Master Techniques in Rhinoplasty

Master Techniques
in Rhinoplasty

(Trang không có chữ)

Master Techniques
in Rhinoplasty
 BABAK AZIZZADEH, MD, FACS
Director
The Center for Advanced Facial Plastic Surgery;
Associate Clinical Professor
David Geffen School of Medicine at UCLA;
Attending Surgeon
Cedars-Sinai Medical Center
Beverly Hills, California
 MARK R. MURPHY, MD
Director
Palm Beach Facial Plastic Surgery
Palm Beach Gardens, Florida
 CALVIN M. JOHNSON, Jr., MD, FACS
Clinical Associate Professor
Department of Otolaryngology–Head and Neck Surgery
Tulane University School of Medicine;
Director
Hedgewood Surgical Center
New Orleans, Louisiana
 WILLIAM NUMA, MD, FACS
Clinical Instructor
Harvard Medical School
Massachusetts Eye and Ear Infirmary;
Director
Beacon Facial Plastic Surgery
Boston, Massachusetts

1600 John F. Kennedy Boulevard
Ste 1800
Philadelphia, Pennsylvania 19103
MASTER TECHNIQUES IN RHINOPLASTY
ISBN: 978-1-4160-6262-2
© 2011 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Chapter 9: Reducing Complications in Rhinoplasty, by Daniel G. Becker, Madeline A. Becker, Jason A.
Bloom, David Gudis, and Jacob Steiger: Daniel G. Becker retains copyright to his contribution only.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, recording, or any information storage and retrieval system,
without permission in writing from the publisher. Details on how to seek permission, further informa­
tion about the Publisher’s permissions policies and our arrangements with organizations such as the
Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website:

This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical
treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and duration
of administration, and contraindications. It is the responsibility of practitioners, relying on their
own experience and knowledge of their patients, to make diagnoses, to determine dosages and the
best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of any methods, products, instruc­
tions, or ideas contained in the material herein.
Library of Congress Cataloging-in-Publication Data
Master techniques in rhinoplasty / [edited by] Babak Azizzadeh … [et al.].—1st ed.
      p. ; cm.
  Includes bibliographical references and index.
  ISBN 978-1-4160-6262-2 (hardcover : alk. paper)  1.  Rhinoplasty—Technique.  I.  Azizzadeh,
Babak.
  [DNLM:  1.  Rhinoplasty—methods.  MV 312]
  RD119.5.N67M29 2011
  617.5’230592—dc22
                 
2011008709
Working together to grow
libraries in developing countries
| |
Acquisitions Editor: Stefanie Jewell Thomas
Developmental Editor: Lisa Barnes
Editorial Assistant: Sheila Smith
Publishing Services Manager: Pat Joiner-Myers
Designer: Lou Forgione
Printed in China
Last digit is the print number:  9  8  7  6  5  4  3  2

v
Contributors
Editors
Babak Azizzadeh, MD, FACS
Director
The Center for Advanced Facial Plastic Surgery;
Associate Clinical Professor
David Geffen School of Medicine at UCLA;
Attending Surgeon
Cedars-Sinai Medical Center
Beverly Hills, California
Mandibular Implants, Middle Eastern Rhinoplasty, Nasal Airway
Obstruction
Mark R. Murphy, MD
Director
Palm Beach Facial Plastic Surgery
Palm Beach Gardens, Florida
Calvin M. Johnson, Jr., MD, FACS
Clinical Associate Professor
Department of Otolaryngology–Head and Neck Surgery
Tulane University School of Medicine;
Director
Hedgewood Surgical Center
New Orleans, Louisiana
Surgical Anatomy and Physiology of the Nose, Primary Open
Structure Rhinoplasty
William Numa, MD, FACS
Clinical Instructor
Harvard Medical School
Massachusetts Eye and Ear Infirmary;
Director
Beacon Facial Plastic Surgery
Boston, Massachusetts
Surgical Anatomy and Physiology of the Nose, Primary Open
Structure Rhinoplasty
Contributors
Peter A. Adamson, MD, FRCSC, FACS
Professor and Head
Division of Facial Plastic and Reconstructive Surgery
Department of Otolaryngology–Head and Neck Surgery
University of Toronto;
Staff Surgeon
Toronto General Hospital–University Health Network
Toronto, Ontario, Canada
The Psychology of Rhinoplasty: Lessons Learned from Fellowship,
Postrhinoplasty Nasal Lobule Deformities: Open Approach
Kamal A. Batniji, MD, FACS
Attending
Hoag Memorial Hospital Presbyterian
Department of Otolaryngology–Head and Neck Surgery
Newport Beach, California
Repair of Acute Nasal Fracture
Rami K. Batniji, MD, FACS
Attending
Hoag Memorial Hospital Presbyterian
Department of Plastic Surgery
Department of Otolaryngology–Head and Neck Surgery
Newport Beach, California
Repair of Acute Nasal Fracture
Daniel G. Becker, MD, FACS
Clinical Associate Professor
Department of Otolaryngology–Head and Neck Surgery
University of Pennsylvania
Philadelphia, Pennsylvania;
Clinical Associate Professor
Otolaryngology–Head and Neck Surgery
University of Virginia
Charlottesville, Virginia
Reducing Complications in Rhinoplasty
Madeleine A. Becker, MD
Associate Director of Consultation-Liaison Psychiatry
Thomas Jefferson University Hospital
Department of Psychiatry and Human Behavior
Philadelphia, Pennsylvania
Reducing Complications in Rhinoplasty
William J. Binder, MD, FACS
Associate Clinical Professor
Department of Head and Neck Surgery
UCLA School of Medicine;
Attending Surgeon
Department of Head and Neck Surgery
Cedars-Sinai Medical Center
Los Angeles, California
Mandibular Implants
Jason A. Bloom, MD
Facial Plastic and Reconstructive Surgeon
Otolaryngology–Head and Neck Surgery
New York University Langone Medical Center
New York, New York
Reducing Complications in Rhinoplasty

vi
Contributors
Kevin Brenner, MD, FACS
Attending Plastic Surgeon
Cedars-Sinai Medical Center
Department of Surgery, Division of Plastic Surgery
Los Angeles, California;
Attending, Plastic Surgery
Box Clinic for Aesthetic and Reconstructive Surgery
Department of Plastic Surgery
Beverly Hills, California
Rib Grafting Simplified, Saddle Nose Deformity
Michael J. Brenner, MD, FACS
Assistant Professor of Surgery
Division of Otolaryngology–Head and Neck Surgery
Southern Illinois University School of Medicine;
Facial Plastic and Reconstructive Surgeon
Otolaryngology–Head and Neck Surgery
Saint John’s Medical Center
Springfield, Illinois
Evaluation and Correction of the Crooked Nose, Thin Skin
Rhinoplasty: Aesthetic Considerations and Surgical Approach
Jay Calvert, MD, FACS
Private Practice
Beverly Hills, California;
Cedars-Sinai Medical Center
Los Angeles, California;
Hoag Hospital
Newport Beach, California
Rib Grafting Simplified, Saddle Nose Deformity
Mack L. Cheney, MD
Professor
Department of Otology and Laryngology
Harvard Medical School;
Division of Facial Plastic and Reconstructive Surgery
Massachusetts Eye and Ear Infirmary
Boston, Massachusetts
Calvarial Bone Grafting in Rhinoplasty
Robert J. Chiu, MD
Private Practice
Today’s Cosmetic Surgery & Laser Center
Pittsburgh, Pennsylvania
The Management of Alar–Columellar Disproportion
Chia Chung, MD
Division of Plastic and Reconstructive Surgery
University of California San Francisco School of Medicine
San Francisco, California
Suturing Techniques to Refine the Nasal Tip
Roxana Cobo, MD
Chief
Private Practice
Service of Otolaryngology
Centro Medico Imbanaco
Cali, Colombia
Mestizo Rhinoplasty
C. Spencer Cochran, MD
Clinical Assistant Professor
Department of Otolaryngology–Head and Neck Surgery
University of Texas Southwestern Medical Center at Dallas
Dallas, Texas
Secondary Rhinoplasty via the External Approach
Marc Cohen, MD
Assistant Clinical Professor
Division of Head and Neck Surgery
David Geffen School of Medicine at UCLA
Los Angeles, California
Nasal Septal Perforation Repair
Minas Constantinides, MD, FACS
Director of Facial Plastic and Reconstructive Surgery
Department of Otolaryngology–Head and Neck Surgery
New York University School of Medicine;
Attending Physician
Department of Otolaryngology–Head and Neck Surgery
New York University Medical Center
New York, New York
The Large Nose
Ted A. Cook, MD
Professor
Department of Otolaryngology–Head and Neck Surgery
Division of Facial Plastic and Reconstructive Surgery
Oregon Health and Science University School of Medicine;
Department of Otolaryngology–Head and Neck Surgery
Division of Facial Plastic and Reconstructive Surgery
Oregon Health and Science University Hospitals
Portland, Oregon
The Middle Vault: Upper Lateral Cartilage Modifications
Richard E. Davis, MD, FACS
Director
The Center for Facial Restoration
Miramar, Florida;
Professor of Otolaryngology (Voluntary)
The University of Miami Miller School of Medicine
Miami, Florida
The Thick-Skinned Rhinoplasty Patient
Raffi Der Sarkissian, MD, FACS
Assistant Clinical Professor
Division of Facial Plastic Surgery
Boston University School of Medicine;
Staff Physician
Division of Facial Plastic Surgery
Massachusetts Eye and Ear Infirmary;
Staff Physician
The Boston Center for Plastic Surgery
Boston, Massachusetts
Cartilage Grafting in Rhinoplasty and Nasal Reconstruction
Brian W. Downs, MD
Evergreen ENT and Facial Plastic Surgery
Morganton, North Carolina
The Middle Vault: Upper Lateral Cartilage Modifications

Contributors
vii
Frank P. Fechner, MD
Instructor
Department of Otology and Laryngology
Harvard Medical School;
Assistant
Facial Plastic and Reconstructive Surgery
Massachusetts Eye and Ear Infirmary
Boston, Massachusetts;
Active Medical Staff
Department of Otolaryngology
University of Massachusetts Medical Center;
Affiliate
Department of Otolaryngology
University of Massachusetts Medical School
Worcester, Massachusetts
The Large Nose
Kenton Fong, MD
Division of Plastic and Reconstructive Surgery
Stanford University School of Medicine
Stanford, California
Suturing Techniques to Refine the Nasal Tip
Andrew S. Frankel, MD
Associate Professor
Department of Otolaryngology
Keck School of Medicine
University of Southern California
Los Angeles, California;
Private Practice
Lasky Clinic
Beverly Hills, California
Nasal Analysis
Alvin I. Glasgold, MD, FACS
Clinical Professor
Surgery
University of Medicine and Dentistry of New Jersey
Robert Wood Johnson Medical
New Brunswick, New Jersey;
Private Practice
Glasgold Group Plastic Surgery
Highland Park, New Jersey
The Mobile Tripod Technique: A Universal Approach to Nasal Tip
Modification
Robert A. Glasgold, MD, FACS
Clinical Assistant Professor
Department of Surgery
University of Medicine and Dentistry of New Jersey
Robert Wood Johnson Medical
New Brunswick, New Jersey;
Private Practice
Glasgold Group Plastic Surgery
Highland Park, New Jersey
The Mobile Tripod Technique: A Universal Approach to Nasal Tip
Modification
Ryan M. Greene, MD, PhD
Fellow
Department of Otolaryngology–Head and Neck Surgery
Division of Facial Plastic and Reconstructive Surgery
University of Miami
Miami, Florida
A History of Modern-Day Rhinoplasty, Rhinoplasty in the Aging
Patient
Ronald P. Gruber, MD
Division of Plastic and Reconstructive Surgery
Stanford University School of Medicine
Stanford, California;
Division of Plastic and Reconstructive Surgery
University of California, San Francisco
San Francisco, California
Suturing Techniques to Refine the Nasal Tip
David Gudis, MD
Resident
Department of Otorhinolaryngology–Head and Neck Surgery
University of Pennsylvania Health System
Hospital of the University of Pennsylvania
Philadelphia, Pennsylvania
Reducing Complications in Rhinoplasty
Jack P. Gunter, MD
Clinical Professor
Department of Otolaryngology–Head and Neck Surgery
Department of Plastic Surgery
University of Texas Southwestern Medical Center at Dallas
Dallas, Texas
Secondary Rhinoplasty via the External Approach
Tessa A. Hadlock, MD
Associate Professor
Department of Otology and Laryngology
Harvard Medical School;
Director of Facial Nerve Center
Department of Otology
Massachusetts Eye and Ear Infirmary
Boston, Massachusetts
Calvarial Bone Grafting in Rhinoplasty
Peter A. Hilger, MD, FACS
Professor
Department of Otolaryngology
Division of Facial Plastic Surgery
University of Minnesota;
University-Fairview Hospital
Minneapolis, Minnesota;
Regions Hospital
St. Paul, Minnesota
Evaluation and Correction of the Crooked Nose, Thin Skin
Rhinoplasty: Aesthetic Considerations and Surgical Approach
Raj Kanodia, MD
Staff Member
Department of Otolaryngology
Hollywood Community Hospital
Los Angeles, California;
Camden Surgery Center
Beverly Hills, California
Endonasal Rhinoplasty: Transcartilaginous Approach

viii
Contributors
Sanjay P. Keni, MD
Director
Keni Facial Plastic Surgery Center
Palos Heights, Illinois, and Chicago, Illinois;
Active Medical Staff
Department of Surgery
Division of Otolaryngology
Atlanticare Regional Medical Center
Atlantic City, New Jersey
The Mobile Tripod Technique: A Universal Approach to Nasal Tip
Modification
William A. Kennedy, III, MD
Attending Surgeon
Department of Head and Neck Surgery
Albert Einstein University;
Attending Surgeon
Department of Head and Neck Surgery
North Shore/LIJ Hospital
New York, New York
Mandibular Implants
Michael M. Kim, MD
Assistant Professor
Department of Otorhinolaryngology
Mayo Clinic Arizona
Phoenix, Arizona
Short Nose
Russell W. H. Kridel, MD, FACS
Clinical Professor and Director
Department of Otolarygology–Head and Neck Surgery
Division of Facial Plastic and Reconstructive Surgery
University of Texas Health Sciences Center, Houston
Houston, Texas
The Management of Alar–Columellar Disproportion
Samuel M. Lam, MD, FACS
Director
Lam Facial Plastic Surgery Center & Hair Restoration Institute
Willow Bend Wellness Center
Plano, Texas
Asian Rhinoplasty
Babak Larian, MD, FACS
Assistant Clinical Professor of Surgery
University of California, Los Angeles
Los Angeles, California;
Director
Cedars-Sinai Head and Neck Cancer Center
Beverly Hills, California
Nasal Airway Obstruction
Arnold Lee, MD
Director
Facial Plastic and Reconstructive Surgery;
Assistant Professor
Otolaryngology–Head and Neck Surgery
Tufts Medical Center
Boston, Massachusetts
Nasal Reconstruction
Kimberly Lee, MD
Assistant Clinical Professor of Surgery
Division of Head and Neck Surgery
David Geffen School of Medicine at UCLA;
Attending Physician
Division of Head and Neck Surgery
Cedars-Sinai Medical Center
Los Angeles, California;
Director
Beverly Hills Facial Plastic Surgery Center
Beverly Hills, California
Nasal Airway Obstruction
Robin W. Lindsay, MD
Assistant Professor of Surgery
Department of Otolaryngology–Head and Neck Surgery
Uniformed Services University of the Health Sciences;
Attending Surgeon
Department of Otolaryngology–Head and Neck Surgery
National Naval Medical Center
Bethesda, Maryland
Calvarial Bone Grafting in Rhinoplasty
Jason A. Litner, MD, FRCSC
Private Practice
Profiles Beverly Hills
Beverly Hills, California
The Psychology of Rhinoplasty: Lessons Learned from Fellowship,
Postrhinoplasty Nasal Lobule Deformities: Open Approach
Grigoriy Mashkevich, MD
Assistant Professor
Otolaryngology–Head and Neck Surgery
New York Medical College
Valhalla, New York;
Assistant Professor
Otolaryngology–Head and Neck Surgery
Division of Facial Plastic Surgery and Reconstructive Surgery
New York Eye and Ear Infirmary
New York, New York
Middle Eastern Rhinoplasty
Kate Elizabeth McCarn, MD
Resident Physician
Otolaryngology–Head and Neck Surgery
Oregon Health and Science University
Portland, Oregon
The Middle Vault: Upper Lateral Cartilage Modifications
Umang Mehta, MD
Department of Otolaryngology–Head and Neck Surgery
Keck School of Medicine
University of Southern California
Los Angeles, California;
Lasky Clinic
Beverly Hills, California
Nasal Analysis

Contributors
ix
Sam P. Most, MD, FACS
Associate Professor
Chief, Division of Facial Plastic and Reconstructive Surgery
Department of Otolaryngology–Head and Neck Surgery
Stanford University School of Medicine
Stanford, California
Nasal Osteotomies
Paul S. Nassif, MD, FACS
Assistant Clinical Professor
Department of Otolaryngology
Division of Facial Plastic and Reconstructive Surgery
University of Southern California School of Medicine;
Attending Physician
Cedars-Sinai Medical Center
Department of Ear, Nose, and Throat
Los Angeles, California
African American Rhinoplasty
Gilbert Nolst Trenité, MD, PhD
Professor Doctor
Ear, Nose, and Throat Department
Academic Medical Center
Amsterdam, The Netherlands
Correction of the Pinched Nasal Tip Deformity
Aric Park, MD
Fellow
Facial Plastic and Reconstructive Surgery
University of Southern California
Los Angeles, California
Nasal Reconstruction
Amit Patel, MD
Assistant Professor
Facial Plastic and Reconstructive Surgery
Department of Surgery
University of Kentucky
AB Chandler Medical Center
Lexington, Kentucky
Primary Endonasal Rhinoplasty: Double-Dome Technique via
Intercartilaginous Dome-Delivery
Anand D. Patel, MD
Facial Plastic Surgeon
Devenir Aesthetics
Austin, Texas
The Management of Alar–Columellar Disproportion
Santdeep H. Paun, FRCS
Consultant Surgeon
Nasal and Facial Plastic Surgery
Departmental Lead Clinician
St. Bartholomew’s Hospital
London, England
Correction of the Pinched Nasal Tip Deformity
James M. Pearson, MD
Clinical Assistant Professor
Department of Otolaryngology
University of Rochester;
Department of Otolaryngology
Stone Memorial Hospital
Rochester, New York
The Underprojected Nose and Ptotic Tip
Stephen W. Perkins, MD
Clinical Associate Professor
Department of Otolaryngology–Head and Neck Surgery
Indiana University School of Medicine;
President
Meridian Plastic Surgery Center;
President
Meridian Plastic Surgeons
Indianapolis, Indiana
Primary Endonasal Rhinoplasty: Double-Dome Technique via
Intercartilaginous Dome-Delivery
Annette M. Pham, MD
Fellow
Department of Otolaryngology–Head and Neck Surgery
Division of Facial Plastic and Reconstructive Surgery
University of Miami
Miami, Florida
A History of Modern-Day Rhinoplasty
Vito C. Quatela, MD, FACS
Clinical Associate Professor
Department of Otolaryngology
University of Rochester;
Department of Otolaryngology–Head and Neck Surgery
Strong Memorial Hospital
Quatela Center for Plastic Surgery
Rochester, New York
The Underprojected Nose and Ptotic Tip
Jeffrey D. Rawnsley, MD
Clinical Associate Professor
Director, Facial Aesthetic Surgery
Division of Head and Neck Surgery
David Geffen School of Medicine at UCLA;
Attending Surgeon
UCLA Division of Head and Neck Surgery
Ronald Reagan Medical Center
Los Angeles, California
Nasal Septal Perforation Repair

x
Contributors
Anthony P. Sclafani, MD, FACS
Professor
Department of Otolaryngology
New York Medical College
Valhalla, New York;
Director of Facial Plastic Surgery
Department of Otolaryngology
The New York Eye and Ear Infirmary
New York, New York;
Attending Surgeon
Institute for Aesthetic Surgery and Medicine
Northern Westchester Hospital Center
Mount Kisco, New York
Alloplasts in Nasal Surgery
Anil R. Shah, MD, FACS
Clinical Instructor
Otolaryngology–Head and Neck Surgery
University of Chicago
Chicago, Illinois
Endonasal Rhinoplasty: Transcartilaginous Approach
Robert L. Simons, MD, FACS
Clinical Professor
Department of Otolaryngology–Head and Neck Surgery
Division of Facial Plastic and Reconstructive Surgery
University of Miami;
Medical Board Chairman
The Miami Institute for Age Management and Intervention
Miami, Florida
A History of Modern Day Rhinoplasty
Peyman Solieman, MD
Private Practice
Profiles Beverly Hills
Beverly Hills, California
Postrhinoplasty Nasal Lobule Deformities: Open Approach
Jacob Steiger, MD
Boca Regional Hospital
Steiger Facial Plastic Surgery
Boca Raton, Florida
Reducing Complications in Rhinoplasty
Ravi S. Swamy, MD, MPH
Department of Otolaryngology–Head and Neck Surgery
Stanford University School of Medicine
Stanford, California
Nasal Osteotomies
Jonathan M. Sykes, MD, FACS
Professor and Director of Facial Plastic and Reconstructive
Surgery
Department of Otolaryngology
University of California Davis Medical Center;
Faculty
Department of Otolaryngology
Mercy San Juan
Sacramento, California;
Faculty
Department of Otolaryngology
Sutter Roseville
Roseville, California
Cleft Lip Rhinoplasty
Wyatt C. To, MD
Director
Facial Plastic Surgery
The Cosmetic and Skin Surgery Center
Frederick, Maryland
Primary Open Structure Rhinoplasty
Dean M. Toriumi, MD
Professor
Division of Facial Plastic and Reconstructive Surgery
Department of Otolaryngology–Head and Neck Surgery
University of Illinois, Chicago
Chicago, Illinois
Rhinoplasty in the Aging Patient
Tom D. Wang, MD
Professor
Department of Otolaryngology–Head and Neck Surgery
Division of Facial Plastic and Reconstructive Surgery
Oregon Health and Science University
Portland, Oregon
The Middle Vault: Upper Lateral Cartilage Modifications,
Short Nose

xi
To my loving and dedicated wife Jessica. Life would be meaningless without you.
Babak Azizzadeh
This book is dedicated to my wife, Sherry, who has enabled me to fulfill my dreams. To our beautiful children Ned,
Nicholas, and Grayson, you are the lights that guide us. To my mother and father, Maureen and Robert, for
preparing me for a life of happiness. And to my sister and brother, Diane and David, for sharing in our joy.
Mark R. Murphy
This book is dedicated to my wife Monica. An extraordinary woman and Mother without whom my life would feel
unfulfilled. To our children, Lucas and Thomas, for being the beacons in our lives. To my parents for encouraging
me to pursue my dreams.
William Numa

xii
Acknowledgments
We would like to thank the numerous friends, family, and
colleagues who have contributed to the completion of this
text. Foremost, we need to acknowledge those who have
introduced us to this fine art, our mentors, Calvin Johnson,
Norman Pastorek, Tessa Hadlock, Vito Quatela, Keith
Blackwell, Mack Cheney, Mark Varvares, Daniel Deschler,
and Anthony Labruna. You have been both patient and
demanding. By constantly insisting on the pursuit of per­
fection and providing reassurance during its humbling
path, we owe our sincere gratitude.
To our colleagues Babak Larian, Guy Massry, Paul
Nassif, Robert Glasgold, and Samuel Lam. Your constant,
honest communication has helped us continue to move the
field forward where our mentors left off.
We also need to thank those whose tireless efforts have
made possible the completion and production of this text,
Lisa Barnes, Rebecca Gaertner, Stefanie Jewell-Thomas,
Alex Baker, the wonderful staff at Elsevier, and the
AAFPRS and its audiovisual department staff.
And to those who have inspired us to pursue this
wonderful career, Robert Murphy, Dr. Siamak Danesh­
mand, and Dr. Amiro Tamara.
Finally, we must also acknowledge our patients who
have trusted us in the most personal way. It is for them
and future patients that this text attempts to serve.
Babak Azizzadeh
Mark R. Murphy
Calvin M. Johnson, Jr.
William Numa

xiii
Preface
When deciding to embark on this project, we set out to
delineate a comprehensive book demonstrating conven­
tional as well as alternative and competing techniques and
concepts in rhinoplasty.
This text compiles a number of different rhinoplasty
techniques from those who do it best. We have selected
contributing authors from different backgrounds based on
their accomplishments and expertise in rhinoplasty. Only
time-tested techniques are being presented in the text to
ensure that both young and experienced surgeons can
master the essentials and subtleties of aesthetic and func­
tional rhinoplasty.
Some techniques described in this book will be more
technically challenging to execute than others, and some
may require more patience, skill, or practice. Some tech­
niques will be more predictable and leave less of the final
surgical outcome to the seemingly capricious nature of the
contracture associated with the cicatricial healing process,
and yet some others may even fall into disfavor with time
because of dissatisfaction with their long-term outcome
after a seemingly excellent short-term result. However, all
the techniques described in this book and in all subse­
quent publications by any authors that follow us and
those who precede us, constitute an integral part of the
constant learning process associated with becoming stu­
dents with voracious appetites for the art and science of
rhinoplasty. We hope reading this book will elicit a healthy
exchange of information enriching our collective experi­
ence, rather than generate a reflexive reaction toward any
given technique we happen to be less familiar with. Our
apprentices will become our teachers and vice versa
several times over.
Once the reader assimilates the foundations of the
applied basic sciences, the different surgical techniques,
personal preferences, and, most important, the rationale
for those preferences, the surgical process is described
in detail through text, illustrations, intraoperative photo­
graphs, and a highly detailed comprehensive surgical atlas
on DVD. By providing these components, we hope to
inspire the next generation of master rhinoplasty
surgeons.
Babak Azizzadeh
Mark R. Murphy
Calvin M. Johnson, Jr.
William Numa

Video Contents
DISC 1 (9996078558)
Aligning the Stars: A History of
Modern Rhinoplasty*
Robert L. Simons, MD, FACS • Charles B. Cox, MA
Augmentation Rhinoplasty with Small
Dorsal Reduction*
Calvin M. Johnson, MD
Correction of Increased Tip Projection, A
Bulbous Tip, and Dorsal Hump via Open
Rhinoplasty (Advanced Rhinoplasty Course)*
Jack P. Gunter, MD
External Rhinoplasty: Dependent Tip and
Dorsal Hump*
Dean M. Toriumi, MD
Mobile Tripod Technique: Vertical
Angle Division
Robert A. Glasgold, MD, FACS
Nasal Septal Perforation Repair
Jeffrey D. Rawnsley, MD
DISC 2 (9996084469)
Structure Approach in Rhinoplasty: Bulbous
Nasal Tip*
Dean M. Toriumi, MD
Open Septorhinoplasty in the Overprojected
Crooked Nose*
Peter A. Adamson, MD, FRCSC, FACS
Cosmetic Endonasal Double-Dome Tip
Rhinoplasty with Hump Removal and
Chin Augmentation using Single Mersilene
Mesh Implant*
Ronald Gruber, MD
DISC 3 (9996084523)
Delivery Flap Approach for Double-Dome
Tip Rhinoplasties, Patient A (Advanced
Rhinoplasty Course)*
Stephen W. Perkins, MD
Delivery Flap Approach for Double-Dome
Tip Rhinoplasties, Patient B (Advanced
Rhinoplasty Course)*
Stephen W. Perkins, MD
Endonasal “Double-Dome” Correction of
a Broad Flat Trapezoid Tip*
Stephen W. Perkins, MD
Endonasal Tip Rhinoplasty for the
Correction of Trapezoid Tip Collapsing Alae
(Advanced Rhinoplasty Course)*
Stephen W. Perkins, MD
Spreader Flaps in External Rhinoplasty*
Ronald Gruber, MD
DISC 4 (9996084582)
The “Pinocchio” Nose*
Stephen W. Perkins, MD
Droopy Tip Rhinoplasty*
Russell W.H. Kridel, MD, FACS
Rhinoplasty Techniques for the
Twisted Nose*
Ira D. Papel, MD
Reconstruction of Caudal Nasal Support
Structure via Open Rhinoplasty*
Ted A. Cook, MD
*Used with the permission of the American Academy of Facial Plastic and Reconstructive Surgery.

1
C H A P T E R O N E 
A History of Modern-Day Rhinoplasty
Robert L. Simons • Annette M. Pham • Ryan M. Greene
INTRODUCTION
From the Edwin Smith Surgical Papyrus to the Sushruta
legacy to early nasal surgery techniques, the roots of
modern-day rhinoplasty stem from the early beginnings
of nasal reconstruction. Early on, it was recognized that
the nose was a complex structure, a prominent and central
feature of the face that was susceptible to disfigurement
by trauma, infection, tumors, and even punishment. For
this reason, mutilation, deformity, or an unattractive nose
was linked to a social stigma, which then supported
the necessity for the development of nasal reconstructive
techniques. Understanding the complexities of the nose
through reconstruction allowed pioneers in nasal surgery
to embark upon the exploration of corrective surgery, or
cosmetic rhinoplasty, for aesthetic purposes. It is this
journey through time that will be traced to understand
the history of contemporary rhinoplasty.
EARLY BEGINNINGS
The oldest known surgical treatise is known as the Edwin
Smith Surgical Papyrus. While the exact dating is contro­
versial, it is believed to have dated back to around 1600
BC.1,2 In 1862, the treatise was discovered and purchased
in Egypt by an American egyptologist, Edward Smith. It
was later translated from its ancient hieroglyphic script
in 1930.1
The treatise describes the diagnosis and surgical man­
agement for 48 cases. Among these cases, three involved
the management of different types of nasal fractures. The
treatment was simple—nasal manipulation with place­
ment of external splints, such as those made from thin
wood padded with linen, and nasal packing made of lint,
swabs, or plugs of linen.1,3 Thus, it is apparent that even
in early civilizations, the importance of the basic princi­
ples of fracture stabilization after manipulation as well as
internal lining support with packing was well recognized
and documented.
THE SUSHRUTA LEGACY AND
THE INDIAN METHOD
The art and science of total nasal reconstruction are
thought to have originated in India with the work of a
prominent figure, Sushruta, whose name literally meant
“the one who is well heard” or “the one who has thor­
oughly learned by hearing.”4 Although his precise age is
controversial, Sushruta probably lived around 1000 to
800 BC, a period known as “The Golden Age” in ancient
India.4 His greatest contribution to surgery was his
description of nasal reconstructive surgeries, using differ­
ent methods for a variety of nasal defects. One method,
in particular, used skin from the forehead as a pedicled
flap, which later was referred to as the “Indian method.”
THE ITALIAN METHOD
The knowledge of nasal reconstructive surgery then spread
from India to Arabia to Persia and finally to Europe. This
undoubtedly occurred as the world became smaller and
different civilizations had greater communication and
contact through wartimes and invasion by leaders such as
Alexander the Great. However, this period of shared infor­
mation came to a halt when religious leaders forbade
medical discoveries and exploration, as a manual occupa­
tion such as surgery was considered beneath respectable
men and even borderline heretic.
With the revival of scholasticism in Europe during the
fifteenth and sixteenth centuries, an interest in reconstruc­
tive plastic surgery was renewed. Nasal reconstruction was
again revisited, and this time, for reconstruction of a nasal
defect, the Branca family of Sicily described the use of an
arm flap.2 Although first described by them, this “Italian
method” of reconstruction was credited to Gasparo
Tagliacozzi (1546–1599), a professor of anatomy at
Bologna. He wrote scientifically and philosophically on
the subject in his treatise entitled De Curtorum Chirurgia
per Institionem, Libri Duo.1

2
Robert L. Simons • Annette M. Pham • Ryan M. Greene
anesthesia. However, the inception of aseptic technique
mainstreamed by Lister in the 1840s and the introduction
of anesthetics, including the use of topical cocaine, brought
about a new era in plastic surgery—corrective, or cos­
metic, surgery. The background was now set for surgeons
to explore methods for correction of more than an obvious
deformity secondary to trauma, infection, or tumors;
rather, to embark upon the task of corrective surgery for
aesthetic purposes.
In 1845, the background was thus set for the renowned
Berlin professor Johann Friedrick Dieffenbach (1792–
1847) to introduce the idea of revision surgery on the
reconstructed nose to improve the cosmetic outcome.3 It
was he who wrote, “The nose is man’s most paradoxical
organ. It has its root above, its back in front, its wings
below, and one likes best of all to poke it into places where
it does not belong.”5
In addition, Dieffenbach is credited with making
surgery more tolerable with the use of anesthesia. He
wrote a comprehensive textbook entitled Operative Chiru­
rgie and described the use of external incisions as well as
excisions to correct nasal deformities (Figure 1-1). It is
interesting to note that in that time period, surgeons were
preoccupied with external approaches, even for placement
of dorsal augmentation grafts (via longitudinal and gla­
bellar incisions) for correction of saddle-nose deformities,
as described by Israel and von Mangold.5
As a result, it was almost unheard of to perform a
proper rhinoplasty with a completely intranasal approach
until 1887, when John Orlando Roe (1849–1915) (Figure
1-2), an otolaryngologist from Rochester, New York, pro­
duced his landmark paper, “The Deformity Termed Pug
Nose and Its Correction by a Simple Operation.”5 In this
paper, Roe described the first endonasal rhinoplasty to
THE DEVELOPMENT OF CORRECTIVE
RHINOPLASTY
Ultimately, one must be reminded that tracing the journey
through time from Egypt to India to Europe is relevant in
understanding that the roots of corrective rhinoplasty
stem from reconstructive surgery. With the development
of reconstructive techniques, surgeons began to better
understand the complexity of nasal structure, form, and
function. The basic principles of reconstruction became
established with emphasis on the importance of a proper
nasal framework, endonasal lining, and external skin cov­
ering. As a result, surgeons became free to explore how
best to correct nasal deformities.
In 1818, the highly esteemed German surgeon Carl
von Graefe (1787–1840) became the first to coin the term
“rhinoplasty” when he published his major work entitled
Rhinoplastik. von Graefe detailed in his book three suc­
cessful rhinoplasties—the first using the Indian method
with a forehead flap technique; the second, the Tagliaco­
tian method; and the third, a modified free arm graft that
he called the German method.1 The textbook itself was
208 pages long and listed 55 previous books and articles,
the most recent being that of a British surgeon named
Joseph Carpue (1764–1846).3 In an 1816 article, Carpue
had described two successful nasal restorations using the
Indian method originally described by Sushruta.1
Thus far, with all of the nasal reconstructive tech­
niques, surgeries were described with great attention to
detail and illustrations. An underlying theme throughout
the description was a stated need to strike a balance
between the need for the surgery in order to correct a
deformity with the willingness of the patient to withstand
the “barbaric” procedures without a reliable form of
Figure 1-1  Dieffenbach’s method of external excisions to alter the size of the nose. (From Davis JS. Plastic surgery: its principles and practice. Philadel­
phia: P. Blakiston’s Son & Co., 1919.)

CHAPTER ONE  A History of Modern-Day Rhinoplasty
3
From this point, Joseph became immersed in the
study of plastic surgery. During World War I, Joseph was
chief of the Section of Facial Plastic Surgery in the ENT
Department of the Charité Hospital in Berlin, where he
was given the title of professor in 1918.1 He analyzed and
classified different nasal deformities—developing differ­
ent surgical techniques to address them. In addition, he
correct the tip in a patient with a “pug nose.” Following
this, in 1891, he published another paper discussing
an aesthetic rhinoplasty in which the entire nose was
addressed, including refinement of the tip and reduction
of a prominent dorsal hump.
The following year, in 1892, Robert Weir (1838–
1927) (Figure 1-3) published his data on using grafts to
restore “sunken noses,” or the saddle-nose deformity.1 He
also described a case of a corrective rhinoplasty performed
in separate stages. He used Roe’s endonasal technique for
reducing the dorsal hump and narrowing the nose. Then,
in another, separate procedure, he reduced the width of
the nasal tip as well as the nasal alae by wedge resections,
which to this day are still referred to as “Weir
incisions.”1
THE FATHER OF MODERN RHINOPLASTY
Chronologically, although the two American surgeons,
Roe and Weir, were the first to describe their work in cor­
rective rhinoplasty, the man who is credited with the title
of “father of modern rhinoplasty” is Jacques Joseph
(1865–1934) (Figure 1-4). In 1898, Joseph, then an
orthopaedic-trained surgeon, presented to the Berlin
Medical Society the case of a young man who had an
extremely large nose and who had suffered from social
ridicule. Joseph successfully reduced the nose using exter­
nal incisions. More important, Joseph presented his idea
that the effects of successful aesthetic surgery were not
only manifest on the patient’s physical appearance but
also on the patient’s emotional psyche.
Figure 1-2  John Roe, M.D. (1848–1915). (Photograph courtesy of
Simons RL: Coming of age: a twenty-fifth anniversary history of the American
Academy of Facial Plastic and Reconstructive Surgery. New York: Thieme
Medical Publishers, 1989.)
Figure 1-3  Robert F. Weir, M.D. (1838–1927). (Photograph courtesy
of Simons RL: Coming of age: a twenty-fifth anniversary history of the Ameri­
can Academy of Facial Plastic and Reconstructive Surgery. New York:
Thieme Medical Publishers, 1989.)
Figure 1-4  Jacques Joseph, M.D. (1865–1934). (Photograph courtesy
of Simons RL: Coming of age: a twenty-fifth anniversary history of the Ameri­
can Academy of Facial Plastic and Reconstructive Surgery. New York:
Thieme Medical Publishers, 1989.)

4
Robert L. Simons • Annette M. Pham • Ryan M. Greene
in New York City as well as for their written contributions
to the art of rhinoplasty, were not known for their
teaching.
In contrast to Safian and Aufricht, who were both
plastic surgeons, Samuel Fomon (1889–1971) (Figure
1-6) had no surgical experience and no private practice,
and he did not treat patients. Instead, he was an academi­
cian, a teacher of anatomy at the University of Illinois,
one who prepared young physicians for their state board
examinations.7,8
In the late 1930s, Fomon identified facial plastic
surgery and rhinoplasty in particular as subjects lacking
in depth of understanding or teaching, and he set about
to fill the gaps.8 He researched the literature, traveled
extensively in Europe, and, speaking German, spent
meaningful time with Joseph in Berlin. In 1939, he pub­
lished his treatise entitled Surgery of Injury and Plastic
Repair.9 The extensive material on the nose mirrored to
some extent Joseph’s earlier text, but the information was
now more widely available to Americans, and generally
well-received by the medical community.
Fomon’s interest was not to produce a library refer­
ence but rather to provide a practical guide for physicians
who wanted to perform rhinoplasty. With wartime and
travel injuries on the rise and the advent of antibiotics
leading to a decrease in prior surgical procedures, for
many surgeons the time was right to explore new
territories.
In 1940, Fomon offered a course on rhinoplasty and
otoplasty to interested otolaryngologists in Boston. As
interests in what he was teaching grew, Fomon expanded
his courses to include cadaveric laboratory dissections, as
developed surgical instruments to carry out his opera­
tions. Eventually, his artistic skill (as evidenced by his
own drawings) and documentation of his operations were
produced in a comprehensive textbook entitled Nasen­
plastik und Sonstige Geischtsplastik in 1928, which was
followed by a second edition in 1931.1
After World War I, Joseph, often referred to as “Joseph
Noseph,” continued at Charité Hospital for a few years
before opening his own clinic, where he developed an
enormous practice in facial plastic surgery.6,7 With his
reputation at its zenith, Joseph began offering a few
apprentice positions (Gustave Aufricht from Hungary
was one) and, to a greater number of international sur­
geons, a fee-set opportunity to watch the master operate
(Figure 1-5).
STUDYING THE ART OF RHINOPLASTY
Among the foreigners who came to study under Joseph,
three men, in particular, stand out in contributing to how
the art of rhinoplasty is studied and taught today. Joseph
Safian (1886–1983) and Gustave Aufricht (1894–1980)
both deserve credit for introducing Joseph’s methods to
the United States in the 1930s.5 In 1935, Safian’s textbook
entitled Corrective Rhinoplastic Surgery shed light on the
different techniques that Joseph had described as the text­
book was written in basic English terms, allowing the
medical community to easily adopt Joseph’s methods.
Aufricht similarly introduced Joseph’s methods to the
English-speaking world by describing Joseph’s techniques
in multiple papers. In 1940, his significant contribution
was introducing the use of a dental compound splint (of
which the basic design and principle remain in use today)
as opposed to Joseph’s method of postoperative splinting
using only adhesive and gauze dressings, which had
resulted in an occasional hematoma complication.5 Safian
and Aufricht, although both known for their rhinoplasties
Figure 1-5  Photograph of Jacques Joseph in the operating room (From
Joseph J. Nasenplastik und sonstige Gesichtsplastik nebst einem Anhang
ueber Mammaplastik. Leipzig, Germany: Verlag von Curt Kabitzsch, 1928.)
Figure 1-6  Samuel Fomon, M.D. (1889–1971). (Photograph cour­
tesy Lenore Fomon.)

CHAPTER ONE  A History of Modern-Day Rhinoplasty
5
otolaryngologists throughout the country were encouraged
to attend his courses.
THE FOMON TEACHING MODEL
CONTINUES
For a legacy to grow, the teacher needs students to spread
the gospel. Seated in the front row, four seats from Fomon
in that first 1942 course in New York City was Irving
B. Goldman (Figure 1-9). Goldman (1898–1975), who
would become the first president of the American Academy
of Facial Plastic and Reconstructive Surgery (AAFPRS),
visited Europe prior to studying and teaching with Fomon
and then began his own course and society at New York
Mt. Sinai Hospital in the early 1950s.7,8
Similarly motivated was another early Fomon student
and instructor, Maurice H. Cottle (1898–1981) (Figure
1-10). His home base was Chicago, and by 1944 he was
offering his own course at the Illinois Masonic Hospital
(Figure 1-11). This annual course was then given at Johns
Hopkins University in 1954 when the American Rhino­
logic Society was organized. Its dedicated message about
fundamental functional requirements in nasal surgery had
been forcefully reinforced through the years by many
Cottle disciples, including Pat Barelli, Robert Hanson,
Raymond Hilsinger, and Kenneth Hinderer, and none
more passionate than Eugene Kern, who served as profes­
sor of rhinology and facial plastic surgery at the Mayo
Clinic in Rochester, Minnesota.
Cottle and Goldman both used the Fomon teaching
model: morning operations, afternoon lectures, and
evening cadaver dissections. Manuals accompanied didac­
tic sessions. Without television, videotapes, or CDs avail­
able, students strained to see what was happening at the
well as live surgery to provide physicians with a practical
guide and hands-on learning experience with rhinoplasty
techniques. Patients were brought to Fomon by the stu­
dents, and as one student stated, “Dr. Fomon taught us
a lot of theory, and in turn we taught him surgical
technique.”8
Seeking a larger forum, Fomon moved his headquar­
ters to the Manhattan General Hospital in New York City
in 1942. At its inception, the Fomon course was of 6
weeks’ duration—early morning lectures, followed by two
live surgeries, afternoon lectures, and then evening cadaver
dissections. Students, 50 to 75 in a class, crowded the
amphitheater, observing procedures as best they could
through binoculars.
In the early 1940s in New York City, a few surgeons,
including Aufricht, Safian (Figure 1-7), as well as Jacques
Malianac and Eastman Sheehan, had studied with Joseph
in Germany and were known for their proficiency in rhi­
noplasty but not necessarily their teaching. Fomon’s
course at Manhattan General was the one place where
students were welcome despite an environment in which
neither the newly formed plastic surgery organization nor
the older otolaryngology establishment endorsed the
courses.
It took two prominent otolaryngologists to give cre­
dence and official recognition to Fomon’s efforts. One was
Dr. George Coates of Philadelphia, professor at the Uni­
versity of Pennsylvania and the long-term editor of the
Archives of Otolaryngology. The other was Dean Lierle,
chairman at the University of Iowa. For many years the
secretary of the American Board of Otolaryngology (ABO),
Dean Lierle, was known as “Mr. Otolaryngology.”7,8 His
residency was a model for broad, in-depth head and neck
training. A prominent member of his faculty, Bill Huffman,
who was double board-certified in otolaryngology and
plastic surgery, was sent to study with Fomon for 6 months
(Figure 1-8). When Fomon was invited to teach at Iowa,
Figure 1-7  Irving B. Goldman, M.D. (left) and Joseph Safian, M.D.
(right), two prominent rhinoplasty surgeons in New York City. (Photograph
courtesy of Robert L. Simons, M.D.)
Figure 1-8  William C. Huffman, M.D. (left), and Dean M. Lierle, M.D.
(right). (Photograph courtesy of Richard Farrior, M.D.)

6
Robert L. Simons • Annette M. Pham • Ryan M. Greene
THE GROWTH OF STUDENTS
One of Fomon’s most successful students was one of his
earliest, Howard Diamond from New York City (Figure
1-14). Diamond’s reaction to the first rhinoplasty proce­
dure he saw perhaps differs little from that of most people.
In his own words: “It scared the hell out me,” although
he found that the instant resultant change fascinating.8 As
Diamond recalled, “Fomon was a very sharp, organized
guy, but what a production: ‘7000 instruments and 14
nurses.’ ”8
For Diamond, rhinoplasty worked best when it was
simple and uncomplicated. He really believed that “if you
make it look easy it will always look good.”8 Diamond’s
popularity in the New York City area was unparalleled.
Every morning, he had four to five cases, with the intra­
cartilaginous approach becoming his trademark for
quickly defining the nasal tip.
Another early student of Fomon’s was Ira Tresley
from Chicago (Figure 1-15), a man who shared Dia­
mond’s love for the operation and the desirability of dis­
tilling its essence to a few instruments and as little
manipulation of the tissues as possible. Viewed by many
at the time as the most technically skillful of rhinoplasty
surgeons, Tresley, like Diamond, had a sufficiently large
number of people seeking his service that he could pick
and choose his cases. Diamond and Tresley both eschewed
formal teaching, but their surgical ways influenced many
of the teachers to come.
In the late 1940s and then into the 1950s, either
directly or indirectly, Fomon’s teaching ignited spheres of
rhinoplasty activity. Morey Parkes, who trained at New
York’s Harlem Eye and Ear Hospital, once said, “It wasn’t
until I heard a lecture and took a course from Dr. Fomon
that I became really inspired.”8 Not long after, he took his
operating room table or in other instances invited the
masters or their designated appointed instructors to visit
(Figures 1-12 and 1-13).
Goldman and Cottle had similar teaching protocols
but vastly different didactic philosophies and textural
content. Cottle emphasized rhinology and the mainte­
nance of nasal function; Goldman stressed aesthetics
rather than just physiology. Fomon, Cottle, and Goldman
were all mesmerizing teachers who demanded allegiance
from their growing number of societal members.
Figure 1-9  Testimonial dinner given for Samuel Fomon at the course on April 24, 1942. In the front row, Irving B. Goldman and Samual Fomon are
seated fourth and seventh from the left, respectively. (Photograph courtesy of Simons RL: Coming of age: a twenty-fifth anniversary history of the American
Academy of Facial Plastic and Reconstructive Surgery. New York: Thieme Medical Publishers, 1989.)
Figure 1-10  Maurice H. Cottle, M.D. (1898–1981). (Photograph
courtesy of Simons RL: Coming of age: a twenty-fifth anniversary history of
the American Academy of Facial Plastic and Reconstructive Surgery. New
York: Thieme Medical Publishers, 1989.)

Figure 1-11  Participants of the Cottle rhinoplasty course in 1951 at Illinois Masonic Hospital in Chicago, Illinois. (Photograph courtesy of Simons RL:
Coming of age: a twenty-fifth anniversary history of the American Academy of Facial Plastic and Reconstructive Surgery. New York: Thieme Medical
Publishers, 1989.)
Figure 1-12  Maurice H. Cottle in the operating theatre at a 1950 course
in Portland, Oregon. (Photograph courtesy of Robert L. Simons, M.D.)
Portland, OR
1950
Figure 1-13  Irving B. Goldman (3rd from right) at an invited course in
Cuba in 1951. (Photograph courtesy of Sidney Feuerstein, M.D.)

8
Robert L. Simons • Annette M. Pham • Ryan M. Greene
Dickinson (Figure 1-16) and Richard Farrior (Figure
1-17), who would make their marks in Pittsburgh, Penn­
sylvania, and Tampa, Florida, respectively.
Back in New York, Goldman’s course was taking hold
and also making its mark. Early assistants, or lieutenants
as they were called, returned year after year to listen to
Goldman and to teach his methodology. Among them were
practice to the West Coast and joined Jesse Fuchs,
Ed Lipsett, and then Wally Berman, who had finished a
3-year fellowship with the renowned double–board-
certified chairman of plastic surgery, John Marquis
Converse in New York. Together, Fuchs, Lipsett, Berman,
and Parkes pioneered Los Angeles’ fertile territory in
facial plastic surgery.
Similarly inspired were successive senior residents at
the University of Iowa in 1949 and 1950—namely John
Figure 1-14  Howard Diamond, M.D. (Photograph courtesy of Robert
L. Simons, M.D.)
Figure 1-15  Ira Tresley, M.D. (Photograph courtesy of Simons RL:
Coming of age: a twenty-fifth anniversary history of the American Academy
of Facial Plastic and Reconstructive Surgery. New York: Thieme Medical
Publishers, 1989.)
Figure 1-16  John T. Dickinson, M.D. (1918–1978). (Photograph
courtesy of Simons RL: Coming of age: a twenty-fifth anniversary history of
the American Academy of Facial Plastic and Reconstructive Surgery. New
York: Thieme Medical Publishers, 1989.)
Figure 1-17  Richard Farrior, M.D. (Photograph courtesy of Simons RL:
Coming of age: a twenty-fifth anniversary history of the American Academy
of Facial Plastic and Reconstructive Surgery. New York: Thieme Medical
Publishers, 1989.)

CHAPTER ONE  A History of Modern-Day Rhinoplasty
9
Figure 1-18  Fomon course held in New Orleans, Louisiana, in 1957. Dr. Jack Anderson is seen standing at the extreme right in the back row. (Pho­
tograph courtesy of Jack Anderson, M.D.)
Irvin Fine, Samuel Bloom, Sidney Feuerstein, Trent Smith,
Jan Beckhuis, and Lionello Ponti from Rome, who were
all superb teachers in their own right.
But one of best student-teacher stories to be told
involves a tall young man captured in two group shots
taken at courses given in New Orleans. The first, a Fomon
course in 1957 (Figure 1-18), followed a year later by a
Goldman course in 1958 (Figure 1-19). His name was
Jack Anderson. Early in his career, Anderson attended a
meeting in Houston, Texas, called the Southern Graduate
Assembly.8 Samuel Fomon, a guest speaker, had an exhibit
that included wax moulages of all the stages of rhino­
plasty. “It was just gorgeous,” Anderson recalled.8 It was
created for Fomon by Walt Disney Studios and was
reported to cost $30,000, which in today’s economy would
be 10 times as much. Enthralled with what he heard and
saw, Anderson went to take Fomon’s course in New York
City in 19528 (Figure 1-20).
He returned to New Orleans with an undying enthu­
siasm for rhinoplasty, which he characterized as the
“queen of operations.”8,10 He soon became an active
member of Fomon’s Society—now organized as the
American Otolaryngologic Society for the Advancement of
Plastic and Reconstructive Surgery. It was this organiza­
tion, together with Goldman’s American Facial Plastic
Society, that amalgamated into the AAFPRS in 1964.6,7
THE QUEEN OF OPERATIONS FUELS
FURTHER TEACHING AND
ORGANIZATIONAL EFFORTS
In the formative years, the fuel that powered the edu­
cational and organizational efforts of AAFPRS leaders
was that “queen of operations”—rhinoplasty. The early
officers of this organization were known for their work in
rhinoplasty (Figure 1-21).
Anderson, along with Richard Farrior and John Dick­
inson, started a Plastic Surgery Study Club.10 The group
included Oscar Becker and Ira Tresley of Chicago; Louis
Feit, Joseph Gilbert, Abe Silver, Bennie Rish, and Irving
Goldman from New York; Jesse Fuchs and Morey Parkes
from Los Angeles, William Wright from Houston; and the
latest member in 1963, a plastic surgeon from Boston,

Figure 1-19  The 1958 Goldman postgraduate course in rhinoplasty held in New Orleans under the auspices of Tulane University. Goldman stands
eighth from the left in the front row, and Jack Anderson is fourth from the right in the second row. (Photograph courtesy of Simons RL: Coming of age: a
twenty-fifth anniversary history of the American Academy of Facial Plastic and Reconstructive Surgery. New York: Thieme Medical Publishers, 1989.)
Figure 1-20  Fomon course held in New York City in 1952. Fomon is seated in white in the front row, and Jack Anderson is standing at the far right in
the back row. (Photograph courtesy of Jack Anderson, M.D.)

CHAPTER ONE  A History of Modern-Day Rhinoplasty
11
Figure 1-21  Rhinoplasty teachers gather for a course in Key Biscayne in 1980. Standing from left to right are Sidney Feuerstein, M. Eugene Tardy,
Lionello Ponti, Jan Beekhuis, Frank Kamer, Jack Anderson, Leslie Bernstein, Gaylon McCullough, Bob Simons, Trent Smith, Richard Webster, Claus Walter,
Charles Gross, William Wright, Irvin Fine, and Tony Bull. (Photograph courtesy of Robert L. Simons, M.D.)
Richard Webster (Figure 1-22). They were men with dif­
ferent backgrounds from across the country. Men who
would meet periodically to watch one another operate and
then question and criticize what they saw but always with
the desire to better understand the operation, and in so
doing they became better teachers—a capsule of the
ethos that would successfully drive the newly organized
AAFPRS.
Anderson’s enthusiasm for rhinoplasty was conta­
gious. As an active teacher at Tulane University, he drew
the undivided attention of such young residents as Jack
Gunter, Ferd Becker, Calvin Johnson, and later, Wayne
Larrabee and Mack Cheney. Always placing value on
training and youthful input, Anderson spearheaded the
academy’s fellowship program, which began in 1974.7 His
first fellow was David Ellis, closely followed by another
outstanding student teacher, Gaylon McCullough (Figure
1-23). Ellis was from Toronto, Canada—a place that joins
New York, Chicago, Iowa, Los Angeles, and New Orleans
as important landmarks in the American rhinoplasty
journey.
Figure 1-22  Richard C. Webster, M.D., on the left, convincing Bob
Simons (center) and Richard Farrior (right) of his tip philosophy. (Photograph
courtesy of Robert L. Simons, M.D.)

12
Robert L. Simons • Annette M. Pham • Ryan M. Greene
was limited. The ongoing annual-based courses provided
the introduction and graduate education for many stu­
dents. Thus, a bonus for the residents at New York’s Mt.
Sinai Hospital was Goldman’s annual June Course. A
group picture taken at the 1965 course is evidence of
Robert Simons’ early involvement, as well as that of an
equally young and enthusiastic Tony Bull from London
(Figure 1-25).
Irving Goldman was the primary teacher and surgeon
at the course from 1953 to 1969. After that, it was led by
Sidney Feuerstein, Samuel Bloom, and Robert Simons,
with William Lawson taking charge during the later part
of its more than 40-year existence. A partial list of the
second- and third-generation teachers receiving their
baptism at Mt. Sinai included Frank Kamer, William
Friedman, Harold Deutsch, Sid Sattenspiel, Mark
Krugman, William Lawson, William Binder, Charley
Gross, William Silver, Alvin Glasgold, Steve Pearlman,
and Geoff Tobias.
Ongoing courses developed their own traditions if not
mystique. At Mt. Sinai, the endonasal approach, marginal
incisions for delivery of the alar cartilages, and vertical
division of the dome and reposition, rather than excision
of cartilages to control tip projections, were part of
the normal operation. These tenets were gospel to the
Mt. Sinai crowd while blasphemy to others.
CHICAGO COURSES
In Chicago, interest in rhinoplasty was equal to that in
New York City. A different experience, more eclectic and
THE IOWA EXPERIENCE
In the early 1960s, a highly talented and focused teacher
named Leslie Bernstein (Figure 1-24) joined the faculty
at the University of Iowa. Trained in South Africa and
London, Bernstein brought a background in dentistry and
oral maxillofacial surgery and began his own courses in
1963. He was invited to write the chapter on nasal trauma
in Fomon’s 1970 rhinoplasty text. The forward in that
book was penned by another esteemed facial plastic
surgeon, John Conley, who writes of Fomon, “His original
school in the 1940s opened the doors for the study of these
techniques, removing it from occult position into
the professional arena of the interested specialist and
supraspecialist.”8
Bernstein’s rhinoplasty course, emphasizing the
importance of anatomy, cadaver dissections, and artistic
skills, has an unparalleled 45-plus—year run. Ultimately,
the Iowa experience propelled the careers of men like
Chuck Krause, Roger Crumley, Marc Connelly, Karl
Eisbach, and Shan Baker. Bernstein’s persistent teaching
presence, first at Iowa and then in Sacramento and San
Francisco, provided a platform for teaching and learning
to many, including Richard Goode, Trent Smith, Robert
Simons, Corey Maas, William Silver, and others.
THE GOLDMAN COURSE
It is important to remember that prior to fellowships
in the mid-1970s, residency training in rhinoplasty was
variable. Exposure to the operation prior to videotapes
Figure 1-23  Gaylon McCullough, M.D. (Photograph courtesy of Robert
L. Simons, M.D.)
Figure 1-24  Leslie Bernstein, M.D. (Photograph courtesy of AAFPRS
archival files.)

CHAPTER ONE  A History of Modern-Day Rhinoplasty
13
Figure 1-25  Goldman rhinoplasty course in 1965 at Mount Sinai Hospital in New York City. Circled are Bob Simons (left) and Tony Bull (right). (Pho­
tograph courtesy of Robert L. Simons, M.D.)
not as controlled as that of Goldman’s course, occurred
annually at Cook County General Hospital.
One of the primary beneficiaries was a young Univer­
sity of Illinois resident, M. Eugene Tardy (Figure 1-26).
Tardy had first seen rhinoplasty as an intern at Tampa
General Hospital where he met Richard Farrior. As a resi­
dent helping to organize cadaver dissections at the Cook
County courses, his knowledge grew as he listened and
learned from people like Richard Webster, William Wright,
Jack Anderson, John Conley, Carl Patterson, Lou Tenta,
Jack Kerth, and John Dickinson. Dickinson also brought
to the course an ex-Tulane resident named Jack Gunter.
Although it was several years prior to the official academy
fellowships, Gunter spent a year (1968–1969) with
Dickinson in Pittsburgh in a facial plastic surgery fellow­
ship granted and funded by the National Institutes of
Health and arranged with the help of Dean Lierle. This
subsequently led to Gunter’s teaching involvement with
the academy, especially in its early soft tissue courses.
Among Tardy’s mentoring influences, however, the
most significant was Ira Tresley. Tardy was intrigued after
watching Tresley’s normal three cases on a Saturday
morning by “how he made the operation look so easy, but
Figure 1-26  M. Eugene Tardy, M.D. (Photograph courtesy of M.
Eugene Tardy, M.D.)

14
Robert L. Simons • Annette M. Pham • Ryan M. Greene
Figure 1-27  Ivo Padovan demonstrating his external approach to rhi­
noplasty. (Photograph courtesy of Richard Farrior, M.D.)
it wasn’t so easy” (personal communication). With superb
technique and communications skills, Tardy continued to
raise the level of rhinoplasty teaching. His use of photo­
graphic diagrams and cadaver dissections, along with his
high-quality operative demonstrations, made him a highly
sought-after teacher both at home and abroad.
In fact, one can look at Chicago’s rhinoplasty history
and easily make a case that Tardy anchors a very strong
“T” line. Starting from the early days, there were Tresley,
Tenta, Tardy, Thomas, Toriumi—with Tardy separating
the prefellowship and postfellowship years.
Another of today’s outstanding teachers from Illinois
and now in New York is Norman Pastorek, who was 2
years Tardy’s junior at Illinois and who gives tremendous
credit to Tresley and Tenta for his early training. And then
there were the two residents in the Chicago program at
Cook County Hospital in the early 1960s prior to the
training of Tardy and Pastorek. One was an otolaryngol­
ogy resident named Jack Kerth, who was associated in
practice with Dr. Tresley when the renowned surgeon died
in 1971. More important in our historic journey was
Kerth’s later enthusiastic mentoring at Northwestern Uni­
versity, which helped to inspire a talented band of men
who would go on to make their mark in the rhinoplasty
world. Within a 5-year period in the 1980s, the group of
graduates from Northwestern included W. Russell Ries,
Vito Quatela, Jonathan Sykes, Tom Wang, and Dean
Toriumi.
The other example of the early “Chicago Influence”
was a resident in plastic surgery at Cook County in 1962,
Jack Sheen. Sheen’s first exposure to rhinoplasty during
his residency was, in his own words, “the damndest pro­
cedure you ever saw.”8 His job was to stand by and
monitor the blood loss, and when the figure hit 1500 mL,
the case was stopped (personal communication). Lacking
sound aesthetic training while in his residency program,
Sheen observed Tresley operate on a Saturday morning.
Like others who had observed Tresley, this experience was
once described as, “an epiphany—on the table the cases
looked great. It was like watching a magician.”8
Sheen began his practice where demand and competi­
tion were high—Beverly Hills, California. His observa­
tions about rhinoplasty slowly made a mark in the plastic
surgery world.11 He moved from a reductive to a more
balanced augmented approach. He perceived rhinoplasty
as changing structure rather than reducing it. His sugges­
tions about augmenting the radix and middle vault, creat­
ing internal stress in the tip with cartilage grafts, and
preoperatively recognizing short nasal bones or malposi­
tioned alar cartilages challenged the current-day rhino­
plasty concepts. His book, first published in 1978 and
then reedited in 1987, was an eye opener.11
A CHANGE IN RHINPLASTY CONCEPTS—
THE EXTERNAL APPROACH
In 1970, at the first AAFPRS International Symposium
held in New York City, a tremendous impact on traditional
rhinoplasty concepts occurred. A relatively unknown
surgeon from Yugoslavia named Ivo Padovan (Figure
1-27) was given 10 minutes to present his experience and
that of his teacher, Dr. Ante Sercer, regarding the external
approach to rhinoplasty. The paper was generally dis­
missed by all 1000 present at the Waldorf Astoria Hotel

CHAPTER ONE  A History of Modern-Day Rhinoplasty
15
in New York City, except for two men from Toronto,
Canada: Wilfred Goodman and David Bryant. By the next
International Symposium in 1975 in Chicago, Goodman
(Figure 1-28) was able to present 250 cases using the
external transcolumellar approach, extorting the advan­
tages of visualization and versatile management. Further
reinforcing the message that the external approach was
advantageous, he applied it to all patients.
The new approach intrigued Jack Anderson. His
interest peaked even more following a postmeeting plane
ride discussion with his good friend, David Bryant. Further
assurances were received from a former fellow of Wilfred
Goodman’s in Toronto, Kris Conrad, who replied to
Anderson, “No” when asked, “Is anybody suing you for
opening these noses in Canada?”8
Once satisfied as to its safety and acceptance, Ander­
son began using the external approach and encouraged
his scientifically motivated colleague, William Wright
from Houston, Texas, to do the same. Fellows helped with
the transition of their mentors. Calvin Johnson was associ­
ated with Anderson in 1980 when Peter Adamson came
for a fellowship from Toronto with first-hand experience
in the external approach (Figure 1-29). Wright received
encouragement from his first fellow, Russell Kridel, who
would later join his practice.
There are very few people in the history of facial
plastic surgery to match Jack Anderson, when it came to
motivating people or initiating action. With his initial
report of success in 100 successive cases in the early 1980s
followed by publication of his monograph, “Rhinoplasty:
Emphasizing the External Approach” in 1986, the word
spread and the rhinoplasty revolution regarding approach
had begun. Surgeons and students thought that they could
Figure 1-28  Wilfred Goodman, M.D. (Photograph courtesy of Cana­
dian archival files.)
Figure 1-29  Jack Anderson, M.D. (left), with his fellow Peter Adamson,
M.D. (right), in 1980. (Photograph courtesy of Peter Adamson, M.D.)
see and treat more accurately. The pendulum of prefer­
ence for endonasal versus external swung widely to the
latter.
To better understand this cataclysmic change, it is
interesting to examine the personal evolutions of two of
today’s outstanding rhinoplasty teachers: Calvin Johnson
(Figure 1-30) and Jack Gunter (Figure 1-31). They were
both initial students of Anderson with his early transcar­
tilaginous endonasal approach and tripod theory. Both
men expressed early frustration with knowing exactly
what Anderson was doing with his knives or feeling secure
in what they could see or achieve on a regular basis with
this endonasal approach.
For Johnson, the operation remained intolerably
unpredictable until the nuances and the finer points of
the external approach were clarified by Anderson and
Adamson. Armed with a better understanding of the
external approach and with an appreciation of what grafts
could achieve in a structural look as portrayed in Sheen’s
Figure 1-30  Calvin Johnson, M.D. (Photograph courtesy of Calvin
Johnson, M.D.)

16
Robert L. Simons • Annette M. Pham • Ryan M. Greene
Nicholas Tabbal—familiar names and figures because of
their participation at various academy courses and meet­
ings. An ecumenical presence to which the names of four
other fine plastic surgeons—Gary Burget from Chicago,
Frederick Menick from Arizona, Gilbert Aiach from
France, and Ivo Pitanguy from Brazil—should be added.
Gunter also introduced diagrammatic templates (Figure
1-32) for recording surgical procedures and became an
ardent supporter of the use of grafts for the maintenance
of nasal contour.
A LEGACY OF RHINOPLASTY
TEACHING CONTINUES
Thus, Johnson and Gunter were two examples of personal
educational evolutions. Each of their fellowship trainings
extended beyond its first teachings, as they developed and
taught new thought processes, concepts, and practices.
This pattern continued as the legacy of rhinoplasty teach­
ing was evidenced in the careers of three of the early
AAFPRS fellowship graduates in the 1970s.
There was Fred Stucker (Figure 1-33), who left his
naval command to study with Tardy and Beekhuis and
who then went on to teach scores of residents and fellows
at the Philadelphia Naval Hospital and then Louisiana
State University. His latest achievement is a recently com­
piled rhinoplasty experience with more than 8000 cases.
Another was Gaylon McCollough, who spent his fel­
lowship years with Jack Anderson, Richard Webster, and
Wally Berman, developing ideas about domal sutures.
More important, McCollough contributed to initiating the
training of such current teachers as Devinder Mangat,
Steve Perkins, Keith La Ferriere, Wally Dyer, Donn
Chatham, William Beeson, Randy Waldman, and
Daniel Russo.
Furthermore, there was Ted Cook, longtime director
of Facial Plastic Surgery in Portland, Oregon. He trained
with Richard Farrior and Richard Webster before
infusing rhinoplasty goals and standards into a cadre of
talented surgeons and teachers such as Richard Davis,
Vito Quatela, Stephan Park, Craig Murakami, Tom Wang,
Oren Friedman, and David Kriet.
Overall, Stucker, McCullough, and Cook played major
roles in contributing to the legacy of rhinoplasty teach­
ings. In addition to this group of esteemed players, Tardy’s
first fellow, Regan Thomas, should be added as he also
played a role in the teaching legacy. Ultimately, they were
all instrumental in strengthening spheres of rhinoplasty
activity not just at home but also abroad.
FORMING AN INTERNATIONAL ALLIANCE
As formal teaching and courses in America developed,
European surgeons and teachers also made their
Figure 1-31  Jack Gunter, M.D. (Photograph courtesy of Robert L.
Simons, M.D.)
text,11 Johnson sought to develop the concepts of the open
structured rhinoplasty.
The promotions and clarification of his thinking cul­
minated in the publication of his textbook Open Structure
Rhinoplasty in 1990. Two of his fellows, both residents
from Northwestern University, contributed to the develop­
ment of the textbook. First, in the early stages there was
help offered by Vito Quatela. Then in 1988 during his
6-month fellowship with Johnson, Dean Toriumi truly
took control of the book’s organization and timely
publication.
For Jack Gunter, there was a similar lack of confi­
dence and excitement about rhinoplasty until he went to
a Triological Society meeting in Ft. Worth, Texas, in 1980
to listen to his old teacher, Anderson, talk of his 100
consecutive cases using the external approach. Gunter,
who had taken a residency at Michigan in plastic surgery
and who would soon be double board-certified, started to
use the external approach in all of his secondary rhino­
plasties. He wrote a paper on the open approach of revi­
sion rhinoplasty in the late 1980s12 and certainly was
instrumental in introducing the new approach to the
plastic surgery world, a world that had been familiar with
the rhinoplasty teachings of John Marquis Converse,
Ralph Millard, George Peck, Tom Rees, and Jack Sheen.
What was missing was a sustained forum for the unique
needs of nasal surgery education.
Much to his credit, Gunter pioneered the annual rhi­
noplasty course for plastic surgeons in Dallas, Texas, in
1983. Over the past quarter-century, it provided a launch­
ing pad for the thoughts of surgeons such as Mark Con­
stantian, Ron Gruber, John Tebbetts, Steven Byrd, Rollin
Daniel, Rod Rohrich, Bahman Guyuron, Tony Wolf, and

CHAPTER ONE  A History of Modern-Day Rhinoplasty
17
the way, Europe’s academy, the Joseph Society, was born.
In Italy, first Valerio Michelli Pelligrini, then Georgio Sul­
centi, and currently Pietra Palma arranged instructional
sessions. In Mexico, Efrain Davalos, a former student of
Cottle, asked leaders of the AAFPRS to come to Moralia
for an annual course in facial plastic surgery. In Bogota,
Colombia, Fernando Pedroza, who had trained with
Anderson and Webster, invited similar teachers to come
motivate and educate.
The rhinoplasty universe was expanding with stars in
Europe, South America, Mexico, Australia, the Middle
East, South Africa, and Asia. A new vibrant galaxy called
the International Federation of Facial Plastic Surgery
Societies (IFFPSS) with members from the United States,
Canada, Mexico, Colombia, Brazil, Australia, and Europe,
now led by Drs. Gilbert Nolst-Trenite from the Nether­
lands and Roxana Cobo from Colombia, had arrived.
THE GROWTH OF MODERN-DAY
RHINOPLASTY CONTINUES
The story of growth in modern-day rhinoplasty might be
most purely appreciated in a genealogic sense when recall­
ing fatherly figures like Jerome Hilger, who taught about
internal osteotomies in the 1960s, or Richard Farrior, who
mentored so many (including his son) and then followed
the tracks of their offspring. With Peter Hilger, the past
president of the AAFPRS, and Edward Farrior, a
co-director of the most recent Advanced Rhinoplasty
Course, a proud legacy is evident.
However, to understand and put this story of growth
in proper prospective, it is relevant to return to Chicago
contributions, sharing their experiences to develop and
bring new concepts to their own practices. They included
Tony Bull from London, Lionello Ponti from Rome, Rudi
Myer from Switzerland, and Claus Walter with his com­
posite and spreader grafts from Germany. In addition,
another German, an otologist named Horst Wullstein,
along with John Conley and Richard Farrior were instru­
mental in promoting the first facial plastic surgery courses
in Europe.
As in this country, with history repeating itself, courses
produced group interest. And with Bull and Walter leading
Figure 1-32  Rhinoplasty worksheet designed by Jack Gunter, M.D. (Photograph courtesy of Jack Gunter, M.D.)
Figure 1-33  Fred Stucker, M.D. (Photograph courtesy of Fred Stucker,
M.D.)

18
Robert L. Simons • Annette M. Pham • Ryan M. Greene
Certainly it was predicted by Samuel Fomon over six
decades ago, when speaking at the first annual meeting of
the American Otolaryngologic Society for the Advance­
ment of Plastic and Reconstructive Surgery in New York
City in 1943. He concluded his remarks on the role of
plastic surgery in the field of otolaryngology by stating, “I
envisage the appearance of a galaxy of outstanding names
in this society which will sparkle through the pages of
history along with those of the masters of the past.”8
To which I add, let the names and contributors of the
past become recognized makers, markers, and milestones
as we continue our steady ascent into the future.
REFERENCES
1. Eisenberg I. A history of rhinoplasty. S Afr J. 1982;62:
286–292.
2. Snell GED. A history of rhinoplasty. Can J Otolaryngol.
1973;2:224–230.
3. Whitaker IS, Karoo RO, Spyrou G, Fenton OM. The birth of
plastic surgery: the story of nasal reconstruction from the
Edwin Smith Papyrus to the twenty-first century. Plast
Reconstr Surg. 2007;120:327–336.
4. Sorta-Bilajac I, Muzur A. The nose between ethics and
aesthetics: Sushruta’s legacy. Otolaryngol Head Neck Surg.
2007;137:707–710.
5. Rogers BO. Early historical development of corrective
rhinoplasty. In: Millard DR Jr, ed. Symposium on corrective
rhinoplasty. St Louis: CV Mosby; 1976:18–31.
6. Simons RL, Hill TS. Facial plastic surgery: subspecialty helps
otolaryngology define its boundaries. Otolaryngol Head Neck
Surg. 1996;115:1–14.
7. Simons RL. Coming of age: a twenty-fifth anniversary history
of the American Academy of Facial Plastic and Reconstructive
Surgery. New York: Thieme Medical Publishers; 1989.
8. Simons RL. Aligning the stars: the history of modern
rhinoplasty. Video presentation at the American Academy of
Facial Plastic and Reconstructive Surgery meeting.
Washington, DC, September 2007.
where the student-teacher-student planetary rotation is
most clearly visible. In 1979, Regan Thomas was Eugene
Tardy’s first official fellow. Then in 2002, he returned to
Chicago as chairman of the Department of Otolaryngology–
Head and Neck Surgery at the University of Illinois,
essentially becoming Tardy’s boss. On faculty at the time
of his return is a young rhinoplasty star, Dean Toriumi
(Figure 1-34). Toriumi had benefited from the tutelage
and relationship with Tardy, spending the last 3 months
of his Northwestern University residency with Tardy and
then, following his fellowship with Calvin Johnson and
Wayne Larrabee, devoting a decade of rhinoplasty teach­
ing and study in Tardy’s world at the University of Illinois.
With Thomas, the former pupil of Tardy, understanding
well the needs of a student and a star, he afforded new
departmental support for Toriumi.
With all cases now documented on videotape, the
replay ability to see what was done, what worked, and
what did not provided monumental strides in teaching
and decision-making (Figure 1-35). The clarity of Toriu­
mi’s message and his use of large grafts to stabilize the
nasal framework are compelling. The younger member of
the Chicago trio today shines brightly.
CONCLUDING THOUGHTS
In tracing this journey through time, the history and
development of rhinoplasty from early nasal reconstruc­
tive techniques to modern-day corrective rhinoplasty
provide a story of growth and evolution. It is a story neces­
sitating a coordinated alignment of all the aforementioned
pioneering rhinoplasty surgeons, or cast of characters—in
essence, an “alignment of the stars.” However, the “cosmic
changes” should come as no surprise to the veteran star
gazers. Expected are continuing bursts of radiant light,
somewhere or somehow in our forever changing world of
rhinoplasty.
Figure 1-34  M. Eugene Tardy, M.D., flanked by J. Regan Thomas,
M.D., and Dean M. Toriumi, M.D. (Photograph courtesy of M. Eugene
Tardy, M.D.)
Figure 1-35  Dean Toriumi being videotaped in the operating room.
(Photograph courtesy of Chuck Cox, photographer of AAFPRS.)

CHAPTER ONE  A History of Modern-Day Rhinoplasty
19
9. Fomon S, Bell J. Rhinoplasty: new concepts, evaluation and
application. Springfield, IL: C C Thomas; 1970.
10. Anderson JR. The dynamics of rhinoplasty. In: Proceedings of
the Ninth International Congress in Otorhinolaryngology.
Excerpta Medica, International Congress Series 206.
Amsterdam: Excerpta Medica; 1969.
11. Sheen JH, Sheen AP. Aesthetic rhinoplasty. St. Louis: Mosby;
1978.
12. Gunter JP, Rohrich RJ. External approach for secondary
rhinoplasty. Plast Reconstr Surg. 1987;80:161–174.

21
C H A P T E R T W O 
Surgical Anatomy and Physiology
of the Nose
William Numa • Calvin M. Johnson, Jr.
Rhinoplasty surgery requires a robust understanding of
the surgical anatomy and physiology of the nose and nasal
airway. Only by building on this solid foundation can a
rhinoplasty surgeon adjust and tailor surgical techniques
to fit unique individual patient needs. By balancing the
patient’s concerns with the surgeon’s diagnosis after a
complete examination, the surgeon can determine which
set of techniques are most suitable to accomplish the
surgical goals set out for each individual patient.
There is valuable information to be gained from
inspection and palpation of the patient’s nasal structures,
including the skin, cartilage, bone, and dynamic interplay
of these structures in animation during the preoperative
assessment. There are features of each individual nose
that the surgeon will want to preserve; it may be the dorsal
height for one patient or the ala–columellar relation for
another. The preoperative analytical and diagnostic
aspects of rhinoplasty surgery are at least as important as
the execution of any given technique outlined in the
remainder of this book.
The scope of this chapter is to serve as a practical
clinical reference to applied surgical anatomy and physiol­
ogy as related to rhinoplasty. For the purposes of clarify­
ing preferred directional anatomical references, these have
been depicted in Figure 2-1.
The skin and soft tissue envelope drapes the nasal
skeleton, composed of the nasal bones, corresponding to
the upper third of the nasal pyramid, and the lower two
thirds, represented by the paired upper lateral cartilages
(ULCs), paired lower lateral cartilages (LLCs), and
septum in the midline. It is through the modification of
these supporting structures that the rhinoplasty surgeon
will be able to build the foundation onto which the skin
and soft tissue envelope (S-STE) will rest, giving a pleas­
ant appearance. Careful consideration should be given to
the structural integrity of this foundation, as it will need
to overcome both the natural aging process and the con­
tractile forces associated with the cicatricial healing
process following surgery. No compromises on nasal func­
tion need to be made in the name of accomplishing an
aesthetically pleasing result.
THE SKIN AND SOFT TISSUE ENVELOPE
The thickness, elasticity, and general characteristics of the
S-STE can be confirmed by palpation of the nose. However,
clues to its thickness are present on inspection. The pres­
ence of acne or adnexal structures such as fine hair in the
supratip region, as seen in some patients, will provide
Figure 2-1  Preferred directional anatomic references per­
taining to rhinoplasty.
Dorsal
Caudal
Project
Deproject
Counter-rotate
Rotate

22
William Numa • Calvin M. Johnson
Figure 2-2  Topographic key landmarks on (A) frontal and (B) oblique views of the nose. 1, Glabella; 2, nasion; 3, rhinion; 4, tip-defining points; 5, infratip
lobule; 6, columella; 7, nasolabial angle; 8, soft tissue triangles (facets); 9, alar lobules; 10, alar–facial groove; 11, nasal sill; 12, supraalar crease.
A
B
7
6
5
4
4
8
9
8
11
10
9
12
3
2
1
4
4
3
2
1
12
10
9
7
6
5
8
Figure 2-3  Topographic key landmarks. A, Lateral view of the nose. 1, Glabella; 2, nasion; 3, rhinion; 4, supratip break; 5, tip-defining point; 6, infratip
lobule; 7, columella; 8, nasolabial angle; 9, soft tissue triangle (facet); 10, alar–facial groove. B, Base view of the nose. 1, infratip lobule; 2, columella; 3, medial
crural footplate; 4, soft tissue triangle (facet); 5, recurvature lower lateral cartilage; 6, nasal sill; 7, alar-facial groove.
A
B
8
7
6
5
4
9
10
3
2
1
7
6
3
4
1
2
4
5
5
6
3
7
insight into the skin thickness and the vascular supply
that accompanies it. Topographic analysis of the nose is
useful to discuss and accurately describe different ana­
tomic landmarks1,2 (Figures 2-2 through 2-6).
When divided into upper, middle, and lower thirds,
the middle third of the nose, or that part covering the
rhinion (osteocartilaginous juncture of the nose), will be
the thinnest. In adults, the upper third of the S-STE will
be the thickest, followed by the lower third. Adolescents
and patients of ethnicity other than Caucasian will tend
to have thicker S-STE on the supratip region of the lower
third of the nose. However, the area of skin overlying
the nasal domes will typically remain very thin. This
underscores the importance of concentrating on avoiding
irregularities to the middle third and around the area of
the domes of the nose, so as to prevent its long-term col­
lapse or irregularities, after soft tissue swelling subsides
and the aging process ensues. The skin thickness of the
soft tissue envelope of the nose will play a significant role
in the degree of postoperative edema seen. Thin-skinned
patients are found to have less edema that resolves faster
than the greater, persistent edema found in patients with
thicker skin.
The importance of these anatomic issues is evident
when making surgical decisions. A straight-line removal
of a nasal hump can result in an overreduced profile.

CHAPTER TWO  Surgical Anatomy and Physiology of the Nose
23
Figure 2-4  Cadaveric dissection demonstrating principal components of the nasal anatomy. 1, Nasal bones; 2, nasomaxillary suture line; 3, ascending
process of the maxilla; 4, osteocartilaginous junction (rhinion); 5, anterior septal angle; 6, upper lateral cartilage (ULC); 7, lateral crus of the lower lateral
cartilage (LLC); 8, sesamoid cartilage; 9, alar lobule (fibrofatty tissue).
1
2
3
6
8
7
4
9
5
7
6
3
2
4
1
Nasal
bones
Nasomaxillary
suture line
Ascending
process
of maxilla
Osseocartilaginous
junction (rhinion)
Upper lateral
cartilage
Anterior
septal angle
Caudal free edge of
upper lateral cartilage
Sesamoid
cartilage
Pyriform
aperture
Alar
lobule
Lateral crus of
alar cartilage-lateral
portion
Lateral crus of
alar cartilage-central
portion
Tip
defining point
A
Intermediate
crus
Infratip
lobule
Columella
Medial crural
footplate
Figure 2-5  A, Nasal anatomy, lateral view.
Continued

24
William Numa • Calvin M. Johnson
Nasofrontal
suture line
Nasal
bone
Intranasal suture line
Osseocartilaginous
junction (rhinion)
Nasomaxillary suture line
Ascending process
of maxilla
Levator labii
superioris muscle
Cephalic portion
of upper lateral cartilage
Pyriform margin
Sesamoid cartilage
Cartilaginous dorsum
Upper lateral cartilage
Intercartilaginous ligament
Quadrangular cartilage
Anterior septal angle
Tip defining point
of alar cartilage
Lateral crus of
alar cartilage
Concavity of lateral crus
Lateral aspect of lateral crus
Alar lobule
B
Infratip lobule
Columella
Perpendicular
plate of
ethmoid
Vomer
Palatine
crest
Caudal
support
Dorsal
support
Quadrangular
cartilage
Cartilage
available
for graft
harvest
Maxillary
crest
Premaxilla
C
B, Nasal anatomy, oblique view. C, Nasal anatomy, midline.
Figure 2-5, cont’d.

CHAPTER TWO  Surgical Anatomy and Physiology of the Nose
25
in direct relation with the perpendicular plate of the
ethmoid. In the crooked nose deformity secondary to
trauma, these structures are commonly deviated together.
Particular attention to the varying degrees of thickness
and length of the bone should be kept in mind when plan­
ning and executing medial and lateral (and occasionally
intermediate) osteotomies. Lateral osteotomies can pre­
dispose to nasal airway collapse secondary to compromise
of the internal and/or external nasal valves, if care is not
taken to perform these osteotomies at the level of the
attachment of the inferior turbinate. The majority of the
trajectory of the osteotomy takes place within the thicker
maxillary process, with the exception of the cephalic end
of the osteotomy, where the lateral osteotomies converge
at the nasal bones (Figure 2-9).
The nasal bones overlap the cephalic margins of the
ULCs. Surgeons should keep in mind that most nasal
dorsal hump deformities are composed of the cartila­
ginous dorsum in continuity with the medial extension
of the ULCs. Consequently, the bony component of the
dorsal hump is often of lesser magnitude.1,2
THE CARTILAGINOUS FRAMEWORK
Conforming the two lower thirds of the nose, the carti­
laginous nasal framework contributes important factors
to nasal appearance and function. Intrinsic to the ana­
tomic description of the cartilaginous framework of the
nose is the description of the tip support mechanisms
(Table 2-1).
Three major tip support mechanisms have been
described2: (1) the size, shape, and resiliency of the LLCs,
(2) the fibrous attachments of the medial crura to the
caudal septum, and (3) the scroll, a fibrous recurvature
attaching the cephalic border of the LLCs to the caudal
Differential reduction of the cartilaginous and bony profile
must be calibrated depending on the individual thickness
of the overlying S-STE (Figure 2-7). It is equally impor­
tant to adequately analyze the depth of the radix, as it
can provide a natural balance to the nose. Significant
deepening of the radix will accentuate any dorsal promi­
nence. Conversely, in a carefully selected setting, a radix
graft will balance the nasal profile, decreasing the amount
of resection necessary to balance the nasal dorsum
(Figure 2-8).
The nasal ala is composed of fibrofatty tissue and is
devoid of cartilaginous structure, except for its attach­
ments with the sesamoid cartilages through which it
relates to the ULC, LLC, and the pyriform aperture.
THE NASAL SUPERFICIAL
MUSCULOAPONEUROTIC SYSTEM
The major mimetic muscles of the nose include the levator
labii superioris–alaeque nasi, depressor septii nasi, alar
nasi, and transverse nasalis muscle. These are encased
and interconnected throughout by a fibrous fascia referred
to as the nasal superficial musculoaponeurotic system
(SMAS). Maintaining the integrity of this vascularized
layer is important when placing grafts and implants to
maximize engraftment and minimize infections. Signifi­
cant ptosis of the nasal tip or deformity occurring during
animation will respond to addressing these muscles by
either Botulinum toxin use or by surgical ablation.
THE BONY FRAMEWORK
The bony nasal pyramid is composed of the nasal bones
and the nasal process of the maxilla. The nasal bones are
Figure 2-6  Nasal anatomy, base view.
Lobule
Infratip lobule
Columella
Ala
Nostril
floor
Nostril
sill
Alar base
Alar-facial
junction
Medial
crural
footplate
Nasolabial
junction
Nasal spine
Maxillary
crest
Caudal
septum
Anterior septal angle
Apex of alar cartilage
Medial angle of dome
Lateral angle of dome
Alar cartilage
transitional segment-
intermediate crus
Lateral crus
alar cartilage
Medial
crus alar
cartilage
Medial
crural
footplate
Nostril
aperture
Lateral alar
sidewall
Alar
lobule

26
William Numa • Calvin M. Johnson
Figure 2-7  A, Dorsal profile of a large bony and cartilaginous hump. B, Dorsal profile reduction (bony and cartilaginous) with more aggressive resection
at the rhinion. C, Dorsal profile reduction demonstrating the importance of the thickness of the skin and soft tissue envelope in the upper, middle, and
inferior third of the nose while carrying out a dorsal reduction.
A
B
C
Figure 2-8  A, Deep radix accentuating dorsal hump. B, Radix graft. C, Correcting apparent dorsal hump by addressing radix depth with radix graft.
A
Radix
graft
B
C

CHAPTER TWO  Surgical Anatomy and Physiology of the Nose
27
laterally, the caudal edge of the LLC will curve away from
the nasal alar rim2 (see Figure 2-5A).
In the frontal view, the LLCs will flare out at an angle
not usually more acute than 40 degrees from the midline.3
The ULCs form a significant part of the middle third of
the nose, also know as the middle vault (Figure 2-10B).
Their attachment to the LLC through the recurvature
between them (also known as the scroll) will be responsi­
ble for part of the degree of upper and lower mobility of
the LLC. The internal nasal valve is composed of the
angle created between the ULC and the cartilaginous
septum. Weakness of the ULC, short nasal bones, and/or
an overly aggressive resection of the cartilaginous dorsal
hump without reconstruction using spreader graft place­
ment can predispose this area to collapse. The LLCs have
been described as a tripod4 where their medial crura cor­
respond to the base of the tripod (Figure 2-11). Modifica­
tion of the length of the tripod’s leg length and support
can affect the nasal structure, shape, function, and
appearance.4–6
THE NASAL SEPTUM
The septum can be conceptually divided into a cartilagi­
nous (quadrangular) portion and a bony portion. The
bony portion is composed of the perpendicular plate of
the ethmoid posterosuperiorly, the maxillary crest inferi­
orly, and the vomer posteriorly. When a septoplasty is
performed, be it in isolation, as part of a septorhinoplasty,
or as a means to harvest septal cartilage for any grafting
purposes, care must be taken to preserve at least one
centimeter of caudal and septal cartilage in the form of
border of the ULCs. Six minor nasal tip support mecha­
nisms have been described: (1) dorsal cartilaginous
septum (anterior septal angle), (2) interdomal ligament,
(3) membranous (caudal) septum, (4) nasal spine, (5)
sesamoid complex, and (6) LLC’s attachment to the
S-STE.
The LLC contributes, in a great degree, to the char­
acteristics of the size and shape of the lower third of the
nose. In the area of the nasal domes, its caudal margin
courses just under the level of the skin (Figure 2-10). The
LLC can be followed posteriorly, superiorly, and laterally
into the middle third of the nose. As the LLC is followed
Figure 2-9  A, Medial and lateral osteotomies, correcting open roof deformity following cartilaginous and bony dorsal reduction. B, Medial, lateral, and
intermediate osteotomies. C, Designing medial fading osteotomy.
A
Medial
osteotomy
Intermediate
osteotomy
Lateral
osteotomy
A.
B
C
Table 2-1  Major and Minor Tip Support Mechanisms
Major Tip Support Mechanisms
1. Size, shape, and resiliency of the lower lateral
cartilages (LLCs)
2.  Fibrous attachments of the medial crura to the
caudal septum
3. Scroll, a fibrous recurvature attaching the cephalic
border of the LLC, to the caudal border of the
upper lateral cartilages (ULCs)
Minor Nasal Tip Support Mechanisms
1. Dorsal cartilaginous septum (anterior septal angle)
2. Interdomal ligament.
3. Membranous (caudal) septum
4. Nasal spine
5. Sesamoid complex
6. Attachment of LLC to the skin and soft tissue
envelope

28
William Numa • Calvin M. Johnson
antigens. The turbulent airflow within the nose is funneled
around the warm, moist turbinates humidifying and
preparing the air for its passage into the lower airway.
Coursing through the nasal airway, the temperature of
the air is regulated and aerosolized particles come in
contact with chemoreceptors generating afferent responses
accounting for olfaction. Therefore, olfaction can be
altered with changes in nasal airflow. Significant altera­
tions in intranasal anatomy and nasal airflow can affect
the resonating characteristics mediated by the nose on
an “L strut” to ensure an adequate degree of nasal dorsal
and tip support (Figure 2-12).
PHYSIOLOGY OF THE NOSE
Nasal function includes olfaction, resonation of speech,
humidification, as well as being the first line of defense in
the respiratory tract by serving as a filter to particulate
matter and the initial anatomic response site to inhaled
Figure 2-10  A, Nasal base view demonstrating lower lateral cartilages including medial,
lateral, and intermediate crura. B, Nasal bones, upper lateral cartilage and lower lateral cartilage.
Internal nasal valve corresponds to the angle bound by the septum and the upper lateral cartilage
seen on the right inset.
Lateral
crus
Medial
crus
Middle
(intermediate)
crus
A
Upper
lateral
cartilage
Lower
lateral
cartilage
Sagittal
Frontal
Dorsal
septum
Internal
nasal valve
Upper
lateral
cartilage
Axial
B
Nasal
bone
Dorsal
septum
Sesamoid
cartilage
Figure 2-11  Tripod concept.
Central limb
of tripod
Combined
medial crura
form one limb

CHAPTER TWO  Surgical Anatomy and Physiology of the Nose
29
a pinched appearance. If both the ULCs and LLCs are
weak or deformed, the entire cartilaginous wall may col­
lapse, causing the nostrils to resemble narrow slits. The
integrity of the nasal valve area depends on several factors:
(1) the integrity and resilience of the ULCs, (2) attach­
ments of the ULCs, and (3) intrinsic nasal musculature.
The alar muscles are the least important of these factors.13
Therefore, the ULCs and their attachments are critical in
the preservation of the integrity of the internal nasal valve
area and maintaining normal nasal airflow.14
EFFECT OF SPECIFIC SURGICAL
MANEUVERS ON NASAL PHYSIOLOGY
When performing a rhinoplasty, a septoplasty is often
performed to straighten the nasal septum or harvest septal
cartilage for grafting purposes. In most cases, the septo­
plasty improves the nasal airway and therefore the nasal
airflow.
Infracture of the nasal bones can affect the nasal valve
area if the lateral osteotomies disrupt the caudal edge of
the ULC and move it toward the nasal septum. Not only
is the airway narrowed in dimension, but also the nasal
valve area is disturbed, which can result in collapse of the
internal nasal valve with normal inspiration. By perform­
ing lateral osteotomies at the pyriform aperture, at about
the level of the attachment of the inferior turbinate, a
segment of caudal nasal bone is preserved along the
maxilla. When this segment of caudal nasal bone is pre­
served, the widely patent portion of the nasal airway and
the external nasal valve are left undisturbed.
speech. Vasomotor responses (allergic and nonallergic)
can be elicited by antigenic exposure, temperature changes,
exertion, and trauma. Nasal airflow ushers aerosolized
particles toward the olfactory neuroepithelium at the crib­
riform plate and the superior portions of the septum and
lateral nasal wall.10
Nasal function relies on constant airflow. The nose
provides the greatest resistance to airflow, contributing
approximately 50% of the total airway resistance during
quiet respiration.11,12 Within the adult nose, the internal
nasal valve area constitutes its narrowest portion and is
thus the major flow-limiting segment.2,3 The nasal valve
area is bound superolaterally by the caudal border of the
ULC, by the quadrangular cartilage medially, by the pyri­
form aperture inferiorly, and by the anterior portion
of the inferior turbinate posteriorly (Figure 2-10B and
2-13).7–9 Alterations within this critical area of the nose
may have severe consequences in nasal resistance and
airflow.
While performing rhinoplasty, certain structures may
be altered, ultimately affecting nasal airflow resistance.
The entire nasal cavity shares in the formulation of the
airflow pattern during inspiration and expiration. Nega­
tive pressure is generated during inspiration and positive
pressure during expiration. The normal nasal vestibule is
designed to withstand expected nasal pressures experi­
enced during normal breathing. However, during deep
inspiration, negative pressure generated via the Venturi
principle and Bernoulli effect may force the ULCs medi­
ally onto the septum, reducing the area of the nasal valve
and resulting in a temporary obstruction of the nasal
airway.
Weakness or deformity of the ULCs may result in
nasal valve collapse and subsequent nasal obstruction
even during normal inspiration. Weakened ULCs can also
result in collapse of the lateral nasal wall at the juncture
between the middle and lower nasal third, giving the nose
Figure 2-12  Septal anatomy.
1 cm dorsal
cartilaginous
strut
1 cm
caudal
strut
Figure 2-13  Internal nasal valve.
Internal nasal valve

30
William Numa • Calvin M. Johnson
compromising the structural integrity or cosmetic appear­
ance of the nose.
REFERENCES
1. Tardy ME. Rhinoplasty: the art and the science. Philadelphia:
WB Saunders; 1997.
2. Tardy ME, Toriumi DM. Philosophy and principles of
rhinoplasty. In: Cummings CW, Fredrickson JM, Harker LA,
et al., eds. Otolaryngology: head and neck surgery. 2nd ed.
St. Louis: Mosby–Year Book; 1993.
3. Toriumi DM. New concepts in nasal tip contouring. Arch Fac
Plast Surg. 2006;8(3):156–185.
4. Anderson JR. A reasoned approach to nasal base surgery.
Arch Otolaryngol. 1984;110(6):349–358.
5. Whitaker EG, Johnson CM Jr. The evolution of open
structure. Rhinoplasty Arch Fac Plast Surg. 2003;5:291–300.
6. Soliemanzadeh P, Kridel RW. Nasal tip overprojection:
algorithm of surgical deprojection techniques and introduction
of medial crural overlay. Arch Fac Plast Surg.
2005;7:374–380.
7. Rice DH, Kern EB, Marple BF, Mabry RL, Friedman WH.
The turbinates in nasal and sinus surgery: a consensus
statement. Ear Nose Throat J. 2003;82(2):82–84.
8. Leopold DA, Holbrook EH. Physiology of olfaction. In:
Cummings CW, Flint PW, Haughey BH, et al, eds.
Otolaryngology: Head and neck surgery. 4th ed. Philadelphia:
Mosby Elsevier; 2005:chap 37.
9. Johnson CM Jr, Toriumi DM. Open structure rhinoplasty.
Philadelphia: WB Saunders; 1990.
10. Leopold DA, Hummel T, Schwob JE, Hong SC, Knecht M,
Kobal G. Anterior distribution of human olfactory epithelium.
Laryngoscope. 2000;110(3):417–421.
11. Butler J. Work of breathing through the nose. Clin Sci.
1960;19:55–62.
12. Speizer F, Frank R. A technique for measuring nasal and
pulmonary flow resistance simultaneously. J Appl Physiol.
1964;19:176–178.
13. May M, West JW, Hinderer KH. Nasal obstruction from facial
palsy. Arch Otolaryngol. 1977;103:889–891.
14. Kern EB. Surgical approaches to abnormalities of the nasal
valve. Rhinology. 1978;16:165–189.
15. Sheen JH, Sheen A. Aesthetic rhinoplasty. 2nd ed. St. Louis:
CV Mosby; 1987.
Removal of a bony dorsal hump usually has little
effect on nasal airway resistance because this maneuver
affects only the most superior region of the nasal airway
and does not usually change the airway itself. However,
care must be taken when reducing the cartilaginous
portion of a dorsal hump as excessive manipulation or
resection of the ULCs can compromise the internal nasal
valve region and can result in collapse and increased nasal
resistance. Scar contracture or adhesions in the region
of the internal nasal valve can result in severe nasal
obstruction that is difficult to correct. When the ULCs
collapse medially onto the nasal septum, using spreader
grafts,15 medial ULC “flap” grafts, or suturing the ULCs
back onto the nasal septum restores stability to the middle
vault.
Resection or weakening of the LLCs can result in alar
collapse on inspiration. If the LLCs must be divided, the
resected ends should be sutured to one another, restoring
their integrity, with or without alar onlay grafts to provide
additional support. Reductive surgery of the lower third
of the nose can also compromise the integrity of the nasal
valve region by disrupting the interdomal ligament (inter­
cartilaginous membrane). This ligament also plays a role
in the patency of the nasal valve by providing a caudal
attachment of the ULC to the LLC.
Finally, overaggressive alar base reduction may exces­
sively reduce the nostril size, thus compromising the nasal
airway. Obstruction at the level of the nostrils can be a
significant problem, as these can collapse in a valve-like
fashion on inspiration. If reductive surgery is undertaken,
the underlying nasal infrastructure must be reconstructed
to prevent airway collapse and disruption of normal nasal
physiology. Dynamic collapse of the external nasal valve
can be reconstructed by implanting alar onlay (Batten)
grafts. However, once overreduced, the alar base is diffi­
cult to reconstruct.
When performing rhinoplasty with a knowledgeable
command of the nasal anatomy and physiology, preopera­
tive and intraoperative observations can be used to predict
and identify structural problems, addressing them without

31
C H A P T E R T H R E E 
Nasal Analysis
Andrew S. Frankel • Umang Mehta
INTRODUCTION
Nasal analysis in the setting of the preoperative consulta­
tion is undoubtedly one of the most critical elements of
the rhinoplasty process. This is the time in which the
patient and surgeon communicate expectations, build
rapport, and mutually decide whether to proceed with
surgery. In addition, it provides an opportunity for the
surgeon to analyze the patient’s anatomy and personal
aesthetics, thereby developing a surgical plan leading to
the most sought-after result: a satisfied patient. A well-
executed surgery and beautiful result from the surgeon’s
perspective will be frustrating for both parties if the
patient’s desires are not considered. This chapter will
examine the various components of nasal analysis, includ­
ing patient history, nasal proportions, the tripod concept,
nasal subunits, physical examination, photography, and
imaging.
PATIENT HISTORY
A proper preoperative history must begin with the patient’s
demographic data, comorbidities, previous surgery (par­
ticularly any prior nasal surgery or other cosmetic sur­
geries), medications, prior hospitalizations, medication
allergies, and family/social history and a thorough review
of systems. The patient should complete a list of medica­
tions, including over-the-counter medications, herbal sup­
plements, and vitamins. The use of nasal steroid sprays,
antihistamines, and decongestant sprays such as oxy­
metazoline (Afrin) and phenylephrine (Neo-Synephrine)
should be documented. A history of tobacco, alcohol, and
drug use should be obtained. Components of the social
history, such as profession and marital status, can provide
a more complete picture of the patient as a whole and
offer some clues regarding the patient’s expectations of
surgery and support system. The age of the patient is also
important, as a 55-year-old patient is less likely to tolerate
a dramatic change in appearance than is a 16-year-old.
It is important in teenagers to ascertain just where they
are along their growth curve so as to render a result that
ultimately balances with the other facial features. In
teenage females, our rule is to wait at least until 2
years following menarche before performing elective
rhinoplasty—typically sixteen years old. In teenage males,
we typically wait until the age of 17.
After reviewing the general history, we begin the
assessment of the nose by asking the open-ended question,
“What is it that you don’t like about your nose?” This
allows the patient to describe, in his or her own words,
the specific aspects of the nose that are most bothersome
to them. It is helpful to note the order in which patients
mention these features, as this typically reflects the degree
to which they are bothered by each aspect. This exercise
is also very useful in getting a preliminary sense of the
patient’s own aesthetic sense and expectations, as well as
his or her attention to detail. Such information can help
determine at this early stage the chance for a successful
outcome.
This is followed by the question, “How long have you
been bothered by your nose?” At this stage, any history
of nasal trauma or prior nasal surgery is elicited and dis­
cussed in more detail. The desire for a rhinoplasty should
generally be one that has been present for some time, and
persons who have recently decided to have the operation,
on a whim, should be counseled and asked to return
several months later once they have given it further
thought. The motivation for seeking nasal surgery is
revealed at this time. Patients are spurred to consider a
rhinoplasty for a variety of reasons and the specific factors
may impact the surgical plan. For example, a patient
seeking a rhinoplasty to erase physical signs resulting
from past domestic abuse may benefit from a more pro­
found change than would a 55-year-old attorney who has
recently noted that her nasal tip is drooping with age. The
surgeon must also carefully assess whether the patient
exhibits signs of body dysmorphic disorder. Patients who
fixate on their nose in an unhealthy manner or who have
unreasonable expectations regarding the impact that the
nose will have on their life (e.g., promotion at work) are
likely to be persistently unhappy after rhinoplasty.
Functional issues such as nasal obstruction, allergic
rhinitis, or chronic rhinosinusitis are extremely pertinent
in rhinoplasty. The surgeon should ascertain if one side of
the nose is more difficult to breathe through than the other
and assess the severity of the breathing difficulty. Sleep
habits such as snoring, the use of nasal breathing strips,

32
Andrew S. Frankel • Umang Mehta
inferior turbinate. The paired lower lateral cartilages sit
caudal to the upper lateral cartilages. The lower lateral
cartilages are divided into three segments—the medial,
intermediate, and lateral crura. The medial crura overlap
the caudal edge of the septum. The region between the
lower lateral and upper lateral cartilages is called the
scroll, which is the recurvature of the upper lateral carti­
lages. This scroll can be prominent in some individuals.
The skin and soft tissue envelope overlying the bony-
cartilaginous framework of the nose must also be under­
stood. The skin of the nose varies in thickness significantly.
The upper third is moderately thick but tapers into a
thinner region over the rhinion or mid-dorsum. The skin
over the lower third of the nose is more sebaceous and
thick and tends to hypertrophy with age. Below the skin
lies the nasal superficial musculoaponeurotic system, or
nasal SMAS. There are four major groups of nasal muscles:
dilators, compressors, elevators, and depressors. The dila­
tors are the dilator naris anterior and dilator naris pos­
terior. The sole compressor is the transverse nasalis.
Elevators include the procerus and levator labii superioris
alaeque nasi while the depressors are the depressor septi
nasi and alar nasalis.
NASAL PROPORTIONS
A thorough discussion of the rhinoplasty consultation
must first begin with a consideration of nasal proportions.
The nasofrontal angle is defined as the angle between a
line tangent to the nasal dorsum and a line tangent to the
glabella through the nasion. This should measure between
115 and 135 degrees1 (Figure 3-1). An obtuse nasofrontal
and sleeping on one side must be documented. It is also
worth documenting whether the symptoms are seasonal,
positional, or related to certain foods. Patients should be
asked about symptoms such as recurrent epistaxis as well.
Computed tomography (CT) scan of the sinuses is often
useful for patients with functional concerns.
Any prior history of nasal surgery, including previous
rhinoplasty, septoplasty, or functional endoscopic sinus
surgery, should be discussed. Prior operative reports can
be quite useful in formulating a surgical plan, although it
is important to recognize that these notes are not always
accurate. The timing of the most recent rhinoplasty is
important to consider because the nose will continue to
change over 12 or more months as postoperative edema
resolves and wound contracture takes place. The surgeon
must also question the patient about previous breast
surgery when considering harvest of costal cartilage. Simi­
larly, prior otoplasty or ear surgery is pertinent when
auricular cartilage may be needed.
The patient’s ethnic background can provide insight
into their particular cultural aesthetic. A patient from
South America, for example, will likely have a different
idea of what constitutes an attractive nose than a similarly
aged patient of Middle Eastern descent. This sort of
consideration is essential for delivering a surgical result
that the patient desires, even if it varies from the surgeon’s
own inclination. Additionally, appreciation for cultural
differences helps with the process of preoperative imaging
and facilitates development of a sense of trust with the
patient.
NASAL ANATOMY
An understanding of the anatomy of the nose is obviously
quite crucial for the rhinoplasty surgeon. The underlying
structural framework of the nose consists of the paired
nasal bones superiorly and the five major nasal cartilages
caudally. The nasal bones are attached to the frontal bone
superiorly, the lacrimal bones supero­laterally, and the
ascending processes of the maxilla inferolaterally.
The bony septum is composed of the perpendicular
plate of the ethmoid posterosuperiorly and the vomer
posteroinferiorly. The quadrangular cartilage, which can
vary dramatically in size among different ethnic groups,
provides the structure for the anterior portion of the
septum. This cartilage is the predominant support of
the dorsal and caudal portions of the lower two-thirds of
the nose.
The upper portion of the quadrangular cartilage flares
along its dorsal edge and is fused between the upper
lateral cartilages. This is particularly relevant in the
setting of profile reduction, as this flared segment is the
excised portion. This can lead to narrowing and collapse
of the middle vault if not properly supported. The internal
nasal valve is comprised of the angle formed by the
septum, the upper lateral cartilage, and the head of the
Figure 3-1  The nasofrontal angle should measure between 115 and
135 degrees.

CHAPTER THREE  Nasal Analysis
33
Less frequently discussed angles include the nasofa­
cial angle and nasomental angle. The nasofacial angle
represents the angle formed by a vertical line from the
glabella to the pogonion, as it intersects with a line from
the nasion to the nasal tip. This angle can vary from 30
to 40 degrees (Figure 3-4). The nasomental angle describes
the angle between the nasion-tip line and the line from
the tip to the pogonion. The range of this angle is from
120 to 132 degrees (Figure 3-5).
A significant relationship exists between the nose and
chin and the two must be considered in conjunction with
one another. The chin should ideally reach a vertical line
Figure 3-2  A shallow nasofrontal angle of nearly 180 degrees (A). On AP view, this obtuse angle causes the nose to appear excessively long (B).
A
B
angle gives the illusion of a very long nose on frontal view,
as the patient lacks a well-defined nasal starting point
(Figure 3-2).
The nasolabial angle is composed of the angle formed
by a line from the subnasale to the most anterior point of
the columella and a line connecting the labrale superius
to the subnasale. This angle should ideally measure 90 to
95 degrees in men and 95 to 110 degrees in women
(Figure 3-3). As a general rule, individuals with shorter
stature can tolerate a more obtuse nasolabial angle as
there will be less visible nostril when viewed from the front
by average-statured individuals.
Figure 3-3  Nasolabial angle. Normal range is 95 to 110 degrees for
females and 90 to 95 degrees for men.
Figure 3-4  Nasofacial angle, ideally 30 to 40 degrees.

34
Andrew S. Frankel • Umang Mehta
Figure 3-5  Nasomental angle, 120 to 132 degrees.
Figure 3-6  The Frankfort horizontal plane: a line drawn between the
superior edge of the tragus and the infraorbital rim should parallel the floor.
drawn from the nasion, perpendicular to the Frankfort
horizontal plane. The Frankfort horizontal plane repre­
sents the line drawn from the superior edge of the tragus
to the infraorbital rim, which should be parallel to the
ground in standard photographs (Figure 3-6). An under­
projected chin must be discussed with the patient, as this
can give the illusion of an overprojected nose. The option
of chin augmentation should be offered in these
situations.
The ideal projection of the nose has been described
by Crumley as a 3 : 4 : 5 right triangle. The shorter side of
the triangle represents the tip projection, the distance
from the alar crease to the tip. The ratio between this
measurement and the distance between the nasion and
tip-defining point should be 0.6.2 This tip projection ratio
was previously described by Goode, with the ideal ratio
between 0.55 and 0.61 (Figure 3-7).
On base view, the ratio between the tip complex
(infratip) and columella should be 1 : 2, with symmetric,
ovoid-shaped nostrils that are thinner at the apex than
the base (Figure 3-8). On lateral view, the ideal ala to tip
lobule ratio is 1 : 1. The extent of columellar show is also
a significant consideration. It is recommended by most
authors that the columellar show be between 2 and 4 mm,
although in our experience, most patients favor between
2 and 3 mm.3
The width of the nose, as it relates to the overall width
of the face, is another important consideration. The
concept of “vertical fifths” has been well established, with
the width of the nose from the lateral edge of one ala to
the other approximating the width from the medial to
lateral canthus. This should be equal to one-fifth of the
overall width of the face. Therefore, the medial canthus
and lateral edge of the ala should align in a vertical line.
The face can also be divided into horizontal thirds. The
trichion to glabella portion represents the upper third;
glabella to subnasale, the middle third; and subnasale to
menton, the lower third4 (Figure 3-9). Overresection of
the caudal septum shortens the nose and can decrease the
length of this middle third of the face. This also can lead
to the appearance of an overly long upper lip. The width
of the dorsum is important and should create a smooth
curved line from the medial brow to the nasal tip.
TRIPOD CONCEPT
The nasal tip can be conceptualized as a tripod, where the
lateral crura constitute the superior legs and the combined
medial crura conform the third leg. Any maneuver that
changes the shape of one leg of the tripod will cause a
corresponding tilt in the nasal tip.
Following the tripod concept, shortening the inferior
leg (combined medial crura) would counterrotate the
nasal tip and decrease projection. Conversely, increasing
the length of this leg, through the use of a columellar strut,
for example, can increase rotation and projection. Alter­
natively, increasing the length of the superior legs of the
tripod (the lateral crura) causes counterrotation and
increased projection, whereas decreasing the length of the
superior limbs leads to increased rotation but decreased
projection. Lengthening all three limbs of the tripod would
increase tip projection (without significant rotation),
whereas a decrease in all three limbs would decrease
projection.

CHAPTER THREE  Nasal Analysis
35
Figure 3-7  Goode’s ideal tip projection: 0.55 to 0.6 of the length of the nose, from tip to nasion.
C
A
= 0.55 to 0.60
B
A
C
Figure 3-8  Ideal base view. Tip should be one-half the height of the columella.
The interrelation of the tripod complex with the
septum must not be disregarded, however, and some
authors advocate a tripod-pedestal concept. In this analy­
sis of tip dynamics, the septum comprises the pedestal
against which the tripod rests. This approach offers insight
into the manner in which changes in the anterior septal
angle or suturing of the lower lateral cartilage complex to
the septum can result in powerful changes in tip rotation
and projection.5 A newer model for understanding tip
dynamics is the “M-Arch,” proposed by Adamson. This
concept involves the visualization of the lower lateral
cartilages as independent arches, with the lateral limb of

36
Andrew S. Frankel • Umang Mehta
NASAL SUBUNITS
The subunit concept in facial plastic surgery is instrumen­
tal in planning nasal surgery, particularly in nasal recon­
struction. The aesthetic unit of the nose is divided into
nine subunits, based on convexities and concavities of the
nasal surface. The reflection of light in a disparate manner
from these areas of convexity and concavity creates pre­
dictable areas of light and shadows over the nose. This
gives the illusion of borders between subunits, providing
optimal locations for incision placement. Scars across a
particular subunit tend to be more noticeable.
The nine subunits of the nose are the dorsum, paired
lateral nasal walls, paired soft triangles, paired alar sub­
units, tip, and columella7 (Figure 3-11).
PHYSICAL EXAMINATION
A systematic examination of the nose begins with an
assessment of the thickness of the skin and soft tissue
envelope. In thin-skinned individuals, changes to the
bony-cartilaginous framework are more readily seen,
which can be positive in terms of making the intended
changes to the appearance of the nose. The obvious dis­
advantage of a thinner envelope is that underlying grafts
and irregularities will be more readily palpable and visible.
Thick skin limits the amount of refinement that is achiev­
able and may result in more protracted swelling postop­
eratively. It is important to note the sebaceous nature of
the tip skin and to discuss this finding with patients so as
to manage expectations appropriately.
The bony pyramid is carefully palpated and examined
to check for any deviation or bony prominences. The
length of the nasal bones is an important predictor of
potential postoperative problems. Short nasal bones in
conjunction with a long middle nasal vault can lead to
collapse of the upper lateral cartilages, if the middle nasal
vault is not supported with spreader grafts and reconstitu­
tion to the dorsal septum. In addition to the deviation of
the pyramid as a whole, concavity or convexity of each
individual nasal bone can be palpated. Excessively curved
nasal bones may, in rare cases, necessitate intermediate
osteotomies. The most common complaint in patients
seeking rhinoplasty is the removal of a dorsal hump. The
nature of this procedure should be planned during preop­
erative nasal dorsal palpation, determining whether the
area of concern is predominantly bony or cartilaginous.
The height of the radix, nasofrontal angle, and nasal
starting point should also be noted. These can be impor­
tant measurements to review with the patient during the
imaging portion of the consultation as most patients are
unaware of the aesthetic implications of this portion of
the nose.
Examination of the septum involves both external and
internal assessment. Externally, a C-shaped deformity of
Figure 3-9  Vertical fifths and horizontal thirds.
Hairline
Glabella
Subnasale
Mention
1/3
1/3
1/3
1/3
2/3
1/5
1/5
1/5
1/5
1/5
Figure 3-10  Adamson’s M-Arch model of tip dynamics, note the inter­
mediate crus.
Lateral
crus
Intermediate
crus
Medial
crus
each arch cephalically positioned. This model represents
advancement in our understanding of the nasal tip because
it considers the importance of the intermediate crura of
the lower lateral cartilages, which are not included in the
tripod concept6 (Figure 3-10).