Core Procedures In Plastic Surgery: Cẩm Nang Các Quy Trình Cốt Lõi Trong Phẫu Thuật Tạo Hình

39
Operative techniques
• With the inferior-lateral border of the orbicularis oculi
muscle as a depth gauge, the dissection is carried over
the lateral border of the zygomaticus major muscle into
the subcutaneous plane.
• Dissection is then carried down the lateral border of the
zygomaticus major muscle to the level of the modiolus
(Fig. 2.30).
• In patients with minimal nasolabial fold depth, dissection
stops short of the fold to preserve attachment of the fat to
the cheek flap (Fig. 2.31).
• In patients with deep nasolabial folds, usually associated
with a thin face, complete dissection across the nasolabial
fold into the lip is done (Fig. 2.32).
• Inferiorly, the dissection continues down the fascial
fusion plane at the anterior border of the
sternocleidomastoid muscle.
• Here a short 2–3 cm “back cut” in the investing fascia
and platysma is made about 4 cm below the mandibular
border.
• The “back cut” is made at this level to avoid any aberrant
branches of the marginal mandibular facial nerve.
• The SMAS is divided horizontally above the zygomatic
arch over to the lateral orbicularis.
• Using the visible edge of the orbicularis as a depth
marker, the dissection is carried over the malar area to
release the zygomatic retaining ligaments.
Figure 2.26  (A) In patients with malar deflation or malar pad descent, an extended SMAS dissection can be performed in which the SMAS dissection is extended into the
malar region in an attempt to re-elevate ptotic malar fat back upward over the zygomatic prominence. The incisions begin at the junction where the zygomatic arch joins the
body of the zygoma. From this point, the incision in the SMAS is angled superiorly toward the lateral canthus and along the lateral orbital rim. The incision in the SMAS is
then carried medially and inferiorly toward the peripheral extent of skin flap undermining, angling toward the uppermost portion of the nasolabial fold (the amount of
subcutaneous undermining is shaded in pink, whereas the amount of SMAS undermining is shaded in yellow.) (B) The malar-SMAS dissection is then performed in
continuity with the cheek-SMAS dissection. Dissecting in the malar region carries the dissection directly along the superficial surface of the zygomaticus major and usually
exposes the lateral aspects of the zygomaticus minor as well. To obtain adequate mobility in terms of SMAS dissection, it is necessary to elevate the malar portion of the
dissection completely from the zygomatic eminence and free it from the zygomatic ligaments. To obtain mobility in terms of SMAS movement affecting the jowl contour, the
uppermost portions of the masseteric cutaneous ligament commonly are divided, especially where they merge with the zygomatic ligaments of the malar area. If these fibers
are not divided, they will restrict the upward redraping of jowl fat. On division of the upper portion of the masseteric cutaneous ligaments, the buccal fat pad becomes
evident, and commonly the zygomatic nerve branches traversing toward the undersurface of the zygomaticus major muscle are visualized. This diagram illustrates the typical
degree of mobilization performed in our extended SMAS dissection.
A
B

40
•
• Facelift
2
Figure 2.27  It is commonly necessary to extend the malar SMAS dissection more
peripherally than the subcutaneous dissection to obtain adequate flap mobility of
the soft tissues lateral to the nasolabial fold. This portion of the dissection is easily
performed by simply inserting the scissors in the plane between the superficial
surface of the elevators of the upper lip and the overlying subcutaneous fat. Once
the scissors are inserted in the proper plane, the surgeon bluntly dissects in a
series of passes past the nasolabial fold (area marked in green). As long as the
scissors remain superficial to the elevators of the upper lip, motor nerve injury will
be prevented. Usually three or four passes are required to obtain adequate flap
mobility.
Figure 2.28  The vectors of redraping of the extended SMAS flap are determined
according to the preoperative evaluation of the patient and are generally more
cephalad than skin flap redraping.
• With completion of this release, the entire subcutaneous
cheek mass, from mandible to orbit, will freely move
superiorly.
■ It is paramount to mobilize the cheek in a pure vertical
– not horizontal or oblique – direction. The primary
vector is vertical along the lateral orbital rim (Fig. 2.33).
• Key sutures are placed in the deep temporal fascia and in
the mastoid fascia.
• The periauricular SMAS is then completely closed with a
continuous suture to disperse the tension from the key
sutures.
• Redundant skin is trimmed in place and closed in similar
fashion as described above.
Subperiosteal midfacelift (Chapter 11.8)
(Video 2.7)
• In this author’s particular technique, the subperiosteal
midfacelift is often combined with a functional lower
blepharoplasty in an effort to rejuvenate the lower eyelid
while preserving its function.
• The midfacelift begins with Xylocaine 0.5% mixed with
epinephrine at 1/200 000 dilution, which is infiltrated in
the temporal and midface areas.
• The midface is approached from above through a
temporal incision, and from below through an intraoral
buccal mucosal incision.
• The length of the incision in the temporal area will
depend on the technique used.
• In the open approach, the incision is either a coronal
incision if the forehead lift is also done concomitantly or
a limited temporal-frontal incision.
• Dissection in the temporal area separates the superficial
temporal fascia from the temporal fascia proper in the
upper temporal area, and the superficial temporal fascia
from the intermediate temporal fascia in the lower
temporal area.
Video
2.7

41
Operative techniques
Figure 2.29  In the high SMAS technique, the skin flap is thinly dissected only to the extent of estimated skin excision.
Subgaleal
dissection
Subcutaneous
dissection 4cm
Subcutaneous tunnel
superior to arch
Only skin expected
to be removed is undermined
Subcutaneous dissection of neck from
mastoid to midline superficial to platysma
Figure 2.30  Complete release of the SMAS.
SMAS incision
Upper lateral corner of SMAS
remains attached to skin
Temporal branch,
facial nerve
Marginal mandibular
branch of facial nerve
Dissection from beneath SMAS
over zygomaticus major thus
releasing restraint of investing fascia

42
•
• Facelift
2
• Subperiosteal dissection of the midface is connected with
the temporal optical cavity over the anterior two-thirds of
the zygomatic arch (Fig. 2.34).
• Dissection includes elevation of the soft tissues from the
external lateral orbital rim.
• The sutures applied to the midface have the following
effects: suspension, volumetric remodeling, and lifting.
• The author routinely uses four sutures per side (Fig. 2.35):
• The first suture anchors the anterior central SOOF
(suborbicularis oculi fat) to the most anterior portion of
the temporal fascia proper near the lateral orbital rim
using a 4-0 polydioxanone (PDS) suture.
• Prior to passing to the temporal area it can be anchored
to the immediately superior arcus marginalis which will
act as a pulley to direct the anterior SOOF towards the
orbital rim area helping to efface the tear trough area.
• The second suture anchors the lateral SOOF to the
compound periosteum/SOOF tissue 3 cm inferior and
vertical to the lateral canthal tendon insertion using a 3-0
PDS suture.
• The third suture, the modiolus suspension, anchors the
fibro-adipose tissue just inferior to the most anterior
portion of the intraoral incision to the temporal region
using a 4-0 PDS suture.
• The final suture is applied to the Bichat’s or buccal fat
pad.
• To place the suture, you must first open the anterior-
medial wall of the fat pad, just medial to the masseter
tendon using a blunt and long scissor.
• In the endoscopic technique, dissection continues in this
plane until the superior border of the zygomaticus arch is
reached.
• With upward traction of the temporal flap, the
periosteum of the zygomaticus arch is elevated with a
sharp periosteum elevator.
• In the open approach the intermediate temporal fascia
with its attached intermediate fat pad is elevated 2–3 cm
above the zygomaticus arch and the periosteum is
dissected in continuity.
• This fascial flap will be used as an anchor suspension of
the midface.
• Next, the intraoral buccal incision is made at the level of
the first premolar and done either vertically or slightly
obliquely.
• The initial incision is done through the mucosa only, then
the buccinator muscle is spread with the periosteal
elevator and a subperiosteal dissection is carried out on
the maxilla and malar bones.
• Medially, this extends to the pyriformis area and laterally
underneath the fascia of the masseter muscle.
• This lateral extension goes about 2.5 cm over the
masseter tendon.
• Dissection superiorly is done to separate the orbicularis
muscle attachments to the inferior orbital rim, thus
releasing the arcus marginalis.
• The attachments around the infraorbital nerve are freed
after the fixation points on the midface are applied and
just before their fixation in the temporal fascia proper.
Figure 2.31  In patients with minimal nasolabial fold depth, dissection stops short
of the fold to preserve attachment of the fat to the cheek flap
Stops before anterior
facial vascular and
lymphatic territory
Figure 2.32  Cheek dissection across the nasolabial fold into the lip in patients
with deep nasolabial folds.
Dissection across
nasolabial fold onto lip

43
Postoperative considerations
• For the lower blepharoplasty in this instance, this author
makes a skin incision 2 mm below the ciliary border
which is extended directly into the crow’s foot area.
• The full thickness lower eyelid skin is “peeled” off the
orbicularis muscle layer for an average of 1.5–2 cm
inferiorly, creating a pure skin flap.
• The exposed lateral extension of the preseptal portion is
anchored to the most anterior portion of the temporal
fascia proper with a 5-0 or 6-0 Prolene suture.
• For this maneuver, a window in the lateral orbital portion
of the orbicularis muscle is created with a blunt
dissection.
• The lower eyelid incision can be closed as described in
the blepharoplasty chapter.
Postoperative considerations
• Most surgeons use light dressings to protect the incisions
and to act as an absorbent for wound drainage.
• Once the blades of the scissors are opened, the fat pad
will extrude from its encased buccal space.
• It is then gently pulled with two blunt scissors and
delivered with external pressure on the cheek.
• Once the fat pad has been delivered, a 4-0 PDS suture
with an RB1 needle is weaved into the fat pad utilizing
two or three passes.
• This suture is then anchored to the loop of the SOOF
suture applied beforehand, using a “piggy backing”
technique.
• This limits the upward mobilization of the buccal fat pad
and its potential avulsion.
• All the sutures anchored to the temporal area are done
using the endoscopic sliding Peruvian fisherman’s knot.
• A 2 mm “butterfly” drain is introduced via a mini stab
incision.
• The last suspension suture is applied to the superficial
temporal fascia at the inferior lip of the temporal entrance
port and anchored to the temporal fascia proper above
and anterior to it.
• The scalp is closed with staples.
• The midface cavity is irrigated with antibiotic solution
and closure of the intraoral incision is done with
interrupted 4-0 chromic catgut sutures.
• Once the midface lift is completed, the lower
blepharoplasty can be performed.
Figure 2.33  The cheek mass is suspended vertically (shown with key sutures),
and the entire SMAS flap is closed with a continuous suture to disperse the tension
from the key sutures. An orbicularis flap is then done to suspend the orbicularis.
Fig. 2.34  The “endo-midface” is approached by a single temporal and an intraoral
incision. For this reason, it is better called an endotemporo-midface procedure. The
midface and temporal cavities are connected across the zygomatic arch. The
subperiosteal dissection here is critical to avoid injuring the frontal branch of the
facial nerve. The midface dissection extends under the masseteric fascia for
2–3 cm.

44
•
• Facelift
2
• Dressings should not be tight or constrictive, but rather
soft and comfortable and are typically removed on the
first postoperative day.
• In the initial postoperative period, the patient is kept still
and blood pressure is monitored closely.
• If an increase in blood pressure is endogenous, it should
be treated pharmacologically.
• The patient should keep the head of the bed elevated, but
avoiding flexion of the neck.
• Avoiding the use of a pillow for 10–14 days will help
keep the patient’s head in a neutral, non-flexed position.
• Cool packs to the face will increase comfort and help
decrease swelling.
• Analgesics and antinauseants are used as necessary.
• Patients are usually permitted to have a shower and
wash their hair when the incisions are sealed from the
environment – usually 2–4 days postoperatively.
• Photographic documentation of the surgical result should
be deferred for at least 6 months to allow for all
postoperative swelling to settle completely.
Complications and outcomes
Hematoma
• Postoperative hematoma is the most common facelift
complication.
• Incidence in women has been reported at 2–3%.
• Incidence in men has been reported between 4 and 8%.
• Hematomas typically develop in the first 12 h after
surgery.
• If an expanding hematoma is identified it should be
promptly drained.
• If skin flap compromise is suspected and there is a
delay in returning to the operation, a temporary solution
can be the removal of sutures in order to relieve pressure
(Fig. 2.33).
Sensory nerve injury
• A self-limiting paresthesia which usually recovers
completely in 6–12 months can occur after facelift
surgery.
• The great auricular nerve is the major sensory nerve at
greatest risk of damage during facelift surgery.
• If knowingly transected during facelift surgery,
either partial or complete, it should be repaired
intraoperatively.
Motor nerve injury
• Damage to a facial nerve branch can easily go unnoticed
by the surgeon until muscle paralysis is identified
postoperatively. However, permanent paralysis is a rare
event and has been reported to occur in less than 1% of
cases.
• Persistent dysfunction may be due to surgical traction
or the effect of cautery near a nerve branch; these issues
can be expected to resolve spontaneously over days or
weeks.
• If a facial nerve branch has been transected or wrapped
in a suture, complete functional recovery may still be
possible if the target muscle receives collateral
innervation.
• The most commonly injured branches are thought to be
the buccal branches, although long-term sequelae are
rare due to multiple interconnections between nerve
branches.
• Damaged temporal or marginal mandibular branches are
less likely to recover because they are terminal branches
with less collateral support.
Unsatisfactory scars
• Improper placement of incisions can lead to distortion of
the ear and unnatural shifting of the hairline.
• Excessive tension can lead to loss of hair, depigmentation
and widened scars, and/or hypertrophic scars.
Fig. 2.35  An endoscopic browlift is shown in conjunction with an endoscopic
midfacelift. For the midfacelift, four sutures are used to obtain the maximal
remodeling and beneficial effect of the subperiosteal dissection. The anterior SOOF
(suborbicularis oculi fat) effaces the infraorbital V deformity. The lateral SOOF lifts
the midface. The MS (modiolus suspension) lifts the corner of the mouth. These
three sutures also produce imbrication, thus increasing the anterior projection of the
cheek. The last suture suspension is the buccal (Bichat’s) fat pad (BF). This is the
structure that helps more than any other to create the Ogee line of the midface.
BF with
suspension suture
MS with
suspension
suture
SOOF with
suspension
suture

45
Further reading
Alopecia
• Loss of hair can occur along the incision line or within
the hair-bearing scalp which has been raised as a flap.
• Permanent hair loss can be treated in some cases by
mobilization of an adjacent flap of hair-bearing scalp.
• For significant alopecia, achieving adequate coverage
with hair growth in the proper direction is best achieved
with micro-hair-grafting.
Skin loss
• Factors which can contribute to the avascular loss of skin
include excessive tension, an overly thin flap, hematoma,
constrictive dressings, and perhaps the most damaging of
all – smoking.
• Established skin necrosis should be dealt with
conservatively; the majority of such cases will eventually
heal spontaneously. Scar revision can be done at a later
date.
Infection
• Infection is reported to be rare in facelift surgery, with
various series indicating an incidence of less than 1%.
Further reading
Coleman SR. Facial recontouring with lipostructure. Clin
Plast Surg. 1997;24(2):347.
A pioneer of facial fat grafting presents early experiences
with lipoinjection of the face.
Coleman SR. Structural fat grafting. St Louis: Quality
Medical; 2004.
This text is a comprehensive review of the history, basic
science and technical details of fat harvest and fat injection.
Gosain AK, Amarante MTJ, Hyde JS, et al. A dynamic
analysis of changes in the nasolabial fold using
magnetic resonance imaging: Implications for facial
rejuvenation and facial animation surgery. Plast
Reconstr Surg. 1996;98:622.
A comparative MRI study demonstrates the changes in
subcutaneous fat which develop with age. The authors
conclude that superficial fat in the cheek becomes ptotic
while the underlying elevators of the lip do not elongate
with age.
Jones BM, Grover R. Avoiding hematoma in cervicofacial
rhytidectomy: a personal 8-year quest. Reviewing 910
patients. Plast Reconstr Surg. 2004;113:381.
The authors review a large facelift series where the most
common complication of facelift surgery, hematoma, is
addressed. Variables thought to influence the formation of
hematoma were reviewed, including the use of dressings,
drains, soft tissue adhesives and epinephrine.
Marten TJ. Facelift planning and technique. Clin Plast Surg.
1997;24(2):269–308.
This review article covers the planning, surgical marking
and technical details of two layer facelift surgery. Details
regarding the skin incisions are emphasized.
Mitz V, Peyronie M. The superficial musculoaponeurotic
system (SMAS) in the parotid and cheek area. Plast
Reconstr Surg. 1976;58:80.
This paper is the first description of the superficial
musculoaponeurotic system.
Rohrich RJ, Pessa JE. The fat compartments of the face:
anatomy and clinical implications for cosmetic surgery.
Plast Reconstr Surg. 2007;119:2219–2227.
Anatomic dissections are presented which demonstrate how
the subcutaneous fat of the face is partitioned into multiple,
independent anatomical compartments. In some locations,
the septae dividing the fat compartments are aligned with
retaining ligaments.
Rohrich RJ, Pessa JE, Ristow B. The youthful cheek and the
deep medial fat compartment. Plast Reconstr Surg.
2008;121(6):2107–2112.
Anatomic dissections of deep facial fat are presented (fat
which is deep to the muscles of facial expression). The deep
fat is compartmentalized by septae, creating the deep medial
fat pad, and the suborbicularis oculi fat.
Stuzin J. Restoring facial shape in facelifting: the role
of skeletal support in facial analysis and midface
soft-tissue repositioning (Baker Gordon Symposium
Cosmetic Series). Plast Reconstr Surg. 2007;119:362.
This review discusses the changes in facial shape which
occur with aging, the surgical means we have to correct
these changes, and alterations which should be made with
different degrees of underlying skeletal support.
Stuzin JM. Discussion: essays on the facial nerve: Part I.
Microanatomy. Plast Reconstr Surg. 2010;125(3):
890–892.
Stuzin JM, Baker TJ, Gordon HL. The relationship of the
superficial and deep facial fascias: relevance to
rhytidectomy and aging. Plast Reconstr Surg.
1992;89:441.
Anatomic dissections confirm the presence of retaining
ligaments previously described by other authors as well as
newly described masseteric ligaments. The authors discuss
the support these structures supply between fixed bone and
deep fascia and the superficial fascia.
Tzafetta K, Terzis J. Essays on the facial nerve: Part I.
Microanatomy. Plast Reconstr Surg. 2010;125(3):
879–889.
The authors review facial nerve anatomy and present
anatomic findings which confirm extensive arborization
between facial nerve branches. The discussion by Stuzin
highlights clinically important issues.

©2014, Elsevier Inc. All rights reserved.
3 Chapter
Rhinoplasty
Brief introduction
• Regardless of your preferred technique, a thorough
knowledge of nasal anatomy and understanding of nasal
airflow and physiology are the foundations for successful
aesthetic and functional rhinoplasty.
• Proponents of open rhinoplasty argue that closed
rhinoplasty is difficult because the surgeon does not have
good binocular vision through small incisions, the
dissection is blind, the anatomy is complex, and the
operation is technically difficult.
• Proponents of endonasal or closed rhinoplasty
techniques point to two common considerations:
■ First, by separating columellar skin from the
medial crura, the surgeon loses an important
component of tip stability and projection, which
therefore requires some method (suture fixation or
columellar strut) to support the medial crura so that a
new nasal tip can be made. The strut can impart
rigidity to the columella and increases graft
requirements.
■ In primary patients, this consideration may be
unimportant, but in secondary patients, whose donor
sites are already depleted, every bit of graft material
counts.
■ Though incisions are limited, endonasal rhinoplasty is
not a blind operation. Most procedures are performed
under direct vision with greater access than endoscopic
surgery permits.
■ The operative strategy, making skeletal changes
through limited incisions and judging progress by
feeling the surface, is precisely the same discipline
required by suction-assisted lipectomy.
■ Limited pocket dissection minimizes the need for graft
fixation and simplifies some procedures.
■ Solid or crushed grafts can be used in ways that
would be tedious or impossible by the open
approach, although some solutions have been
described.
This chapter was created using content from
Neligan & Warren, Plastic Surgery 3rd edition,
Volume 2, Aesthetic, Chapter 18, Open technique
rhinoplasty, Rod J. Rohrich and Jamil Ahmad/
Chapter 19, Closed technique rhinoplasty,
Mark B. Constantian.
SYNOPSIS (OPEN RHINO)
■ Accurate preoperative analysis and clinical diagnosis set the
foundation for successful primary open rhinoplasty.
■ Open rhinoplasty allows anatomic exposure, identification, and
correction of nasal deformities.
■ Component dorsal hump reduction allows accurate and incremental
reduction of the nasal dorsum while preventing problems with
internal valve collapse or dorsal irregularities.
■ Nasal tip suturing techniques allow control of definition without
damaging the osseocartilaginous framework and compromising
support.
■ Knowledge of the normal course of recovery and potential
complications is key to managing patient expectations in the
postoperative period.
SYNOPSIS (CLOSED RHINO)
■ Nature is predictable – therefore nasal phenomenology can be
understood.
■ Rhinoplasty has consistent “behavioral” rules, like all surgery
– therefore the surgeon can control the result.
■ Nasal deformities are not limitless or lawless but follow patterns
– therefore their solutions follow patterns.
■ Sequential intraoperative photography teaches nasal behavior and
structural interactions.
■ Follow the technical rules that apply to all other surgery: limit
dissection, morbidity, and tension on closure.
■ Reconstruct anatomically.
■ Never forget function.
■ Never forget the patient’s own aesthetic.
■ Remember that most problems are under the surgeon’s control.
■ Always follow your patients closely.

47
Preoperative considerations
require treatment, but they do supply cautionary
notes.
■ The most common grouping in both primary
and secondary patients was the triad of low
radix, narrow middle vault, and inadequate tip
projection.
■ The second most common grouping was the
association of all four anatomic traits.
• For many years, the following concepts provided the
basis for analysis of the obstructed nose:
■ The bony and cartilaginous septal partition, deformed
by congenital or traumatic causes, may obstruct the
nasal airway.
■ Compensatory hypertrophy of the contralateral inferior
turbinate frequently occurs, so that both airways
eventually become obstructed.
• These concepts are more understandable if the reader
considers airway size to be the product of at least four
factors: (1) mucosal sensitivity to the environment or
hereditary factors; (2) inferior turbinate hypertrophy from
many causes; (3) septal deviation; and (4) position and
stability of the lateral nasal wall during the dynamic
process of ventilation.
Preoperative considerations
• Obtain information on the patient’s medical and
emotional suitability to undergo rhinoplasty.
• Feelings of inadequacy, immaturity, family conflicts,
divorce, and other major life changes may be unhealthy
motivating factors behind the patient seeking aesthetic
surgery.
• Poor postoperative patient satisfaction is often based on
emotional dissatisfaction as opposed to technical failure,
and this can be avoided by the preoperative identification
of these unhealthy motivating factors.
• Review past medical history and specifically note a
history of allergic disorders, including hayfever and
asthma, and other problems, including vasomotor rhinitis
and sinusitis. These conditions should be controlled prior
to rhinoplasty, however, patients should be informed that
they may be exacerbated in the postoperative period and
can persist for weeks to months.
• Nasal obstruction is usually found in patients with
a long history of allergic rhinitis secondary to inferior
turbinate hypertrophy. Engorgement of the inferior
turbinates causes these symptoms to be worse at
night. Patient’s may also complain of headache because
of the inadequacy of the inferior turbinate to warm
inspired air.
• Prior nasal trauma and surgeries, including rhinoplasty,
septal reconstruction/septoplasty and sinus surgery,
should be noted.
• Smoking, alcohol consumption, and use of illicit drugs, in
particular cocaine, can compromise outcomes.
Medications including acetylsalicylic acid, nonsteroidal
anti-inflammatory drugs, fish oil, and certain herbal
supplements may cause increased risk of bleeding and
postoperative ecchymosis.
• In rhinoplasty, there are four common anatomic variants
that predispose to unfavorable results:
• Low radix or low dorsum:
■ Low radix or low dorsum begins caudal to the level of
the upper lash margin with the patient’s eyes in
primary gaze.
■ The low radix is one of several primary causes of nasal
imbalance: an upper nose that seems too small for its
lower nasal component.
■ When the radix begins lower than the upper lash
margin, dorsal length is therefore shorter and so nasal
base size appears larger.
■ If the surgeon reduces the nasal dorsum, the patient’s
preoperative skeletal and skin sleeve maldistribution
will worsen and the lower nose will appear even
larger.
■ The surgeon should instead either limit tip reduction
or raise the dorsum segmentally or entirely to balance
the nasal base.
• A narrow middle vault:
■ Arbitrarily defined as any upper cartilaginous vault
that is at least 25% narrower than the upper or lower
nasal third. This variant is a trait that places the
patient at special risk for internal valvular obstruction,
which can exist preoperatively or may be produced by
dorsal resection.
■ Inadequate tip projection is defined as any tip that
does not project to the level of the anterior septal
angle.
■ Alar cartilages sufficiently strong to support the tip to
the level of the septal angle are “adequately
projecting”; alar cartilages too weak to do so are
“inadequately projecting”.
■ The practical value of this definition lies in its ability
to define treatment: adequately projecting tips do not
need increased support, whereas inadequately
projecting tips do.
■ “Alar cartilage malposition” describes cephalically-
rotated lateral crura whose long axes run on
an axis toward the medial canthi instead of
toward the lateral canthi, the position of orthotopic
lateral crura.
■ This anatomic variation was first recognized by Sheen
as an aesthetic deformity that produced a round or
boxy tip lobule with characteristic “parentheses” on
frontal view.
■ Malposition also has two additional ramifications that
are not aesthetic:
■ First, the abnormal cephalic position of the
lateral crura places them at special risk if an
intercartilaginous incision is made at its normal
intranasal location.
■ Second, most malpositioned lateral crura do not
provide adequate external valvular support, and so
malposition is not only associated with boxy or ball
tips but also the leading cause of external valvular
incompetence.
■ None of these four anatomical variants (low radix or
low dorsum, narrow middle vault, inadequate tip
projection, and alar cartilage malposition) always

48
•
• Rhinoplasty
3
surgery and deformities that may persist after surgery,
including notches, grooves, and irregularities. Facial
disproportions and asymmetries should be pointed out to
the patient as these may require orthognathic surgery to
address.
• Identifying the patient’s expectations preoperatively is a
key component to postoperative patient satisfaction and
successful rhinoplasty.
• Common concerns include asymmetry, tip deformities,
dorsum irregularities, and nasal airway obstruction.
• The patient should attempt to rank these concerns in
order of importance.
• A patient who focuses on minor or uncorrectable
problems or who has unrealistic expectations despite
extensive discussion will likely be disappointed following
surgery regardless of the aesthetic improvement; it is
better to avoid operating on these patients.
• In general, the ideal candidate for surgery has
legitimate concerns and realistic expectations, and is
secure, well informed and understands the limitations of
surgery.
• The acronym SYLVIA has been used to describe the ideal
patient: secure, young, listens, verbal, intelligent, and
attractive.
• The poor candidate for surgery has excessive concerns
about minimal deformities and unrealistic expectations,
and is insecure, poorly informed, and fails to recognize
the limitations of surgery. These patients are likely to be
unsatisfied following surgery regardless of the aesthetic
improvement. They should be approached with caution
and in most cases should not be operated on.
• The acronym SIMON has been used to describe this
patient: single, immature, male, overly expectant, and
narcissistic traits.
• Proper identification of causative factors of nasal airway
obstruction is key to successful treatment. Nasal airway
obstruction can have both medically and surgically
correctable causes.
• Common surgically correctable causes include nasoseptal
deviation, internal or external valve dysfunction, and
inferior turbinate hypertrophy.
• Primary and secondary rhinoplasty patients differ in
three characteristic ways.
■ First, the secondary patient’s scarred, contracted soft
tissues will not tolerate aggressive dissection, multiple
incisions, or tight dressings.
■ Second, graft donor sites may have already been
harvested, necessitating the use of more difficult
Table 3.1  External nasal analysis
Frontal view
Facial proportions
Skin type/quality
Fitzpatrick type, thin or thick,
sebaceous
Symmetry and nasal
deviation
Midline, C-, reverse C-, S- or
S-shaped deviation
Bony vault
Narrow or wide, asymmetrical, short or
long nasal bones
Midvault
Narrow or wide, collapse, inverted-V
deformity
Dorsal aesthetic lines
Straight, symmetrical or asymmetrical,
well or ill defined, narrow or wide
Nasal tip
Ideal/bulbous/boxy/pinched, supratip,
tip defining points, infratip lobule
Alar rims
Gull-shaped, facets, notching,
retraction
Alar base
Width
Upper lip
Long or short, dynamic depressor
septi muscles, upper-lip crease
Lateral view
Nasofrontal angle
Acute or obtuse, high or low radix
Nasal length
Long or short
Dorsum
Smooth, hump, scooped out
Supratip
Break, fullness, polybeak
Tip projection
Over- or underprojected
Tip rotation
Over- or underrotated
Alar–columellar
relationship
Hanging or retracted alae, hanging or
retracted columella
Periapical hypoplasia
Maxillary or soft tissue deficiency
Lip–chin relationship
Normal, deficient
Basal view
Nasal projection
Over- or underprojected, columellar–
lobular ratio
Nostril
Symmetrical or asymmetrical, long or
short
Columella
Septal tilt, flaring of medial crura
Alar base
Width
Alar flaring
Table 3.2  Internal nasal exam
External valve
Collapse
Internal valve
Narrowing, collapse
Mucosa
Edema, irritation
Inferior turbinates
Hypertrophy
Septum
Deviation, tilt, spurs, perforation, cartilage
Masses
Polyps, tumors
• Anatomic examination includes both external nasal
analysis (Table 3.1) and internal nasal examination (Table
3.2). In addition, facial analysis plays a key role in
achieving facial harmony after rhinoplasty.
• Standardized photography is obtained for every patient
presenting for rhinoplasty and includes frontal, lateral,
oblique, and basal views of the patient.
• It is useful to review photographs with the patient to
identify areas of concern that can be addressed with

49
Anatomical pearls
Figure 3.1  The structural layers of the nose, which separate those anatomical
units that move together. The investing soft tissues and alar cartilages glide over
the inner, fixed, semirigid layer, which contains the bony vault, the upper
cartilaginous vault, and the nasal septum.
$
%
(distorted septum or concha), painful (costal), or
frightening (calvarial) donor sources.
■ Third, the secondary rhinoplasty patient’s morale is
often more fragile. Having already invested money,
time, discomfort, and emotion in one or more
unsuccessful procedures, what secondary rhinoplasty
patients’ fear most and need least are additional
disappointments.
• For secondary rhinoplasty patients, the surgeon should
be careful to construct a plan that is based on a clear
understanding of what is possible and founded on sound
surgical and biologic principles that maximize the airway
and respect the patient’s aesthetic goals.
• Before agreeing to operate on a patient, the surgeon must
be able to answer each of the following questions
affirmatively:
■ Can I see the deformity? This question eliminates
delusional patients or those with minimal defects that
may not be surgically correctable.
■ Can I personally fix it? This criterion will vary from
surgeon to surgeon and must be based on operative
experience and ease in correcting specific problems.
■ Can I manage the patient? A patient who is unacceptably
nervous, impossible to examine, or unwilling to
comply with preoperative and postoperative
instructions is a poor candidate, even if all other
conditions are met.
■ If there is a complication, will the patient remain controlled
and cooperate with treatment? No patient enjoys a
complication, but there are those who, although
disappointed, quietly understand and will await the
proper time for revision. There are others who become
hysterical, angry, disruptive, or accusatory and want
an immediate correction.
■ Does the patient accept the margin of error inherent in
surgery? This is the most important criterion. The
patient’s willingness to accept the imperfection that is
inherent in surgery is a willingness to accept the
imperfection that is inherent in being human.
Anatomical pearls
• It is helpful to conceptualize the nose as a system of two
interrelated layers (Fig. 3.1).
• The outer layer, like a soft, elastic sleeve, slides over the
inner semi-rigid layer and contains the entire investing
nasal soft tissues plus the alar cartilages and their
associated lining.
• The inner layer contains everything else (the bony and
upper cartilaginous vaults, the nasal septum, and their
associated linings.)
• This two-layer concept associates those structures that
behave together anatomically and functionally, and
provides an explanation for the “global” manifestations
of some surgical changes (e.g., the effect of dorsal
reduction or augmentation on nasal length).
• The internal nasal valve is formed by the articulation of
the caudal and anterior (or dorsal) edges of the upper
lateral cartilages with the anterior septal edge (Fig. 3.2).
• The external nasal valve is composed of the cutaneous
and skeletal support of the mobile alar wall (the alar
cartilage lateral crura with their associated external and
vestibular skin coverings).
Upper cartilaginous vaults
• The width and stability of the upper cartilaginous vault
(formed by the upper lateral cartilages and the anterior
septal edge), the critical area of the internal nasal valves,
depend not only on the width of the bony vault but also
on the height and width of the middle vault roof.
• Resection of the middle vault roof during hump
reduction removes this most critical anterior stabilizing
force on the upper lateral cartilages, which will fall
medially and produce a characteristic “inverted V”
deformity and consequent narrowing at the internal
valves.
• Middle vault collapse virtually always occurs when the
cartilaginous roof has been resected, whether or not
osteotomy has been performed, but may not be visible if
the overlying soft tissues are sufficiently thick.
• To avoid middle vault collapse and internal valvular
incompetence, the surgeon should plan to reconstruct the
normal distracting forces by a substantial dorsal graft or
by spreader grafts, which provide the same degree of
functional mean nasal airflow improvement (see below).
Middle and lower cartilaginous vaults
• The upper lateral cartilages are supported caudally by
their relationship to the cephalic margins of the lateral
crura in the region of the so-called “scroll”.
• Radical alar cartilage resection can compromise middle
vault support and may leave an external deformity
typified by deepening and lengthening of the alar creases.

50
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3
• In combination with the internal nasal valve, the anterior
extent of the inferior turbinate can be responsible for up
to two-thirds of the upper-airway resistance.
• Inferior turbinoplasty is performed in patients with nasal
airway obstruction secondary to inferior turbinate
hypertrophy refractory to medical management.
• Overly aggressive surgical management may be
complicated by bleeding, mucosal crusting and
desiccation, ciliary dysfunction, chronic infection,
malodorous nasal drainage, or atrophic rhinitis.
• In most cases, inferior turbinoplasty with outfracture of
the inferior turbinate or submucous resection is adequate
to achieve significant improvement (Fig. 3.3).
• In cases of severe inferior turbinate hypertrophy,
submucous resection of the inferior turbinate is
indicated.
• Autologous grafts are preferential to homografts and
alloplastic implants because of their high biocompatibility
and low risk of infection and extrusion.
• Disadvantages include donor site morbidity, graft
resorption, and unavailability of sufficient quantities of
graft material.
• Grafts are most commonly obtained from septal, ear, and
costal cartilage. Other sites include calvarial, nasal bone,
and the olecranon process of the ulna.
• Resect the upper lateral cartilages submucosally only
when failure to do so would allow them to prolapse into
the airway or when necessary to shorten the nose.
• The point of intersection of the upper and lower lateral
cartilages creates the “watershed” area between the
internal and external nasal valves, and aggressive surgery
in this area also affects external valvular competence,
particularly in patients whose alar cartilage lateral crura
are cephalically rotated.
Dorsum and tip
• Tip projection, that is, the intrinsic ability of the alar
cartilages to support the tip lobule independent of dorsal
height, depends on alar cartilage middle crural size,
shape, and substance.
• Septal deviation can involve deviation of the septal
cartilage, perpendicular plate of the ethmoid bone, or
vomer away from the midline and can cause obstruction
of one or both of the nasal airways, along with external
deviation of the nose.
• Nasal deviations can generally be classified into three
basic types: (1) caudal septal deviations; (2) concave
dorsal deformities; and (3) concave/convex dorsal
deformities (Table 3.3).
• Septal tilt is the most common type where the
quadrangular cartilage and perpendicular plate of the
ethmoid are straight but the quadrangular cartilage is
tilted to one side internally and to the opposite side
externally. Hypertrophy of the inferior turbinate
contralateral to the side of internal deviation is usually
present.
• The turbinates exist as three or four bilateral extensions
from the lateral nasal cavity.
• The inferior turbinate consists of highly vascular
mucoperiosteum covering a thin semicircular conchal
bone and is involved in regulation of filtration and
humidification of inspired air.
Figure 3.2  The nasal valves. The internal valves are formed
by the articulation of the upper lateral cartilages with the
anterior (dorsal) septal edge; the external valves are formed by
the alar cartilage lateral crura and their associated investing
soft tissue cover.
Internal valve
External valve
Table 3.3  Classification of nasal deviations
I. Caudal septal deviation
a. Straight septal tilt
b. Concave deformity (C-shaped)
c. S-shaped deformity
II. Concave dorsal deformity
a. C-shaped dorsal deformity
b. Reverse C-shaped dorsal deformity
III. Concave/convex dorsal deformity (S-shaped)

51
Anatomical pearls
used where structural support is necessary. Donor site
morbidity and scarring are minimal.
• Costal cartilage provides abundant autogenous graft
material. It can be used for tip grafts, columellar strut
grafts, nasal spreader grafts, alar cartilage grafts, and
dorsal onlay grafts. Given the size, amount, and intrinsic
qualities, costal cartilage lends itself well to use as a dorsal
onlay graft and where structural support is required.
• It can be carved into any shape. However, allowing at
least 30 min to pass prior to carving allows initial
warping to occur, minimizing late deformity.
• The straightest, smoothest cartilage graft is used for the
nasal dorsum to reconstruct this dominant area covered
by thin soft tissues.
• If septum is available, it is used. Failing that, use rib
cartilage for the dorsum.
• Bone that may be unsuitable elsewhere can be used
instead for spreader grafts, lateral wall grafts, or alar wall
grafts. And primarily in closed techniques, solid or
lightly crushed cartilage scraps can fill regional
depressions.
• The key principle in all augmentation is to match the
graft material to the patient’s soft tissue characteristics
and to his or her aesthetic goals.
• Unmodified rib cartilage is stiff, ear cartilage is rubbery,
and septal cartilage is the most “plastic”.
• Thicker skin needs more augmentation to provide a given
result but will hide more underlying flaws.
• Thinner skin requires softer, well contoured grafts that
will not show excessively.
• A graduated approach to nasal tip surgery requires a
combination of techniques including the cephalic trim,
the use of a columellar strut graft, nasal tip suturing, and
nasal tip grafting.
• Compared with the closed approach, the open approach
may cause mild loss of tip projection due to disruption of
ligamentous support and increased skin undermining. As
such, columellar strut graft and nasal tip suturing
techniques are often employed to maintain nasal tip
support during open rhinoplasty.
• Nasal tip grafts are used in primary rhinoplasty only if
adequate tip projection, definition, or symmetry cannot
be obtained by the use of the previously discussed
techniques. Visible nasal tip grafts are used infrequently
in primary rhinoplasty because of the potential for
long-term resorption leading to asymmetries or sharp
angulations requiring revision.
• Tip suturing techniques (Table 3.4) are used to refine the
tip by controlling the subtle contours of the lower lateral
cartilages.
• When nasal tip grafts are used, it is important that they
have smooth, tapered edges. Nasal tip grafts of all shapes
and sizes have been described (Fig. 3.4).
• The presence of deformities of the alar rims such as alar
notching or retraction, facets of the soft tissue triangles,
malposition of the lateral crura, or functional problems
including external valve collapse may require the use of
lateral crural horizontal mattress sutures, lower lateral
crural turnover flaps, alar contour or lateral crural strut
grafts to correct.
• Concerns regarding donor site morbidity, graft
availability, and graft resorption will necessitate the use
of homologous or alloplastic implants.
• Septal cartilage is the primary choice for autogenous
grafts in rhinoplasty. It can be used in all areas including
tip grafts, dorsal onlay grafts, columellar strut grafts, and
nasal spreader grafts. It is easily harvested, leaves
minimal donor site morbidity, and is available in the
operative field.
• The ear can provide a significant amount of cartilage for
rhinoplasty when septal cartilage has been depleted. It
can be used for tip grafts, dorsal onlay grafts, alar
contour grafts, and reconstruction of the lower lateral
cartilages. However, its flaccidity does not allow it to be
Resected lateral
mucosa and
lamina propria
Figure 3.3  Inferior turbinate outfracture and submucous resection.

52
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3
Table 3.4  Tip suturing techniques
Medial crural suture
Interdomal suture
Transdomal suture
Joined transdomal suture
Intercrural septal suture
Lateral crural mattress suture
Figure 3.4  Nasal tip cartilage grafts. (A) Supratip; (B) infratip; (C) anatomic.
A
B
C
Figure 3.5  Percutaneous discontinuous lateral nasal osteotomies. (A) Low-to-high; (B) low-to-low; (C) double-level (right).
Low-to-high
Low-to-low
Double-level
A
B
C
• Nasal osteotomies are a key component to shape the
bony vault in rhinoplasty. They are used to narrow a
wide bony vault, close an open-roof deformity, or
straighten deviated nasal bones.
• The goals of nasal osteotomies are maintenance or
creation of smooth dorsal aesthetic lines and obtaining a
desirable width of the bony vault.
• Osteotomies can be classified by approach (external or
internal), type (lateral, medial, transverse, or a
combination), and level (low-to-high, low-to-low, or
double-level) (Fig. 3.5).
• A transition zone of decreased bony thickness exists
along the frontal processes of the maxilla near its junction
with the nasal bone, from the pyriform aperture to the
radix.
• This area of relatively thin bone allows for consistent
osteotomies and predictable fracture patterns.
• Relative contraindications to the use of osteotomies
during rhinoplasty include patients with short nasal
bones, elderly patients with excessively thin nasal bones,
those with relatively thick nasal skin, and some
noncaucasian patients with extremely low and broad
noses.

53
Operative techniques
Operative techniques
Open rhinoplasty (Video 3.1)
• It is our preference to perform primary open rhinoplasty
under general endotracheal anesthesia.
• Prior to sterile prep, the nose and septum are infiltrated
with a total of 10 mL 1% lidocaine with 1 : 100 000
epinephrine.
• Oxymetazoline-soaked cottonoid pledgets are inserted
into the nasal cavities. One drop of methylene blue
is instilled in the oxymetazoline to differentiate
this from the local anesthesia and prevent inadvertent
injection.
• Comparable hemostasis can be obtained using lidocaine
with oxymetazoline while avoiding the use of a
controlled substance with potential cardiac effects, as
seen with cocaine.
• Adequate exposure during primary open rhinoplasty is
best obtained using a transcolumellar incision with
infracartilaginous extensions.
• Several transcolumellar incisions are commonly used,
including stair-step, inverted-V, and transverse.
• Blood supply to the nasal tip is preserved with the
transcolumellar incision provided that extensive defatting
of the nasal tip or extensive alar base resections above the
alar grooves are not performed.
• We prefer to use a stair-step incision made at the
narrowest part of the columella (usually its midportion,
Fig. 3.6), which camouflages the scar, provides
landmarks for accurate closure, and prevents linear scar
contracture.
• The incision is carried into the nasal vestibule and
then continued along the caudal border of the medial
crus towards the middle crus of the lower lateral
cartilage.
Figure 3.6  Transcolumellar stair-step incision.
Figure 3.7  Transcolumellar stair-step incision with infracartilaginous extensions.
Infracartilaginous
Transcolumellar
• After everting the ala using external digital pressure
against a double hook placed within the alar rim, a
separate incision is started at the caudal border of the
lateral crura and connected with the medial incision,
caudal to the middle crus (Fig. 3.7).
• Fine dissecting scissors are used to elevate the nasal
skin in a supraperichondrial plane starting from the
columellar incision in a superior direction to the
nasal tip.
• Next, dissection is started over the lateral crus and
continued in a medial direction connecting the
supraperichondrial dissection planes over the middle
crus.
• Dissection to elevate the nasal skin in the
supraperichondrial plane is carried superiorly to 2 mm
above the keystone area.
Video
3.1

54
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3
• For dorsal reduction of the bony hump less than 3 mm, a
down-biting diamond rasp is used to reduce the bony
dorsum incrementally.
• Rasping should proceed along left and right dorsal
aesthetic lines and then centrally, employing short
excursions of the rasp for maximal control.
• Care is taken to avoid avulsing the attachments of the
upper lateral cartilages from the undersurface of the
nasal bones.
• If a larger reduction of the bony dorsum is required, a
guarded 8 mm osteotome can be used.
• The osteotomy should start at the caudal aspect of the
nasal bones and is directed towards the radix. A rasp is
used for final adjustments.
• Only in limited circumstances is reduction of the upper
lateral cartilages indicated. Overresection must be
avoided to prevent internal valve collapse or long-term
dorsal irregularities. Patients with short nasal bones and
high and narrow osseocartilaginous framework are at
higher risk for these problems.
• Spreader grafts may be added, and are indicated in
primary rhinoplasty to recreate the dorsal aesthetic lines,
widen the midvault, or correct the deviated nose (Fig. 3.9).
• They may be fashioned from harvested septal cartilage
and are typically 5–6 mm in height and 30–32 mm in
length and can be placed either unilaterally or bilaterally.
• If indicated for improvement of the dorsal aesthetic lines
they can be visible, placed above the plane of the dorsal
septum, and if indicated to improve function of the
internal nasal valve they can be invisible, placed below
the plane of the dorsal septum.
• Spreader grafts are secured to the septum using 5-0 PDS
horizontal mattress sutures.
• Following re-establishment of the cartilaginous midvault,
percutaneous osteotomies are performed to correct
widened or asymmetrical nasal bones, or close the
open-roof deformity if present after dorsal reduction.
• A Joseph elevator is then used to elevate nasal skin in a
subperiosteal plane off nasal bones to radix.
• This dissection over the nasal bones is only performed in
the central area to allow for bony dorsal hump reduction,
while the lateral periosteal attachments of the bony side
wall should not be disrupted as they provide necessary
stability to the bony vault after percutaneous osteotomies
have been performed.
Component dorsal hump reduction
• Dorsal hump reduction without careful attention to the
anatomic and physiologic functions of the nasal dorsum
and internal nasal valve can lead to irregularities of the
nasal dorsum, excessive narrowing of the midvault, the
inverted-V deformity, and underresection or
overresection of the osseocartilaginous hump.
• We prefer a graduated approach using component dorsal
hump reduction (Table 3.5) over earlier techniques of
composite dorsal hump reduction (Fig. 3.8).
• Preservation of the upper lateral cartilages during dorsal
reduction of the cartilaginous septum is important in
achieving smooth dorsal aesthetic lines.
• Equal resection of the septum and upper lateral cartilages
results in rounding of the dorsum and excessive resection
of the upper lateral cartilages results in the inverted-V
deformity.
Table 3.5  Component dorsal hump reduction
Separation of the upper lateral cartilage from the septum
Incremental reduction of the septum proper
Incremental dorsal bony reduction (using a rasp)
Verification by palpation
Final modifications, if indicated (spreader grafts, suturing
techniques, osteotomies)
Keystone area
Figure 3.8  Nasal dorsum.

55
Operative techniques
Figure 3.9  Dorsal spreader grafts.
Spreader grafts
Figure 3.10  Submucoperichondrial dissection.
Septal reconstruction
• Exposure of all deviated structures through the open
approach.
• Release of all mucoperichondrial attachments to the
septum, especially the deviated part.
• Straightening of the septum, and if necessary septal
reconstruction, while maintaining an 8–10 mm caudal
and dorsal L-strut.
• Restoration of long-term support with buttressing caudal
septal batten or dorsal nasal spreader grafts.
• If necessary, submucous resection of hypertrophied
inferior turbinates.
• Precisely planned and executed external percutaneous
osteotomies.
Septal graft harvest
• A 15-blade scalpel is used to score the
mucoperichondrium of the septal angle
• A Cottle elevator is used to develop the
submucoperichondrial pocket on one side of the septum
(Fig. 3.10).
• Dissection should be continued to the maxillary crest and
posteriorly to the vomer (Fig. 3.11).

56
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• Rhinoplasty
3
Figure 3.11  Submucoperichondrial flaps.
1
2
3
4
• The contralateral mucoperichondrium may be left
attached to the septum and only the portion of the septal
cartilage to be harvested is released. This method leaves
contralateral mucoperichondrium attached to the L-strut
for more support and decreases the amount of dissection
and dead space with the potential for hematoma
formation.
• Alternatively, development of these
submucoperichondrial pockets can be performed
bilaterally, allowing for improved visualization.
• Care is taken to avoid perforations of the mucosa.
Anterior perforations should be repaired with 5-0
chromic gut sutures while posterior perforations can be
left as they allow for drainage of any blood.
• An 8–10 mm wide dorsal and caudal L-strut is created
using a 15-blade scalpel to incise the septal cartilage
parallel to the dorsal edge of the septum from the
perpendicular plate of the ethmoid to a point 8–10 mm
from the caudal edge of the septum (Fig. 3.12). This
incision is then continued posteriorly and parallel
to the caudal edge of the septum until the crest of the
maxilla.
• During septal cartilage harvest, pressure on the L-strut
must be avoided to prevent its fracture. If this occurs, it
should be repaired to restore nasal support.
• After cartilage grafts have been fashioned, any excess
material should be replaced between the
mucoperichondrial flaps in case it is required in
subsequent procedures.
• The mucoperichondrial flaps can be sutured together
using a 5-0 chromic gut quilting suture and are bolstered
by placement of Doyle splints to support the
mucoperichondrial flaps and minimize dead space.
Ear cartilage
• An anterior approach is used if autogenous graft material
is required for tip grafts or lower lateral cartilage
reconstruction (Fig. 3.13).
• A posterior approach is used if a longer, more malleable
piece of cartilage is required.
Figure 3.12  Septal L-strut.
• Hemostasis is obtained and the incision is closed with a
5-0 plain gut running suture.
• A tie-over Xeroform-cotton bolster held in place with a
3-0 nylon suture through the anterior and posterior
auricular skin is used to obliterate dead space and
prevent hematoma formation.
• This is removed on postoperative day 3.

57
Operative techniques
Columellar strut graft
• An intercrural columellar strut graft is used to maintain
or increase nasal tip projection, and aids in unifying the
nasal tip. It can be either floating or fixed (Fig. 3.16).
• A floating columellar strut graft is used more commonly
to maintain tip projection and is positioned between the
medial crura and rests in the soft tissues 2–3 mm anterior
to the nasal spine.
• A fixed columellar strut graft is used to increase tip
projection and is positioned between the medial crura
and rests on the nasal spine.
• The columellar strut graft is typically fashioned from
septal cartilage, to measure 3 × 2 mm.
• The columellar strut graft is placed in a pre-dissected
pocket and with the tip defining points held at the same
level, a 25 G needle is placed through the medial crura
and columellar strut graft to stabilize the complex for
suturing.
• A 5-0 PDS suture is used to stabilize the medial crura to
the columellar strut graft, followed by two additional 5-0
PDS sutures to unify the nasal tip complex.
• The columellar strut graft is then trimmed to alter or
refine the infratip lobule.
Nasal tip suturing techniques (Fig. 3.17)
• Medial crural sutures: used to correct medial crural
asymmetries, to reduce flaring, to control the overall
width of the columella, and stabilize a columellar strut.
• Interdomal sutures: used to increase infratip columellar
projection and definition, further increase tip projection,
or narrow the interdomal distance.
• Transdomal sutures: used to control dome asymmetry
(Fig. 3.18).
• Intercrural septal sutures: used to alter tip rotation (Fig.
3.19) (usally a 5-0 clear nylon is used for permanency).
• Lateral crural mattress sutures: used to reduce the
convexity and straighten the lateral crus (Fig. 3.20).
Costal cartilage
• Various authors have described harvesting costal
cartilage from different ribs but it is the author’s
preference to harvest the ninth rib because it is straight
medially and provides 4–5 cm of autogenous graft
material (Fig. 3.14).
• If there is concern about pneumothorax during
costal cartilage harvest, the wound is filled with
saline and positive-pressure ventilation can be
performed by the anesthesia provider to ensure
that there are no gas bubbles escaping from the chest
cavity.
• If the parietal pleura has been violated, the tip of a red
rubber catheter is inserted into the defect and a 3-0 Vicryl
pursestring suture is performed around the catheter. The
anesthesia provider performs a Valsalva maneuver while
suction is applied to the red rubber catheter. As the
catheter is withdrawn, the pursestring suture is tied to
seal the parietal pleural defect followed by wound
closure.
• An upright chest X-ray should be performed
postoperatively to confirm resolution of the
pneumothorax.
The nasal tip
• Cephalic trim should be performed with the bulbous or
boxy tip (Fig. 3.15).
• Paradomal fullness is secondary to prominence of the
cephalic border of the middle and lateral crura of the
lower lateral cartilages.
• Cephalic trim of this area reduces paradomal fullness and
helps to define the tip and narrow the distance between
the tip defining points.
• A rim strip of at least 5 mm is preserved for adequate
support of the external valve.
• Calipers should be used to measure the rim strip
accurately.
Figure 3.13  Harvesting ear cartilage.

58
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• Rhinoplasty
3
Figure 3.14  Harvesting costal cartilage.
Figure 3.15  Cephalic trim. (A) Lateral and middle crura;
(B) lateral crus (right).
A
B

59
Operative techniques
Alar contour grafts
• Used as a simple and effective method to correct and
prevent alar notching or retraction, and facets of the
soft tissue triangles, after correcting the tip deformity
(Fig. 3.21).
Lateral crural strut grafts
• Used to support weak lateral crura, prevent collapse of
the external nasal valve, address malposition of the
lateral crura, or increase tip projection (Fig. 3.22).
• A 4 × 25 mm lateral crural strut graft rests on the
pyriform aperture posteriorly. The anterior aspect of the
graft is placed deep to the lateral crus and secured with
two or three 5-0 PDS simple interrupted sutures.
Nasal tip grafting techniques
• A shield graft: used to increase tip projection,
and improve definition of the tip and the infratip
lobule.
• Placed adjacent to the caudal edges of the anterior
middle crura and extends into the tip. It is placed
so that it extends 2–3 mm past the tip defining
points and should be sutured with at least two
5-0 PDS sutures to the caudal margins of the dome
and medial crura.
• Approximately 8 mm wide and 10–12 mm long.
The width of the base of the graft is the same as
the distance between the caudal margins of the medial
crura.
• An onlay graft: placed horizontally over the
alar domes and is used to camouflage tip
irregularities and can provide increased tip
projection.
• Cartilage removed from the lower lateral cartilages
after cephalic trim is usually sufficient for use as an
onlay graft.
• An anatomic tip graft: in primary rhinoplasty, the
anatomic tip graft is reserved for the patient with
inadequate tip projection or thick skin.
• A combination of the shield and onlay grafts and
reflects the surface anatomy of the ideal tip.
Figure 3.16  (A) Floating and (B) fixed columellar strut grafts.
A
B
A
B
C
Figure 3.17  Nasal tip suturing techniques. (A) Medial crural; (B) transdomal;
(C) interdomal.

60
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• Rhinoplasty
3
The alar–columellar relationship
• The alar–columellar relationship demonstrated on the
lateral view is dictated by the relative positions of the
alar rim and the columella to a line drawn through
the long axis of the nostril (Fig. 3.23). The ideal distance
from the long axis to both the alar rim superiorly and the
columella inferiorly is 1–2 mm.
• Six classes of alar–columellar relationship have been
described:
• Class I (Hanging columella): the distance from the long
axis to the columella is greater than 2 mm while the
distance from the long axis to the alar rim is 1–2 mm.
■ Correction involves resection and reapproximation of
the membranous septum to reposition the columella
superiorly. It may also be necessary to resect part of
the caudal septum or medial crura if they contribute to
the hanging columella.
• Class II (secondary to alar retraction): the distance from
the long axis to the columella is 1–2 mm while the
distance from the long axis to the alar rim is greater than
2 mm.
■ Correction may involve caudal repositioning of the
lateral crus, the use of alar contour or lateral crural
strut grafts, or composite grafts from the septum or
concha.
• Class III: A combination of both classes I and II and
requires the use of techniques described for both classes.
• Class IV (hanging ala): the distance from the long axis to
the columella is 1–2 mm while the distance from the long
axis to the alar rim is less than 1 mm.
A
B
Figure 3.18  (A, B) Joined transdomal sutures.
Figure 3.19  Intercrural septal suture.
Figure 3.20  Lateral crural mattress suture.

61
Operative techniques
Figure 3.21  Alar contour grafts.
Figure 3.22  Lateral crural strut grafts.

62
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• Rhinoplasty
3
Figure 3.23  Alar–columellar relationships. (A) Class I; (B) class II; (C) class III; (D) class IV; (E) class V; (F) class VI.
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
D
E
F
■ Correction involves resection of a horizontal ellipse of
vestibular skin no more than 3 mm in width to raise
the hanging ala.
• Class V (secondary to columellar retraction): the distance
from the long axis to the columella is less than 1 mm
while the distance from the long axis to the alar rim is
1–2 mm.
■ Correction involves placing a contoured columellar
strut graft between the medial crura to push the
columellar skin inferiorly.
• Class VI: a combination of both classes IV and V and
requires the use of techniques described for both classes.
Percutaneous lateral nasal osteotomies
• Various authors have described their experience using
different approaches, including intranasal, intraoral, and
percutaneous techniques. We prefer percutaneous lateral
discontinuous osteotomies because this technique results
in a more controlled fracture with less intranasal trauma
while minimizing morbidity, including bleeding,
ecchymosis, and edema (Fig. 3.24).
• A 2 mm incision is made in the nasofacial groove at the
level of the inferior orbital rim and a sharp 2 mm straight
osteotome is inserted through the incision and parallel to
the surface of the maxilla, down through the periosteum.
• A lateral subperiosteal sweep to the bony nasofacial
groove is performed to displace the angular artery
laterally and prevent its injury.
• The discontinuous osteotomy is performed from
inferiorly, preserving the caudal aspect of the frontal
process of the maxilla at the pyriform aperture to prevent
collapse of the internal nasal valve, to the level of the
medial canthus superiorly and then continued into a
superior oblique osteotomy medially.
• The osteotomy should not be continued superior to the
medial canthus to avoid injury to the lacrimal system.
• After the osteotomies have been completed, the thumb
and index finger are used to exert gentle pressure to
perform a greenstick fracture of the nasal bones to

63
Operative techniques
Figure 3.24  Percutaneous discontinuous lateral nasal osteotomies.
A
B
Figure 3.25  Alar base surgery. (A) Alar flaring; (B) alar flaring with modification of nostril shape.
reposition them in the desired location. If more than
gentle pressure is required, the osteotome should be
reinserted to ensure that there are no significant areas of
nonosteotomized bone between the discontinuous
perforations.
Closure
• Closure of the incisions is begun by lining up the
transcolumellar stair-step incision in the midline and at
the junction of the columellar skin and nasal vestibule
bilaterally.
• This closure must be meticulously performed to prevent
notching leading to a noticeable columellar scar.
• The bilateral infracartilaginous incisions are closed
next with simple interrupted sutures using 5-0
chromic gut.
• The mucosa should be exactly reapproximated,
particularly around the middle crura, to prevent
distortion of the soft triangle or webbing at the nasal
vestibule.
Alar base surgery
• Alar base surgery is indicated for abnormalities including
alar flaring, nostril asymmetry, excessively large nostrils,
elongated alar side walls, widened alar base, large alae,
and alar asymmetry (Fig. 3.25).
• Alar flaring is the most common problem requiring
modification of the alar base. The relationship between
the alar and basal planes, alar base width, and the nostril
shape and size should be taken into consideration when
choosing the appropriate surgical technique.
• Alar flaring in the presence of normal nostril shape and
symmetry is corrected by limiting excision to the alar
lobule; the incision is not continued into the vestibule.
The incision is not made directly in the alar-cheek groove
but within 1 mm of the groove, allowing for an everted
closure with improved scarring. In addition, 1–2 mm of
the alar base is preserved, preventing alar base notching.
• Alar flaring with nostril asymmetry or excessively large
nostrils requires a wedge excision of the alar lobule and
vestibule. The alar lobule incision is continued into the
vestibule 2 mm above the alar groove. The medial
incision is made using an 11-blade scalpel angled 30°
laterally, resulting in a small medially based flap.
Straight-line closure is avoided to prevent distortion of
the nostril or notching of the nostril sill.
Closed Rhinoplasty
Access
• The operation is routinely performed under general
anesthesia.
• The patient is placed supine with the arms and legs
padded and the knees slightly flexed; the operating table
is in 10–15° reverse Trendelenburg position to minimize
bleeding.
• After induction of general anesthesia, the nose is blocked
with a freshly prepared solution of 1% lidocaine with

64
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• Rhinoplasty
3
• With Joseph scissors (Fig. 3.27) and then a broad Cottle
periosteal elevator, the soft tissues are elevated over the
bony and upper cartilaginous vaults only as necessary for
access.
• It is important for the surgeon to obtain smooth elevation
of all soft tissues to ensure good cover and avoid dermal
injury.
• If no transfixing incision is necessary, the
intercartilaginous incision stops at the junction of the
anterior and middle thirds of the membranous septum.
• If the caudal septum requires shortening, the incision can
be carried toward the anterior nasal spine.
Dorsal resection
• Producing a straight dorsum from a convex one is not a
simple matter.
• The surgical plan must consider: (1) radix position;
(2) dorsal height, and (3) the adequacy of tip support.
• The author performs the dorsal resection under direct
vision using a sharp Fomon rasp.
• Resection of the dorsal border of the septum is
accomplished with a No. 11 blade from which the tip has
been broken to avoid lacerating the contralateral dorsal
skin.
• The dorsum should feel and appear perfectly smooth
through the skin surface after dorsal resection.
Nasal spine–caudal septum
• Caudal septal resection may change the relationship of
the columella to nostril rim, nasal length, subnasale
contour, and upper lip carriage.
• If the nasolabial angle and upper lip relationships are
satisfactory, no transfixing incision and no caudal septal
or nasal spine modifications are necessary.
• If columellar position is satisfactory but the subnasale is
full, a short incision can be made in the posterior
membranous septum and septal floor, the nasal spine
exposed and resected with a small rongeur.
epinephrine 1 : 100 000 (20 mL of 1% lidocaine plus 0.2 mL
of epinephrine 1 : 1000).
• Infiltration begins at the nasal root, along each lateral
nasal wall, into the columella, across the maxillary arch,
and into the alar lobules to vasoconstrict the branches of
the primary supplying vessels (angular, anterior
ethmoidal, superior labial) and the relevant nerves
(anterior ethmoidal, infraorbital, infratrochlear).
• This infiltration usually consumes about 7 mL of the
anesthetic solution, the rest of which is saved for the
septal surgery.
• Nasal vibrissae are shaved with a No. 15 blade, and the
nose is thoroughly cleansed internally with a povidone–
iodine solution.
• Internal preparation of the nose should be even more
fastidious than skin preparation, not the reverse,
remembering that the nasal lining is the real operative
surface.
• For hemostasis and anesthesia of the nasopalatine nerve,
the internal nasal and posterior nasal branches of the
anterior ethmoidal nerve, the internal nasal branch of the
nasociliary nerve, and the nasal branch of the anterior
superior alveolar nerve, two cotton packs soaked in 4%
cocaine solution and squeezed dry with sterile gauze are
placed in each airway. Only 4 mL of 4% tinted cocaine
solution is made available for each patient (160 mg),
safely below the maximum allowable dosage (200 mg).
• The patient’s face is prepared and draped.
• The author ordinarily skeletonizes the nose through
unilateral or bilateral intracartilaginous incisions
(Fig. 3.26), depending on whether alar cartilage
modification will be necessary.
• The incision runs from the lateral end of the caudal
reflection of the upper lateral cartilage around the septal
angle.
Figure 3.26  The intercartilaginous incision, which can be lengthened into a
transfixing incision if necessary, gives access to the dorsum, upper and lower
lateral cartilages, and the septal angle. Dorsal modification; upper and lower lateral
cartilage resection; spreader, radix, dorsal, and lateral wall grafts can all be
performed through this excellent access point under direct vision.
Figure 3.27  The intercartilaginous skeletonizing incision begins at the apex and
proceeds laterally only as far as necessary. Dorsal access and visualization are
easiest for a right-handed surgeon through a left-sided incision, and vice versa. If
the surgeon does not need to shorten the upper or lower lateral cartilages, only a
single intercartilaginous incision is needed.

65
Operative techniques
performing any submucous resection to preserve stability
and to make spreader graft placement simpler.
• Recent trauma (within 3 months) is an indication to
postpone the rhinoplasty until any fractures have healed
and until postoperative edema allows accurate judgment
of the aesthetic contours.
• If they are needed, spreader graft tunnels are performed
before septoplasty.
• Spreader graft tunnels are facilitated by prior
infiltration beneath the mucoperichondrium with local
anesthetic.
• By identifying the septal angle, the surgeon can incise to
cartilage beneath each mucoperichondrial flap and
develop the tunnels themselves with the sharp end of a
Cottle perichondrial elevator.
• Each tunnel must follow the dorsal septal edge and
should extend beneath the caudal edge of the bony arch
on each side, leaving a narrow mucoperichondrial
attachment along the top edge.
• For septoplasty access, the initial mucoperichondrial
incision is made 15 mm above (cephalad to) the caudal
septal edge.
• Using first the sharp and later the blunt end of a Freer
elevator in one hand and a Frazier suction in the other,
dissection proceeds under the mucoperichondrial flap
onto the perpendicular plate of the ethmoid and over any
posterior bony obstructions.
• Once the first flap has been developed, the sharp end of
the elevator can cut the septal cartilage at the site of the
opening incision and dissection then proceeds on the
second side.
• Elevation of the perichondrium at the junction of septal
cartilage and vomer is particularly difficult because the
periosteal and perichondrial fibers are interlaced.
• Because the periosteal fibers are stronger, the mucosal
flaps are less likely to tear if the surgeon begins
dissection beneath the maxillary and vomerine
mucoperiosteum and works cephalad.
• The first septal cut is made 15–20 mm below the dorsal
septal edge with angled Knight septal scissors, which cut
through septal cartilage and ethmoid.
• Make sure that both blades are within the
mucoperichondrial flaps before making the cut.
• A parallel cut is performed 10 mm inferiorly, and using
Killian septal forceps, the first graft, now free on three
sides, can be twisted so that the ethmoid fractures and is
removed in one piece.
• This maneuver often provides an initial graft of
25–30 mm long containing the flattest, thickest, longest
piece of septal cartilage, ideal for a dorsal graft.
• Dissection continues posteriorly and caudally with the
sharp end of a Cottle perichondrial elevator.
• The septal cartilage in the vomerine groove can often be
dislodged by a bit of judicious wiggling with a narrow
osteotome.
• With an osteotome and septal forceps, additional
pieces of vomer or perpendicular plate of the ethmoid
can be removed if obstructing or if additional graft
material is needed, always working under direct
vision.
• If the columella is low but the nasolabial angle is
satisfactory, the caudal or membranous septum is
resected, paralleling the nostril rims and without
shortening the nose. Finally, if the columella is low or the
nasolabial angle is acute, more caudal septum and
membranous septum is resected anteriorly than
posteriorly.
• Be cautious about over-resection; 1 or 2 mm makes the
difference between normal columellar position and
retraction.
Alar cartilage resection
• In the majority of primary rhinoplasties in which only
conservative reductions of the cephalic lateral crura edges
are necessary, the cartilages are modified retrograde
through the intercartilaginous incisions.
• If the cartilages are distorted, they can be delivered as
bipedicle flaps by intercartilaginous and
infracartilaginous incisions.
• If only the arch needs interruption (e.g., to narrow
the tip or to resect a “knuckle” at the lateral genu),
only that portion of the alar cartilage should be
exposed.
• If the lateral crus or dome areas are so distorted
that a simple reduction or tip grafting will not provide
the intended result, the distorting structures can be
dissected free from the vestibular and overlying skin
and (1) resected and replaced after modification;
(2) resected and replaced by septal cartilage grafts, or
(3) delivered as a medially based flap, and replaced along
the alar rims.
• Radical freeing of the lateral crura, dome resection, or
division of the alar cartilage arch reduces tip projection
and so tip grafts are necessary to reconstruct the lobule.
Lining should never be resected to avoid vestibular
stenoses and iatrogenic airway obstruction.
Upper lateral cartilages: shortening the nose
• A variety of interventions shorten the nose. In descending
order of their effect, they are dorsal resection, caudal
septal resection, resection of the cephalic edges of the alar
cartilage lateral crura, and resection of the anterocaudal
ends of the upper lateral cartilages.
• The posterior edges of the upper lateral cartilages should
be left to abut the lateral crura; mucosa should never be
resected.
• The caudal edge of the upper lateral cartilage can be
drawn downwards by a single hook in its lining,
exposing the caudal edge for submucosal resection with
Joseph scissors.
Septoplasty, spreader graft tunnels
• Septoplasty is performed to relieve an airway obstruction
from septal deflection and to provide graft material for
the reconstruction itself.
• The surgeon should leave 15–20 mm intact, undissected
cartilage along the nasal dorsum and 15 mm caudally in

66
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• Rhinoplasty
3
Alar wedge resection
• In considering the degree of resection, the surgeon should
assess the proportion of tip lobular size to nostril length,
remembering that tip grafting (if part of the preoperative
plan) will increase tip lobular size and may eliminate the
need for nostril reduction.
• Because the alar rim has both external and vestibular skin
surfaces, the requirements of each must be assessed and
treated individually.
• If nostril size is excessive, however, it is important to
preserve a medial flap at the sill to lessen the possibility
of alar notching.
• Even with the medial flap, excess resection of even 1 mm
can notch the nasal floor.
• Be conservative.
• An external incision made slightly outside the alar crease
is preferable in order not to destroy this important
landmark, a unique structure that simple skin repair does
not reduplicate.
• Accurate closure with 6-0 nylon suffices and this suture
should be removed by 5 days; 5-0 plain catgut is used for
the nasal floor.
Spreader grafts
• Although septal cartilage provides the ideal spreader
graft, strips of costal or conchal cartilage, ethmoid, or
vomer may be used instead (Fig. 3.28).
• After spreader grafts are placed, caudal slippage can be
avoided by a single 4-0 plain catgut transfixing suture
placed at the septal angle.
Lateral wall and columellar grafts
• Cartilage provides the ideal lateral wall graft, split
tangentially or crushed to fit the defect.
• Augment the columella through a short lateral incision in
the membranous septum, limiting cephalic dissection so
that the grafts provide adequate augmentation but do not
disappear between the medial crura.
Tip grafting
• The surgeon who uses tip grafts commonly finds
that they not only increase tip projection but also
alter tip lobular and nostril contour; increase lobular
volume (reducing relative nostril size); impart a different
ethnic character; and enlarge the nasal base, therefore
changing the balance between dorsal height and tip
projection.
• Tip grafts are placed through an infracartilaginous
incision on the side from which the surgeon operates.
• It is important to dissect the recipient pocket adequately,
but not so liberally that the grafts cannot create the
required support and projection.
• Complete access incision closure is mandatory to
minimize infection.
• The grafts should be manipulated as little as possible and
rinsed in saline in an antibiotic solution before insertion.
• In areas of severe deflection, tears in the
mucoperichondrial flaps may be unavoidable, but the
surgeon should nevertheless proceed cautiously and
repair any tears.
• Close the septal pocket with 4-0 chromic mattress sutures.
Turbinectomy
• Partial inferior turbinectomy, defined as a trim of the
anterior edge sufficient to obtain 3 mm clearance to the
septum or nasal floor, is valuable adjunctive airway
treatment if indicated.
• Turbinate crushing and outfracture may suffice in
patients whose turbinates contain significant cystic bone
and in whom adequate airway size can be achieved
without resection.
• When resection is necessary, biopsy forceps allow smaller,
more incremental changes than angled scissors.
• The raw surfaces left will contract and epithelize, further
reducing the size of the remaining turbinate.
Graft placement and wound closure
• Close some of the wounds with 5-0 plain catgut sutures
before placing grafts so that their position will be easier
to maintain.
• This sequence keeps grafts from slipping out of one
incision as the surgeon closes another.
Osteotomy
• Before performing any osteotomy, the surgeon should be
sure that one is necessary.
• If the lower nasal third is already appropriately wider
than the bony vault, narrowing the upper nose further
may be counterproductive by making the nasal base
appear larger.
• If there is a high septal deviation, bilateral
osteotomies may create a newly asymmetric nose
because one nasal bone will move medially farther
than the other.
• In the elderly patient (in whom comminution of
the nasal bones may occur), the patient who wears
heavy eyeglasses, or the patient with nasal bones
extending less than one-third the distance to the septal
angle (in whom middle vault width depends partially on
bony vault width), the surgeon may wish to omit
osteotomy.
• Finally, osteotomy may lengthen a long nose further by
reducing support beneath a large skin sleeve.
• A single lateral osteotomy that begins intranasally, low at
the pyriform aperture, and ends higher toward the nasal
root (at the attachment of the nasal pyramid to the
maxilla) is effective and seems the most anatomically
correct.
• Gentle digital pressure causes a greenstick fracture at the
remaining cephalic attachment and will re-form the bony
pyramid.
• Use a guarded osteotome facing the button laterally to
constantly assure correct orientation.

67
Postoperative considerations
• Both Denver and Doyle splints are removed, typically on
postoperative day 7, along with any columellar sutures. If
the patient has undergone extensive septal reconstruction,
the splints are left in place for approximately 10 days.
Alar base sutures are also removed on postoperative
day 10.
• A nasal drip pad is fashioned using 2 × 2 gauze and held
in place under the nose with paper tape secured to tape
on the cheeks.
• Despite better symmetry, a straighter bridge, or increased
tip contour, many patients are disappointed 1 week after
surgery and need repeated assurance that the nose is still
swollen.
• Generally, most of the nasal swelling and ecchymosis will
resolve within 3–4 weeks of following surgery; however
soft tissue edema, both external and internal, may take
6–12 months to resolve and external subtle nasal
definition and internal nasal airflow will continue to
improve over this period.
• First- or second-generation cephalosporins are generally
used for antibiotic prophylaxis.
• Some surgeons will prescribe a short course of high-dose
corticosteroids which is started intraoperatively and
continued in the early postoperative period to minimize
edema and ecchymosis.
• Intraoperatively, 8 mg intravenous dexamethasone can be
given and continued postoperatively in the form of oral
methylprednisolone (Medrol Dose Pack) for 6 days.
Although the efficacy of high-dose corticosteroids
remains debatable, newer data suggest their utility in
open rhinoplasty.
• Postoperative pain and discomfort are highly variable. In
general, oral narcotic analgesia is used for several days,
after which nonsteroidal anti-inflammatory drugs are
adequate.
• The author now places tip grafts in almost every patient,
except for those whose preoperative tip aesthetics are
excellent.
Postoperative considerations
• Postoperative care begins preoperatively with a thorough
review of the plan of care and expected postoperative
recovery.
• SteriStrips are often applied starting at the supratip
break, carefully contouring the soft tissue to the
underlying osseocartilaginous skeleton and then
continuing superiorly along the dorsum with SteriStrips
of progressively shorter length.
• A Denver dorsal splint (Shippert Medical Technologies,
Centennial, CO) is shaped over a cylindrical object with a
diameter similar to the width of the osseous base of the
nose. This splint is applied over the superior two-thirds
of the dorsum and the edges are compressed medially to
support the osteotomized nasal bones. The inferior edge
of this splint should be superior to the supratip area.
• If septal reconstruction and/or inferior turbinoplasty was
performed, Doyle septal splints (Micromedics, St Paul,
MN) are applied to avoid hematoma formation deep to
the mucoperichondrial flaps, support and stabilize the
structures, protect the septal mucosa, and prevent
synechiae formation between adjacent mucosal
surfaces.
• These splints are covered with antistaphylococcal
antibiotic ointment, inserted into each of the nasal
cavities and secured using a 3-0 nylon horizontal mattress
suture through the membranous septum, loosely tied to
prevent ischemia of this delicate tissue.
Figure 3.28  (A) Septal cartilage is not uniform in thickness, but
broadens along its anterior edge, where it becomes confluent with the
upper lateral cartilages and forms the middle vault roof. (B) Any dorsal
resection thicker than 2 mm interrupts this cartilaginous arch and removes
the widened septal area, regardless of whether the mucosa is intact.
(C) The surgeon has now created a disequilibrium in which the upper
lateral cartilages are no longer held apart by the spreading action of the
intact roof. Even if the internal valves were not incompetent preoperatively,
they are now. (D) Spreader grafts recreate the former intact septal width
and reconstitute competent internal valves. Thus spreader grafts are
indicated whenever the internal valves are incompetent preoperatively or
when the surgeon resects an intact cartilaginous roof, unless the nasal
contour independently suggests a substantial dorsal graft (which
duplicates the functional effect of spreader grafts).
A
B
C
D

68
•
• Rhinoplasty
3
moderate bleeding for the first 48–72 h postoperatively,
after which drainage subsides.
• A total of 3% of patients, however, classically re-bleed
between postoperative days 5 and 10.
• Head elevation greater than 60°, oxymetazoline nasal
spray into the affected nostril, and gentle pressure for 15
minutes are usually enough to stop any mild epistaxis.
• If epistaxis persists, removal of Doyle splints and silver
nitrate cautery, followed by anterior nasal packing can be
attempted.
• If bleeding remains refractory, posterior nasal packing
should be considered along with hospital admission for
observation.
• In less than 1% of patients, major epistaxis occurs and
should be addressed in the operating room with
exploration and cauterization. Inferior turbinate resection
is usually the source.
• If all of the above measures fail, consultation for
angiographic embolization should be obtained.
• Regardless of the location, all hematomas should be
drained.
• Hematomas deep to the skin will cause fibrosis leading to
scarring and contour deformities affecting the final nasal
appearance.
• Septal hematomas (ecchymotic septal mass that resembles
a “blackberry”) can create septal perforations or necrosis
of septal cartilage leading to a saddle-nose deformitiy.
• Hematomas can usually be drained in the office with
appropriate lighting. Following drainage, the area should
be packed to prevent recurrence for 24 hours and then
reinspected.
• Although infections are rare following rhinoplasty,
diligent physical examination to identify early signs of
infection allows early initiation of treatment to prevent
serious complications such as tissue necrosis, toxic shock
syndrome, and cavernous sinus thrombosis. In the event
of an infection, internal nasal splints or packing may
need to be removed.
• In cases of severe cellulitis, the patient may need to be
admitted for intravenous antibiotics. Abscesses are
usually found at the nasal dorsum, nasal tip, and the
septum. Any abscess identified should be drained and
• During the initial 48 hours following rhinoplasty, the
patient should keep his/her head elevated greater than
30° degrees and gently apply cold compresses to help
decrease postoperative edema and ecchymosis.
• Head elevation should be continued until there is no
longer edema in the morning. This is typically 7–10 days.
• The patient should avoid any straining, including
strenuous activity or heavy lifting, for 3 weeks. Trauma
and pressure on the nose, including wearing glasses,
should be avoided for 6 weeks.
• The following sequence generally occurs in most patients
during the first postoperative year:
■ The nose becomes longer and “deskeletonizes” as
upper lip edema abates, so that the nasolabial angle
decreases and the nostrils become less visible.
■ The nasal base rotates caudally, depending on skin
elasticity and the degree of skeletal support; the long
preoperative nose has the greatest tendency to
elongate postoperatively.
■ The profile assumes its final postoperative shape
sooner than the frontal view; the nose narrows on
frontal view for at least 12–18 months, particularly in
the middle third. During this time, the unsupported
middle vault narrows and demarcates from the caudal
edges of the bony vault. The nasal skin tries to assume
its preoperative shape, a characteristic that has
particular implications for tip grafting: the flatter, more
contracted preoperative tip will compress tip grafts
and alter postoperative contour more than the larger
tip with a more pliable soft tissue cover.
■ Skeletal irregularities or asymmetries may appear (and
sometimes disappear).
■ Areas of underlying skeletal change or grafts may
become visible and suggest the need for revision;
conversely, early postoperative improvement may
become obscured by soft tissue contraction and
thickening.
Complications and outcomes
• Following rhinoplasty, most patient dissatisfaction is seen
in the lower third of the nose, including the nasal tip,
followed by the middle and upper thirds.
• Poor results in the lower third typically arise from nasal
tip asymmetries, notching of the alae, and inadequate tip
rotation.
• Common problems in the middle third include supratip
fullness or a pinched supratip.
• Complaints in the upper third include excessive
reduction of the dorsum, asymmetrical or ill-defined
dorsal aesthetic lines, and other dorsal irregularities.
• The reported incidence of significant complications
following rhinoplasty ranges from 1.7 to 18%.
• Common complications following rhinoplasty include
bleeding, infection, prolonged edema, deformities and
deviation, and nasal airway obstruction (Table 3.6).
• Epistaxis is one of the most common complications
following rhinoplasty. Most patients, particularly those
who have undergone septal or turbinate surgery, have
Table 3.6  Complications following rhinoplasty
Anosmia
Arteriovenous fistula
Bleeding (ecchymosis, epistaxis, hematoma)
Deformities and deviation
Epiphora
Infection (cellulitis, abscess, granulomas, toxic shock syndrome)
Intracranial injury
Nasal airway obstruction (external valve collapse, internal valve
collapse, septal deviation, synechiae, vestibular stenosis)
Nasal cyst formation
Nasolacrimal apparatus injury
Prolonged edema
Scarring
Septal perforation

69
Further reading
• Deviations are managed similarly to deformities. Mild
deviation may be corrected using nasal molding
techniques. The patient is instructed to apply controlled
pressure using his/her thumb along the nasal side wall
3–4 times per day for 4–6 weeks postoperatively. If the
deviation is significant or persistent beyond 1 year,
surgical treatment is required.
• Following rhinoplasty, most patients experience
transient nasal airway obstruction secondary to
edema. This typically resolves over 2–3 weeks as
edema subsides.
• When nasal airway obstruction persists after 3 weeks,
internal nasal examination using a topical vasoconstrictor
should be performed to identify the cause.
• If it is secondary to edema, nasal decongestants can be
used but topical vasoconstrictors should not be used for
more than 7 days because of rebound congestion
following cessation of these medications.
• If an anatomical cause of obstruction is identified, such as
internal nasal valve collapse or synechiae, surgical
treatment will be required but should be delayed for at
least 1 year to allow for complete resolution of edema
and maturation of scar tissue.
• The “post-rhinoplasty red nose” is a cutaneous
manifestation of postoperative circulatory readjustment
and is displayed varyingly in patients; many never
develop this condition, whereas others develop it after
the first rhinoplasty.
• Most improve spontaneously during the first
postoperative year. When the condition persists, laser
treatment is simple and effective.
• Lacrimal duct injury, cerebrospinal fluid rhinorrhea,
cavernous sinus thrombosis, meningitis, permanent
anosmia, recurrent intradermal cysts and blindness after
corticosteroid injection for supratip deformity have been
reported but are fortunately uncommon.
• Although it is difficult to determine an exact revision rate
following primary open rhinoplasty, a recent survey
revealed that 58% of those surveyed cited their revision
rate less than 5% while another 33% reported their
revision rate between 6 and 10%.
Further reading
Constantian MB. Rhinoplasty: craft and magic. St Louis:
Quality Medical; 2009.
The author’s complete text. Covers nasal phenomenology, so
that preoperative and postoperative deformities can be seen
to form patterns; therefore the solutions are not limitless but
also form patterns. The rhinomanometric improvement in
airflow is given for each case where the information was
available, and analysis and exposition of intraoperative
changes are emphasized. Chapters cover not only rhinoplasty
analysis and technique but anatomic variants, function,
right brain training for rhinoplasty, body dysmorphic
disorder, and the author’s own complications.
Edwards B. A new drawing on the right side of the brain. New
York: Penguin Putnam; 1999.
irrigated, and purulent material should be cultured to
guide antibiotic therapy.
• Toxic shock syndrome has been described after
rhinoplasty with the use of both nasal packing and
internal nasal splints.
• It is an acute, multisystem disease caused by release of
exotoxins from Staphylococcus aureus or Streptococcus
pyogenes causing excessive activation of inflammatory
cells and release of inflammatory cytokines, often
resulting in tissue damage and organ dysfunction.
• Patients can present with fever, a diffuse macular
erythroderma rash, desquamation, nausea, vomiting,
diarrhea, tachycardia, and hypotension.
• Removal of nasal packing or internal nasal splints,
administration of intravenous antibiotics, supportive care,
and intensive care unit monitoring are indicated in this
rare event.
• Soft tissue edema in the early postoperative period is
largely prevented by preoperative patient education
about postoperative care and recovery, perioperative
corticosteroid use, head elevation, taping, and application
of cold compresses. Most edema will resolve within 4
weeks.
• Septal perforations occasionally occur after difficult
septoplasties but can be minimized by cautious dissection
over the vomer, by repairing tears in the
mucoperichondrial flaps, and by placing 1 mm silicone
splints on each side of the septal partition before the nose
is packed.
• Even with these precautions, the occasional septal
perforation may be unavoidable and is usually
asymptomatic.
• Small perforations may cause a curious whistling.
• Larger perforations cause crusting, epistaxis, and rhinitis
as the turbulent airflow spins through the perforated
mucosa.
• Temporary rhinitis may occur for several weeks
postoperatively, particularly when an obstructed airway
has been improved.
• Late soft tissue edema persists several months to more
than a year postoperatively and represents scar
remodeling. It can be seen in situations such as secondary
rhinoplasty or patients with thick skin.
• Patients should be reassured that it will resolve on
its own.
• In certain circumstances where excessive scarring
threatens to cause loss of definition, such as in the
supratip area or radix, corticosteroid injection may be
indicated to decrease the production of scar tissue.
• Triamcinolone acetate 3–5 mg (10 mg/mL) mixed with
2% lidocaine in a 1 : 1 ratio is injected into the supratip
area with a 27 G needle.
• Depending on the clinical scenario, injections may be
administered as early as 1 week postoperatively and
repeated at 4- and 8-week intervals.
• Deformities may be identified in the postoperative
period. Mild deformities should be observed. If they
persist beyond 1 year, surgical treatment is required.
Significant deformities should be corrected as soon as
they are identified to avoid patient dissatisfaction.

70
•
• Rhinoplasty
3
Rohrich RJ, Raniere Jr J, Ha RY. The alar contour graft:
correction and prevention of alar rim deformities
in rhinoplasty. Plast Reconstr Surg. 2002;109:
2495–2505.
Deformity of the alar rim is a common problem after
primary and secondary rhinoplasty. It is caused by
congenital malposition, hypoplasia, or surgical weakening of
the lateral crura, with the potential for both functional and
aesthetic consequences. The authors describe the use of the
alar contour graft to provide the foundation for the
re-establishment of a normally functioning external nasal
valve and an aesthetically pleasing alar contour.
Rohrich RJ, Gunter JP, Deuber MA, et al. The deviated nose:
optimizing results using a simplified classification and
algorithmic approach. Plast Reconstr Surg.
2002;110:1509–1523.
The deviated nose frequently causes both functional and
aesthetic problems. The authors present a classification and
approach to the deviated nose that relies on accurate
preoperative planning and precise intraoperative execution
of corrective measures to return the nasal dorsum to
midline, restore dorsal aesthetic lines, and maintain airway
patency. An operative algorithm is described that emphasizes
simplicity and reproducibility.
Rohrich RJ, Janis JE, Kenkel JM. Male rhinoplasty. Plast
Reconstr Surg. 2003;112:1071–1085.
Rohrich RJ, Muzaffar AR. Rhinoplasty in the African-
American patient. Plast Reconstr Surg.
2003;111:1322–1339.
Rohrich RJ, Muzaffar AR, Janis JE. Component dorsal hump
reduction: the importance of maintaining dorsal
aesthetic lines in rhinoplasty. Plast Reconstr Surg.
2004;114:1298–1308.
Dorsal hump reduction may result in dorsal irregularities
caused by uneven resection, overresection or underresection
of the osseocartilaginous hump, the inverted-V deformity,
excessive narrowing of the midvault, and collapse of the
internal valve. The authors present a technique for
component dorsal hump reduction that allows a graduated
approach to the correction of the nasal dorsum by
emphasizing the integrity of the upper lateral cartilages
when performing dorsal reduction.
Rohrich RJ, Ahmad J. Rhinoplasty. Plast Reconstr Surg.
2011;128:49e–73e.
Sheen JH, Sheen AP. Aesthetic rhinoplasty. 2nd ed. St Louis:
Mosby;1987:988–1011.
This two volume text is the 2nd edition of the book that
started the revolution in rhinoplasty of the 1980s and
beyond. Our entire rhinoplasty lexicon derives from it.
Virtually all of the text is still current and any surgeon
seriously interested in learning rhinoplasty and its modern
roots should own and study a copy.
A delightful and instructive adventure into art. Most of us
lose the ability to “see” what is really in front of us as the
left brain begins to dominate at about age 10, which is why
most adults draw at that level of sophistication. Yet plastic
surgery, not only rhinoplasty but breast reduction, TRAM
flap shaping, forehead flaps, and many other procedures
benefit from the ability to call upon right-brain skills at will.
This book teaches how, in an entertaining way.
Fomon S, Gilbert JG, Caron AL, et al. Collapsed ala:
pathologic physiology and management. Arch
Otolaryngol. 1950;51:465.
A classic paper on what we now call external valvular
collapse by a pioneer who intuitively understood what the
next generation of surgeons forgot: that each airway has two
sides.
Ghavami A, Janis JE, Acikel C, et al. Tip shaping in primary
rhinoplasty: an algorithmic approach. Plast Reconstr
Surg. 2008;122:1229–1241.
Underprojection and lack of tip definition often coexist.
Techniques that improve both nasal tip refinement and
projection are closely interrelated. The authors present a
simplified algorithmic approach to creating aesthetic nasal
tip shape and projection in primary rhinoplasty to aid the
rhinoplasty surgeon in reducing the inherent
unpredictability of combined techniques and improving
long-term aesthetic outcomes.
Gunter JP, Rohrich RJ. Management of the deviated nose:
the importance of septal reconstruction. Clin Plast Surg.
1988;15:43–55.
Gunter JP, Landecker A, Cochran CS. Frequently used grafts
in rhinoplasty: nomenclature and analysis. Plast
Reconstr Surg. 2006;118:14e–29e.
Howard BK, Rohrich RJ. Understanding the nasal airway:
principles and practice. Plast Reconstr Surg.
2002;109:1128–1146.
Phillips KA. The broken mirror: understanding and treating body
dysmorphic disorder. New York: Oxford University
Press; 2005.
A text written by a noted authority on body dysmorphic
disorder, intended for the lay public but so well referenced
that it can be an introduction and reference work for the
interested physician as well.
Rohrich RJ, Krueger JK, Adams Jr WP, et al. Achieving
consistency in the lateral nasal osteotomy during
rhinoplasty: an external perforated technique. Plast
Reconstr Surg. 2001;108:2122–2130.
The lateral nasal osteotomy is an integral element in
rhinoplasty. The authors present a reproducible and
predictable technique for the lateral nasal osteotomy and
discuss the role of the external perforated osteotomy
technique in reproducing consistent results in rhinoplasty
with minimal postoperative complications.

©2014, Elsevier Inc. All rights reserved.
4 
Chapter
Otoplasty
Preoperative considerations
• Otoplasty is unique in that it is perhaps the only cosmetic
procedure that can be performed in childhood, and both
parents and grandparents may be involved in surgical
decision making for the patient who cannot yet express
himself or herself.
• The overall size and shape of the ear is evaluated
to determine if the ear is prominent with an
otherwise normal size and configuration, or
if there are abnormalities in addition to the
prominence.
• The upper third of the ear is evaluated to determine if it
is prominent, if the antihelix/superior crus of the
triangular fossa is well formed and if the helical rim is
well defined.
• The middle third of the ear is evaluated to determine
if the concha is overly deep or protruding.
• The relationship between the antihelix and the helix
is examined to determine if any underdevelopment
of the antihelix/superior crus in the upper third extends
into the middle third or if it is confined to the upper
third.
• The lobule is evaluated to determine if it is prominent.
• Even if the lobule is not particularly prominent on initial
examination, it may become prominent once the upper
two-thirds of the ear have been corrected
• Asymmetry is noted, mostly because patients and
families will always comment on it.
• In asymmetric cases it is usually preferable to operate on
both ears rather than attempt to set back only the
prominent ear to match its less prominent counterpart
(see Fig. 4.1).
• The degree of prominence/deformity and the age at
presentation will determine when a surgical
recommendation is made.
This chapter was created using content from
Neligan & Warren, Plastic Surgery 3rd edition,
Volume 2, Aesthetic, Chapter 22, Otoplasty,
Charles H. Thorne.
SYNOPSIS
■ Analysis. Analyze the problem in thirds.
■ Endpoint. Know what normal looks like, so you know your surgical
endpoint.
■ Do not be destructive. Do not do anything to the ear that cannot be
reversed.
■ Skin is precious but weak. Preserve skin in the sulcus and do not
rely on skin tension to maintain ear position.
■ Lobule. Consider lobule setback in every case.
■ Asymmetry. In asymmetric cases, operate on both ears most of
the time.
■ Facelifts are otoplasties. Do not deform the tragus, lobule or
sulcus.
Brief introduction
• “Otoplasty” refers to surgical changes in the shape or
position of the ear.
• The most common indication is the patient with
prominent, but normally shaped, ears.
• The single most important exercise for the surgeon,
before performing any procedure in the otoplasty
spectrum, is to have the characteristics of a normal ear
firmly in his/her mind. With proper choice of technique,
the surgeon can usually avoid the uncorrectable problems
of over-correction and unnatural contours (Figs 4.1, 4.2).
• It has also never been shown that an otoplasty retards
auricular growth.

72
•
• Otoplasty
4
• In some cases, the parents may want the child to
participate in the decision process and that will
necessitate later intervention.
• It is common to have patients present at approximately
18 years of age, when they are legally independent, or
later when they have earned the money for the
procedure.
• It is not unusual for adults at almost any age to request
correction, either because they have wanted it all their
lives or because their desire to have other procedures
(e.g., a facelift), has led to the realization that their ears
are also prominent.
Anatomic/technical pearls
• While the delicate, complex contours of the ear
may be difficult to create de novo (i.e., microtia),
anatomic considerations are minimal in standard
otoplasty.
• There is abundant blood supply, making almost any
combination of incisions acceptable without the risk of
necrosis.
• There are no motor nerves in the neighborhood. The
terminal branches of the great auricular nerve will
always be injured but normal sensory function usually
returns.
• The one anatomic structure that can be compromised in
otoplasty is the external auditory canal (conchal setback
narrows the meatus). Otherwise, the anatomic
considerations of otoplasty are those of preservation:
■ Preservation of the sulcus.
■ Preservation of the natural softness of the auricular
contours.
■ Preservation of the normal landmarks such as the
posterior wall of the concha (i.e., the middle third of
the antihelix).
• Otoplasty surgery is all about the endpoint. The right
endpoint can be achieved with a thorough knowledge of
a normal ear. If the surgeon remembers the following
regarding how the ear should look from various vantage
points it will aid tremendously in the intraoperative
decision-making:
■ From the front, the helical rim should be visible,
poking out from behind the antihelix.
■ From the side, the contours of the ear should be round
and soft, never sharp.
■ From behind (and this is the most helpful to the
surgeon who is sitting behind the patient
intraoperatively), the contour of the helical rim should
be a straight line, not a “C”, or a “hockey stick”, or
any other shape. If the helical contour is a straight line,
it almost ensures that a harmonious correction will be
achieved.
■ Regardless, if the ultimate correction is slightly
under- or slightly over-corrected, a harmonious
correction will read as “normal” to the outside world
and almost all patients will be happy. This is perhaps
the single most important lesson from this chapter.
• For young children with very prominent ears and whose
parents desire early correction, otoplasty is recommended
as early as age 4 years.
• Four years of age can be viewed as a minimum for most
otoplasty procedures.
• When the entire ear requires reconstruction, as in
microtia, this author prefers to wait until approximately
10 years of age.
Figure 4.2  Main components of the prominent ear. (Reprinted with permission
from Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg.
2005;115(4):60e–72e.)
Loss of antihelical fold
Conchal excess
Concho scaphal angle
greater than 90º
Crura of antihelix
Crus of helix
Anterior
incisure
Tubercle
of tragus
Tragus
External
meatus
Intertragal
incisure
Lobe
Antitragus
Posterior sulcus
Antihelix
Helix
Concha
Scapha
Tubercle
of helix
Triangular fossa
Figure 4.1  Anatomical structures of the ear. The tubercle of the helix is
synonymous with Darwinian’s tubercle. (Reprinted with permission from Janis JE,
Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg. 2005;115(4):60e–72e.)

73
Operative techniques
Figure 4.3  Technique for the standard otoplasty. The
combination of Mustarde sutures, conchal resection/closure
and concha-mastoid sutures is shown. (A) Suture placement.
(B) Suture tightened and ties appropriately. (C) Position of
sutures as shown from the surgeon’s vantage point.
A
B
C
• The last judgment is how close to the head the ear should
be placed. The final position of the ear should be over-
corrected minimally to allow for some relapse, but not
enough to create an unsatisfactory result if no relapse
should occur.
Operative techniques
Standard otoplasty for prominent ears
of normal size
• The incision is made in the retroauricular sulcus.
• In the upper third of the ear, it can be extended up to
the back of the ear to provide adequate exposure to place
Mustarde sutures between the triangular fossa and
scapha.
• No skin is excised, except a small triangle from the
medial surface of the lobule (not the retrolobular skin),
taking care to preserve enough tissue for a normal
earlobe and retrolobular sulcus.
• This skin excision on the lobule is frequently necessary
for repositioning of the lobule at the end of the
procedure.
• The cartilage is exposed on the posterior (medial) surface
of the ear and soft tissue is excised from deep to the
concha.
• In the region of the earlobe, deep dissection is performed
under the concha in preparation for lobule repositioning.
Branches of the great auricular nerve will be seen and
divided.
• Mustarde concha–scapha and triangular fossa–scapha
sutures are placed using 4-0 clear nylon sutures on an
FS-2 needle (Fig. 4.3).
• The number of sutures depends on the how far
into the middle third of the ear the antihelical deficiency
extends.
• These sutures are placed in order to create a soft
curvature to the antihelix and no attempt is made to
correct the prominence of the ear at this point.
• The Mustarde sutures are not parallel to each other but,
instead, are arranged like spokes on a wheel, all pointing
toward the top of the tragus (center of the wheel).
• Care is taken to create a superior crus that curves
anteriorly such that it terminates almost parallel to the
inferior crus.
• If the superior crus is created such that it is a direct,
cephalad extension of the antihelix (straight line), the
result will appear unnatural and amateurish.
• A small crescent of cartilage (≤3 mm at its widest point)
is excised from the posterior wall of the concha, at its
junction with the conchal floor.
• The defect in the concha is closed primarily using
numerous 4-0 nylon sutures.
• It is important that the conchal resection be placed
precisely as lack of attention to the placement of the
conchal resection is a common cause of complications.
• If the resection is too large or if it is too far up the
posterior conchal wall, then it will irrevocably deform the
antihelix.
• If the resection is too far anterior, in the floor of the
concha, it will not decrease the height of the posterior
conchal wall and the closure may be visible.
• A conchal setback suture (Furnas suture) is then placed
between the reduced concha and the mastoid fascia using
a single 3-0 nylon or 3-0 PDS suture.
• This combination of a small conchal resection and a
small conchal setback avoids the distortion of a large
conchal resection and the unreliability of a large conchal
setback.
• This author avoids conchal setback alone in all
but the mildest cases as it can narrow the external
auditory meatus to the point of significant stenosis
(Fig. 4.4).
• The earlobe is repositioned by closing the triangular
defect on the medial surface of the lobule created by the
skin excision (Fig. 4.5).
• The 5-0 PDS sutures do not just approximate the skin;
rather, they approximate the skin AND take a bite of the
concha deep in the sulcus (similar to Gosain and
Recinos).
• Ideally, the endpoint of earlobe repositioning should be
slight over-correction because the skin will stretch over
time.
• The skin is approximated using 5-0 plain gut sutures
(Figs 4.6, 4.7).

74
•
• Otoplasty
4
Otoplasty for large ears or ears with
inadequate helical rim definition
Incision
• An incision is made on the lateral (visible) surface of the
ear, just inside the helical rim (or where the helical rim
would be if it is underdeveloped).
• In addition, an incision in the retroauricular sulcus may
also be required depending on what additional
maneuvers are required.
• The lateral incision is extended through the
cartilage. The posterior surface of the cartilage is
dissected, just as if a standard posterior incision had been
made.
• In the case of excessively large ears, the scaphal cartilage
(and perhaps some scaphal skin) are trimmed to the
desired size and shape.
• Care is taken to excise more cartilage than skin.
• At this point the helical rim will be too long for the new
scapha and will require shortening at the end of the
procedure.
• Mustarde sutures are placed if necessary through this
anterior access.
• Conchal resection/setback and earlobe repositioning are
performed through a separate incision in the sulcus if
necessary (Fig. 4.8).
• A wedge is then removed from the helical rim so
that it will fit the scapha, which is now of lesser
circumference.
• The desired resection will leave the helix the correct
length for the new scapha and allow closure without
excess tension.
• The helix is reapproximated carefully using horizontal
mattress sutures of 5-0 nylon sutures attempting to evert
the skin edges to avoid notching.
• The lateral incision is closed with a combination of a few
interrupted 5-0 plain sutures and a running 6-0 plain
suture.
Figure 4.4  Placement of Furnas concha-mastoid sutures. Note that suture placement too close to the external auditory canal can constrict the canal (far right). (Reprinted
with permission from Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg. 2005;115(4):60e–72e.)
A
B
C
Figure 4.5  Lobule repositioning. The technique for lobule repositioning is shown.
A triangle of skin is excised on the earlobe, never compromising the appearance of
the lobe or the ability for the patient to wear earrings. Sutures are placed close to
the skin defect while catching a bite of the concha deep in the closure.
A
B
Figure 4.6  Otoplasty. The patient is shown before (A) and after (B) standard
otoplasty. The upper, middle and lower thirds of the ear have been set back in a
harmonious fashion. The contours are soft and natural.
A
B

75
Operative techniques
Otoplasty for constricted ears
• Constricted ears are tremendously variable and no single
technique is applicable to all. Tanzer divided constricted
ear deformities into three types: type 1 – involving only
the helix, type II – involving the helix and scapha, type
III – extreme cupping of the ear.
• The simplest constricted ear deformity is the “lop ear”, in
which the upper pole of the ear is turned over. There is
always deficiency of tissue in this region.
• In some cases, it is adequate to excise directly the leading
edge of the overhanging skin and cartilage to create a less
hooded appearance.
• In more significant deformities (Tanzer type II), it is
necessary to expand the overhanging cartilage with radial
cuts and reinforce the area with a conchal graft.
• Other constricted ears may appear prominent because the
helical circumference is inadequate as if the helix has
been tightened excessively like a drawstring, forcing the
ear forward. Thus the ear cannot lie flat because the
excessively short helical rim draws the auricle into
a cup.
• Any attempt to set back a constricted ear must be
accompanied by elongation of the helix.
• The most common technique for elongating the helix is
by a variation of the incision described above for large
ears.
• The incision is made inside the helical rim and extended
anteriorly around the crus of the helix into the
preauricular region to the junction of the ear and the
temporal scalp.
• The crus of the helix is then mobilized and when
standard otoplasty maneuvers are performed, the crus of
the helix is recruited into the helical rim.
• The donor site in the concha is closed primarily as if the
crus of the helix had been taken for a composite graft to
the nose.
Figure 4.7  Otoplasty. (A,B) Posterior view before and after otoplasty. The helical rim contour is straight and the scars are hidden within the sulcus. (C,D) Frontal view
showing harmonious correction and soft natural contours.
A
B
C
D
Figure 4.8  Ear reduction. The technique of ear reduction is shown. (Redrawn from
Argamaso RV. Ear reduction. Plast Reconstr Surg. 1990;85(2):316.)
A
B
C

76
•
• Otoplasty
4
• Any excess or unusable crus of the helix is discarded.
• In the case of more severely constricted ears (Tanzer type
III), it is preferable to discard the cartilage and construct
a framework as if the patient had classic microtia.
Otoplasty for cryptotia
• Cryptotia is the rare condition where the upper portion
of the ear is buried beneath the temporal scalp. The ear
can often be pulled out of the scalp to examine it.
• Correction is performed by pulling the ear out of its bed
in the scalp, incising around it in order to release it fully,
and resurfacing the defect behind the upper pole of ear
with a skin graft or a local flap.
• In some cases, the auricular cartilage is normal in contour
and only requires the soft tissue rearrangement described
above for correction.
• In other cases, the cartilage is misshapen, as in a lop ear,
and requires cartilage grafting to augment the deficient
native cartilage framework in addition to the soft tissue
considerations.
Otoplasty for Stahl’s ears
• Stahl’s ear is defined by an abnormal crus extending
superolaterally and the deformity is variable.
• In the mildest cases, the extra crus is barely noticeable
and can be ignored and the otoplasty performed as if it
were a standard case of prominent ears.
• More severe deformities include excess scapha in the
region of the abnormal crus and termination of the
abnormal crus in a point (“Mr Spock” ears).
• In the most severe cases, there is also complete absence of
the normal superior crus.
• Correction of the deformity mandates resection of the
abnormal crus.
• The author makes an incision inside the helical rim as
described above but not through the cartilage.
• The skin is carefully dissected off the lateral surface of
the cartilage (Fig. 4.9).
• The abnormal crus is resected and placed as an onlay
graft to reconstruct the absent superior crus.
• The cartilaginous defect left by the resected crus is closed
primarily and the skin is then reapproximated.
Correction of aging, elongated ear lobes
• A number of techniques have been described and the
anatomy of the individual patient dictates the design.
• The most common procedure in the author’s hands,
however, is amputation of the caudal border of the lobule
with scar placement on the back side of the earlobe
where it is not visible.
• The ideal contour is drawn on the lobule. The excision is
designed asymmetrically so that the incision is made
caudal to this line on the lateral surface and cephalic to it
on the medial surface.
• This asymmetry leads to greater resection from the
medial side of the ear lobe and creates a longer skin flap
on the lateral surface.
Figure 4.9  Correction of Stahl’s ear. The lateral skin is reflected, the abnormal
crus is excised, the cartilage defect is closed primarily and the cartilage from the
excised crus is used as an onlay graft to recreate the normal superior crus. (A)
The skin incision is shown inside the helical rim. (B) The abnormal crus is excised.
(C) The cartilage defect is reapproximated and the excised cartilage is placed as an
onlay graft to reconstruct the superior crus. (D) The final result. (Redrawn from
Kaplan HM, Hudson DA. A novel surgical method of repair for Stahl’s ear; a case
report and review of current treatment modalities. Plast Reconstr Surg.
1999;103:566–569.)
A
C
B
D
• The lateral flap is thinned so it is more mobile than its
medial counterpart.
• The combination of the asymmetric design, the thinner
lateral flap and the fact that the ends of the defect are not
located precisely on the margin of the lobule but rather
slightly medial to it, result in the ultimate scar being
hidden on the medial surface of the lobule. Numerous
sutures, meticulous tapering and some patience are
required for the best outcome.
Correction of earring-related complications
• While a number of procedures have been described for
correction of elongated piercings, the author has found
that simple excision and closure is most effective.

77
Complications and outcomes
■ If recurrent hypertrophic scars or real keloids develop,
the author recommends scar revision with
postoperative radiation beginning immediately on the
day of the scar revision.
Postoperative considerations
• A piece of Xeroform and a soft bulky dressing are placed
on the skin. The purpose of the dressing is to protect the
repair, keep the skin of the ear moist, and to absorb
drainage.
• No attempt is made to put pressure on the ear and often
a doughnut of gauze is placed around each ear
specifically to avoid pressure.
• The dressing is left in place 3–5 days depending
on when the most convenient day for an office visit
occurs.
• The patient or family is instructed to wear a loose
headband at night only. The goal is to have no pressure
on the ear during the day and only enough at night to
prevent inadvertent pulling forward of the repaired
auricle.
• The nocturnal headband is continued for 4–6 weeks,
although most patients confess to discarding it much
sooner than that. Remember, the headband should only
be tight enough so that it does not fall off.
Complications and outcomes
• Most patients who undergo otoplasty are satisfied with
the results, making the procedure gratifying for the
surgeon as well.
• Suture complications are relatively common:
■ The Nylon Mustarde sutures may eventually protrude
through the posterior skin. This may occur within the
first few weeks or not for years.
■ In some cases, the sutures are associated with
inflammation or a granuloma.
■ Suture removal immediately cures any apparent
infection and does not seem to lead to recurrence of
the prominent ear.
• The second most common complication is under-
correction or recurrence:
■ While this is not ideal, it is far better in this author’s
opinion than over-correction or distortion.
• Infection and hematoma may also occur.
• Unfortunately, patients requesting secondary procedures
are not uncommon. The most common complaints of
these patients are:
• Over-correction. This can usually be improved by
removing sutures, undermining skin and occasionally
placing a skin graft.
• Visible cartilage irregularities or unnatural contours.
Firmin has the best and most impressive series of patients
in this category in whom she has removed the damaged
cartilage and placed expertly carved pieces of rib
cartilage.
• This technique applies to both elongated earring holes
and those that have torn completely through the lobule
margin.
• In the case of a complete traumatic cleft lobule, a Z-plasty
can be added in an effort to avoid a notch.
• In reality, an everted closure using horizontal mattress
sutures seems to yield equivalent results at the lobule
margin.
• The medial and lateral skin is closed with nylon sutures,
and no deep, absorbable sutures are used.
• Avoiding absorbable sutures in the subcutaneous tissue
of the lobe seems to minimize the inflammation and
shorten the recovery and the waiting period before
re-piercing.
• The earlobes can be re-pierced in 6 weeks, depending on
how stiff and fibrotic they are after the repair.
Correction of facelift deformities
around the ear
• Facelift deformities of the ear are frequently unfixable,
leading to lesson number one in facelifting: AVOID
THEM. Problems fall into the following categories:
■ Deformities of the lobule (pixie ear): the result of
excessive anterior and inferior traction on the lobule
due to inexpert trimming of the facelift flap. Such
deformities are completely avoidable but difficult to
correct.
■ The facial skin should be trimmed so that the ear can
barely be pulled out from under it.
■ Deformities of the tragus: consist of either anterior
traction on the tragus, amputation of some of the tragal
cartilage or excess facial skin at the bottom of the tragus
that serves as an across-the-room surgical signature.
■ There is little that can be done for the first two
conditions, since too much tissue has been removed.
■ A lack of definition of the caudal tragus can be
corrected by removing a triangle of skin from the
caudal aspect of the tragus to recreate the natural,
right-angle contour.
■ Deformities of the retroauricular sulcus: placing facelift
incisions high up on the back of the ear repeatedly
may result in thinning of the skin and a pulled back
appearance.
■ Once the deformity is created, there is no solution
except release of the ear and placement of a full
thickness skin graft.
■ Unsightly scarring: can frequently be improved by
excision and additional facelifting maneuvers as long
as no tension is placed on the closure.
■ The facelift flap should be redraped and trimmed so
the edges are touching. While a few sutures are placed,
no sutures should really be necessary in the
preauricular region or the postauricular sulcus.
■ Hypertrophic scars are more problematic. Therefore,
revision of scars should be approached with
trepidation.
■ Kenalog injection is helpful and eliminates the need
for revision in many cases.

78
•
• Otoplasty
4
• Unpleasing shape of the ear (e.g. telephone ear,
protruding lobules).
• Unpleasing shapes of the ear such as telephone ear
(where the middle third of the ear is over-corrected
relative to the upper and lower poles) can usually be
improved significantly simply by restoring the natural
contour harmony.
• Under-correction, usually of the upper pole of the ear.
Often easily corrected by revision otoplasty.
Further reading
Argamaso RV. Ear reduction with or without setback
otoplasty. Plast Reconstr Surg. 1989;83(6):967–975.
Converse JM, Wood-Smith D. Technical details in the
surgical correction of the lop ear deformity. Plast
Reconstr Surg. 1963;31:118–128.
Firmin F. Ear reconstruction in cases of typical microtia.
Personal experience based on 352 microtic ear
corrections. Scand J Plast Reconstr Surg Hand Surg.
1998;32(1):35–47.
Furnas DW. Correction of prominent ears by concha
mastoid sutures. Plast Reconstr Surg. 1968;42:
189–193.
Gosain AK, Recinos RF. A novel approach to correction of
the prominent lobule during otoplasty. Plast Reconstr
Surg. 2003;112(2):575–583.
Kajikawa A, Ueda K, Asai E, et al. A new surgical correction
of cryptotia: A new flap design and switched double
banner flap. Plast Reconstr Surg. 2009;123(3):897–901.
Kaplan HM, Hudson DA. A novel surgical method of repair
for Stahl’s ear: a case report and review of current
treatment modalities. Plast Reconstr Surg.
1999;103(2):566–569.
Luckett WH. A new operation for prominent ears based on
the anatomy of the deformity. Surg Gynecol Obstet.
1910;10:635.
McDowell AJ. Goals in otoplasty for protruding ears. Plast
Reconstr Surg. 1968;41:17–27.
Matsuo K, Hirose T, Tomono T, et al. Nonsurgical correction
of congenital auricular deformities in the early
neonate. A preliminary report. Plast Reconstr Surg.
1984;73:38–51.
This is the first report showing the enormous potential for
neonatal molding of congenital ear deformities.
Mustarde JC. The correction of prominent ears using simple
mattress sutures. Br J Plast Surg. 1963;16: 170–178.
Spira M. Otoplasty: what I do now – a 30-year perspective.
Plast Reconstr Surg. 1999;104(3):834–840.
Stenstroem SJ. A “natural” technique for correction of
congenitally prominent ears. Plast Reconstr Surg.
1963;32:509–518.
The technique of otoabrasion is described. The technique was
fully embraced by a large number of surgeons.
Tanzer RC. The constricted (cup and lop) ear. Plast Reconstr
Surg. 1975;55:406–415.
Thorne CH. Otoplasty. Plast Reconstr Surg. 2008;122(1):
291–292.
The author of this chapter demonstrates his preferred
otoplasty technique in a video and emphasizes the role of
endpoint visualization when performing the procedure.
Webster GV. The tail of the helix as a key to otoplasty. Plast
Reconstr Surg. 1969;44(5):455–461.
This paper describes a technique for repositioning the lobule
that is a classic but with which the author of this chapter
has not had success.

©2014, Elsevier Inc. All rights reserved.
5 
Chapter
Abdominoplasty
Brief introduction
• Abdominoplasty is one of the most commonly performed
aesthetic procedures which encompasses not only
aesthetic features but also structural reconstruction of the
abdominal wall.
• Due to the number of variations and modifications of
abdominoplasty procedures, it is critical to select the
appropriate technique based upon patient characteristics
in order to minimize morbidity and postoperative
disability while providing a desirable and predictable
result.
• Pregnancy is the most common cause of abdominal wall
aesthetic deformities because the skin and
musculoaponeurotic structures are stretched beyond their
biomechanical capability to retract.
• Massive weight loss after dieting or bariatric surgery
results in excess, inelastic skin and subcutaneous tissue
and a laxity of the abdominal wall musculature.
• Fat accumulation occurs in a distribution pattern that
varies according to the gender. Normal anatomic
abdominal proportions can be found in Figure 5.1.
■ Women tend to add local adiposity in the lower trunk
and hip region as well as posterior thigh region which
can result in cellulite, or fibrous septa within the
subcutaneous tissue.
■ Men tend to add intraabdominal adipose tissue
resulting in an increase in abdominal girth.
Preoperative considerations
• In addition to standard documentation of other medical
co-morbidities and medications, the medical history
should also include documentation of the following: a
detailed weight history including current BMI, history of
This chapter was created using content from
Neligan & Warren, Plastic Surgery 3rd edition,
Volume 2, Aesthetic, Chapter 25, Abdominoplasty
procedures, Dirk F. Richter and Alexander Stoff.
SYNOPSIS
■ Assessment of the abdominal region includes a detailed medical
and physical history, including pregnancies, prior surgeries
especially in the lower truncal area, and weight changes.
Preoperative identification of any existing ventral hernia including
diastasis recti is imperative.
■ Essential abdominal exam findings include the existence and
localization of vertical and horizontal tissue excess, the relationship
between fatty excess and skin excess, and examination of the
umbilical stalk with exclusion of umbilical hernia.
■ Further perioperative adjuncts include preoperative bowel
evacuation for reduction of intraabdominal pressure, careful
intraoperative tissue handling, maintainance of an adequate body
temperature, sufficient medical thromboembolism prophylaxis,
precise intraoperative preparation with respect to anatomical key
points, postoperative compression treatment and early
management of postoperative complications such as seromas.
■ The fleur-de-lis abdominoplasty allows an improvement of the
entire abdominal area with simultaneous tightening of the waist
circumference. Hereby it is essential to initially assess and
temporarily close the vertical line prior to resection of the lower
abdominal redundant tissue. Care should be taken to avoid
extending the vertical incision line cranially between the breasts.
■ In patients after massive weight loss, aesthetic outcome will
improve by high-lateral-tension and fleur-de-lis abdominoplasty.
However, in most cases circumferential truncal procedures are
necessary for superior results.
■ The preservation of the loose areolar epifascial tissue allows
preservation of subfascial lymphatic vessels which reduces the
incidence of seroma formation.
■ It is mandatory to analyze any suspected skin tumor in the area of
excised tissue.

80
•
• Abdominoplasty
5
D
R
W
H
E
C
A
B
Figure 5.1  Anatomical landmarks. Normal abdominal anatomic proportions. The
approximate measurements for an average female abdomen are listed. These vary
according to individual height and bone structure. The umbilicus is located in line
with the most superior point of the iliac crest in 99% of patients. A, Distance
between top of mons and anterior vilvar commissure. Average height is 5–7 cm.
B, Distance between umbilicus and top of mons. Average height is 11–13 cm.
C (=A + B) Distance between umbilicus and top of anterior and vulvar commissure
(C=D). E, distance between the costal margina and the iliac crest. The proportion of
this distance to the width of the base of the rib cage (R) determines whether the
patient is long waisted or short waisted. The normal proportion (E : R) is roughly
1 : 3 (long waisted approaches 1 : 2, short waisted approaches 1 : 3).The rib cage
tapers inferiorly. A more narrow lower rib cage relative to the width under the
armpits helps to emphasize the waist by creating a subtle V. H, hip width. A wider
pelvis than rib cage emphasizes the waist; the waist is more defined when RW, Natural waist – the narrowest point of the torso. (Note that the umbiculus
usually sits below the natural waist by about 1–4 cm). Relative to the hips, this
waist-to-hip (W : H) ratio in healthy women is roughly 0.72 : 1; in healthy men, it is
roughly 0.83 : 1. Note that the natural contour of the healthy abdomen reveals a
subtle epigastric sagittal depression transitioning to a mild infraumbilical convexity.
A subtle vertical sulcus at the lateral rectus border, which is more distinct in a
muscular person, may also be seen.
weight fluctuations, and/or history of prior bariatric
procedures; a detailed pregnancy history including
number of pregnancies/children and history of cesarean
section; history of other abdominal surgeries, including
suction assisted lipectomy, and abdominal hernias.
• Physical examination should be performed in the seated
and upright positions, and should focus on the following
findings and measurements:
■ Quality of skin.
■ Thickness of adipose tissue by pinching.
■ Number and location of folds.
■ Location of abdominal wall defects.
■ Patient’s favored clothings.
■ Preexisting scars.
■ Status of abdominal musculature.
■ Distance from umbilicus to top of mons, from
umbilicus to sternal notch, and from anterior vulva
commissure to top of mons.
■ Waist and hip measurement, waist-to-hip ratio.
• In cases of diagnostic uncertainly, a computed
tomography or magnetic resonance imaging test can be
helpful in determining the presence of hernia.
• Patient weight should be stable for at least 12 months
preoperatively; with any desired weight loss achieved
prior to the surgery.
• Cessation of smoking should occur ideally 6 weeks prior
to the surgery and after, but at the least 2 weeks prior
and for at least 2 weeks postoperative to minimize the
risk for postoperative wound complications.
• Patients should take antiseptic showers in the evening
and morning prior to the surgery, the abdominal folds
and the umbilicus should be cleaned thoroughly with
cotton sticks and antiseptic solutions.
• Anticoagulant drugs must be avoided prior to surgery.
The patient should also avoid perioperative use of
various homeopathic drugs and nutritional supplements,
which can induce bleeding.
Anatomic pearls
• The abdominal wall is embryonically derived in a
segmental manner, reflected in blood supply and
innervation.
• The umbilicus:
■ Situated in the midline, approximately 9–12 cm above
the mons pubis.
■ The periumbical area is characterized by a round or
eliptoid shape with a slight depression of 4–6 cm in
diameter.
■ The fascia surrounding the umbilicus can be unstable
with an increased incidence for hernias, resulting in a
risk of bowel injury during umbilical dissection.
■ The blood supply to the periumbilical area is supplied
by branches from the subdermal plexus, from both
deep inferior epigastric arteries as well as the median
umbilical ligament.
• The skin of the abdomen has areas of increased
adherence to the underlying fascia (“zones of
adherence”), such as the anterior superior iliac crest and
the linea alba.
• The abdominal subcutaneous tissue is divided by two
layers of fascia, the superficial Camper’s fascia and the
deep Scarpa’s fascia, a strong fibrous layer of connective

81
Operative technique
tissue which is continuous with the fascia lata of the
thigh.
• The superficial fat layer has a more compact character
with smaller lobules and a rich vascularization, while the
deeper fat layer contains larger lobules with a more
scattered pattern.
• The abdominal musculature includes four paired
muscles, which are the rectus abdominis, connected in
the median linea alba, the external oblique and internal
oblique and the transversus abdominis muscle, which
incorporate into the anterior and posterior rectus sheath
at the linea semilunaris (Fig. 5.2).
• The abdominal lymphatic system is divided into a
supraumbical system which drains into the ipsilateral
axillary lymph node basin and an infraumbilical drainage
system which drains into the ipsilateral superficial
inguinal lymph node basin.
• The lymph vessels in the infraumbical area pass through
the subscarpal plane, explaining the importance of
Scarpa’s fascia preservation in abdominal wall surgery.
• Huger described different zones of the abdominal blood
supply which should guide the surgeon in planning and
performing a safe operation (Fig. 5.3):
■ Zone 1: the midline supplied by the vertically oriented
deep epigastric arcade.
■ Zone II: the lower abdominal circulation supplied by
the superficial epigastric, superficial external pudendal,
and superficial circumflex iliac systems.
■ Zone III: the lateral aspect of the abdominal wall
(flanks) supplied by the 6 lateral intercostal and 4
lumbar arteries.
• In standard abdominoplasty procedures, the cutaneous
blood supply to zone I and a main part of zone II is
disrupted, resulting in an abdominal flap perfusion
mainly supplied by zone III. Therefore it is crucial to
study any preoperative existing scar, such as subcostal
cholecystectomy incisions. In certain circumstances,
even a vertical midline incision can jeopardize flap
perfusion.
• Cutaneous sensation of the abdominal wall is derived
from the anterior and lateral cutaneous branches of the
intercostal nerves 8 to 12.
• The anterior branches pass between the internal oblique
and transversus abdominis muscles, enter the rectus
abdominis muscle and reach the overlying fascia and
skin.
• The lateral cutaneous branches penetrate the intercostal
muscles in the midaxillary line, ending in the
subcutaneous layer.
• Both branches are responsible for the overlapping of the
sensory dermatomes T5 to L1.
• The ilioinguinal and iliohypogastric nerves, not involved
in innervation of the abdominal wall, can be disrupted
and injured in lateral transverse lower abdominal
incisions, resulting in consistent sensory loss in the area
of the groin and medioventral thigh (Fig. 5.4).
• Patients with significant health risks, with unrealistic
surgical goals and body dysmorphic disorder are primary
contraindications for an elective abdominoplasty
procedure.
• Relative contraindications to abdominoplasty include
right, left, or bilateral upper quadrant scars, further
severe co-morbid conditions (e.g., heart disease, diabetes,
morbid obesity, cigarette smoking), eventual future plans
for pregnancy, a history of thromboembolic disease, and
morbid obesity (BMI >40).
• Patients with disposition to keloids or hypertrophic scars
have to be informed, and must accept the postoperative
scarring associated with these conditions.
Operative technique (Video 5.1, Video
5.2, Video 5.3)
Marking and positioning
• The patient should be marked preoperative in the upright
position. Borders of underwear, where possible, should
be marked in an attempt to place the scar in a hidden
position (Fig. 5.5).
• The expected resection should be estimated by the pinch
test (Fig. 5.6).
• The lower incision line will run parallel to the scar line
and is normally below the abdominal fold, and 6–7 cm
superior to the vulvar commissure.
• The upper incision line is an estimate and should be
tailored intraoperatively depending on tension.
• Local fat depots are marked for guidance with adjunctive
liposuction.
• Perioperative thromboprophylaxis with sequential
compression devices should be implemented in all
patients having abdominal wall surgery. In many cases,
the intraoperative and postoperative use of heparin may
also be indicated.
• While antibiotic prophylaxis is not universally required, it
may be indicated as a single preoperative dose, especially
if a hernia is present.
• Patient positioning on the operating room table should
include adequate padding of feet, knees, buttocks, back
(especially for hyperlodosis cases), shoulders, and head.
In addition, the patient’s hips should be placed at the
level of the break in the table for adequate flexion during
the wound closure portion of the case.
Mini abdominoplasty
• Characterized by a transverse incision that is shorter than
the incision used in full abdominoplasty procedures.
• Indicated in patients with a mild to moderate skin laxity
and tissue excess of the lower (infraumbilical) abdomen,
together with a sufficient distance between the symphysis
and the umbilicus.
• Common for young women with a pre-existing
Pfannenstiel incision to benefit from this technique.
• A distance of at least 9 cm between the upper
resection line and the umbilicus should be strictly
respected to avoid an unaesthetic appearance. If, after skin
resection, the distance is expected to be less than 9 cm,
umbilical transposition should be preferred (Fig. 5.7).
Video
5.1
Video
5.2
Video
5.3

82
•
• Abdominoplasty
5
B
Semilunaris line
Arcuate line
Figure 5.2  (A) Anatomy of the musculature of the abdominal wall with arterial supply. (B) Arcuate line and linea semilunaris.
A
Superficial
circumflex
iliac artery
Deep
circumflex
iliac artery
Subcostal
artery
Pectoralis major
Rectus abdominis
External oblique
Internal oblique
Transversus
abdominis
Superficial inferior
epigastric artery
Deep inferior epigastric artery
Superior
epigastric artery
Superficial external pudendal artery
Anterior rectus
sheath
(reflected)

83
Operative technique
• Therefore, this technique represents a good alternative
between mini abdominoplasty and standard
abdominoplasty procedures.
Standard abdominoplasty (Fig. 5.9)
• Indicated in patients presenting with skin and soft tissue
excess of the upper and lower abdomen who will accept
a periumbilical scar.
• The inferior incision is made first and carried down
through scarpa fascia to the rectus fascia.
• The abdominal flap elevated in a suprafascial plan.
• Through a circumferential, peri-areolar incision, the
umbilicus is freed from the abdominal flap.
• The primary limitation of this procedure is the
presence of upper abdominal skin folds and
rolls; these patients will require one of the more
extensive procedures described subsequently in this
chapter.
Abdominoplasty with umbilical
transection (Fig. 5.8)
• Abdominoplasty with a prefascial release and
transposition of the umbilicus without circumferential
release from the abdominal flap thereby avoiding a
perumbilical scar.
Figure 5.3  Zones of blood supply (Huger WE, 1978).
Superficial epigastric artery
Ascending branch of deep
circumflex iliac artery
Intercostal artery
Subcostal artery
Lumbar branches
Zone I
Zone II
Zone III
Zone III
Inferior epigastric artery
Superior epigastric artery
Table 5.1  Indication for different techniques
Mini
Modern
Short-T
Standard
HLT
Anchor
Circular
Reverse
Lower abdomen
+
++
++
+++
+++
+++
+++
0
Periumbilical
(+)
+
+
++
++
+++
++
(+)
Upper abdomen
0
(+)
+
++
++
+++
++
+++
Diastasis/hernia
(+)
+
++
++
++
+++
++
(+)
Flanks/hips/thighs
0
0
0
(+)
+
++
+++
0

84
•
• Abdominoplasty
5
• The umbilicoplasty can be performed in many ways
including skin incisions involving an elliptoid, chevron,
or shield shape.
• The umbilicus is best secured using absorbable deep-
dermal sutures and a running skin closure.
• Two subcutaneous drains are often inserted to assist with
postoperative fluid drainage.
High-lateral-tension (HLT) abdominoplasty
• Extended modification of the traditional abdominoplasty
procedure that also treats the hips and the lateral
thigh.
• A modified skin incision/resection is utilized to lead to
more conservative resection centrally with wider excision
of the lateral skin (Fig. 5.10).
• Suitable for patients that want their hips and lateral
thighs addressed, patients after massive weight loss, and
• Supraumbilically, the abdominal flap is undermined
primarily in the midline to the level of the xiphoid.
• In cases of rectus diastasis, plication of the
anterior rectus sheath from the xiphoid to the
symphysis is accomplished using non-absorbable
suture material.
• Paramedian plication of the anterior rectus sheath may
facilitate a correction of an asymmetrically located
umbilical stalk or for accentuation of an hourglass figure
with further waist tightening.
• The patient is flexed at the hip approximately 30° and the
abdominal flap is pulled infero-medially to determine the
appropriate position of the superior skin incision.
• Once the superior skin incision is made, the medial
portion of the wound is temporarily closed to allow
marking of the new location for the umbilicus.
• Wound closure is performed in layers, and if significant
dead space exists, progressive tension sutures may be
used.
Latissimus dorsi
Lateral cutaneous branches
of intercostal nerve
Lateral cutaneous branches
Anterior lamina of rectus sheath
Transversus abdominis
Anterior cutaneous branch
Rectus abdominis (cut)
Arcuate line
Transversalis fascia
Serratus anterior
Intercostal nerve
Tenth intercostal nerve
Eleventh intercostal nerve
Subcostal nerve
Iliohypogastric nerve
Ilio-inguinal nerve
External oblique (cut)
External oblique
Internal oblique (cut)
Inguinal ligament
Round ligament of uterus
Figure 5.4  Abdominal nerves.

85
Operative technique
Figure 5.5  Markings are to be performed with respect to the anterior vulva
commissure and the umbilicus.
Figure 5.6  Pinching of the abdominal tissue in upright and supine position.
9cm
6-7cm
Figure 5.7  Preoperative markings for a short scar abdominoplasty. The red line
demonstrates the resulting scar line. It is essential to respect the umbilico-pubic
distance. The distance from the upper resection line to the umbilicus should be at
least 9 cm.
in patients for whom an abdominoplasty is deficient and
a lower body-lift is beyond their needs (Fig. 5.11).
Fleur-de-lis abdominoplasty
• Includes a vertical midline scar that allows elimination of
horizontal and vertical skin/subcutaneous tissue
redundancy.
• Suitable for patients suffering from a tissue excess of the
lower and particularly of the upper abdomen in the
horizontal direction. This often includes patients after
massive weight loss and in those who have preexisting
midline abdominal scars.
• The key in planning this procedure is to independently
assess the horizontal and vertical excess of skin and fat
tissue (Fig. 5.12).
• In this technique, the umbilicus must be integrated into
the vertical scar.
• In general, the vertical resection should be performed
first and prior to horizontal resection to reduce the risk of
over-resection (Fig. 5.13).
Reverse abdominoplasty
• Performed in patients who require tightening of skin in
the upper abdomen alone.
• The most common indication is the massive weight loss
patient who has undergone a conventioanal
abdominoplasty and still suffers from persistent skin and
soft tissue excess of the upper abdomen.
• The marking is performed with the patient in
upright position. The patient is asked to slightly
bend forward for demonstration of tissue excess.
This enables an optimal assessment of the vertical

86
•
• Abdominoplasty
5
A
B
C
D
E
F
Figure 5.8  Intraoperative view of abdominoplasty with umbilical transection. (A) Markings in the supine position; (B,C) preservation of scarpa fascia; (D,E) preparation of
the umbilical stalk; (F) closure of the umbilical base with non-resorbable suture material;
and horizontal tissue excess. The inframammary fold is
then marked extending laterally to the anterior axillary
line. The width of resection is generally less then 15 cm
(Fig. 5.14).
• In selective cases, the excess tissue may be utilized
deepithelialized and rotated cranially for autologous
augmentation of the breast as part of a mastopexy
procedures.
Vertical abdominoplasty
• The vertical abdominoplasty refers to a purely vertical
incision with lateral mobilization of abdominal soft
tissue.
• Indicated in patients with a preexisting scar in the
abdominal midline who seek improvement of abdominal
contour without additional transverse scars.

87
Operative technique
G
H
I
J
Figure 5.9  A 42-year-old woman with remarkable amount of striae distensae in the periumbilical region after a single pregnancy. Pre- and postoperative oblique and front
images of a standard abdominoplasty procedure with incomplete elimination of striae.
A
B
C
D
(G,H) assessment of the distance between upper resection line and the umbilicus with resection of the redundant tissue; (I) refixation of the umbilical
stalk to the anterior rectus sheath and (J) the intraoperative result.
Figure 5.8, cont’d