Cosmetic Facial Surgery

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Dome
Lateral
crus
Facet
Medial
crus
Footpads of the
medial crura
Accessory
cartilages
Columellar
segment
Footplate
segment
Dormal
segment
Lobular
segment
Intermediate
crus
FIGURE 8-15.  The lower lateral crural cartilages (LLCC) of the nose from a
caudal viewpoint. Nasal tip shape and structural integrity are most notably
affected by these tip cartilages. The caudal septum (not shown) also has
a significant role in tip support and a smaller role in tip shape. Manipulation
of the LLCC is one of the most common maneuvers to alter nasal tip
appearance during rhinoplasty.
Infratip break or
columellar-lobular angle
Anterior septal angle
Tip lobule
Supratip break
Rhinion
Nasion
Columella
Transverse nasalis muscle
Levator labii
superioris muscle
Caudal free edge of
upper lateral cartilages
Upper lateral cartilages
LLC
FIGURE 8-16.  Key points of reference and terminology for nasal structures are seen from a lateral view. LLC represents the
lower lateral cartilages (lateral crus shown only), which commonly require manipulation during tip rhinoplasty. The anterior septal
angle (a portion of quadrangular septal cartilage) is an important landmark for tip support and final profile appearance. Failure
to lower a projected anterior septal angle or lack of tip projection can lead to fullness or a “pollybeak” deformity.
mention it specifically, they must be asked whether they have
any breathing problems, current or past, or if they have had any
history of trauma. Patients may not mention past surgery on an
evaluation form, so asking if they have had any previous nasal
surgeries is extremely important. A history of seasonal allergies
or periodic nosebleeds is important to note. Once all the
patient’s complaints have been recorded on an appropriate film
or diagram, a detailed systematic exam is performed, assessing
skin quality, general shape and support of the nose, and any
external or internal nasal deformities or lesions.
During the entire consultation, the patient’s mental status
must be evaluated to detect evidence of possible body dysmor-
phic disorder or any other worries that may create problems in
the postoperative period.32,33 The young male rhinoplasty patient
is often one of the more challenging patients when it comes to
achieving a result they will be completely happy with on a long-
term basis. Classic signs of potential problems are patients who
bring in magazines of movie stars with a particular shape of
nose; some may be realistic, but a more in-depth evaluation of
this patient must be undertaken. Ideally you hope to only
operate on a patient one time, because second surgeries are
always more challenging and difficult. In addition to the routine
workup for medications and history of surgery, it is important
to rule out any history of chronic use of nasal sprays such as
Afrin or the possible history of cocaine use.
Taking photographs is an important part of record keeping
that can be invaluable for treatment planning.34 Quality photo-
graphs in six standard views are needed: frontal (full face), two
lateral, two 45-degree (oblique) views, and a basilar view (Figure
8-19). Other photos may occasionally be necessary, such as
relaxed frontal and high-smiling frontal and lateral views to
evaluate nasal tip displacement from an overactive depressor
muscle. Standardization of the photographs is critical for follow-
up and evaluating your own results over time. Since it may take
a year or more to see the final changes that can occur after
rhinoplasty, good photographs are essential.
Initial assessment of skin thickness should be noted through-
out the upper and lower nose, along with the amount of

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Chapter 8  •  RHINOPLASTY
Frontal
sinus
Cribriform
plate
Perpendicular plate of
the ethmoid bone
Quadrangular
septal cartilage
Vomer
Sphenoid
sinus
Nasal crest of
the maxilla
Anterior
nasal
spine
FIGURE 8-17.  Anatomic structures that make up the nasal septum are shown along with adjacent structures. The two bones
plus the quadrangular cartilage forming the nasal septum may all require treatment during a septorhinoplasty if deviation exists
or harvesting of grafts is indicated. Understanding the anatomy in detail is critical for the cosmetic surgeon.
Supratrochlear nerve
Supraorbital nerve
Infraorbital nerve
Infratrochlear nerve
External nasal
branch of the
anterior ethmoidal
nerve
Superior labial
artery
FIGURE 8-18.  Sensory nerve supply to the external nose comes from the ophthalmic and maxillary branches of cranial nerve
V. The external nasal branch of the anterior ethmoidal nerve is cut during elevation of the nasal skin flap during rhinoplasty, but
patients rarely complain of numbness because of the profound collateral nerve supply.

Chapter 8  •  RHINOPLASTY
185
because the thick skin limits the amount of shrinkage that can
safely be achieved by standard rhinoplasty. Rhinophyma, which
is an overgrowth of sebaceous glands secondary to rosacea, can
be treated by addressing the outer skin alone (Figure 8-20).
Proportional evaluation of the nose related to the face is
critical. Classic methods that were developed by Leonardo da
Vinci and others are commonly performed. For example, the
width of the alar base compared to the intercanthal distance is
sebaceous-type nasal skin. Elasticity is noted by a simple pinch
test and stretching the skin over the nose. Palpation, particularly
in the nasal tip, is used to assess the amount of support over the
nasal tip itself and gain a sense of possible irregularities that
cannot be simply visualized. Thin-skinned patients have the
potential for a very nicely sculpted nose but are also at risk of
showing every flaw. On the other hand, patients with bulbous
tips but very thick skin may not get the result they hoped for
Frontal view
Base view
Lateral or profile views
Oblique or 45 degree views
A
B
C
D
E
F
FIGURE 8-19.  Six standard photographic views should be
taken for all rhinoplasty patients before and after surgery.
Except for the base view, the patient’s head should always
have the Frankfort horizontal plane parallel with the floor.

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Chapter 8  •  RHINOPLASTY
an easy assessment and can quickly give an idea of proportion,
as can simply measuring the distance and recording the base of
the nose. The length of the nose is also assessed from the radix
to the nasal tip and must be based on proportion to the rest of
the face. In addition to nasal length, angulation from the lateral
view is extremely critical, particularly in the nasal frontal and
nasolabial angles. The ideal nasal frontal angle is between 115
and 130 degrees and is slightly more obtuse in females (see
Figure 8-9). It can appear very different when a nasal dorsal
hump is present and also from a significant amount of bossing
in the glabellar and frontal region or even a deepened or shallow
radix area. The depth of the radix can be assessed by evaluating
the distance from the pupil to the nasion from the lateral view;
it should be in the range of 4 to 9 mm on average. Reporting
the amount of nasal dorsal hump or possible saddle nose defor-
mity is important, along with whether the patient feels they
have a large hump, a small hump, or none at all. The patient
should be asked whether they prefer a straight nasal dorsum or
like the appearance of a more “scooped” look to assess what they
would ultimately be happy with. Performing computer simula-
tion can be helpful in particular patients who may have an
unrealistic expectation of what can be performed. Surgeons vary
in whether they like this idea, since the actual result may not
resemble the prediction. If using computer simulation, it is
critical to inform the patient that this is a simulation only, the
results may vary, and it is simply a tool to guide surgical plan-
ning and assess what can be realistically achieved.35 For the right
patient, computer simulation can be invaluable for determining
what he or she is hoping to achieve, as well as what bothers
them most of all.
Nasal Tip Clinical Evaluation
Evaluation of the nasal tip is essential to rhinoplasty surgery.
Beyond skin texture and thickness, the general shape of the nasal
tip should be evaluated (e.g., bulbous, pinched, twisted, asym-
metric, boxy, overly projected, underprojected). The general
definition related to tip defining should be assessed for whether
there is a good supratip break, infratip break, or if the nose is
amorphous in shape with limited or no tip-defining points or
visible architecture of the lower cartilages. Following general
shape, noting the nasolabial angles as well as the amount of
supratip break or whether there is a pollybeak deformity (reverse
of supratip break) created by prominence of the anterior septal
angle is vital to document (see Case 7).
Tip projection and support are assessed based on palpability
and visualization. Assessment of the nasal tip projection is dif-
ficult because occasionally the amount of projection can appear
greater than what actually exists, such as in the case of a ptotic
tip with a nasal dorsal hump. Often, once the other portions of
the nose are addressed, the amount of projection changes. The
Goode method of assessing projection is one of many, whereas
RT represents the distance between the radix and the pronasale
(Figure 8-21); the ideal tip projection is 0.55 to 0.60 of RT. It
can also be measured from nasion to nasal tip (0.55 to 0.60 of
N-NT). Another method is Crumley’s method, which is based
on measurements of a nasal triangle that proportionately equals
3-4-5 based on lines perpendicular and parallel to the Frankfort
A
B
C
D
FIGURE 8-20.  Before (A, C) and 6 months after (B, D) direct skin shave
and laser skin resurfacing to treat a condition known as rhinophyma. The
patient had only external skin treatment. It was previously believed that
rhinophyma was due strictly to heavy alcohol abuse, but it has been shown
to be primarily related to overgrowth of sebaceous glands secondary to
rosacea.

Chapter 8  •  RHINOPLASTY
187
horizontal (3 AP-NT, 4 N line to AP, 5 N-NT).36 Another
method for assessing tip projection implies that the length of
the upper lip from subnasale to labrale superius should be equal
to the tip projection measured from subnasale to pronasale. In
any case, the amount of projection related to the dorsum as well
as from the anterior face is critical.37-45
The columella must also be assessed and should ideally have
2 to 4 mm show from a lateral view. Not only should there be
2 to 4 mm of alar show from a lateral view but the ala must
be evaluated simultaneously for proper position. Evidence of a
hanging columella or a retracted columella should be noted
when assessing true columellar show. The ala must be assessed
along with the position of the anterior nasal spine and the
amount of skin in the base of the columella that can be visual-
ized directly at the nasolabial angle itself.46-51 A retracted colu-
mella can be very unaesthetic. It may be due to inadequate
tissue support over the anterior nasal spine or simply an
enlarged ala that gives the illusion of a retracted columella. The
relation of the columella to the alar rim can be a mix of situ-
ations (Figure 8-22). The nasolabial angle is a very important
measurement to note and is classically just over 90 degrees in
men and 95 to 110 degrees in women. This angle can be
affected by not only the amount of tip rotation and caudal
septum but also by the amount of anterior nasal spine projec-
tion or even the effects of the entire maxilla and upper incisor
teeth. Overzealous cartilage resection can create a nasal tip that
is too short or overrotated and a nasolabial angle that is too
obtuse (see Figure 8-82).
In assessing the overall projection of the nose and proceeding
downward to the anterior nasal spine, it is important to evaluate
Frankfort horizontal
Goode or Crumley’s method
for nasal projection evaluation
3
4
5
Nasofacial angle
normal 30-40
degrees
A
B
FIGURE 8-21.  A, Nasal tip projection evaluation by Goode method uses the length from alar point to nasal tip (AP-NT) divided
by nasion to nasal tip (N-NT), which should ideally be 0.55 to 0.60. Crumley’s method is based on measurements that  
proportionately equal 3-4-5 based on lines perpendicular and parallel to the Frankfort horizontal: 3, AP-NT; 4, N line to AP;  
5, N-NT. B, The nasofrontal angle is glabella to nasion intersected by N-NT line. It is commonly more obtuse in females
than males.
the face as a whole, since problems requiring orthognathic
surgery (e.g., maxillary deficiency, mandibular problems) can
indirectly affect the shape and appearance of the nose.52 The
combination of a nasal dorsal hump and microgenia creates
proportional discrepancy a patient may want to have corrected.
A patient with a weak chin or mandible often feels like their
nose is unaesthetic because the total facial disharmony accentu-
ates the often more mild nasal deformity. Often, placement of
a chin implant on someone who has microgenia with a nasal
dorsal hump will clinically make the nose more appealing and
even appear smaller because of a more proportionate face overall.
Patients requiring orthognathic surgery who have maxillary
hypoplasia along with malar hypoplasia may have other prob-
lems that contribute to the aesthetics of the nose; therefore
achieving the patient’s overall desire may require more than a
simple rhinoplasty. Simultaneous orthognathic surgery and rhi-
noplasty can be performed, but one must understand that major
tip changes may occur when the entire maxilla and its anterior
nasal spine are moved (Figures 8-23 and 8-24). Also, the nasal
base must be controlled with intraoral alar base cinch sutures,
since releasing the periosteum at the pyriform rim allows the
nasal base width to widen. Like any aesthetic surgery of the
face, proportion is key in attaining a harmonious and natural
appearance, keeping in mind that good function is absolutely
critical.
Function of the nose can be assessed by several methods,
including simply having the patient take deep breaths in while
holding the nose closed on either side. Other tests involve
cotton-tipped applicators placed just inside the nose or a caudal
test with a finger pulling on the skin on the outside of the nose

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Normal ala
Retracted ala
Hooded ala
Normal
columella
Retracted
columella
Hanging
columella
Columella and Alar Rim Relationship
FIGURE 8-22.  The relationship between the alar and columellar shapes
can be seen here. Alar retraction may be genetic in origin but can
also be secondary to overresection of lower lateral cartilage or from
previous rim-type intranasal incisions. Normal columellar “show”
should be 2 to 4 mm on average. Excess columellar show may be
secondary to excessive caudal septum, medial crural cartilage, an
enlarged anterior nasal spine, or combination.
to assess internal valve problems. Noting valve problems before-
hand, both internal and external, can help prevent an unhappy
patient postoperatively. It is much easier to prevent these pro­
blems with spreader grafts performed during the primary
surgery if indicated rather than performing reconstructive
surgery on an operated nose that has significant scar tissue (see
Figure 8-75).53
Patients who have already undergone previous nasal surgery
may have external nasal valve collapse from overresection of the
lower lateral cartilages. External nasal valve collapse can also be
seen in a thin or narrow nose, a very aged nose, or even in
patients with some facial paralysis.54-57 Internal nasal valve col-
lapse that may have been created by scarring from previous
rhinoplasty surgery often requires spreader grafts to correct. The
Cottle test for diagnosis of nasal valve collapse is performed by
using your finger to pull laterally on the cheek and lateral wall
of the nose to open the nasal valve. Classically, patients breathe
much easier when this test is performed (positive Cottle sign).
Breathe Right strips, regularly used by athletes, have adhesive
that allows the device to act as a temporary spreader graft. The
splints open the internal nasal valve from the skin side and do
allow at least temporary increase of nasal airflow whether nasal
valve collapse exists or not. Actual inspection inside the nose
with a nasal speculum can help identify any major perforations
that could be caused by pathology or even a history of cocaine
use. The speculum exam will also note any major deflections of
the septum as well as enlargements or asymmetries of the tur-
binates. The state of the nasal mucosa, such as inflammation
from allergies, should be noted during an intranasal exam.
Treatment Planning
A good treatment plan prior to rhinoplasty surgery is an abso-
lute necessity. It is critical to plan for possible problems requir-
ing additional procedures such as graft harvesting from behind
the ear, rib, hip, or other location. Presurgical photographs
along with possible radiographs, such as cephalometric radio-
graphs, may be helpful in deciding on a sequence to the surgery
and a detailed plan (see Figure 8-19). Many surgeons will also
use waxed paper overlays to mark out exactly what they are
hoping to achieve, which can be invaluable when beginning
one’s rhinoplasty surgical career. A logical treatment order
should be planned and followed. As an example, portions of the

Chapter 8  •  RHINOPLASTY
189
visualization; in most surgeons’ hands, the ability to place grafts
or reduce cartilage can be performed more precisely. The argu-
ment for a closed technique involves the possibility of less dis-
ruption of blood supply and lymphatics, leading to possibly less
postoperative edema. The other obvious advantage is that no
external scar would be present. Also, some feel it may be faster
in their own hands and is less disruptive to some of the attach-
ments that may allow for better support of the nose. Although
I personally use both techniques depending on the particular
situation, the external open rhinoplasty is certainly an easier
approach in my hands and allows for teaching purposes. The
main benefit from using an open rhinoplasty is the ability
procedure that may increase bleeding (e.g., osteotomies) should
not be performed early during the surgery, since they could
create problems during delicate cartilage work. Most surgeons
will develop their own comfortable treatment outline and follow
the general treatment order each time.
External Versus Endonasal Technique
The argument for or against an open or closed rhinoplasty will
likely exist for at least a few more decades and be easily argued
either way. Certainly there is no one technique that maintains
clear superiority over another. The advantages of an open or
external rhinoplasty are obvious in that it has superior
A
B
C
D
FIGURE 8-23.  An 18-year-old female patient before (A, C) and 5 months after (B, D) orthognathic surgery and an open sep-
torhinoplasty. A large nasal dorsal hump was reduced and used for an anterior strut graft. A strut was placed for tip refinement
and support following resection of a large amount of surrounding cartilage. Alar batten grafts were required to prevent external
valve collapse and obtain a pyramidal tip shape versus a “pinched” appearance following cephalad reduction of cartilages.
Despite alar base sutures, the nasal base remained wide because of simultaneous maxillary impaction to correct the vertical
maxillary excess. Still, facial and nasal proportions improved dramatically.

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Chapter 8  •  RHINOPLASTY
A
B
C
D
E
F
FIGURE 8-24.  A 35-year-old before (A, C, E) and 5 years after (B, D, F) simultaneous orthognathic surgery of the maxilla and
mandible along with rhinoplasty. Alar base sutures are required to prevent significant base widening. Correcting the lower facial
third proportion also helped improve nasal proportions and the overall result.

Chapter 8  •  RHINOPLASTY
191
General Anesthesia or
Intravenous Sedation
Another debate with regard to rhinoplasty surgery is the type of
sedation or anesthetic used during surgery. Local anesthesia,
without a doubt, is required for vasoconstriction, but the type
of sedation varies among providers. In my own practice, all
our rhinoplasty surgeries are performed under general anesthesia
for complete control of the airway. Rhinoplasty surgery is a
technique that may easily lead to significant blood in the
nasopharynx and oropharynx. Major problems with airway
management are increased with sedation techniques where the
airway is not protected. Also, simple problems such as coughing
or movement during surgery can create a nuisance during a
poorly controlled intravenous (IV) sedation. Many surgeons
today still perform the procedure under IV sedation; it can work
very well but must be carefully managed to avoid airway
compromise.
Incision Options
Multiple incision options exist for various rhinoplasty tech-
niques; however, the external rhinoplasty has the most standard
incision, which involves a transcolumellar incision that is
blended into a marginal incision. The marginal incision is one
that can be used for either an open or closed technique. A
marginal incision is an intranasal incision that essentially hugs
the caudal margin of the lower lateral cartilages while the caudal
margin of the lateral crural cartilage typically follows just along
the entire extent of the lower lateral crus (Figure 8-27). As the
incision approaches the facet or internal crus, it often can be
made 1 to 2 mm more cephalic than the actual margin of the
cartilage to help prevent alar retraction. Also, the marginal inci-
sion along the medial crus can be made further cephalically than
the actual margin if significant treatment of the medial crus or
for more precise placement of tissue grafts.. Fortunately, the
external transcolumellar scar, if placed well and meticulously
closed, is rarely ever an aesthetic complaint. In the vast majority
of cases, it is nearly invisible after prolonged healing (Figure
8-25). It is critical to understand nasal base proportions and
where ideally to place the external incision just above the medial
footpads to allow for optimum healing (Figure 8-26).
The debate over closed versus open rhinoplasty could go on
indefinitely.58-61 As with any surgical procedure where multiple
techniques exist, the best technique is actually the one that
works best for you. The typical patient will simply be happy if
their surgery goes smoothly and the results are all they had
hoped to achieve, regardless of the incision type chosen.
Columellar incision from an
open rhinoplasty
FIGURE 8-25.  Average healing of an external columellar scar 2 months
following open rhinoplasty.
Tip lobule
Alar base
1/3
2/3
1/2
1/2
Columella
Columellar
incision
Infratip lobule
Nostril sill
Ala
Medial crural footpads
Alar facial junction
A
B
FIGURE 8-26.  This view from the nasal base demonstrates ideal proportions and a desirable general pyramidal shape. From
below, the tip lobule should be approximately half the width of the nasal base and one-third the total projection height. The
placement of a transcolumellar incision for an external rhinoplasty is made just at the top of the medial footpads.

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Chapter 8  •  RHINOPLASTY
area can be very thin, and rough manipulation can create poor
healing postoperatively. Care must be taken in elevating this flap
to prevent crushing the tissue or excessive stretching with retrac-
tors. Closure of the columellar incision must also be meticulous,
using interrupted sutures in a precise fashion to ultimately
achieve a very well-hidden scar during open rhinoplasty.
Incisions for a closed rhinoplasty can be more varied, depend-
ing on what needs to be accomplished and surgeon preference.
The marginal incision is still the most basic and common
incision for an internal or closed rhinoplasty. It typically stops
at the base of the medial crural footpad rather than having an
extension across the columella. The medial extent of the mar-
ginal incision can also extend inferiorly if additional access is
required for septoplasty or for cartilage harvesting. Another
optional incision for an endonasal approach is the transcartilagi-
nous incision, which is performed approximately in the midpor-
tion of the lateral crus or lower lateral cartilages and can also be
extended medially and inferiorly for septoplasty as required. The
advantage of a transcartilaginous incision is limited dissection
to remove a cephalic strip and avoid the scroll area between the
placement of a strut is indicated. This allows for more exposure
of the medial crural cartilages than would be attained if the
incision were truly at the marginal edge.
For the transcolumellar portion of the external rhinoplasty,
the incision should be made with a #11-blade scalpel to create
precise edges and distinct corners in which reapproximation can
be made easily and predictably. The incision should also be
placed in a location that would be at least visible postoperatively,
typically about a third of the distance from the alar base, extend-
ing up toward the nasal tip. This usually corresponds with the
top of the nasal footpads of the medial crural cartilages. The
actual shape of the incision is variable. A straight-line incision
should be avoided because this would leave the most noticeable
scar and possibly some notching laterally. Various shapes and
techniques have been used to perform this transcolumellar inci-
sion, the most common being either a stairstep technique or a
W or inverted V incision (Figure 8-28). The key to having an
incision that looks nearly invisible postoperatively is meticulous
surgical technique where tissues are not crushed or compro-
mised by inappropriate retraction. The tissue in the columellar
Columellar
incision
Caudal edge of
LCC
Avoid a rim
incision
Marginal
incision
A
B
C
FIGURE 8-27.  A classic method for exposing (skeletonization) the lateral crural cartilages (LCC) via a marginal incision, which is
used for endonasal and open rhinoplasty. A and B show where to identify and make the marginal incision immediately adjacent
the “margin” of the caudal edge of the lower lateral cartilages (LLC) versus a rim incision, which should be avoided. C, The
medial portion of a marginal incision is made easier by twisting the nasal tip with the opposite hand to expose the edge of
medial crura.

Chapter 8  •  RHINOPLASTY
193
Marginal incision
Optional transcolumellar incisions
A
C
D
B
FIGURE 8-28.  View from the nasal base demonstrates various options for transcolumellar shapes and positions. The placement
of the external rhinoplasty transcolumellar incision connects to the medial portion of intranasal marginal incisions just above the
medial footpads.
upper lateral cartilages that may prevent problems with support.
Through one transcartilaginous (or intracartilaginous) incision,
a surgeon can both thin the nose by removing cephalic cartilage
of the lateral crus and gain access to the dorsum for dorsal
reduction. The transcartilaginous (intracartilaginous) incision,
endorsed heavily by some surgeons, is somewhat more challeng-
ing for the novice surgeon and does have limitations on the
amount of work that can be performed through it, particularly
complex grafting (Figure 8-29).
Another incision for an endonasal rhinoplasty is the inter-
cartilaginous incision, which is made as described between the
upper lateral and lower lateral cartilages (Figure 8-30). This
incision cuts through the scroll area, which may cause future
problems with support but does allow easy access to the nasal
dorsum. When combined with the marginal incision during an
endonasal rhinoplasty, the entire lower lateral cartilage structure
can be inverted and “delivered” by exteriorizing the lower lateral
cartilages using scissors (Figure 8-31). Temporarily exteriorizing
the cartilage helps visualize this cartilage to help perform graft-
ing as well as precise tissue resection without an external
incision.
Other techniques may involve incisions next to the inferior
alar rim for resection of widened alar rims and narrowing of the
alar base. An alar base resection, known as a Weir-type resection,
involves a portion of the nasal sill and occasionally extends into
the alar-facial groove (Figure 8-32). The Killian incision can also
be used for isolated septoplasties or more abbreviated surgeries
for access to the septum (Figure 8-33). Also, complete transfix-
ion, partial transfixion, or hemitransfixion incisions are classic
incisions through the membranous portion of the nasal septum
(Figure 8-34). A hemitransfixion incision is performed on one
side of the membranous septum to gain access to this portion
of the nose. Partial or complete transfixion incisions can drop
the tip somewhat or more significantly, depending on how far
the cut is made through the membranous septum, which resides
between the caudal septum and medial crural cartilages.
Local Anesthesia
The local anesthesia component for rhinoplasty, whether open
or closed, is critical for a near-bloodless field and precise tech-
nique. Whether one chooses to use IV sedation or general
anesthesia, local anesthesia for postoperative pain control and
vasoconstriction is required. The local anesthesia used must be
placed in the proper tissue planes just over the nasal bones and
cartilages rather than in the subcutaneous tissues or muscular
tissue around the nose. On average, 12 mL of 2% lidocaine with

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Chapter 8  •  RHINOPLASTY
Marginal incision
Intercartilaginous
incision
Intercartilaginous
incision
Transcartilaginous
incision
Transcartilaginous
incision
Rim incision
Rim incision
Marginal
incision
Marginal
incision
B
C
A
FIGURE 8-29.  Classic methods for exposing the lateral crural cartilages (LCC). The rim incision immediately inside the nasal rim
should be avoided because it increases the chance of alar retraction. The intracartilaginous incision (also known as a trans-
cartilaginous incision) splits the LLC and is somewhat more technically challenging. The intercartilaginous incision is made
between the LLC and upper lateral cartilages through the scroll region.
LLC
ULC
Nasal
bones
Intercartilaginous incision during closed rhinoplasty
A
B
FIGURE 8-30.  During a closed rhinoplasty, an intercartilaginous incision can be used in addition to a marginal incision for access
to the dorsum and to help deliver the lower lateral cartilages (LLC) for exposure and manipulation. The incision cuts through
the scroll, where LLC and upper lateral cartilages (ULC) are joined. Abnormal scarring here could potentially create valve com-
promise and breathing difficulties.

Chapter 8  •  RHINOPLASTY
195
Scroll area
Marginal incision
Intercartilaginous incision
LLC
Marginal incision
A
B
FIGURE 8-31.  A, Lateral crus of the lower lateral cartilages (LLC) is delivered through only a marginal incision without disruption
of the scroll area. B, Intercartilaginous incision was added through the scroll area. More incisions were made to deliver the
cartilage for slightly better exposure of the LLC. In either of these closed rhinoplasty cases, the LLC is manipulated.
A
B
FIGURE 8-32.  Alar base resections are used to narrow an alar base and nostril size. Care must be taken to avoid asymmetry,
dehiscence, and constriction.
Partial transfixion incision
above medial footpads attachments
Killian incision
for septal access
Complete transfixion incision
severs medial footpad attachments
FIGURE 8-33.  The complete and partial transfixion incisions both extend through the membranous septum, but the complete
incision extends through the medial footpad connections to the caudal cartilaginous septum to deproject the nose. A Killian
incision (shown) is typically used for isolated septoplasty access.

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Chapter 8  •  RHINOPLASTY
1 : 100,000 epinephrine is adequate to inject an average nose.
An additional 5 to 10 mL may be required on large noses or on
noses where a significant amount of septal work or turbinate
work may also be required.
Prior to injection of local anesthesia, the nasal hairs should
be trimmed, and a very small amount of 0.05% oxymetazo-
line–soaked cottonoids or pledgets are placed just inside the
nose along the septum and inferior middle turbinates as well
as the superior nasal vault (Figure 8-35). It is critical to squeeze
out excess topical liquid prior to placement. Excess amounts
of this fluid have been known to create flash pulmonary edema
due to unopposed alpha-agonist effect that can be life threaten-
ing. Doses should be kept to a minimum and never simply
dropped in large quantity via a syringe. Children appear to
be more at risk for flash pulmonary edema secondary to
topical alpha agonists, most likely owing to the higher risk
of overdose using standard volumes. Other alpha agonists
often used just inside the nose include 4% cocaine and 0.25%
phenylephrine.
The use of these topical agents causes a significant increase
in vasoconstriction and opening of the nasal cavity for better
visualization, particularly when working on the nasal septum or
turbinates. They are not absolutely required when performing
isolated rhinoplasty where little if any work would be needed
on the septum or turbinates. Local anesthesia, if properly placed,
will usually suffice.
A separate set of instruments for placing and removing nasal
packs soaked with topical anesthetics should be available during
the injection phase prior to a full sterile prep and drape. Per-
forming intranasal injection with the use of a good light and
nasal speculum allows for precise placement of local anesthesia
intranasally. After applying topical judiciously, local anesthesia
is injected first along the points of major nerve and vessel entry
Partial transfixion incision
Just above medial footpads
Through the medial footpads
Complete transfixion incision
A
B
FIGURE 8-34.  A, Partial transfixion incision through the membranous
septum for access to the cartilaginous septum and limited disruption to
tip support. B, Lower complete transfixion incision can significantly weaken
tip support and deproject the nose if desired.
A
B
FIGURE 8-35.  Gauze with a topical vasoconstrictive agent such as 0.05% oxymetazoline is placed inside the nose immediately
prior to injection of local anesthesia. The topical can significantly shrink intranasal mucosa but must be limited in volume to
prevent problems from tachycardia or even flash pulmonary edema.

Chapter 8  •  RHINOPLASTY
197
time is allowed for adequate vasoconstriction to occur before an
incision is made. Ideally, 15 minutes should pass following local
anesthesia prior to making the initial incision.
Closed Rhinoplasty
The term closed or endonasal rhinoplasty means there are no
external incisions on the nose. Obviously, patients would prefer
to not have a scar on the nose when having aesthetic nasal
into the nose, both inside and out (Figure 8-36). It is also
injected along the plane just above the upper and lower lateral
cartilages as well as nasal bones. Local is also placed along the
planned incision line, followed by injection along the perichon-
drium of the septum if septal work or harvesting of grafts is
indicated. Additional injection can be used along the anterior
nasal spine and nasal base if alar base reduction is planned. By
injecting prior to the final sterile prep and drape, additional
Alar facial groove near the
angular artery
Anterior nasal spine and branches
of the superior labial artery
Caudal
septal
Nasal tip and overall nasal cartilages
Glabella
At the margin of the
incision
A
B
C
D
E
F
FIGURE 8-36.  Local anesthesia placed in the proper planes is critical for a bloodless plane. The major vessels entering the nose
are injected, along with direct minor ballooning of the anesthetic over structural cartilages, nasal bones, and the septum.

198
Chapter 8  •  RHINOPLASTY
approximately 5 mm posterior to the caudal edge of the septum
to gain access. When performing a closed rhinoplasty, the nasal
septum can be approached through the intercartilaginous inci-
sion as it extends down onto the septum or through a marginal
incision or intracartilaginous incision that can be extended onto
the septum to allow for septal access and harvesting of grafts as
needed. A rim incision has been classically described; as the
name implies, it runs just to the inside edge of the alar rim.
Access can be obtained to all the cartilages and dorsum from
this incision; however, because of its proximity to the rim, sig-
nificant alar retraction can occur with this incision, which in
most cases should be avoided. A marginal incision is typically a
more prudent approach and gains the same access as the rim
incision but with less risk of alar retraction.
Through any of these incisions, access can be gained with an
osteotome to the piriform rim to perform the lateral or medial
osteotomy. An additional small incision just over the piriform
rim inside the nose can be added for improved positioning of
the osteotome as needed. Incisions in the inferior turbinate are
occasionally required for reduction of enlarged turbinates during
the rhinoplasty. Small punctures are made at any point inside
the nose to add additional grafts, such as small plumping grafts
over the anterior nasal spine for a retracted columella. Incisions
just inside the alar rim at the base can also be performed to
reduce a wide alar base but also are visualized externally and are
no longer considered an endonasal incision.
Sequencing in Closed Rhinoplasty
Sequencing for closed rhinoplasty, as with an open rhinoplasty,
depends on what the surgeon hopes to achieve and surgeon
preference. Many sequences have been described and each has
its pros and cons. The sequence that follows is for convenience,
and the rationale is described. It assumes that all aspects of the
nose may require treatment. Obviously, if only a tip-plasty is
required, many steps can be skipped prior to this portion of the
procedure.
Typical Sequence for Closed Rhinoplasty
1. Bilateral marginal incisions (Marginal incisions are typically
workhorse incisions that are used on most every rhinoplasty
and could be converted to an open rhinoplasty if problems
occurred during the closed technique.)
2. Skeletonization and exposure of the nasal bones and
cartilages
3. Dorsal reduction (This is my preference prior to tip-plasty,
because performing this after delicate tip work may cause
disruption of fine sutures and grafts commonly used in
the tip.)
4. Septoplasty (Extension of the marginal incision if used
only, or a Killian incision, or intercartilaginous incision—
performed at this point because if grafts are needed, they are
commonly used during the tip-plasty to be performed next.)
5. Tip work
a. Lateral cephalic strip excision (Removal of excess cartilage
gains additional grafting material and is ideally performed
before more delicate tip work or suturing.)
b. Placement of columellar struts along with tip suturing
and tip grafts
surgery, even though the classic transcolumellar rhinoplasty is
rarely objectionable. Other advantages of closed rhinoplasty
include the possibility of less swelling (decrease in lymphatic
obstruction) and decreased loss of support from attachments
that would have otherwise been severed with an open technique.
There is no consensus among surgeons that these two additional
benefits are actually significant or, in fact, truly beneficial in
most situations. However, the external scar is avoided and, for
some patients, may be a deciding factor in whether they have
the procedure or not (Case 1).
There are many options with regard to the closed technique
in rhinoplasty. The simplest technique involves a marginal inci-
sion only to gain access to the upper portion of the upper and
lower lateral cartilages and the nasal bones. Through dissection
and elevation of tissues and proper retraction, cephalic strips
can be taken to narrow the nose, along with nasal dorsal reduc-
tion and lateral osteotomies, all through this single marginal
incision on each side.
Other options include complete transfixion and partial
transfixion of incisions, which can deproject the nose as well as
gain access to the nasal septum. A complete transfixion incision
is made just behind the medial crural cartilages of the lower
lateral cartilage ridges, extends across the membranous nasal
septum just in front of the cartilaginous septum, and extends
inferiorly to separate the foot pads of the medial crural cartilages
from the caudal septum.62 The only difference between this and
a partial transfixion incision is that the foot pads are not tran-
sected with the partial transfixion incision, which is stopped
just shy and has less effect on nasal tip projection. Transfixion
incisions can be used when one would like to subtly deproject
the nose but not make major adjustments in the tip cartilages
themselves.
Additional intranasal incisions for the closed rhinoplasty
include an intracartilaginous incision performed on each side
(see Figure 8-33). The intracartilaginous incision is made just
inside the nostril and approximately in the middle of the lateral
crural cartilages.63 The incision can be made completely through
the cartilage to narrow the tip slightly and cause rotation of the
nose (see Figure 8-35). Additionally, the cephalic portion of this
cartilage can be removed to further narrow the nose. Finally, the
nasal dorsum can also be approached through the intracartilagi-
nous approach. The intracartilaginous approach is somewhat
more technique sensitive and has limitations on how much can
be performed related to a tip-plasty without adding an addi-
tional marginal incision.
An intercartilaginous incision can also be used for closed
rhinoplasty. This incision, as implied, is placed between the
upper lateral cartilages and cephalic edge of the lower crural
cartilages. The incision allows easy access to the nasal dorsum.
By combining an intracartilaginous incision and a marginal
incision, a bipedicle flap is created which can be rotated, causing
what is considered “delivery” of lower lateral cartilages to easily
and precisely remove excessive cephalic portions of the lower
lateral cartilages along the lateral crural border (see Figure 8-36).
A Killian incision is commonly used when one would like
to perform an isolated septoplasty from an intranasal approach,
particularly when a simultaneous rhinoplasty is not going to be
performed. The incision is made on either side of the septum

Chapter 8  •  RHINOPLASTY
199
cause disruption of fine sutures and grafts commonly
used in the tip.)
4. Septoplasty (The transdomal approach has excellent
access and is a definite advantage of the open approach
for harvesting septal cartilage or performing a difficult
septoplasty—performed at this point because if grafts are
needed they are commonly used on the tip-plasty to be
performed next.)
5. Tip work
a. Lateral cephalic strip excision (Removal of excess
cartilage gains additional grafting material and is
ideally performed before more delicate tip work or
suturing.)
b. Tip suturing and placement of columellar struts and
other tip grafts such as shield or Batten grafts
6. Lateral osteotomies (Micropuncture technique is per-
formed near the end of the procedure because earlier
performance prior to tip work could potentially produce
unnecessary bleeding that would make delicate tip work
more challenging.)
7. Alar base modification if indicated (This is performed
last, simply because a better idea of proportion can be
gained after tip work and osteotomies and following
closure of the endonasal incisions; closing the alar base
incisions prior to closure of other endonasal incisions
will likely cause tearing at the alar base, requiring
resuturing.)
8. Taping and splinting
Open Rhinoplasty Technique
Incisions
Following injection of local anesthesia, the open rhinoplasty
typically starts with making one of four classic incisions across
the columella with a #11-blade scalpel. Extreme precision
renders the most aesthetic closure and final appearance of this
single external incision (Figure 8-37).
Care must be taken to make sure the incision is at the cur-
vature of the medial foot pad of the lower lateral cartilages; this
gives the best aesthetic result and proper access to the lower
lateral cartilages. Next, the marginal incisions that blend into
the transcolumellar incision are made. Marginal incisions are
classically made with a #15-blade scalpel or buffalo knife and
must hug the caudal margin of the lower lateral cartilages; this
can be more challenging than one would think. As with many
surgical procedures, the technique often appears easier to the
novice surgeon when watching than when actually making the
incision. A tip to help avoid problems when making this stan-
dard incision is to avoid accidentally cutting the edges of the
nasal rim with the edge of the #15 blade by proper retraction
using the middle finger of your nondominant hand and a large
7-mm double skin hook. The incision that proceeds from inside
the nasal vault just beneath the dome is the most difficult area
to reach when performing marginal incisions. Another tech-
nique that facilitates reaching this area is to twist the nose with
the full finger and the thumb of the nondominant hand to allow
easy placement of the #15 blade high in the dome region of the
nose. Flipping the caudal edge of the lateral crus out with the
6. Lateral osteotomies (Micropuncture technique is performed
near the end of the procedure because earlier performance
prior to tip work could potentially produce unnecessary
bleeding that would make delicate tip work more
challenging.)
7. Alar base modification if indicated (This is performed last,
simply because a better idea of proportion can be gained after
tip work and osteotomies and following closure of the endo-
nasal incisions; closing the alar base incisions prior to closure
of other endonasal incisions will likely cause tearing at the
alar base, requiring resuturing.)
8. Taping and splinting
Open Rhinoplasty
An open rhinoplasty or external rhinoplasty is performed to gain
better access to the nasal skeleton and cartilaginous tissues. As
the name implies, an external incision, which is typically trans-
columellar, is made in one of several different fashions (see
Figure 8-28). A stairstep, V, or W incision is commonly used to
break up the incision and produce a much better aesthetic
outcome than a straight-line incision, which should be avoided.
The incision should be made just at the curvature of the medial
crural foot pads to hide the incision when the patient is looking
straight ahead. Incisions above or below this level are more
conspicuous and can have unwanted notching. Meticulous
closure of this incision and proper placement typically produces
an external incision that is rarely visible or objectionable to the
patient.
The number-one benefit of an open rhinoplasty is complete
visualization of the cartilages and bony structures that require
modification. This allows much easier graft placement and a
better appreciation of what may be required. Also, revision
rhinoplasty cases often require an open rhinoplasty to visualize
what has been previously performed and address severe
scarring that can occur on the nose that has been operated
on multiple times (Cases 10, 12, and 13). For teaching
purposes, the open rhinoplasty helps to clearly demonstrate
what technique is being performed and precisely where grafts
are being placed. The challenging nose or overshortened
nose can often be managed much easier with an open
approach (Cases 6, 19, and 20). One must remember that by
detaching all the tissues and elevating the columellar skin
itself, care must be taken not to damage the skin as it is being
retracted. The columellar skin and adjacent vestibular skin is
often extremely thin, thus rough handling of tissue must be
avoided.
For external rhinoplasty, just as in closed rhinoplasty, the
sequence follows surgeon preference but must adhere to least a
few guidelines. Depending on what is required for treatment,
there is a common sequence for external rhinoplasty:
1. Bilateral
marginal
incisions
and
transcolumellar
incisions
2. Skeletonization and exposure of the nasal bones and car-
tilages (Elevation of the columellar flap can be performed
before or just after exposure of the lower lateral cartilages
through the marginal incisions.)
3. Dorsal reduction (This is my preference prior to tip-
plasty, because performing this after delicate tip work may

200
Chapter 8  •  RHINOPLASTY
Columellar incision with
a #11 blade
Elevation with
converse scissors
Marginal incision
Marginal incision
Staying thin and parallel
with the medial crura
A
B
C
D
E
F
FIGURE 8-37.  The initial steps for an open rhinoplasty. Initial flap elevation much be made carefully over the delicate medial
crural cartilages to avoid accidentally nicking the cartilage.
middle finger of the nondominant hand and the skin hook
forces the edge of the cartilage to be visualized. Along with a
notable change in hair pattern along this area, this can help the
novice rhinoplasty surgeon find the proper incision line. Care
must be taken with this incision to avoid nicking the cartilage,
since the mucosa in this area is extremely thin and becomes even
thinner over the medial crural cartilages adjacent to the trans-
columellar incision.
Flap Elevation (Skeletonization)
Next, skeletonization of the nasal cartilages and bone can
proceed through the marginal and transcolumellar incision,

Chapter 8  •  RHINOPLASTY
201
problem when faced with a patient who presents a challenging
diagnostic dilemma (see Figures 8-80, 8-81, and 8-84). Often
an underprojected nasal tip can make the dorsum appear more
prominent than it truly is. Assuming that the dorsum is truly
prominent, reduction of both the bony and cartilaginous
hump is usually indicated and may be performed using a
number of methods. Most commonly, it is easy to begin with
rasping of the nasal dorsum if the hump is not overly large or
has extremely thick bones. If adequate reduction can be
obtained with rasp use only, it will typically be a smoother
result than using a Rubin osteotome or other form of nasal
bony hump reduction. It also becomes easier to see the carti-
laginous hump that remains following some rasping of a small
nasal dorsal bony hump. The cartilaginous hump is addressed,
which is often more critical when it comes to the aesthetics of
the nose, and can be mistreated easily if the wrong angle is
taken when reducing this portion of the hump (Figure 8-40).
The hump can be reduced by scissor resection through the
upper lateral cartilages and septum or transected with a #15-
blade scalpel. If a large hump is removed with an osteotome,
initial caudal cuts through the septum are performed with a
#15 blade or scissors followed by placement of the osteotome
to remove the entire nasal dorsal hump, both cartilaginous and
bony, in one continuous unit. The Rubin osteotome, which
can be used to remove a large hump at one time, must be
carefully kept at the proper angulation to avoid diving deep
into the nasal bones or tilting to one side or the other, which
could remove an asymmetric amount of bone or cartilage. Fol-
lowing reduction of a bony dorsal hump, the gap (open roof)
created by separation of the septum and lateral nasal bone must
be closed. Closing an open roof after dorsal reduction is per-
formed by lateral osteotomies (see Figure 8-11). Medial oste-
otomies may occasionally be required to correct irregular bony
segments or in cases of extremely thick nasal bones. Lateral
osteotomies can be via a low-to-high or low-to-low osteotomy.
An osteotomy is placed near the lowest portion of the piriform
rim and extended up toward the root of the nose. This is
beginning with the Converse scissors to initially elevate the
mucosa off the lower lateral crural cartilages. A single skin hook
is used inside the vestibular skin cephalad to the marginal inci-
sion, while a double skin hook retracts the vestibule of the nose
outwardly. Proper use of the assistant for counter-retraction is
extremely helpful at this point. The assistant should hold the
single skin hook downward so that the surgeon’s nondominant
hand can use the double skin hook to retract the skin of the
alar rim outwardly while dissecting with the Converse scissors
through the marginal incision and directly on top of the lateral
crural cartilages, leaving minimal tissue on top of the cartilage.
During this part of the dissection, the surgeon must ensure that
no cartilage is cut accidentally and that a clean dissection can
proceed. This will entail trying to be immediately on top of the
cartilage so dissection can proceed near-bloodlessly (Figure
8-38). Following initial dissection on top of the lower lateral
cartilages (and even on top of the nasal dorsum, as desired,
through the marginal incisions), further elevation of the flap can
then proceed via the transcolumellar incision, using a very small
(2 to 3 mm) double skin hook and Converse scissors to com-
plete the elevation of the flap and skeletonize the nose over the
tip, followed by the nasal dorsum.
Complete elevation of the nasal flap (skeletonization) is per-
formed over the nasal tip, upper lateral cartilages, and nasal
bones, taking care to maintain the surgical field as bloodless as
possible. Also, tissues must be treated in a delicate manner,
particularly the skin of the columella during retraction. Dissec-
tion is carried laterally only to the extent that it is needed to
easily visualize the nasal bones and cartilages (Figure 8-39).
Adequate access for dorsal reduction or augmentation is created
as required while still maintaining vital tissue attachment later-
ally that will help support stability of the framework after pro-
cedures such as lateral osteotomies.
At this point, the nasal dorsum can be treated with reduc-
tion or augmentation as deemed appropriate. The majority of
nasal cases require dorsal reduction rather than grafting, but
misdiagnosis of a small saddle nose deformity is a very common
Opposing
retraction
Caudal edge of
LCC
A
B
FIGURE 8-38.  Classic method for exposing (skeletonization) the lateral crural cartilages (LCC). A, Single skin hook retracts the
tissue in opposite directions of a 10-mm double skin hook at the alar rim. B, Dissection using Converse scissors in a spreading
fashion to cleanly expose the lateral crural cartilages (LCC) without any attached soft tissue.

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Chapter 8  •  RHINOPLASTY
Nasal Tip Procedures
The nasal tip defines the nose more than any other part and
continues to change from childhood to late adulthood (Figure
8-41). The tip has the most complex anatomy and classically
requires the most detail work during rhinoplasty. Performing tip
surgery following dorsal reduction allows more precise suturing
techniques and graft placement without the fear of dislodging
it during treatment of the dorsum.64 However, many surgeons
prefer to perform tip surgery initially, since this is often the key
to an aesthetic-appearing nose and critical for obtaining proper
projection and support. Regardless of time during surgery that
the tip is manipulated, the surgeon must always make sure that
adequate support is present in this region prior to final closure.
A simple technique for verification of tip support is compression
of the tip of the nose using gentle finger pressure to see if the
performed to medialize the nasal bones in a portion of the
frontal process of the maxilla to narrow the upper portion of
the nose as well as potentially close an open-roof deformity
created after lowering the nasal dorsal hump.
A lighted Aufricht retractor is very helpful at this point to
obtain excellent visualization and see that the appropriate
amount of bony and cartilaginous hump is removed and no
major irregularities are present that could cause a problem post-
operatively. It is also critical to make sure that enough caudal
septum is removed from the nasal dorsal hump to avoid a “pol-
lybeak” deformity postoperatively (see Figure 8-83). A common
mistake by the novice surgeon is inadequate removal of the
anterior septal angle, leaving fullness in the supratip break
region. Fullness in the supratip region can also be created by
inadequate tip projection or simply loss of tip support following
surgery.
ULC
LLC
Septum
Lighted retractor
helps visualize
nasal bones
A
B
C
D
FIGURE 8-39.  Classic method for exposing (skeletonization)
nasal bones, upper lateral cartilages (ULC), and lower lateral
crural cartilages (LLCC). Following scissor elevation, a lighted
Aufricht retractor and counter-traction helps visualize tissue
higher in the flap. In D, the ULC are separated from the dorsal
septum for possible spreader graft placement.

Chapter 8  •  RHINOPLASTY
203
ASA
ULC and septum
(cartilaginous hump)
A
C
B
FIGURE 8-40.  A–B, Initial exposure of upper lateral cartilages
(ULC) and exposure of the anterior septal angle (ASA). Scissors
are then used (C) to begin resecting the cartilaginous hump
from just below the ASA.
tip can be easily compressed or if it has some evidence of rigidity
(Figure 8-42). A columellar strut graft can commonly be placed
to add additional support to the tip, along with various other
grafts such as onlay or Batten grafts to prevent external valve
collapse.
In addition to tip support, understanding the tripod concept
of the lower lateral cartilages is a necessity to fabricate a rational
treatment plan. The tripod concept is where each of the two
lateral crural cartilages acts as its own leg of a three-legged table
supporting the nasal tip. The third leg is created by the two
medial crural cartilages, which are normally closely approxi-
mated (Figure 8-43).
The classic bulbous nasal tip is often addressed with removal
of a cephalic strip of cartilage along the cephalic edge of the
lateral crural cartilages (Figure 8-44). Ideally, 5 mm of residual
lateral crural cartilage should remain to help prevent external
valve collapse or significant alar retraction. The 5-mm width is
a generality for average cartilage strength; however, additional
thickness may be warranted if the cartilage itself is very thin and
“floppy” versus very thick and rigid. Additional support with
onlay grafts may be required as needed and determined during
the surgical procedure. Cephalic strip excision of cartilage to
narrow the bulbous nasal tip will also cause some tip rotation.
Lack of support that results from removing cartilage in this area
can potentially produce problems in the internal and external
nasal valves, particularly if the mucosa is significantly disrupted
in the scroll area between the upper and lower lateral cartilages.
Following removal of the cephalic strips, the nasal tip is assessed
for symmetry and strength prior to proceeding to any additional
tip maneuvers indicated.
Tip support sutures can be placed along with indicated
grafting prior to final closure. Ideally, the most delicate portion
of the surgery is performed immediately prior to closure to
maintain graft integrity and proper position. A shield graft
is an example of a delicate graft which is often required to
increase tip projection; it can be used to add tip-defining points
in a somewhat amorphous nose but must be carved carefully,
particularly in a thin-skinned patient (Figure 8-45). Other
tip grafts include Batten grafts, which are classically used in
patients with alar retraction or external nasal valve collapse
(Figure 8-46).
Occasionally, columellar struts combined with a modified
Goldman technique or lateral crural steal procedure are required
for maximum projection increase.65,66 The lateral crural steal
procedure is a modification of the Goldman technique to gain
significant tip projection, particularly in very boxy noses such
as ethnic noses that have very thick skin. This procedure should
not be used routinely because of the potential for overnarrowing
of the nose, but it can be a wonderful procedure in the broad
tip that needs added projection, provided support is added using

204
Chapter 8  •  RHINOPLASTY
Infant
Child
Adult
Elderly
A
B
FIGURE 8-41.  Facial age-related changes in the nose. The nasal tip position is the most notable change. Nasal tip ptosis and
enlargement are the two most obvious nasal changes that occur as one gets older.
a columellar strut (Figure 8-47). The more classic Goldman tip
uses the “interrupted” strip and rotation of the lateral crura
medially but without a strut. This significantly narrows the nasal
tip and increases tip projection and cephalic rotation but at the
cost of potential “pinched” nasal tip look over time. Other forms
of a Goldman tip include transection through the dome of each
lower lateral cartilage followed by transdomal suturing alone to
pinch the tip together. This can narrow the nose in such a way
that it may lead to external valve collapse later in life and a nose
that appears excessively narrowed. Today, modifications of the
classic Goldman tip, using struts and maintaining tip-defining
points, help maintain tip support and prevent external valve
collapse.
Septal Harvesting and Support
Septal cartilage is an excellent source of cartilage for grafting to
the nose during rhinoplasty. It can be approached through a
closed Killian incision or via an open transdomal incision
during open rhinoplasty for easy access. In an open approach,
a mucoperichondrial flap is elevated on either side of the
septal cartilages and can be extended over the vomer and
perpendicular plate of the ethmoid as required. Columellar
struts are suitably obtained from a portion of the quadrangular
cartilage of the septum if it is relatively straight, leaving approxi-
mately 1 cm of residual septum for support both along the
dorsum and caudally (Figure 8-48). The caudal edge of the nasal
septum can be resected more aggressively if it is crooked or
deflected off the maxillary crest, but this must be replaced by a
suitable strut graft for support of the nasal tip. Excessive caudal
septum, in cases such as a hanging columella, can be trimmed
to improve the nasolabial angle as well as shorten the elongated
columella. When trimming caudal septum, a curved excision
rather than a straight line is made to create a pleasing infratip
break and not a harsh straight line (Figure 8-49). The septum
must be thought of as part of the nasal tip. It has a profound
impact on the tip position and support (Figure 8-50).
Major Tip Support Categories
1. Lower lateral cartilage size, thickness, shape, and strength
2. Attachment of the medial crural footpads to the caudal
septum
Text continued on page 209.

Chapter 8  •  RHINOPLASTY
205
A
B
C
FIGURE 8-43.  The tripod concept is the idea that the nasal tip is made up of lower lateral cartilages that function like a three-
legged table (A). Lengthening or shortening any leg(s) will change the shape or position of the nasal tip. Tip rotation and
projection are significantly affected by this concept. In B, a columella strut supports the tip and could potentially rotate it. An
onlay graft helps prevent over-rotation or collapse, whereas cephalic strip excision will cause cephalic tip rotation.
A
B
C
FIGURE 8-42.  A, An Asian patient’s nose showing a saddle deformity of the
dorsum in the upper photo. B–C, Extreme lack of nasal tip support is dem-
onstrated. Verification of nasal tip support and strengthening as required using
strut grafts is critical for superior long-term results in many rhinoplasty patients.

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Chapter 8  •  RHINOPLASTY
Classic area for a
cephalic strip excision
Elevation of a cephalic strip
Intact mucosa side
5 mm left behind
Optional onlay graft
Cautery marks for planned
cephalic strip excision
A
B
C
D
E
F
FIGURE 8-44.  Classic excision of a cephalic strip of lower lateral cartilage. A–C, Average marking for excision. D–F, Elevation
of the strip while taking care to leave mucoperichondrium and intranasal mucosa intact. If indicated for strength, the strip can
be added back to the caudal edge (lower right) for support while still narrowing and rotating the tip itself.
Shield graft
A
B
FIGURE 8-45.  A shield graft can aid in nasal tip projection and creation of tip-defining points. Care must be taken to carve and
secure shield grafts precisely, particularly in patients with thin skin.

Chapter 8  •  RHINOPLASTY
207
Ear conchal bowl cartilage
Batten grafts
A
D
E
F
B
C
FIGURE 8-46.  View from the nasal base demonstrates external nasal valve collapse (A) and correction using a Batten (onlay type) cartilage graft to correct
the collapse (B). C, Batten grafts along with plication of the medial footpads to increase tip projection and support. Occasionally, removal of a cephalic
strip of cartilage can be used as a batten graft (D). Overresection of cartilage can produce valve collapse. Auricular conchal bowl cartilage is a great
source (E) for batten grafts because of its slight curvature; it was used as batten grafts in F.
A
B
FIGURE 8-47.  A lateral crural steal procedure and a strut graft. The discontinu-
ous strip of lateral crural cartilage is rotated medially to increase projection. A
strut is secured between the crural cartilage for added support. This is an
aggressive technique and used in thick-skinned individuals who need major
tip projection and narrowing.

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Chapter 8  •  RHINOPLASTY
Caudal septum via transdomal approach
X
X
Y
Y
A
B
C
D
FIGURE 8-48.  A–B, Quadrangular cartilage is exposed through a transdomal open approach. C, A support of 1 cm dorsally
and caudally is left behind; residual cartilage can safely be used for grafting. D, Harvested quadrangular cartilage (X) is shown
being added to the caudal septum (Y) as a strut.

Chapter 8  •  RHINOPLASTY
209
3. Scroll attachments of the cephalic lower lateral cartilages
attached to the caudal edge of the upper lateral cartilages
4. Caudal septum and lower lateral cartilage tip attachments
Minor Nasal Tip Support Categories
1. Dorsal cartilaginous septum
2. Interdomal ligament
3. Skin attachment to lower lateral cartilages
4. Anterior nasal spine
5. Membranous septum and attachments
6. Lower lateral sesamoid cartilages
Dorsal Hump Reduction and Osteotomies
Reduction of a dorsal hump is one of the most common maneu-
vers performed during a rhinoplasty. This can be done via an
internal or external rhinoplasty. Patients often come in request-
ing removal of a dorsal hump only. Often, removal of a hump
only may cause problems with proportion if additional proce-
dures are not accomplished to keep the tip and sides of the nose
looking evenly proportioned with a new straight profile.
The nasal dorsal hump comprises both the nasal bones and
upper lateral cartilages. Relative percentages of bone and carti-
lage vary by patient. Humps made from short nasal bones and
long upper lateral cartilages are at greater risk for internal nasal
valve collapse. The peak of the dorsal hump is at the rhinion,
where the nasal bones and upper lateral cartilages join. The skin
is often thin but mobile over the rhinion (see Figure 8-12).
When treating the nasal dorsal hump, the most common
mistake is inadequate removal of cartilaginous hump at the
caudal end of the nasal dorsum. The next most common
problem is irregularity created by lateral osteotomies to close an
open roof deformity. Care must be taken to avoid the major
complications, particularly ones that would produce breathing
compromise or obvious aesthetic deformities. One must remem-
ber that by making the nasal dorsal hump smaller, it is likely
that the sides of the nose will also require narrowing, potentially
compromising airflow.
Ideally, a small hump should be addressed with rasping of
the bony nasal dorsum initially, followed by careful resection of
1 cm
1 cm
Gap for caudal
lengthening
Caudal repositioning
of septum
Graft
A
B
C
FIGURE 8-49.  A, Quadrangular cartilage is exposed and a section prepared
for harvesting, leaving behind at least 1 cm of support dorsally and cau-
dally. B–C, Aggressive treatment for a severely short nose. The dorsal
septum can be lengthened by cutting into and advancing it caudally. The
new position is maintained by a dorsal strut of stacked cartilage sutured
on each side (C) of the original dorsal septum to increase its length.
A
B
FIGURE 8-50.  A shield graft can aid in nasal tip projection and creation of tip-defining points. Care must be taken to carve and
secure shield grafts precisely, particularly in patients with thin skin.

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Chapter 8  •  RHINOPLASTY
In the case of an extremely wide nose, difficult anatomy, or
irregular fractures, medial osteotomies are occasionally required
to improve the aesthetics and have a more favorable fracture line
(Figure 8-53). The type of osteotomy performed laterally is
debatable. A sliding osteotomy with a Neivert osteotome is
easily learned by the beginner but is fraught with problems such
as collapse of the nasal bones and potential major tearing of the
mucosa, despite a tissue guard on one side of the instrument
(Figure 8-54). Because the osteotome slides through tissue and
bone, the mucosa could easily tear, along with creation of major
bony displacement. Ideally, a small 2- to 3-mm micro-osteo-
tome can be used in a perforating fashion along the planned
osteotomy line. This is followed by finger pressure to complete
lateral osteotomies with less tissue damage and less bleeding
(Fig. 8-55). Because of the potential for bleeding, osteotomies
are more often than not performed near the end of the proce-
dure to prevent unwanted bleeding that may create problems
during delicate tip surgery.
The cartilaginous dorsal hump is removed following dorsal
bone rasping in an average-sized dorsal hump. If a large nasal
dorsal hump exists, the cartilaginous hump is then removed
prior to bony hump removal, using a Rubin osteotome. The
cartilaginous portion of the hump is initially incised caudally,
followed by placement of the Rubin osteotome from below into
the slot created just below the anterior septal angle. The osteo-
tome must be kept at a perfect angulation to avoid asymmetric
removal of cartilaginous or bony dorsum. When extending
cephalically, the osteotome must proceed slowly to avoid plung-
ing the instrument deep at the root of the nose, where overresec-
tion would create a significant deformity requiring grafting.
The fact that the nasal dorsal hump is lowered automatically
creates a flattened pyramid structure from the basal view, and
the cartilaginous hump using a scalpel combined with scissor
resection. The approach to the nasal dorsum can be through a
marginal incision or an intercartilaginous incision. Once the
entire nasal dorsal hump is exposed, the choice is made whether
to perform a rasping reduction of the nasal dorsum or whether
an osteotome would be required because of the large size of the
nasal dorsum and/or thick nasal bones. On rare occasions, the
nasal bones are extremely thick and dense at the nasal root and
require a rotary instrument to “drill down” heavy, thick bones
(Figure 8-51). If a drill is required, such as in the case of an
obtuse nasofrontal angle, drills can be found that have a protec-
tive sleeve to avoid damage to the overlying skin.
On average, a standard nasal dorsal hump or small nasal
hump can be rasped initially, followed by direct vision resection
of the cartilaginous portion of the hump. Typically this will
leave a small open roof deformity where there is separation of
the nasal bones and upper lateral cartilages on each side of the
septum that requires closure via osteotomies. Most of the time,
lateral osteotomies are performed alone. The lateral osteotomy
extends from a position low on the piriform rim up to the level
of the medial canthus. This is performed to in-fracture the nasal
process of the maxilla along with the upper portion of the nasal
bones just below the nasofrontal suture line. The osteotome can
be placed through a marginal incision, or a new incision can be
made just inside the nasal cavity along the piriform rim where
a 2- to 4-mm osteotome is used to make sequential small per-
forations in the nasal process of the maxillary bone up through
the nasal bone, level with the medial canthus in the average
patient (Figure 8-52). Finger pressure is then used to complete
the osteotomy by medializing the bone and closing an open roof
deformity commonly created by reduction of a nasal dorsal
hump.
Bone removed by
rasp, drill, or
osteotome
Lateral
osteotomy
C
B
A
FIGURE 8-51.  On rare occasions, dense bone from a large nasal hump requires additional removal (A) using a rotary drill (e.g.,
patients with very obtuse nasofrontal angles). A Rubin osteotome (B) can then be used to remove a large, thick dorsal hump.
Of the three options, rasping is the safest and most precise way of reducing a dorsal hump (C). Any technique should render
the deepest portion of the nasal root level with the medial canthus and below the nasofrontal suture line.

Chapter 8  •  RHINOPLASTY
211
A
B
C
D
E
F
Correct angulation at piriform rim
Piriform rim
FIGURE 8-52.  A, Placement of an osteotome via a marginal incision. B, Osteotome is directly placed through mucosa over the
piriform rim. C–E, Lateral osteotomies performed intraorally during orthognathic surgery. F, Osteotomies are made through an
alar base resection incision.
lateral osteotomies not only close the open roof deformity but
also narrow it to produce a more pleasing pyramidal appearance.
Asymmetries in the nose, particularly ones caused by nasal bone
asymmetry, can be improved with the osteotomy as well. Patients
with previous fractures require lateral osteotomies simply to
straighten the nose by repositioning bones to their original loca-
tion (Figure 8-56). The position of the nasal frontal angle at the
radix nasi is also something that must be considered when
reducing the hump. Changing the height of the radix either
higher or lower than the medial canthus level will appear abnor-
mal postoperatively. Osteotome reduction of the nasal dorsal
hump is more prone to creating problems in the position of the
radix and should be used cautiously.
Bony hump removal is one of the most common maneuvers
requested by patients for rhinoplasty, but care must be taken to
avoid overresection and the creation of irregularities. Occasion-
ally a small hump can be rasped down and trimmed without
the need for osteotomies. Patients with large nasal dorsal humps
and a very high, narrow nasal vault are at greater risk for internal
nasal valve collapse because of further narrowing of the angula-
tion from upper lateral cartilages to the septum. Dorsal hump
resection and osteotomies in this particular subclass of patient

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Chapter 8  •  RHINOPLASTY
Medial osteotomy
Lateral osteotomy
FIGURE 8-53.  A classic low-to-high lateral osteotomy begins at the piriform
rim, adjacent to the tail of the lateral crural cartilages. Medial osteotomies
are not required in most situations but like the lateral osteotomy should
not extend above the medial canthus level.
A
B
C
FIGURE 8-54.  A classic “sliding” or “continuous” internal lateral osteotomy is performed using an osteotome with a blunted guide
that runs along the medial (inside) portion of the bone. Unfortunately, despite careful use with a guide, internal mucosal tears
have been shown to be more severe and frequent compared to using a perforating osteotomy technique.
may actually require simultaneous cartilaginous spreader grafts
to prevent unwanted breathing problems in the future (Figure
8-57). Transdorsal mattress sutures in the upper lateral cartilages
may also help maintain internal valve integrity.67 The goal for
removal of a nasal dorsal hump should be not only removal of
the hump but creation of a very pleasing overall outline of the
nose with good proportions. A lighted retractor is invaluable for
discovering irregularities that may be created during reduction
of the nasal dorsal hump. Control of the nasal tip must be
considered following hump reduction, even with simply tip
suturing alone (Figure 8-58). Tip-suturing techniques at the
dome can increase projection and control rotational vectors
(Figure 8-59). Removal of a dorsal hump can cause unwanted
tip over-rotation, and occasionally a columellar strut is required
for patients who have a hump and tip ptosis preoperatively
(Figure 8-60).
Alar Base Reduction
If alar base narrowing is required, it should be performed after
performing osteotomies and closure of the intranasal incisions.
Weir-type alar base sutures could tear easily if they were to be
closed prior to major retraction for intranasal manipulation. A
common method for reducing a wide alar base with large nostril
diameters is to remove a small section of skin and mucosa just
inside the nasal seal inferiorly and laterally but not extend later-
ally into the alar crease where it would be visible (Figure 8-61).
This is often very sebaceous skin that tends to not heal as well
as thinner skin of the nose and must be closed in layers with
sutures that last at least 2 weeks to avoid dehiscence at the inci-
sion sites. To avoid asymmetric excision, an Adson-type forceps
can be used to hold the position for excision and a #15 blade
cutout performed on each side of the retractor in equal dis-
tances. Simply “eyeballing” the excision will often lead to asym-
metric nostril size and the need for revision. An alar base suture
across the entire nasal base can further support narrowing of
the nose and help prevent dehiscence as well as postoperative
widening during smiling. The narrowing of the nasal base can
increase tip projection alone but can be very significant when
combined with tip grafts or tip-suturing techniques (Figure
8-62). However, care must be taken to avoid overresection of
the nasal base, which can be difficult to correct and very deform-
ing. The result from overnarrowing the nasal base is similar to
Text continued on page 218.

Chapter 8  •  RHINOPLASTY
213
A
B
C
D
E
F
FIGURE 8-55.  Micropuncture lateral osteotomy technique. The osteotomy begins low but not at the base of the piriform rim and
extends to a level just below the nasofrontal suture line. The angulation of the osteotome (using the leading edge) shown here
is critical to keeping it positioned well and achieving a clean, smooth cut in the bone.

214
Chapter 8  •  RHINOPLASTY
A
B
FIGURE 8-56.  Before (A) and 3 months after (B) repair of a deviated nose from a recent facial fracture. The patient only wanted
correction of the deviation and could be treated using lateral osteotomies alone.
Interpositional
spreader grafts
A
B
FIGURE 8-57.  Spreader grafts shown here were fabricated from septal cartilage and temporarily held in place by 25-gauge
needles to aid in suture plication. The grafts are placed between the septum and upper lateral cartilages to correct or prevent
internal nasal valve collapse.

Chapter 8  •  RHINOPLASTY
215
A
C
D
E
B
FIGURE 8-59.  Classic tip-suturing techniques with needles (A) to temporarily stabilize position and initial suturing of the medial crura (B). Individual trans-
domal sutures (C) can maintain tip-defining points. The divergence in the tip-defining points shown in (D) is narrowed with a horizontal mattress suture
across both domes (E).
1 year post op
5 years post op
A
B
C
FIGURE 8-58.  A 38-year-old white female 1 year and 5 years following an open rhinoplasty. Her dorsal hump was reduced,
along with tip narrowing by way of basic cephalic strip excision. Using tip-suturing techniques alone maintained good tip pro-
jection over the years; no additional grafting or strut placement was required.

216
Chapter 8  •  RHINOPLASTY
4 mm Cephalic
strip excision
Osteotomy
Columellar
strut graft
A
B
C
D
E
FIGURE 8-60.  A 27-year-old female before and 1 year after open rhinoplasty. A columellar strut was used after reducing the
bulbous tip by excising 4-mm-wide cephalic strips from the lateral crural cartilages. Patients with dorsal humps and tip ptosis
often benefit from additional tip support to maintain adequate tip projection over time. To temporarily hold the strut in position
during suture plication, 25-gauge needles can be used as shown.

Chapter 8  •  RHINOPLASTY
217
A
B
C
FIGURE 8-61.  Alar flare reduction (Weir-type resections) can be performed in patients with disproportionately wide ala and nasal
base. Brown-Addison forceps are helpful to excise symmetric amounts of tissue bilaterally (A). After resection (B), a trans-alar
base suture may be placed if indicated prior to skin closure. Alar base narrowing can produce additional tip projection (C) and
improved nasal tip-to-base proportion for the appropriate patient.

218
Chapter 8  •  RHINOPLASTY
A
B
FIGURE 8-62.  Before and 3 months following alar flare reduction (Weir-type resections) along with transdomal tip suturing to
dramatically increase tip projection.
a cleft lip and palate patient with major tip and nostril collapse
(Figure 8-63). Cleft patients have poor septal cartilage and often
require better-quality cartilage from sources such as the ear or
rib (Figure 8-64).
Wound Closure and Nasal Dressing
Closure of the internal marginal incisions can be done using
interrupted or running resorbable sutures such as 5-0 plain gut,
whereas an external transcolumellar incision typically heals
much better with a few interrupted 5-0 Prolene or nylon sutures
that can be removed at 1 week postoperatively when the splint
is taken off. Care must be taken to pass the needle through
mucosa only for intranasal incisions. Accidentally piercing lower
lateral cartilages or grafts may cause asymmetries or alar rim
abnormalities. A transseptal suture using a straight needle with
4-0 plain gut can be used if the septal mucosa was elevated. The
transseptal mattress suture helps to close dead space and prevent
septal hematoma. Alar base incisions, if used, are closed last to
prevent tearing during nasal manipulation from intranasal inci-
sion closure. The alar base has sebaceous tissue that heals poorly
and can easily have sutures extrude early, with wound dehis-
cence. Therefore, the alar base should be closed in layers with
sturdy suture such as 4-0 Monocryl. Following final incision
closure, the nose and oropharynx are suctioned for any residual
blood. The nose is dried and prepped with tincture of benzoin
or Mastisol to allow initial tape dressing using brown Micropore
paper tape. This is followed by placement of an external nasal
splint—either a moldable aluminum splint or a heat-molded
thermoplastic splint—to maintain good position of the bones
following osteotomy and decrease postoperative edema (Figure
8-65). Typically the patient wears the nasal splint for 1 week
prior to removal.
Postoperative Care
Rhinoplasty is an outpatient surgery in the vast majority of
cases, and patients should be given detailed written and oral
instruction for postoperative care to help avoid problems.
Ideally, the patient should be seen on postoperative day 1 and
again at 1 week. The day-after appointment can be used to
review what was done, what to do over the next week, and to
ensure the patient has no complications such as signs of septal
hematoma. The chance is rare but could be devastating if left
untreated. Still, many surgeons choose to wait 1 week for the
first follow-up appointment. During the first postoperative
week, the patient is instructed to elevate the head 30 to 45
degrees while sleeping or lying down. Elevation decreases edema
and reduces the chance of epistaxis by lowering venous pressure
in the face. Ideally, patients should use ice or bags of frozen
green peas over the eyes and nasal bridge as much as possible
the first 48 to 72 hours. The patient is told to apply antibiotic
ointment with a cotton-tipped applicator inside the nose twice
a day for the first week (beneficial as both a moisturizing and
antibacterial agent). The patient is also instructed to use saline
nasal spray as often as they desire to help flush the nose of debris
and keep it moist. To prevent the rebound vasodilatory effect,
use of vasoconstrictive nasal sprays such as Afrin is strictly for-
bidden during recovery. Diluted hydrogen peroxide (50% water,
50% peroxide) is allowed on a cotton-tipped applicator to help
clean the inside of the nose during the first week. Nose blowing
is prohibited for at least 3 weeks, but the patient can sniffle as
much as they like. External sutures and the nasal splint are care-
fully removed at the 1-week postoperative appointment. Most
patients are seen again at 1 month postoperatively, and early
photos are taken.
Complications and Treatment
Hematoma
Fortunately, the chance of a postoperative hematoma from rhi-
noplasty is less than 1%. By far the most common area to form
a hematoma after a septorhinoplasty is the septum. An obvious
septal hematoma requires evacuation immediately. Leaving the
hematoma to resorb can cause necrosis of the supporting carti-
lage of the nose and produce problems such as septal perforation

Chapter 8  •  RHINOPLASTY
219
A
B
C
FIGURE 8-63.  Before and 1 week after reconstructive rhi-
noplasty on an 11-year-old male with past cleft lip and
palate repair. A rib graft was harvested and fabricated as
a columellar strut graft, along with combined dorsal and
tip graft. Additional cartilage batten grafts were placed
along with a small skin graft inside the right ala to further
help prevent collapse and improve general shape. Due to
severe scarring, this type of problem is challenging to
correct; silicon stents may be required for the first week
to help control early relapse.
or a saddle nose deformity. The use of transseptal resorbable
mattress sutures (straight double arm needle with 4-0 plain gut)
will decrease the rate of septal hematoma by closing the dead
space from septal mucosal elevation.
Bleeding
Severe bleeding intraoperatively is rare if no bleeding disorder
exists and assuming good local anesthesia with vasoconstriction
is achieved. The blood supply to the nose and septum, as dis-
cussed previously in this chapter, is excellent and should be well
understood in case excessive bleeding does occur during surgery.
Most of the time, isolated areas of excess bleeding can be well
controlled with meticulous electrocautery and/or temporary
pressure with gauze soaked with a small amount of 1% phen-
ylephrine. Staying in the correct dissection plane, immediately
opposed to cartilage and bone, will help maintain a near-
bloodless dissection. The most likely time for unwanted bleed-
ing is during lateral osteotomies. A careful micropuncture
technique can help lower the risk of excessive bleeding during
this procedure, performed near the end of most rhinoplasties.
Patients should be instructed that for 10 days prior to surgery,
they should avoid aspirin and other nonsteroidal antiinflamma-
tory drugs (e.g., ibuprofen), vitamin E, many herbal medica-
tions, garlic, fish oils, Ginkgo biloba, and other mediations that

220
Chapter 8  •  RHINOPLASTY
Medial rib exposure adjacent to
the sternum, rib 6 or 7
Rib cartilage
harvest
Silicone dorsal strut versus carved rib cartilage
A
B
C
FIGURE 8-64.  Rib harvest shown is from the cartilaginous attachment to the sternum and level with the patient’s inframammary
fold. The rib is an excellent source for major cartilage. It cannot be carved as smoothly as a synthetic silicone graft but must
be carved as carefully as possible to prevent problems from irregularities.
may increase bleeding. Avoidance of these medications, perfect
technique, postoperative head elevation, and cold compresses
will all help decrease the chance of unwanted bleeding and limit
the amount of postoperative ecchymosis.
Excessive postoperative bleeding (2% to 4% chance) may
occur when the patient’s heart rate and blood pressure elevate.
For this reason, they should be instructed to avoid vigorous
activities during the first week. Also, increased venous pressure
in the head and neck from Valsalva maneuvers (e.g., coughing
or straining) or bending over at the waist will increase the
chance of postoperative epistaxis. The patient must be instructed
to refrain from such activities in the early postoperative period.
Even if no active bleeding occurs, ecchymosis can be worse
(Figure 8-66).
Should epistaxis occur while the patient is at home, they can
initially attempt ice, elevation, and relaxation (to lower heart
rate and blood pressure). Persistent or severe bleeding should be
evaluated immediately and treated appropriately. Kiesselbach’s
plexus along the lower anterior septum (see Figure 8-6) is a
common area for nosebleeds and may require electrocautery for
persistent hemorrhage. Posterior nasal bleeding can be con-
trolled with packing (gauze or balloon). On rare occasions,
severe posterior bleeding not controlled by local measures may
require radiographic evaluation and possible thrombolic
obliteration. One should keep in mind that extremely severe
episodic epistaxis more than 1 month following nasal surgery
may be a sign of an A-V malformation and requires an appropri-
ate work-up.
Infection
Again, abundant blood supply to the nose makes infections
from rhinoplasty extremely rare (less than 1% for even minor
infections). Severe infection requiring IV treatment or hospital-
ization is even more rare. Still, change in mental status, high
fevers, and periorbital erythema must be treated aggressively and
computed tomography evaluation initiated because of the prox-
imity of the brain and ocular orbit.
Minor infections may be seen as early as 1 week postopera-
tively or several years later and are commonly associated with
exposed permanent sutures or grafting material. If purulence is
present, drainage and culture should be obtained. However,
most foreign body infections present as minor erythema, pain,
or a bad smell. Exposed suture or graft material should be
removed immediately (many times using local anesthesia only).
The most common organisms are Staphylococcus, Streptococcus,
or Haemophilus. Pseudomonas, Actinomyces, or others may on
rare occasion be seen. In addition to oral antibiotics (first-
generation cephalosporins as first-line treatment), topical

Chapter 8  •  RHINOPLASTY
221
A
B
C
FIGURE 8-65.  A, Initial taping of the nose following rhinoplasty. Tincture of benzoin or Mastisol can be applied to the skin first
to allow the tape to remain in place for 1 week, even when getting wet. A thermoplastic nasal splint is molded (B) while warm.
C, Edges extend just to the nasofacial groove, nasion, and supratip break.
FIGURE 8-66.  One week postoperative appearance following rhinoplasty
with lateral osteotomies. Cold compresses and head elevation can help
decrease bruising, but despite best efforts, this amount of ecchymosis
can be normal.
Bactroban ointment can be applied inside the nose twice daily.
As many as 15% of the population are colonized with MRSA
(methicillin-resistant Staphylococcus aureus). This must be con-
sidered when choosing oral antibiotics. In general, most infec-
tions are minor but must be treated because they are from
something that was used inside the nose, such as suture
or grafting material. Meticulous placement of all grafts and
permanent suture with excellent tissue coverage will help limit
the occasional postoperative minor infection.
Graft Exposure or Wound Breakdown
Cartilage, bone, soft tissue, or synthetic grafts all can potentially
become exposed or extrude from the nose. They can also be the
source of a chronic or acute infection. It is important to use
grafts that are not only well contoured but also well fixated. As
with any graft, mobility during the early phase of healing is
asking for problems. The need for quality soft-tissue coverage
with a robust blood supply is also critical for success of a graft
and to prevent future exposure or wound breakdown.68-74 This
is one of the main reasons that the multi-operated nose has so
many problems. Fibrosis, thinning soft-tissue coverage, and a
decreased blood supply from previous surgeries greatly increases
the risk for future wound problems and graft exposure. Syn-
thetic grafts such as silicone dorsal onlay grafts have a theoretic
increase in exposure rate over time. A solid silicone implant will
form a peri-implant capsule but is not incorporated into the soft
tissue or blood supply like an autologous graft. However, even
autogenous grafts such as cartilage can occasionally act similarly
to synthetics and never become truly incorporated into the nose
but merely function as a foreign body that is well tolerated.
Treatment and prevention of graft and wound problems involve

222
Chapter 8  •  RHINOPLASTY
A
B
C
FIGURE 8-67.  A, A young female patient is shown before rhinoplasty. B, Same patient 1 month postop with a nice reduction
of the overprojected tip and anterior nasal spine but slightly depressed dorsum. C, Minutes after 0.1 mL of a common inject-
able filler was used to improve the subtle depression along the dorsum.
prompt removal of exposed grafts and careful placement with
good stability and tissue coverage.
Autogenous dorsal and tip grafts must be carved meticu-
lously to prevent irregular edges from creating damage and
atrophy to the soft-tissue nasal drape, both inside the nose and
out. Synthetic nasal grafts do not have a great reputation in the
United States compared to places such as Asia, but they do offer
a perfectly smooth design that can work well if stabilized early
and adequate soft-tissue coverage is ensured. Rhinoplasty is
truly a cosmetic surgery where every millimeter counts, particu-
larly on the thin-skinned patient. Even final closure in hidden
intranasal regions must be scrupulous to prevent irregular scar-
ring, graft exposure, or wound breakdown.
Prolonged Postoperative Edema
Edema is to be expected, and the patient should be forewarned
of the typical amount of swelling. The patient must also under-
stand that changes to the nose and some subtle shrinkage may
occur microscopically for up to a year. However, there are some
cases where postoperative edema may be prolonged and even
have the potential for permanent fullness if not treated. The
classic area for unwanted prolonged edema is in the supratip
area of the nose. True abnormal edema here can persist occasion-
ally and lead to permanent fibrosis and unwanted fullness. The
key is to make sure the region is actually edema and not simply
a structural flaw. If inadequate tip projection was accomplished
or the anterior septal angle left too high, then the structural
problem may actually require a revision surgery later. But if the
supratip area is merely boggy with edema, it can be treated with
injections of steroid (Kenalog) and/or 5-FU (fluorouracil). The
injection should be only a few drops and ideally not given until
3 months postoperatively but can occasionally be used cau-
tiously at 1 month. One example of a dosage we use is a mix
of 0.1 mL of 40% Kenalog with 0.1 mL of 5-FU. Again, only
a few drops are placed and only for obvious edema in the supra-
tip region where the skin is typically thickest. Gentle message
of the nose and postoperative edema can be performed by the
patient after 1 month. The focus is on the fact that some edema
is normal, and the patient must allow adequate time to pass.
Usually no treatment is required.
Irregularities, Asymmetries, and Depressions
The patient who returns after months or even years with com-
plaints of unwanted aesthetic problems such as irregularities,
asymmetries, depressions, or other problems is a diagnostic and
treatment dilemma.75,76 The rate of revision rhinoplasty surgery
has been quoted at various percentages but is often relatively
high compared to other cosmetic procedures. Because the nose
is an isolated organ in the middle of one’s face, even minor
problems are often noticed and objectionable to a patient.
Ideally, a nonsurgical treatment should be considered if the
function of the nose is good and existing problems are fairly
minor. Revision surgery after rhinoplasty can be very challeng-
ing, and entire books have been dedicated to this topic.
Today, soft-tissue fillers such as hyaluronic acid fillers (Juve-
derm or Restylane) require no allergy testing and can last up to
1 year. These fillers are easy to use and offer an alternative to
revision nasal surgery in a very large number of cases. For
example, depressions near the dorsum are easily filled with a
very few drops of the injectables. Even inadequate tip projection
can be improved with careful use of fillers (Figure 8-67). Certain
asymmetries may be improved using injectable fillers as well. If

Chapter 8  •  RHINOPLASTY
223
Shield graft
Columellar strut graft
Batten grafts
A
B
FIGURE 8-69.  Tip grafts must be carved carefully and secured well to help avoid exposure or movement of these delicate grafts.
The soft-tissue coverage is also critical for preventing postoperative problems from graft placement.
Lacimal sac
Lateral osteotomy
FIGURE 8-68.  Fortunately, the lacrimal sac is relatively well protected from
injury from a classic lateral osteotomy. Osteotomes still must be used
carefully near the medial canthus and must remain medial to the canthus
at this level.
a depression or inadequate fullness on one side is creating the
asymmetric appearance, then filling the void will also improve
the symmetry. There are also a few off-label permanent fillers
on the market, such as Silikon 1000 by Alcon, which could be
used similarly to the temporary fillers. A microdroplet technique
with very small aliquots must be used to prevent overfill or
superficial placement. Smaller doses are also recommended and
repeated only as required, with a minimum of 1 month between
patient visits. Granulomas have been known to form from
contaminated silicone products or from large volumes. The
temporary hyaluronic acid fillers offer a nice trial period before
using a permanent injectable and are reversible by using hyal-
uronidase if the patient does not like the result.
Persistent hard (cartilage or bone) excesses usually require
surgical removal. Osteotomies are a common culprit for irregu-
larities. Some worry that the lacrimal system could be damaged
by lateral osteotomies, but the lacrimal sac is well protected if
the osteotome does not drift extremely far laterally near the eye
(Figure 8-68). Aesthetic problems that are accompanied by
functional problems, such as compromised breathing, almost
always require revision surgery with grafting procedures. Exter-
nal or internal nasal valve collapse is the most common of these
conditions. External nasal valve collapse usually requires place-
ment of alar, onlay, or Batten-type cartilage grafts to reinforce
the lateral wall of the nasal tip (Figure 8-69). Auricular cartilage
grafts from the conchal bowl make ideal material for correction
of external valve collapse because of the slight convex curvature
that helps keep the ala from collapsing inward. Internal nasal
valve collapse typically requires cartilaginous spreader grafts
placed between the septum and the upper lateral cartilages.
Straight septal cartilage is an ideal source for spreader grafts
because of the flat shape that is easily carved. There have been
some reports of correction of internal valve collapse by nonsur-
gical methods using various injectable fillers. Major loss of tip
support is an indication for surgical revision using strut grafts.
When patients have suffered terrible fibrosis and major tip
collapse from many surgeries, rib grafting may be needed for
adequate strength and size to correct a very challenging situation
(see Figures 8-82 and 8-83).77,78
Case Presentations
Figures 8-70 to 8-90 present cases diverse in diagnosis and treat-
ment planning. Undoubtedly, other rhinoplasty surgeons might
have chosen a variety of other techniques. The beauty of rhino-
plasty is that the specific technique can be variable or even tortu-
ous as long as the result produces a happy patient.
Text continued on page 245.

224
Chapter 8  •  RHINOPLASTY
Case 1
FIGURE 8-70.  A 57-year-old female before and 5 years after internal rhinoplasty. A relatively simple procedure yielded nice
long-term results. A small dorsal hump reduction was performed along with minute (2 mm) cephalic strip excision of each lateral
crus from the lower lateral cartilages and tip reinforcement with sutures. Lateral osteotomies were performed to close the small
open roof created by hump reduction.
A
D
E
F
G
H
I
B
C

Chapter 8  •  RHINOPLASTY
225
Case 2
FIGURE 8-71.  A 22-year-old female before and 2 months after open rhinoplasty. A fairly basic rhinoplasty was selected, since
the patient had normal to thick skin and very strong cartilages. A dorsal hump reduction was performed along with small cephalic
strip excision and tip reinforcement with sutures. The procedure was nearly identical to Figure 8-70, but an open approach
was used purely as surgeon’s preference, and similar results are seen.
A
D
E
F
G
H
B
C

226
Chapter 8  •  RHINOPLASTY
Case 3
FIGURE 8-72.  A 21-year-old female before and 1 year after internal rhinoplasty and alar base reduction. A relatively straightforward
procedure was performed to narrow the tip. Some loss of tip-defining points may have occurred from overzealous tip narrow-
ing. A disproportionately wide alar base was narrowed using Weir-type tissue excisions just inside the alar rim inferiorly.
A
C
F
G
H
D
E
B

Chapter 8  •  RHINOPLASTY
227
Case 4
FIGURE 8-73.  A 52-year-old Hispanic female patient before and 1 year after open rhinoplasty. Because her cartilages are soft,
a strut was required to maintain tip projection integrity following hump reduction and resection of portions of the upper and
lower lateral cartilages. A small “plumping” graft of morselized cartilage was also placed over the anterior nasal spine to decrease
columellar retraction in this region. Sutures across the dorsum to each upper lateral cartilage were used in hopes of preventing
internal nasal valve collapse.
Horizontal mattress sutures to
open the internal nasal valve
were placed past trimming of
upper lateral cartilages
Trimming of
caudal septum
Plumping graft
Columellar
strut graft
A
B
C
F
G
D
E
H

228
Chapter 8  •  RHINOPLASTY
Case 5
FIGURE 8-74.  A 30-year-old female before and 2 years after open rhinoplasty. Dorsal hump reduction was performed along
with lateral osteotomies, using a micropuncture technique to close the “open roof” created by hump reduction. A small anterior
columellar strut was used to compensate for inadequate tip support and help with tip rotation and projection.
A tip strut was required to help
support a narrowed tip and to
aid in rotation and projection.
‘Weir’ type alar base tissue
resections to narrow the base.
Some rim flattening can occur if
cartilage support is inadequate.
A
D
E
G
H
B
C
F

Chapter 8  •  RHINOPLASTY
229
Case 6
FIGURE 8-75.  A 48-year-old female patient before and 5 years after open rhinoplasty. Thin spreader grafts were placed because
a large hump reduction was performed along with lateral and medial osteotomies on this patient with a preoperative narrow
vault. Compromise of the internal nasal valve is at risk, and spreader grafts lower the incidence of valve problems. Dorsal hump
reduction was performed, along with small cephalic strip excision and tip reinforcement with sutures.
Resected tissue
shown in red
Lateral osteotomies
Medial osteotomies
Smaller spreader
grafts
A
B
C
F
G
D
E

230
Chapter 8  •  RHINOPLASTY
Case 7
FIGURE 8-76.  A 44-year-old male patient before and 1 year after open rhinoplasty. A cartilaginous dorsal hump at the anterior
septum created a “pollybeak” deformity. The patient had a history of nasal trauma and a relative saddle deformity over the nasal
bones. A nasal tip strut graft was used to aid in tip projection, along with a small dorsal onlay graft to treat a slight cephalic
saddle nose deformity. The anterior septal angle was significantly reduced.
Dorsal onlay graft
Resected
cartilage
Lateral micropuncture
osteotomy
Strut graft
Lowered
anterior
septal angle
Dorsal onlay graft
A
D
E
G
I
H
F
B
C

Chapter 8  •  RHINOPLASTY
231
Case 8
FIGURE 8-77.  A 35-year-old female before and 1 year after open rhinoplasty. A dorsal bony hump reduction was performed
along with lateral osteotomies via a micropuncture technique. A small anterior strut was used to compensate for inadequate
tip support following removal of a large portion of bulbous lower lateral tip cartilage. The bulbous nasal tip takes on a  
much nicer pyramidal shape as seen from the basal view. A complete transfixion incision was used to help decrease tip
projection.
A
B
C
F
G
D
E