Atlas of Asian Rhinoplasty (Volume 3) – Tác giả chưa rõ – Hướng Dẫn Giải Phẫu & Phẫu Thuật Mũi (file pdf)

790
Infection
The rate of implant-related infection is reported to be as high as 5.3%, but the true incidence varies for each operator. The
author sees implant-related infection in about 0.5% of patients who undergo implant-based dorsal augmentation.
Early symptoms and signs of an infection include pain, swelling, redness, heating sensation, and tenderness (Fig. 16.30).
Infection will require implant removal, with the return of low dorsum becoming a source of stress between the patient and
surgeon. Post-rhinoplasty infection can also destroy the cartilage and soft tissue. The resulting contracture can induce severe
nasal deformity. Also, the infection can become systemic, developing into life-threatening complications such as toxic shock
syndrome, endocarditis, and myelitis. As such, the use of implants should always prompt a meticulous approach to infection
prevention.
Causes
Post-implantation infection is caused by inadequate antiseptic technique, bleeding, excessive tissue tension, and dead space,
in addition to patient factors such as immunosuppression, excessive stress, and smoking. The surgeon should appreciate the
increased risk of post-implantation infection in patients undergoing complex septorhinoplasty or patients with rhinosinusitis,
recent increase in rhinorrhea (e.g., recent episode of cold, allergic season), complicated revisional surgery, or history of bac-
terial infection.
Fig. 16.30 Post-rhinoplasty infection
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Prevention of Infection
Aseptic technique must be observed completely. The whole face should be prepped with povidone-iodine (Betadine) solu-
tion. Vibrissae are trimmed within the nasal cavity, which is also washed with the solution afterwards.
A carved implant should be kept submerged in a mixture of Betadine solution and antibiotics prior to insertion into the
pocket. Patients with higher risk of infection should be instructed to apply mupirocin (Bactroban) ointment into the nasal
cavity using a cotton swap, from fifth day prior to surgery, which is associated with 97.9% decrease in Staphylococcus
aureus.
The risk of infection is higher for rigid implant and for implants with larger surface area. Thus, chance of infection can be
lowered with small and soft implant with low height.
Hematoma formation increases the chance of infection. Meticulous hemostasis and compression dressing are important
not only for hematoma as a complication but also for prevention of infection. In patients with higher-than-expected bleeding
tendency, a drain may be left behind for a day. A postoperative hematoma should be aspirated when it undergoes liquefaction
after a week.
It is important to maintain an optimal physical condition before and after an operation. In patients with rhinitis or sinusitis,
these problems should be managed first prior to commencing rhinoplasty.
Prophylactic antibiotics should be used for any rhinoplasty operation that incorporates implant augmentation.
Treatment
The discovery of an infection should prompt immediate administration of broad-spectrum IV antibiotics and removal of
internal splint. All involved implants should be removed. Irrigation of implant pocket and administration of antibiotic are not
effective if the implant is not removed. The attempt at salvaging the implant will prolong the treatment duration and increase
the likelihood of secondary complications such as fistula, scar tissue formation, and contracture. Obtaining culture and anti-
biotic sensitivity is a must when removing the implant. The empty implant pocket should be irrigated vigorously with
Betadine solution mixed with antibiotics. The surrounding granulomatous tissue is removed using a curette. The capsule will
need to be removed if infected, granulomatous, or sclerotic.
The antibiotic regimen should be changed as soon as the sensitivity test result becomes available. However, a culture may
not identify the pathogen if antibiotic treatment had been administered prior to obtaining the culture. If the culture result is
null and the infection does not appear to be improving after a week of broad-spectrum antibiotic, the coverage should be
changed to a quinolone or other agents that cover gram-negative bacteria and Pseudomonas.
A great number of authors recommend a staged approach to the management of implant-related infection, by which the
implant is removed first with the revisional operation performed at a later time after the infection has subsided. The revisional
surgery is usually performed 6–12 months after implant removal. A smaller portion of surgeons have reported a single-stage
operation by which the implant removal is followed by immediate augmentation using autogenous tissue. From the patient’s
perspective, the single-stage approach is advantageous as they do not have to face the stress and contracture risk of staged
operation. However, the patient must also submit to the high risk of recurrent infection and graft loss. As such, the single-
stage operation should be considered and offered to select patients who fully understand and are capable of accepting this
risk. After a single-stage operation, postoperative antibiotic should be administered for at least 2 weeks.
Even in a patient without any symptoms and sign of infection, exploration of the nose during revisional surgery can some-
times reveal pus-like exudate below the nasal implant. Such chronic subclinical infection is usually associated with simulta-
neous hump reduction and implant augmentation, with the exudate usually found in the dead space between the open roof
and implant.
The patients will experience chronic or repeated episodes of swelling and edema without definite signs of infection. This
is considered to be a chronic inflammation or foreign-body reaction and can be distinguished from infection.
Implant-Related Complications

792
Secondary Tip and Columella Surgery
Unsatisfactory Tip Projection
After tip projection, a patient may feel that the projection was not adequate enough or the projected tip may become lower
over time. The inadequate projections have several mechanisms:
1. Weak medial crura
2. Hanging medial crura
3. Retracted short columella
4. Inadequate structural graft
5. Tight thick skin of the tip
6. Strong depressor septi nasi muscle
7. Scar contracture from columella
An underprojected nasal tip should be corrected by addressing these mechanisms.
Weak Medial Crura
Medial crura of lower lateral cartilages are important structures that determine tip height.
Compared to Caucasians, the medial crura are smaller and weaker in Asians, with absent medial crura being not a rare
finding (Fig. 16.31). With such medial crura, the nasal tip will be low and collapse easily with the slightest of pressure.
Weak medial crura can lead to failure of cartilage onlay or shield graft for a couple of reasons. The cartilage graft may end
up dropping between both domes of lower lateral cartilages, or the weight of onlay graft may twist or compress down on the
medial crura (Fig. 16.32). These mechanisms can lead to inadequate nasal tip projection.
For these reasons, weak medial crura should be supported using columella strut or septal extension graft. Once the central
column is secure, tip onlay graft can be added for further projection (Fig. 16.33).
a
b
Fig. 16.31 Weak twisted medial crura (a) and congenital absence of medial crura (b)
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a
b
Fig. 16.32 Cartilage onlay graft can fail to project the tip with weak medial crura in two ways. (a) Twisted medial crura. (b) Compression of the
medial crura by the graft
a
b
c
Fig. 16.33 Tip-revisional surgery to correct unfavorable tip projection. (a) Unfavorable tip projection results from deviated medial crura after
cartilage onlay graft. (b) The twisted medial crura is straightened using columellar strut graft (conchal cartilage), which increases nasal tip height.
(c) Additional tip projection is provided by medialization of lateral crura
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Hanging Medial Crura
With hanging columella, or if hanging columella can be induced with minor depression of nasal tip, simple placement of car-
tilage onlay graft can worsen the hanging columella. This can induce loss of tip height. Thus, correction of hanging columella
is a prerequisite for projection of a low nasal tip (Fig. 16.34). Correction of hanging columella is described in Chap. 13.
a
b
c
d
e
f
g
h
Fig. 16.34 Nasal tip projection in hanging columella. (a–d)
This patient with flat nasal dorsum and low tip with hanging
columella underwent a closed rhinoplasty, which consisted of
dorsal augmentation (silicone implant), hanging columella
correction (medial crural-septal suture), and tip projection with
interdomal suture and conchal cartilage onlay graft. (e–h)
Postoperative photographs demonstrate satisfactory projection
of the nasal tip
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Retracted Columella
In a nose with retracted short columella, tip projection is difficult to achieve with simple cartilage onlay graft, and the minor
projection of nasal tip will be lost within a short amount of time (Fig. 16.35). The revisional surgery will have to employ
either columellar strut graft or septal extension graft to project and elongate the columella.
a
b
Fig. 16.35 Tip projection will usually be unsuccessful if the short
retracted columella is not corrected to be complete and stable
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Inadequate Structural Graft
It is not a rare occurrence that a strong structural graft (e.g., columellar strut graft or septal extension graft) is followed by
tip drooping over a long term.
Columellar strut graft is an extremely useful tip projection technique in Asian rhinoplasty. With time, however, factors
such as disruption of tip-supporting fibrous tissue and scar contracture can induce re-drooping of the projected tip.
Columellar strut graft should be used only if it can offset these negative factors with a net positive effect for tip projection.
The graft is appropriate for supporting weak medial crura that could become twisted and compressed down. Graft material
must be sufficiently thick for adequate strength. A strut graft prepared from very weak and thin septal cartilage cannot with-
stand the force of scar contracture. Tip drooping from inadequate columellar strut graft should be addressed by adequate
release from the scar tissue, and any weak strut graft should be exchanged with a strong and firm graft.
Tip drooping can occur several months to years after septal extension graft from partial resorption of graft, graft weakness
and collapse, or deviation of the graft or L-strut (Fig. 16.36). As such, the graft needs to be sufficiently thick and strong. A
graft that is marginally strong enough to support a projected tip height may appear to be doing its job in the early postopera-
tive period but will eventually be overcome by the force of scar contracture and collapse, resulting in loss of projection
(Fig. 16.37). During the revisional surgery, the weak and thinned septal extension graft should be exchanged with a stronger
graft. Any deviation in the L-strut should be addressed at the same time.
a
b
c
d
Fig. 16.36 Tip drooping after septal extension graft. (a–c) In this patient, the tip drooping and columellar deviation developed after a septal exten-
sion graft. (d) The problems are due to deviation of the L-strut and graft
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a
b
c
d
Fig. 16.37 Tip drooping after septal extension graft. (a, b) In this patient, the tip drooping developed some time after a septal extension graft.
(c–e) Intraoperative exploration reveals the cause to be graft collapse secondary to partial resorption of proximal part of the graft. The collapsed
graft is located far beneath the lower lateral cartilage domes
e
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Thick Tight Skin of the Tip
In Asians, the nasal tip skin is often thick and tight. Such thick skin will be highly resistant to stretching after suture tech-
niques or cartilage graft. Also, the heavy soft tissue can place a large burden on the weak medial crura, which will hinder the
effort to project the tip or even lead to net loss of tip height. To overcome this tension and weight of the skin, the tip will
require a strong structural graft such as fixed type of columellar strut graft or septal extension graft.
Strong Depressor Septi Nasi Muscle
In a patient with smiling tip, the action of depressor nasi septi muscle may result in tip drooping after a tip plasty. In these
patients, columellar strut graft is a must to overcome the pulling power of the muscle. In addition, the muscle itself must be
resected or repositioned (Fig. 11.52).
Asymmetric Nasal Tip and Columella Deviation
Asymmetric nasal tip after an unsuccessful rhinoplasty is always accompanied by columella deviation and nostril asymmetry
(Fig. 16.38). Secondary asymmetric tip is caused by the following factors:
1. Deviated long dorsal implant
2. Improper positioning of tip onlay/shield graft
3. Improperly performed suture techniques on lower lateral cartilages
4. Deviated medial crura and deformed lateral crura
5. Improperly performed septal extension graft
6. Uncorrected dorsal/caudal septal deviation
7. Scar contracture
Fig. 16.38 Secondary nasal
tip asymmetry is accompanied
by columella deviation and
nostril asymmetry
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Deviated Long Dorsal Implant
In Asian rhinoplasty, the implant for dorsal augmentation is made to span from the radix to the supratip. In the past, surgeons
have placed long implants that reach into the nasal tip. If such a long implant is deviated, one of the lower lateral cartilages
will be depressed by the implant, which will cause the asymmetry of nasal tip and nostrils (Fig. 16.39).
This problem is corrected by replacing the offending implant with a shorter one and by realigning the displaced lower
lateral cartilage to proper symmetric position. The nasal tip may also require suture technique and columellar strut graft
(Fig. 16.40).
a
b
Fig. 16.39 Deviated long implant is another cause of tip and
nostril asymmetry
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Fig. 16.40 Correction of deviated nasal tip from deviated long implant. (a, b) A deviated long implant is responsible for deviation and asymmetry
in the tip, columella, and nostril. (c) The L-shaped implant is deviated to the right side. (d) Removal of the implant reveals asymmetry in the lower
lateral cartilages. (e) Lower lateral cartilages are made symmetric using columellar strut graft (conchal cartilage). (f, g) At 4 weeks, the lower nose
is significantly more symmetric
a
b
c
d
e
f
g
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Improper Positioning of Tip Onlay/Shield Graft
Tip asymmetry can be caused by improper positioning of cartilage onlay graft/shield graft on the dome of lower lateral
cartilages. This problem is corrected by repositioning the graft to the central location over the dome (Fig. 16.41).
a
b
c
Fig. 16.41 Deviated cartilage onlay graft. (a) Deviated nasal tip. (b) Cartilage onlay graft is not located centrally over the domes, which was
repositioned during the operation (not shown). (c) After 4 years, the nasal tip remains symmetric
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Improperly Performed Suture Technique
Improperly performed suture techniques can create asymmetry in the lower lateral cartilages. This will require a redo of the
cartilage workup. However, deformation and distortion of the lower lateral cartilage may require additional grafts such as
columellar strut graft and lateral crura onlay graft (Fig. 16.42).
a
b
c
d
Fig. 16.42 Deviated nasal tip from deformed lower lateral cartilages. (a) Deviated nasal tip. (b) Improperly performed suture technique was the
cause for asymmetry and deformation of the lower lateral cartilages. (c) Lower lateral cartilages are realigned using columellar strut graft (septal
cartilage). (d) The nasal tip deviation is corrected
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803
Deviated Medial Crura
Deviated medial crura are caused by improperly performed techniques, deviated columellar strut graft, deviated long implant,
and placement of cartilage onlay graft on weak medial crura. A deviation in medial crura is corrected by addressing these
factors. Columellar strut graft is perhaps the most versatile technique (Fig. 16.43).
a
b
c
d
e
f
Fig. 16.43 Correction of deviated medial crura. (a, b) A patient with deviated tip/columella and nostril asymmetry. (c) The medial crura are
twisted. (d) The medial crura are straightened with columellar strut graft. (e, f) Postoperative photographs show symmetry in the tip, columella,
and nostril
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804
Deformed Lateral Crura
Deformed lateral crura induce pinched deformity and asymmetry of the nasal tip, as well as nostril asymmetry (Fig. 16.44).
Post-rhinoplasty deformations of lateral crura include buckling, disruption, asymmetric alignment, and cephalic
malpositioning.
Fig. 16.44 Deviated tip from deformed lateral crura. (a, b) A patient with pinched and deviated tip. (c) The lateral crura are misaligned and buck-
ling. (d, e) L-shaped columellar strut graft and lateral crural onlay graft were used to correct the misalignment and buckling deformity. (f, g) Early
postoperative photographs (2 weeks) show symmetric nasal tip and absence of pinching deformity
a
b
c
d
e
f
g
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Improperly Performed Septal Extension Graft
Tip and columellar deviation with nostril asymmetry is not rare after septal extension graft, which has a couple of causes.
First cause is fixation of the graft to an already deviated caudal septum. The second—more common and pertinent—cause is
the weakness of graft or dorsal and caudal L-strut of the septum. If the L-strut is weak, placement of a unilateral septal exten-
sion graft can lead to bending of the L-strut and graft deviation, which can result in deviation of nasal tip and columella
(Fig. 16.45). The deformation of L-strut can be observed during the operation but can also occur over a long term following
the operation.
This is addressed by removing the graft and correcting the L-strut deviation. Correction of deviated caudal and dorsal
septum is described in Chap. 15. A deviated graft can be reused, but a batten graft should be placed on the side opposite of
the reused graft to support the L-strut. If this bilateral graft cannot be arranged, the septal extension graft should be aban-
doned in lieu of columellar strut graft or derotation graft (Fig. 16.46).
Fig. 16.45 A unilateral septal extension graft can lead to warping
of weak L-strut, which in turn can result in graft deviation and tip/
columella deviation
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806
a
b
c
d
e
f
g
Fig. 16.46 Correction of columella and nostril asymmetry from deviated septal extension graft. (a, b) Previously, this patient had undergone
septal extension graft for short-nose correction, with subsequent development of columella deviation and asymmetry of tip/nostril. (c) This defor-
mity results from deviated caudal septum and graft, which becomes worse with posterior pressure on the tip. (d) The graft and caudal septum are
deviated. (e) After graft removal, the deviated caudal septum and tip length are addressed using derotation graft (conchal cartilage). (f, g)
Postoperative photographs at 9 months
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Deviated Caudal Septum
In a patient with deviated columella, nostril asymmetry, and tip deviation, the caudal septum must be evaluated prior to a
revisional surgery. Deviated caudal septum is often the fundamental problem behind a deviated columella. Correction of
caudal septal deviation is described in Chap. 15.
Pinched Tip
Pinched tip is an unaesthetic appearance of nasal tip characterized by excessively narrowed tip, deep alar groove extending
to the alar rim, shadowing between the lobule and ala, and ball-shaped tip (Fig. 16.47).
Pinched tip is caused by weakness, collapse, or malposition of the lateral crura of lower lateral cartilages. This deformity
may be congenital or secondary to prior rhinoplasty or trauma.
Primary pinched tip is caused by hypoplasia or cephalic malposition of lower lateral cartilages. Most instances of pinched
tip, however, occur as a complication to a previously failed tip plasty.
A pinched tip not only represents an aesthetic problem but can also be associated with functional problems such as diffi-
culty in breathing due to external nasal valve collapse.
Fig. 16.47 Pinched tip
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808
Causes of Secondary Pinched Tip
Secondary pinched tip is caused by a variety of causes.
Over-Resection of Cephalic Margin of Lateral Crura
The most common cause of pinched tip is iatrogenic weakening of the lateral crura. The lateral crura are frequently trimmed
for correction of bulbous tip. However, over-resection of cephalic margin of lateral crura weakens the remaining portion of
lateral crura, which allows the cartilage to buckle and results in the pinched tip (Fig. 16.48).
In most Asian patients with bulbous tip, the lower lateral cartilage is not large, and the tip bulbosity is caused by thick skin
and soft-tissue abundance. Trimming of cephalic margin off relatively normal lateral crura can lead to pinched tip. As such,
bulbous tip correction in Asian patients should be performed by conservative trimming of the cephalic margin of lateral
crura. If the cephalic trimming is deemed necessary, the remaining lateral crura should have at least 6 mm of width for car-
tilaginous support. It is not rare to observe delayed formation of pinched tip from lateral crura collapse via gradual scar
contracture.
a
b
Fig. 16.48 Pinched tip from buckling of lateral crura
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Inadequate Suture Technique on the Lateral Crura
Pinched tip can also be caused by transdomal suture or spanning suture of lateral crura. The problem can occur via excessive
suture tension or too wide and deep of suture bite. These technical failures can induce notching of dome area, buckling of
lateral crura, and cephalic malpositioning of lateral crura, which all leads to pinched tip (Fig. 16.49).
a
b
c
Fig. 16.49 Pinched deformity from cephalically positioned lateral crura with buckling, caused by improper tip suture techniques
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810
Disruption of Lateral Crura
Disruption of lateral crura during a prior nasal tip plasty can lead to pinched tip, accompanied by external valve insufficiency
(Fig. 16.50).
Fig. 16.50 Disrupted lateral
crura
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Improper Nasal Tip Projection
Another cause of pinched tip is excessive projection of the nasal tip using either long L-shaped implant or multilayered car-
tilage onlay graft (Fig. 16.51).
a
b
c
Fig. 16.51 Pinched-tip deformity following tip augmentation with L-shaped implant
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812
Inadequate Closure of Inframarginal Incision
The closing of open rhinoplasty incision is the last but perhaps the most important step. The skin should be closed without
tension and symmetric. Inappropriate closure can lead to formation of pinched tip.
Correction of Pinched Tip
Mild pinched-tip deformity can be corrected using cartilage batten graft and alar rim graft, via endonasal approach. However,
the open approach may be required for more severe pinched tip or for excessive scar tissue which makes for difficult identi-
fication and delivery of lateral crura. Open approach is recommended for most cases of secondary pinched-tip deformity, as
the approach allows more accurate assessment and correction of the problem.
Pinched tip is addressed using the following operative techniques.
Augmentation of Pinched Soft Tissue with Cartilage or Dermal Graft
A nose with normal lower lateral cartilages can appear pinched due to the lack of soft tissue in the alar rim. In such pinched
nose, the depressed area can be augmented using cartilage or dermal graft, which is introduced via a small intranasal incision
(i.e., closed approach) (Fig. 16.52). Considering the resorption rate, cartilage graft is preferred over dermal graft. Among
the commonly used cartilage sources, the auricular cartilage most closely approximates the surface shape necessary for
augmentation.
a
b
Fig. 16.52 Pinched-tip correction using dermal graft. (a) In this patient, the pinched tip was corrected by placing dermal graft in the alar rim. (b)
Postoperative photograph shows marked improvement
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813
Alar Rim Graft
Alar rim graft is one of the most commonly performed and effective procedures for pinched-tip correction in Asian rhino-
plasty. This graft can simultaneously address pinched-tip deformity and alar retraction.
The graft can be prepared from septal cartilage, conchal cartilage, and rib cartilage. The graft has a width of 2–3 mm and
a length that matches the size of pinched deformity. The thicker ear cartilage is not a problem with thick skin, but can become
visible through thin skin. To prevent the graft visibility, the graft pocket should be made closer to the vestibular skin than the
outer skin, and the graft margin should be beveled (Fig. 16.53).
a
b
c
Fig. 16.53 Pinched-tip correction with alar rim graft. (a) Pinched tip. (b) The alar rim graft was prepared from septal cartilage. (c) Postoperative
photograph shows improved shape of nasal tip
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Alar Batten Graft
The oval-shaped alar batten graft is placed in the subcutaneous plane in the weak, pinched area of ala sidewall (Fig. 16.54).
The graft shape and pocket location can vary across patients.
For graft donor, the septal cartilage is the most preferred source for the thickness and strength of cartilage, but the conchal
cartilage is a decent alternative. Via either closed or open approach, the subcutaneous pocket is created at the location of
maximal weakness or pinching. When ala batten graft is placed on the lateral crura, the graft can also be considered as a
lateral crural onlay graft, which is an anatomic graft placed on structural cartilages.
The graft has to be slightly larger than the pinched or weakened area. However, the pocket should not be wider than the
graft itself, as to stabilize the graft and prevent migration. The graft does not need fixation, particularly if the graft was placed
via closed approach. However, the graft can be fixated to nearby cartilage structure or using pullout suture, if ever it is a
concern for graft migration or if the procedure was performed using an open approach.
a
b
c
Fig. 16.54 Pinched-tip correction with alar batten graft. (a) Deficiency in the soft tissue of left ala is responsible for pinched appearance. This
area was augmented using alar batten graft. (b) Graft design. (c) Postoperative photograph at 3 months
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Lateral Crural Onlay Graft
Weakened lateral crura can be strengthened with lateral crural onlay grafts, which is an onlay cartilage graft used to strengthen
the weakened or collapsed lateral crura. This graft is effective in correcting the pinched tip, ala collapse, and external valve
insufficiency due to buckling and discontinuity of lateral crura (Fig. 16.55).
While septal cartilage can be used for this purpose, conchal cartilage is more suitable because the natural convexity recre-
ates a more natural shape for the lateral crura. The graft is 3–4 mm wide and as long as it needs to be to cover the collapsed
area of lateral crura. The graft end should extend slightly beyond the weakened or collapsed portion of lateral crura. The
prepared graft is placed on the collapsed lateral crura, and underlying collapsed cartilage is fixed to the graft to be suspended
and strengthened, with 5-0 PDS suture.
If the severe pinched deformity extends beyond the lateral crura into the alar rim, the onlay graft itself is not enough and
will require the addition of alar rim graft.
a
b
c
d
e
Fig. 16.55 Pinched-tip correction with lateral crural onlay graft. (a) Pinched tip and collapsed right ala. (b) The right lateral crus is buckling. (c,
d) Lateral crural onlay graft (conchal cartilage) was used to straighten the crus. (e) Immediate postoperative photograph shows complete correction
of ala collapse
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816
Lateral Crural Strut Graft
Lateral crural strut graft is a cartilage graft placed under the lateral crura and extended laterally to the pyriform aperture
(Fig. 16.56). The graft can be prepared from any type of cartilage, but the author prefers to use septal cartilage, if available.
This graft is effective for pinched tip with ala collapse due to weakness, buckling, or discontinuity of lateral crura—and
especially effective for correcting valve collapse. In addition to strengthening and elevating collapsed lateral crura, the graft
can also reorientate cephalically malpositioned lateral crura. For this, the lateral crura should be elevated fully off the under-
lying vestibular mucosa. Lateral crural strut graft is attached to the distal part of lateral crura. The graft should extend beyond
the pyriform aperture. Caudally placed pocket to hold the distal lateral part of the graft is formed. The graft is moved caudally
and placed into the pocket to maintain caudal rotation of lateral crura.
Fig. 16.56 Lateral crural strut graft
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817
Alar Spreader Graft
The alar spreader graft is effective for pinched tip due to over-resection of lateral crura or excessive tightening of the lateral
crural spanning suture (Fig. 16.57). The best donor source for this graft is septal cartilage. If the septal cartilage is unavail-
able, conchal cartilage can also be used. A rectangular or triangular graft is placed between the two lower lateral cartilages
to elevate and lateralize the lateral crura.
If the pinched tip is accompanied by upturned short nose, a derotation graft can be performed as an alar spreader graft to
address both short-nose correction and pinched-tip correction (Fig. 16.58).
Fig. 16.57 Alar spreader graft
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818
a
d
b
e
c
f
Fig. 16.58 Pinched and upturned tip correction with derotation graft. (a–c) This patient with pinched and upturned tip underwent implant
exchange, alar spreader type of derotation graft, and alar rim graft (conchal cartilage). (d–f) At 2 months, the nasal tip no longer appears pinched
nor upturned
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819
Umbrella Graft
The umbrella graft can restore the discontinuity of lateral crus or dome and restore any buckling in the crura. It can also
increase the interdomal distance, which can address narrow nasal tip (Fig. 16.59).
a
b
c
d
Fig. 16.59 Umbrella graft. (a, b) Distorted medial crura and buckling of lateral crura. (c, d) Deformed medial and lateral crura are restored with
umbrella graft (septal cartilage and conchal cartilage)
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820
Correction of Improper Nasal Tip Projection
A dorsal implant placed on top of the dome should be removed, as well as any excessively stacked cartilage onlay graft.
Then, the dome is raised using a columellar strut graft, and 1–2 layers of onlay graft are placed on top of the domes. If the
tip remains pinched, the alar rim graft should be performed in addition, which prevents depression of the proximal alar rim
towards the nostril. The overall effect is a natural ala-tip contour without any pinched deformity.
Retracted Ala
The need to correct alar retraction is common in secondary rhinoplasty. Acquired alar retractions are caused by the following issues:
1. Improperly performed transdomal and lateral crural spanning sutures
2. Over-resection of cephalic margin of lateral crura
3. Scar contracture
4. Tight closure of inframarginal incision after multilayered cartilage onlay graft on the dome may cause the pinched tip and
alar retraction because of the disproportional projection of the tip/ala skin to the vestibular skin (excessively high infratip
lobule compared to the nostril apex height)
Correction of Acquired Retracted Ala
The correction of acquired alar retraction is not different from that for primary alar retraction.
The cephalically rotated lower lateral cartilage should be released from the scar tissue and scroll area. The freed cartilage
is then moved in caudal direction (Fig. 16.60).
a
b
c
Fig. 16.60 Correction of alar retraction. (a) A patient with retracted ala. (b) Exploration reveals the lower lateral cartilages to be cephalically
rotated, with the right side being worse. (c) The lower lateral cartilages are released and mobilized caudally. The lower lateral cartilages can be
maintained in the new position using the derotation graft (not shown)
16 Secondary Rhinoplasty

821
Alar rim graft is the easiest method of correcting mild alar retraction. Moderate alar retraction will require alar spreader
graft or alar extension graft (Fig. 16.61). Severe alar retraction or retraction of distal ala rim is addressed using alar extension
graft plus V-Y advancement flap, or composite graft. These techniques are described in Chap. 13.
Fig. 16.61 Correction of alar retraction. (a) A patient with secondary retracted ala and deviated silicone implant. The retraction is worse on
the right side. (b) Deformed lateral crura are cephalically positioned. (c, d) Conchal cartilage is used for columellar strut graft and alar
spreader graft. (e) Alar rim graft was performed only for the right side. (f) At 3 months, the ala retractions have been corrected
a
b
c
d
e
f
Secondary Tip and Columella Surgery

822
Acquired alar retraction is often accompanied by scar contracture of the vestibular roof. In such cases, cartilage graft does
not adequately stretch the soft tissue, and composite graft may be more appropriate.
Composite graft is harvested from the anterolateral surface of auricle. Skin and cartilage from the cymba concha of oppo-
site ear provides the best donor site, as it matches the shape and concavity of the inner surface of alar rim. In addition to
cymba concha, the graft can be prepared from cavum concha. Most cases of composite graft for secondary rhinoplasty are
performed via open approach. In open approach through the columella and inframarginal incision, the composite graft is
sutured to the caudal margin of the lateral crura on the vestibular side. Composite grafting can be performed in combination
with other techniques.
To address alar retraction due to tight closure of inframarginal incision, excessive amount of onlay graft atop alar dome is
removed. The dome height is raised using columella strut graft or columella strut graft plus derotation graft. Then, an addi-
tional amount of cartilage onlay graft is added back. With Asian patients with small and weak alar cartilage, columella strut
graft can induce cephalic rotation of lower lateral cartilage, which can worsen alar retraction. If this were to occur, a septal
extension graft can be performed in lieu of columella strut graft, or the columella strut graft is performed along with derota-
tion graft. Any remaining alar retraction will still require alar rim graft.
Supratip Deformity
Supratip deformity is defined as fullness or bulging immediately cephalad to the nasal tip. Also referred as pollybeak defor-
mity, it can be a primary (congenital) or a secondary deformity. Guyuron et al. described the supratip deformity as a hallmark
of poorly executed rhinoplasty or inauspicious healing. This deformity is not an infrequent cause of secondary rhinoplasty,
and even experienced surgeons will have to occasionally deal with this complication.
Causes of Secondary Supratip Bulging
1. Under-resection of dorsal hump, especially under-resection of caudal dorsal hump.
2. Scar tissue formation: Supratip bulging can develop from scar tissue formation after resection of dorsal septal cartilage
and/or cephalic margin of lateral crura. Paradoxically, over-resection of cartilage can still result in paradoxical supratip
bulging. Most such paradoxical supratip bulging occurs in thick-skinned nose because of the dead space caused by the
inability of thick skin to shrink and redrape.
3. Improperly performed redraping of the skin envelope after correction of bulbous tip.
4. Pseudobulging caused by underprojected tip.
5. Improperly performed derotation graft.
Correction of Supratip Bulging
The treatment for supratip deformity does not greatly differ between primary and secondary deformities, except for the fact
that secondary supratip deformity begins with nonsurgical treatment.
16 Secondary Rhinoplasty

823
Fig. 16.62 Triamcinolone injection to supratip bulging
Nonsurgical Treatment
For supratip bulging due to scar tissue formation, the author uses intralesional injection of triamcinolone as the first-line
treatment. The dosing and frequency of steroid injection vary across surgeons. Most commonly, an injection will consist of
0.1–0.2 cc of 10–40 mg/mL triamcinolone. The first injection is performed any time between 1 and 6 weeks after operation,
with second injection performed 1–4 weeks thereafter. Three to six injections are performed.
If supratip bulging is identified immediately after bulbous tip correction, the author begins triamcinolone injection at
1–2 weeks. Triamcinolone (40 mg/mL) is mixed with 1% lidocaine with epinephrine to a concentration of 10 mg/mL. The
lidocaine-epinephrine mixture helps to decrease the pain and also limit the diffusion of triamcinolone outside of the supratip
area. Between 0.1 and 0.3 cc of this solution is injected in the supratip bulge, in the deep portion of subcutaneous scar tissue
(Fig. 16.62), using a 1 mL tuberculin syringe with 30-gauge needle. The injection is begun in the midline but is fanned
throughout the bulging area. Blanching of the skin implies dermal injection. If this occurs, the operator should alter the injec-
tion plane deeper into the subcutaneous tissue. Also, dermal injection can induce cutaneous atrophy. Prior to injection, the
syringe should be aspirated to make sure that the needle tip is not within a vessel lumen. Supratip tape or splint is applied for
5 days after each injection. The author usually follows up with three more injections at 2-week intervals. If the bulging does
not respond after a single cycle of injections, additional injections will not be helpful, and the supratip bulging will need to
be addressed at 6 months to a year with a corrective operation. If the intralesional injection is effective, the next cycle of
injections should be delayed for 2 months. Side effects of triamcinolone injection include soft-tissue atrophy (depression and
irregularity), skin depigmentation, telangiectasia, fat necrosis, ulceration, resorption of cartilage graft, and blindness (embo-
lism of the retinal vessel).
Secondary Tip and Columella Surgery

824
Surgical Treatment
Surgical correction of supratip bulging consists of lowering the bony and cartilaginous dorsum, debulking of supratip scar
tissue, and projection of nasal tip.
Cartilaginous Dorsal Reduction
A supratip bulge can be caused by a hump in the caudal portion of the dorsal cartilage, which will require a resection. The
hump should not be addressed in a single resection, but should be revised in multiple steps, while the operator evaluates the
overall contour of the dorsum. If the tip is projected during the same operation, the caudal dorsum height should be adjusted
according to the height of newly projected nasal tip.
If the mid-septal cartilage is already harvested from a prior septal operation, lowering the caudal portion of dorsal septum
can severely weaken the septal L-strut with the potential for collapse. In this case, the hump should still be reduced, but a
spreader graft should be used to reinforce the dorsal septum.
A supratip bulge can be due to the lateral crura of lower lateral cartilages. In this case, the lateral crura will need to be
lowered and moved in caudal direction using cephalic trimming or derotation suture (Fig. 16.63).
16 Secondary Rhinoplasty

825
a
b
c
d
e
f
g
h
i
j
k
Fig. 16.63 Correction of supratip bulging (pollybeak deformity). (a–c) In this patient, the pollybeak deformity developed after hump reduction
and tip plasty. (d, e) The supratip bulging was caused mainly by the lateral crura and dorsal septal cartilage. (f) Dorsal septal cartilage has been
lowered by resection. (g, h) Cephalic portion of lateral crura has been sutured to the lowered dorsal septum. The nasal tip projection was revised
using cartilage onlay graft. (i–k) Postoperative photographs
Secondary Tip and Columella Surgery

826
Supratip Debulking and Supratip Suture
A supratip fullness due to excessive scar tissue will require scar tissue excision (Fig. 16.64). Direct contact between the skin
flap and underlying cartilage is very important in decreasing the risk of dead space and scar formation. For this purpose,
supratip suture, suggested by Guyuron, is used to fixate the skin envelope to underlying cartilage (Fig. 16.65). With a tem-
porary skin suture at the columella, the supratip bulge is marked on the skin, and the corresponding underlying dorsal septum
is also marked. The temporary suture is removed, and a 5-0 Vicryl suture is passed through the subcutaneous tissue directly
beneath the skin mark, which is loosely approximated to the marked point in the underlying cartilage. To avoid dimpling or
necrosis of supratip skin, the suture must not be tied too strongly.
After supratip suture, a compression tape and splint are applied to the supratip area. The compression tape should be
applied for longer than 3 weeks. Prophylactic intralesional triamcinolone injection is given during and after the operation.
a
b
c
Fig. 16.64 Supratip fullness from scar tissue
16 Secondary Rhinoplasty

827
Fig. 16.65 Supratip suture
Secondary Tip and Columella Surgery

828
Tip Projection
Secondary tip projection is usually performed using a structural graft such as columellar strut graft or septal extension graft
(Fig. 16.66).
a
b
c
d
Fig. 16.66 Correction of pollybeak deformity. (a, b) In this patient, the pollybeak deformity was addressed with dorsal septal hump reduction and
tip projection using columellar strut graft. (c, d) Postoperative photographs
16 Secondary Rhinoplasty

829
Contracted Short Nose
The formation of capsule is considered to be caused by macrophage-induced immune reaction. Capsule formation for sili-
cone implant is a normal physiologic response, which only becomes pathologic if the capsule becomes thicker and causes
nasal deformation. Nasal contracture can occur even with a rhinoplasty operation without silicone implant.
Common causes of contracture include multiple operations, infection, and hematoma. However, there is enough of a
variation across individuals that some patients will experience nasal contracture despite complete lack of any signs or symp-
toms of inflammation.
Contracted nose refers contracture of scar tissue or capsule tissue causing nasal deformity in the following manner
(Fig. 16.67).
First, deformation of lower lateral cartilages (upturned nasal tip): The contracture pulls the lower lateral cartilages in the
cephalic direction, which causes upturned nasal tip and short nose. The nostril show increases, as well as the columellolabial
angle.
Second, scar contracture near the membranous septum induces retracted columella.
Third, the contracture deforms the alar rim (unilateral or bilateral), which leads to pinched tip and/or retracted ala. If
severe, external valve collapse can lead to functional problem.
Fourth, contracture along the lateral margins of dorsal implant will cause a pair of parallel dimpling.
Fifth, contracture of the soft tissue can increase the pressure on the distal end of an implant, which can lead to thinning
and redness of the tip skin. This can move the implant in cephalic direction (Fig. 16.68).
Correction of contracted short nose is one of the most challenging areas within secondary rhinoplasty. The contracted
short nose is difficult because, firstly, the abundance of scar tissue significantly hinders the release of lower lateral cartilages
and, secondly, the nasal skin does not stretch easily due to the scar tissue. In many cases, there is a dearth of donor cartilage
because of prior rhinoplasty operations.
a
b
Fig. 16.67 A typical configuration of contracted nose: upturned nasal tip with increased nasolabial angle, excessive nostril show, retracted colu-
mella, and pinched nostril apex. In this patient, the implant margins are also demarcated by the capsular contracture along implant margins
Contracted Short Nose

830
a
b
c
Fig. 16.68 Nasal contracture pulls the nasal tip in the cephalic direction. An implant will exert a tremendous amount of pressure in the nasal tip
soft tissue and result in thinning and redness of the skin. The contracture can also move the implant in cephalic direction
16 Secondary Rhinoplasty

831
Operative Techniques
Contracted short-nose correction consists of release of lower lateral cartilages from the surrounding scar tissue and scroll
area, release of skin envelope, and fixation of repositioned lower lateral cartilages.
Release of Lower Lateral Cartilages
Release of the lower lateral cartilages is the most important step in correction of contracted short nose (Fig. 16.69). This
process requires an incredible amount of patients on the part of operator because of the amount of scar tissue adhering to the
lower lateral cartilages. The scar tissue is mainly adherent to scroll area and membranous septum.
Upon open rhinoplasty incision, the skin/scar tissue flap is elevated from the lower lateral cartilages. Scar/capsule tissue
which adheres firmly to the lower lateral cartilage should be released very meticulously (Fig. 16.70). After elevating the skin/
scar tissue elevation, the lower lateral cartilages are released from scroll area. Though the copious amount of scar tissue
makes this a challenging step, all of the fibrous connective tissue should be released between the two cartilages, leaving
behind only the whitish vestibular mucosa.
The accessory ligament of hinge complex does not always need to be transected, but this does allow additional caudal
movement of lower lateral cartilage.
Release of membranous septum is very important for correction of contracted short nose and should not be neglected.
Most instances of contracted nose contain membranous septal scarring. Without releasing this scar tissue, it is not possible
to correct a short-nose contraction. Release of this scar tissue allows a significant amount of caudal movement of the lower
lateral cartilages (Fig. 16.71). Performed after release of scroll area and hinge complex, this step should release all remaining
fibrous scar tissue—except for the mucosa. A significant amount of operative time will be dedicated to this step, as the tiniest
of scar bands must be released. This step may result in small mucosal puncture that must be repaired.
a
b
Fig. 16.69 Release of lower lateral cartilages from scar tissue and scroll area
Contracted Short Nose

832
Fig. 16.70 Any scar tissue that places caudal traction onto lower
lateral cartilages should be released completely
a
b
Fig. 16.71 Releasing membranous septal scarring allows a significant amount of caudal advancement of lower lateral cartilages
16 Secondary Rhinoplasty

833
Release of Skin Envelope
Even with adequate caudal repositioning of lower lateral cartilages, a tight skin envelope will prohibit the desired increase in
nasal length. Release of skin envelope in contacted nose is much more difficult but also crucial than in patients with primary
short nose.
As with release of skin soft-tissue envelope (SSTE) in primary short nose, the SSTE of contracted nose will require a wide
dissection. As mentioned in the section on primary short-nose correction in Chap. 12, the author dissects and releases the
SSTE beyond the pyriform aperture.
In contracted short nose, simple dissection does not allow adequate stretching of the skin envelope, as the skin envelope
is strapped by the underlying scar tissue. Thus, the skin envelope must also be released from the underlying scar tissue, which
means the dissection must occur in dual plane (Fig. 16.72).
Fig. 16.72 Dual-plane dissection. (a)
Scar tissue adheres to the skin and alar
cartilage. (b) Dissection under the scar
tissue to elevate the skin-scar flap from
underlying osseocartilaginous frame
(deep-plane dissection). (c) Lower lateral
cartilages are released. (d) Scar and
capsule tissue are separated from the
overlying skin envelope (superficial plane
dissection). The skin can be stretched and
elongated. (e) Septal extension graft is
used to fixate the lower lateral cartilages
a
b
c
d
e
Contracted Short Nose

834
Deep-Plane Dissection
The dissection begins at the columellar open rhinoplasty incision and proceeds under the skin and scar tissue. The skin and
scar tissue are elevated from the medial crura, and the dissection is carried towards the tip. The dissection will be relatively
easy in the staging area, but will become more difficult towards the dome, where the scar adhesion from prior operation
hinders progress. Despite this, a patient and meticulous dissection will allow elevation of the scar tissue and skin envelope
as a single layer. Subsequently, the skin-scar tissue is dissected in the cephalic direction towards the upper lateral cartilages
and further up towards the radix. The dissection should be made wide, with the lateral dissection extending past pyriform
aperture. The soft tissue around hinge complex should be separated from the underlying bone. Finally, the nasal envelope
will extend in the caudal direction with minimal tension. This represents the deep-plane dissection, and the elevated flap
contains both the SSTE capsule and scar tissue.
Superficial Plane Dissection
Following the deep-plane dissection, the superficial dissection is performed in the plane between the skin envelope and the
scar/capsule tissue (Fig. 16.73). Without this superficial plane dissection, the scar tissue/capsule will prevent the skin from
stretching enough to accommodate the caudal advancement of lower lateral cartilages.
The dissection is begun in the distal portion of the elevated skin-scar (capsule) flap. The scar tissue and capsule are teased
apart from the skin layer. The superficial plane dissection should also be performed widely to the radix area, to accommodate
for maximal extension of the skin. The completion of superficial dissection will result in two flaps—skin envelope and scar
tissue-capsule flap. The skin should stretch in caudal direction with minimal resistance.
a
b
c
d
Fig. 16.73 Deep-plane dissection. (a–c) The superficial plane dissection is performed. The scar/capsule is released from the overlying skin enve-
lope. (d) Scar/capsule tissue is now completely released
16 Secondary Rhinoplasty

835
Fixation of Repositioned Lower Lateral Cartilages
The released lower lateral cartilages are repositioned caudally and fixated using one of the two techniques to increase the
nasal length: septal extension graft and derotation graft.
Septal Extension Graft
Septal extension graft is the most commonly performed operative technique for short-nose correction. Because of the fixa-
tion to caudal or dorsal septum, the graft can provide a very strong supporting structural graft. Operative details are described
in Chaps. 9 and 12.
Septal extension graft is useful for simultaneous caudal rotation of tip and columella projection (Fig. 16.74). The graft
allows precise placement of nasal tip, and the technique is relatively easy to learn and perform for a novice operator.
However, this technique results in a rigid tip, with the appearance of witched tip while smiling. Also, the batten-type
septal extension graft is usually performed as a unilateral graft, which is associated with high rates of columella deviation
and nostril asymmetry. During the procedure, the operator should have a low threshold for converting the graft into a bilateral
type of septal extension graft or using a batten graft to reinforce the weak L-strut. If there is no clear solution to stabilizing
the septum, the septal extension graft should be abandoned in favor of another technique such as derotation graft.
The septal extension graft needs to be more than 20 mm in length. In a study of Korean cadavers, Kim et al. reported that
the mean area of septal cartilage available for harvest was 12.1 × 18.0 mm with an L-strut of 10 mm. Because of this, the
septal cartilage available for harvest is often too small to be used as an effective extension graft.
Contracted Short Nose

836
Fig. 16.74 Correction of short contracted nose. (a–d)
In this patient, the short contracted nose was addressed
with septal extension graft. (e–h) Photographs at
3 weeks after operation
a
e
b
f
g
c
h
d
16 Secondary Rhinoplasty

837
Fig. 16.75 Hybrid septal
extension graft
To overcome the problem of inadequate septal cartilage, the septal extension graft technique was modified as the hybrid
septal extension graft. A pair of carved irradiated homologous costal cartilages (IHCCs), approximately 1.0 mm in thickness
and 10–15 mm in length, are grafted on both sides of the caudal septum (batten type). Ear cartilage can be used as an alterna-
tive to IHCC (Fig. 16.75). The harvested small septal cartilage is located between two IHCC batten grafts and rigidly fixated
using 5-0 PDS. The nasal tip tripod is then pulled caudally for fixation with 5-0 PDS sutures between bilateral domes of
lower lateral cartilages and anterior edge of septal cartilage graft. The hybrid septal extension graft for short-nose patients
can get nasal lengthening and tip projection, even in patients with a very small septal cartilage (Fig. 16.76).
In most cases of contracted nose, the septal cartilage has already been harvested and is not available for further harvest.
When the septal cartilage is unavailable, graft can be prepared from costal cartilage (Fig. 16.77).
Costal cartilage warps after being sliced into thin pieces. As such, the harvested block of costal cartilage should be sliced
into multiple pieces of 1–1.5 mm thickness and submerged in a normal saline solution containing antibiotic agent for an hour.
Among these, a symmetric pair of warped slices should be inserted on both sides of the dorsal septum. The major disadvan-
tages of costal cartilage graft are the invasive harvest procedure, graft warping, donor-site morbidity (e.g., pneumothorax,
hemothorax, chest wall scar), and extremely rigid nasal tip. If the septal cartilage is not available for harvest and the costal
cartilage is too calcified, another option is to use irradiated homologous costal cartilage (IHCC) grafts.
There is a controversy regarding the usefulness and resorption of IHCC. Some have reported that an IHCC undergoes
complete resorption, given enough time. However, the author believes that satisfactory outcome can be obtained when using
quality product with appropriate techniques for handling (Fig. 16.78). Although rare, the operator must explain the potential
for complications following IHCC implantation, including infection, facture, fragmentation, and resorption. IHCC should be
a last resort in select cases where no other graft source is available.
Contracted Short Nose

838
Fig. 16.76 Correction of short contracted nose using hybrid septal extension graft. (a–d) In this patient, the short-nose deformity is caused by
severe contracture. (e) Lower lateral cartilages are release and pulled caudally from scar tissue and scroll area. (f) The hybrid septal extension graft
was performed using septal cartilage and IHCC. The patient also underwent implant removal, capsulectomy, and augmentation using dermofat
graft (not shown). (g–j) At 14 months after operation, the nose is marked improved
a
b
c
d
e
f
g
h
i
j
16 Secondary Rhinoplasty