Orthognathic Surgery

1641
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
•  Figure 38-15  A woman in her mid
20s requested cosmetic rhinoplasty and
the improvement of her nasal breathing.
She also has a mild long face growth
pattern and prominent ears. She re­
quested that surgery be limited to the
nose. The nasal objectives included the
removal of the dorsal hump, the narrow­
ing of the mid dorsum, and the improved
positioning of the tip. She underwent an
open rhinoplasty that included nasal os­
teotomies (in-fracture); dorsal reduction
(bone and cartilage); tip refinement (re­
shaping of the lower lateral cartilages and
septal cartilage caudal strut grafting); sep­
toplasty; and inferior turbinate reduction.
A, Frontal views before and after recon­
struction. B, Oblique facial views before
and after reconstruction. C, Profile views
before and after reconstruction.
A
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Or
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O thththththththth
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1642 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 38-16  A woman in her early 50s requested cosmetic rhinoplasty and the improvement of her nasal breathing.
She hoped for improved tip projection and the removal of the dorsal hump. She underwent an 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, Oblique facial views
before and after reconstruction. B, Profile views before and after reconstruction.
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
Orth
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r ery; J.C. Posnick
Orth
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u g
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A
B

1643
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
•  Figure 38-17  A woman in her late 40s requested cosmetic rhinoplasty to improve tip projection and to reduce the
dorsal hump. She also requested relief of the hooding of the upper eyelids. She underwent an open rhinoplasty that
included nasal osteotomies (in-fracture); dorsal reduction (bone and cartilage); and tip refinement (reshaping of the lower
lateral cartilages and septal cartilage caudal strut grafting). She also underwent upper blepharoplasty (removal of excess
skin). A, Oblique facial views before and after reconstruction. B, Frontal views before and after reconstruction.
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

1644 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 38-18  A 28-year-old man of
Arabic descent had previously sustained a
fracture of the nasal bones. As a result, he
had difficulty breathing and was displeased
with the aesthetics (i.e., dorsal hump, crooked
nose, drooped nasal tip). He underwent an
open rhinoplasty that included nasal osteoto­
mies (in-fracture); dorsal reduction (bone and
cartilage); nasal tip maneuvers (reshaping of
the lower lateral cartilages and septal cartilage
caudal strut grafting); spreader grafts (septal
cartilage); 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
©Elsevier Inc.
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©Elsevier Inc.
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1645
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
•  Figure 38-19  Demonstration of a typical unilateral cleft lip nasal malformation. A, Worm’s-eye view of a newborn
with unilateral cleft lip and palate (UCLP). B, Illustration showing the typical dysmorphology of the maxillary base,
the caudal septum, and the nasal tip in a newborn with unrepaired unilateral cleft lip and palate.
A
B
malformation, asymmetric anatomic distortions (e.g., dis­
placement of the septum to the non-cleft side) also require
special consideration.225,252 In the bilateral complete cleft lip
nasal malformation, there is minimal asymmetry but short­
ening of the height of the columella is to be expected (see
Figs. 38-31 and 38-32).
Nasal Deformities in the Newborn with
Unilateral Cleft Lip and Palate
(see Figure. 38-19)
• The perpendicular plate of the ethmoid deviates toward
the cleft side.
• The posterior aspect of the quadrangular cartilage devi­
ates toward the cleft side.
• The anterior aspect of the quadrangular cartilage deviates
toward the non-cleft side.
• The anterior nasal spine deviates toward the non-cleft
side.
• The bony pyramid of the nose (nasal bones) deviates
toward the non-cleft side.
• The nasal bones are asymmetric and generally flattened
on the cleft side.
• The ULCs are asymmetric and have a disturbed junction
with the LLCs on the cleft side.
• There is a tendency toward the bifidity of the
nasal tip.
• There is a buckling of the lateral crus of the LLC on the
cleft side.
• There is a downward position of the medial crus of the
LLC on the cleft side.
• There is a deviation of the nasal tip to the cleft side.
• There is a deviation at the nasal base to the non-cleft
side.
• There is a lateral, downward, and posterior displacement
of the alar base on the cleft side.
Basic Nasal Reconstructive Maneuvers
during the Primary Unilateral Lip Repair
(Figures. 38-20 and 38-21)
• Along the lateral aspect of the nose, the nasal soft tissues
(including the inferior turbinate) are released from the
piriform rim and the lateral nasal wall with the use of an
elevator (Fig. 38-21, A).
• Next, the buckled and flattened lateral crus of the LLC
is released from the overlying nasal soft tissues with the
use of Stevens scissors (Fig. 38-21, B).
• The elevated lateral nasal flap (including the inferior
turbinate) will be advanced medially, superiorly, and
anteriorly to facilitate nasal sill and floor reconstruction
(Fig. 38-20, D).
• Along the medial aspect of the nose, the nasal soft tissues
(including the medial crus of the LLC) is released from
the anterior nasal spine and septal cartilage with the use of
an elevator and Stevens scissors (Fig. 38-21, C ). The ele­
vated medial nasal flap will be advanced laterally to facili­
tate nasal sill and floor reconstruction (Fig. 38-20, D).
• The release of the orbicularis oris muscle from its abnor­
mal soft-tissue and bone attachments is accomplished
with the use of Stevens scissors. Reconstruction of the
orbicularis oris muscle with interrupted sutures achieves
continuity across the lip (Fig. 38-20, D).
• Recurrent buckling of the lateral crus of the LLC early
after surgery is limited by the placement of an intranasal
stint (i.e., packing). Sutures through the nasal soft tissues
and LLC may also be used to elevate and maintain the
shape of the rim (Fig. 38-21, D).
Three typical patients with UCLP that have been treated
with the techniques described are shown after primary
repair (Figs. 38-22 through 38-24). Maneuvers that are
Text continued on p. 1650

1646 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 38-20  A, Illustration of the typical facial malformations and distortions in a newborn with unilateral cleft lip and palate.
A

B
C
D
E
F
B, Illustration of the modified “Millard” rotation and advanced cutaneous flaps used by this author for primary lip reconstruction and the
basic nasal maneuvers that are simultaneously carried out. Incision locations for the lip rotation flap (greater segment) and the lip advancement flap (lesser segment)
are outlined. Incision locations for the medial and lateral nasal flaps are also shown. C, The incisions are made and the flaps are elevated. Redundant tissue is
excised, and the dissection of each lip flap from the underlying bone and cartilage is completed. The three tissue layers (i.e., the skin, the orbicularis oris muscle,
and the underlying oral mucosa) are further separated from each other. D, The orbicularis oris muscle, having been released from its abnormal bony and soft-tissue
attachments, is sutured across the midline to the base of the columella. Before this is done, the medial and lateral nasal flaps will have been elevated (see Fig.
38-21). After the orbicularis oris muscle has been repaired with sutures, the anterior aspect of the nasal floor is reconstructed with the use of the medial and lateral
nasal flaps. E, The cutaneous lip rotation and advancement flaps are then approximated without tension over the repaired muscle for wound closure. The corner
of the advancement lip flap fills the void at the base of the columella and is secured with suture. Precise approximation of anatomic landmarks with fine sutures
is then undertaken to align the vermilion–mucosa junction and the vermilion–cutaneous junction. The philtral column and the nasal sill are also sutured. F, The
underlying oral mucosa is reconstructed and sutured to establish a functional vestibule. Note: Alveolar clefting and oronasal fistula remains.
• Figure 38-20, cont’d

1648 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 38-21  Illustrations of unilateral cleft nasal maneuvers that are carried out as part of the primary lip and nasal reconstruction.
A, Along the lateral aspect of the nose, the nasal soft tissues (including the inferior turbinate) are released from the pyriform rim and
the lateral nasal wall with the use of an elevator that is inserted through the open lip. B, Next, the buckled and flattened lateral crus
of the lower lateral cartilage is released from the overlying nasal soft tissues with the use of Stevens scissors inserted through the open
lip. The elevated lateral nasal flap (including the inferior turbinate) will be advanced medially, superiorly, and anteriorly to facilitate nasal
floor reconstruction (see Fig. 38-20, D). C, Along the medial aspect of the nose, the nasal soft tissues (including the medial crus of
the lower lateral cartilage) are released from the anterior nasal spine and septal cartilage with the use of an elevator and Stevens scis­
sors. The elevated medial nasal flap will be advanced laterally to facilitate nasal floor reconstruction (see Fig. 38-20, D). D, Recurrent
buckling of the lateral crus early after surgery is limited with the use of an intranasal stint (packing). Sutures through the nasal soft
tissues are also placed to pexy the lower lateral cartilage.
Orth
r ognathic Sur
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r ery; J.C. Posnick
A
C
B
Lateral nasal flap elevation prior to lip repair
Dissection of LLC from overlying skin prior to lip repair
D
Nasal stent in place (UCLP)

•  Figure 38-22  A newborn with a complete unilateral cleft lip and palate on the left side is shown before and 4 years after primary repair. He
did not undergo any taping, molding, pinning, or adhesion procedures before the lip repair. When he was 3 months old, he underwent primary
cleft lip repair in combination with primary nasal reconstruction as described (see Figures 38-20 and 38-21). When he was 12 months old, he
underwent cleft palate repair with the use of the Bardach two-flap technique. He is shown A, as a newborn; B, at 18 months of age (6 months
after palate repair); and C, at 3 years of age.
©Elsevier Inc.
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•  Figure 38-23  A child was born with incomplete clefting of the left primary palate; the secondary palate is also clefted. There is marked nasal
deformity and clefting through the alveolus. She did not undergo any taping, molding, pinning, or adhesion procedures before the lip repair. At
the time of primary cleft lip repair, she underwent nasal reconstructive maneuvers as described previously in the legends for Figs. 38-20 and
38-21. This was followed by palate repair when she was 12 months old with the Bardach two-flap technique. She is shown A, as a newborn;
B, at 3 months of age (1 week after primary repair); C, at 1 year of age just before palate repair; D, at 4 years of age; and E, at 8 years of age
after alveolar bone grafting.
D
E
A
B
C
©Elsevier Inc.
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©Elsevier Inc.
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1650 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 38-24  A newborn with a complete UCLP on the right side is shown before and 7 years after primary repair. She did not undergo
any taping, molding, pinning, or adhesion procedures before the lip repair. At 3 months of age, she underwent primary cleft lip repair in com­
bination with primary cleft nasal reconstruction as described previously in the legends for Figs. 38-20 and 38-21. When she was 12 months
old, she underwent cleft palate repair with the Bardach two-flap technique. She is shown A, as a newborn; B, at 3 months of age (2 weeks
after primary lip and nose repair); and C, at 7 years of age just before alveolar bone grafting.
©Elsevier Inc.
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Surg
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C.
C.
C.
C.
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©Elsevier Inc.
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Su
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Surg
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ry; J.C.
C.
C.
C.
C.
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©Elsevier Inc.
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Or
O thththththththth
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g atatatatatatatatatatata hicicicicic Su
Su
Surg
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ry; J.C.
C.
C.
C.
C.
C.
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A
B
C
B
C
performed by some clinicians to alter the nasomaxillary
anatomy before primary reconstruction (i.e., taping, naso­
alveolar molding, Latham pinning, lip adhesion) were not
carried out in any of these patients.2,78,117,229,244 Interestingly,
the American Cleft Palate–Craniofacial Association param­
eters of care document that addresses primary cleft lip and
nasal repair includes only the following statements172:
• Surgical repair of the cleft lip is usually initiated
within the first 12 months of life and may be per­
formed as early as is considered safe for the infant.
• Presurgical maxillary orthopedics to improve the
position of the maxillary alveolar segments before
surgical closure of the lip may be indicated for some
infants.
• The nasal deformity is an integral part of the cleft lip
[malformation]. Depending on the severity, primary
nasoplasty may be performed at the time of primary
lip repair.
• A preliminary lip adhesion is a procedure that may be
used in selected patients before definitive lip repair.
• The goal of lip repair is to restore the normal func­
tional and anatomic features.
Interestingly, a recent survey of North American cleft
surgeons indicated that only 50% of clinicians carry out
any form of primary nasal reconstruction.12,236 Ongoing
evidence-based clinical research will be required to further
clarify standards of care that address primary cleft lip and
nasal repair.
Residual Nasal Deformities in the Adolescent
or Adult with Repaired Unilateral Cleft Lip
and Palate
Residual nasal deformities in the adolescent or adult with
repaired UCLP are characterized first by uncorrected features
of the primary malformation that may be compounded by
previous surgical maneuvers and ongoing unfavorable naso­
maxillary growth. Lesser degrees of the malformation will
be seen in the adult, depending on the success of primary
nasal reconstructive maneuvers.31,33,60,127,147,160,177,178,232,253,254
The most favorable definitive rhinoplasty results in the
patient with UCLP are achieved when issues with the under­
lying maxillary skeleton (including irregularities and defects
of the floor of the nose, the piriform rims, and the anterior
nasal spine) are first corrected (Figs. 38-25 through 38-30).
Even if mixed-dentition bone grafting of the cleft skeletal
defects is successful, nasal rim and floor recontouring and
orthognathic procedures will be required in the majority of
patients before definitive rhinoplasty is performed (see
Chapter 32). The correction of the presenting UCLP nasal
deformities in the adolescent or adult requires consideration
of the following:
• The maxillary position in relation to the mandible
below and the facial skeleton above
• The shape and symmetry of the piriform rims, the
nasal floor, and the anterior nasal spine
• The morphology of the osseocartilaginous nasal vault
• The symmetry and projection of the nasal lobule
and tip
• The quality of the nasal soft-tissue envelope
• The quality of the internal nasal lining
• The deformities of the septum and the turbinates
Alar Rims and Nasal Tip
The ipsilateral alar rim may lie caudal, lateral, and posterior
as compared with the contralateral side. A hypoplastic mal­
posed LLC may be superimposed on a residual underlying
maxillary deformity. An incompletely repaired orbicularis
oris muscle may also be a factor. Nasal tip projection is often
inadequate, with asymmetry and foreshortening toward the
cleft side.

1651
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
•  Figure 38-25  A teenage girl was born
with UCLP of the right side. Despite her
having recently undergone a rhinoplasty
by another surgeon, residual nasal defor­
mities remained. She was referred by her
orthodontist to this surgeon with concern
about the residual cleft dental issues
and jaw alignment. The patient wished to
discuss the appearance of protruding
ears and residual cleft nasal deformities.
The bothersome nasal features included a
dorsal hump, a drooped and asymmetric
nasal tip, and difficulty breathing. She
refused any further maxillary skeletal
procedures. She agreed to an open rhino­
plasty that included nasal osteotomies
(in-fracture and straightening); dorsal re­
duction (bone and cartilage); nasal tip
maneuvers (modification of the lower lat­
eral cartilages and septal cartilage caudal
strut grafting); septoplasty; and inferior
turbinate reduction. She also underwent
simultaneous external otoplasty that in­
cluded conchal reduction (elliptical exci­
sions) and deepening of the scaphal folds
(Mustarde stitches). A, Frontal views be­
fore and after reconstruction. B, Oblique
facial views before and after reconstruc­
tion. C, Profile views before and after
reconstruction.
C
Or
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Orththththth
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Surg
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C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
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Or
Orthth
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gnatatathicicicic Su
Su
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Surg
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C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Posnicicicicick
Or
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gnatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicic Su
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C.
C.
C.
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C.
C.
C.
C.
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C.
C.
C.
C.
C.
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C.
C Pos
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Orthththtr ogn
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1652 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
Orth
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Orth
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Orth
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Orth
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A
B
•  Figure 38-26  A teenage girl who was born with UCLP of the left side underwent primary lip and palate repair at
another institution. She was referred to this surgeon and underwent successful bone grafting during the mixed dentition
followed by the orthodontic closure of the cleft–dental gap. Growth of the maxilla was satisfactory, with good occlusion
achieved with the use of orthodontic mechanics. She was displeased with the residual cleft nasal deformities, which
included an asymmetric flat tip of the nose, a cicatrized left nasal opening, and a lifelong history of difficulty breathing
through the nose. She underwent an open rhinoplasty that included nasal osteotomies (in-fracture and straightening);
minimal dorsal reduction (bone and cartilage); nasal tip maneuvers (modification of the lower lateral cartilages and septal
cartilage caudal strut grafting); septoplasty; and inferior turbinate reduction. A, Frontal views with smile before and after
reconstruction. B, Oblique facial views before and after reconstruction.

1653
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
Orth
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Orth
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C
Irreversible cicatrated external nasal valve
D
C, Profile views before and after reconstruction. D, Worm’s-eye views before and after recon­
struction. Note the irreversibly cicatrized left external nasal valve as a result of overresection at the time of primary lip
repair.
Skeletal Framework of the Nose
The nasal bones are frequently wide and asymmetric. The
dorsum itself may be high, low, or normal, with much
individual variation. The mid cartilaginous vault may be
curved, with collapse toward the side of the cleft.
Maxillary Base
The maxilla may be sagittally retrusive but more so on the
cleft side, which results in the ipsilateral pyriform aperture
being located caudal, lateral, and posterior. Previous bone
grafting to the hard palate, the alveolus, and the floor of the
nose may have been ineffective, with continued defects and
asymmetry.
Nasal Airway
Asymmetric narrowing of the nasal cavity with obstruction
to airflow is generally present. The septum may be displaced
from the vomerine groove, and the cartilaginous portion
may be thickened and buckled. The inferoanterior portion
of the septum is typically displaced away from the cleft,
whereas the superior cartilaginous septum curves into the
cleft as it rises to the tip. The inferior turbinates, especially
on the cleft side, are frequently hypertrophic; they consume
much of the airway space with the collapse of the internal
nasal valve. The bony septum may also be deviated. The
floor of the nose just above the incisors will be asymmetric
• Figure 38-26, cont’d
Text continued on p. 1661

1654 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 38-27  A 16-year-old girl who was born with van der Woude syndrome that included complete UCLP and
lower lip pits was managed by this surgeon since the time of her birth. She underwent lip and palate repair during early
childhood, and this was followed by successful bone grafting and fistula closure during the mixed dentition. She had
normal maxillary growth and underwent standard orthodontic treatment with maintenance of the cleft–dental gap (see
Fig. 32-7). She underwent an open rhinoplasty when she was 15 years old that included nasal osteotomies (in-fracture
and straightening); minimal dorsal reduction (bone and cartilage); nasal tip maneuvers (reshaping of the lower lateral
cartilages and septal cartilage caudal strut grafting); septoplasty; and inferior turbinate reduction. A, Oblique facial views
before and after rhinoplasty. B, Profile views before and after rhinoplasty.
Orth
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r ery; J.C. Posnick
Orth
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u g
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Orth
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Orth
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A
B

1655
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
Orth
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r ery; J.C. Posnick
Orth
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Orth
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Orth
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A
B
•  Figure 38-28  A high school student was born with a complete UCLP of the left side. He underwent lip and palate
repair at another institution. He was then referred to this surgeon during the mixed dentition and underwent successful
bone grafting and fistula closure. The cleft–dental gap was closed with orthodontic mechanics. He developed a jaw
discrepancy that was characterized by maxillary deficiency with secondary deformity of the mandible and chin region (see
Fig. 32-8). Six months after successful orthognathic surgery and orthodontic treatment, he underwent cleft rhinoplasty
that included rib cartilage (caudal strut) grafting. He is shown before and then after orthognathic and nasal reconstruction.
A, Frontal views in repose before and after reconstruction. B, Frontal views with smile before and after reconstruction.
Continued

1656 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
Orth
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Orth
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Orth
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r ery; J.C. Posnick
Orth
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C
D
C, Oblique facial views before and after reconstruction. D, Profile views before and after
reconstruction.
• Figure 38-28, cont’d

Orth
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Orth
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Orth
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Orth
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A
B
•  Figure 38-29  A young man was born with complete UCLP. He was treated by other surgeons with procedures that included primary cleft lip
repair; cleft lip revision; primary cleft palate repair; cleft palate revision; the placement of superiorly based pharyngeal flap; iliac grafting of the cleft
defect; cleft rhinoplasty; and Le Fort I osteotomy with distraction osteogenesis (RED device). When he was 17 years old, he was then referred to
this surgeon with residual cleft deformities that included the following:
• Nasopharyngeal stenosis with obstructive sleep apnea (apnea–hypopnea index: 11.4 events/hour, with desaturations to 89%)
• Persistent oronasal fistula
• Residual cleft jaw deformity with Class III open-bite malocclusion
• Chronic nasal obstruction with septal deviation and enlarged turbinates
• Residual cleft nasal deformity
• Cleft lip scar deformity with a lack of continuity of the orbicularis oris muscle
The patient agreed to a comprehensive orthodontic and surgical approach. His procedures included the following: redo Le Fort I osteotomy in two
segments (+7 mm horizontal advancement , transverse widening, and oronasal fistula closure) with iliac grafting; bilateral sagittal split osteotomies
of the mandible (horizontal advancement and clockwise rotation); oblique osteotomy of the chin (horizontal advancement and vertical shortening);
redo septoplasty; redo inferior turbinate reduction; and recontouring of the nasal rims. One year later, the patient underwent cleft rhinoplasty, includ­
ing rib cartilage (caudal) strut grafting; cleft lip scar revision, including repair of the orbicularis oris muscle; and the revision of the pharyngeal flap
to relieve stenosis. A postoperative attended sleep study confirmed complete resolution of the obstructive sleep apnea. A, Frontal views in repose
before and after reconstruction. B, Facial view with smile before and after reconstruction.
Continued

1658 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
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Orth
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Orth
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Orth
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C
D
C, Oblique facial views before and after reconstruction. D, Profile views before and after recon­
struction. Note that the pharyngeal flap revision (release of stenosis) was important to resolve mucous trapping and to
improve breathing.
• Figure 38-29, cont’d

1659
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
Orth
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Orth
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Orth
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Orth
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A
B
•  Figure 38-30  A teenager was born with complete UCLP of the left side. He was treated by this surgeon with proce­
dures that included cleft lip repair (3 months of age); cleft palate repair (12 months of age); superiorly based pharyngeal
flap (5 years of age); and cleft bone grafting with fistula closure during the mixed dentition (8 years of age). He is con­
genitally missing the left maxillary lateral incisor and the first bicuspid. He underwent standard orthodontic treatment and
had satisfactory growth of the jaws. Dental gaps remain for eventual implants and dental restorations. When he was 15
years old, he underwent nasal reconstruction that included septoplasty; inferior turbinate reduction; and rhinoplasty includ­
ing rib cartilage (caudal) strut grafting. A, Frontal views in repose before and after reconstruction. B, Frontal views with
smile before and after reconstruction.
Continued

1660 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
C
D
Orth
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Orth
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Orth
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Orth
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C, Oblique facial views before and after reconstruction. D, Profile views before and after
reconstruction.
• Figure 38-30, cont’d

1661
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
• The nasal tip is flat and broad, and it appears bifid.
• The nasal alae are flat and wide. From a worm’s-eye view,
the alar rims appear to be “S”-shaped.
• The base of the alae on each side are displaced laterally
and sometimes inferiorly and posteriorly.
• Both nostrils are horizontally oriented.
• The LLCs are typically severely buckled and deformed.
The medial crura are short and widely separated at the
nasal tip. The lateral crura are flat and elongated.
• The dome of the nasal tip is angled obtusely.
• The nasal floor is clefted (open).
• The columella, the caudal end of the septum, and the
anterior nasal spine are displaced anteriorly as a reflection
of the forwardly projected premaxilla.
• The nasal tip and the nostrils may be asymmetric as a
reflection of the displaced premaxilla.
Basic Nasal Reconstructive Maneuvers
for the Primary Bilateral Lip Repair
(Figs. 38-32 and 38-33)
• The philtral flap is raised as part of the primary bilateral
lip repair. Circulation to the philtral flap is based on
attachment to the columella soft tissues. Elevation of the
medial and lateral nasal soft-tissue flaps for nasal sill and
floor reconstruction is carried out after the philtral skin
flap is accomplished (Fig. 38-32, B,C ).
• Along the lateral aspect of the nose, the nasal soft tissues
(including the inferior turbinate) are released from the
pyriform rim and the lateral nasal wall with the use of
an elevator (Fig. 38-33, A).
• Next, the buckled and flattened lateral crus of the LLC
is released from the overlying nasal soft tissues with the
use of Stevens scissors (Fig. 38-33, B).
• The elevated lateral nasal flap (including the inferior
turbinate) will be advanced medially, superiorly, and
anteriorly to facilitate nasal sill and floor reconstruction
(Fig. 38-32, D).
• Along the medial aspect of the nose, the nasal soft tissues
(including the medial crus of the LLC) are released from
the anterior nasal spine and septal cartilage with the use
of an elevator and Stevens scissors. The elevated medial
nasal flap will be advanced laterally to facilitate nasal sill
and floor reconstruction) (Fig. 38-33, C ).
• The release of the orbicularis oris muscle from its abnor­
mal bone and soft-tissue attachments is accomplished
with the use of Stevens scissors. Reconstruction of the
orbicularis oris muscle with interrupted sutures achieves
continuity across the lip. Just before muscle approxima­
tion, gentle mechanical (orthopedic) “thumb” pressure
can be applied to the premaxilla if needed to improve its
position. Reasonable alignment of the premaxillary
segment just before repair is preferred to achieve a
tension-free soft-tissue lip closure (Fig. 38-32, D).
• Recurrent buckling of the lateral crus of the LLC early
after surgery is limited by the placement of a stent (i.e.,
and irregular, thereby further preventing the normal flow
of air. The external valve may be scarred and cicatrized
from previous surgery, which also further constricts nasal
airflow.
Analysis of Residual Nasal Deformities in the
Adolescent or Adult with Repaired Unilateral
Cleft Lip and Palate
Key Points
• Is the nasal lining deficient or just distorted?
• Is the overlying nasal soft-tissue envelope deficient or just
distorted?
• Are the nasal bones deformed and require recon­
struction?
• How is the dorsal height? How is the mid-dorsal
width?
• Is the bony vault crooked?
• Is the mid-cartilaginous vault crooked?
• Is the nasal tip projection adequate?
• Does the external nasal valve have scar cicatrization?
• What is the extent of the LLC deficiency? Will augmen­
tation be required?
• Is the skeletal component of the nasal aperture deficient
and asymmetric? If so, bone grafting, fistula closure, and/
or recontouring will be required.
• Is the maxilla hypoplastic? If so, orthognathic surgery
will be indicated.
• What are the current areas of nasal obstruction
• External nasal valves?
• Internal nasal valves?
• Turbinated cavities?
• Posterior (cavity) apertures?
• Tight pharyngeal flap?
• Tonsils and adenoids?
In most patients with repaired UCLP, an adequate over­
lying soft-tissue envelope and underlying internal nasal
lining are present. Although the nasal bones are deformed,
they are usually adequate to allow for reconstruction through
a combination of osteotomies and dorsal reduction. The
mid-cartilaginous vault may be crooked to the extent that
spreader grafts are required. A cartilage caudal strut graft
will be required for tip straightening and projection in
virtually all cases. If the septal cartilage is available, it is
usually adequate. If greater structural support is required,
the use of rib cartilage is preferred. If the quality of the LLC
is adequate, reconstruction simply by recontouring and
suture-pexy is carried out. If not, then augmentation of the
LLC with additional cartilage grafting is required (i.e., alar
contour graft or lateral crural strut graft).
Nasal Deformities in the Newborn with
Bilateral Cleft Lip and Palate (Fig. 38-31)
• The columella is short, but there is a wide variation in
this feature among individuals.
Text continued on p. 1666

1662 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 38-31  Demonstration of typical bilateral cleft lip nasal malformation. A, Worm’s-eye view of a newborn
with complete bilateral cleft lip and palate. B, Illustration that indicates typical dysmorphology of the maxillary
base, the caudal septum, and the nasal tip in a newborn with unrepaired bilateral cleft lip and palate (BCLP).
C and D, Facial and computed tomography scan views of a newborn with BCLP. An asymmetric forwardly
projecting premaxilla is shown.
Or
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D

1663
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
•  Figure 38-32  A, Illustration of typical facial malformations and distortions in a newborn with complete BCLP.
A
Continued

B
C
D
E
F
G
B and C, Illustrations of the basic technique used by this surgeon for primary bilateral cleft lip reconstruction. In B, the
incisions are indicated (dotted lines), with redundant tissue to be excised shown (diagonal lines). In C, the philtral skin flap has been elevated with
circulation maintained through the soft tissues of the columella. The lateral lip flaps include vermilion–mucosa soft-tissue extensions to be used for
the reconstruction of the central red lip. The orbicularis oris muscle has been dissected free of its abnormal bony and soft-tissue attachments and
also released from the overlying lip skin. The medial and lateral nasal floor flaps have already been elevated within each nostril (see Fig. 38-33).
D, The orbicularis oris muscle is then approximated across the midline and sutured together at the columella base. Just before muscle approxima­
tion, gentle mechanical orthopedic “thumb” pressure can be applied to the premaxilla if needed to improve its position. Improved alignment of the
premaxillary segment just before repair will allow for a tension-free soft-tissue lip closure. The anterior portion of the nasal floor is then reconstructed
on each side by suturing the advanced medial and lateral nasal floor flaps. E, The vermilion–mucosa extensions of each lateral lip flap are approxi­
mated and sutured in the midline to create the vermilion–mucosa junction. F, The philtral flap is aligned with the advanced vermillion extensions of
the lateral lip flaps (i.e., the vermilion–cutaneous junction) and sutured in place. The cutaneous layer of each lip flap is advanced and sutured first
at the columella base and then at the vermillion on each side. The philtral columns and the nasal sills are sutured. G, The intraoral mucosa is
aligned to establish a functional vestibule. Excision of redundant red lip was initially accomplished just after elevating the philtral flap. The lip side
of the vestibule is reconstructed with mucosa from the advanced lateral lip flaps. The alveolar side of the vestibule is reconstructed with the retained
mucosa on the premaxillary segment. Note: Alveolar clefts and fistulas remain.
• Figure 38-32, cont’d

1665
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
•  Figure 38-33  Illustrations of the bilateral cleft nasal maneuvers that are carried out as part of the primary repair. A, Along the lateral
aspect of the nose, the nasal soft tissues (including the inferior turbinate) are released from the pyriform rim, and the lateral nasal wall is
released with an elevator inserted through the open lip. B, Next, the buckled and flattened lateral crus of the lower lateral cartilage is
released from the overlying nasal soft tissues with a Stevens scissors inserted through the open lip. The elevated lateral nasal flap (including
the inferior turbinate) will be advanced medially, superiorly, and anteriorly to facilitate nasal floor reconstruction. C, Along the medial aspect
of the nose, the nasal soft tissues (including the medial crus of the lower lateral cartilage) are released from the anterior nasal spine, and
septal cartilage with the use of a Stevens scissors inserted through the open lip. The elevated medial nasal flap will be advanced laterally
to facilitate nasal floor reconstruction. Recurrent buckling of the lateral crus is limited early after surgery with the use of an intranasal stint
(packing) in each nostril. Sutures through the nasal soft tissues are also placed to pexy each lower lateral cartilage.
A
B
C

1666 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 38-35  A, A newborn girl with complete BCLP is shown. At the time of primary cleft lip repair, she underwent nasal reconstructive
maneuvers as described in the text (see Figs. 38-32 and 38-33). B, She is next shown just 1 week after primary lip and nasal reconstruction.
C, She is then shown at 1 year of age just before cleft palate repair. Note the decreased height of the columella that is part of the malformation;
she will require definitive nasal reconstruction with the use of an open technique and a rib cartilage caudal strut during the early teenage years
(Fig. 38-36).
©Elsevier Inc.
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©Elsevier Inc.
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gn
gnatatatatatathicicicicic Su
Su
Su
S rg
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ry
ry
ry; J.C.
C.
C.
C Pos
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©Elsevier Inc.
Or
Or
Or
O ththththth
r ogn
gn
g atathicicicicicicicicicic Su
Su
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Surg
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ry; J.C.
C.
C Pos
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osnicicicici k
•  Figure 38-34  A newborn with complete BCLP, tracheomalacia, and other congenital anomalies is shown. At the time of primary cleft lip
repair, he underwent nasal reconstructive maneuvers as described in the text (see Figs. 38-32 and 38-33). He is shown A, soon after birth and
B, at 3 months of age, just 1 week after primary cleft lip and nasal reconstruction. C, He is next shown at 2.5 years of age having also under­
gone cleft palate repair via the Bardach two-flap technique.
©Elsevier Inc.
Or
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O ththththththth
r ogn
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gn
gn
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gn
gnatatatatatatatatatatata hicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
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Surg
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ry; J.C.
C.
C.
C.
C.
C.
C.
C Pos
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©Elsevier Inc.
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O ththththththththththththtr ogn
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g atatatatatathicicicicicicicic Su
Su
Su
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Surg
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ry; J.C.
C.
C.
C.
C.
C.
C.
C Pos
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os
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©Elsevier Inc.
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Or
Or
Or
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Orthththththththththththth
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ry
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ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
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C.
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C.
C.
C.
C.
C.
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C. Pos
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osnicicicicici k
packing) in each nostril. Sutures through the nasal soft
tissues and LLCs on each side may also be used to elevate
and maintain the shape of the nasal rims.
Two typical patients with bilateral cleft lip and palate
(BCLP) who have been treated with the use of the tech­
niques described are shown after primary lip and nasal
repair (Figs. 38-34 and 38-35). Pre-BCLP lip-repair
maneuvers have been described in the literature for the
purpose of repositioning a protrusive premaxilla and to
improve nasal anatomy. They include: taping; the use of a
nasoalveolar molding device; the use of a Latham pinning
device; lip adhesion; and the application of gentle direct
mechanical (orthopedic) backward pressure on the premax­
illa.2,26,78,117,229,244,153 Each of these maneuvers has its strong
advocates and its vocal detractors. Despite decades of
dispute and discussion, standards of care that involve this
important cleft reconstruction topic remain limited.172
Residual Nasal Deformities in the Adolescent
and Adult with Repaired Bilateral Cleft Lip
and Palate
Residual nasal deformities in the adolescent or adult with
repaired BCLP include any uncorrected features of the
primary malformation that may be compounded by previ­
ous surgical maneuvers and ongoing unfavorable nasomaxil­
lary growth. Lesser degrees of the malformation will be seen
in the adolescent and adult depending on the success of
primary nasal reconstructive maneuvers. The most favorable
rhinoplasty results are achieved only after deformities of the
underlying maxillary skeleton (i.e., the floor of the nose,
the piriform rims, and the anterior nasal spine [e.g., maxil­
lary hypoplasia]) are first reconstructed. It is now clear that,
for a majority of individuals with repaired BCLP, orthog­
nathic procedures will be required to correct baseline facial
disharmony before definitive rhinoplasty (see Chapter 33).

1667
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
Congenital and Posttraumatic
Saddle-Nose Deformities
The hallmark of most congenital and posttraumatic saddle-
nose deformities is the deficiency of both the osseous and
cartilaginous vaults. The surgical correction of a saddle-nose
deformity was first described by Robert Weir in 1889,
when he wrote a report entitled “Restoring Sunken Noses.”
He implanted the breastbone of a freshly killed duck below
the skin of a severely shrunken nose in a young syphilitic
patient as a means of reconstruction.250 In current times,
a frequent form of saddle nose results from either congenital
deformity (e.g., bifid cleft nose, Binder syndrome, cranio–
fronto–nasal dysplasia; Figs. 38-41 through Fig. 38-44) or
from an acquired postnasal fracture cause (e.g., complex
naso–orbito–ethmoid fractures, direct low-velocity trauma
to the nasal bones in the growing child; Fig. 38-45).184
The congenital and posttraumatic saddle nose as defined
includes the deformity of the osseous vault (i.e., the
nasal bones) and the cartilaginous vault (i.e., the quadran­
gular cartilage). These saddle-nose deformities generally
present with an acceptable soft-tissue envelope and
nasal lining. They also generally have an intact septum
(i.e., no septal perforation). The reconstruction required
for these saddle-nose deformities will vary with their
cause (e.g., cocaine related, autoimmune conditions, iat­
rogenic postseptoplasty-induced “depressed” nose).* The
postseptoplasty saddle-nose deformities present with an
intact osseous vault but with significant septal perforations
that result in a depressed cartilaginous vault; this is dis­
cussed later in this chapter.
Residual BCLP nasal deformities in the adolescent or adult
that frequently require correction include the following:
• A short columella and a lack of caudal projection of
the inferior aspect of the septum
• The flattening of the osseocartilaginous vault
• Nasal tip bifidity
• The buckling of the downward rotation of the LLCs
• The lateral displacement of the alar bases that results
in the horizontal rotation of the nostrils
In addition to the usual open rhinoplasty maneuvers
carried out in the adolescent or adult with a repaired BCLP,
the short columella defines the deformity.178,221,253 Correc­
tion of the short columella in a patient with BCLP is prefer­
ably accomplished with the use of a crafted autogenous rib
cartilage caudal strut graft. This option is an effective
method to provide structural support for the stretching of
the columella skin and the nasal soft-tissue envelope over
the graft to achieve needed projection (Figs. 38-36 through
38-39). The rib cartilage graft is stabilized to the base of the
maxilla with a no. 35 threaded Kirschner wire (K-wire).
After modification, the LLCs are sutured together and over
to top of the rib cartilage caudal strut to form the superficial
aspect of the new tip (Fig. 38-40).
The American Cleft Palate–Craniofacial Association
parameters of care document that addresses secondary
cleft lip nasal reconstruction includes only the following
statements172:
• Although rhinoplasty and nasal septal surgery are
usually advocated only after the completion of nasal
growth, earlier intervention for reasons of airway
problems or nasal tip deformity may be indicated.
• The repair of the cleft lip nasal deformity can be
accomplished with limited external incisions on
the nose.
• The timing of nasal surgery should be discussed with
the patient and the family so that the goals are under­
stood and the expectations are realistic.
• The patency of the nasal airway should be considered
when planning either nasal reconstructive procedures
or secondary velopharyngeal operations (e.g., a pha­
ryngeal flap, another type of pharyngoplasty).
Until clear parameters regarding the timing and tech­
nique of secondary cleft nasal surgery become available,
individual surgeon experience and personal preferences will
remain standard practice. Unfortunately, this can easily lead
to frustration and miscommunication among the patient,
the family, and the treating clinicians.
Timing of Definitive Cleft
Nasal Reconstruction
To maximize long-term nasal breathing, adequate sinus
drainage, and the enhancement of facial aesthetics, a defini­
tive cleft rhinoplasty should only be undertaken after
successful alveolar bone grafting, including the stabilization
of the premaxilla in the case of BCLP and fistula closure.
If orthognathic corrections are required, then definitive
nasal reconstruction is best delayed until at least 6 months
after successful skeletal reconstruction. Recent studies con­
ducted at both Boston Children’s Hospital and the Hospital
for Sick Children in Toronto, Ontario, Canada, confirm
that approximately 50% of adolescents and adults with
UCLP and 65% to 77% of adolescents and adults with
BCLP will require orthognathic surgery. The correction of
the cleft jaw deformity is preferably carried out when the
patient is between 15 and 18 years old and before gradua­
tion from high school (see Chapters 32, 33, and 34).
*References 42, 63, 64, 106, 107, 119, 154, 175, 180, 181, 183, 221,
230, 242, 250, 251, 253
Text continued on p. 1687
NOTE:  This author does not favor repetitive limited
rhinoplasty maneuvers performed throughout
childhood. Although they are well intended, nasal
procedures carried out after the primary repair but
before definitive reconstruction may result in additional
scarring and distortions that will limit long-term
aesthetic and functional airway results.

1668 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 38-36  A child was born with
complete BCLP. She underwent two
attempts at cleft lip repair at another insti­
tution that resulted in wound dehiscence
and necrosis of the philtral soft tissues.
This was likely the result of a combination
of factors, including the following: 1) a pro­
trusive premaxilla before repair; 2) inade­
quate release of and then repair of the
orbicularis muscle; 3) and the incisions
used to elevate the philtral flap. She was
referred to this surgeon and then under­
went successful lip reconstruction that
included gentle mechanical and orthope­
dic “thumb” pressure on the premaxilla
just before approximation of the orbicu­
laris oris muscle. This was followed by
palate repair with the use of the Bardach
two-flap technique when she was 14
months old and then successful bone
grafting during the mixed dentition. During
the patient’s early teenage years, there
was harmonious growth and adequate
sagittal projection of both jaws. The teeth
were orthodontically aligned, with closure
of the cleft–dental gaps. The cleft nasal
deformity was characterized by a short
columella and a wide depressed tip. The
soft-tissue deficiency of the upper lip (phil­
trum) remained as a result of necrosis
during infancy. A decision was made to
not construct an Abbe flap, which would
scar the lower lip and result in a “patch”
(color mismatch) with the upper lip. An
open rhinoplasty was carried out that
included modification of the lower lateral
cartilages and rib cartilage caudal strut
grafting with stretching of the nasal soft
tissues to create improved tip position and
shape. Composite resin buildups and
contouring of the hypoplastic anterior
maxillary teeth were carried out by a
restorative dentist after definitive nasal
reconstruction. A, The patient is shown at
4 months of age, when she was referred
to this surgeon, and at 14 years of age
after successful lip and palate repair
during infancy, bone grafting during the
mixed dentition, and just before the
removal of the orthodontic appliances and
definitive nasal reconstruction. B, Oblique
facial views before and at 15 years of age
after nasal reconstruction. C, Profile views
before and at 15 years of age after nasal
reconstruction.
C
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C.
C.
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C Pos
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o nicicicicicicicicick
Or
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g atatatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicicicicicicicicici Su
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C.
C.
C.
C.
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C Pos
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osnicicicicicicicicicicicicicici k
Or
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Orththththththththththththth
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g atatatatatatatathicicicicicicicicicicicic Su
Su
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C. Pos
os
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Or
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g atatatatatatatatatatatatatata hicicicicicicicicicicicicic Su
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C. Pos
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A
B

1669
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
•  Figure 38-37  A teenage girl of Arabic
descent was born with complete BCLP.
She has been managed by this surgeon
since birth. She underwent primary lip
and nasal repair and palate reconstruction
during childhood and then successful
bone grafting during the mixed dentition.
She required the correction of a cleft
jaw deformity when she was 15 years
old. The procedures included maxillary
Le Fort I osteotomy; sagittal split ramus
osteotomies; osseous genioplasty; sep­
toplasty, inferior turbinate reduction, and
nasal floor recontouring. Six months later,
the patient underwent definitive nasal
reconstruction to correct a wide nasal
bridge and a depressed tip. Her open
rhinoplasty included nasal osteotomies
(in-fracture and straightening); dorsal
reduction (bone and cartilage); and nasal
tip maneuvers (modification of the lower
lateral cartilages and rib cartilage caudal
strut grafting). A, Frontal views before
and after cleft orthognathic and nasal
reconstruction. B, Oblique views before
and after cleft orthognathic and nasal
reconstruction. C, Profile views before
and after cleft orthognathic and nasal
reconstruction.
C
Or
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Orththth
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C.
C Pos
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C.
C.
C.
C Pos
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O thththththththththththththththththththththth
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g atatatatatatatatatatatatatatata hicicicicicicicicicicicicicicic Su
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C.
C.
C.
C.
C.
C.
C. Pos
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gnatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicicicicicicic Su
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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
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; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C. Pos
os
os
os
os
os
os
os
os
os
osnicicicicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
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g atatatatatatatatatatatathicicicicicicicicicicicicicic 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
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ry
ry
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ry
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ry; J.C.
C.
C.
C.
C.
C.
C. Pos
os
o nicick
A
B

1670 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 38-38  A teenage Hispanic male was born with complete BCLP. He underwent lip and palate repair and inef­
fective bone grafting during the mixed dentition by another surgeon. When referred to this surgeon, he presented with
maxillary hypoplasia, mobile premaxilla, cleft dental gaps, residual fistula, and alveolar clefts. He underwent maxillary Le
Fort I osteotomy in three segments and osseous genioplasty. Six months later, he underwent definitive rhinoplasty to
manage residual and secondary cleft deformities, including a wide bridge, a depressed nasal tip, and difficulty breathing
(see Fig. 33-10). His open rhinoplasty included nasal osteotomies (in-fracture and straightening); dorsal reduction (bone
and cartilage); nasal tip maneuvers (modification of the lower lateral cartilages and rib cartilage caudal strut grafting);
septoplasty; and inferior turbinate reduction. A, Frontal views before and after reconstruction. B, Profile views before and
after reconstruction.
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
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A
B

1671
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
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 38-39  A boy who was born with complete BCLP. He underwent lip and palatal repair and unsuccessful bone
grafting at another institution. He presented to this surgeon when he was 17 years old with severe jaw and nasal deformi­
ties, malocclusion, and dental needs. After successful orthognathic surgery and dental rehabilitation, he underwent an
open rhinoplasty that included nasal osteotomy (in-fracture); dorsal reduction (bone and cartilage); and nasal tip maneuvers
including rib cartilage (caudal strut) placement (see Fig. 33-16). A, Frontal views in repose before and after reconstruction
and rehabilitation. B, Frontal views with smile before and after reconstruction and rehabilitation.
Continued

1672 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
C
D
C, Oblique views before and after reconstruction and rehabilitation. D, Profile views before and
after reconstruction and rehabilitation.
• Figure 38-39, cont’d

1673
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
B
A
Incision location
Rib cartilage exposed
Harvested graft
•  Figure 38-40  Intraoperative views of rib cartilage grafting technique. A, The incision, which is 4 cm in length, is
directly over the rib cartilage to be harvested. The rib cartilage is then exposed, sectioned, and removed from the chest
wall. B, The harvested rib cartilage graft is crafted as a caudal strut that is approximately 4 cm.
Continued

1674 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
C
K-wire secured at nasal base
(through anterior maxilla)
projecting up to pierce and secure strut graft
K-wire secured at nasal base
(through anterior maxilla)
projecting up to pierce and secure strut graft
Lower lateral cartilages to be
“suture-pexed” over top of rib graft
Caudal portion of septal cartilage
Crafted rib cartilage graft secured
to nasal base through K-wire
D
E
C, Through the open rhinoplasty technique, the base of the anterior maxilla is exposed. A
Kirschner wire (#35 threaded) is inserted through the nasal base and the anterior maxilla. It is left to project 4 mm out of
the bone. D, The caudal portion of the intact septal cartilage is shown in relationship to the projecting Kirschner wire.
The caudal aspect of the quadrangular cartilage may be cut back to prevent buckling against the graft. E, The crafted
rib strut graft is secured to the nasal base through the projecting Kirschner wire to ensure stability. The lower lateral
cartilages will then be “suture-pexied” to each other and over the top of the caudal graft. The soft-tissue envelope of the
nose is shown draped over the strut graft before the lower lateral cartilage are sutured together and over the tip.
• Figure 38-40, cont’d

1675
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 38-41  A 17-year-old boy who was born with Binder syndrome was referred to this surgeon with nasomaxillary deficiency. Examina­
tion confirmed cartilaginous vault and premaxillary deficiency. He underwent orthodontics that included maxillary bicuspid extractions, orthog­
nathic surgery (Le Fort I osteotomy and genioplasty), and nasal reconstruction (corticocancellous iliac graft; see Fig. 29-1). A, Frontal views
before and after reconstruction. B, Profile views before and after reconstruction.
Continued

1676 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
C
D
Removed silastic implants
Crafted iliac bone graft
Dorsum
Tip
Columella
C
C, Worm’s-eye views before and after reconstruction. D, Intraoperative views of removed Silastic implants (placed by
another surgeon) and crafted iliac corticocancellous bone graft placed at the time of reconstruction.
• Figure 38-41, cont’d

1677
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 38-42  A 15-year-old girl was born with a mild Tessier 0 and 14 craniofacial cleft. There is congenital separation of the nasal
bones and the septum. The degree of orbital hypertelorism is minimal. She underwent reconstruction that included nasal osteotomies
(in-fracture) and augmentation of the dorsum of the nose (from the radix to the tip) with a crafted fixed full-thickness cranial bone graft.
The lower lateral cartilages were sutured over the top of the cranial graft to create the new nasal tip. Access was gained through
coronal scalp and open rhinoplasty (columella splitting) incisions. A, Frontal views before and after reconstruction. B, Close-up frontal
view of the nose before and after reconstruction.
Continued

1678 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
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
C
D
C, Oblique views before and after reconstruction. D, Profile views of nose before and after reconstruction.
• Figure 38-42, cont’d

1679
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
©Elsevier Inc.
Or
Orthth
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gn
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g atatatatatatatatatathicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C Pos
os
os
osnicicicick
©Elsevier Inc.
Orth
r ogn
gn
gn
gn
gn
gn
gnatatatatatatatathicicic Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry; J.C.
C.
C Pos
osnicici k
©Elsevier Inc.
Or
Or
Or
Orthththththth
r ogn
gn
gn
gn
gn
gn
g atatathicicicicicic 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; J.C.
C.
C.
C.
C. Pos
os
os
os
os
o nick
©Elsevier Inc.
Or
Or
Or
Or
Or
O ththththth
r ogn
gn
gn
gn
gn
gn
gn
g atatatathicicicicici 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; J.C.
C.
C.
C Pos
os
os
osnicick
E
F
G
E, Close-up profile view of nose before and after reconstruc­
tion. F, Worm’s-eye view of nose before and after reconstruction. G, Intraoperative view
of crafted full-thickness cranial graft (45 mm in length). View of the frontonasal region
with plate and screw fixation to create the correct nasofrontal angle.
• Figure 38-42, cont’d

1680 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
Orth
r ognathic Surg
r ery; J.C. Posnick
A
B
•  Figure 38-43  A child was born with a severe Tessier 0 and 14 craniofacial cleft. She underwent repair of the cleft lip when she was 1 year
old; this was followed by cleft palate closure when she was 18 months old at another institution. She was referred to this surgeon when she was
4 years old for craniofacial reconstruction. She underwent a bifrontal craniotomy and facial bipartition (FB) osteotomies. The two halves of the
face were then three-dimensionally repositioned for the correction of upper-face hypertelorism and to close the cleft of the nose and the upper
jaw. A, Frontal and computed tomography scan views early after birth. B, Facial and computed tomography scan views after lip repair but before
palate closure.

1681
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
C
D
After facial bipartition and
resection of central segment
After reconstruction
Prior to craniotomy
After craniotomy
C, Illustrations of the craniofacial skeleton with proposed and completed facial bipartition and anterior
cranial vault osteotomies and reconstruction. D, Intraoperative views before craniotomy; after craniotomy; after FB osteotomy and
resection of the central segment of the nasofrontal region; and after FB and cranial vault reconstruction.
• Figure 38-43, cont’d
Continued

1682 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
F
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
E
E, Intraoperative views through coronal scalp incision after cranial vault and FB reconstruction. F, Facial views
before and after reconstruction. A, C, D, E, and F from Posnick JC: The role of plate and screw fixation in the treatment of craniofacial
malformations. In Gruss JS, Manson PM, Yaremchuk MJ, eds: Rigid fixation of the craniomaxillofacial skeleton, Stoneham, Mass, 1992,
Butterworth, pp 512-526.
• Figure 38-43, cont’d

1683
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
C
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orthththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
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gn
gn
gn
gn
gn
gn
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gn
gn
gn
gn
g
tatatatatatatatatatatatathicicicicicicicic 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; J.C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
o nicicicicicicicicicicicicicici k
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or hthththththththth
r ogn
gn
gn
gn
gn
gn
gn
gnatatatatathicicicic Su
Su
Su
Surg
r ery
ry
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
osnicicicicicicicicici k
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththth
r ogn
gn
gn
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gn
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gn
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g atatatatatatatatatatatatatathicicicicicicicic 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; J.C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
o nicicicicicicicicici k
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g
tatatatatatatatathicicicic Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry; J.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
o nicicicicicicicicicicicicicicicick
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
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Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
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gn
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gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicici 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; J.C.
C.
C.
C.
C.
C.
C.
C Pos
os
o nicick
©Elsevier Inc.
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 thththththththththththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
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gn
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gn
gn
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gn
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gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatath cicicicicicicicicicicicicicicicicicicicicicici 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; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
osnicici k
A
B
•  Figure 38-44  A child was born with frontonasal
dysplasia that was characterized by upper-face
hypertelorism and a bifid nose. This proved to be
a non-progressive malformation without significant
functional consequences, but it did result in facial
dysmorphology. When he was 9 years old, the
patient underwent anterior cranial vault and facial
bipartition osteotomies through an intracranial
approach to improve the upper-face hypertelorism,
including nasal reconstruction. A, Facial views in
repose before and after surgery. B, Facial views
with smile before and after surgery. C, Profile views
before and after surgery.
Continued

1684 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
E
D
D, Intraoperative views of the upper orbits and the anterior cranial vault before and after reconstruction. The views indicate
the planned craniotomy, the osteotomies, and the naso–fronto–ethmoid ostectomy; after craniotomy, the facial bipartition and the mid-nasal os­
tectomy; and after the correction of the upper and midface hypertelorism, including a full-thickness cranial bone graft that is fixed in place from
the radix to the tip of the nose. After stabilization of the nasal bone graft, the lower lateral cartilages were pexied over the tip of the graft through
the exposure provided by the columella skin incision. E, Three-dimensional craniofacial computed tomography scan views before and after
reconstruction.
• Figure 38-44, cont’d

1685
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
Or
Or
O ththth
r ogn
gnatatata hicici Su
Surg
r ery
ry; J.C.
C.
C.
C.
C.
C. Pos
os
o nicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnathicicicicici Su
Su
Surg
r ery
ry
ry; J.C.
C.
C Pos
os
os
os
os
os
os
o nicicicicicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththth
r ogn
gn
gnatatatathicicicicic Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C. Pos
os
os
os
o nicicicici k
Or
Or
Or
Or
Orththththththththththththth
r ogn
gn
gn
gnatatathicicic Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry; J.C.
C.
C Pos
os
os
os
os
osnicicicicici k
A
B
C
Or
Or
Orthththth
r ogn
gn
gn
gn
gn
gn
gn
g
tatatathicicicicicic 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; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
o nicicicicicicicicicicicicicicicicicicicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orthththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatathicicicicicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
r ; J.C.
C.
C.
C Pos
os
os
os
os
os
os
o nicicicicicici k
•  Figure 38-45  A 4-year-old boy fell and
hit the bridge of the nose on a hard table.
Over the next several years, a saddle
deformity developed. He arrived to this
surgeon for evaluation when he was 8
years old and then underwent reconstruc­
tion; this was carried out through coronal
scalp and open rhinoplasty (columella
splitting) incisions. The reconstruction
included nasal osteotomies (in-fracture);
the placement of fixed full-thickness
cranial grafts; and the suture pexy of the
lower lateral cartilages over the top of the
graft (see Fig. 35-2). A, Frontal view at
3 years of age just before injury and then
at 8 years of age just before surgery.
B, Frontal views before and 6 months after
reconstruction. C, Oblique views before
and 6 months after reconstruction.
Continued

1686 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
D
E
Parietal donor site
D, Lateral skull radiographs of the nose before and 6 months after reconstruction. E, Intraoperative views
through the coronal scalp incision demonstrating the frontonasal region and the proposed right cranial vault donor site. Crafted
full-thickness cranial bone grafts are shown before placement for nasal reconstruction. The close-up view of the frontonasal region
shows the full-thickness cranial bone grafts in place and stabilized with microplates and screws.
• Figure 38-45, cont’d

1687
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
the end result is a flattened, splayed, and sometimes asym­
metric osseous vault in combination with a depressed
cartilaginous vault. The trauma event or the congenital
anomaly also leads to ULC and LLC displacement with
poor tip projection, flaring of the alae, widening of the
domes, and rounding of the anterior nares. The extensive
traumatic or congenital anomalies that caused the saddling
of the cartilaginous and osseous vault will also result in
mechanical nasal airway obstruction. When this occurs
during childhood, the forced oral respiratory pattern with
a constant open-mouth posture often results in a long
face growth pattern over the ensuing years (see Chapters
4 and 21).
The correction of a severe saddle-nose deformity of the
bony and cartilaginous vaults requires the insertion of a
deep dorsal graft from the radix to the tip that is ideally
constructed from either autogenous cartilage or autogenous
bone (see Fig. 35-45). Rib cartilage has advantages over
bone in that it restores flexibility to the cartilaginous vault
and tip, it is often considered easier to harvest, and it is less
prone to resorption. It has the disadvantages of having a
tendency to warp, not adhering to the underlying osseous
vault, and not replacing like for like over the osseous vault.
Autogenous bone (e.g., calvarial, iliac, rib) has the advan­
tages of ease of crafting, adherence to the underlying basal
bone when properly immobilized (fixed), and replacing like
for like tissue over the osseous vault. It has the disadvantages
of requiring more complex donor site harvesting, having a
tendency for partial resorption, and resulting in a firm nasal
tip that is prone to fracture. Whether autogenous cartilage
or bone is used to correct the osseous and cartilaginous
vaults, reliable reconstruction requires satisfactory skin
Surgical Approach to the Combined Collapse
of the Osseous and Cartilaginous Vaults
Surgical attempts to correct the postseptoplasty pattern of
saddle-nose deformity have been reported for at least the
past century. McDowell and colleagues discussed the mul­
tiple heterogeneous implant methods used during his time,
which included inorganic materials (e.g., gold, silver, tin,
thallium, Vitallium, plastic, silicone) and organic implants
(e.g., ivory, cartilage, bone, fibrin, fascia).138 Fomon and
colleagues described the use of autogenous materials for
the restoration of nasal contour (i.e., fat, dermis, cartilage,
and bone).64 Historically, local transposition flaps were
often recommended to augment the internal (mucosa)
lining or the external (skin) cover. By the 1950s, most
clinicians agreed that individuals who presented with
marked depressions of the cartilaginous and bony dorsum
required firm, deep, layer grafts or implants. Surgical recon­
struction is now thought to require grafting from the radix
to the tip and often from the tip down to the base of the
maxilla. Today, autogenous tissue is generally used, but
donor-site preference, fixation techniques, and how the
graft holds up at the recipient site remain important
questions.
Posttraumatic saddle-nose deformities of the bony vault
often result from displaced fractures with secondary col­
lapse after incomplete reduction (see Fig. 38-45). In addi­
tion, a crush injury to the nose during early childhood
will result in impaired growth and progressive deformities.
Another subgroup of patients with saddle-nose deformity
presents during adolescence with congenital nasal and
dentofacial anomalies (see Fig. 38-41). Whatever the cause,
©Elsevier Inc.
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Pre-surgery
6 months after surgery
16 years after reconstruction
F, Close-up lateral views of the nose just before surgery and at 6 months and then 16 years after
reconstruction.
• Figure 38-45, cont’d

1688 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
cover, internal nasal lining, and LLCs that can be pexied
over the graft to form the superficial aspect of the new
nasal tip.
Autogenous graft options to consider include the
following:
1. Rib costochondral graft (radix to tip). This is combined
with a separate rib cartilage caudal strut graft that
extends from the base of the maxilla (stabilized with
a K-wire). It is then secured with sutures to the dorsal
costochondral graft at the tip. The LLCs are sutured
over the grafts to form the height of the new
nasal tip.
2. Rib cartilage graft (radix to tip). A no. 35 K-wire may
be inserted through the dorsal strut graft to prevent
warping. The dorsal graft is combined with a separate
rib cartilage caudal strut graft that extends from the
base of the maxilla (stabilized with a K-wire). The
caudal graft is then secured with sutures to the dorsal
strut rib cartilage graft at the tip. The LLCs are
sutured over the grafts to form the height of the new
nasal tip.
3. Calvarial graft (radix to tip). The crafted calvarial bone
graft is firmly secured with K-wires or titanium plates
and screws to the underlying nasal bones. The LLCs
are sutured over the graft to form the height of the
new nasal tip.
4. Iliac graft (radix to tip). The crafted iliac graft is firmly
secured with a K-wire or titanium plates and screws
to the underlying nasal bones. The LLCs are sutured
over the graft to form the height of the new nasal tip.
Extension of the bone graft into an “L” shape as a
caudal strut may be done to limit the fracture and
resorption of the dorsal strut.
Cocaine-Related and Autoimmune and
Iatrogenic Saddle-Nose Deformities
The hallmark of most cocaine-related, autoimmune, and
iatrogenic saddle-nose deformities is significant septal perfora­
tions that result in deficiency (depression) of the cartilaginous
vault, generally with an intact osseous vault (Fig. 38-46).
Cocaine is an alkaloid that was originally used by
South American Indians as a stimulant. It was introduced
to medicine by Koller in the 1880s as a local anesthetic.119
The recreational use of cocaine is a common form of
drug abuse throughout the world. At least 30 million
Americans are estimated to have used cocaine at least
once (i.e., 20% of the adult population), and 6 million
use it with some regularity (i.e., once a month or more).56
It is estimated that approximately 20% of users become
addicted. The most commonly used route of administra­
tion for the drug is intranasal inhalation or “snorting.”58
Cocaine’s intense local vasoconstrictive effects and mucosal
irritation from substances with which it is “cut” (e.g.,
talc, mannitol, lactose, amphetamines, borax, plaster of
Paris) may lead to inflammation and ulceration of the
nasal mucosa.66,227 Permanently exposed septal cartilage
in combination with bacterial overgrowth will lead to
osteochondritis and further necrosis and perforations,
thereby resulting in the loss of structural support and
the collapse of the nasal dorsum.19,246 Less common but
reported complications in the sinonasal region after cocaine
abuse include oronasal fistulas, palatal destruction, and
even complete midface necrosis.216,224,228 All reported cases
of palatal perforations from cocaine insufflation initially
presented with a limited perforation of the nasal septum
followed by progressive destruction of the associated
structures.7,14,65,71,87,134,212,242
The adverse effects of cocaine on the nasal structures were
first systematically reported by Owens in 1912.167,170 He
described a range of cocaine-induced deformities, from a
pinhole perforation to progressive degrees of mucosal ulcer­
ation, destruction of the septal cartilage, and, in extreme
cases, the destruction of the nasal and maxillary bones.
When a nasal septal perforation is small and anterior, it can
cause a disconcerting whistle during breathing. When the
hole is larger and more posterior, as it is in most individuals
who present for the surgical evaluation of a saddle nose, it
will have destroyed most of the septal cartilage.145 Businco
and colleagues reported on a series of 104 patients who
habitually inhaled cocaine more than 10 times per month.22
They were observed for at least 2 years. Among them, 11
patient (11%) had nasal septal perforation. Of these 11
patients, 8 had nasal septal perforation of just the quadran­
gular cartilage; in the other 3, the perforation also involved
the bony tract (i.e., the vomer-perpendicular ethmoidal
lamina).
Over the years, the management of cocaine-induced
septal perforations has included the placement of “buttons”
to block the defect; the use of local nasal mucosal flaps;
the use of regional nasolabial flaps; and the use of distant
microvascular repairs.28,56,120,122,132,140,154,155,158,171,204 The flap
options, even when they effectively close the perforation,
typically obstruct normal function of the airway as a result
of their bulk. This author in agreement with most clinicians
that, until a safer and more reliable vascularized and thin
flap is found and proven to be effective, it is generally best
to maintain good nasal hygiene and not attempt perforation
closure.143
Similar septal perforations and secondary saddle defor­
mities of the cartilaginous vault are sometimes seen after
overly aggressive surgical submucosal resections that have
been carried out to relieve nasal obstruction or after
postoperative or posttraumatic hematoma or infection
(see Fig. 38-46).
The same pattern of saddle-nose deformity is frequently
observed in patients with Wegener granulomatosis.8,61,159
This is a rare multisystem autoimmune disease of unknown
etiology. Its hallmark features include necrotizing granu­
lomatosis, inflammation, and pauci-immune vasculitis in
small and medium-sized blood vessels. In 1897, Peter
McBride gave the first written description of a patient

1689
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
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B
•  Figure 38-46  A middle-aged woman
of Arabic descent with a postsurgical (iat­
rogenic) saddle-nose deformity. Two years
earlier, she underwent an aggressive sep­
toplasty procedure at another institution.
This resulted in a large septal perforation
with the collapse of the cartilaginous vault.
She arrived for evaluation and then under­
went nasal reconstruction that included
rib cartilage grafting with caudal and
dorsal struts as described in text.
A, Frontal views before and after recon­
struction. B, Oblique views before and
after reconstruction. C, Profile views
before and after reconstruction.
Continued