Atlas of Asian Rhinoplasty

538
a
b
c
d
e
f
g
Fig. 11.49 Medial crural-septal suture. (a) This patient has a long drooping tip. (b) Design for the cephalic trimming of lateral crura and strip
resection of caudal portion of medial crura. (c) After the trimming and strip resection. (d, e) Medial crural-septal suture fixed to the septal angle
passes through both medial crura. Interdomal suture has been performed. (f) Spanning suture is placed in the lateral crura, and the medial crural-
septal suture is ready to be tied. (g) Mild tension on the medial crural-septal suture has slightly increased the cephalic rotation
11 Tip-Reduction Surgery: Bulbous Tip Correction and Long-Nose Correction

539
Fig. 11.50 Repositioned lateral crura can
be fixed to the upper lateral cartilage
a
Fig. 11.51 Lateral crural rein flap. Medial crus-based lateral crural rein flaps can be formed from the trimmed portion of cephalic margin of lateral
crura (c), and the cartilage flaps are pivoted in the cephalic direction and fixed between dorsal septum and upper lateral cartilage in the manner of
a mini-spreader graft (d)
Type I: Correction of Long Nose with Drooping Tip

540
d
b
c
Fig. 11.51 (continued)
11 Tip-Reduction Surgery: Bulbous Tip Correction and Long-Nose Correction

541
a
b
c
d
Fig. 11.52 Transection and approximation of DSN muscle. (a) The intraoral incision provides access to the nasal base. Left DSN muscle is
detached from the origin. (b–d) Right DSN muscle is also detached from the origin and the cut ends of muscles are sutured together across the
midline
Fig. 11.53 Augmentation of the paranasal area
with silicone implant can weaken hyperactive
levator labii superioris alaeque nasi muscle
Type I: Correction of Long Nose with Drooping Tip

542
How to Combine Procedures Described Above
Not all of the procedures above need to be performed for long-nose correction. Depending on the nose, a unique combination
of procedures will be required to address the needs of each individual patient. For long-nose correction requiring cephalic
rotation, the author follows the following principle.
A slightly long nose with strong medial crura can be addressed with interdomal suture and medialization of lateral crura
combined with/without partial resection of cephalic portion of lateral crura, and medial crura-septal suture (or tip suspension
suture). This combination approach does not apply, however, for significantly long nose, weak medial crura, short columella,
or drooping tip. In such cases, the following procedures are performed in sequence until all of the problems have been
addressed adequately (Fig. 11.54):
Columella strut graft combined with/without shortening of excess caudal septal cartilage and medial crural-septal suture,
partial resection of cephalic margin of lateral crura, shortening of lateral crura, and strip resection of membranous septum
(only with redundant mucosa).
DSN muscle resection or approximation is performed in the presence of smiling tip.
11 Tip-Reduction Surgery: Bulbous Tip Correction and Long-Nose Correction

543
Fig. 11.54 Correction of long nose with drooping tip. (a–c) She has a long nose with drooping tip. (d) Long lateral crura are seen. (e) Two non-
absorbable medial crural-septal sutures pass through the caudal septum and medial crura. (f) Columellar strut graft using the septal cartilage has
been performed. (g) After cephalic trimming of lateral crura, the medial crural-septal sutures are tied. (h) The DSN muscles are cut from the origin
on each side and sutured together across the midline. (i–k) At 6 months, the long drooping tip has been corrected and remains stable
a
b
c
d
e
f
g
h
i
j
k
Type I: Correction of Long Nose with Drooping Tip

544
Cautions
As much as possible, the manipulation between the medial crura should be minimized to avoid the scar contracture that could
pull down on the nasal tip. Because of this, manipulation of DSN muscle should be performed through the intraoral approach.
Because of the intraoperative edema, long-nose correction will often result in higher-than-expected nasal tip height, and
recovery is associated with slight lengthening of the nose. These factors require slight over-shortening of nasal length.
Even in a nose with normal tip height, correction of dorsal hump can lead to tip drooping, and prevention of tip drooping
will require tip projection using columellar strut graft or cartilage onlay graft. One mild method of projecting the nasal tip is
the modified tongue-in-groove technique that connects the lower lateral cartilage suspension to the septal angle. A long nose
with high septal angle is managed by interdomal suture of lower lateral cartilage, which is suspended to the anterior septal
angle. This will accomplish both the tip projection and nasal shortening. Upon the suspension, both cephalic margins of
lateral crura are fixated to the upper lateral cartilage (Fig. 11.55).
a
b
c
d
Fig. 11.55 Modified tongue-in-groove technique for tip projection. (a) This patient has a dorsal hump and mild tip drooping and hanging columella.
(b, c) After interdomal suture, the lower lateral cartilages are suspended and anchored to the anterior septal angle. (d) Six months after the operation
11 Tip-Reduction Surgery: Bulbous Tip Correction and Long-Nose Correction

545
Treatment of Gummy Smile
Gummy smile describes the condition in which the upper lip shortens with smiling animation and more than 2 mm of upper
gingiva becomes visible (Fig. 11.56). A combination of factors contributes to the development of gummy smile. Skeletal
component includes excessive vertical height of the maxilla and dentoalveolar protrusion, and soft-tissue component includes
short upper lip and excessively long gingiva. In addition, hyperactivity of lip levator muscles is a dynamic cause of gummy
smile and can be caused by depressor septi nasi muscle, levator labii superioris alaeque nasi muscle, levator labii superioris
muscle, and zygomaticus minor muscle (Fig. 1.19).
A gummy smile is managed according to the causative factor. First, skeletal component can be addressed by Le Fort I
maxilla impaction surgery, dentoalveolar surgery, and orthodontic treatment. Second, too large of a gingiva (which is also
caused by delayed passive eruption) can be addressed by partial gingivectomy (gingivoplasty). Third, overactive muscle and
short upper lip can be addressed by muscle resection surgery or botulinum toxin injection.
Fig. 11.56 Gummy smile
Type I: Correction of Long Nose with Drooping Tip

546
Muscle Manipulation and Z-Plasty of the Frenulum
If a patient does not wish to undergo bone surgery or if a gummy smile is caused by muscular component, a rhinoplasty
surgeon can employ dynamic rhinoplasty to lower the upper lip to achieve appropriate coverage of the gingiva at the time of
a rhinoplasty operation. The muscles which can be manipulated to treat gummy smile include depressor septi nasi (DSN)
muscle and levator labii superioris muscle.
To facilitate transection of DSN muscle and lengthening of upper lip mucosal, a Z-plasty incision is made in the upper
labial frenulum (Fig. 11.57). On each side, the DSN muscle is first identified and dissected free, and is detached from the
respective origin. The cut ends are then brought across the midline and sutured to each other. To close the wound, sublabial
mucosal Z-plasty is performed to lengthen the upper lip mucosa.
Myotomy of levator labii superioris muscle is possible through the upper vestibular sulcus incision near the canine. According
to Ishida, however, this can be performed in a safer manner through a lateral incision made at the inner aspect of the nostrils,
with more predictable outcomes (Fig. 11.58). Through the lateral incisions, the skin and subcutaneous tissue are dissected
bluntly from the underlying musculature of the upper lip. The undermined area is limited by the nose (above), the oral commis-
sures (laterally), and the lip mucosa (below). Through these lateral incisions, the levator labii superioris muscles are identified
and transected. They are located immediately lateral and below the incision, and the fibers are oriented vertically.
Fig. 11.57 Z-plasty incision at the frenulum
Fig. 11.58 The left levator labii superioris muscle is exposed
through the incision at the lateral vestibular wall. The division
of muscle decreases gummy smile
11 Tip-Reduction Surgery: Bulbous Tip Correction and Long-Nose Correction

547
Per Rees and La Trenta, a wide periosteal dissection from anterior nasal spine to the pyriform aperture, camouflages a
gummy smile because the upper lip is raised less on smiling (Fig. 11.59). This periosteal elevation frees DSN muscle, levator
labii superioris alaeque nasi muscle, levator labii superioris, and associated soft tissue. This lowers the upper lip elevation
and diminishes the maximum height of gingival exposure. The periosteal elevation and redraping are performed through
frenulum incision and lateral incision, after which the wound is closed.
Fig. 11.59 A wide periosteal dissection from
anterior nasal spine to the pyriform aperture will
camouflage the gummy smile by decreasing the
amount of upper lip excursion
Type I: Correction of Long Nose with Drooping Tip

548
depressor septi
nasi m.
compressor narium
minor m.
anomalous nasi m.
transverse nasalis m.
procerus m.
levator labii superioris
alaeque nasi m.
dilator naris
anterior m.
dilator naris
posterior m.
(alar nasalis m.)
orbicularis oris m.
orbicularis oculi m.
Fig. 11.60 Nasal
musculature
Botox to the DNS and LLSAN Muscles
Outside of operative methods, injection of Botox into the DSN and LLSAN muscles can be highly effective without the
potential complications associated with operations.
Botox in the Nasal Area
Injection of Botox in the nasal area requires a thorough and complete understanding of the nasal muscle anatomy. The major
muscles of the nose are illustrated in Fig. 11.60 and described in Chap. 1.
11 Tip-Reduction Surgery: Bulbous Tip Correction and Long-Nose Correction

549
Bunny Lines
Found on the lateral wall of nasal dorsum, bunny lines are the diagonal lines that reach towards the nasal ala (Fig. 11.61).
This wrinkle develops from repeated contraction of transverse nasalis muscle. This line is most common in Caucasian
females with thin skin and can be more easily observed with smiling, expression of anger, and speech. Secondary bunny lines
can develop as a compensatory effect after Botox injection for glabellar frown line.
Transverse nasalis muscle is blocked by injection of 2–4 units of Botox in each of the nasal sidewalls. The injection
should be kept away from the nasofacial groove, to avoid the levator labii superioris muscle, orbicularis oculi muscle, and
medial rectus muscle. To minimize diffusion of the Botox into neighboring muscles, the area should not be massaged after
an injection. Injection into the angular artery has the potential for thrombosis and blindness, which is to be avoided.
Fig. 11.61 Bunny lines.
Bunny lines are formed from
contractions of transverse
nasalis muscle
Type I: Correction of Long Nose with Drooping Tip

550
Fig. 11.62 The horizontal
wrinkles of the nasal root are
caused by the contractions of
procerus muscle
Horizontal Lines at the Nasal Root
This wrinkle develops from the contraction of procerus muscle (Fig. 11.62). Unlike the bunny line, this line forms in the hori-
zontal direction. The Botox is injected into the radix deep to the wrinkles. Because the skin is thick over the radix, the needle
tip will need to be deep for intramuscular injection. For this, the soft tissue of radix is pinched between the thumb and index
finger of the nondominant hand, and 4–8 units of Botox is injected into the midline of the soft tissue.
11 Tip-Reduction Surgery: Bulbous Tip Correction and Long-Nose Correction

551
DSN Muscle and LLSAN Muscle
Botox injection into the lip elevator muscles will elongate the upper lip and is very useful for gummy smile due to muscle
overactivity. DSN muscle pulls down on the tip and elevates the upper lip. Botox injection to the muscle can project the tip
in patients with smiling tip, but this is ineffective for statically low nasal tip.
For injection, the upper lip is pulled down, and the nasolabial angle is opened. The muscle is stretched, and 2–5 units is
injected at the columellar base (Fig. 11.63). The injection is made in the subcutaneous plane to avoid the orbicularis oris
muscle. Diffusion of toxin into the orbicularis oris muscle can lead to labial sphincter incompetence, with insufficient elon-
gation of the upper lip.
Indiscriminate injection of Botox into all lip levator muscles (the levator labii superioris alaeque nasi, levator labii supe-
rioris, and zygomaticus minor) could easily lead to lip ptosis and asymmetry. It is safer to selectively inject Botox into the
levator labii superioris alaeque nasi muscle, and this yields a more predictable outcome. The injection will deliver 2 units of
Botox at 3–5 mm lateral to each side of nostril (Fig. 11.64).
Fig. 11.63 Botox injection to the DSN muscle
Fig. 11.64 Botox injection to the levator labii superioris alaeque nasi
muscle
Type I: Correction of Long Nose with Drooping Tip

552
Nasal Flutter
Nostril flaring can occur with both excitement and voluntary retraction of the ala wall and is common for wide ala. This is
caused by the action of dilator naris posterior muscle (alar nasalis muscle), which can be blocked with 5–10 units of Botox
into the area of maximal muscular contraction around the nasal ala (Fig. 11.65).
Fig. 11.65 Botox injection to the alar nasalis
muscle
11 Tip-Reduction Surgery: Bulbous Tip Correction and Long-Nose Correction

553
Type II: Correction of Long Nose with Normal Tip Height
Long nose with normal tip height also requires the various types of corrections used for type I long nose. Because of the
normal tip height, a surgeon may think that there is no need for tip projection. However, many of the procedures used for
nasal shortening alter and weaken the tip-supporting structures and often require the use of tip-projection technique in
compensation. These compensatory techniques include the likes of tip cartilage graft and suture techniques (Fig. 11.66).
A special case is simultaneous reduction of hump and shortening of the tip. The hump reduction directly decreases tip height,
and alteration of tip-supporting structure for tip shortening can indirectly lower the nasal tip height. Despite a normal preop-
erative tip height, the operation will necessarily require projection of the tip.
a
b
c
d
e
f
Fig. 11.66 (a–c) In this patient, the nose is long
with the tip at a normal height. (d–f) Despite the
normal height, the nasal tip still required a tip
projection procedure (columellar strut graft) to
maintain the nasal tip height after the long-nose
correction
Type II: Correction of Long Nose with Normal Tip Height

554
Type III: Correction of Long Nose with Overprojected Tip
Overprojected nasal tip with long nose is an extremely rare combination in Asians. Overprojected tip is caused by overdevel-
oped septal cartilage and overdeveloped lateral and medial crura of the lower lateral cartilages. Overdeveloped septal carti-
lage implies increased dorsal height and caudal length. The corrective operation will differ depending on the contributing
factors behind the tip projection.
The most common cause of overprojected tip is overdeveloped septal cartilage, which can be characterized by high anterior
septal angle and long caudal septum. By reducing the height (dorsal septum) and length (caudal septum), the lower lateral cartilages
can be moved into a less projected position. In addition, the dissection required to trim the septum will disrupt and weaken the
interdomal ligament and footplate connection to the caudal septum, which also weakens the support and decreases height of the tip.
If the overprojected tip is caused by large lower lateral cartilages, the long medial and lateral crura should be shortened to
lower the tip. The respective crura can be shortened using the appropriate overlay technique (Fig. 11.67).
Fig. 11.67 Correction of overprojected long nose. (a, b) This patient has a long nose with overprojected tip. (c) Medial crura are long. (d) Design
of the lateral crura shortening. (e) Medial crura are cut and overlapped for shortening. (f, g) Shortening of membranous septum. (h, i) Both the long
nose and overprojected tip are corrected
a
b
c
d
e
f
g
h
i
11 Tip-Reduction Surgery: Bulbous Tip Correction and Long-Nose Correction

555
Long medial crura will require a method of directly lowering the medial crural height, which is performed by transecting
the crura and overlapping the midportion. The location for cutting is determined by the length and proportion of the colu-
mella and lobule. If the columella is disproportionately longer than the lobule, the medial crura are cut in the columellar
segment. If the infratip lobule is long relative to the columella, the medial crura are cut in the lobular segment. In either case,
the appropriate segment of medial crus should be separated from the underlying vestibular skin prior to cutting. Once the
medial crus is cut the overall length of crus is decreased by overlapping the cut ends and securing the overlapped section
using double-mattress sutures with 5-0 PDS.
Cutting and overlapping the medial crura can lower the tip height and also cause caudal rotation of dome (Fig. 11.68). In
overprojected long nose, however, this rotation is less of an issue because of the simultaneous shortening of the lateral crural
shortening. After medial crural shortening, the weakened medial crura should be strengthened using columellar strut graft.
Performed along with medial crural shortening, the lateral crural shortening also de-projects the nasal tip.
The length of nose can be further decreased using the same operations used for type I long nose, such as cephalic trim-
ming of lateral crura, shortening of membranous septum, and medial crural-septal suture.
Fig. 11.68 Cutting and
overlapping the medial crura
can decrease the tip
projection, but also rotate the
dome in the caudal direction.
This caudal rotation can be
prevented by the addition of
lateral crural shortening
Type III: Correction of Long Nose with Overprojected Tip

556
Trimming of the Columella Skin
With long-nose correction, the skin over the columella and tip may become redundant and may require trimming. Trimming
is performed at the columella and alar rim area (Fig. 11.69).
a
b
Fig. 11.69 Trimming of columellar skin. The alar rim and columella skin are trimmed to match the change in tip height and length
11 Tip-Reduction Surgery: Bulbous Tip Correction and Long-Nose Correction

557
Alar Base Reduction
If tip shortening and de-projection induce alar flaring, the alar base needs to be reduced.
Long Nose with Retracted Ala
Retracted ala is not a rare occurrence for long nose. The cephalic rotation of alar dome during long-nose correction often
worsens the preexisting alar retraction. The following techniques can be helpful in avoiding this problem:
• Columellar strut with cephalic rotation of alar dome plus C-S suture
• Alar spreader type of derotation suture
• Alar contour graft
Any preexisting alar retraction should be addressed with long-nose correction. Because length correction can alter the
degree of retraction, the long-nose correction should be performed first before the correction of alar retraction.
If possible, medialization of lateral crura should be avoided as much as possible during long-nose correction. After
cephalic trimming, the spanning suture should be avoided. Even with cephalic rotation of the dome, the lateral crura should
be pushed caudally using derotation suture (Fig. 11.70). During long-nose correction, the alar rim graft is the most appropri-
ate method of correcting alar retraction. Procedures for alar retraction are described in more detail in Chap. 13.
One important caution for long-nose correction is the need for overcorrection (i.e., over-shortening). The supine position
makes it such that the nose can appear to be shorter relative to standing position. Also, intraoperative edema tends to upturn
the nasal tip, and various postoperative factors tend to pull down on the nasal tip. Because of these reasons, there is a need
for over-shortening when correcting the long nose.
Long Nose with Retracted Ala

558
a
b
c
d
e
f
g
h
i
j
Fig. 11.70 Correction of long nose with retracted ala. (a–c) This patient has a long nose with drooping tip, retracted ala, and hanging columella.
(d) The lateral crura are long and cephalically positioned. (e) The caudal septum is shortened, and a columellar strut graft has been placed. (f)
Interdomal suture and transdomal suture are placed on the caudal margin of dome, which induces caudal rotation of lateral crura. (g) The derotation
suture was used to further push the lateral crus in the caudal direction. No alar rim graft was used. (h–j) Eight months after the operation
11 Tip-Reduction Surgery: Bulbous Tip Correction and Long-Nose Correction

559
Further Reading
1. Constantian MB, Hanover NH. The boxy nasal tip, the ball tip, and alar cartilage malposition: variations on a theme—a study in 200 consecu-
tive primary and secondary rhinoplasty patients. Plast Reconstr Surg. 2005;116:28–281.
2. Guyuron B, Uzzo CD, Scull H. A practical classification of septonasal divation and effective guide to septal surgery. Plast Reconstr Surg.
1999;104(7):2202–9.
3. Rohrich RJ, Adams WP Jr. The boxy nasal tip: classification and management based on alar cartilage suturing techniques. Plast Reconstr Surg.
2001;107(7):1849–63.
4. Gruber RP, Friedman GD. Suture algorithm for the broad or bulbous nasal tip. Plast Reconstr Surg. 2002;110(7):1752–64.
5. Nagarkar P, Stark RY, Pezeshk RA, Amirlak B, Rohrich RJ.  Role of the cephalic trim in modern rhinoplasty. Plast Reconstr Surg.
2016;137(1):89–96.
6. Park SG, Jeong H, Ye CH. Multifactorial approaches for correction of the drooping tip of a long nose in East Asians. Arch Plast Surg.
2014;41(6):630–7.
7. Sinno S, Chang JB, Saadeh PB, Lee MR. Anatomy and surgical treatment of the depressor septi nasi muscle: a systematic review. Plast
Reconstr Surg. 2015;135(5):838e–48e.
8. McKinney P. Management of the bulbous nose. Plast Reconstr Surg. 2000;106(4):906–17.
9. Hafezi F, Naghibzadeh B, Nouhi AH. Applied anatomy of the nasal lower lateral cartilage: a new finding. Aesthet Plast Surg. 2010;34(2):244–8.
10. Toriumi DM, Checcone MA. New concepts in nasal tip contouring. Facial Plast Surg Clin North Am. 2009;17(1):55–90.
11. Sazgar AA. Horizontal reduction using a cephalic hinged flap of the lateral crura: a method to treat the bulbous nasal tip. Aesth Plast Surg.
2010;34:642–5.
12. Toriumi DM, Asher SA. Lateral crural respositiong for treatment of cephalic malposition. Facial Plast Surg Clin North Am. 2015;23:55–71.
13. Tardy ME. Rhinoplasty: the art and the science. Philadelphia: WB Saunders CO; 1996.
14. Kalantar-Hormozi A, Beiraghi-Toosi A. Smile analysis in rhinoplasty: a randomized study for comparing resection and transposition of the
depressor septi nasi muscle. Plast Reconstr Surg. 2014;133:261–8.
15. Sheen JH, Sheen AP. Aesthetic rhinoplasty. 2nd ed. St Louis: Mosby; 1987.
16. Byrd HS, Hobar PC. Rhinoplasty: a practical guide for surgical planning. Plast Reconstr Surg. 1993;91(4):642–54.
17. Ahmed O, Dhinsa A, Popenko N, Osann K, Crumley RL, Wong BJ. Population-based assessment of currently proposed ideals of nasal tip
projection and rotation in young women. JAMA Facial Plast Surg. 2014;16(5):310–8.
18. Zlatko Devcic BS, Rayikanti BA, Hevia JP, et al. Nasal tip projection and facial attractiveness. Laryngoscope. 2011;121:1388–94.
19. Kuran I, Öreroğlu AR, Efendioğlu K. The lateral crural rein flap: a novel technique for management of tip rotation in primary rhinoplasty.
Aesthet Surg J. 2014;34(7):1008–17.
20. Pinto EB d S. Relationship between tip nasal muscles and the short upper lip. Aesth Plast Surg. 2003;27:381–7.
21. Arregui JS, Elejalde MV, Regalado J, et al. Dynamic rhinoplasty for the plunging nasal tip: functional unity of the inferior third of the nose.
Plast Reconstr Surg. 2000;106:1624–9.
22. Hwang WS, Hur MS, Hu KS, et al. Surface anatomy of the lip elevator muscles for the treatment of gummy smile using botulinum toxin. Angle
Orthod. 2009;79(1):70–7.
23. Carmen LMS, Fabiane KBV, Felipe RS, et al. Treatment of gummy smile: gingival recontouring with the containment of the elevator muscle
of the upper lip and wing of nose. A surgery innovation technique. J Indian Soc Periodontol. 2014;18(5):656–60.
24. Miskinyar SA. A new method for correcting a gummy smile. Plast Reconstr Surg. 1983;72(3):397–400.
25. Ezquerra F, Berrazueta MJ, Ruiz-Capillas A, Arregui JS. New approach to the gummy smile. Plast Reconstr Surg. 1999;104(4):1143–50.
26. Rees TD, La Trenta GS. The long face syndrome and rhinoplasty. Semin Plast Surg. 1989;3(2):1–23.
27. Sucupira E, Abramovitz A. A simplified method for smile enhancement: Botulinum toxin injection for gummy smile. Plast Reconstr Surg.
2012;130(3):726–8.
28. Ishida LH, Ishida LC, Ishida J, Grynglas J, Alonso N, Ferreira MC. Myotomy of the levator labii superioris muscle and lip repositioning: a
combined approach for the correction of gummy smile. Plast Reconstr Surg. 2010;126:1014–9.
Further Reading

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© Springer Nature Singapore Pte Ltd. 2018
M. K. SUH, Atlas of Asian Rhinoplasty,
Short-Nose Correction
12
While short-nose correction remains a difficult and challenging area, it has also been one subdiscipline which has seen dras-
tic advancements within Asian rhinoplasty.
A short nose exists in a wide variety across individuals. There are short noses without any nostril show nor upturned tip,
short noses with upturned tip, and short noses with upturned tip and alar rim retraction. A short nose without retraction nor
nostril show can be managed relatively easily with dorsal augmentation or shield graft. However, a short nose with severe
nostril show will require an extensive and complex set of operations.
In the past, short noses have been extended using L-shaped silicone implants widely and these continue to be used in
certain Asian countries. However, the use of these L-shaped or long implants is associated with thinning and rupture of nasal
tip skin and hence these should not be used for short- nose correction (Fig. 12.1).
This chapter describes the management of primary short nose, with contracted short nose discussed in Chap. 16.
a
b
Fig. 12.1 Implant exposure through the tip skin

562
Definition of Short Nose
Short nose is difficult to define using absolute measurements.
The perception of nasal length is dependent on the actual nasal length, tip rotation, tip projection, radix height, dorsal line,
and overall length of the face.
The nasal length is measured from the nasion to the nasal tip. The face is divided into vertical thirds, and Byrd suggested
the ideal nasal length to be two-thirds of the midface height (glabella to subnasale). However, the ideal length of a nose dif-
fers across ethnicity and individuals and can vary according to the overall facial length and width as well as the shape of chin
and lips. For a patient with long face, a nose that spans two-thirds of midface height will appear to be extremely long. While
measurement and ratios are important, the subjective perception is just as important, as well as other features of the patient’s
face. With a longer face, Asian patients often want a nose that is slightly shorter than what is considered ideal by the standard
proportion. Although such a nose can appear to be too short, it can also give rise to the illusion of a shorter and younger face.
In addition to the nasal length, another important factor is nasolabial angle. Among Caucasians, the ideal nasolabial angle
is between 95° and 100° for females and 90° and 95° in males. Among East Asians, the preferred nasolabial angle is between
90° and 93°. Even with a nose with appropriate length, a wide nasolabial angle with cephalic rotation of the tip can appear
to be short due to the nostril show.
In most cases, short nose is associated with wide nasolabial angle, but there is a significant variation across individuals.
Tip projection can also have a mild influence over the perception of nasal length. With inadequate tip projection, the nose
can appear to be shorter than it really is. In contrast, projection of a low tip can make the nose appear to be longer.
A nose with low radix makes a nose appear shorter, and radix augmentation can make a short nose appear longer
(Fig. 12.2).
Aside from factors mentioned above, the dorsal line from the profile view contributes to the perception of nasal length. A
straight dorsal line makes a nose appear longer than a curved dorsal line. Because of this, a curved dorsal line can make a
long face appear shorter than it would have been if the dorsal line was straight.
Because of these variables, a short nose should not be defined by simple measurements and ratios but evaluated in the
context of the remainder of face and other factors that influence subjective perception of the nasal length.
a
b
c
Fig. 12.2 (a) In this patient, the low radix makes the nose appear shorter than it really is. (b) The radix was augmented using the conchal cartilage
covered with temporal fascia. (c) The nose appears longer with radix at a neutral height
12 Short-Nose Correction

563
Short Nose Without Nostril Show/Retracted Ala
For short nose without ala retraction nor nostril show, augmentation of the radix and infratip lobule can be a simple and effec-
tive solution.
Radix or Dorsal Augmentation
For a low nasal dorsum, radix or dorsal augmentation can make a nose appear longer than prior to the operation (Fig. 12.3).
This is also true for dorsal augmentation performed in a long drooping nose, which will require a tip- shortening procedure.
Radix augmentation is preferably performed using ear or septal cartilage graft. The harvested cartilage is carved to match
the width and length of the sunken radix in 1–2 layers of graft. To minimize contour irregularities, the cartilage can be
crushed and wrapped in temporal fascia or dermal allograft prior to insertion. Diced cartilage wrapped in temporal fascia is
also a decent alternative technique.
Materials used for whole dorsal augmentation can be categorized into autogenous tissues and implants. Among rhino-
plasty surgeons in the West, autogenous tissue is usually the first choice. For Asian patients, however, patients frequently
have very low dorsum with thick skin, which often requires the use of implants. Each material has a unique set of advantages
and disadvantages, and the choice of augmentation material should be determined according to individual characteristics and
desired amount of augmentation. Dorsal augmentation has been discussed extensively in Chaps. 6 and 7.
a
b
c
d
Fig. 12.3 Dorsal augmentation makes a nose
appear longer. (a, b) This patient with low nasal
dorsum underwent dorsal augmentation using
implant. (c, d) The augmentation makes the nose
appear longer, despite no lengthening procedure
being performed
Short Nose Without Nostril Show/Retracted Ala

564
Shield Graft
Shield graft represents the standard choice in addressing infratip lobule deficiency. Shield graft is a cartilage graft in the
shape of a shield placed in front of the dome (Fig. 12.4). The graft can be prepared from conchal cartilage and septal carti-
lage. The graft margin should be tapered thin to a beveled edge, to minimize visibility through the tip skin. The graft should
be fixed meticulously to the underlying cartilage with 6-0 PDS sutures to avoid the graft margin becoming visible through
the tip skin. When the tip is projected and elongated simultaneously, the shield graft is placed on the alar dome. If the only
tip elongation is needed without any projection, the graft should be placed caudal to alar dome.
For a slightly short nose without nostril show, nasal dorsal augmentation and 1–2 layers of shield graft are very effective
in correcting the short nose (Fig. 12.5).
However, this method is ineffective in addressing any amount of nostril show. Upturned nasal tip with visible nostril will
require the operative techniques described below.
a
b
c
d
Fig. 12.5 Augmentation of the dorsum
and infratip lobule makes a nose appear
longer. (a, b) This patient with a low
dorsum underwent dorsal augmentation
(implant) and shield graft (conchal
cartilage). (c, d) Postoperatively, the
nose appears much longer
Fig. 12.4 Shield graft for the infratip lobule augmentation
12 Short-Nose Correction

565
Short Nose with Upturned Tip and Nostril Show
The principle of short-nose correction is caudal repositioning of the lower lateral cartilages (Fig. 12.6). How far the lower
lateral cartilages can be moved and repositioned caudally determines the degree to which the nose can be lengthened. Caudal
repositioning of lower lateral cartilages consists of three operative steps:
1. Complete release and caudal displacement of the lower lateral cartilages
2. Release of the skin and soft-tissue envelope (SSTE)
3. Fixation of the repositioned lower lateral cartilages
a
b
Fig. 12.6 Principle of short-nose correction is the caudal repositioning of lower lateral cartilages. (a) A short nose. (b) Caudal advancement of
the lower lateral cartilages increases the overall length of the nose
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566
Release of the Lower Lateral Cartilages
Releasing the lower lateral cartilages is the most important step in short-nose correction. The lower lateral cartilages are
released from three neighboring structures: upper lateral cartilages, lateral crural attachment to the pyriform aperture, and
membranous septum (Fig. 12.7).
Membranous septum
Hinge
complex
Scroll area
Fig. 12.7 For short-nose correction, these three places need to be released to allow mobilization of lower lateral cartilages from the upper lateral
cartilages, lateral crural attachment to the pyriform aperture, and membranous septum
12 Short-Nose Correction

567
Release from the Upper Lateral Cartilages (Release of Scroll Area)
The scroll area is the connection between the lower lateral cartilages and upper lateral cartilages. Dissection and release of
the scroll area are the most important steps in the release of lower lateral cartilages. Leaving the vestibular mucosa intact, the
fibrous connective tissue is sufficiently released between the two cartilages (Fig. 12.8).
a
b
Fig. 12.8 Release of scroll area
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568
Release from the Hinge Complex
If scroll area release is insufficient in allowing adequate caudal movement of lower lateral cartilages, it can be helpful to
transect the accessory ligament of hinge complex (Fig. 12.9).
Fig. 12.9 Release of hinge
complex and cutting of
accessory ligament
12 Short-Nose Correction

569
Release from the Membranous Septum
Release of membranous septum is severing of the fibrous connection while leaving alone the mucosa itself. This step is not
always required for primary short-nose correction but can allow for additional lengthening of the nasal tip. However, exces-
sive dissection in this area can lead to scar contraction with secondary tip drooping. As such, the membranous septum should
be released only if the potential benefits outweigh the risk of scar contraction.
Release of the Skin and Soft-Tissue Envelope
Even with full mobilization of the lower lateral cartilages, the nose cannot be adequately lengthened if the SSTE is resistant
to stretching. The SSTE is released through wide dissection. The dissection area can vary according to each short nose. For
a very short nose with tight skin, the author dissects and releases the SSTE beyond the pyriform aperture (Fig. 12.10). During
this step, the SSTE can be released fully by the transection of the transverse nasalis muscle (Fig. 12.11).
Fig. 12.10 The author dissects and releases the
SSTE beyond the pyriform aperture for patients
with tight skin
Fig. 12.11 Transection of transverse nasalis muscle
facilitates lengthening of the SSTE
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570
Fixation of the Repositioned Lower Lateral Cartilages
There are three techniques for fixating the caudally repositioned lower lateral cartilages:
1. Derotation suture
2. Septal extension graft
3. Derotation graft
Derotation Suture
Derotation suture fixes the caudally repositioned lower lateral cartilages to either the dorsal septum or the septal angle, and
it is also referred to as caudal rotation suture and tip extension suture (Fig. 12.12). This technique can be effective for cor-
rection of mild upturned nasal tip with strong lower lateral cartilages (Fig. 12.13). For small and weak lower lateral cartilages
in Asians, the suture technique is limited in addressing the short-nose correction. During the operation, the derotation suture
may appear to provide adequate tip lengthening. However, this gain in nasal length is quickly overcome by the edema and
fibrosis in the thick soft tissue. Therefore, this suture technique should be reserved for patients with strong lower lateral
cartilage. The technique is described extensively in Chap. 9.
Fig. 12.12 Derotation suture
12 Short-Nose Correction

571
a
b
c
e
g
d
f
i
j
h
Fig. 12.13 Derotation suture for short-nose correction. (a–c) This female patient has a short nose with upturned tip. (d, e) Through open rhino-
plasty access, the lower lateral cartilages are mobilized. (f, g) The derotation suture has caudally repositioned the lower lateral cartilages. (h–j) The
resulting nose appears longer, and the nostril show has diminished
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572
Septal Extension Graft
In Asian rhinoplasty, the most commonly employed technique for short-nose correction is septal extension graft. Because of
the fixation to caudal or dorsal septum, this graft can lead to a very strong supporting structural graft for the short nose.
There are three types of septal extension graft (Fig. 9.96). Among these, the batten type of extension graft is technically
less demanding for the novice operator, with more stable outcomes. Because of this, the author most commonly uses this
method over the other two (Fig. 12.14), with the septal cartilage being the preferred site of donor site. If the septal cartilage
is unavailable, costal cartilage can be an alternate source.
a
b
c
e
d
Fig. 12.14 Short-nose correction with
septal extension graft. Case I: (a, b) This
patient has a short nose with upturned
tip and nostril show. (c) Intraoperative
photograph of batten-type septal
extension graft (septal cartilage). (d, e)
Postoperatively, the nose appears longer
with decreased nostril show. Case II:
(a–d) This patient has a flat dorsum and
short nose. She underwent dorsal
augmentation (silicone implant) and tip
plasty with septal extension graft (septal
cartilage). (e–h) Postoperative photo-
graphs at 1 year
12 Short-Nose Correction

573
a
b
e
f
c
d
g
h
Fig. 12.14 (continued)
Short Nose with Upturned Tip and Nostril Show

574
For patients with thick skin, excessive lengthening of the nasal tip can be undone with eventual cephalic rotation of the
lower lateral cartilages, which can be compounded by the problem of the end of septal extension graft becoming exposed
caudally between the domes (Fig. 12.15). To avoid this complication, the lower lateral cartilages should be fixed such that
the domes are wrapped around the caudal end of the septal extension graft, using a nonabsorbable interdomal suture (Fig.
9.112). The septal extension graft is also described extensively in Chap. 9.
a
b
c
Fig. 12.15 Visible caudal end of the septal extension graft through the tip skin. These postoperative photographs are 6 years after the septal exten-
sion graft for the short upturned tip. The end of septal extension graft is visible through the nasal tip skin, which is caused by cephalic traction of
the lower lateral cartilage. To avoid this problem, the domes of lower lateral cartilages should be wrapped around the graft end, using interdomal
suture of nonabsorbable suture material
12 Short-Nose Correction

575
Advantages of Septal Extension Graft for the Short- Nose Correction in Asians
Septal extension graft is useful when a robust projection and caudal rotation of the nasal tip are desired. This technique
allows accurate location of the nasal tip where the operator wants, and is appropriate for the novice surgeon.
Disadvantages of Septal Extension Graft for the Short-Nose Correction in Asians
The graft results in a rigid nasal tip, which can be uncomfortable to patients and can induce the appearance of “witch tip”
when smiling (Fig. 9.116). Also, most instances of batten- type extension graft are performed as a unilateral graft. Gradual
deviation in the unilateral graft itself or the remnant L-strut of septum is a frequent cause of columella deviation and nostril
asymmetry (Fig. 12.16). This asymmetry can occur at any time after an operation, from weeks to months. If there is ever a
doubt as to whether the graft or L-strut will be able to bear the stress, the operator must perform the septal extension graft as
a bilateral graft or reinforce the L-strut with an additional batten graft, or this technique should be abandoned and another
technique such as derotation graft should be performed.
Although the septal extension graft is a strong tip- supporting graft, long-term observation often yields unexpectedly high
frequency of tip drooping. This is because the cartilage often undergoes partial resorption and becomes thin and weak.
Unlike cartilage onlay graft, the smallest thinning or weakening of a supporting structural graft can lead to tip drooping. This
can be more frequently observed in a nose with heavy and thick tip skin (Fig. 12.17). Ultimately, the septal extension graft
can easily undergo tip drooping over time, if the cartilage is not sufficiently thick and strong, and a stable long-term outcome
requires a very rigid nasal tip.
Another common cause of complaint after short-nose correction is centralization of the nasal lobule and ala. This problem
is due to the fact that the septal extension graft advances the tip and columella in the caudal direction while the ala is not
advanced as much. The disproportionate amount of advancement results in the relative retraction of the ala (Fig. 12.18). Such
a nose is associated with aging appearance and untrustworthy countenance.
Another significant disadvantage of septal extension graft is the difficulty of obtaining a graft of sufficient size in Asian
patients. A septal extension graft for short-nose correction requires a graft of more than 20 mm in length. In a Korean cadaver
study by Kim et al., the average size of cartilage available for harvest was 12.1 mm by 18.0 mm, if the remaining L-strut was
kept at a 10 mm width. As such, the septal cartilages are usually too small to be used as an effective extension graft.
Compounding the problem is the fact that patients with small septal cartilage usually require a larger L-strut be left behind.
This problem of inadequate septal cartilage can be addressed by using either the costal cartilage graft or the hybrid septal
extension graft.
Fig. 12.16 Columella deviation and nostril asymmetry following
septal extension graft
Short Nose with Upturned Tip and Nostril Show

576
a
b
c
d
Fig. 12.17 Tip drooping after
septal extension graft. (a, b)
This patient had undergone
short-nose correction using
septal extension graft. The tip
drooping has developed after
the operation. (c, d) Exploration
reveals partial resorption in the
proximal graft, with the
consequent collapse
Fig. 12.18 Septal extension graft advances the tip and columella in the caudal direction
while the ala is not advanced as much
12 Short-Nose Correction

577
Septal Extension Graft with Costal Cartilage
The costal cartilage has been used for septal extension graft if the septal cartilage was unavailable from a previous harvest or
if the cartilage is very small in size. Costal cartilage for the graft can be harvested from the fifth to seventh ribs through the
inframammary fold line. The harvested costal cartilage is 2.5–4 cm in length and is prepared into several slices at 1–1.5 mm
thickness (Fig. 12.19). The sliced cartilages are kept in a normal saline bath containing antibiotic agent to induce warping.
Among the various pieces, two symmetrically opposing grafts are inserted on each side of the dorsal septum (Fig. 12.20).
The costal grafts are fixed to the septum using 5-0 PDS suture to obtain septal extension graft that is straight overall.
Compared to using a straight piece of cartilage unilaterally, the use of symmetrically opposing grafts is associated with a
significantly lower chance of delayed warping and nasal tip deviation.
After fixation of the grafts to the dorsal septum and upper lateral cartilage restoration, the lower lateral cartilages are pulled
caudally and anteriorly and fixed to the end of graft using 5-0 PDS suture. At this point, the graft end is not sutured to the
domes in a side-to-side manner. Instead, the two domes end up covering the graft end via the interdomal suture. This is to mini-
mize the exposure of the graft end with cephalic traction of the lower lateral cartilage from scar contraction (Fig. 12.21). The
use of this interdomal suture to wrap the domes around the graft end can apply to the extension graft using septal cartilage.
Costal cartilage is abundant, durable, and stronger than the septal cartilage. It is a useful alternative to the septal cartilage
when the septum is small or in the presence of severe retracted columella (Fig. 12.22). The benefits of costal cartilage should
be weighed against the invasiveness of the procedure, warping of cartilage, donor-site morbidity (e.g., pneumothorax, hemo-
thorax, and chest wall scar), and a very rigid nasal tip.
a
b
Fig. 12.19 Harvested costal cartilage is prepared into several 1–1.5 mm thick slices to be used as septal extension graft
Short Nose with Upturned Tip and Nostril Show

578
a
b
c
Fig. 12.20 Septal extension graft with costal cartilage. (a) Two symmetrically opposing cartilages are inserted on both sides of the dorsal septum.
(b) 5-0 PDS sutures are used to bring the two cartilage slices together into a straight septal extension graft. (c) Lower lateral cartilages are sutured
to the distal end of graft
a
b
c
Fig. 12.21 Visible distal end of the graft through the tip skin. (a) This patient had undergone septal extension graft with costal cartilage 2 years
prior. After 2 years, the end of graft can be palpated and observed through the skin of infratip lobule. (b, c) The distal end of costal cartilage graft
is exposed beyond the domes of lower lateral cartilages. This was a consequence of the lower lateral cartilages being pulled in the cephalic direc-
tion from scar contracture. To avoid this complication, the domes should be wrapped around the graft end using interdomal sutures
12 Short-Nose Correction

579
Fig. 12.22 Septal extension graft using autogenous
costal cartilage. (a–d) This patient with a history of
multiple rhinoplasties had developed contracted nose
after silicone implant. (e–h) Four years after septal
extension graft using autogenous costal cartilage,
osteotomy, and dorsal augmentation using dermofat graft
a
b
e
f
c
d
g
h
Short Nose with Upturned Tip and Nostril Show

580
Hybrid Septal Extension Graft
This technique is a modification of septal extension graft, developed for Asian patients with small septal cartilage (Fig. 12.23).
The 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). Auricular cartilage can be used as an alternative to IHCC
(Figs. 12.24 and 12.25). The graft is fixated using 5-0 PDS anchoring sutures at 3–4 locations. Subsequently, the small piece
of harvested septal cartilage is inserted between the two IHCC batten grafts and fixed rigidly using 5-0 PDS. The tip tripod
is then caudally pulled for fixation with No. 5-0 PDS sutures between the bilateral domes of lower lateral cartilages and the
anterior edge of the septal cartilage graft. If the harvested septal cartilage is exceptionally small (less than 10 mm length), it
is pulled more caudally between the IHCC grafts, without any contact to the caudal septum (Fig. 12.23b). Tip onlay graft or
shield graft is performed for further tip projection, if necessary.
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. 12.26).
a
b
Fig. 12.23 Hybrid septal extension graft. (a) A small septal
cartilage can be sandwiched between two IHCC or conchal
cartilage batten grafts, which are themselves anchored to the caudal
septum. (b) If the harvested septal cartilage is exceptionally small
(less than 10 mm length), the graft is pulled more caudally between
two batten grafts, without being in contact with the caudal septum
12 Short-Nose Correction

581
a
b
c
d
Fig. 12.24 Configurations for hybrid septal extension graft using IHCCs. (a) IHCC is carved into a thin batten shape, approximately 1.0 mm in
thickness and 10–15 mm in length. (b) Carved IHCC pieces are grafted on both sides of the caudal septum. (c, d) The small harvested septal car-
tilage is placed between the two IHCC batten grafts and fixed with sutures
a
b
c
d
Fig. 12.25 Operative steps in hybrid septal extension graft using conchal cartilage. (a) Two pieces of conchal cartilage are prepared for the graft.
(b) The conchal cartilages are grafted on both sides of the caudal septum. (c, d) The small harvested septal cartilage is placed and fixed between
two conchal cartilage grafts with sutures
Short Nose with Upturned Tip and Nostril Show

582
a
b
e
f
c
d
g
h
Fig. 12.26 Correction of short nose with
upturned tip using hybrid septal extension graft.
(a–d) This patient with silicone implant has a
short nose with upturned nasal tip. (e–h) Four
years after the operation
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583
Derotation Graft
Despite the effectiveness of septal extension graft, the long- term results have been called into question, with increasing num-
ber of patients complaining of the rigid nasal tip. It is within this context that derotation graft has found a welcome role in
the correction of short nose among Asian patients.
The derotation graft is a technique whereby a conchal cartilage graft is used as an intermediary mechanical structure
between the upper lateral cartilages and the caudally repositioned lower lateral cartilages (Fig. 12.27). The operative proce-
dure is detailed in Chap. 9.
a
b
c
d
e
f
Fig. 12.27 Derotation graft for short-nose correction. (a, b) A piece of cymba concha was used as a columellar strut graft prior to the derotation
graft. (c, d) The rest of cymba concha was used as a derotation graft to secure the repositioned lower lateral cartilages. (e, f) Additional tip projec-
tion is obtained using tip onlay graft
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584
The advantage of derotation graft is the provision of tip lengthening while allowing the tip to remain supple and mobile
(Fig. 12.28). The constructed mechanism is independent of the septal cartilage and is much less stressful of a technique to
perform because of this. The technique allows for secondary adjustment of tip length (both shortening and lengthening) with
ease, which is another significant advantage over a septal extension graft.
a
b
c
d
e
f
Fig. 12.28 Derotation graft for short-nose
correction. (a–c) A patient with a short nose and
wide nasal bone. (d–f) One year after the operation
12 Short-Nose Correction

585
Derotation graft not only is useful for primary short nose but can also provide excellent outcome for severe cases of con-
tracted short nose (see Chap. 16).
Tight, thick skin can cause buckling of the derotation graft. In such a case, the derotation graft can be made from two
layers of cartilage (Fig. 12.29).
a
b
c
d
Fig. 12.29 Two-layered derotation graft. (a, b) Derotation graft has a mild buckling, which can become worse by tight skin envelope upon wound
closure. (c, d) An additional layer of smaller cartilage was placed atop the derotation graft to add resistance to buckling
Short Nose with Upturned Tip and Nostril Show

586
The First Choice for the Upturned Short Nose in Asian Patients
Despite the inherent disadvantages, septal extension graft remains the most commonly performed procedure in the correction
of short nose in Asian patients. It is easy for a novice surgeon to become acquainted. The graft has a predictable tip projection
and lengthening, with satisfactory outcomes. As such, the septal extension graft has remained as a milestone for short-nose
correction and the general trend in Asian countries. However, the number is rising among surgeons who have begun to doubt
the long-term outcomes following septal extension graft.
If the graft is strong and thick, the long-term outcome is usually satisfactory. In many Asian patients, however, the septal
cartilage is often thin and weak, and often undergoes partial resorption and more thinning, with resultant tip drooping.
Unilateral application of septal extension graft is often associated with tip and columella deviation as well as columella
asymmetry. This is a special concern among Asian patients in whom the inherent weakness in the septum often translates to
L-strut deviation over time, with subsequent tip and columella deviation. This problem can be avoided with placement of
bilateral extension graft, but this can also cause thinning in the septal cartilage that is sandwiched between the grafts. Even
with successful correction of short nose, septal extension graft cannot sometimes avoid the criticisms regarding the rigid tip
and “wicked” appearance with smiling.
Derotation graft does away with the disadvantages associated with septal extension graft. Above all, the graft can be
applied independently of the size of the septal cartilage. Tip and columella deviation is significantly less likely.
Derotation graft can simultaneously address the short nose and alar retraction. The distal portion of the derotation graft
can be used as an alar spreader graft to spread the alar cartilage laterally (Fig. 9.127).
In the past, the author has relied on the septal extension graft as the primary choice in short-nose correction for Asian patients.
However, the author presently believes that the derotation graft is the better primary option for short-nose correction.
It is an amazing fact that derotation graft uses the soft and pliable conchal cartilage to correct almost all cases of short
nose in Asian patients. Unlike septal extension graft, derotation graft results in a nasal tip that can move freely in both hori-
zontal and vertical directions.
The only cases in which derotation graft is not applicable are severe columella retraction and saddle nose from septal and
mid-vault collapse. In these situations, septal extension graft retains the advantage.
Correction of Short Nose Combined with Retracted Ala
The combination of short nose and retracted ala is a common observation in Asians. In such cases, caudal rotation of the tip
cannot provide a satisfactory outcome. Septal extension graft causes centralization of the tip and lobule, which worsens the
preexisting alar retraction. To address the alar retraction, an additional technique should be used in conjunction with the
septal extension graft, which is discussed in Chap. 13.
Derotation graft can simultaneously address alar retraction and upturned nasal tip. The distal portion of graft can serve as
alar spreader graft to support the alar rim (Fig. 12.30). Another option is to perform alar spreader graft and place the derota-
tion graft on top of the alar spreader graft to further support the alar rim (Fig. 12.31). This avoids the problem of centralizing
effect of septal extension graft and effectively corrects short nose and retracted ala with a single technique.
a
b
Fig. 12.30 Derotation graft for correction of short nose and retracted ala. (a) The cartilaginous framework prior to derotation graft. (b) The lateral
crura are spread laterally and caudally by the derotation graft
12 Short-Nose Correction

587
Fig. 12.31 Alar spreader graft and derotation graft for retracted ala. (a–c) This patient has a nostril show due to short nose and retracted ala.
(d) Columellar strut graft is performed. (e) A piece of conchal cartilage is used as an alar spreader graft. (f) The derotation graft is placed on
top of the alar spreader graft. (g–i) Postoperative photographs at 2 weeks
a
b
c
d
e
f
g
h
i
Correction of Short Nose Combined with Retracted Ala