malpositioning or scarring of the skin or
nasal vestibule, caudal septal deflections, and nasal tip ptosis
(see Fig. 38-4).77 These may be seen after overzealous cleft
lip nasal procedures. Dynamic collapse of the external nasal
valve may be the result of weakened or deficient LLCs and
nasal ala. During rhinoplasty, external nasal valve collapse
is generally prevented by avoiding overaggressive resection
of the LLCs and by preserving the soft-tissue support of the
mobile alar walls. Secondary reconstruction to correct this

1622 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
Surgical Approach to Open
the Nasal Airway
The clarification of any anatomic structures of the internal
nasal valve that are causing blockage should be identified.
This may include the following: 1) the septum 2) the
anterior head of the inferior turbinates 3) the bony nasal
floor 4) the lateral nasal walls (i.e., the tight inlet)
5) the ULCs; and 6) the nasal mucosal lining (i.e., the
synechiae).
The identification of any anatomic components that
interfere with the external nasal valve is also clarified and
the areas surgically corrected, if feasible. This may require
reconstruction of the LLCs, via elevation of the nasal tip or
through the release of scar contracture of the nasal skin or
the vestibular mucosa.
The opening of the posterior nasal (choanae) aperture may
require the following: 1) the reduction of the adenoid pad;
2) the recontouring of the posterior floor of the nose and
the lateral nasal walls; 3) the resection of the vomer and the
perpendicular plate of the ethmoid; or 4) the horizontal
(sagittal) advancement of the maxilla (i.e., Le Fort I
osteotomy).
The partial removal (by direct excision, submucosal
resection, or cauterization) of hypertrophied middle turbi­
nates can, at times, significantly improve a patient’s nasal
airflow. If the middle turbinate is pneumatized (concha
bullosa) and a cause of nasal obstruction found, it should
be reduced by whatever means necessary.
Outcome Assessment of Surgery
to Improve Nasal Breathing
Attempts to objectively measure alterations in nasal function
after medical or surgical interventions that are carried out
for the purpose of improving nasal breathing have proven
to be difficult.31,113-115,118,128,152,171,185,187,189,190,195,215,222,223,226,243
Through acoustic rhinometry and rhinomanometry, at­
tempts at objective postoperative assessments of the nasal
airway have been carried out. Consistent findings with the
use of these measurement techniques are mixed at best. A
spectrum of studies by different investigators has demon­
strated conflicting results with similar research designs.
Studies by Lindemann and colleagues confirm that naso­
physiologic functions (e.g., the heating and humidifying of
inspired air) were improved after successful septoplasty and
appropriate inferior turbinate reductions.126 This positive
effect is believed to be derived from increased volumes and
the direction of physiologic airflow to key places within the
nasal passage, which increases mucosal contact with the nasal
airstream. The improved flow dynamics may also improve
the filtration of particulate matter more effectively.
In addition to objective instrumentation measures of
nasal breathing, researchers have sought a standardized
assessment of results from the patient’s perspective. These
and speculum examination of the anterior septum, the head
of the inferior turbinates, and the external nasal valves
should proceed. Nasoendoscopy allows for a more thorough
examination of the nasal airway and should be undertaken
when indicated to fully visualize the septum, the turbinates,
the meatus, the nasal mucosa, the nasal valves, the posterior
aperture, and other nasal structures. Decongestants may
also be used to further assess the airway. For cases in which
radiologic studies are needed, a coronal sinus computed
tomography scan is useful.
The functional aspects of the nose that a rhinoplasty
surgeon may typically alter include the nasal valve areas and
the turbinated cavity. When completing a septoplasty pro­
cedure with the removal of posterior bony septal deflections,
it is important to avoid injury to the cribriform plate,
because cerebrospinal fluid rhinorrhea would result. As pre­
viously stated, when performing a septoplasty that includes
the removal of deflected portions of quadrangular cartilage,
it is important to maintain adequate caudal and dorsal
struts for support of the nasal dorsum and tip.
The internal nasal valve is defined by both the valve angle
(i.e., the relationship of the ULCs to the septum), which is
typically 10 to 15 degrees, and the valve circumference.
Respiratory obstruction can occur when the valve area is
decreased by septal deviation, mucosal disease (i.e., engorge­
ment of the inferior turbinates), scarring, and traumatic,
neoplastic, congenital, or surgical deformities (e.g., narrow
pyriform rim width, elevated nasal floor).
An example of effective reconstruction occurs when the
internal nasal valves are collapsed after the surgical overre­
section of the ULCs, and spreader grafts (placed between the
nasal septum and the ULC) are used to widen the internal
valve angles. This will decrease nasal airway resistance and
improve respiration.
Nasal airway resistance is greatly affected by the inferior
turbinates, which periodically swell and decrease the inter­
nal valve area. Inferior turbinate hypertrophy may be physi­
ologic or pathologic. For the majority of the population, a
normal “nasal cycle” of the congestion and decongestion of
the turbinates and the nasal mucosa is ongoing, with recip­
rocal changes on the two sides. The total nasal airway
resistance in the healthy nose is remarkably constant, with
changes occurring every 2 to 4 hours in the turbinates and
the mucosal lining. When the inferior turbinates are mark­
edly enlarged and when the process is not reversible with
the use of vasoconstrictors and anti-inflammatory agents,
then surgical reduction of the turbinate hypertrophy (often
in combination with septoplasty) is the treatment of choice
and will generally relieve the symptoms. Doing so will often
open the internal nasal valve and the whole turbinated
cavity. A variety of surgical techniques are used to accom­
plish the goal of inferior turbinate reduction (e.g., partial
excision, electrocautery, submucosal resection, radiofre­
quency ablation, microdebridement).157,173 The overaggres­
sive resection of the inferior turbinates has, on occasion,
resulted in rhinitis sicca or “dry nose.”

1623
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
During the initial consultation, consideration is given
to the following: 1) the patient’s stated objectives 2) any
patient-specific anatomic limitations 3) the surgeon’s con­
cepts of the patient’s facial proportions (i.e., the presence
of a dentofacial deformity or isolated microgenia) and 4)
the patient’s nasal aesthetic unit (i.e., whether to reduce,
augment, or sculpt one or more of the key regions of the
nose).
It is also essential for the surgeon to understand the
patient’s psychological reasons for requesting surgery on
the nose and then to assess that patient’s emotional
maturity and stability. Constantian has outlined specific
red flags for the surgeon to be concerned about, includ­
ing the patient who is seeking surgery for specific external
gain (e.g., an individual who expects that nasal changes
will improve his or her career); the narcissistic male;
and the perfectionist.41 He also warns against operating
on an individual whom “you just don’t like” (i.e., with
whom you are not able to effectively communicate).
Picavet and colleagues documented a high prevalence of
body dysmorphic disorder symptoms among patients
who are seeking rhinoplasty (see Chapter 7).176 Individu­
als who request revision rhinoplasty and those with a
psychiatric history are particularly at risk for ongoing
dissatisfaction.
When the surgeon is satisfied that the patient has a
problem or concern that can be physically and visually
improved and that the patient is realistic with regard to his
or her expectations and without notable psychopathology,
further details of the proposed surgery can be outlined and
frankly discussed.
Definitive Rhinoplasty Planning
A review of the patient’s history, physical findings, facial
photographs, and, if indicated, sinus computed tomogra­
phy scan or other facial radiographs (e.g., lateral cephalo­
metric, Panorex) is generally followed by a second
consultation visit to finalize the operative plan. The surgical
objectives are clarified after 1) hearing the patient’s requests
2) analyzing the overall facial and specific nasal aesthetics
and functional aspects 3) considering patient-specific ana­
tomic limitations 4) discussing all options and 5) consider­
ing the surgeon’s ideal treatment plan.
Basic questions for the surgeon to consider include the
following:
• Are there any medical or psychosocial contraindica­
tions to elective nasal surgery?
• What are the functional nasal findings? Do they cor­
relate with the patient’s symptoms?
• Are there associated maxillomandibular dispropor­
tions that affect the individual’s facial aesthetics?
• What aspects of the patient’s nose would the surgeon
like to change?
efforts have taken the form of symptom-based question­
naires. The most rigorously developed disease-specific
measure for nasal obstruction was created by the Nasal
Obstruction Symptom Evaluation (NOSE) study investiga­
tors.233,234 The NOSE Scale generates an integral patient-
specific score out of a possible 100 points and thus facilitates
quantitative comparisons within subjects at different time
points or among groups of subjects who are undergoing
different treatments. The NOSE Scale is now considered the
reference standard for the assessment of alterations in nasal
breathing. Considering the extent of nasal obstructive
treatment carried out in the United States alone, which is
estimated to cost $5 billion per year, emphasis on standard­
ization and measurable results seems to be indicated (see
Chapter 10).
Initial Rhinoplasty Consultation
During the initial consultation, it is important for the
patient to confirm any functional nasal difficulties and
also to explain his or her facial aesthetic concerns. The
individual may want a nose that is narrower (i.e., dorsal
width reduction), less irregular (i.e., dorsal hump removal)
and with a more attractive nasal tip (i.e., improved defi­
nition and projection). A frequently stated objective—or
at least a personal desire that is expressed when an
in-depth history is taken—is to have the ability to breathe
better.
Aesthetic concerns often relate to an enlarged osseocarti­
lagenous vault (e.g., dorsal hump, increased mid-dorsal
width) or if a previous rhinoplasty was carried an over
reduced dorsum and a narrow width. The lobule and tip may
be drooped and bulbous, with a lack of definition, or they
may be overreduced, pinched, and turned up as a result of
a previous surgery. The nasal base may be overly wide or
constricted, primarily as a reflection of the underlying skel­
etal or cartilaginous structures.
Difficulty with breathing through the nose is often
chronic, with a longstanding mouth-breathing habit. If
this is the case, the facial morphology may be that of a
long face growth pattern (i.e., vertical maxillary excess typi­
cally with an anterior open-bite Class II malocclusion;
see Chapter 21). The obstructive nasal breathing is often
made worse in the presence of chronic allergies or with
ambient changes in humidity. Examination of the internal
nose may reveal septal deviations or per­forations, external
valve stenosis, internal nasal valve obstructions, posterior
nasal aperture stenosis, turbinate enlargement, or an irri­
tated nasal mucosal lining. Con­sideration should also be
given to the adenoids and tonsils, which may be enlarged
and obstructive. The internal nasal valves, the turbinated
cavities, the external nasal valves, and the posterior nasal
aperture may be obstructed by any one of a number of
anatomic structures (e.g., turbinates, septum, ULC, LLC,
nasal skeletal walls or floor, soft tissues).

1624 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
1. Securing a cartilage (strut) graft to the caudal
septum to help control or maintain the tip
position
2. Suturing the middle crura to each other and then over
the top of the secured caudal (strut) graft to improve
tip projection and shape
3. Controlling the columellar–lobular angle by altering
the axis of the caudal strut graft
4. Suturing additional nasal tip grafts in place over the
top of the LLCs
5. Accurately placing and securing spreader grafts to
correct nasal valve collapse, to straighten the nose,
and to correct saddle deformities
6. Placing and suturing cartilage grafts to reinforce,
change the shape of, or replace missing segments of
the lateral crura
7. Placing and securing onlay grafts (over the bony or
cartilaginous vault) to reconstruct or augment the
dorsum of the nose
8. Visualizing and then reducing the bony and cartilagi­
nous nasal dorsum
9. Visualizing and then reducing or modifying the
radix, including the placing and securing of
grafts
An often-stated drawback of the open approach relates
to tip swelling. The amount and duration of tip swelling
after open rhinoplasty is generally greater than that seen
with the closed approach. Therefore, it is reasonable to
consider a closed rhinoplasty for those patients who may
need only nasal osteotomies, dorsal hump reduction, or
minimal tip alterations.
Complications Associated
with Rhinoplasty
Fortunately, in the hands of an experienced nasal surgeon,
the vast majority of well-informed patients undergo an
uneventful operative and postoperative course and are
pleased with their initial and long-term function and
their aesthetic results. However, as with any surgical pro­
cedure, perioperative problems may occur (e.g., infection,
bleeding, airway compromise) in addition to problems
that are specific to rhinoplasty (e.g., septal perforation,
persistent nasal obstruction, suboptimal cosmetic results).*
These potential problems must be considered and openly
discussed in advance to limit patient dissatisfaction.
Infection
Infection occurs in approximately 1% of patients who are
undergoing elective rhinoplasty.35,37,54,83,109,129,166 The routine
use of prophylactic antibiotics that are started just before
• Given the quality of the patient’s overlying nasal
skin and the underlying skeletal and cartilagi­
nous structures, what are the reasonable surgical
options?
• Do the patient’s requests match the surgeon’s thoughts
when taking into account any biologic limitations of
the tissues?
• Does the surgeon think that he or she can interact
effectively with the patient should a complication or
suboptimal result occur?
By the end of the second consultation visit, a definitive
operative plan should be clear in the surgeon’s mind and
accurately conveyed to the patient. The patient and the
surgeon should be comfortable with any compromises that
are agreed to and with the expected outcomes and the
potential risks. If a comfort level is not reached, it is best
not to proceed.
Most primary rhinoplasties require a combination of
the reduction and augmentation of various aspects of the
nose. This will often include the following: 1) the reduc­
tion of the bony and cartilaginous dorsum 2) the reduction
of the cephalic portions of the LLCs (lateral crura) 3)
middle crural suturing 4) cartilage (caudal strut) graft
augmentation and 5) nasal osteotomies with in-fracturing
(to narrow the width, to accomplish the closure of an
open roof, or to straighten a crooked dorsum). When
indicated, the removal of any septal deviations (i.e., car­
tilage and bone) and the reduction of the inferior turbinates
will simultaneously diminish airway resistance and improve
nasal breathing.
Open versus Closed Approach
to the Nose
In the hands of a limited number of experienced nasal
surgeons, the closed (endonasal) approach to gain exposure
of the nose allows for the predictable management of
the patient’s needs.91,198,202,217-221 In this author’s clinical
practice, the open (columella-splitting and bilateral mar­
ginal incisions) approach provides the preferred direct
exposure of the nasal structures in most patients. After
elevation of the nasal soft-tissue envelope via an open
approach, direct inspection of the osseocartilaginous
framework and tip should confirm the preoperative clini­
cal diagnosis. This direct exposure facilitates technical
maneuvers such as the following: 1) bony and cartilagi­
nous reduction 2) excision and suturing of the LLCs
3) the placement and stabilization of grafts and 4) septal
modification. By understanding normal nasal physiology
and what the osseocartilaginous framework and nasal tip
should look like and then seeing the anatomy under
direct vision, the intended results are achieved more often
than not.
As pointed out by many authors, the open approach has
advantages that include the following3,4,33,50,72-76,84,91,101,112:
*References 10, 13, 41, 52, 102, 118, 130, 133, 148, 168, 188, 238

1625
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
Dry Nose Syndrome
Atrophic rhinitis is uncommon, but it may be seen after
turbinate reduction.59,149 There may be gradual and progres­
sive atrophy of the nasal mucosa with a lack of moistening
secretions that leads to crusting that accumulates. The crusts
harbor bacteria; when this is associated with poor aeration
and drainage, an unpleasant odor (ozena) may result.
Burn Injuries
The occurrence of operating room fires and airway burns is
rare. Nevertheless, there is a risk of ignition in the operating
room with any application of electrocautery or lasers. This
risk is increased in the setting of nasal-cannula or face-tent
supplemental oxygen. It can also be a problem in the intu­
bated patient in whom there is an “air leak.” Facial burns,
intraoral and intra-airway burns, and even patient demise
have all been reported. Although burn injuries in the oper­
ating room are rare, they represent approximately 20% of
all malpractice claims for cases performed under monitored
anesthesia care, and 95% of these cases involve surgery of
the head and neck.196
Patient Dissatisfaction
Studies indicate that, on average, 15% of patients who have
undergone cosmetic rhinoplasty procedure will express at
least some dissatisfaction with the result.* In general, rhino­
plasty patients differ from facial aging patients with regard
to their psychological complexity. Most individuals who are
seeking rhinoplasty have always been dissatisfied with some
aspect of their facial appearance, which they attribute to
nasal dysmorphology. Alternatively (at least in theory), the
adult facial aging patient is seeking rejuvenation to restore a
previous “satisfactory” appearance. The rhinoplasty patient
is more likely motivated by lifelong body-image undercur­
rents that mold his or her perception of the nasal appear­
ance. This will influence his or her expectations for surgery
in a way that different from those of the facial aging patient.
Adamson and colleagues report that patients who request
primary rhinoplasty commonly cite their rationale as
including a “dorsal hump” (50%); a “too large” nose (44%);
a bulbous tip (41%); and an “obstructed nasal airway”
(33%).32 Because half of the patients seeking primary rhi­
noplasty cited a “dorsal hump” as the chief concern, the
achievement of an aesthetically pleasing nasal profile is
essential. This is contingent on a thorough understanding
of the underlying nasal anatomy and a complete facial
analysis, which includes the assessment of the true dorsal
hump as well as looking for the presence of a deep radix
or an underprojected tip. Care should also be taken to
establish a pleasing contour and transition between the
dorsum and the tip (i.e., the supratip break) and to
prevent iatrogenic deformities (i.e., supratip “Polly beak”
surgery and continued postoperatively (at least until all
internal nasal packs have been removed) is recommended.
If infection occurs, appropriate drainage and culturing of
the fluid is carried out. The antibiotic regiment is altered,
as indicated.
Bleeding
Intraoperatively, bleeding is generally more of an annoy­
ance than a problem. Minor postoperative nosebleeds are
managed with elevation of the head, compression, packing,
and time. When postoperative bleeding persists, a deter­
mination is made with regard to whether the hemorrhage
is anterior or posterior, and appropriate packing of the
nose is carried out. Cauterization of the bleeding points
and rechecking of the hemoglobin level, the clotting
studies, and the platelet function may be indicated.
Ongoing hemorrhage that requires blood transfusion or
the proximal ligation of branches of the external carotid
artery is exceedingly rare. Bleeding is more likely to follow
turbinate reduction than any other septorhinoplasty
maneuver.
Airway Obstruction
The assessment of nasal breathing and of the entire
upper airway should be carried out and the findings
discussed with the patient and the family before rhinoplasty
occurs.16,18,20,43,94,111,150,151,194,214 The importance of doing
this has been confirmed by Thomson240 and Hellings,104
who independently reported the presence of persistent
nasal airway obstruction as a frequent complaint that
leads to need for revision rhinoplasty. The nasal airway
may also be compromised as a result of rhinoplasty.
Synechiae may form between the septum, the lateral nasal
wall, or the turbinates and require release in the office or,
occasionally, in the operating room. Residual septum deflec­
tions may require removal. Further turbinate reduction may
also be advantageous. The clinician should not ignore the
nasal airway if a favorable result and a satisfied patient
are desired.
Septal Perforation
Full-thickness holes (perforations) in the septum after a
septoplasty are thought to occur in less than 5% of patients.
The occurrence of septal perforations is dependent on the
quality of the patient’s nasal mucosal lining, the surgical
technique, and the complexity of the deformity. Long-term
problems associated with perforations range from annoy­
ance (e.g., crusting, occasional bleeding, whistling as a result
of turbulence on inspiration) to external deformities (e.g.,
saddle-nose depression as a result of septal collapse) with
nasal obstruction; see the discussion later in this chapter.
The repair of septal perforations is extremely difficult. Cur­
rently, a reliable routine method for the correction of septal
perforations has yet to be realized.
*References 41, 52, 67, 68, 102, 116, 176, 191, 245

1626 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
of the operation to achieve patient satisfaction. These
authors recommend allowing 6 to 12 months of healing
before agreeing to further nasal modifications. In most
reported series, only 50% of patients who undergo revision
rhinoplasty will move into the satisfied category.41
Primary Septorhinoplasty: Step-by-Step
Approach (Figs. 38-5 through 38-9)
Preparation and Draping
• Complete the orotracheal (RAE) intubation, and tape
the tube to the skin of the chin.
• Apply the ophthalmic ointment and place the corneal
shields for eye protection.
• If the patient has long hair, tie it in a ponytail.
deformity). Other surgical causes of patient dissatisfaction
include cartilage graft warping, resorption, and palpability.
Another frequent reason for a primary rhinoplasty consult
is a nose that is “too large” (44%). The achievement of
a good nasal profile will therefore frequently depend not
only on the anatomy of various nasal parts but also on
the interplay of the other facial parts (i.e., the maxilla,
the mandible, and the chin region). The discerning clini­
cian must separate out these aspects (i.e., dentofacial dis­
harmony versus nasal disharmony) if patient satisfaction
and a favorable outcome are to be achieved (see Chapters
19 through 23 and Fig. 38-2).
Rohrich and colleagues pointed out the importance of
understanding the psyche of the male rhinoplasty patient.200
These patients are more likely to present with nonspecific
complaints, to be more demanding of the end result, and
to be less attentive during the consultation visit. The clini­
cian must painstakingly set clear and realistic expectations
•  Figure 38-5  Incisions that are used for an open technique rhinoplasty are demonstrated. A, Stair-
step columella (skin) and bilateral (intranasal) rim incisions are illustrated in two views. B, Worm’s-eye
views of the nose before and C, 4 weeks after an open-technique secondary rhinoplasty. Four weeks
after surgery, the skin incision is immature (i.e., red and raised), and the soft tissues remain swollen.
Stair-step
columella
skin incision
Nasal rim incision
B
A
C
Pre surgery
4 weeks after surgery
Text continued on p. 1632

Removal of dorsal cartilage “hump”
under direct vision
Cartilage
vault
D
E
C
Knife used to reduce cephalic excess of
lower lateral cartilages
Scissors used to separate lower lateral cartilages
and expose caudal aspect of septum
F
Removal of dorsal bony “hump”
under direct vision
B
A
•  Figure 38-6  A, Exposure of the deep structures, including the lower lateral cartilages (LLCs), as viewed through an open approach after
the elevation of the soft-tissue envelope of the nose. B, A rasp is used to reduce the bony dorsum of the nose. C, The upper lateral cartilages
and the dorsal aspect of the quadrangular cartilage are also directly visualized through the open approach. D, Dorsal bone reduction (as
described in B) is followed by the sharp knife excision of the cartilaginous dorsal hump. The illustration shows the Aufricht retractor in place,
with a knife (no. 15 blade) used to excise excess dorsal septal cartilage. E, Measurement of the LLCs is carried out with a caliper. In general,
a 6-mm caudal rim of LLC is maintained. The cephalic excess is incised with a knife (no. 15 blade) and then removed with a Stevens scissors.
F, An illustration that shows the scissors dissection to separate the LLCs and to expose the caudal aspect of the quadrangular cartilage.
Continued

1628 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
G
H
I
Anterior septum exposed
1. Knife to expose caudal aspect of
quadrangular cartilage
2. Cottle elevator to dissect septum
3. Speculum to expose septum
1.
2.
3.
Knife to reduce caudal aspect of septal
cartilage to reduce columella show
G
G, Two intraoperative views show the LLCs separated to expose the caudal aspect of septum. H, An illustration that
shows the following: 1) a knife (no. 15 blade) that is used to remove the final layer of perichondrium from the caudal edge of the septal cartilage
before subperichondrial dissection; 2) a Cottle elevator that is used for exposure of the quadrangular cartilage and bony septum (i.e., vomer
and ethmoid); and 3) a speculum that is inserted with a blade placed on each side of the septum. I, If there is excess columella show, then
the caudal aspect of the quadrangular cartilage is reduced (excised) to improve aesthetics. The illustration demonstrates the planned caudal
reduction.
• Figure 38-6, cont’d

1629
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
1. Knife to initiate incision of septal cartilage
2. Swivel knife to complete the excision of septal cartilage
1.
J
K
L
2.
Removal of portion
of ethmoid bone
Reduction of dorsal
cartilage “hump”
Removal of portion of
quadrangular cartilage
Reduction of caudal
cartilage excess
Caudal
strut graft
Removal of
portion of vomer
Caudal strut graft sutured in place, lower lateral cartilages
are then sutured together and over the top of the graft
J, An illustration showing an incision through the quadran­
gular cartilage to initiate submucous resection. It is important to maintain an unin­
jured and adequate dorsal and caudal strut of cartilage to structurally support the
nose. (1) A knife (no. 15 blade) is used to initiate the incision in the septal cartilage.
(2) A swivel knife will then be introduced to complete the actual submucous resec­
tion of the septal cartilage. The cartilage excision corresponds with needed graft
for augmentation or with the removal of septum that is interfering with breathing.
K, An illustration of the extent of maximum septum (bone and cartilage) that may
be removed to improve the airway. This includes much of the quadrangular cartilage
and bone (i.e., vomer and perpendicular plate of ethmoid). The removed quadran­
gular cartilage available graft is shown. The yellow-colored aspect of the removed
quadrangular cartilage indicates the planned caudal strut graft. L, An illustration of
the crafted cartilage (strut) graft sutured to the caudal aspect of the remaining septal
cartilage. The LLCs are then sutured together and over the top of the strut graft.
This type of suture has been called a medial crural fixation suture. The sutures are
placed to fix one medial crus to the other, thereby unifying the medial crura beneath
the domes and then above the strut graft. This combination of techniques allows
for the preferred nasal tip projection, shape, and orientation.
Continued
• Figure 38-6, cont’d

Removed septal cartilage
Inferior excision
LLC graft
Spreader graft
Superior excision
Caudal “strut” graft
M
N
Guarded ostetomy used to complete nasal
osteotomy through intranasal pyriform rim incision
M, Intraoperative views of removed septal cartilage, which can be used as graft material to reconstruct the nose.
The cartilage can be crafted as a caudal strut, spreader grafts, LLC augmentation grafts, or tip onlay grafts. N, Nasal osteotomies are
completed by first identifying the piriform rim intranasally with a speculum; the speculum blades straddle the bony rim. An incision is com­
pleted through the nasal mucosa on the side of the anterior maxilla to expose the piriform rim. The speculum is removed, and a Joseph
elevator is inserted. Subperiosteal tunneling in the location of the proposed osteotomy is carried out. A curved and guarded osteotome is
introduced through the intranasal incision, and the osteotomy is completed. The osteotomy is performed through the pyriform rim (maxilla),
lateral to the nasomaxillary suture, and then up toward the nasofrontal suture on each side. The nasal bones are then in-fractured with finger
pressure and positioned as desired.
• Figure 38-6, cont’d

1631
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
•  Figure 38-7  Profile views of the nose highlighting a young woman before and after rhinoplasty with the use of the techniques described
in the legend for Figs. 38-5 and 38-6. An illustration highlights the combination of dorsal reduction (bone and cartilage) and nasal tip altera­
tion (i.e., caudal strut cartilage grafting and lower lateral cartilage reshaping) typically carried out to achieve the objectives.
©Elsevier Inc.
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•  Figure 38-8  A woman in her 20s underwent a septorhinoplasty procedure as described previously. She is shown at
1 week and 4 weeks after surgery. At her 1-week visit, the custom-formed Aquaplast splint and skin sutures were
removed.
Orth
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Custom-molded splint
1 week after surgery
4 weeks after surgery

1632 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 38-9  Three frequent maneuvers that are used to alter the cartilaginous vault and nasal tip are highlighted. For each of these
three techniques, an illustration and a patient example are shown. Other rhinoplasty maneuvers were also simultaneously carried out on
each patient. A, A frequent surgical technique to improve the position of the nasal tip is the harvesting of the septal cartilage, which is
then crafted as a caudal strut. The caudal strut is sutured to the native septum and vectored to improve tip position and for maintenance.
The lower lateral cartilages are then sutured together and over the top of the graft.
©Elsevier Inc.
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A
• Use Betadine solution (do not use soap, alcohol, Hibi­
clens and so on) to prepare the scalp, forehead, external
ears, face, and neck.
• Complete draping and leave the forehead, external ears,
face, and neck exposed in the operative field.
Surgical Marking
• Locate and use a surgical pen to mark the columella
(stair-step) incision and the bilateral rim (marginal)
intranasal incisions before prepping and draping.
Local Anesthesia
• Inject Xylocaine (1% with 1 : 100,000 epinephrine)
within the soft-tissue envelope of nose as usual for
rhinoplasty.
• Inject Xylocaine (1% with 1 : 100,000 epinephrine) on
each side of the septum, deep to the mucosa and super­
ficial to the cartilage.
• Place either cocaine-soaked (5 mL of 4% solution) or
Afrin-soaked pledgets in each nostril cavity.
Skin Incisions and Flap Elevation
• Incise the columella skin and the intranasal rims with a
knife (#15 blade).
• Elevate the nasal soft-tissue envelope with Stevens scis­
sors as required for an open rhinoplasty procedure.
• Elevate the overlying cutaneous soft-tissue envelope
up the columella, superficial to the LLC and ULC, sub­
periosteal over the nasal bones (with a Joseph elevator)
to the radix, and lateral toward the maxillary process on
each side.
• Clean the subcutaneous tissue off of the superficial
surface of each LLC with the use of Stevens scissors.
Dorsal Reduction
• If a dorsal bony hump requires reduction, it is con­
servatively completed with coarse and fine diamond
rasps.
• If a dorsal cartilaginous hump requires reduction, it is
conservatively incised with a knife (no. 15 blade) under
direct visualization.
Lower Lateral Cartilage Modification
• The LLCs are separated from their midline soft-tissue
connections with the use of Stevens scissors. Dissection
continues down to the caudal aspect of the septum.
• The LLCs are marked with a caliper and trimmed of
cephalic excess. In general, at least 6 mm of caudal LLC
is retained. The redundant cephalic portions are incised
with a knife (no. 15 blade) and removed with Stevens
scissors.
Exposure and Resection of
Portions of Septum
• Identify the anterior aspect of the caudal septal cartilage.
(Dissection to the septum has already been completed
with Stevens scissors.) A knife (no. 15 blade) is used to
remove the final layer of perichondrium from the caudal

1633
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
Spreader grafts from septal cartilage are
sutured in place to straighten
a “crooked” cartilagenous vault
C
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B, Spreader grafts may be crafted from harvested septal cartilage. They are placed on each side of the dorsal aspect of
the quadrangular cartilage and sutured together. Spreader grafts can be helpful to open the internal nasal valves and to straighten a crooked
cartilaginous vault. C, Altering the caudal aspect of the quadrangular cartilage to achieve improved aesthetics in the columella region is often a
necessary aspect of rhinoplasty. When there is excessive “columella show” seen in profile, the excision of the redundant caudal septal cartilage
will be helpful. A patient example and an illustration are shown. In other circumstances, when there is inadequate “columella show” (i.e., retracted
columella), augmenting the caudal aspect of the septum with a cartilage graft will be a useful approach (see Chapter 29).
edge of the septal cartilage before dissection. Next, use a
sharp Cottle elevator to achieve submucosal exposure on
each side of the septal cartilage. Extend the submucosal
dissection inferiorly to the maxillary ridge and posterior
to the vomer. Continue the subperiosteal dissection as
required for the exposure and resection of the deviated
bony septum (i.e., to the vomer and the perpendicular
plate of the ethmoid).
• If the caudal aspect of the quadrangular cartilage requires
reduction (i.e., to limit columella show), it is sharply
incised with a knife (no. 15 blade), and the redundant
portion is removed under direct visualization.
• Submucosal resection of the cartilaginous septum is initi­
ated with the use of a knife (no. 15 blade) to control the
caudal and dorsal aspects of the excision. The knife inci­
sions are located to maintain approximately 10 mm of
caudal and 10 mm of dorsal septal cartilage support for
the nose. This is followed by the insertion of a swivel
knife.
• The swivel knife is used to excise the deviated, buckled,
or thickened septal cartilage (i.e., submucosal resection)
and to harvest a graft, as indicated.
• A rongeur (either a double action or a Takahashi) is used
to remove any buckled, deviated, or thickened portions
• Figure 38-9, cont’d

1634 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
of the vomer and the perpendicular plate of the ethmoid
that are obstructing nasal airflow (i.e., submucosal
resection).
Reduction of Inferior Turbinates
• If the inferior turbinates are hypertrophic and require
partial reduction, this is accomplished by one of several
methods, including scissors resection of the inferior
aspect of each turbinate; out-fracture; submucosal (intra­
mural) removal; or submucosal cauterization.
Completion of Nasal Osteotomies
• A short nasal speculum is inserted intranasally with
one forceps blade placed on either side of the pyri­
form rim.
• An incision is made with a knife with a no. 15 blade
piercing the nasal mucosa down to the bone along the
piriform rim of the maxilla.
• A Joseph elevator is used to dissect (tunnel) subperioste­
ally up toward the nasofrontal suture where the osteot­
omy is to be completed.
• A curved, guarded osteotome is inserted through the
intranasal incision that saddles the pyriform rim. A
mallet is used to drive the osteotome and to complete
the osteotomy.
• The same procedure is completed on the other side.
• The nasal bones are in-fractured, disimpacted for ade­
quate mobility, and then reoriented in accordance with
aesthetic preference.
Reconstruction of Nasal Tip
• Craft the required grafts (e.g., caudal strut, LLC grafts,
spreader grafts, tip graft) with a knife (no. 15 blade) from
the full piece of harvested septal cartilage
• If a caudal strut graft is required, it is crafted and then
positioned near (abutted to) the caudal aspect of septal
cartilage to achieve improved nasal tip position. It is held
in the preferred location with pinching forceps or a
needle and then sutured to the side of the septal cartilage
with the use of interrupted stitches (5-0 Vicryl).
• The LLCs, having been trimmed of cephalic excess, are
sutured together and then over the caudal strut graft
to form the most superficial aspect of the nasal tip
(5-0 Vicryl). This type of suture has been called a
medial crural fixation suture; it is used to fix one medial
crus to the other, thereby unifying the medial crura
beneath the domes and then above the caudal strut
graft.
• The soft-tissue envelope is redraped and the nose is
inspected to confirm adequate dorsal reduction, proper
tip projection and position, satisfactory columella show,
and straightness of the nose. Further refinements are
made, if needed. (They usually are!)
Wound Closure
• After the completion of the septorhinoplasty procedure,
closure of the wound is accomplished.
• To approximate the columella skin (stair-step incision),
a single buried dermal suture is placed (5-0 Vicryl).
• The columella skin closure is with interrupted suture ties
(6-0 nylon).
• The intranasal rim incisions are closed with interrupted
ties (5-0 chromic).
Placement of Dressing
• Routine dressing is placed as they are after a septorhino­
plasty procedure.
• Flexible splints (Reuter) are generally placed (one on
each side of the septum) and secured together with single
suture tie (3-0 nylon).
• Antibiotic ointment (Bactroban) is generally injected
into each nostril cavity.
• When nasal osteotomies are carried out, nasal packing is
helpful to maintain the preferred nasal bone position.
Packing (folded Telfa) is generally inserted equally into
each nostril cavity.
• Tape is placed over the dorsum of the nose (Steri-Strips)
as it is after rhinoplasty.
• A custom splint (Aquaplast) is molded over the dorsum
of the nose as it is after rhinoplasty.
Images of a series of individuals are shown to demon­
strate the spectrum of presentations and the typical results
achieved with the use of the techniques just described (Figs.
38-10 through 38-18).
Cleft Nasal Deformities
Background
Through the dissection of a stillborn fetus with unilateral
cleft lip and palate (UCLP), McComb documented that
tissue distortions and malpositions are primary factors in
the cleft nasal deformity.37,136 Byrd and colleagues also com­
pleted the dissection of a stillborn fetus with UCLP and
confirmed hypoplasia of the LLC complex in addition to
malpositions.25 They also found an abnormal fixation of the
lateral crus to the periosteum of the pyriform rim.
The primary (unrepaired) cleft nasal malformation in an
individual with UCLP is characterized by features that
include the following: 1) malposition and hypoplasia of the
LLC with fibrous attachment of the lateral crus to the pyri­
form rim 2) interruption of the muscle ring (orbicularis
oris) across the clefted nasal sill with abnormal muscle inser­
tions at the alar base to the cheek and to the lip and
3) soft-tissue clefting through the nasal floor (Figs. 38-19
and 38-20). In the unilateral complete cleft lip nasal
Text continued on p. 1645

1635
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
•  Figure 38-10  A teenage girl arrived
with her parents and requested a rhino­
plasty to remove the “hump” that was
seen in profile. She also has a lifelong
history of difficulty breathing through the
nose. She underwent an open rhinoplasty
that included nasal osteotomies (in-
fracture); dorsal reduction (bone and car­
tilage); nasal tip maneuvers (lower lateral
cartilage modification and septal cartilage
caudal strut grafting); septoplasty; and
inferior turbinate reduction. A, Frontal
views before and after reconstruction.
B, Oblique facial views before and after
reconstruction. C, Profile views before
and after reconstruction.
C
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththththththththththththththththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatathicicicicicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
osnicicicicicicicicicicicicicicicicicicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththththththththththththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C. Pos
os
os
os
os
os
os
os
os
os
os
os
osnicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry; J.C.
C.
C.
C. Pos
os
osnicicicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry; J.C.
C.
C.
C Pos
os
os
osnicicicicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththththththththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C. Pos
os
os
o nicicicicicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O ththththththththththththththththththththththththththththththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C. Pos
os
osnicicicick
A
B

1636 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 38-11  A teenage girl arrived
with her parents and requested a reduction
rhinoplasty. She also had difficulty breath­
ing through the nose. She underwent
an open rhinoplasty that included nasal
osteotomies (in-fracture); dorsal reduction
(bone and cartilage); nasal tip refinement
(reshaping of the lower lateral cartilages
and septal cartilage caudal strut grafting);
septoplasty; and inferior turbinate reduc­
tion. A, Facial views before and after recon­
struction. B, Oblique facial views before
and after reconstruction. C, Profile views
before and after reconstruction.
C
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gnatatatatathicicicicicic Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
osnicicicicicicicicicicicicicicicicicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
osnicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orthththththththththththththththththththththththththththththththththth
r o n
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry; J.C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
osnicicicicicicicicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O ththththththththththththththththththththththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicicicicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C. Pos
os
os
o nicicicicicicicicicicicicicicicicicicicicicicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththththththththththththththththththththththththththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C. Pos
os
os
os
os
os
os
o nicicicicicicicicicicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththththththththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicicicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
o nicicicicicicicicicicicicicicicicick
A
B

1637
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
•  Figure 38-12  A teenage girl arrived
with her parents and requested cosmetic
rhinoplasty and the improvement of her
nasal breathing. She underwent an open
rhinoplasty that included nasal osteoto­
mies (in-fracture); dorsal reduction (bone
and cartilage); tip refinement (reshaping of
the lower lateral cartilages and septal car­
tilage caudal strut grafting); septoplasty;
and inferior turbinate reduction. A, Frontal
views before and after reconstruction.
B, Oblique facial views before and after
reconstruction. C, Profile views before
and after reconstruction.
C
Or
Or
O ththththththth
r ogn
g atathicicicic Su
Su
Su
Su
Su
S rg
r ery
ry; J.C.
C.
C Pos
os
os
os
os
osnicicicici k
Or
Or
Or
Or
Or
O thththththththththththththththththth
r ogn
gn
gn
gn
g atatathicicic Su
Su
Su
Surg
r ery
ry
ry; J.C.
C.
C. Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
osnicicicicicicicicicicicicicicicicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry; J.C.
C.
C.
C. Pos
os
osnicicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicicicicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry; J.C.
C.
C. Pos
os
os
osnicicicicicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O ththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatata hicicicicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
r ; J.C.
C.
C Pos
os
o nicicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O ththththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatata hicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C Pos
os
osnicicicici k
A
B
A
B

1638 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
A
B
•  Figure 38-13  A teenage girl arrived with her parents and requested a “smaller and more attractive” nose. Rhinoplasty
to reduce the dorsum and elevate the tip in combination with genioplasty to improve the profile was recommended. She
underwent osseous genioplasty (vertical lengthening and horizontal advancement) and open rhinoplasty that included
nasal osteotomies (in-fracture); dorsal reduction (bone and cartilage); tip refinement (reshaping of the lower lateral cartilages
and septal cartilage caudal strut grafting); septoplasty; and inferior turbinate reduction. A, Frontal views before and after
reconstruction. B, Oblique facial views before and after reconstruction.

1639
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
C
D
C, Profile views before and after reconstruction. D, Lateral cephalometric radiographs before
and after reconstruction. Note the interpositional bloc hydroxyapatite graft that was used to achieve successful chin
lengthening.
• Figure 38-13, cont’d