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a
b
c
d
Fig. 9.117 Tip drooping after septal extension graft. (a) This patient is 1 year out from septal extension graft and suffers from drooping tip. (b, c)
On exploration, the graft has collapsed down from the thinning of the proximal graft due to partial resorption. (d) An example of a failed graft that
has undergone partial resorption and can no longer function as a structural graft
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a
b
Fig. 9.118 Thinning of caudal septal cartilage from bilateral septal extension graft. (a) Septal extension grafts are placed on both sides of the
cartilaginous septum. (b) The caudal portion of septum is paper-thin compared to the more cephalic portion
a
b
Fig. 9.119 Septal extension graft is placed on the right side of caudal septum. A batten graft (auricular cartilage) is placed to the left of caudal
septum to stabilize septal extension graft. The position of these two grafts is made to minimize the overlapping of the caudal septal cartilage
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Derotation Graft
First introduced by Paik, the derotation graft is a very useful technique in correcting the short nose in Asian patients. An
auricular cartilage graft is placed between the fixed structure (dorsal septum and medial portion of upper lateral cartilage)
and the mobile nasal tip (caudally repositioned lower lateral cartilages) (Fig. 9.120).
Septal extension graft has been and continues to be the most commonly performed operation for correction of short and
low tip. However, derotation graft has gained a lot of traction in Asian countries as a legitimate alternative option among
rhinoplasty surgeons. The author believes that the derotation graft may become the more popular option for the short nose in
the future.
a
b
c
Fig. 9.120 Derotation graft and columellar strut graft using the conchal cartilage
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Operative Procedures of Derotation Graft
Graft Harvest
1. Donor
The auricular cartilage is used as donor for this graft. Although both cavum concha and cymba concha can be used, the
symba concha is more appropriate for this graft because it is longer and has less curvature than cavum concha. Between the
two incisions, the anterior incision provides an easier access. For the anterior approach, the incision should be placed slightly
medial to the anterior margin of symba concha (Fig. 9.121).
2. Local Injection
The most important aspect of local injection is to make sure that the needle tip does not enter the space below the peri-
chondrium. The injection plane should be subdermal and supraperichondrial, to allow for the perichondrium to be harvested
along with the cartilage. The perichondrium is important for cartilage stability and strength. If the local injection is made in
the subperichondrial space, the hydrodissection will detach the perichondrium from the cartilage. A cartilage that is har-
vested without perichondrium is too weak to be useful for derotation graft. The cartilage should be harvested with both the
anterior and posterior perichondrium.
3. Elevation of cartilage
The whole symba concha is to be harvested, but the roof of helix should not be violated (Fig. 9.122).
4. Dividing the Graft
The harvested cartilage is divided into 2–3 pieces (Fig. 9.123). The individual pieces are used as a columella strut graft,
derotation graft, and a shield graft. If the harvested symba concha is small, the cartilage is divided into two pieces, as a colu-
mella strut graft and a derotation graft. In this case, the cavum concha will also need to be harvested for shield (onlay) graft.
5. Preparation of the Columella Strut Graft
The upper piece of divided cartilage in Fig. 9.123b is scored halfway down to allow lengthwise folding of the cartilage.
The cartilage is made into a straight strut with several stitches (Fig. 9.124).
6. Preparation of the Derotation Graft
The lower piece of divided cartilage in Fig. 9.123b is used as the derotation graft. The concave margin of this cartilage
piece is tapered thin using a blade to minimize contour irregularity of nasal tip (Fig. 9.125). Too much tapering can result in
decreased rigidity and convexity of the graft. As such, the margin should be minimally tapered or not tapered at all for grafts
that are weak and overly flexible.
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Fig. 9.121 Incision design for the anterior access to the
symba concha
a
b
c
d
Fig. 9.122 Harvest of cymba concha
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a
b
c
Fig. 9.123 (a, b, c): Harvested symba concha is divided into three pieces: derotation graft, columellar strut graft, and shield (onlay) graft. (c) If
the harvested cartilage is small, it can be divided into columella strut graft and derotation graft
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394
a
b
c
d
Fig. 9.124 Manipulation of the symba concha for straight columellar strut graft. (a) The concave side of the cartilage is scored lengthwise with a
No. 11 blade to allow for folding. (b) Cartilage is folded along the long axis with the concave side out. (c, d) The graft is stabilized into a strut
using 4–6 sutures (6-0 PDS)
Fig. 9.125 Tapering the graft
margin on the concave side
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Mobilization of the Lower Lateral Cartilage and Graft Fixation
The prepared graft is fixated in the following manner (Fig. 9.126):
1. The lower lateral cartilages are released from the scroll area, hinge complex, and occasionally membranous septum, as
described above in the septal extension graft technique.
2. The columellar strut graft is placed between the medial crura. This graft is not necessary if the medial crura are strong
enough. However, this is usually not the case in Asian patients. The derotation graft can compress the weak crura and
result in depression of the tip-defining point. Most patients will require columellar strut graft to compensate for the dero-
tation graft.
3. With a traction suture, the lower lateral cartilages are pulled caudally to the desired position.
4. The derotation graft is placed on the dorsal septal cartilage and upper lateral cartilages. The concave side of graft should
be facing the upper lateral cartilages. The exact location of the graft can be adjusted according to the newly repositioned
domal location.
5. The derotation graft is fixated to the underlying cartilage with 5-0 PDS suture. The first fixation suture is started at the
most cephalic portion of the graft, and the subsequent sutures are placed serially in the caudal direction, at 2–3 mm inter-
vals. The suture needle is passed through the paramedian portion of the graft, through the medial portion of upper lateral
cartilage and dorsal septal cartilage, and then passed back through the opposite paramedian portion of the graft and tied.
Thus, the suture knot is located in the midline of the graft. After cephalic one- third of the graft is sutured, the caudal two-
thirds of the graft are sutured to the underlying lateral crura of lower lateral cartilages. There are two methods of securing
the graft to the underlying lateral crura.
(a) In a nose without alar retraction, a spanning suture is placed in the cephalic margin of lateral crura. The caudal portion
of graft is sutured to the cephalic margin of underlying lateral crura.
(b) In the presence of alar retraction, the cephalic margins of lateral crura are not brought together. Instead, the margins
are spread apart, and the caudal two- thirds of graft are brought between the cephalic margins of lateral crura
(Fig. 9.127). This way, the derotation graft lengthens the nasal tip and also acts as an alar spreader graft, which helps
to correct the alar retraction. Depending on the case, an alar spreader graft can be performed first, on top of which the
derotation graft is secured (Fig. 9.128).
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396
a
b
c
d
e
f
Fig. 9.126 Operative sequence for derotation graft. (a) The lower lateral cartilages are released from the scroll area and hinge complex. (b, c) The
columellar strut graft is prepared by folding the conchal cartilage lengthwise. The prepared graft is placed between the medial crura. (d) The dome
of lower lateral cartilage is pulled caudally with traction suture. (e) With the lower lateral cartilage under traction, the derotation graft is placed on
the dorsal septal cartilage and upper lateral cartilage. The first fixation suture to the underlying cartilage is started at the most cephalic part of the
graft. (f) Subsequent sutures are placed serially towards the caudal direction at 2–3 mm interval. (g–j) The caudal two- thirds of graft are now
sutured to underlying lateral crura
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g
h
i
j
Fig. 9.126 (continued)
a
b
Fig. 9.127 Derotation graft for tip lengthening and spreading out the lateral crura
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a
b
c
d
Fig. 9.128 Alar spreader graft and derotation graft. (a) With columellar strut graft in place, the left lateral crura are observed to be in disruption.
(b) The left lateral crura are reconstructed with lateral crural onlay graft with auricular cartilage. (c) Alar spreader graft is performed using auricu-
lar cartilage. (d) Derotation graft is performed on top of the alar spreader graft
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Difficulties in Derotation Graft
Problems encountered during derotation graft include graft buckling, weak lateral crura, low caudal septum, high caudal
septum, and short caudal septum.
Buckling of the Graft
A weak graft can buckle under the longitudinal compression, and does not allow for predictable caudal repositioning of nasal
tip. A buckling graft should be bolstered with an additional layer of cartilage, which must be a little longer than the length of
buckling (Fig. 9.129).
a
b
c
d
Fig. 9.129 Correction of buckled derotation graft. (a, b) This derotation graft has buckling in the midportion. (c, d) An additional layer of conchal
cartilage was used to reinforce the area and correct the buckling
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400
Problem of Weak Lateral Crura
For congenitally weak lateral crura, or if the lateral crura are disrupted from a previous operation, derotation graft may not
allow for adequate caudal rotation of the nasal tip. In such cases, the lateral crura must be bolstered using lateral crural onlay
graft or lateral crural strut graft to support subsequent placement of derotation graft (Fig. 9.128).
Low Caudal Septal Height
For low caudal septal height, derotation graft may not be adequate in caudally rotating the nasal tip. In addition, the graft is
more likely to buckle with low septum. As such, the height of caudal septum should be elevated using a conchal cartilage
graft placed at the upper lateral cartilage and dorsal septum before placing a derotation graft (Fig. 9.130).
a
b
c
d
Fig. 9.130 Low caudal septal height for derotation graft. (a, b) Upon completion of columella strut graft, the septum is observed to be much lower
than the dome. (c) A single layer of conchal cartilage onlay graft is placed atop the caudal dorsal septum. The derotation graft is placed on top of
the onlay graft. (d) Another layer of conchal cartilage graft was used to correct the buckling area in the caudal portion of derotation graft
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Problem of Short Septal Length
A short and retracted caudal septum may not offer an adequate underlying platform to secure the derotation graft. In such
cases, septal cartilage or rib cartilage can be used for a short length of unilateral or bilateral septal extension graft of the
extended spreader type. The derotation graft can be placed on top of this platform (Fig. 9.131).
Fig. 9.131 Short caudal septal length for the derotation graft. (a) Illustration of the mini-spreader graft plus derotation graft for short caudal
septum. (b–d) A patient with short nose, retracted columella, visible nostril, and short caudal septum. (e) A unilateral mini-extended spreader graft
was placed on right side of the caudal septum to increase septal length. (f) The lower lateral cartilages are pulled caudally, and the derotation graft
is fixed to the small underlying area formed by the dorsal septum and mini-spreader graft
a
b
c
d
e
f
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402
How to Manage the Supratip Bulging from This Graft
The derotation graft is located on the caudal dorsal septum and upper lateral cartilage of supratip area. This added thickness
can result in supratip bulging. The dome of lower lateral cartilage is higher than the supratip area and may hide the bulging.
If the bulging does occur, the following procedures can be observed.
1. Lowering the Supratip Dorsal Septum
The dorsal septal cartilage is lowered to compensate for the added height of the derotation graft (Fig. 9.132). The upper
lateral cartilage is divided from the dorsal septum, and the dorsal septum is lowered as much as the graft is thick. The upper
lateral cartilages are then reattached to the lowered dorsal septal cartilage, upon which the derotation graft is fixated.
2. When an implant is to be used for dorsal augmentation, the dorsal septum does not need to be lowered. Instead, the distal
part of the implant can be carved thinly over the derotation graft. Another option is to have the distal end of implant to end
at the cephalic margin of the derotation graft (Fig. 9.133).
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a
b
c
d
e
f
Fig. 9.132 Supratip lowering for derotation graft. (a–c) This patient presented with low radix and short upturned nose. Operative planning included
radix augmentation with implant and tip elongation with derotation graft. (d, e) The supratip dorsal septum is bulging. (f) The upper lateral cartilages
are detached from dorsal septum, and the septum is lowered. (g) The ULCs are repaired to the lowered dorsal septum. (h) The umbrella-shaped colu-
mellar strut graft is used to support both the nasal tip and the derotation graft. (i) The derotation graft is placed on top of the lowered supratip dorsal
septum. (j–l) Postoperative photographs show defined radix and lengthened nasal tip without any supratip bulging
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404
g
h
i
j
k
l
Fig. 9.132 (continued)
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405
Fig. 9.133 Derotation graft and silicone implant. The distal end of
implant ends at the cephalic margin of derotation graft
Cartilage Grafts of the Tip

406
Advantages of the Derotation Graft
Derotation graft is an excellent technique for correction of short nose in Asians and has the following advantages:
1. Compared to septal extension graft, derotation graft contains a soft and movable nasal tip. This is the greatest advantage
of this technique.
2. Tip and columella deviation is less likely, compared to septal extension graft in patients with small septal cartilage.
3. The technique can be performed independent of the septal condition.
4. The graft allows for simultaneous correction of short nose and alar retraction. The distal portion of derotation graft can
laterally spread the lateral crura of lower lateral cartilages, which essentially functions as an alar spreader graft.
5. This technique can avoid centralization of the lobule and ala that occurs with septal extension graft. As such, the witch-
nose appearance is not a complication of this graft.
6. The tip length can be easily adjusted during revisional surgery.
If a patient complains of nasal length after a derotation graft, the length can easily be adjusted in a revisional operation,
which is not the case for septal extension graft.
To shorten the nasal tip, the caudal portion of derotation graft is elevated from the underlying lower lateral cartilage. The
lower lateral cartilages are dissected and rotated cephalically to re-fixate to the derotation graft (Fig. 9.134).
To lengthen the nasal tip, the lower lateral cartilages are dissected, rotated more caudally, and fixed to the derotation graft.
If additional stability is required, a conchal cartilage is harvested and placed as an extension at the caudal margin of the previ-
ous derotation graft (Fig. 9.135).
Disadvantages of the Derotation Graft
1. This technique has a steeper learning curve for beginner surgeons.
2. Even though the graft can project a retracted columella caudally when combined with columella strut graft, the amount
of the columellar projection is smaller than that made possible by a septal extension graft. As such, severely retracted
columella should be corrected using a septal extension graft.
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a
b
c
d
e
f
Fig. 9.134 Revisional surgery to shorten the tip after derotation graft. (a–c) This patient has an upturned nasal tip and pinched deformity due to
scar contracture and several inappropriately performed tip plasty operations. (d–f) Columellar strut graft and derotation graft are used to improve
the nasal tip deformities. (g–i) At 6 months, the tip remains elongated, and continued improvement in pinched deformity. However, the patient felt
that her nose was too long and wanted it to be shorter. (j–l) The caudal portion of derotation graft is elevated from the underlying lower lateral
cartilages. The lower lateral cartilages are dissected to allow for slight cephalic rotation. Then the lower lateral cartilages were fixated again to the
derotation graft. (m–o) At 6 months after the revisional operation, the nasal tip remains in the shortened state
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408
g
h
i
j
k
l
m
n
o
Fig. 9.134 (continued)
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409
a
b
c
Fig. 9.135 Revisional surgery to lengthen the tip after
derotation graft. (a, b) The lower lateral cartilages are
dissected, rotated more caudally. (c) Conchal cartilage is placed
as an extension at the caudal margin of the previous derotation
graft
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410
Alar Rim Graft (Alar Contour Graft)
Alar rim graft is placed along a weak alar rim for structural support. This technique is especially useful in Asian patients with
small, weak lower lateral cartilages (Fig. 9.136). The graft is placed in the alar rim where there is no cartilage and represents
a nonanatomic graft.
b
c
a
Fig. 9.136 Alar rim graft
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Operative Technique
The alar rim graft does not need to be wide to adequately reinforce a weak ala. A width of 1.8–2 mm is adequate, with a
length of 10–15 mm. However, a graft should be 2–3 mm wide to address alar retraction.
The septal cartilage is the most commonly recommended source of graft. The thinnest portion of the septum should be
used to prevent surface irregularities. Alternatives to septal cartilage include cephalic portion of the lateral crus, ear cartilage,
and costal cartilage. Because of the thick skin in Asian patients, thicker ear cartilage is not a significant issue. In patients with
thinner skin, however, one must ensure that the graft does not show through the skin. Carving the lateral end of graft round
and narrow can facilitate the insertion of graft into the pocket.
To prevent the graft visibility through the skin and to avoid the skin puncture during pocket formation, the graft pocket
should be made closer to the vestibular skin rather than the outer skin, and the graft margin should be beveled.
The pocket can be created through a small incision located at the lateral side of the vestibular roof, when performed
through the closed approach (Fig. 9.137). This lateral incision is vertical to the graft direction. A small additional incision
a
b
c
d
e
f
Fig. 9.137 Closed approach for the alar rim graft. (a, b) The graft pocket can be created through the small incision at the lateral and medial side
of the vestibular roof. (c) The pocket is created lateral to the lateral incision. (d, e) Graft is inserted through the lateral incision. (f) The pinched
deformity has been corrected by the alar rim graft
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412
a
b
Fig. 9.138 Alar rim graft through the open approach. (a) The pocket should be as close to the alar rim as possible and parallel to the alar rim. Care
should be taken not to puncture the skin over ala lobule. (b) Graft is inserted into the pocket
a
b
Fig. 9.139 Silicone sheet splint after alar rim graft
may be needed at the medial side of the vestibular roof along the caudal margin of lateral crus. When performing the open
rhinoplasty, the pocket can be made from the medial side of the inframarginal incision (Fig. 9.138). A pair of iris scissors is
used for the pocket dissection. The pocket should be as close to the alar rim as possible and parallel to the alar rim. It is not
uncommon to observe the proximal end of the graft through the skin or the distortion of the soft triangle. In such cases, the
proximal end of the graft should be trimmed or crushed using an Adson tissue forceps.
Once in place, the graft usually does not need a fixation suture. If a suture is needed, the graft is fixated to adjacent soft
tissue. Upon alar rim graft, the formation of dead space should be prevented by the application of bolster suture or silicone
splint (Fig. 9.139).
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Effects of the Alar Rim Graft
1. Moves the alar rim caudally
2. Eliminates alar convexity and concavity
3. Corrects pinched tip
4. Reinforces the external valve
5. Increases the nostril length and flares the ala
Indication of the Alar Rim Graft
The alar rim graft is a simple procedure with a wide array of indications (Fig. 9.140):
Fig. 9.140 Indications of alar rim graft. (a) Retracted ala (right side). (b) Pinched-tip deformity (both sides). (c) External valve insufficiency
(right side)
a
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414
Fig. 9.140 (continued)
b
c
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a
b
c
d
e
Fig. 9.141 Alar rim graft for prevention of pinched tip after multilayer cartilage onlay graft (L&C). (a) Low tip with short medial crura. (b,
c) Conchal cartilage was used to prepare both the columellar strut graft and cartilage onlay graft (three layers cartilage). The onlay graft was
covered with dermal allograft. The prepared grafts were used for tip projection. (d) Closing the columella incision revealed pinched deformity.
(e) Alar rim graft is used to correct the pinched appearance
1. Weak alar rim with alar notching or concave contour
2. Correction of alar retraction
3. Correction of pinched tip
4. Correction of external valve collapse
5. In Asian patients with low tip, multilayered cartilage onlay graft will result in pinched appearance of the nasal tip
(Fig. 9.141). Alar rim graft prevents the collapse of proximal alar rim towards the nostril and thus the pinched deformity.
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416
Lateral Crural Onlay Graft (Lateral Crural Graft)
Lateral crural onlay graft is a cartilage graft used to reinforce a weakened or collapsed lateral crus and change collapsed
shape into a more flat or convex shape (Fig. 9.142).
a
b
Fig. 9.142 Lateral crural onlay graft and lateral crural strut graft. (a) Lateral crural onlay graft. (b) Lateral crural strut graft
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Operative Technique
While septal cartilage can be used for this purpose, a conchal cartilage will be more suitable because its natural convexity
recreates the more natural shape of lateral crura (Fig. 9.143). Between the cavum concha and symba concha, the latter concha
is thinner and longer, which is more ideal of this graft.
The graft should be 3–4 mm wide, with enough length to extend slightly beyond the collapsed location of lateral crura.
Prepared graft is placed on the collapsed lateral crura and underlying collapsed cartilage is fixed to the graft to be suspended
and strengthened, using 5-0 PDS suture. Distal graft end does not usually extend beyond the accessory ligament, compared
to the lateral crural strut graft which extends beyond the distal end of lateral crus.
a
b
Fig. 9.143 Lateral crural graft is used to straighten a buckled lateral crura
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418
Effects of Lateral Crural Strut Graft
1. With conchal cartilage as a donor, this graft usually causes the lateral crura to be more convex, which is opposite of what
happens with the lateral crural strut graft. Therefore, this graft may increase the nasal tip volume.
2. This graft strengthens weak lateral crura.
3. The position of lateral crura does not change with this graft.
Indication of Lateral Crural Onlay Graft
1. Ala collapse due to buckling or discontinuity of lateral crus
2. Pinched tip or narrow tip
3. External valve collapse
Lateral Crural Strut Graft
Lateral crural strut graft is the strip-shaped cartilage graft that is placed under the lateral crus and secured to the undersurface
of lateral crus, and sometimes extends laterally to the pyriform aperture (Fig. 9.144).
The purpose of this graft is either to strengthen the lateral crura or to mobilize the lateral crura caudally. However, it is
more commonly used to strengthen and mobilize the lateral crura. Like the alar batten graft or lateral crural onlay graft, this
graft reinforces the weak sidewall of ala but also flattens and caudally rotates the lateral crura. Also, this graft is less likely
to show through thin skin, compared to lateral crural onlay graft or alar batten graft.
a
b
Fig. 9.144 Lateral crural strut graft. (a) To strengthen and flatten the lateral crura. (b) To mobilize the lateral crura caudally
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Operative Technique
This graft is prepared from a relatively straight, strong piece of cartilage that is carved into a long rectangular shape.
Any cartilage can be used for this graft, but the author’s first choice is the septal cartilage. The second choice would be
costal cartilage, and conchal cartilage would be the last option. Since conchal cartilage has a curvature and is weaker and
shorter than other cartilages, it is not the best choice. Relatively long cymba concha can serve as an alternative source of
graft, because its curvature is less than cavum concha, and long symmetric strips can be taken from a single- donor site. The
width of graft is 3–4 mm.
The first step is to dissect and trim (as necessary) the cephalic portion of lateral crura and detachment of the lateral crura
from the sesamoid cartilage (Fig. 9.145). This allows access to the underside of the lateral crura. Further dissection elevates
a
b
c
d
e
f
Fig. 9.145 Operative steps for lateral crural strut graft. (a–c) The lateral crus is dissected completely off the underlying nasal lining. (d) The
auricular cartilages are placed under the lateral crura and sutured to the lateral crura. (e, f) The grafts fixed to the lateral crura are pulled caudally.
The lateral limbs of graft are inserted into the pocket formed at the level of pyriform aperture
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420
the posterior lateral crura away from the underlying vestibular mucoperichondrial lining. Creation of a pocket under the
lateral crura for the graft placing is performed further, having attached nasal lining along the caudal margin of the lateral
crura and dome area, when the mobilization of the lateral crura is not needed, such as the graft’s purpose being flattening and
strengthening the lateral crura. For caudal mobilization, the lateral crura are dissected completely from the underlying nasal
lining and elevated. The carved cartilage grafts are then inserted in this pocket, that is, under the lateral crura (underlay fash-
ion). The location of anterior end of the graft varies according to the strength of lateral crura, from anterior part to the poste-
rior two-thirds of the lateral crura. The graft is then sutured to the lateral crura with 5-0 PDS. The medial portion of graft
supports the lateral crus, while the lateral portion supports the hinge area.
The lateral crural strut graft can correct cephalically malpositioned lateral crura and retracted ala. In these situations
where the mobilization of the lateral crura caudally from its original position is needed, the operator can move the graft fixed
to the lateral crura caudally and he/she should put lateral part of the graft in the pocket formed at the level of pyriform aper-
ture edge. In this case, a longer graft is required, which provides structural support for the repositioned lateral crura.
Effects of Lateral Crural Strut Graft
1. The lateral crura flatten to the curvature of the graft, which is different from the effect of lateral crural onlay graft.
2. This graft can eliminate the bulbous contour of nasal tip.
3. This graft reinforces weak lateral crura.
4. This graft can caudally reposition the lateral crura.
5. This graft can project the nasal tip.
Indication of Lateral Crural Strut Graft
1. Correction of convex lateral crura, which is correction of a boxy nasal tip
2. Correction of concave lateral crura and collapsed ala (collapsed external valve)
3. Correction of pinched tip/ala
4. Correction of malpositioned lateral crura and/or retracted ala
One of the drawbacks of this graft is that the nostril will feel thicker, particularly from within the nostril.
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Fig. 9.146 Alar batten
graft
Alar Batten Graft
The alar batten graft is a thin, oval-shaped cartilage graft which is placed along the sidewall of ala, usually just superior to
the lateral crura of lower lateral cartilage or on the area of lateral wall weakness (Fig. 9.146). The goal of alar batten grafts
is to prevent collapse of the ala and support the nostril rim where no cartilage exists. In this context, the graft can be catego-
rized as a nonanatomic graft. Thus, the exact location of the graft can be adjusted according to the weak or pinched area of
ala sidewall.
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422
Operative Technique
Alar batten grafts can be implanted through either a closed or an open approach. The grafts should be placed deep under as
much skin and soft-tissue cover as possible, to avoid the graft showing through the skin.
The graft donor sites are the usual sources of cartilage (ear, nasal septum, and rib). Septal cartilage is the most preferred,
but the conchal cartilage is a decent donor source. Costal cartilage is reserved for a strong graft.
A cartilage is carved into an oval shape. The width and length of the graft are determined by alar weakness (Fig. 9.147).
The graft margin is finished to a beveled edge, to minimize the risk of the graft showing through alar skin.
The length of alar batten graft is usually shorter than the lateral crural graft. The graft needs to be larger than the pinched
area or the weak area. However, the pocket should not be wider than the graft itself, to minimize graft migration. Graft fixa-
tion is not required, particularly if performed through closed approach. For open approach or if there is a possibility of migra-
tion, the graft can be fixed to the lateral crura or fixated using a pullout suture.
Fig. 9.147 Alar batten graft
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Effects of Alar Batten Graft
Alar batten graft adds support to a weakened alar sidewall and collapsed external valve. This graft can also improve the
contour of a pinched-tip deformity.
Indication of Alar Batten Graft
1. Pinched tip of primary origin or iatrogenic origin
2. External valve insufficiency
Alar Spreader Graft
Alar spreader graft is a spanning graft placed between the domes of lower lateral cartilages. It is used to spread out collapsed
or cephalically malpositioned lateral crura (Fig. 9.148).
Fig. 9.148 Alar spreader graft
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424
Operative Techniques
The best graft material is the septal cartilage. If the septal cartilage is not available the conchal cartilage is a decent
alternative.
The graft is fashioned into a bar or a triangle and placed between the lower lateral cartilages to lateralize the lateral crura
(Fig. 9.149). The graft is secured to the underlying dorsal septal cartilage at the midportion, and the distal end of graft is
secured to the vestibular side of cephalic margin of the lateral crura with 5-0 PDS. Too long of a graft can cause an alar flar-
ing. Morselized cartilage can be placed near the cephalic edge of the graft to cover for any dorsal irregularity.
Fig. 9.149 Alar spreader graft
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Effects of Alar Spreader Graft
1. This graft can spread the malpositioned lateral crura laterally.
2. This graft can prop up and elevate the curled-in or collapsed cephalic margin of lateral crura.
3. This graft can improve the external valve function.
4. Splay effect: A harvested conchal cartilage is carved into a triangular shaped graft. This graft is placed superficial to the
anterior septal angle and caudal margin of the upper lateral cartilage. This graft can elevate the caudal margin of upper
lateral cartilage by spring effect, and can improve the internal valve function (Fig. 9.150).
Fig. 9.150 Upper lateral splay graft
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426
Indication of Alar Spreader Graft
1. Alar collapse and pinched-tip deformity
2. Cephalically malpositioned lateral crura with alar retraction
3. Nasal valve insufficiency
Interdomal Graft
Interdomal graft is placed between the two domes of lower lateral cartilages and widens the interdomal distance, which cor-
rects narrow tip (Fig. 9.151).
Fig. 9.151 Interdomal graft
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Subdomal Graft
Subdomal graft is a rectangular cartilage wedge that is placed between the undersurface of dome and underlying mucosa
(Fig. 9.152). This graft supports the dome and can correct a narrow nasal tip.
Fig. 9.152 Subdomal graft. Rectangular shaped cartilages are
placed in a pocket between the dome and underlying vestibular
skin
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428
Operative Technique
The vestibular mucosa is detached from the undersurface of dome to form the pocket. A small piece of the cartilage (1.5–
3.0 mm by 5–8 mm) is inserted into this pocket and sutured to the dome with 6-0 PDS.
Plumping Graft
Plumping graft is placed in front of the anterior nasal spine (ANS) to correct the acute columellolabial angle (Fig. 9.153).
The graft can be made from conchal cartilage, septal cartilage, and rib cartilage and can be used in the form of block carti-
lage, crushed cartilage, or diced cartilage.
The graft can be fixated to the ANS, but it is better to create an accurately fitting pocket that does not require fixation of
the graft. Compared to the graft thickness, the relative amount of projection is low for the columellolabial angle. The supine
position and intraoperative tissue swelling can lead an operator to underestimate the amount of projection necessary. As such,
plumping graft should be performed on the side of overcorrection.
Fig. 9.153 Plumping graft
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Techniques for Tip Rotation
Cephalic Rotation of the Tip
Cephalic rotation of nasal tip is a basic technique for correction of long nose.
Wedge-Shaped Resection of the Caudal Septum
Long caudal septum will require a wedge resection. To allow for cephalic rotation of the nasal tip, the anterior portion of
caudal septum should be resected more widely (Fig. 9.154).
If the area of resection is small, membranous septum will not need to be disturbed. However, a wide resection will require
removal of redundant membranous septum or redraping of the extraneous section in the posterior direction using absorbable
quilting suture. Improper management of redundant membranous septum can lead to postoperative bulging and fullness of
the membranous septum. It can also promote caudal rotation of the nasal tip.
a
b
Fig. 9.154 Caudal septal shortening. For effective cephalic rotation of the tip, the anterior section is more widely resected off the caudal septum
Techniques for Tip Rotation

430
Partial Resection of Cephalic Portion (Cephalic Trimming) of Lateral Crura
Nasal tip can rotate cephalically as a result of the cephalic trimming of the lateral crura (Fig. 9.155). Also, this procedure
decreases nasal tip volume and supratip fullness. Removal of the cephalic portion of lateral crura has the following mecha-
nisms for decreasing nasal tip volume.
First, cephalic trimming decreases the horizontal width of lateral crura. Second, the distance decreases between the two
lateral crura. Third, the stress increases in the remaining caudal portion of lateral crura, which decreases convexity of lateral
crura, further decreasing nasal tip volume.
The extent of resection can vary depending on the nose and patient wishes. For cephalic rotation, the area to be resected
is determined by the overlapping volume between the cephalic margin of lateral crura and upper lateral cartilages (Fig. 9.156).
After releasing the scroll area, the portion of lateral crura to be resected is marked. The cartilage is initially scored and
then resected using Metzenbaum scissors (Fig. 9.157). A minimum of 6–7 mm of lateral crura should be preserved to prevent
alar collapse. The remaining portion of lateral crura is placed under increased stress, which decreases the degree of convex-
ity. Because of this, over-resection can result in pinched ala, alar retraction, external valve collapse, and nasal tip
asymmetry.
Even with an adequate width of lateral crura, postoperative scar contracture may buckle and collapse the lateral crura.
Therefore, the width of lateral crura to be preserved should vary according to the thickness and strength of the cartilage. If
profound scar contracture is anticipated, the cephalic margin should either be trimmed just a little bit or not be trimmed at
all. Because scar contracture is difficult to predict accurately, the cephalic trimming of the lateral crura should be conserva-
tive. This is especially the case in Asian patients with thick skin and small, weak lower lateral cartilage. Among Caucasians,
cephalic trimming is a commonly performed tip plasty procedure, but it should be a highly selective procedure for Asian
patients. In Asian patients, the technique does not reduce a significant amount of tip volume while becoming a frequent cause
of pinched tip, external valve collapse, retracted ala, and nasal tip asymmetry.
Fig. 9.155 Cephalic trimming of lateral crura
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431
a
b
c
d
Fig. 9.156 Cephalic trimming for cephalic rotation of the dome. (a) Lateral crura in a long nose. (b, c) Cephalic rotation of the dome will have
the lateral crura come into contact with upper lateral cartilage. The portion of lateral crura that interferes with this cephalic rotation is marked. (d)
The marked cephalic portion is trimmed
Techniques for Tip Rotation

432
a
b
c
d
Fig. 9.157 Cephalic trimming of lateral crura. (a) The cephalic portion of lateral crura is marked for trimming. (b) A blade is used to score the
crura along the marking. (c) The cephalic portion is resected using Metzenbaum scissors. (d) The lower lateral cartilages after cephalic trimming
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Lateral Crural Shortening
Resection of lateralmost portion can cause the lateral crura to migrate towards the pyriform aperture (Fig. 9.158). The ves-
tibular skin is freed from the underside of lateralmost part of lateral crura. The exposed lateral crura are incised. The anterior
limb of lateral crura is then transposed over the posterior limb and sutured in place using 5-0 PDS sutures in the horizontal
mattress fashion. The amount of lateral crural overlay is determined by the degree of rotation or shortening of tip.
Fig. 9.158 Lateral crural
shortening
Techniques for Tip Rotation

434
Columellar Strut Graft
Columellar strut graft can facilitate tip projection, cephalic rotation of dome, and caudal advancement of subnasale. This
technique is especially useful in inducing and maintaining cephalic rotation of dome in long nose with weak medial crura.
Medial Crural-Septal Suture
Using a 5-0 nylon, the suture needle is passed through the medial crus on one side, through the anterior caudal septal carti-
lage, and then through opposite medial crus. Gently tying the suture will project and rotate the tip in cephalic direction.
For this suture to serve its proper purpose, the caudal septum needs to be located in midline, and the medial crura should
not be weak. For weak medial crura, this suture can lead to buckling of medial crura. In such cases, a columellar strut graft
can be helpful.
ANS Augmentation
ANS augmentation can project the tip and also it can rotate the tip cephalically.
Caudal Rotation of the Tip
For congenitally upturned nasal tip, techniques available for caudal rotation are spanning suture, derotation suture, derotation
graft, and septal extension graft.
These techniques can also be used for caudal rotation of nasal tip that is rotated cephalically by a suture technique or colu-
mella strut graft, in Asian patients with relatively short nose.
Correction of Asymmetric Lower Lateral Cartilages
Height Discrepancy of Medial Crura
Difference in the height of medial crura will translate to asymmetric height in the nostril apex. This should be corrected by
shortening the longer medial crus or elongating the shorter medial crus.
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Shortening of Longer Medial Crus
The columellar segment is cut from the longer medial crus, and the overlapping suture is placed afterwards (Fig. 9.159).
a
b
c
d
e
Fig. 9.159 Shortening of longer medial crus. (a) Medial crural shortening by overlay. (b) Nostril asymmetry. (c) The medial crus is longer on the
right side. (d) Shortening of right medial crus. (e) Postoperative photograph demonstrates improved symmetry of the nostrils
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436
Lengthening of Shorter Medial Crus
If the medial crura do not differ significantly in length, the nostril apex on the short side can be elevated to match the other
longer side. Once symmetric, the crura are stabilized with columella strut graft. If the medial crura are highly asymmetric in
length, the shorter medial crus is transected and extended to an equal length by fixing the separated segments onto the colu-
mellar strut graft (Fig. 9.160).
Fig. 9.160 Lengthening of shorter medial crus
9 Nasal Tip Plasty: Suture Techniques and Cartilage Grafts