Essentials of Aesthetic Surgery

572
Part VII Facial Surgery
Crease is released anteriorly from underlying tissues.
Dissection may be carried forward and laterally to release mandibular ligaments.
Skin is undermined as much as needed to address the platysmal bands and the most
inferior horizontal cervical crease.
Dissection is carried laterally as needed to expose platysma.
Fat is preserved in thin patients.

under direct vision.
Deeper structures can be addressed with this directed anterior approach.
Platysmal procedures are performed using this approach.
Platysmal muscle approximation is closed with nonabsorbable, permanent sutures
(such as Mersilene or Prolene).
SPECIFIC TECHNICAL CONSIDERATIONS
25,26
• In an obtuse, fatty neck, some fat is always present beneath the platysma.
• The fat lies in the midline and extends toward the submandibular gland.
• The medial border of the platysma is elevated, and fat is excised between and deep
to the platysma.
is essential to prevent

• If a lymph node is present, it is included in the specimen.
• The platysma is reapproximated at this level to prevent dehiscence from an
insecured closure.
8 (Fig. 44-5)
• This should be considered a rare procedure.
• After subplatysmal fat excision, the muscles are exposed through a submental
incision.
• The anterior belly of the digastric is tangentially excised, totally excised, or plicated
in the midline.
• A tangential excision is more common and starts anteriorly at the muscle origin.
Digastric muscle excision.
Digastric
muscle
Mylohyoid
muscle

573
Chapter 44 Necklift
9,27-28
• An enlarged submandibular gland is visualized after excision/retraction of the
anterior digastrics.

• Despite ptosis of the gland on preoperative assessment, addressing it surgically is
uncommon.
• Various methods have been described: Partial resection, suture suspension to
mandibular border, and transcervical suspension.
• Excision involves grasping with an Allis clamp and excising in piecemeal fashion with
needletip cautery.
• A drain should be placed if the gland is excised.
• A rare may result, along with nerve injury.
ENDOSCOPIC NECKLIFT
This procedure is more of a historical interest, because visualization is improved using a
lighted retractor, an appropriate retraction, and a small submental incision.
Involves a 3-4 cm submental incision and 1 cm retroauricular incisions with the aid of

No skin excision is performed with this technique.
SHORT CAR FACELIFT AND NECKLIFT

• Ideally, patients with no excess neck skin
• Presence of jowling
• An aged neck-face interface

• A vertical vector on the SMAS and slight diagonal vector on the skin will improve the
jawline/upper neck.
• The neck can be contoured using liposuction or through submental direct incision.
• If the neck is opened, then the planes of face and neck dissection are connected in
the subcutaneous plane.
• Facial portion of the procedure is done through a prehairline incision below the
sideburn and a preauricular retrotragal incision ending at the earlobe.

sternocleidomastoid muscle.
• A sub-SMAS dissection is performed at the junction of adherent and mobile SMAS to
join a diagonal SMAS incision at the zygomatic prominence.

posteriorly in the neck.
• Alternative approaches, such as SMASectomy and SMAS plications, can be
performed through this limited incision.


• Facial skin is directly pulled upward with a diagonal vector posteriorly.
• Excess skin is trimmed, tailored, and inset.

574
Part VII Facial Surgery
Short-scar facelift and necklift.
Incision follows
lateral border of
platysma muscle
Zygomatic
prominence
Angle of
the mandible
FULL CAR FACELIFT AND NECKLIFT

• Aging changes of face and neck

• Inelastic and excess skin of face
• Poor and excess skin of neck
• Visible static platysmal bands down to inferior cervical
neck crease below the thyroid
• Visible submandibular gland


neck, the is continued
to prevent notching the occipital hairline and to
remove more excess skin (Fig. 44-7).
• Essentially, the concept of skin excess excision follows that
of removal of a dog-ear along anatomic boundaries.
• The key aspect is to then to remove
skin.
• The retroauricular sulcus is closed with a
incorporating deep fascia to prevent scar migration.
• The facelift approach is individualized and discussed in Chapter 40.

Occipital
hairline incision.

575
Chapter 44 Necklift
SKIN FLAP PROCEDURES
A of pull is required for a youthful, harmonious necklift procedure.
A is required when using the

TIP: Avoid excising the skin before considering redraping and redistribution.
If skin excision is necessary, then a retroauricular or hairline incision should be
considered, according to amount requiring removal.
31
• In patients with severe and massive anterior neck redundancy, skin can be excised
using a direct approach.
• A can restore a youthful contour to the cervical angle.
32
• The initial procedure was done through a midcervical skin excision through which
preplatysmal and subplatysmal fat was excised.31
• Platysma is closed in the midline.
• In men, persistent scarring in the neck is only occasionally acceptable in those who
present with a very generous skin redundancy.
33
• This option is popular for patients who have had
Despite adequate analysis and treatment of excess skin, a
may rarely be necessary, and this should be discussed with patients.
PLATYSMAL PROCEDURES
The platysma can be * Once
platysmal diastasis is addressed with any of the procedures discussed previously, either
alone or in combination, the surrounding skin is recruited in the midline. This medial
tightening leaves skin tethered laterally to the attachments of the lateral platysmal fascia,
which is generally stronger. The skin is then allowed to contract or is excised laterally

described.
21,35-39
PLATYSMAL FLAP CERVICAL RHYTIDOPLASTY
Sectional myotomy of the medial edge of the platysma allows lateral rotation and


banding.
TIP: When performing a myotomy, consider the ability of the thyroid cartilage to


*References 5, 6, 8, 20, 22, 34.

576
Part VII Facial Surgery
SUSPENSION
SUTURES
Suspension sutures
running along the inferior
border of the mandible

on the platysma can

jawline.
Sutures are interlocked at
the midline and tacked to
the mastoid fascia.
PLATYSMAL MUSCLE
SLING
A sling is made by
dividing the platysma
horizontally across the
entire width.
A wide gap is created, decreasing the popularity of the procedure.
Muscle tissue bunches on the cephalad portion of the platysma, creating a
phenomenon known as the

CORSET PLATYSMAPLASTY
An anterior open approach to the neck is required through a submental incision.
The neck skin is elevated and medial edges of the platysma infolded using a permanent
suture.
The neck skin is shifted posteriorly, but the platysmal pull is forward and toward the
midline anteriorly.
The anterior pull of the platysma is a key element that is called
No muscle is resected.
The redundant neck skin can be allowed to contract, or it can be excised laterally.
Occasionally, a very low 3-4 cm transection from the medial edge allows comfortable

Suspension sutures, interlocked at midline, run
along the inferior mandibular border.

577
Chapter 44 Necklift
A multilayered seam approximates the full height of the midline platysma muscle
edges, creating a “waistline” to the neck from an anterior plastysmal shift.

notch.
Crisscrossing and backtracking are advocated to maintain a straight seam.
A nonabsorbable suture is used for plication (Mersiline or Prolene).


jawline and neck-jaw transition beautifully. This is done with an occasional second row
of running vertical oblique sutures.
Additional submandibular suturing may be done to treat residual bulging in the area by


POSTOPERATIVE CARE
Analgesia control is routine, supplemented with sleeping pills, antiemetics, and
instructions for their use.



the neck lymphatics.
Drains are used to eliminate serum and a small amount of blood, potentially reducing
postoperative edema.
Management of blood pressure is essential in preventing hematoma.
Drains are removed as necessary on postoperative day 1 after the patient examination.
Without applying pressure, cotton dressings or foam tape and an elastic garment are

Operative dressings are removed on postoperative day 1 and replaced with a neck strap

NOTE:

578
Part VII Facial Surgery
Patients are instructed to maintain an open neck angle, e.g., as when leaning forward
while sitting, with the elbows on the knees, and looking straight ahead.
Wounds are cleaned with half-strength hydrogen peroxide and coated with a topical
antibiotic as needed.
All nonabsorbable skin sutures are removed by day 7.
Strenuous activity is restricted until week 6.
Instructions for facelift recovery are similar to those for necklift recovery.
COMPLICATIONS AND SUBOPTIMAL RESULTS
Postoperative problem areas result from and

Any tissue level can result in an unpleasing appearance, including:


suction or defatting subcutaneously, especially in the thin neck.

subplatysmal fat.

such as subplatysmal fat, digastric muscle, and submandibular gland.



by undercorrection.


retroauricular sulcus.

the retroauricular area.




uniformly preserving 3-5 mm of subcutaneous fat

submental incisions.


most common.
be used for plication.

as indicated.

directed.

579
Chapter 44 Necklift






can result in poor retroauricular or anterior tragal scars.


TOP TAKEAWAYS

The neck is a continuum of the face, adding a level of beauty while providing an
important life function.



Adequate skin elasticity is essential for short-scar procedures.

Kybella should not be injected in patients with dysphagia; into or in close
proximity to the marginal mandibular branch of the facial nerve; or close to the
salivary glands, lymph nodes, or muscles.

or the may be injured
by traction.

Postoperative problem areas result from and

REFERENCES
1. Ellenbogen R, Karlin JV. Visual criteria for success in restoring the youthful neck. Plast Reconstr
Surg 66:826, 1980.
2. Vistnes AM, Souther SG. The anatomical basis for common cosmetic anterior neck deformities.
Ann Plast Surg 2:381, 1979.
-
ers, 2010.
4. Cardoso de Castro C. The anatomy of the platysma. Plast Reconstr Surg 66:680, 1980.
5. Aston SJ. Platysma muscle in rhytidoplasty. Ann Plast Surg 3:532, 1979.
6. Guerrerosantos J. The role of platysma muscle in rhytidoplasty. Clin Plast Surg 5:29, 1979.
-
tion. Clin Plast Surg 10:379, 1983.

the submental area of the face. Plast Reconstr Surg 99:1586, 1997.
9. Singer DP, Sullivan PK. Submandibular gland I: an anatomic evaluation and surgical approach to
submandibular gland resection for facial rejuvenation. Plast Reconstr Surg 112:1150; discussion
1155, 2003.
10. Brandt FS, Bellman B. Cosmetic use of botulinum A exotoxin for the aging neck. Dermatol Surg
24:1232, 1998.
11. Kane MA. Nonsurgical treatment of platysmal bands with injection of botulinum toxin A. Plast
Reconstr Surg 103:656, 1999.

bands. Plast Reconstr Surg 103:643, 1999.

580
Part VII Facial Surgery
13. Oni G, Hoxworth R, Teotia S, et al. Evaluation of a microfocused ultrasound system for improv-
ing skin laxity and tightening in the lower face. Aesthet Surg J 34:1099, 2014.
-
tion: a comparative trial evaluating 678 consecutive face lifts. Plast Reconstr Surg 113:398, 2004.
15. Courtiss EH. Suction lipectomy of the neck. Plast Reconstr Surg 76:882, 1985.


surgery. Plast Reconstr Surg 1155:1761, 2005.
18. Gryskiewicz JM. Submental suction-assisted lipectomy without platysmaplasty: pushing the
(skin) envelope to avoid a facelift for unsuitable patients. Plast Reconstr Surg 112:1393, 2003.
19. Mladick RA. Neck rejuvenation without facelift. Aesthet Surg J 25:285, 2005.

101:473, 1998.

22. Connell BF. Contouring the neck in rhytidectomy by lipectomy and a muscle sling. Plast Re-
constr Surg 61:376, 1978.
23. Hamilton JM. Submental lipectomy with skin excision. Plast Reconstr Surg 92:443, 1993.
24. Gradinger GP. Anterior lipectomy with skin excision. Plast Reconstr Surg 106:1146, 2000.
25. Millard DR, Pigott RW, Hedo A. Submandibular lipectomy. Plast Reconstr Surg 41:513, 1968.

rejuvenation. Plast Reconstr Surg 83:53, 1989.
27. Sullivan PK, Freeman MB, Schmidt S, et al. Contouring the aging neck with submandibular
gland suspension. Aesthet Surg J 26:465, 2006.

Surg 122:938, 2008.
29. Eaves FE, Nahai F, Bostwick J. The endoscopic neck lift. Op Tech Plast Reconstr Surg 2:145,
1995.

31. Adamson JE, Horton CE, Crawford HH. The surgical correction of the “turkey gobbler” defor-
mity. Plast Reconstr Surg 34:598, 1964.

47:534, 1971.

1983.
34. Fuente del Campo A. Midline platysma muscular overlap for neck restoration. Plast Reconstr
Surg 102:1710; discussion 1715, 1998.
-
tomic study and analysis of 20 cases. Plast Reconstr Surg 117:2001, 2006.

37. Guerrerosantos J. Managing platysmal bands in the aging neck. Aesthet Surg J 28:211, 2008.
38. Feldman JJ. Corset platysmaplasty. Plast Reconstr Surg 85:333,1990.


for neck rejuvenation: a 13-year follow-up evaluation. Aesthetic Plast Surg 29:332, 2005.
41. Giampapa VC, Bitzos I, Ramirez O, et al. Suture suspension platysmaplasty for neck rejuvenation

42. Giampapa VC, Di Bernardo BE. Neck recontouring with suture suspension and liposuction: an
alternative for the early rhytidectomy candidate. Aesthetic Plast Surg 19:214, 1995.
43. Meade RA. Neck lift. In Janis JE, ed. Essentials of Plastic Surgery. New York: Thieme Publishers,
2006.

581
FUNCTIONAL ROLE OF NOSE1

Nasal airway: 50% of airway resistance
Nasal cycle
• Alternating constriction and dilation of nasal mucosa on each nasal side
• Normal cycle is
• Abnormalities can be present from obstruction, allergies, or vasomotor irregularities
(i.e., sensitivity to heat-cold changes).
RELEVANT ANATOMY
SKIN
and are often underestimated components in
2
Skin is in the (tip, alae).
Skin is in the with more gliding.
Understanding the contractile properties of each patient’s nasal skin is critical to the
outcome.

paradomal and tip regions) may be obscured by thick, poorly contractile skin.
• Debulking of skin and soft tissue can be an important maneuver.
Thicker skin
Thinner skin
Skin and soft tissue over the radix and tip region is typically thicker and less elastic
than over the dorsum.

582
Part VII Facial Surgery
NASAL MUSCLES


• Includes

• Flares nostrils

• Helps external valve to stay open
• Elevates nostrils
3,4
• An important muscle in dynamic tip ptosis
• Raises upper lip and pulls nasal tip down
• Can be transpositioned or transected as part
of rhinoplasty
5
• Can be chemodenervated for diagnostic or
treatment purposes
BLOOD SUPPLY
The lateral nasal artery is one of the most important vessels in nasal blood supply,
and preserving it promotes healing and helps to prevent deleterious postoperative skin changes.
Angular
artery
Facial
artery

nasal
artery
Arcades
Columellar
branches
Superior
labial artery
Dorsal
nasal
branch
Most blood supply is located within
CAUTION:


• Lateral nasal branch arises from this artery 2-3 mm above alar groove.
NOTE:
The depressor septi
nasi muscle and other musculature

position.
Depressor
septi nasi

superioris
alaeque nasi

583
Chapter 45 Rhinoplasty

of cadaver specimens
• Excessive defatting of skin that violates subdermal plexus can compromise
vascularity of tip/columellar skin.
TIP:
of scar tissue, and previously dissected nasal tip skin may be more prone to vascular
compromise during dissection.

• Branches: Superior labial artery and angular artery

• Dedicated columellar branch from superior labial artery


arteries to sidewalls and upper third of nose
INTERNAL NASAL VALVE
Narrowest segment of nasal airway
Two thirds of airway resistance



EXTERNAL NASAL VALVE
Dynamic structure: Mobile alar sidewalls and caudal septum

Internal nasal valve narrows while external valve opens during the negative pressure



1,6

• Slitlike nostril rims (vertical/narrow: iatrogenic or inherent)
• Thin alar sidewalls


not provided during inspiration.
TIP:


lateral crural strut grafts, may be necessary.

584
Part VII Facial Surgery
NASAL VAULTS
Bony, upper cartilaginous, and
lower cartilaginous

Paired nasal bones and ascending process of the
maxilla
Proximal third to half of nose
Ethnic variations in length may exist.

Known also as nasal midvault

• Underlap nasal bones 6-8 mm (keystone area)



septum



TIP:

septum and incremental dorsal reduction.7

Paired lower lateral, middle, and medial crura (cartilages)
Responsible for nasal tip shape and external valve support
NASAL TIP
Shape and position are critical in
rhinoplasty.

act like legs of a tripod8,9 (Fig. 45-5).
• Variations in length and strength

position and shape.
Nasal tip supported by several
9-11 (Fig.
45-6):

with piriform aperture
• Domal suspensory ligament
Nasal
bone
Upper lateral
cartilage

lateral
cartilage
The three nasal

bones (bony vault), upper
lateral cartilage (midvault),
and lower lateral cartilage
(lower vault).
The nasal
tip “tripod concept”
helps when trying to
understand dynamic
changes in nasal tip
shape and position

central medial crura
and bilateral lower
lateral cartilages.

585
Chapter 45 Rhinoplasty

• Medial crural ligaments
• Anterior septal angle
Fibrous
attachments
Piriform aperture
abutment
Fibrous
connections
Suspensory
ligament
of tip

and with aging.
SEPTUM
Perpendicular plate
Septal cartilage
Nasal crest
of maxilla
Vomer
All anatomic parts of the septum must be addressed in nasal airway obstruction,
including the nasomaxillary and vomerine spicules that are often seen.
Septal cartilage, perpendicular plate of ethmoid, and vomer
Perpendicular plate of ethmoid is continuous with the cribriform plate.
• Surgical or traumatic fractures of the perpendicular plate can result in CSF

• Rhinoplasty fracture technique must be meticulous, gentle, and in a lateral direction
to prevent cribriform injury.

586
Part VII Facial Surgery
INTERNAL NASAL VALVE

Normal valve angle is
Angles <10 degrees can lead to nasal airway obstruction.
Internal nasal valve provides of total airway resistance.
True and function through increasing the internal
nasal valve angle.
Internal
valve
External valve
10-15 degrees
Valve angle
Nasal valve
Head inferior
turbinate
The internal nasal valve is one of the most important aspects in septorhinoplasty and

EXTERNAL NASAL VALVE

Dynamic structure
Nasal muscles help to keep open during inspiration
Alar contour grafts and lateral crural (alar) strut grafts can strengthen and reinforce
external nasal valve.
TURBINATES
Superior, middle, and inferior turbinates
Extensions of lateral nasal cavity wall

airway resistance.
is capable of up to at internal nasal
valve region.
TIP: Often, a simple outfracture (micro or mini) of the inferior turbinate, with or
without mucosal resection, is all that is needed to improve nasal airway obstruction
caused by turbinate hypertrophy. A complete turbinectomy is rarely indicated and can
result in an “open nose” deformity with imbalance in airway resistance.

587
Chapter 45 Rhinoplasty
NASAL OBSTRUCTION
TYPES OF NASAL AIRWAY OBSTRUCTION
Seasonal or obstruction related to dust, pollen, or other antigens
Possible severe mucosal disease

deviation
NASAL OBSTRUCTION COMPLAINTS
Nasal crusting
Dry mouth (from mouth breathing, especially during sleep)
Frequent sore throats
Sinus problems
NASAL OBSTRUCTION HISTORY
Time of onset
Duration of obstruction
Precipitating events
Rhinorrhea (amount, duration)
Epistaxis
History of trauma or surgery
Use of medications, nasal sprays
Use of alcohol, tobacco, and drugs (especially cocaine)
History of headaches, visual disturbances, and middle ear symptoms
TIP: A deviated septum or other nasal obstruction can be a trigger for migraine
headaches. Ask specifically about migraine headache history. Migraines that are

correction.
PHYSICAL EXAMINATION
Visual clues
• Allergic shiners: Dark circles under eyes suggesting allergic rhinitis
• Supraalar pinching or an excessively narrow midvault (inverted-V deformity) may

• Watch midvault motion during nasal respiration.

SENIOR AUTHOR TIP: Most patients who have breathing problems may not be aware
of how else they can breathe, having been breathing through their mouth their entire
life. Observation of lips being open and careful examination of the internal nose is crucial
to prevent compounding the problems. Evaluation of the septum may reveal deviation,
synechia, or perforation.

588
Part VII Facial Surgery


• Cottle maneuver: Hold unilateral cheek laterally to stabilize the nasal sidewall on
one side while occluding the contralateral airway.

then internal nasal valve narrowing may be present.

• Evaluate for notching or potential thereof, especially at soft triangle.



• Can use thumb to push up nostril rims to observe internal nasal valve angle without

• Use speculum and visualize septum, valve, turbinates with and without a
vasoconstrictive agent.
• Evaluate for polyps, crusting, mucosal color (excessive erythema suggests allergies).
• In the septum look for spurs, deviation, perforations (postsurgical or from cocaine
use).
MEDICAL THERAPIES
Mucosal disease from common cold (viral rhinitis) most common cause
• Bacterial rhinitis may complicate viral rhinitis.
• Acute and chronic bacterial infection can be treated with a combination of:




• Check for concomitant sinus disease, because rhinosinusitis is common, with one
aggravating the other.
Allergic rhinitis
• Allergen (environmental exposure) avoidance
• Antihistamines
• Intranasal steroid regimen
• Allergy test
Rebound vasodilation and nasal mucosa hypertrophy-
hypersecretion

Neo-Synephrine and Afrin

decongestants.
– Allergic rhinitis, nasal polyposis, septal deviation, turbinate hypertrophy

steroids, and possibly an oral steroid taper
Ozena: Primary atrophic rhinitis
• Causes: Aggressive submucous septal resection, total turbinectomy
• Squamous metaplasia of normal columnar mucosal cells
• Treatment: Irrigation with saline solution, high-dose vitamin A, possible surgical
closure of the nostrils

589
Chapter 45 Rhinoplasty
INDICATIONS AND CONTRAINDICATIONS
AESTHETIC
Initiated by patient
Proper patient selection is critical.
• As with any aesthetic procedure, expectations must be realistic and achievable (see
Chapter 1).
• This becomes more of a challenge in secondary rhinoplasty patients (see Chapter
46).
• SIMON: Acronym to describe male rhinoplasty patients
ingle, immature, male, obsessive, and narcissistic

• Good communication must assimilate surgeon’s analysis and goals with those of
patients.

may be imprudent.


those unsure of their aesthetic goals).
• Generally, rhinoplasty should address the imbalances between the nose and
face.
12,15-17



gone.”



TIP: Much of the history of rhinoplasty is rooted in ethnic rhinoplasty. Ethnic patients
may present a unique challenge. Clinically relevant variations in patient desires,
nasofacial morphology, and anatomic nuances should be taken into account in
preoperative evaluation and surgical planning.2,12,15,18-20
FUNCTIONAL
This chapter does not focus on functional techniques; however, when performing a
rhinoplasty, comprehensively addressing the nasal airway is critical.
Patients without nasal airway obstruction before rhinoplasty may develop airway
problems postoperatively unless preventative measures are taken.
• For example:

dorsal reduction and osteotomies are performed.
12,21
can be prevented by placing lateral crural strut and/or
alar contour grafts and recognizing alar malposition.

590
Part VII Facial Surgery
Septoplasty1,6,13,14,22
• Important to perform simultaneously
of most grafts used in aesthetic
rhinoplasty

(Fig.
45-9).
• All bony protrusions and spicules should be excised to


turbinate.

should be thoroughly addressed.
TIP: A large elevator (Boies) or nasal speculum should freely pass, without resistance,
into the bilateral nasal airway after septoplasty.
SENIOR AUTHOR TIP:
dorsum and development of a hump that was not present intraoperatively.
One of the most common reasons for unsuccessful straightening of a caudal nose
deviation is failure to detect and reposition the dislodged caudal septum in the correct
position on the nasal spine and maxillary crest. This requires removal of the redundant
overlapping portion of the cartilage to facilitate repositioning the septum in the midline.
PREOPERATIVE EVALUATION
TIP: The key component of a successful rhinoplasty is accurate, detailed, and thorough
preoperative analysis. Rhinoplasty has evolved into a more predictable operation
because of improvements in preoperative assessment of the nasal imbalances and
aesthetic deformities. After proper preoperative analysis, a component-directed surgical
plan can be developed to help guide the surgeon during rhinoplasty.
Preoperative analysis requires an external examination of AP, lateral, and basilar views in
addition to an internal airway examination.
Ethnic variations should be taken into account, because anatomic variations in

Chapter 47).
• Racial incongruity should be prevented.


TIP: Thick skin requires more aggressive cartilage frame modifications and
conservative soft tissue debulking to reveal the true nasal shape.2,18-20,23
>15 mm

591
Chapter 45 Rhinoplasty
ANTEROPOSTERIOR VIEW


AP view of face can be divided into

45-10, ).
• Intercanthal width and alar base
widths should coincide with

A line can be drawn to bisect the nasal
dorsum, upper lip, Cupid’s bow, and
central incisors to assess magnitude of
nasal deviation (Fig. 45-10, B).
Facial asymmetries are considered.
Nasal deviation may be caudally located
presenting a “twisted” appearance.
Role of asymmetry in size and shape of
nasal and malar bones is evaluated.


(Fig. 45-11, )
• Symmetry, deviation, width, and
shape are important.
• Should be gently diverging
curvilinear lines extending from
medial eyebrow (superciliary ridge)

(Fig. 45-11, B)
• Should be of alar base
width
• Asymmetries may exist from

the nasal bones and ascending
process of the maxilla.
• Commonly, one side is wider
(projecting more laterally) than
the other.
(Fig. 45-11, C)
• Should coincide with
(generally)
• If wider than intercanthal width,

dictate operative plan
1 5
1 5
1 5
1 5
1 5
A
B
Dividing the face into

proportion in facial width. B, A vertical
line drawn down the dorsum tip, Cupid’s
bow, and chin can help to determine
nasal deviation, caudal deviation, and chin
asymmetry.
A
B
C
D
Dorsal aesthetic contour lines
are curvilinear in females and descend from

points. B, Nasal bones are generally narrower
than the alar base width by about 20%-25%.
C, Alar base width is generally equivalent to
the medial canthi; however, many variations
exist. D, Generally, aesthetically pleasing nasal
tip highlights are diamond shaped.

592
Part VII Facial Surgery
• Evaluation:



25-27
• Retraction or excess inherent “nostril show” is evaluated.
• On lateral view, alar-columellar relationship should be balanced.

• Outline of infratip breakpoint should appear like a
(Fig. 45-11, D)

columellar-lobule breakpoint

• Domal angle and angle of domal divergence are assessed.
• Imbalance in nasal tip aesthetic contour has various descriptions, such as bulbous,
boxy, amorphous, and wide.
TIP: Evaluating tip aesthetics, as with other nasal proportions, requires careful

nose provide important clues about the underlying framework. For example, asymmetry

the lateral, middle, and medial crura.
SENIOR AUTHOR TIP: The intercanthal midline should be used as a reference (not the
point bisecting the intereyebrow distance), because patients may pluck their eyebrows


• Excess columella or hanging columella leads
to excess infratip lobule.
• Breakpoints should be in harmony making a
diamond shape.

should be considered.
BASILAR VIEW
Alar rims should form an
Nostril height (columellar length) to infratip
lobule height ratio should be approximately
respectively.
Nostril inclination is approximately
NOTE:
Nostril has teardrop shape.

equilateral triangle.
1 3
2 3
Nostril height is
approximately 60%, whereas infratip
height is 40%, of the basilar view
height. Ethnic variations exist
particularly relative to nostril length
and shape.

593
Chapter 45 Rhinoplasty
LATERAL VIEW
Multiple lengths and angles contribute to an aesthetically pleasing lateral view (Fig.
45-13).


• Formed by the intersection of the line between the glabella and the soft tissue
nasion and the nasal dorsum tangent
• NFA should be approximately


45-15)
• Female dorsum should be to this line.
• Male dorsum should be .
• Angle of this line and where it begins can change the appearance of length.


Nasofrontal
angle
Supratip break
Tip-defining points
Columellar-lobular
angle
Columellar-labial
angle

Nasofrontal
angle
N
G
D

femininity versus masculinity. (D, Dorsum; glabella; nasion.)

594
Part VII Facial Surgery
Radix
TDP
Radix
TDP
The radix is often higher and the nasofrontal angle more obtuse in men versus women.
(TDP,

variations are important to recognize in patient preference.
(Fig. 45-17)16
• Ideally tip projection should be of the distance of a line drawn from the
alar-cheek crease to the most anterior tip point (see Fig. 45-17, ).
• Alternatively, tip projection is 0.67 × the nasal length.
5
• Can also be assessed on basilar view
• Must be proportionate to chin and lip projection

595
Chapter 45 Rhinoplasty
Tip projection. A, The nasal tip is generally 50% of the total nasal projection from the
alar-cheek junction. B, The nasal projection is approximately 67% of the nasal length (radix or nasal
root to the most projected tip point). Morphological variations and preferences exist.
1.0
0.67
B
A
B
A
A = 50%-
60% of AB
(Fig. 45-18)
• Draw line extending from anterior and posterior nostril rim.
• Draw plumb line that is perpendicular to natural horizontal facial plane.
• Angle between the nostril line and plumb line is the nasolabial angle (see Fig.
45-18, ).
and
NOTE:
• Columellar-labial angle: Junction of columella with upper lip; varies with degree
of columellar fullness and “hang”
• Columellar-lobular angle: Junction of columella with the infratip lobule
(30-45 degrees)
A
Natural horizontal
facial plane
95-110 degrees
B
30-45 degrees
Tip rotation. A, The angle between the nostril vertical line with the natural horizontal
facial line is the nasolabial angle. B, The columellar-labial angle varies based on tip shape and
breakpoints.

596
Part VII Facial Surgery
INFORMED CONSENT
Should include, but not be limited to, the following:
Varies depending on degree of undermining and soft tissue thickness.
Patients with thick sebaceous skin may swell for a longer time, as do most secondary

location where edema subsides and the result is evident.
Ecchymosis: Mostly limited to lower lid but can be completely periorbital
• May not be seen if osteotomies are not performed
Some darker-pigmented ethnic patients can show long-term “staining” of thin eyelid
tissues.

• Synechia in internal nasal valve region can be seen if component dorsal reduction

• Columellar incision almost always heals well but can be compromised in thin-
skinned patients, smokers, and revision patients.
Abscess is rare, usually a cellulitis that resolves with a short course of oral
antibiotics
• May be more common when multiple grafts used
• Higher rate may be observed with nonautologous material.
Septal hematoma or prolonged bleeding from mucosal surfaces is rare
because of inherent drainage routes from surgery.

• Recurrent deviations or new deviations created
• Contour irregularities
• Irregular or poor skin retraction

Worsening or new nasal airway obstruction
Change in smell, taste, and cyclical rhinitis
• Usually temporary


EQUIPMENT
TIP: Scissors and osteotomes need to be sharp for accuracy.
KEY INSTRUMENTS

• Converse angled

• Tissue scissors (small) for trimming mucosa, skin
• Septal scissors

597
Chapter 45 Rhinoplasty

• No. 9 oromaxillofacial elevator useful for dorsal subperiosteal dissection (is an ideal
width)
• Septal double-ended elevator (Cottle)
• Freer
• Boies (“butter knife”)

• Converse or other retractor for nasal skin retraction
• Self-retaining retractors that have a chain or hanging weight are useful.
• Ball-tip double-hook
• Double- and single-hook

• Adson-Brown
• Small-tip Adson-type for skin closure

• 2 mm
• Curved 4 mm and 6 mm with guards
• Straight 4 mm and 6 mm with lateral guards: For dorsal reduction

• Takahashi forceps
• Glabellar and array of nasal dorsum rasps (Fomon downbiting)
SURGICAL TECHNIQUE: OPEN APPROACH
ADVANTAGES11
Binocular vision
• Can three-dimensionally assess incremental changes to nasal frame
Evaluation of complete deformity and asymmetries without distortion
Facilitates precise diagnosis and correction of deformities
Use of both hands
Increases options for original tissue and array of cartilage grafting techniques (with

Direct control of bleeding with electrocautery
DISADVANTAGES
External nasal incision (columella)
Operative time prolonged
Increased or prolonged tip edema
Columellar incision problems (separation or delayed wound healing)
Grafts need suture stabilization
GENERAL PRINCIPLES

• Incisions join bilaterally at internal edges of columella (along medial crura) where
incision is continued to join transcolumellar incision.
Transcolumellar incision can be stairstepped or made as an inverted-V.

598
Part VII Facial Surgery
TIP: It may be safest and most predictable to work from lateral to medial in elevating
the nasal skin. An assistant can use countertraction with a Brown forceps to help expose
the caudal edge of the lower lateral crura. Inadvertent transection or laceration of
cartilage is most likely to occur near the soft triangle at the middle crura (domal region).
Cross-hatch incisions with the posterior edge of a No. 15 blade at various points to
facilitate easy approximation at the end of the case.

countertraction with a double hook under each dome, pulling caudally.
• “Hug” the perichondrium or go subperichondrially.
Continue dissection to keystone using angled scissors, and perform subperiosteal
elevation with a No. 9 elevator or Joseph elevator to radix.
Dissect between medial crura to expose caudal septum and, if necessary, the anterior
nasal spine.


ADVANTAGES
No external incision scar
Dissection limited to areas of interest


Postoperative edema lessened
Operative time shorter
Faster recovery
Intact tip-graft pocket
Allows composite grafting to the alar rim
DISADVANTAGES
Need for experience and great reliance on preoperative diagnosis
Does not allow simultaneous viewing by surgeon and student
Does not allow direct visualization of nasal anatomy

SENIOR AUTHOR TIP: Although the endonasal approach has advantages, we think that
in most cases, the ability to directly visualize the internal anatomy while dynamic and
interrelated alterations are being made in the open technique outweighs the advantages
of a closed approach. Throughout the years much of what we have learned in secondary
rhinoplasty stems from the inadequacies of the closed approach. Precise surgical
execution and experience are required for both approaches.
GENERAL PRINCIPLES
Placement of incisions is related to type(s) of deformity.
Preoperative diagnosis (as with open rhinoplasty) is essential.
Translation of internal changes on the skin envelope must be assessed throughout the
surgery.

599
Chapter 45 Rhinoplasty
Incision Types
(Fig. 45-19)


Made within the

usual cephalic trim incision line)

approach

alar rim

• Intercartilaginous incision is made
along with an infracartilaginous
incision (or marginal incision), and

anatomic pocket.
• A retrograde or eversion approach can
also be used.
• Facilitates most tip-suturing techniques


: A continuation of the intercartilaginous or transcartilaginous incision


Attachments of medial crural footplates and caudal septum preserved



treatment
Does not disrupt junction of caudal septum and medial crura or
membranous septum
SURGICAL TECHNIQUES: NASAL DORSUM
NOTE:

DORSAL HUMP REDUCTION
First step in rhinoplasty, before tip work
Dorsal osteocartilaginous frame exposed
Do NOT
Using a 7,30:





1
1
2
2
3
3
Marginal incisions allow caudal
access to the lower lateral crura and, when
joined with a transcolumellar incision,
provides the open approach to rhinoplasty.
( Intercartilaginous; transcartilaginous;
marginal.)

600
Part VII Facial Surgery
• Use downbiting rasps to shave osseous hump. Use a double-guarded osteotome
(4 or 6 mm) to reduce bony and septal humps as one unit (good for large humps)

• Fine-tune rasp any irregularities.
TIP:
as possible before leaving the operating room. Correct all irregularities and contour
problems in surgery. Evaluate the basilar view as well for any nostril discrepancies, which
patients will notice and report. A ptotic tip that is corrected may reveal underlying
nostril asymmetry that was not evident preoperatively.

21
conservatively performed.

nasal valve while creating smooth dorsal aesthetic lines.




SENIOR AUTHOR TIP:



12-14,31 (Fig. 45-20)




cartilaginous septum.

convex, larger spreader graft than the contralateral side); straighten or buttress a
deviated septum; maintain dorsal aesthetic lines
Spreader grafts
Spreader grafts allow internal nasal valve patency.

601
Chapter 45 Rhinoplasty
OSTEOTOMIES


Double-level
Webster
triangle
Various starting points and endpoints of osteotomy patterns exist.
Can be performed tip work
• Because it is related to dorsal aesthetics, osteotomies are performed along with all

Average nasal bone length:
• Asian and black patients may have very short nasal bones.

vault if performed in these patients.

• To narrow wide nasal sidewalls
• To close an open-roof deformity
• To straighten a deviated nasal pyramid

• Ethnic patients with broad, short nasal bones
• Elderly patients with thin bones
• Heavy eyeglass wearers
• Short nasal bones in general:

Thicker nasal bone above medial canthus line at radix
Thicker nasal bone region may be amenable to medial or “J-type” osteotomy


All bony “cuts” should be performed with a very sharp osteotome.

For minimally wide nasal base and/or small open roof; begins low
(adjacent to piriform aperture, extending cephalad to intercanthal level, curving
high on nasal sidewall)
Good for excessive bony nasal width correction or large
open roof; more bone recruited and medialized; allows more natural and smooth
transition from native curve upward at ascending process of maxilla toward the
nasal dorsum
• Easily combined with a medial component or “J-type” extension at canthal level for a
more controlled “transition” point

602
Part VII Facial Surgery
Good for asymmetry, especially with excessive convexity close to or
at maxillary junction; lateral osteotomy near nasomaxillary suture is performed,
followed by a low-to-low osteotomy; also useful for complex secondary nasal bone
deformities
34,35
May cause more disruption of internal mucosa and more edema/
ecchymosis
Uses a small imperceptible stab incision with a sharp 2 mm
osteotome



reinject during case, before osteotomy.)


reference.

bleeding.

cephalad.


TIP: The osteotomy path is marked on the skin preoperatively. Iced or a cold gauze is
used as a compress, with the table in a reverse Trendelenburg position. The osteotome
is angled so that one edge is in contact, increasing sharpness and control. One to

performed after the osteotomies, if the nasal bones remained stable, to smooth any
raised bony edges from the repositioned nasal bones.

• Helpful for reducing a narrow upper vault, thick or wide superior bony vault, high
nasal deviations
• Types: Medial oblique and paramedian
• Must be performed caudal to intercanthal level
• Bony cuts can be made from dorsal approach when osteocartilaginous exposure
achieved

DORSAL AUGMENTATION




• Radix alone can be augmented when indicated.

increased
Can be combined with osteotomies to create narrowing appearance of dorsum
• Requires appropriate nasal bone length

603
Chapter 45 Rhinoplasty

• Septal cartilage, conchal cartilage (suboptimal), autologous or irradiated rib

cartilage (diced cartilage fascial graft), silicone
• Caveats:


necessary.

necessary.

future extrusion.

graft.


techniques seem to be replacing this technique.

• Partial incisions (scores) made to allow bending into V-, U- (better for thin-skinned
patients), and A-frame shapes (Fig. 45-22)
• May be stacked and covered with temporal fascia or other fascia (mastoid, rectus)

in contour and without visible edges. A, V-frame. B, U-frame. C, A-frame.
A
B
C

• Unpredictable and hard to keep a straight shape
• Crushing and morselizing may help.


which dorsum has been overresected
• Stabilization with sutures and threaded 0.028 K-wires recommended to prevent
movement and warping
• K-wire placed at dorsum and removed at 1 week
• Threaded K-wire through the cartilage or perichondrial wrapping may reduce
warping rates.
• Secured to anterocaudal septum with sutures
SENIOR AUTHOR TIP: Place cartilage grafts in saline solution for 30 minutes to help
predict warping characteristics. Use the Gibson principle of balanced cartilage carving.
36
• Developed after Surgicel-wrapped technique introduced37
• Fascia-wrapped diced cartilage construct is becoming very widely used.

604
Part VII Facial Surgery

• Short-term studies show excellent results.
• Malleable and aesthetically appealing
• Easy technique allowing the use of cartilage remnants
• Can be divided into its components


the aesthetic results.

in long term, as opposed to worst case scenario for straight rib grafts which can
require reoperation for warping.
SEPTOPLASTY
See the section Surgical Techniques: Deviation and Nasal Airway Obstruction for details.
Should be performed only after all dorsal work complete, including osteotomies

Final dorsal resections may be necessary to smooth out dorsum after osteotomies.


Increasing septal and nasal length:
• Various forms of septal extension grafts can be used to lengthen the central nose.38
SURGICAL TECHNIQUES: NASAL TIP
TIP PROJECTION
Support structures are important to tip shape, position, and projection.
• Suspensory ligaments
• Fibrous connections between the upper and lower lateral cartilage
• Tip projection is decreased when the tip is dissected because of detachment of
these support structures.
STRUCTURES INFLUENCING TIP PROJECTION

• Including the shape and position of the footplates

Middle crura add minimally to overall tip projection but can be manipulated through
tip-suturing techniques.
Position of the anterior nasal spine
INCREASING TIP PROJECTION
Graduated (incremental) approach (Fig. 45-23)
Columellar strut aids in establishing and maintaining tip projection.
Transdomal sutures can elevate and project tip minimally.
Final placement of onlay grafts further shapes and increases projection.
• Be aware of graft palpability and visibility in thin-skinned patients.

605
Chapter 45 Rhinoplasty
ASSESSMENT OF TIP PROJECTION/REFINEMENT

• Analytical (0.67 × Ideal nasal length)
• Aesthetic (50%-60% anterior to upper lip vertical)
• Aesthetic nostril-to-tip ratio (2:1)
Inadequate tip

Cephalic trim
Invisible/nonpalpable techniques
Medial crural suture
Transdomal suture
Interdomal suture
Medial crural septal suture
Complete
Adequate
Inadequate
Tip grafts
Reassess tip

(intraoperatively) and
nostril-tip balance
• Visible/palpable
techniques (if
inadequate tip
projection and/or

and/or
• Nostril-shaping
techniques
(if nostril-tip
imbalance)
• Intercrural columellar strut
• Septal extension graft
Normal tip projection
No operative intervention


• Alar contour graft
Algorithm for sequencing tip shaping and position.

606
Part VII Facial Surgery
(Fig. 45-24)
• Placed between medial crura and sutured to
medial crura
• Maintains and/or increases tip projection



nasal spine region; mobile

increase in tip projection is required


immobile

necessary

rigid.”

TIP UTURING TECHNIQUES
Types of sutures. A, Medial crural sutures. B, Interdomal sutures. C, Transdomal
sutures.
A
B
C
Provide an additional 1-2 mm tip projection
Projection can be increased by shaping the domes.
TIP: Nasal tip sutures are a critical tool in tip shaping. The degree by which they are



A columellar strut graft
reinforces proper tip projection and
stability.

607
Chapter 45 Rhinoplasty
(Fig. 45-26)
• Placed to unify the medial crura
• Often, at least two required
• Columellar strut can be incorporated caudal
or cephalad to this.
• When medial crura are strong, strut may

provides the stable platform for tip position
and projection.

• Horizontal mattress suture placed at lateral
and medial genu of middle crura
• The more lateral this suture is placed on the

into the tip complex, and more tip projection
is provided.
• Also helps to equalize domal and other tip asymmetries
• The tighter the suture, the more sharp the dome shape and projection.
TIP:
and highlights cast on the nasal skin preoperatively helps to detect tip asymmetries,

in overall nasal shaping, along with improvement of asymmetries.


• Depending on degree of tightness, the interdomal space is incrementally narrowed.



• Attaches medial crura to septum
• Assists in tip positioning, decreasing columellar show, and changing columellar and
nasolabial angles

• Powerful suture in positioning nasal tip complex
• Can increase tip rigidity
Medial crural sutures
can rotate the tip complex when
placed high on the caudal septum or
a columellar strut graft.

608
Part VII Facial Surgery
TIP GRAFTS
A
B
One- to two-layer
cap graft
using cephalic
trim remnants
C
E
D
Tip grafts. A, Infralobular tip graft. B, Onlay tip graft. C, A soft cap graft can be placed
D and E, A subdomal
graft can reorient and stabilize the domes.
(see Fig. 45-27, )

• Provides appropriate infratip and supratip breakpoints when desired
• These include variations on shield grafts.
• A hexagonal or diamond shape is fashioned.
• Scoring the diamond horizontally sharpens the breakpoint.

609
Chapter 45 Rhinoplasty
TIP:
and projection. Edges should be beveled and softened. Grafts may be double layered,
combined, or sutured together or to the native cartilage and soft tissues for added


(see Fig. 45-27, B)
• Increases domal (tip) projection

• Width and length will alter tip contours.

respective dome.
• Double and triple layering may be indicated to further increase tip projection and
angularity of the domal dimensions.
(see Fig. 45-27, C)
• Cephalic trim remnant
• Thin, pliable, and not easily visible or palpable

48 (see Fig. 45-27, D and E)
• Useful for correcting domal asymmetry and a pinched nasal tip

• Suturing multiple grafts together to improve nasal shape and control breakpoints
• Useful in increasing tip projection and shaping in thicker-skinned patients with
severely underprojected tips (e.g., black noses)
SENIOR AUTHOR TIP: A tip graft and a columellar strut cannot be used interchange-

projection is the consequence of inadequate lobule volume.
DECREASING TIP PROJECTION


• Release ligamentous attachments of lower lateral crura and medial crura.
• This sets tip complex back in and on itself.
• Transect lower lateral crus and suture it back to itself in a more posterior orientation.
• Vestibular undermining is required.

• Can also correct convexities, which may be accentuated in overprojected noses

49
• Transect 2 mm posterior to junction of medial crura with middle crura (“medial
genu”).


• Separate the lower lateral crura from the cartilaginous septum.
• Undermine and transect lower lateral crura with overlapping of lateral segments.
• Simultaneously corrects malposition
• Transect medial crura and overlap

610
Part VII Facial Surgery
TIP: Consider the nasal tip as supported with a tripod, with the two lower lateral crura
and medial crura representing the feet. The position and rotation of the tip can be
adjusted by altering the length of the various crura incrementally and systematically.
BOXY NASAL TIP44



30 degrees



between the domes and domal width within each dome.

variations cause this morphology:
• Type I:
Interdomal sutures are required to close angle.
• Type II: Wide domal arc but normal angle of divergence. Domal cephalic trim with
transdomal sutures is needed.
• Type III:
sutures are required.
Caveat: Additional suturing and grafts may be required to enhance improvement,
especially in thick-skinned patients.
SURGICAL TECHNIQUES: ALAR BASE AND NOSTRILS
CORRECTION OF WIDENED ALAR BASE
B, Extension into the sill will narrow the interalar
distance and reduce the nostril aperture.
A
B

611
Chapter 45 Rhinoplasty
Assess
• Compare maximum alar width with width of ala at the base.
>2 mm, then the problem is and a precisely
measured should be excised to the vestibule (sill).
<2 mm, then the problem is excessively
(increased interalar distance).
vestibule-sill




ALAR RIM DEFORMITIES
Commonly a result of overresection of the lower lateral crura or improper support
during initial rhinoplasty
Native, unfavorable morphology, such as alar-
columellar discrepancies and lower lateral crural
malposition can cause alar rim problem.
25 (Fig. 45-30)
• Indicated in secondary rhinoplasty with minimal

remaining



malposition
indicated when:
• Excess lining loss
• Severe alar scarring

Technique: 6 by 2 mm (use wider grafts if indicated);
septal cartilage preferred; subcutaneous and tight
pocket in alar rim
• Graft should not distort aesthetics of alar rim with nasal tip shape relation.
SENIOR AUTHOR TIP: When the alar retraction is significant, an internal V-Y
advancement would provide a better means of correcting the deformity without having
to harvest a composite graft. On patients with normal or thick skin, the use of a supratip
suture, as described elsewhere, will eliminate the dead space and reduce the potential
for a supratip deformity.
Alar contour graft
placed in a new “nonanatomic”
subcutaneous position.

612
Part VII Facial Surgery
50 (Fig. 45-31)
• Carved grafts from septum or conchal
cartilage and sandwiched between vestibular

• Often extend to piriform area in a
subcutaneous alar rim pocket
• May be used with or without transecting/
relocating the native lower lateral crura








undermined.

straight 3-4 by 15-25 mm piece.

subcutaneous pocket near piriform



51
• Horizontal mattress sutures placed 6 mm apart through lateral crura at most convex
point

52 (Fig. 45-32)

caudolateral crura
• Objective: Improve strength, position, and shape of lateral crura

can correct convexity and concavities while creating a stronger bilaminate structure.

grafts can be placed with or without
transection and translocation of the
lower lateral crura.

613
Chapter 45 Rhinoplasty
SURGICAL TECHNIQUES: DEVIATION AND NASAL AIRWAY
OBSTRUCTION
NASAL DEVIATION

previous traumatic causes)

Wide exposure
Release attachments to deviated segments.

Septal deviation must be corrected, including straightening of concavities, tilts, and





(more likely in secondary cases)

periosteum or using a drill hole


side.






CAUTION:







deformities.
SENIOR AUTHOR TIP: When the anterocaudal septum is deviated, a septal rotation
suture, I have previously described, would move the septum to the midline.

614
Part VII Facial Surgery
NASAL AIRWAY OBSTRUCTION
Septal deviations must be corrected.
Septoplasty is often required.
• May unmask or worsen turbinate hypertrophy
if turbinates not treated
Wide medial crural footplates (Fig. 45-33)
• Footplates resected or suture-cinched
together (4-0 chromic), along with soft tissue
excision between medial crura
Internal nasal valve collapse or narrowing

• Alar batten grafts that support overresected
or weakened area lateral to lateral crura
External valve collapse



lateral support and maintenance of position.


Turbinate hypertrophy
• In severe septal deviation, contralateral inferior turbinate undergoes hypertrophy to
even out airway resistance
• Correction of septal deviation may lead to worsened airway obstruction from
turbinate on hypertrophied side.
• Turbinate(s) may be outfractured laterally or reduced with submucosal cautery.
53-55

2 mm osteotome
• Excessive turbinate resection should be avoided because can lead to





dysfunctions mentioned previously.
Submucous resection

mucosa


osteotome or a Cottle elevator to simply microfracture bony elements without
removal)

turbinate elements laterally and out of the airway
TIP: Do NOT completely excise or perform complete inferior turbinectomy, because
it can cause ozena, crusting, and atrophic rhinitis. Warn patients undergoing turbinate
manipulation of possible prolonged malodor, nasal dripping, and more prolonged
postseptorhinoplasty oozing.
Medial crural footplate
sutures narrow the columellar base
and can improve symmetry.

615
Chapter 45 Rhinoplasty
POSTOPERATIVE CARE
Patients should be given instructions for postoperative care. Instructions should be fairly
detailed, as shown below.
Avoid smoking.
For 2 weeks do not consume foods that require excess lip movement such as apples and
corn on the cob. You will probably have bloody nasal discharge for 3-4 days and may
change the drip pad under your nose as often as needed.
Do not rub or blot your nose, as this will tend to irritate it.

Try not to sneeze, but if you do, sneeze through your mouth.
While the nasal splint is on, you may have your hair washed beauty-salon fashion.
The nasal splint will be removed 6-7 days after surgery.
After the splint is removed, do not wear glasses or allow anything else to rest on your
nose for 4 weeks. Glasses should be taped to the forehead.
Contacts can be worn as soon as the swelling has decreased enough for them to be
inserted.
Keep the inside edges of your nostrils and any stitches clean by using a cotton-tipped
applicator saturated with half-strength hydrogen peroxide and then applying a thin
coating of Polysporin or bacitracin ointment.
You may advance the applicator into the nose as far as the cotton, but no farther.
Protect your nose from excessive exposure to the sun for 6 months.
Avoid strenuous activity (INCREASING YOUR HEART RATE ABOVE 100 BEATS PER

over.
Avoid lifting anything heavier than 10 pounds for 3 weeks after surgery.
After your sutures are removed and the internal/external splints are removed, we
recommend using saline solution (salt water) (Ocean Spray or generic saline nasal
spray) to gently remove crusty formation from inside your nose, especially if you had
internal nasal surgery such as septal reconstruction or inferior turbinate resection.
If you have increased nasal bleeding with bright red blood (with a need to change the
nasal pad every 30-40 minutes) notify your doctor immediately. You should sit up and
apply pressure to the end of your nose for 15 minutes, and you can use Afrin spray to
stop the oozing in the interim. Bleeding usually stops with these maneuvers.
It often takes approximately 1 year for the last 10% of the swelling to resolve. Your nose

to others, and things will gradually return to normal.
COMPLICATIONS
FUNCTIONAL EDICAL COMPLICATIONS
These complications are generally less common than aesthetic or contour-related
complications.


Commonly from anterior septum (Kiesselbach triangle)
More common with turbinate manipulation

616
Part VII Facial Surgery
Various methods of tamponading, vasoconstriction, and blood pressure control are
treatments.
DDAVP injections have been reported to assist in both perioperative and postoperative
recalcitrant epistaxis.56

Rare
Higher rates of methicillin-resistent (MRSA) in some regions
in the United States may warrant prophylactic and postoperative use of mupirocin
ointment on and inside the nares.
More common with nonautologous implants
Multiple grafts may lead to infection.




Airway not addressed properly
Deviations not corrected
Internal nasal valve narrowing or synechia
Excessive midvault narrowing or nasal bone collapse

Can often be assessed as early as 3 months when most edema has resolved
AESTHETIC COMPLICATIONS
Most common complications are and

Poor contractile ability
• More common in thick-skinned ethnic noses
Excessive thinning from overzealous debulking and violation of subdermal plexus



frame support

leading to an overoperated nasal appearance

Excessive narrowing
• Overzealous tip suturing (tightening, large bites) or excess/improper graft
placement
Asymmetrical domes, domal height, poor medial crural alignment
Visible grafts and graft warping
Overprojection or underprojection of nasal tip

• Poor analysis and/or nasal tip–shaping techniques
• Destructive maneuvers without support grafts and struts

617
Chapter 45 Rhinoplasty

Persistent deviations
Asymmetries
Visible osteotomy lines from too high a placement
Excessive narrowing
Collapse
Inverted-V deformities


Tip and dorsum disproportion
Excess infratip lobule bulk
Polly beak deformity
Persistent droopy tip


• Persistent depressor septi nasi muscle overactivity from lack of treatment

TOP TAKEAWAYS


of scar tissue, and previously dissected nasal tip skin may be more prone to
vascular compromise during dissection.

Often, a simple outfracture (micro or mini) of the inferior turbinate, with
or without mucosal resection, is all that is needed to improve nasal airway
obstruction caused by turbinate hypertrophy. Complete turbinectomy is rarely
indicated and can result in an “empty nose” deformity with imbalance in airway
resistance.


development of a hump that was not present intraoperatively.





Higher rates of MRSA in some regions in the United States may warrant
prophylactic and postoperative use of mupirocin ointment on and inside the
nares.
REFERENCES
-
ryngoscope 86:540, 1976.



rhinoplasty: anatomic study and clinical application. Plast Reconstr Surg 105:376, 2000.
4. Ghavami A, Janis JE, Guyuron B. Regarding the treatment of dynamic tip ptosis using botulinum
toxin A. Plast Reconstr Surg 118:263, 2006.

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Part VII Facial Surgery
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safety of the transcolumellar incision in rhinoplasty. Plast Reconstr Surg 95:795, 1995.
6. Howard BK, Rohrich RJ. Understanding the nasal airway: principles and practice. Plast Reconstr
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9. Janeke JB, Wright WK. Studies on the support of the nasal tip. Arch Otolaryngol 93:458, 1971.

support in open versus closed rhinoplasty. Plast Reconstr Surg 103:255, 1999.
11. Gunter JP. The merits of the open approach in rhinoplasty. Plast Reconstr Surg 99:863, 1997.

13. Gunter JP, Rohrich RJ. Management of the deviated nose. The importance of septal reconstruc-
tion. Clin Plast Surg 15:43, 1988.


15. Joseph J, ed. Nasenplastick und Sonstige Gesichtsplastik Nebst Einen Anhang Ueber Mam-

16. Byrd HS, Hobar PC. Rhinoplasty: a practical guide for surgical planning. Plast Reconstr Surg
91:642, 1993.
17. Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg 8:156, 2006.

111:1322, 2003.
19. Daniel RK. Hispanic rhinoplasty in the United States with emphasis on the Mexican American
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deformities in rhinoplasty. Plast Reconstr Surg 109:2495, 2002.
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27. Guyuron B. Alar rim deformities. Plast Reconstr Surg 107:856, 2001.
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29. Guyuron B, Ghavami A, Wishnek SM. Components of the short nostril. Plast Reconstr Surg
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31. Sheen JH. Spreader graft: a method of reconstructing the roof of the middle nasal vault fol-
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32. Guyuron B. Nasal osteotomy and airway changes. Plast Reconstr Surg 102:856, 1998.

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Chapter 45 Rhinoplasty
33. Gruber R, Chang TN, Kahn D, et al. Broad nasal bone reduction: an algorithm for osteotomies.
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43. Tebbetts JB. Shaping and positioning the nasal tip without structural disruption: a new sys-
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cartilage suturing techniques. Plast Reconstr Surg 107:1849; discussion 1864, 2001.

1987.
46. Daniel RK. Rhinoplasty: creating an aesthetic tip. Plast Reconstr Surg 80:775, 1987.

rhinoplasty. Plast Reconstr Surg 103:1491, 1999.
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plasty. Plast Reconstr Surg 99:943, 1997.
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Reconstr Surg 139:386e, 2017.

of surgical techniques. Plast Reconstr Surg 138:419e, 2016.
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lowing septorhinoplasty and turbinectomy. Plast Reconstr Surg 128:728e, 2011.

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INDICATIONS
POSTOPERATIVE FUNCTIONAL OR AESTHETIC DEFORMITY
Poor preoperative diagnosis
• Failure to properly identify the structural problem resulting in functional
compromise or aesthetic imbalance
1
Inappropriate surgical planning or inadequate technique resulting in distortion of
supporting osteocartilaginous framework
Problematic wound healing
• Prolonged edema, ecchymosis, unfavorable scarring, obstructive or restrictive
webbing, and occasionally hyperesthesia
PATIENT DISSATISFACTION
Undesirable functional or aesthetic outcome
and are most common complaints.2
Inadequate preoperative counseling with regard to postoperative course, recovery
time, desired and expected outcomes
Unrealistic expectations
• Even with appropriate preoperative counseling, some patients continue to have
unrealistic expectations

outcome.
3,4
Postoperative deformity and patient dissatisfaction do not always correlate.
MOST COMMON DEFORMITIES OR PROBLEMS
Displacement/deviation of anatomic structures
Underresection by overly cautious surgeons
Overresection by overly aggressive surgeons5
Contour irregularities secondary to disruption of framework or unfavorable scarring

transillumination (e.g., in dorsal silicone implants)


Bahman Guyuron